Chapter 4: Population-specific status report: HIV/AIDS and other sexually transmitted and blood borne infections among youth in Canada – Determinants of vulnerability and resilience
Chapter 4 – Determinants of Vulnerability to and Resilience against HIV and Other STBBIs among Youth
While most youth in Canada make the transition to adulthood free from HIV and other sexually transmitted and blood borne infections (STBBIs), some do not. Some youth are more vulnerable to infection than others due to a variety of challenges, obstacles and conditions within their social, cultural, economic and physical environments. Existing literature has tended to focus on particular groups of youth as “at risk” of infection based on individual characteristics or behaviours, and/or because of their membership in a particular social group. These characterizations ignore the social, cultural, economic and structural conditions that affect the lives of youth and their opportunities for making health-related decisions. This chapter explores these conditions to help provide a more holistic understanding of how they influence the pathways youth take to adulthood. To reduce rates of HIV and other STBBIs among youth in Canada, it will be critical to address the complex factors that affect their vulnerability to infection and create conditions that promote healthy decision making.
Health status improves at each step up the income and social hierarchy. High income determines living conditions, such as safe housing and ability to buy sufficient good food. The healthiest populations are those in societies which are prosperous and have an equitable distribution of wealth.Footnote 1
Socio-economic status (SES) is a measure of individuals’ or families’ position relative to others within a hierarchical social structure, and is commonly based on education, employment and income. SES is one of the strongest predictors of individual health. In general, those with lower SES tend to have poorer health outcomes than those with higher SES. On average, the more advantaged people are with respect to education, employment and income, the better their health. Chapter 2 provided data on education, employment and income among youth in Canada. Here, we describe how these factors create opportunities and challenges for youth with respect to their health.
Education contributes to better health by providing individuals with knowledge, and personal and social skills that better equip them to access, understand and use health information or services. Youth who drop out of school and those with lower levels of education may be missing key opportunities to acquire these important tools.
Education also leads to increased opportunities for employment and higher income.Footnote 2 Post-secondary education is becoming increasingly important for entry and progression in the labour market in Canada. Young people who have not completed their high school education face limited choices for employment and may struggle for basic necessities. To meet basic needs, some may engage in activities such as sex work that increase their vulnerability to HIV and other STBBIs.
Truncated or lower levels of education can also have an indirect impact on health by limiting access to adequate housing, food and health services. Data drawn from the Enhanced Street Youth Surveillance in Canada (E-SYS) found that high school completion was relatively low among street-involved youth in Canada. Less than one-third of street-involved youth aged 18 years or older had graduated from high school, a level three times lower than the general population. Street-involved youth were 10 times more likely to report poorer physical and mental health than their peers.Footnote 3 Over half of street-involved youth experienced barriers to accessing health services. Among these, half cited structural barriers such as lack of personal identification (owing to unstable residence) and financial constraints.
Parental education also plays a key role in the health and wellbeing of youth. A study of more than 2,000 Nova Scotia high school students examined the association between sexual activity, sexual risk taking and household socio-economic status.Footnote 4 Early age of first sexual intercourse among both females and males was associated with lower parental education and not living with both parents.Footnote 5 For males, having an unemployed father was an additional factor for early age of first sexual intercourse. By comparison, factors that tend to protect against early age of first sexual intercourse, non-condom use and unplanned intercourse included living with both parents and having parents with higher levels of education and employment.Footnote 6 Knowledge and skills are often passed on to youth from parents or caregivers. In addition, the education parents receive affects their own employment and income and the resources to which the family has access.
Employment can impact the health of young people in a variety of ways.Footnote 7 First and foremost, it provides access to financial and material resources (e.g. prescription drug benefits) necessary to protect one’s health. The psychological stress of financial insecurity compounds the negative health effects by disrupting daily routines, lowering self-esteem and increasing overall anxiety. Unemployment also increases the likelihood of individuals turning to drinking, smoking and drug use as coping mechanisms.
Access to personal and family income is another factor that influences youth health and development. As discussed, personal income makes it easier to purchase prescription drugs, condoms and other health care materials. It can also provide individuals with a sense of independence, self-esteem and self-worth, all of which contribute to their resilience in the face of poor health outcomes. For youth living with parents or caregivers, family income is a more important indicator of the resources to which they have access to support their health, than their personal income. Data from youth aged 10 to 19 years in the 2002-2003 Canadian Community Health Survey demonstrated higher rates of condom use at last sexual intercourse among youth living in higher income families.Footnote 8 Lower income household (<$50,000/year) also predicted earlier age of first sexual intercourse, multiple sexual partners, previous history of STIs and unprotected sexual intercourse.Footnote 9 Similarly, data from the National Population Health Survey showed that youth from families with higher incomes (>$50,000/year) were less likely to report smoking or binge drinking or to have had more than one sexual partner in the past year. Over the same period, they were more likely to have “always” used a condom.Footnote 10
Inadequate personal or family income may also lead to health-compromising behaviours to provide the basic necessities of life. These behaviours may put individuals at increased risk of poor health outcomes, including infection with HIV or other STBBIs. For example, street-involved youth who cannot access social assistance find alternative ways to make money and to meet their basic needs. Common sources of income for street-involved youth reported in the Enhanced Street-youth Surveillance Study included survival sex work and selling drugs.Footnote 11 Street-involved youth have identified sex work and selling drugs as more lucrative sources of income, despite the risks of being arrested, experiencing violence, or becoming infected with HIV or other STBBIs.Footnote 12
4.2 GenderFootnote i
Gender refers to the array of society-determined roles, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis. “Gendered” norms influence the health system's practices and priorities. Many health issues are a function of gender-based social status or roles.Footnote 13
Sex and gender are two distinct concepts. While there is no single agreed-upon definition, sex typically refers to biological characteristics including anatomy (e.g. body size, reproductive organs) and physiology (e.g. hormonal activity) that distinguish males and females.Footnote 14 Gender refers to socially and culturally determined expectations and norms regarding appropriate behaviour, characteristics and roles.Footnote 15 For example, the concept of gender is responsible for the widely held belief in Canada that newborn girls be dressed in pink and boys in blue. Gender affects the health of individuals in a variety of ways including norms of acceptable behaviour, expectations within sexual relationships and access to health services.
The norms and expectations grounded in concepts of gender influence the ways sexuality is perceived and experienced. Gender norms influence sexual partners, types of sexual behaviours engaged in, and the context in which sexual behaviour takes place. Gender norms around sexuality often differ for males and females. For example, in some societies it may be acceptable for males to have sexual experiences before marriage, whereas expectations about female behaviour may be more restrictive. These gendered norms are established through socialization at a young age. Youth learn specific gender norms and expectations, which influence their health outcomes throughout life.Footnote 16
Gendered roles of masculinity and femininity affect sexuality, sexual behaviour and sexual relationships in ways that create power imbalances in sexual relationships and disparities in health outcomes. For example, youth may be taught gendered norms of sexual behaviour in which males are viewed as dominant and in control in a sexual relationship. This places women at risk of being unable to negotiate condom use if her male partner does not want to and to experience sexual violence or coercion by her male partner.
In the Cedar Project cohort, young Aboriginal women were found to have higher HIV infection rates than their male counterparts.Footnote 17 Over 80% of the young female participants reported unprotected heterosexual intercourse, in addition to 70% who reported experiences of forced sex.Footnote 18 Study results showed that safer sex methods including condom use were compromised because of power imbalances between males and females, including young women’s fear of violence and/or abandonment by their male partners.Footnote 19 Interviews conducted with 30 self-identified Aboriginal youth aged 15 to 19 in Vancouver’s Downtown Eastside and on two reserves on Vancouver Island revealed a different perspective on how genders interact and negotiate safer sex.Footnote 20 Results from this study showed that young women played an active role in sexuality and safer sex while young men were sometimes coerced by their female partners to not use condoms.Footnote 21 Specifically, young women sometimes pressured their male partners to avoid condom use.Footnote 22 Among this population, pregnancy and parenting are highly valued, which may explain the pressure by females not to use condoms.
Gender norms around masculinity may also impact males’ willingness to use condoms. For example, gender norms of masculinity may support the belief that condoms are a sign of weakness. Studies have shown less condom use and higher sexual risk behaviours among youth in communities where stereotypical male and female gender norms were dominant.Footnote 23
Gender norms can also influence perceptions towards and access to health services. Studies of young heterosexual men suggest that social constructions of masculinity affect sexual health service access and HIV testing behaviours.Footnote 24 In a cohort of 50 sexually active self-identified heterosexual men (aged 15-23) in Nova Scotia, participants reported that they did not want to seek out conventional sexual health and HIV education and prevention services, despite the fact that Youth Health Centres were available throughout the province.Footnote 25 Young men reported concern about being seen as sexually inexperienced, unknowledgeable or “gay”, if they sought out information about sexual health and HIV education and prevention services.Footnote 26
Gendered norms and attitudes held by health professionals can also impact access to health services differently for people of different genders. For example, in one study, young male participants reported not feeling welcome in sexual health clinics due to a perceived female-centered physical atmosphere.Footnote 27 This included clinic décor and displays of posters and pamphlets on women’s sexual health issues.Footnote 28 In another study by Planned Parenthood Toronto, participants expressed that sexual health services were primarily targeted to women and their reproductive health issues.Footnote 29 Young male participants identified the need for gender-neutral and youth-friendly settings as a way to increase access to sexual health services for males.Footnote 30 The perception that these services are targeted to females leads males to believe that they are not important to their health and reduces the likelihood that they will access them. Results from the Toronto Teen Survey (TTS) found that young men access sexual health services less often, and are less likely to ask for sexual health information; yet, they want to know about sexuality.Footnote 31
Transgender youth face unique challenges with respect to gender norms and expectations. For example, lack of knowledge or awareness about this population among health professionals can affect the access transgender people have to quality health services. The TTS interviewed a small number of transgender youth who reported fear of being judged and discriminated against by health professionals because of transphobia.Footnote 32 Results also showed that clinics often do not recognize transgender youth identities or meet their sexual health needs.Footnote 33 Among participants, half had accessed sexual health services but reported that they were unhappy with them. The study identified the importance of using gender-neutral language, creating a space for youth to self-identify, and training professional and medical staff on gender identity to better meet the needs of the transgender youth.Footnote 34
A key component of everyone’s identity, sexual orientation is made up of an individual’s self-identification, physical and emotional attraction towards another person and behaviours. These elements interact in multiple, complex and sometimes inconsistent ways. For example, an individual may self-identify as heterosexual and may be mostly physically and emotionally attracted to members of the opposite sex. However, they may feel slight emotional or physical attraction to some members of the same sex and may act on these attractions. As a result, sexual orientations exist along a continuum, from exclusively homosexual to exclusively heterosexual, with various sexual identities in between.Footnote 35 Sexual orientation begins to develop in early childhood and continues over an individual’s lifetime.
Sexual orientation is another important determinant of health that can influence vulnerability to HIV and other STBBIs. Non-heterosexual youth including lesbian, gay, bisexual and queer or questioning youth experience poorer physical, mental, emotional and sexual health than heterosexual youth. Sexual orientation affects health outcomes in a variety of ways. First, given the nature of certain STBBIs, the risk of transmission varies significantly, depending on the type of exposure. Though transmission occurs most often through sexual activity or drug use practices, the probability of being infected or infecting someone else depends on the type of act in which youth engage.Footnote 36 For example, a recent analysis of the literature provides evidence that vaginal intercourse has a lower per act probability of transmitting HIV than anal intercourse.Footnote 37 Therefore, sexual orientation affects health outcomes like HIV and other STBBI directly because of the types of behaviours in which youth engage.
It also affects health indirectly as a result of social, psychological and cultural conditions. In particular, non-heterosexuals experience greater levels of stress due to social and cultural attitudes towards sexual minorities, rejection and social isolation, and the pressures of having to manage their identity according to the environment. Stressors such as these, sometimes called “minority stress”, lead to high blood pressure, anxiety and other physiological responses that result in poorer physical and mental health. They can also result in health-compromising coping mechanisms such as substance use, unprotected sexual activity or sex work.Footnote 38 For some sexual minority youth, substance abuse can be an attempt to self-medicate to manage stigma or shame, to deny same-sex feelings, or as a defence mechanism against ridicule or discrimination by others.Footnote 39 For example, self-identified sexual minority youth who participated in the Toronto Teen Survey explained that engaging in unprotected or risky sexual behaviour helped them cope with the negative social environment in which they live, despite the risk of HIV and other STBBIs.Footnote 40
Compared to their heterosexual peers, research has shown that lesbian, gay and bisexual, youth are more likely to experience first sexual intercourse before 14 years of age, to consume drugs and alcohol before intercourse, to have multiple sexual partners, to have been pregnant or to have got their partner pregnant, to self-report problems with drugs and alcohol, and to be involved in survival sex work.Footnote 41 Similarly, among a cohort study of Montreal high-school students, self-identified gay, lesbian or bisexual youth reported significantly higher rates of smoking, drinking, and use of marijuana and hard drugs than their heterosexual peers.Footnote 42 In a sample of youth from rural British Columbia, lesbian, gay, and bisexual youth were more likely than their heterosexual peers to report substance use as a way of coping with stigma and discrimination.Footnote 43
Homophobia is another health-compromising stressor. Social and cultural attitudes towards sexual minorities are often expressed in negative ways ranging from more covert forms of discrimination to more visible forms of verbal harassment, physical violence or other forms of bullying. These experiences can lead to physiological responses (e.g. high blood pressure, anxiety), mental illness (e.g. depression), poor mental health (e.g. low self-esteem), substance use, and self-harm (e.g. suicide).Footnote 44 Among youth in particular, these experiences can jeopardize academic achievement and increase the likelihood of school dropout, learning difficulties and social isolation.Footnote 45 In a national sample of high school youth from the First National Climate Survey on Homophobia in Canadian Schools, over half (56.6%) of lesbian, gay, bisexual, transgender, queer and questioning youth reported verbal harassment due to their perceived sexual orientation, compared to 14.1% of other youth.Footnote 46 In a 2008 Quebec study of 2,747 high school students, 38.6% of participants reported having been victims of an act of violence at school based on their identity or on the way that their peers perceived their sexual identity.Footnote 47
As a result of their sexual orientation and social attitudes, sexual minority youth may be removed from key protective factors in their lives, such as connections to their family, school or community.Footnote 48 Social isolation can increase the likelihood of these youth engaging in negative coping behaviour. The effects of homophobia and social isolation may be heightened for sexual minority youth from rural and remote communities who are more likely to migrate to big cities to escape stigma and discrimination.Footnote 49 Moving to urban areas also physically removes these youth from family and peers. For example, a small qualitative cohort of 13 two-spirit Aboriginal youth reported that 90% of them had migrated to Toronto because of the homophobic attitudes and abuse they had faced, both from families and the broader community.Footnote 50 Sexual minority youth who migrate to urban centres may experience additional challenges such as racism, poverty and isolation, unemployment, unstable housing, lack of access to health and other services, and sexual exploitation.Footnote 51 For other sexual minority youth, moving to an urban centre can be empowering and can increase resiliency by removing them from a negative social environment.
Researchers have begun to focus on strategies for fostering resilience among sexual minority youth. For example, the McCreary Centre Society examined strategies to help support sexual minority youth at school. These included providing safe and caring schools, promoting healthy attitudes about risky behaviours, supporting families in parenting roles, providing opportunities to get involved, and creating an environment for positive youth development.Footnote 52 A positive school environment helps to foster coping skills among sexually diverse youth that support learning, finishing high school and aspiring to post-secondary education.Footnote 53
Some persons or groups may face additional health risks due to a socio-economic environment, which is largely determined by dominant cultural values that contribute to the perpetuation of conditions such as marginalization, stigmatization, loss or devaluation of language and culture and lack of access to culturally appropriate health care and services.Footnote 54
Chapter 2 presented data to profile the increasing ethno-cultural diversity of youth in Canada. Culture is an important element of people’s identity and is made up of behaviours, practices, values and attitudes. These elements of culture are shaped by other elements of human identity including race, ethnicity, gender or sexual orientation. Culture is also shaped by historical, socio-economic and political contexts, by power relations within and between groups and by the institutionalized attitudes and practices that result.
Culture, race and ethnicity are important determinants of health outcomes, including infection with HIV and other STBBIs. First, culture shapes knowledge, attitudes and behaviours in ways that influence an individual’s vulnerability or resistance to these infections. For example, research indicates a gap in knowledge about sexuality and HIV among racialized and immigrant communities in Canada.Footnote 55 Substance use, a well-researched risk factor for HIV and other STBBIs, is shaped by cultural values, too. Cultural values and attitudes play a part in: whether people use alcohol, tobacco or drugs; the age at which they begin using substances; frequency of use; and the contexts in which they use certain substances. Cultural values also include beliefs about health and illness themselves, such as: sources or causes of illness; whether and how illnesses can be treated; who is able to treat illness; and who should be involved in making treatment decisions. For example, in some cultures illnesses such as HIV are believed to be caused by supernatural forces, while in others it is believed to be caused by a virus. These culturally-based beliefs shape youths’ perceptions of their vulnerability to infection, the precautions they take to avoid them, their use of preventive health services (e.g. HIV or STI testing) and the treatments they seek if they experience symptoms. Cultural values also include perceptions about sexual identity. In particular, non-heterosexual identities take on other meanings and values in different cultural contexts. In many cultures, non-heterosexual identities are feared and perceived negatively (i.e. homophobia). In others, non-heterosexual identities are revered. Similarly, cultural values include perceptions of sexuality which impact the norms and patterns of sexual relationships such as how and with whom people communicate about sex, and the types of behaviours engaged in. For example, cultural values and attitudes may dictate whether youth in certain ethno-cultural groups feel comfortable discussing issues of sexuality with parents or health professionals. South Asian youth who participated in the Toronto Teen Survey reported a general discomfort communicating about sexuality and sexual health with their parents. They also expressed concern that their parents would find out about any consultation with a sexual health clinic.Footnote 56
Culture, race and ethnicity are also closely linked with socio-economic status, gender roles and other determinants of health. Ethno-cultural minorities are disproportionately represented in lower socio-economic categories in Canada.Footnote 57 Several factors contribute to lower socio-economic status among ethno-cultural minorities including internalization of racial stereotypes, history of colonization, racial discrimination and employment inequality.Footnote 58 The effects of lower socio-economic status on vulnerability to HIV and other STBBIs also affect ethno-cultural minority youth disproportionately (e.g. less access to health services or information, inability to afford condoms or other prevention). In addition, gender roles are also shaped by cultural contexts in ways that create differences among ethno-cultural youth in their vulnerability to HIV and other STBBIs. For example, in some cultures, female gender roles are constructed in ways that place greater restrictions on women’s sexuality, their ability to make decisions in sexual relationships and power to choose with whom they have sex. These gender roles in turn increase the vulnerability of women in these groups to HIV and other STBBIs.
Cultural values can also create social, political and structural conditions which affect sexual health among youth in Canada. In particular, racial discrimination or a history of colonization can limit opportunities for ethno-cultural minority youth to protect, improve or maintain their health. For example, these conditions can limit access to health information or services or access to education and employment. A comparison of data collected in the Toronto Teen Survey, suggests that the history of colonization and racial discrimination continues to fuel structural and social racism, exclusion and discrimination among the Black, African and Caribbean youth communities. This in turn affects access to sexual health information and services and drives higher rates of HIV and other STBBIs.Footnote 59 Black youth in this study were the least likely to report having access to sexual health services and explicitly identified racism as a factor preventing them from doing so.Footnote 60
Research also points to the effects of the historical marginalization of Aboriginal peoples in Canada. Data from a cohort of 61 Aboriginal youth living in urban and rural Ontario emphasized the multi-generational effects of colonization on Aboriginal communities, families and parents. These effects included lower self-esteem, loss of self-care and parenting skills, recurring cycles of violence and substance use, and lower likelihood of using condoms during sexual intercourse.Footnote 61 Participants linked individual HIV-related risk behaviours, such as substance use, with the historical context of discrimination and violence resulting from colonization.Footnote 62 In a separate study of 18 homeless women in Edmonton, aged 19-26, who were moving out of homelessness, nine self-identified Aboriginal participants reported that the historical legacy of colonization, racism and poverty had major impacts on the overrepresentation of female Aboriginal youth on the street and their ability to find stable and safe housing. For young Aboriginal women, historical and ongoing discrimination and sexism were factors that amplified their vulnerability to homelessness and HIV infection.Footnote 63 Participants also noted that their spirituality and connection to Aboriginal culture helped them to survive on the street and to transition out of it.Footnote 64 In this way, culture can be a source of resiliency for some groups.Footnote 65 For Aboriginal people, resilience involves the ability to withstand challenges and maintain identity.Footnote 66 Initiatives have been developed throughout Canada to support and build on Aboriginal youth resiliency and to impart skills to cope with the consequences of colonization and HIV vulnerability.Footnote 67
Experiences of immigration can compound the challenges, obstacles and opportunities youth face in protecting their health. For example, the experience of migrating to Canada can be a challenge for some as they learn a new language, adjust to a new social status and income, or struggle to find employment. Experiences of migration can impact access to health services, such as testing or treatment for HIV and other STBBIs, or seeking out health information. For some newcomers, meeting basic needs such as food, shelter and clothing may be so challenging that finding health services or taking care of their health are not priorities. Others may come from countries where HIV and other STBBI prevention, screening and treatment are not widely available. As a result, they may have little experience, knowledge or awareness of these services and lack comfort in accessing them.Footnote 68
Newcomers may also struggle to negotiate the norms and expectations of their own culture and those of other cultural groups in Canada. Some may feel a loss of control over their lives or lower self-esteem, while others may experience greater control over their bodies and their sexuality in a new country.Footnote 69 Experiences of migration can impact access to social support and information, resulting in feelings of social isolation or lack of awareness about available health services.
The earliest years are pivotal to a child’s growth and development. Nurturing caregivers, positive learning environments, good nutrition and social interaction with other children all contribute to early physical and social development in ways that can positively affect health and wellbeing over a lifetime.Footnote 70
Early childhood experiences and the family environment can have a positive impact on human development and health throughout the life course. In particular, the presence or lack of family support can contribute to long-term physical and mental health outcomes. Many children experience positive parenting, live in a well-functioning family, and have strong connections with their family and community.Footnote 71 Family connectedness, family function and quality of relationships between youth and their parents or caregivers shape the norms, attitudes and behaviours of youth in ways that influence their vulnerability to or resilience against HIV and other STBBIs.
Data from the 1992-2003 British Columbia Adolescent Health Survey (AHS) of youth in grades 7 to 12 (N=72,000) suggests that family connectedness is an important protective factor in the healthy development of young people. Among adolescent males, those with the highest levels of family connectedness were less likely to have ever had sex, to have had sex before age 14, or to have caused a pregnancy compared to same-age peers with the lowest levels of family connectedness. Similarly, females with the highest degree of family connectedness had lower odds of ever having had sex, of engaging in early first sexual intercourse, and of becoming pregnant compared to females of the same age with the lowest levels of family connectedness.Footnote 72 Positive relationships during childhood between parents and children can increase children’s resiliency later in life, and act as a protective factor against health-compromising behaviour.
Substance use during pregnancy is another factor related to healthy childhood development given its health consequences and adverse effects for mother and child. The use of substances such as injection drugs during pregnancy can also increase the likelihood that mothers will contract HIV or hepatitis C and pass these infections onto their children. Data from the 2007-2008 Canadian Community Health Survey found that 5.8% of mothers surveyed consumed alcohol during pregnancy.Footnote 73 That prevalence might be as high as 10.8% according to data from the Canadian Maternity Experiences Survey (MES), in which 5,882 mothers participated.Footnote 74 Marital status, smoking status, immigrant status and reaction to pregnancy were also found to be important correlates with maternal alcohol use during pregnancy.Footnote 75 The initial health consequences of maternal alcohol use extend into adulthood and can include early adult alcohol abuse and increased likelihood of alcohol dependence.Footnote 76 The impact of alcohol use on youths' vulnerability to HIV and other STBBIs is well-documented throughout this report.
Similarly, tobacco use during pregnancy can lead to long-term adverse health effects. In 2007, 10% of Canadian women aged 20-44 who had been pregnant in the previous five years reported that they smoked regularly during their most recent pregnancy.Footnote 77 Studies have shown that maternal smoking during pregnancy is associated with increased risk of behavioural problems such as inattention and attention deficit hyperactivity disorder,Footnote 78 as well as increased lifetime risk for problems with alcohol use.Footnote 79
Women who use alcohol, tobacco or other drugs during pregnancy may experience stigma in accessing substance use treatment services and health care, including prenatal services.Footnote 80 Furthermore, those women most vulnerable to substance use during pregnancy are often the most difficult to reach. The Canadian Prenatal Nutrition Program (CPNP) specifically targets at-risk pregnant women facing life circumstances such as poverty, teenage pregnancy, alcohol or substance use, family violence, social and geographical isolation and recent arrival in Canada.Footnote 81 A 2004 to 2009 summative evaluation of the program found that participants who entered the program earlier in their pregnancy were more likely to decrease or stop smoking and/or alcohol consumption, adopt positive health practices and experience healthier birth outcomes.Footnote 82 Programs such as these demonstrate the importance of supporting the health of pregnant women, and women at risk of becoming pregnant, to reduce the likelihood that they and their children will be vulnerable to poor health outcomes, including HIV and other STBBIs.
Attachment to community provides children with the opportunity to develop trust, self-esteem and emotional control and to build positive relationships with others.Footnote 83 A greater sense of community belonging has been linked to higher self-reported general and mental health.Footnote 84
Using a nationally representative sample of Canadian youth aged 15-19, the National Population Health Survey examined the effects of community involvement on risk behaviours.Footnote 85 Results suggested that regular contact with neighbours, membership in community organizations and participation in religious services were associated with lower likelihood of tobacco use, binge drinking, having multiple sexual partners and inconsistent condom use.Footnote 86 Theoretical models indicate that a sense of community through friendship groups, neighbourhoods, faith and religious institutions, schools, and clubs or sports teams can influence healthy decision making and other behaviours among youth. It does this by establishing norms of behaviour and health-supporting attitudes, and fostering a greater sense of self-worth and self-esteem.Footnote 87
Stress plays an important role in helping children develop the skills they need to cope with situations throughout life. While some levels of stress can be positive, intense and prolonged stress may result in short- and long-term negative health effects.Footnote 88 During childhood, young people are highly sensitive and susceptible to adverse childhood experiences, such as physical or sexual abuse, parental depression, and parental substance use. These experiences may result in short-term and chronic stressors that affect healthy childhood development as well as vulnerability to and resilience against HIV and other STBBIs.Footnote 89
A large body of research demonstrates the link between childhood stressors and health outcomes in later life. For children who are victims of sexual, physical, emotional or mental abuse, the consequences extend beyond the early years of life. The experience of childhood sexual abuse is often linked with lower self-esteem, early age of first sexual intercourse, difficulties discussing contraception and safer sex with partners, non-condom use, multiple sexual partners, teen pregnancy, and a history of sexually-transmitted infections.Footnote 90 Childhood stressors have also been linked to post-traumatic stress disorder, mental illness and physical diseases including eating disorders and alcohol and drug abuse.Footnote 91 Data from a sample of over 17,000 participants in the Adverse Childhood Experiences Study, a collaboration between the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente’s Health Appraisal Clinic in San Diego, suggest a strong relationship between experiences of traumatic or abusive childhood events before the age of 18 and a wide range of health and behavioural problems, such as depression, suicide attempts, alcoholism, smoking and substance abuse, risk for intimate partner violence, multiple sexual partners and sexually transmitted infections.Footnote 92
Childhood stressors are experienced more often by certain groups of youth in Canada. The Canadian Centre on Substance Abuse reported that groups of youth who experience increased vulnerability (i.e. street-involved, those in custody, sexual minority and gender-variant, Aboriginal, and those with mental health issues) are more likely to have undergone sexual and physical abuse, other forms of violence, and stigma and racism. Notably, rates of HIV and other STBBIs are higher among these groups than among the general youth population in Canada.
Data from the Enhanced Street Youth Surveillance Study supports research which suggests street-involved youth are disproportionately affected by childhood stressors. Among youth who participated in cycle 5 of E-SYS, 58.8% reported having been physically abused, 15.0% sexually abused, 65.3% emotionally abused, and 60.7% having been neglected.Footnote 93 For street-involved youth, the experience of childhood emotional, physical and/or sexual abuse is a major factor in their decision to leave the family home, Footnote 94 which can lead to a cycle of exposure to other risk factors for HIV and other STBBIs. Data from the At-Risk Youth Study (ARYS), a cohort study of street-involved youth in British Columbia, suggests that stressors such as childhood emotional and sexual abuse are linked to initiation into injection drug use and engagement in survival sex work among this population.Footnote 95 Data from a longitudinal sample of Aboriginal youth in British Columbia, aged 14-30, who were participating in the Cedar Project, suggests that Aboriginal youth are also disproportionately affected by childhood stressors. Among this sample, 43.6% of the 605 participants reported a history of childhood sexual abuse.Footnote 96 Among those in the sample reporting recent involvement in sex work, 76% had a history of sexual abuse.Footnote 97 Young Aboriginal women who had experienced sexual abuse were more likely to report injecting cocaine daily, being HIV positive, having been assaulted recently, and being involved in survival sex work in the six months prior to the interview.Footnote 98 Participants in the male cohort who had been sexually abused also reported higher rates of HIV, HCV and STIs, and involvement in sex work.Footnote 99
Sexually diverse youth are also at increased risk of experiencing childhood stressors. A Montreal-based qualitative study of 40 MSM with histories of childhood sexual abuse found that such abuse impacted adult sexual risk taking and led to increased vulnerability to HIV. In particular, study participants reported that experiences of sexual abuse led to negative views of homosexuality, low self-esteem, poor ability to negotiate sexual relations, drug or alcohol abuse, problems related to the body and suicidal ideation.
Early experiences affect a child’s development and are critical in lifelong health and wellbeing. While many youth find positive mechanisms to cope with and overcome abuse and other early life stressors, some do not. Public health interventions that foster resilience among youth through family and community connectedness may help mitigate the effects of childhood stressors.
Support from families, friends and communities is associated with better health. Such social support networks could be very important in helping people solve problems and deal(ing) with adversity, as well as in maintaining a sense of mastery and control over life circumstances.Footnote 100
Social environment is an important determinant of health and wellbeing.Footnote 101 This chapter has already outlined the protective effects of family and community connection against behaviours that increase the risk of HIV and other STBBIs. Peers and school environments also influence vulnerability to and resilience against HIV and other STBBIs.
Relationships with peers play a significant part in sexual behaviour among youth. A review of literature on the impact of peer groups on sexual behaviours concluded that youth were most likely to adopt their peers’ sexual norms and to engage in sexual practices that they believed their peers approve.Footnote 102 However, the types of behaviour engaged in may depend on dominant attitudes in the peer network. For example, some research suggests that peers promote inconsistent condom useFootnote 103 and earlier age of first sexual intercourse,Footnote 104 while other research finds that peers groups promote health-enhancing behaviours.Footnote 105
Still other studies indicate that peer groups may also have an indirect effect on sexual behaviour among youth. For example, a study conducted in northwestern Quebec followed 312 students from kindergarten through seventh grade to explore the association between peer rejection and factors such as age of first sexual intercourse, general delinquency and self-esteem.Footnote 106 The study found that peer rejection was indirectly associated with early age of first sexual intercourse through its association with lower self-esteem.Footnote 107
Youth who live on the street or are street-involved are embedded in peer networks that can be a source of both resiliency and vulnerability to HIV/AIDS and other STBBI. Previous sections of this chapter presented evidence that street youth engage in risk behaviours such as drug use, inconsistent condom use and sex work to a greater extent than youth not involved in the street. It is possible that peer networks, coupled with other social, cultural, and structural conditions, promote adoption of risk behaviours among street-involved youth. At the same time, research also suggests that peer networks of street-involved youth provide a source of support and may foster resiliency. Street-involved youth place great importance on the support they receive from friends.Footnote 108 For example, in a study conducted in Alberta among youth at risk of homelessness or who were homeless at the time of the study, participants reported feeling a “sense of camaraderie and community” with their peers.Footnote 109 They viewed street culture in general as a main component of their social life and put great emphasis on ‘hanging out’ with friends.Footnote 110 Studies report that many street-involved youth value their community highly and feel the need to band together as they are often a minority in shelters. Street friends were often described as family who provided support in dealing with the challenges of street life.Footnote 111 A qualitative study of 18 young women in the early stages of exiting street life reported that street community offered a sense of social competency, belonging and freedom to be themselves.Footnote 112 In other words, street relationships, families and friendships can be important resources for survival.Footnote 113
School connectedness has been shown to reduce the likelihood of having multiple sexual partners and using condoms inconsistently.Footnote 114 It has also been shown to reduce the likelihood that youth will engage in behaviours that put them at risk for HIV and other STBBIs.Footnote 115 Quality of relationships with teachers is one aspect of the school environment that may provide resilience against behaviours that lead to HIV and other STBBIs. Higher levels of perceived support from teachers have been linked to a lower likelihood of having ever engaged in sex and a higher likelihood of consistent condom use.Footnote 116
The school environment is a particularly important determinant of health for sexually diverse and gender-variant youth. Schools can be particularly hostile for lesbian, gay, bisexual, transgender, queer or questioning youth who are vulnerable to isolation and discrimination.Footnote 117 Stressors related to homophobic violence, discrimination and stigmatization can place sexually diverse and gender-variant youth at increased risk for physical, emotional and mental health problems.Footnote 118 Social connectedness and inclusive environments provide a safe space for sexually diverse youth to grow and foster healthy behaviours.Footnote 119
Positive relationships with teachers and school peers can help sexually diverse youth cope with the stresses associated with coming out and with formation of their sexual identity. Teachers can help create positive, inclusive and supportive school environments and play a key role in reducing incidents of bullying and violence against sexually diverse and gender-variant youth.Footnote 120 Moreover, peer-to-peer and support group networks, such as gay-straight alliances, can help decrease isolation, alienation and despair. Safe and affirming schools support the health, safety and education needs of all youth. Overall, strong social ties to family and community can help to develop and support youth’s resilience to HIV and other STBBI.
4.6.3 Support for youth living with HIVFootnote ii
Literature about youth living with HIV is scarce. Qualitative in-depth interviews with 34 HIV-positive youth (aged 12-24) living in Ontario underlined the importance of a strong supportive social network to overcome the specific challenges of living with HIV.Footnote 121 Many of the participants had rich support networks consisting of their parents, other family members and friends. These youth also highlighted the social support value of knowing other young people living with HIV.Footnote 122 Moreover, the participants had mostly positive comments about youth services and reported regular contact with one or more service providers.Footnote 123 Young people living with HIV identified the need for tailored, youth-friendly programs, such as summer camps or youth drop-ins, to help build their social support networks.Footnote 124
Disclosure in sexual relationships is a common issue faced by youth born with HIV.Footnote 125 Two Montreal-based qualitative studies of youth (aged 10-22) with perinatally acquired HIV reported the fear of being rejected, stigmatized, betrayed and misunderstood when disclosing their HIV status to peers.Footnote 126 Although they felt the need to disclose their status, they were also concerned about being rejected and identified several conditions required before they would feel comfortable disclosing their status to a peer or partner. These included having a trustworthy and meaningful relationship with the other person, feeling loved and being involved in a romantic relationship.Footnote 127 However, many of the first experiences of disclosure reported were with a significant peer, not a romantic partner. Disclosure to an intimate partner came later in their lives.Footnote 128 Participants explained that they were fully aware of the need to prevent HIV transmission to their partner and that they felt responsible for doing so.Footnote 129 Similar results were found in a qualitative study of 10 children (aged 9-16) who were perinatally infected with HIV (interviews included 11 family members and 11 service providers in British Columbia).Footnote 130 Some youth were concerned about being rejected or stigmatized after they disclosed their status to a romantic partner. Findings suggest the importance of support for youth living with HIV as they transition into adulthood.Footnote 131
Mental health is the “capacity of each and all of us to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges that we face. It is a positive sense of emotional and spiritual wellbeing that respects the importance of culture, equity, social justice, interconnections and personal dignity.”Footnote 132
Mental health is an important aspect of overall health and wellbeing. Levels of self-esteem, self-efficacy and general life satisfaction are predictors of behaviours among youth that increase risk of HIV and other STBBIs.
Low self-esteem has been shown to influence sexual risk behaviour, including inconsistent condom useFootnote 133 as well as injection drug use. For example, data from a 2008 cohort study of street-involved youth aged 14-24 in New York City and Toronto suggests that youth who reported higher self-esteem also reported better health and less substance use than those with low self-esteem.Footnote 134 Lower levels of self-esteem were shaped by social exclusion, marginalization and resource deprivation.Footnote 135 The study results suggest that self-esteem plays an important protective role against substance use and abuse.Footnote 136 Similarly, among a sample of street-involved youth across Canada, participants with lower self-esteem were at higher risk of becoming street-involved and were more vulnerable to drug use, sex work and other behaviours that increased their susceptibility to HIV and other STBBIs.Footnote 137 Studies have also shown that self-efficacy (i.e. the measure of one’s own ability to complete tasks and reach goals) to be predictive of risk factors for HIV and other STBBIs, including inconsistent condom use.Footnote 138 For example, a study of Aboriginal youth in Regina, Saskatchewan, revealed that youth with higher self-efficacy were more likely to use condoms.Footnote 139
Youth may experience challenges and life events that increase stress and lead to depression, anxiety, post-traumatic stress disorder and suicide. In turn, mental illness increases vulnerability to HIV and other STBBIs.Footnote 140 The link between mental illness and risk behaviours is especially pronounced among youth who are disproportionately affected by childhood stressors, stigma and discrimination such as sexually diverse and gender-variant youth, immigrants and newcomers to Canada, and ethno-cultural minorities. For example, data collected from youth over a three-year period revealed that risks of suicidal behaviour or mental health illness were most strongly associated with gay, lesbian or bisexual sexual identities.Footnote 141 Immigrants and newcomers to Canada are also at risk for mental illness due to the physical, emotional, social and financial stress of moving to a new country. Factors such as learning a new language, underemployment, low socio-economic status, separation from family and cultural background can also lead to stress, depression or anxiety.Footnote 142
Mental illness is also an important health determinant for youth managing chronic STBBIs such as HIV, hepatitis B or HCV. People living with these chronic conditions were twice as likely to experience depression and anxiety compared to the general population.Footnote 143 At the same time, depression and other mental illnesses can interfere with the ability of people living with chronic diseases to take their medications as prescribed, exercise, eat properly and communicate with family, friends and health service providers.Footnote 144 In addition, the stigma associated with mental illness may discourage youth from seeking care and support and result in feelings of shame or negative coping mechanisms.Footnote 145
Much like vulnerability to HIV and STBBIs, mental health and mental illness are influenced by multiple factors in a broader social context. To reduce the vulnerability of youth populations to HIV and other STBBIs, it is important to address these factors. The literature suggests that supporting positive mental health among young people (e.g. self-esteem, self-efficacy, sense of worth, satisfaction with life) has benefits not only for avoiding mental illness, but for protecting against HIV and STBBIs as well.
For some youth, it can be difficult to find a safe, stable place to live. There are few safe and affordable housing opportunities for young people with minimal incomes.Footnote 146 Similarly, street-involved youth transitioning out of the street face challenges in finding living arrangements that are affordable, safe and in good condition.Footnote 147 Furthermore, youth may face discrimination from property owners, and may not have access to references from previous rental properties or to advance rental payments such as certified cheques.Footnote 148 Studies of street-involved youth in Canada have reported multiple barriers to finding affordable, subsidized and adequate housing.Footnote 149 In one study of this population, participants underscored the poor conditions of affordable apartments such as lack of cleanliness, disrepair and their location in underserved neighbourhoodsFootnote 150 and indicated that they would rather return to the street or to shelters.Footnote 151
Besides unstable housing, many street-involved youth experience hidden homelessness, meaning that they have no permanent dwelling but make use of a range of transitional living arrangements. Among street-involved youth from the Enhanced Street Youth Surveillance study: 38.8% indicated that they would be sleeping in a shelter or hostel that night; 19.6% reported that they had their own home to go to; 14.2% would go to a parent’s home; 11.6% would stay with friends or a significant other; and nearly 10% would sleep on the street.Footnote 152 Other vulnerable groups of youth, including youth who use injection drugs, also experienced unstable housing. Among youth who participated in I-Track (2005-2008), over half of both male and female youth had lived in a mix of stable and unstable housing in the previous six months (52.1% of male and 56.3% of female youth).Footnote 153
Research also shows that the lack of affordable housing in middle-class neighbourhoods pushes street-involved youth away from safer neighbourhoods to disadvantaged areas.Footnote 154 In disadvantaged neighbourhoods youth are more likely to become involved with peers who are engaged in drug injection or other risk behaviours, and may have more limited access to health services or health information. Living or being street-involved in a neighbourhood where there is an active drug scene can increase vulnerability to drug consumption, injection, and survival sex, which increases the risk of exposure to HIV.Footnote 155
The street environment can also affect the ability of street-involved youth to inject drugs safely. A Montreal study of 39 street-involved youth with HCV who injected drugs examined the impact of street-living on safer injection practices.Footnote 156 Youth who use injection drugs and lack stable, safe housing may be forced to inject on the street in precarious conditions to avoid being caught by law enforcement.Footnote 157 In these circumstances, using clean injection equipment is a challenge.Footnote 158 Among a cohort of street-involved youth in Vancouver who reported injection drug use in the past six months, similar findings emerged.Footnote 159 About three-quarters (76.5%) reported injecting in a public setting at least once and 27.2% reported injecting in public all the time.Footnote 160 Youth in the study reported that they most often injected on the streets (74.7%), public washrooms (40.7%), parking lots (37.7%) and parks (36.4%).Footnote 161 Because clean equipment is not often available in those situations, public injection can increase the risk of HIV, HCV and other injection-related infections.Footnote 162 Furthermore, living on the street or in unstable conditions can be an obstacle to accessing health care and taking medications as prescribed.Footnote 163 One such obstacle would be a lack of a physical place to store medication.Footnote 164
Access to stable, adequate and supportive living conditions is also a concern for youth living in long-term care facilities. Results from the Youth, Disability, HIV Vulnerability & Prevention Community-Based Participatory Research Project in the Greater Toronto Area revealed that physical restrictions in their care facility limited the ability to engage in sexual activity. As a result, youth had developed strategies to have intercourse in unsafe and uncomfortable spaces, such as bathhouses and in public (e.g. the street, parks). Research suggests that condom use in these spaces is less likely.Footnote 165
Data from a Canadian cohort study of 4,000 sexually active youth between 15 and 19 years old also found that household size was associated with non-condom use at last intercourse.Footnote 166 While living in a household with a large number of persons was a risk factor for non-condom use, living in a larger dwelling with more bedrooms was a protective factor. Study authors suggested that decreased privacy may promote sexual activity in other locations where parental supervision and access to condoms is limited.Footnote 167 This study underlines the important role that the physical environment plays in the ability of youth to mitigate sexual risk and engage in protected intercourse.Footnote 168
There is limited research on the impact of incarceration on youths’ vulnerability to HIV and other STBBIs. Rates of drug use (both injection and non-injection) among youth in prison suggest there is potential for infection while incarcerated. A study of 417 youth (aged 14-19) in custody in British Columbia reported considerable non-injection drug use among participants.Footnote 169 Nearly all of the youth (98%) reported having used marijuana, over 80% had used mushrooms or ecstasy, and 72% had used cocaine. While reported injection drug use was less than 8%, the study noted that this population of incarcerated youth might be at risk of transitioning to injection drug use in the future.Footnote 170
The challenges and obstacles faced by youth who have been released from prison may also create conditions that make them more vulnerable to HIV and other STBBIs. For example, they may have difficulty finding employment, have limited income to support basic needs, and face stigma and discrimination as a result of their incarceration. Having a history of imprisonment has been linked to unstable housing and homelessness.Footnote 171 For example, 58.8% of street-involved youth from the Enhanced Street Youth Surveillance study reported ever being in a detention facility, youth detention centre, prison or jail, overnight or longer.Footnote 172 Among street-involved youth from the ARYS cohort, 80.5% reported ever having been incarcerated.Footnote 173 Among I-Track youth, 16.3% reported incarceration in the past six months.Footnote 174
Challenges to meeting basic needs upon release can lead to negative coping mechanisms such as injection drug use, unprotected sex and sex work. Findings from a study of street-youth in Vancouver suggested a strong link between incarceration and methamphetamine use.Footnote 175 At the same time, a history of incarceration may also have protective effects and promote help-seeking behaviours upon release. For example, among street-involved youth, previous incarceration was found to be associated with a higher participation rate in some form of addiction treatment.Footnote 176
Personal health practices and coping skills refer to those actions by which individuals can prevent diseases and promote self-care, cope with challenges, and develop self-reliance, solve problems and make choices that enhance health. Definitions of lifestyle include not only individual choices, but also the influence of social, economic, and environmental factors on the decisions people make about their health. There is a growing recognition that personal life “choices” are greatly influenced by the socio-economic environments in which people live, learn, work and play.Footnote 177
Sexual health education is an essential tool in the prevention of HIV and other STBBIs because it provides individuals with information, motivation and behavioural skills to support sexual health and avoid these negative health outcomes. The Canadian Guidelines for Sexual Health Education states that:
Sexual health education should be available to all Canadians as an important element of health promotion programs and services. All Canadians have a right to sexual health education that is relevant to their needs. Diverse populations such as (lesbian, gay, bisexual, transgender, transsexual, two-spirit, queer and questioning individuals), seniors, individuals with disabilities (physical/developmental) and socio-economically disadvantaged individuals such as street-involved youth often lack access to information and education that meets their specific needs.Footnote 178
There are many formal and informal vehicles for delivering sexual health education. Schools are key for this delivery, but capacity varies across Canada depending on the provincial or territorial curriculum, whether the school is public, private or has a faith-based curriculum, and on teacher training. The vast majority (92%) of Canadian-born youth participants in the Toronto Teen Survey said that they had received some form of sexual health education.Footnote 179 However, newcomer youth (i.e. in Canada for three years or less) had significantly lower rates of sexual health education by 18 years old.Footnote 180 Seventy-eight percent reported some learning about HIV; yet, HIV/AIDS was also one of the top three priorities in sexual health that youth want to learn more about.Footnote 181 Youth in this study also reported that they wanted information about healthy relationships, pleasure, pregnancy, sexual orientation, and HIV/AIDS and STBBI prevention. They also said that they would prefer to get this information from professionals, such as physicians, nurses and sexual health educators.Footnote 182
Knowledge about HIV and other STBBIs has historically been quite high among youth in Canada.Footnote 183 For example, results from the M-Track study showed that gay, bisexual men, two-spirit men, and other MSM aged 15-24 had relatively high levels of knowledge about HIV.Footnote 184 Most participants knew that having sex with one monogamous, uninfected partner can reduce the risk of HIV transmission (~84%), and that people can protect themselves from HIV by using a condom correctly every time they have anal sex (~80%).Footnote 185 Almost all youth correctly identified that a healthy-looking person can have HIV (~93%), while approximately 75% of youth knew that they would not necessarily have symptoms if they contracted an STI.Footnote 186 Nevertheless, knowledge related to sexual health, HIV and other STBBIs may be declining. Data from The Canadian Youth, Sexual Health and HIV/AIDS Study, found that knowledge about sexual health and HIV has fallen among youth aged 12-16 since 1989; for example, the study reported that a large proportion of youth in this age group believed that AIDS could be cured.Footnote 187 Results from the Canadian Association for Adolescent Health online study of more than 1,000 youth aged 14-17 also pointed to lack of knowledge about STBBIs. Barriers to accessing accurate sexual health information may be driving these low levels of knowledge.Footnote 188 For example, 69% of youth reported in the online study that they could not find sexual health information and 62% reported that they had experienced other obstacles in getting information.Footnote 189
Effective and broad-based sexual health education that addresses the diverse needs of all individuals is critical in helping youth avoid HIV and other STBBIs. It ensures that youth have access to non-judgmental information to make informed decisions about their own health. It can also increase the ability of youth to build resilience to the social, economic, and cultural risk factors that threaten their sexual health.
Youth have different perceptions of their personal risk of contracting HIV. While perceptions of illness can be shaped by cultural values, they can also be influenced by factors such as income level, knowledge of the disease and HIV-related discrimination and stigma. For some, HIV is a disease experienced by other people, not them. On the other hand, some youth hold fatalistic views about their health and future.Footnote 190 For example, in a study of Aboriginal youth, participants reported feelings of hopelessness and a “general feeling of despair about the future,”Footnote 191 which included the risk of HIV infection. Other studies have found that some Aboriginal youth perceived HIV as a community issueFootnote 192 and commonly experienced being in contact with someone affected by or living with HIV.Footnote 193 Awareness of and ongoing discussions about HIV among Aboriginal youth in their communities may be a positive resiliency factor.
Young men and women vulnerable to HIV infection have different responses to testing for infection. For example, some want to know their status while others do not and avoid testing. Reasons for deciding to undergo testing are diverse. The fear of a positive HIV test result is commonly reported by youth as a motive for not testing.Footnote 194 In addition, the stigma associated with a positive HIV test may deter youth from testing.
Perceptions of personal risk to HIV infection can influence subsequent HIV testing practices. Among participants in the M-Track survey who did not self-report as HIV positive or who had never been tested for HIV, the most common reason for not being tested was the perception that they were at low risk (reported by approximately 48% of youth).Footnote 195 Approximately 28% of youth also reported they were afraid to get tested and a roughly equal proportion reported they already knew their HIV status (27%).Footnote 196 The Ontario component of the M-Track study, the Lambda Study (N=2,438), reported similar findings on HIV testing among gay and bisexual youth.Footnote 197 The youngest participants (aged 16-19) had the lowest testing rate, with 46.2% never having been tested.Footnote 198 About one-quarter (25.9%) of those aged 20 to 24 had never been tested, which represents an increase in testing rates over time.Footnote 199 The British Columbia ManCount (N=1,139) survey, also linked to the M-Track study, found that 23% of gay, bisexual men, two-spirit and other MSM participants under the age of 30 had never been tested for HIV.Footnote 200
In the I-Track survey, a high proportion of participants reported having been tested for HIV (81.0%) and HCV (79.3%).Footnote 201 Among those who had never been tested for HIV, the most commonly reported reasons included: “I have never thought about it” (22.6%), “I am at low risk for HIV infection” (14.5%), “I could not deal with knowing I was infected” (12.9%), “I am worried about being discriminated against” (9.7%), and “It could affect my relationships” (9.7%).Footnote 202 Among street-involved participants in the Enhanced Street Youth Surveillance study, over 70% perceived their risk of getting HIV, STIs or viral hepatitis as being none or low.Footnote 203 However, large proportions reported previous testing for HIV (81.3%), HCV (76.0), chlamydia (75.1%) and gonorrhea (73.6%).Footnote 204
Health services, particularly those designed to maintain and promote health, to prevent disease, and to restore health and function contribute to population health. The health services continuum of care includes treatment and secondary prevention.Footnote 205
Some youth experience difficulty accessing health services because of their geographical location or physical environment. Youth in rural and isolated communities experience more difficulties accessing a family physician and STBBI/HIV testing services than youth in urban centres which can contribute to health inequalities among rural and urban youth.Footnote 206 Studies conducted with youth and health care workers in remote communities in British Columbia identified several structural barriers to health services for this population.Footnote 207 These included the geographic inaccessibility of health clinics, limited operating hours (e.g. during school or work hours) and lack of public transportation. These barriers are further compounded among youth who must rely on parents or guardians to access clinics.
Physical location can also pose an obstacle. For example, street-involved youth may lack an identification card, may be unable to travel for services or may not be able to frequent them during standard hours of operation. A Calgary study found that street-involved youth were more inclined to access emergency health services such as hospital emergency rooms and walk-in clinics than to use preventive services.Footnote 208 Street-involved youth who had never lived on the street were more likely to access preventive services such as family physicians while youth currently living on the street were more likely to use mobile clinics during non-standard business hours.Footnote 209
Concerns about confidentiality are a consistent theme in the literature on barriers to health services access among youth. Young people worry that their sexual practices and sexual health outcomes will be disclosed to parents, and that they will be judged by health professionals and their friends and communities.Footnote 210
As a result, youth may worry that their test results for HIV and other STBBIs will be disclosed to family, friends and the community,Footnote 211 motivating them to travel to another neighbourhood or community to protect their confidentiality. However, travelling to other locations is not always possible, particularly for youth living in rural or remote areas. In a study of youth living in British Columbia, concerns about confidentiality and anonymity were higher among those living in northern rural communities than among those living in urban settings.Footnote 212
The stigma associated with HIV and STBBIs compounds confidentiality concerns for youth living with or at risk for infection. Research suggests youth may increasingly be relying on alternative sources for health services and information, including Internet-based resources. Health service providers have begun to explore the potential for online health services in an effort to address confidentiality issues. For example, Ottawa Public Health, a local health authority in Ontario, recently explored using the Internet to provide youth with laboratory requisition forms for HIV and other STBBIs without a physician visit. The number of downloads of the requisition form and the increase of laboratory tests conducted during the campaign attested to its popularity among area youth.Footnote 213 However, such services may not be established enough to address fully the concerns of youth about confidentiality. Qualitative research with HIV-positive Ontario youth aged 12-24 explored the Internet as a channel for health promotion and information.Footnote 214 Although participants reported high rates of Internet access, use and interest, few used it to seek health information or services.Footnote 215 Reasons identified included concerns about confidentiality when viewing HIV websites.Footnote 216 Although participants did not use the Internet for health information, they were enthusiastic about future opportunities to have HIV-positive youth create a website for health promotion and social networking.Footnote 217
Stigma and discrimination are further factors that affect youth access to health services and information. Results from the Toronto Teen Survey showed that many sexually diverse and gender-variant youth had had negative experiences accessing sexual health services, mainly because they felt that service providers stigmatized them and lacked awareness of their particular needs.Footnote 218 For example, young gay men in the study reported negative experiences with the health care system, significant gaps in sexual health services adapted for men, lack of comprehensive sexual health education in schools, fear and stigma associated with STBBIs and HIV/AIDS, and the impact of homophobia and gender norms.Footnote 219
Discrimination based on race and ethnicity can also discourage youth from seeking out health services. For example, results from the Toronto Teen Survey showed that Black youth experienced racism when reaching out for sexual health services.Footnote 220 This population also reported the lowest rates (34%) of sexual health clinic attendance.Footnote 221 Youth of Aboriginal or Asian backgrounds also reported being less likely to visit health services for sexual health information or testing, while White youth reported being most likely to do so.Footnote 222 Among Aboriginal participants in a community-based cohort, 12.3% of youth indicated that they experienced fear, discrimination and avoidance during their testing experience.Footnote 223
Just as the identity of individuals is made up of many elements (e.g. gender, age, sexual identity, race, ethnicity, ability), discrimination can be experienced on multiple levels. These multiple layers of discrimination based on race, ethnicity, religion, age, socio-economic status, ability, gender or sexual identity can compound obstacles to accessing health services and information about HIV and other STBBIs.Footnote 224 The Teens Resisting Urban Trans/Homophobia (TRUTH) project examined the impact that various forms of social exclusion, such as homophobia and heterosexism, have on newcomer lesbian, gay, bisexual, transgender and queer youth in Toronto.Footnote 225 Preliminary results showed that these youth experienced multiple layers of discrimination in the forms of homophobia, transphobia and racism, which, in turn, created barriers to accessing health and information services.Footnote 226
Stigma and discrimination, including homophobia and racism, can result in youth having negative experiences when accessing services and care.Footnote 227 Reduced access to services can further contribute to their vulnerability to STBBI and HIV infection.Footnote 228 Many service providers recognize the need for sexual health counselling and services that address the specific needs of youth, including structural discrimination, and support diversity through culturally inclusive programs.
The inequalities in rates of HIV and other STBBIs are impacted in complex ways by broader social, cultural, economic and structural determinants of health that influence the health status and wellbeing of youth throughout their lives. This chapter has provided an overview of how these determinants of health create inequities among youth, making some groups of youth more vulnerable to HIV and other STBBIs. It is important that programs and interventions aimed at the prevention and control of these illnesses identify and address broader determinants of vulnerability among youth. Chapters 5 and 6 provide an overview of the current response to HIV and other STBBI among youth in Canada, including research efforts to expand our knowledge of determinants of vulnerability and programmatic responses to risk of infection.
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