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Decolonizing Gender, Sexuality & Mental Health

How has trauma inflicted upon my people through Residential Schools and the Sixties Scoop impacted our views around gender and sexuality? How has religion changed how we view relationships? How has language extraction impacted the ways we talk about gender and sex? These are questions I ask myself when I think about why Indigenous people have disproportionately high rates of sexually transmitted infections, including HIV/AIDS. Indigenous communities can also be very transphobic and homophobic, due to the impacts of colonialism and the pervasiveness of homophobia and transphobia elsewhere in society.

The biggest underlying issue that is affecting us is stigma and how that continues to impact the mental health of Indigenous people across Canada.

I am a Saulteaux-Cree First Nations person who identifies as Two Spirit, Queer and Trans. I grew up in an urbanized community, and spent a big part of my life within the Friendship Centre movement surrounded by other Indigenous people. I feel a great deal of privilege being trans and queer while growing up in an urban community because I have had a significant amount of access to resources and space to explore my identity compared to my Two Spirit & Indigenous LGBTQ+ friends in the North.

I have access to knowledge and information that has allowed me to expand my knowledge on sexuality and gender. I have had access to spaces that are affirming for my identity and I know where to meet other LGBTQ+ people. I have choices in which communities I choose to spend my time with. I know how to access Hormonal Transition Therapy and know that my transitioning costs can be covered under Indian Status. I have been able to learn and advocate more about sexuality and gender without the fear of being outed. Because of my access to my resources, I’m not afraid to be myself. Because of feeling comfortable with my identity, I am comfortable with my body and exploring and learning how to talk about sexual health. It’s also been easier for me to destigmatize my own views around sexuality and gender and to even pursue a career in sexual health. I have learned how to navigate the health system with ease because of this. I know where to go to for a routine sexual health check-up, and I wouldn’t be afraid if I was diagnosed with an STI. I know what contraception methods are available to me under Indian status and how to get Plan B for cheap. I know how to access counselling services for sexual assault, and also where and how to access an abortion if I ever need one. I have had access to a basic understanding of sexual health because of the public school curriculums I have been a part of. I think these are things that many of us take for granted.

For the past year and a half, I’ve been working alongside many different Indigenous communities to broaden their understanding of sexual health, gender and sexuality. I’ve also worked with many Indigenous youth leaders who do the same work. Storytelling and sharing circles, where participants sit in a circle to share stories without interruption, are ways that Indigenous people share knowledge with each other and have become foundational to my work. It is important for me to put time into listening to the various experiences that Indigenous people go through when it comes to sexual health, sexuality and gender. It was through this process I learned more concretely about how the violent history of colonialism has impacted many Indigenous people across Canada, and how many Indigenous people still hold stigma around sexual health, sexuality and gender. I have met many Indigenous people who have shared their stories with me and they have allowed me to share pieces of them with others for the purpose of starting these conversations.

The stories I have heard many times in multiple different ways from various people have had the same theme: ​fear​.​ ​From fear around coming out to their families and communities due to homophobia and transphobia, to fear of being gossiped about in a small community after being spotted by a community member at the sexual health clinic. Another person shared how an HIV/AIDs service provider breached confidentiality of a client’s HIV status, and how it impacted their life. The most dangerous part of these stories is stigma and how it silences people and results in negative mental health impacts for those experiencing these incidents.

Indigenous people who identify as Two Spirit and LGBTQ+, as well as Indigenous people post-diagnosis, are more likely to experience suicidal thoughts at some point in their lives. Conversations around sexual health, sexuality and gender can be difficult for many Indigenous people because these words have potential to hold a lot of power, and also possess a history of trauma. This is because of the legacies that systems like Residential School and the Sixties Scoop have created.

Indian Residential Schools were government-sponsored Christian-based schools to assimilate Indigenous children into European culture. Many children were forcibly taken from their families to attend and were punished for speaking their native language or practicing their culture. The educational curriculum was inadequate, and many Indigenous children were sexually abused throughout Residential School.

The Sixties Scoop was a government-run practice of forcibly taking Indigenous children throughout the sixties and placing them into foster homes and adoption. Being separated from your community, culture and language is traumatizing for Indigenous children, and we have seen the effects that these systems have created for Indigenous people currently. When Indigenous children were separated from their culture and language, they were also separated from teachings around the fluidity of gender and their roles and because many Indigenous people now strongly believe within the Christian faith, it has also stigmatized our views around sexuality. It was through these systems that talking about sexual health, sexuality and gender has become shameful to talk about, as well as traumatic.

How then do we approach the stigma of sexual health, sexuality and gender? I have learned through my work that storytelling and sharing circles are a very powerful way for Indigenous people to share their stories of misconception, pain, trauma and stigma while also reconnecting to culture. Sharing circles have potential to be healing and can take a trauma-informed approach. They are a crucial way to help Indigenous people learn and unpack the ways that we view gender and sexuality, and to help destigmatize conversations about healthy sexuality, sexual health and harm reduction. It’s through these conversations that we will begin to turn shame into resilience.

Sexual and mental health: Two sides of the same coin

By Laurie Edmiston

The attendees at the 2016 Canadian Mental Health Association (CMHA) conference, Mental Health for All, were a new audience for CATIE. This was the first time CATIE was invited to attend as an exhibitor to a mental health conference. Most people who stopped by our booth had never heard about us, but after chatting to one mental health worker from the Niagara region, she said: “I wish I had known about you guys six months ago.”

This woman had shared a story about an HIV-positive client who was having sex without a condom. I asked, “Have you heard about treatment as prevention? Undetectable viral loads or pre-exposure prophalysis (PreP)?” She was somewhat familiar with these forms of HIV prevention, but only after researching these topics on her own.

Another person stopped by, this time from correctional services. He picked up some client brochures on HIV basics and safer injecting. He didn’t realize that CATIE offered so many printed resources on harm reduction and that some were created with prisons in mind.

Both of these service providers didn’t know that CATIE provides all frontline workers with information on HIV and hepatitis C, whether they work in the field or not. We could have saved them a lot of time by giving them the information their clients need.

These are just two encounters from one meeting that took place last year in Toronto. But these stories highlight the importance of sexual health organizations working with mental health organizations to increase knowledge around health and harm reduction.

Physical health + mental health = overall health

Physical health and mental health are two important aspects of our overall health. These two branches interconnect and contribute to a person’s overall well-being. HIV and mental health also intersect and should not exist in silos. In order to improve the lives of people living with HIV or at risk of HIV, we need to partner with people working in mental health so that both sectors can share expertise and build skills and capacity.

This is what we know.

Mental health conditions are risk factors for HIV transmission. There is a correlation between poor mental health and engaging in risky behaviours. Some people use drugs, sex or alcohol as a coping mechanism for stress, anxiety or low self-esteem. Using substances or sex as ways of coping can lead to dependency. When a person is dependent on something, their judgement can be impaired when having sex or injecting drugs, putting them at risk of HIV or hepatitis C.

Mental health conditions can affect the other health outcomes of people living with HIV. Sometimes an HIV diagnosis can provoke mental health conditions due to the fear or the isolation of coping with a new illness. Other people living with HIV may feel lonely or depressed throughout periods of their life because of the stigma and discrimination they might encounter. Studies show that people living with HIV are more likely to be diagnosed with one of several mental health conditions. We also know that HIV, the disease itself, can impact the brain due to its effects on the central nervous system. All of the above affect quality of life.

People living with HIV who are on treatment can live long lives and they can be happy and healthy too, but only if they are connected to the proper care and services. We must help them receive this care and make sure they do not fall through the cracks. Research also shows that poor mental health also makes it harder for some HIV-positive people to stay adherent to treatment, find HIV care and stay in care.

What can we do as service providers?

The HIV and mental health sectors should come together and collaborate on a number of initiatives that would improve the health of people living with HIV or at risk of HIV. Here’s just a short list:

  1. Screen HIV-positive people for mental health conditions and offer mental health referrals to people in need. Integrating mental health services into HIV care can increase access to support and decrease the stigma associated with HIV and mental health.
  2. Develop skills-building workshops that promote positive mental health. CATIE, for example, offers a workshop for frontline workers called “HIV and Emotional Health”. This workshop stresses the importance of building healthy relationships, developing positive self-esteem, and adopting sex-positive and harm reduction approaches. Teaching clients these skills leads to resiliency and improved overall health.
  3. Use peer-based approaches to provide information on HIV and to build positive mental health. CATIE and a national group of healthcare providers developed the resource Practice Guidelines for Peer Health Navigation for People Living with HIV, after it became evident that peers serve as role models, helping HIV-positive people develop self-esteem and a positive outlook. It has also been shown that peer health navigation allows people living with HIV to better navigate healthcare systems, putting them in touch with the services they need to thrive.
  4. Provide training for staff to learn more about HIV, hepatitis C, mental health and how manage these conditions. This could be as simple as providing resources, tools and courses designed for frontline staff working with people living with HIV. CATIE has range of materials available for order, free of charge. We also offer online courses through eduCATIE.ca.

It’s our job as community health program planners, social workers, corrections officers, public health nurses and doctors, to work together to make sure that people at risk of HIV or living with HIV get the treatment and support they need, whether that be antiretrovirals, cognitive behavioural therapy, opioid substitution therapy or a peer-led discussion group. Let’s work together to make that happen!

For more information on HIV and emotional wellness, contact CATIE: call our toll-free line at 1-800-263-1638, browse the website at www.catie.ca or email us at [email protected]. CATIE offers information in English and French.

Recommended resources:

Hot pillow talk: new and fabulous sex news

Ready for some pillow talk?, the theme of this year’s Sexual and Reproductive Health Awareness Week, couldn’t have arrived at a more opportune time when it comes to HIV and safe sex.

You bet we want to talk! And sexual partners who are serodiscordant – one HIV-positive, the other HIV-negative – have every reason to interject a little celebration with that pillow chat. That’s because the science of HIV transmission is now declaring that with or without a condom, if someone with HIV is on treatment, engaged in care, and has an undetectable viral load, they do not pass HIV to their sex partners!

The “fabulousness” of this news cannot be overstated. We are now at an historical moment, celebrating the most significant development in the HIV world since the advent of effective combination therapy 20 years ago. A person taking antiretroviral treatment who has an ongoing undetectable viral load can declare “I’m not infectious!”

How did we get here?

The research on treatment as prevention has been slowly accumulating for many years. In July 2016, two large studies (PARTNER and HPTN 052) published final results showing that not a single HIV transmission occurred between serodiscordant sexual partners when the person living with HIV was on treatment, had an undetectable viral load and was engaged in care. With these results, “we now have 10,000 person years (of follow-up) with zero transmissions from people who are suppressed,” acknowledged Dr. Myron Cohen (principal investigator of HPTN 052).

Convinced by this body of evidence, CATIE recently endorsed the Consensus Statement of the Prevention Access Campaign, celebrating the fact that “undetectable equals untransmittable”. This revolutionary statement, pushed forward by a dedicated group of people living with HIV, has prompted CATIE to adjust our messaging on this topic. It’s important for all frontline service providers working in HIV to understand the evolution in language so they can convey accurately these new revelations concerning HIV transmission.

In the spirit of ‘starting a conversation’ for the best possible care during Sexual and Reproductive Health Awareness Week, let’s unpack this message of “undetectable equals untransmittable,” or “U=U” in its familiar short-hand.

Can we really say that the risk does not exist?

Yes! We can and we must. While research has reported “zero transmissions,” the idea of “zero risk” is uncomfortable to many because it is impossible for research to ever conclude that a risk is zero. Statistically, we cannot rule out that a very small risk may exist, no matter what the data show us. However, focusing on the possibility of a very rare event can also be misleading. In this case, a large body of evidence is telling us that people with undetectable viral loads do not transmit HIV, and in research jargon we say that the risk is negligible (meaning insignificant or not worth considering).
But what does negligible mean to the average person? It certainly does not convey the excitement that people living with HIV are feeling about this amazing news. Negligible may be an accurate word but it is not a suitable message. If the risk is negligible then we must be willing to accept that it is not important.

HIV- negative and HIV-positive people need to hear this message

HIV-negative people need to know that an HIV-positive person who is on treatment and engaged in care, and maintains an undetectable viral load, is a very safe sexual partner because their HIV is diagnosed and the virus is controlled. This is counter to what prevention messaging said for years, where the HIV-negative partners of people living with HIV were considered to be at highest risk. We now know that the majority of HIV transmissions come from people who are living with HIV and don’t know it (the undiagnosed). This paradigm shift requires us to take up new messages that clearly communicate where the risk actually lies – not with HIV-diagnosed people who have and maintain undetectable viral loads.

It is also important for people living with HIV to hear this message so they can be confident in their ability to have healthy sex lives. People living with HIV continue to face stigma that affects their lives in many ways. By continuing to focus on a risk that is negligible, we do nothing to combat HIV-related stigma. The U=U message can reduce HIV stigma by removing the fear that people living with HIV are “infectious” and “risky” sex partners.
We need to ensure that our HIV prevention messages help, rather than harm, the people to whom we are speaking. With a little creativity and boldness, these messages can be meaningful to the communities we serve while remaining strongly grounded in the science.

More information can be found at the CATIE web site section entitled Undetectable Viral Load and HIV sexual transmission. You can also see prevention resources on catie.ca and add your organization’s name to the Consensus Statement of the Prevention Access Campaign. Let’s get the word out! Get tested, get on treatment, become undetectable and have lots of great sex!
By Camille Arkell, CATIE’s Knowledge Specialist, Biomedical Science of Prevention, and Laurie Edmiston, CATIE’s Executive Director. 

More prevention tools in the box

New science is giving us more options to prevent HIV.

In acknowledgement of Sexual and Reproductive Health Awareness Week, it is fitting to talk about the great advances that have been made in preventing the sexual transmission of HIV.

For about 30 years, sex educators have trained most of us to know that condoms are the most effective form of protection against HIV and other sexually transmitted infections.

But today, we have many more tools in the HIV prevention toolbox. Medication that can reduce the risk of an HIV-negative person becoming infected when taken before an exposure (PrEP) or after an exposure (PEP) to HIV. Treatment that can dramatically reduce the risk of an HIV-positive person passing on the virus. Strategies that can further reduce the risk of infection when combined with another prevention option.

More choices are always welcome. But with more choices, there are more factors to consider.

PrEP, or pre-exposure prophylaxis, is the ongoing use of anti-HIV medications by an HIV-negative person to reduce their risk of HIV infection. Several studies show that the use of a daily pill called Truvada as PrEP can reduce the risk of HIV transmission by over 90% if used consistently and correctly. But if the pill isn’t taken regularly, it’s less effective.

PEP, or post-exposure prophylaxis, is the use of anti-HIV medications by an HIV-negative person to reduce the risk of HIV infection from a single exposure to HIV. It needs to be started as soon as possible (but generally within 72 hours) after an exposure and involves taking medications every day for a full month. PEP is not meant to be used as a regular method of preventing HIV infection, but only in the case of an emergency.

Treatment as prevention is a secondary benefit of antiretroviral treatment (ART), the medication used by people living with HIV. In addition to improving the health of an HIV-positive person, ART can reduce the amount of HIV (viral load) in the bodily fluids to undetectable levels – lowering the risk of HIV transmission through anal and vaginal sex. Several studies show that ART can reduce the risk of HIV transmission by more than 90% if used consistently and correctly.

Keep in mind that these three prevention strategies only reduce the risk for HIV; they have no effect on the risk for other sexually transmitted infections (STIs). And since the presence of STIs can increase the risk of getting or passing on HIV, regular STI testing and (if needed) treatment is important to make sure these prevention strategies are as effective as possible.

To reduce the risk of other STIs, condoms – both external (“male”) and internal (“female”) – are still the most effective prevention strategy. That doesn’t mean they’re perfect, against STIs or HIV. Research suggests many people struggle to use condoms effectively, making its practical effectiveness against HIV infection, even when used consistently, anywhere from 70 to 80%. Even if a condom is used perfectly, some STIs can still be transmitted because a condom doesn’t cover all the parts of the body where these infections can be found. But if a condom is used correctly and doesn’t break, slip or leak, then there is no risk of HIV transmission because an exposure to HIV cannot occur.

All prevention strategies have their own advantages and limitations. But what they all have in common is that none of them are effective unless they are used correctly and consistently. How well a particular prevention strategy works can vary from person to person, so it’s important for individuals to choose the tools that work best for them.