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THE EXPERIENCE OF
SPECIFIC POPULATIONS
http://www.aidslaw.ca/
The patterns and effects of stigma and discrimination vary among the
diverse populations affected by HIV/AIDS. While there are similarities
in the experiences of different populations (as discussed above), there
are also features that are specific to particular populations. These
features either are not encountered by other populations or are
experienced differently.
This section of the Paper aims to describe stigma and discrimination
as experienced by specific populations affected by the HIV epidemic in
Canada. The differentiation of populations affected by HIV/AIDS is a
social and cultural construction. Such differentiation may itself
contribute to discrimination,133 as when drug users or sex
workers are vilified as "vectors of disease." On the other hand, the
failure to recognize and acknowledge publicly the experiences of a
particular population in the course of the HIV/AIDS epidemic has also
led to neglect and avoidance of that population's needs, as gay men have
found in the "de-gaying" of AIDS.134 In the judgment of the
author, the dangers of neglecting the experiences of people exceed the
dangers of stereotyping the experiences of people. Accordingly, this
section of the discussion paper proceeds by populations, however
imperfectly described or designated.
Gay and Bisexual Men
Anyone who believes a gay man can explore the experience of being at
risk for HIV disease without considering the experience of being gay is
hopelessly mistaken.135
The family of a gay man living with HIV/AIDS in a smaller Canadian
province wanted nothing to do with him. When he was ill, they were told
he was dying of cancer. His mother was aware that he was dying of AIDS
and arranged for billeting in a larger city in that province with the
help of an AIDS service organization. She paid for the services in cash,
and also made a cash donation after his death, because she did not want
her credit union to know that she was making contributions to an AIDS
service organization.
Two men applied to rent an apartment. One of them gave the name of an
organization of people with HIV/AIDS as a reference. He also had to
indicate that he was on social assistance. The landlord called the
organization to find out if he could catch AIDS. He was worried that
they would come all over the carpet, and that he would become infected
if he had to clean the apartment after they left. The two men were
denied the apartment.
The education co-ordinator [in an AIDS service organization] is not
comfortable with gay and lesbian issues. ... [The executive director of
an AIDS service organization] puts a damper on any initiatives that come
out of [the men who have sex with men program]. He wants us to work
within a certain framework - visible but not too visible.136
Epidemiology
Health Canada reports that "[t]he HIV/AIDS epidemic in Canada is no
longer as concentrated among men who have sex with men as it was in the
early-to-mid 1980s, but this group is still a significant part of the
epidemic": 137
• 72.5 percent (10,943) of the total number of AIDS cases (15,101)
reported to Health Canada were attributed to men who have sex with men,
and an additional 4.3 percent (655) were attributed to the combined
category of men who have sex with men and use injection drugs;
• the annual number of AIDS cases attributed to men who have sex with
men leveled off from 1992 to 1994 and has decreased since then, but the
proportion of AIDS cases attributed to the combined category of men who
have sex with men and use injection drugs has steadily increased (4.9
percent in 1996).
• the number of new cases of HIV infection among men who have sex
with men as a proportion of the total number of new cases has been
decreasing since the mid 1980s. However, at the end of the 1980s there
appears to have been a resurgence of HIV infection among younger men who
have sex with men.138 The rate of infection in a cohort of
gay and bisexual men in Vancouver between the ages of 18 and 30 was 3.1
percent as of December 1996, twice as high as the authors of the study
expected;139 and
• a significant proportion of men who have sex with men continue to
have unprotected anal sex with both regular and casual partners.
Patterns of Stigma and
Discrimination
As the Final Report on gay and lesbian legal issues and
HIV/AIDS documents, prejudice against homosexuality has resulted in a
predominantly negative legal, social, and cultural environment for gay
men, lesbians, and bisexuals:140
• gay and lesbian adolescents have little support within their
family, among their peers, and at school in recognizing and affirming
their sexual orientation and in developing relationships with other gays
and lesbians.
• an overwhelming majority of gay men and lesbians have been verbally
abused, and many gay men and lesbians have been threatened, chased or
followed, assaulted, or otherwise abused.
• same-sex sexual activity was until recently considered a crime, and
the Criminal Code still includes provisions that discriminate on
the basis of sexual orientation, including legal age of consent for anal
intercourse.
• literature and information about same-sex relationships have been
censored by schools and libraries, and literature and information about
same-sex sexual activities (including safe-sex educational materials)
have been seized by Canada Customs.
• sexual orientation was only recently made a prohibited ground of
discrimination in the Canadian Human Rights Act (after almost two
decades of struggle to realize this basic protection), and has not yet
been made a prohibited ground of discrimination in the human rights
legislation of Alberta, Prince Edward Island, and the Northwest
Territories.
• gay men and lesbians in a same-sex relationship are not assured of
the right or access to employment benefits, may experience
discrimination based on sexual orientation in obtaining custody of or
access to children or in other parenting arrangements, cannot sponsor
their partners for immigration under the family class, and are
vulnerable to exclusion in the event of the illness or death of their
partner.
The early prevalence of HIV/AIDS among gay men in North America has
resulted in an enduring association between HIV/AIDS and homosexuality.
The predominantly negative attitudes toward homosexuality have
influenced people's attitudes and behaviour toward people with HIV/AIDS
in general, and gay and bisexual men in particular.141 As a
result:
• people have a more negative attitude toward people with HIV/AIDS
than they do toward people with other diseases, regardless of the sexual
orientation or presumed cause of infection of the person living with
HIV/AIDS;
• people have a more negative attitude toward gay men with HIV/AIDS
than toward other people with HIV/AIDS, are more likely to blame gay men
for being HIV-positive, and are less inclined to help gay men with
HIV/AIDS;
• people with HIV/AIDS may be stigmatized and discriminated against
because they are assumed to be homosexual; and
• gay and bisexual men are stigmatized and discriminated against
because they are assumed to be HIV-positive or the cause of the HIV
epidemic.
Research has shown that people who support the rights of same-sex
couples to marry, adopt or have children, and enjoy the same employment
benefits as heterosexual couples, have less fear of AIDS.142
It is important to note that men who have sex with men may not
identify as gay or bisexual and may have a very loose association with
the "gay community."143 The categories "men who have sex with
men," "bisexual," and "gay" comprise a diversity of identities, cultures
and behaviours. The degrees to which men considered under these
categories may have appropriated the negative stereotypes and stigmas
associated with homosexual activity or identity in their surrounding
culture will vary.144
Impact of Stigma and
Discrimination
Vulnerability to Infection
A comparison of two cohorts of gay men in Vancouver - one recruited
between 1982 and 1984 (the Vancouver Lymphodenopathy AIDS Study), the
other recruited since 1995 (the Vanguard Project) - shows that there has
been a decline in the frequency of high-risk sexual behaviours among gay
and bisexual men over the decade.145 At the same time, a
significant proportion of gay men and bisexual men (particularly young
men) continue to engage in risky sexual behaviour.146
As the section on gay, lesbian and bisexual youth (below) discusses
more fully, growing up and coming out in an unsupportive or hostile
environment contributes to risk of HIV infection and other risks to
health and well-being. The Vanguard Project found that, among 147 young
gay and bisexual men, 18 percent had experienced domestic violence, 11
percent had experienced gay bashing, 25 percent had experienced sexual
abuse, 55 percent had seriously considered suicide, and 33 percent had
attempted suicide. Twenty-two percent had been diagnosed with a mental
disability or mood disorder, most commonly depression.147 The
authors conclude:
A disturbing proportion of young [men who have sex with men] report
having considered suicide or made suicide attempts, which is consistent
with high levels of depression. Various other forms of violence appear
to be common for young [men who have sex with men]. The relationship
between violence and HIV requires further investigation. Along with
other forms of psychologic distress - including depression, substance
abuse and homophobia - violent life experiences likely impact negatively
on self-esteem and negotiating skills, which could in turn lead to
heightened vulnerability to HIV infection.148
Testing and Confidentiality
For men who have sex with men, whether or not they identify as gay or
bisexual, taking an HIV- antibody test has both personal and social
consequences. The decision to take the test may involve overcoming a
number of fears, including the fear of being infected with HIV, of
having infected others, of illness or death resulting from HIV
infection, of disclosure as a gay or bisexual man or as a person with
HIV, or of stigma or discrimination based on HIV status or sexual
orientation.
Toward the end of the 1980s, as the prospects for treatment improved,
gay and bisexual men were encouraged to be tested. At the same time,
AIDS organizations pressed for wider access to anonymous testing in
order to assure people of complete confidentiality. Even so, a national
survey of gay and bisexual men in Canada in 1991-92 found that the
probability of expressing an intention to take an HIV-antibody test
varied between 2 percent and 94 percent, and that an individual's
personal evaluation of the consequences of taking the test was the most
important variable in determining the probability of expressing an
intention to take it.149 The authors describe the
significance of their findings as follows:
The intention to take the test is mainly affected by attitudes.
According to the theoretical framework adopted for this study,
"attitude" is defined as a personal evaluation of the consequences of
adopting a given behaviour. Such factors as the possibility of having
one's name on a government list or having one's career or insurance
affected define one's attitude to taking the test. Perceived lack of
anonymity seems to be a dominant attitudinal determinant.150
Numerous studies suggest that availability of anonymous testing
encourages people to come forward to be tested, particularly those who
are at greatest risk for HIV infection.151 Of particular
significance for gay and bisexual men is the finding of a study on the
effect of a decision to discontinue anonymous testing in 82 of 100
counties in North Carolina in 1991. There was a 12.4 percent decrease in
testing of gay men in counties that ended anonymous testing; gay and
bisexual men accounted for 10 percent of all tests in counties that
retained anonymous testing, but 4 percent of all tests in counties that
discontinued it.152 As long as the social environment is
hostile to gay and bisexual men, HIV testing programs must take into
account the risks - perceived as well as actual - that an HIV test
entails for gay and bisexual men.
Disclosure and Concealment
I have always hidden my homosexual tendencies from my family and
friends. To now come out and say I am gay and I have AIDS, it's a double
stigma. Unfortunately, the stigma attached is attached to you at the
time you need support, you are afraid of dying, and you are hurting
pretty badly. I am better off passing as normal.153
This observation from a gay man living in Newfoundland is a reminder
that for gay and bisexual men, disclosure of HIV status is a
double-edged sword. As the authors of a study of disclosure among gay
men observe:
It may open up the opportunity to receive social support. However, it
may also lead to added stress, due to stigmatization, discrimination and
disruption of social relationships. Conversely, concealing one's HIV
status from significant others can be stressful in itself and can
interfere with obtaining and adhering to potentially critical medical
treatments. Concealment can also have negative effects on significant
others' well-being, since they may experience guilt, confusion or anger
when they find out about the individual's illness (especially if this
occurs after the individual is very sick or has died).154
Gay men with HIV/AIDS are more likely to disclose their HIV status to
their lover or their closest friends, whom they perceive to be more
helpful and supportive, and less likely to disclose to their family,
coworkers or employer.155 The reasons for not disclosing
include fear of discrimination (particularly at work) and the desire to
conceal one's homosexuality. As one man put it, "My parents don't know
I'm gay."156 Disclosure of HIV-status and sexual orientation
to one's family often occur at the same time:
The level of denial and crisis in families who were not aware of a
son's homosexuality until a diagnosis of AIDS may be fairly high. Among
men who have already revealed their sexual orientation to their
families, the stigma of a diagnosis of AIDS may reopen old wounds as
family members are forced by the crisis of the illness to once again
confront and express their feelings regarding sexual orientation.
Disclosure of homosexuality to parents is often more difficult than
disclosure to others because parental reaction is usually negative and
the family perceives the disclosure as a crisis. Depending on their
value system, parents may apply stereotypes about homosexuality to their
son, perceiving him as a potential child molester or a sinner condemned
to everlasting punishment. Also, parents may fear that others in their
social network will apply similar negative values to the whole family,
leading to isolation and ostracism.157
Disclosure may be particularly problematic for bisexual or
heterosexual men if they are divulging previous same-sex activity for
the first time:
At the time I told my wife, my fiancée, I told her about me having
experienced being with a man before and so this was the first time this
subject had even come into the light. She didn't have any suspicion or
inclination so it was kind of hard to deal with.158
Not all families, however, respond negatively.159 It is
significant that one gay man gauged his family's likely response to his
HIV status according to their prior response to his sexual orientation:
I didn't really have that much fear they wouldn't accept me because
they knew from a very young age that, you know, from thirteen that I was
gay. ... They were very, very supportive right from the very beginning.160
Caregivers of gay or bisexual men with HIV/AIDS are also adversely
affected by the stigma of HIV/AIDS and homosexuality. As one study
found, going public as a caregiver can mean harassment, rejection, and
the loss of jobs, friends and housing.161 The authors report
that "[g]ay caregivers who were less open about their sexual orientation
usually were very cautious about going public, especially outside of the
gay community," while parents "often perceived themselves failures as
parents, or were accused of poor parenting by others."162
Employment
As noted above, gay and bisexual men are less likely to disclose
their HIV status to co-workers and employers than to lovers and friends.163
The association between fear of AIDS and aversion to homosexuality means
that disclosing HIV status may mean encountering homophobic attitudes.164
As one gay man recounted:
One day on the floor where we were discussing this whole issue of
AIDS and homosexuality and that kind of thing, one person said, they
should all be isolated in a commune or shot. Now this is a nurse I
worked with for a year and a half, shoulder to shoulder....165
AIDS may be used to harass gay men:
I heard they caught wind that I was gay. I had a pop or coffee
sitting there. "Don't forget that he has AIDS."166
People may incorrectly assume that a gay man has HIV:
A gay man was laid off from his job as a caretaker for a large
condominium when his employer concluded, incorrectly, that he was
HIV-positive because he had been ill.
Gay men may be fired or may resign for fear of discrimination once it
becomes known that they or their lover are HIV-positive.167
The report of a recent survey of people with HIV/AIDS in Québec notes
that there are three types of "silence" at work - silence about sexual
orientation, silence about HIV status, and silence about HIV
medications.168 People who are currently not working would
rather not return to their previous employer because of the level of
stress and discrimination and the attitude of their employer. They would
prefer to work in a context that is more open to sexual orientation, HIV
seropositivity, and combination therapy. Gay and bisexual men are more
likely to disclose their HIV status when their employer is aware of
their sexual orientation and when their employer is gay or bisexual.169
Discrimination and harassment in the workplace on the basis of sexual
orientation is prohibited by human rights legislation in all
jurisdictions except Alberta, Prince Edward Island, and the Northwest
Territories. However, as the Final Report on gay and lesbian
legal issues and HIV/AIDS observes, the difficulty in a human rights
complaint is that discriminatory attitudes are often subtle, and that it
is not always easy to prove that a particular decision was based on
sexual orientation, disability, or indeed any specific prohibited ground
of discrimination.170 In addition, the complaints procedure
is time-consuming, slow in providing redress, and emotionally draining,
thereby discouraging individuals from lodging or pursuing their
complaints.
Health Care
In order to recognize the risk of HIV infection, provide appropriate
counselling and testing, and early treatment, it is important that
physicians in general be knowledgeable about and comfortable with men
who have sex with men. This involves such things as taking a history of
sexual orientation and sexual activity, assessing risks of transmitting
or acquiring HIV, and taking a history of sexually transmitted diseases
- practices that are not routine for all physicians.
A study of 300 physicians attending AIDS-related continuing education
courses in Ohio between 1987 and 1989 found that only 42.4 percent
routinely took a history of sexually transmitted diseases, only 24.7
percent routinely assessed the risk of transmitting or acquiring HIV,
and only 17.6 percent routinely took a history of sexual orientation.
Parallel studies were conducted at the same time among gay men. Less
than half (41.6 percent of 573 men) had discussed their sexual
orientation with their personal physician. When asked why they had not,
74 percent responded that they were never asked.171 Thus, an
opportunity to establish an open relationship between physicians and men
who have sex with men, as well as to provide education about HIV/AIDS
and early testing for HIV, was lost.
There is evidence that these problems continue today. A study of the
experiences of gays, lesbians, bisexuals, and transsexuals with
physicians in Ontario found that 41 percent of physicians do not discuss
safe sex with their clients.172 Twenty-eight percent of
clients also experienced discrimination because of HIV. It is possible
that the practices of physicians who specialize in HIV/AIDS care are
more appropriate.173 Nevertheless, two individuals consulted
in the preparation of this Paper reported that physicians in two smaller
cities were known to hold positions or make remarks that gay men found
objectionable. In one case, the physicians was the only specialist for a
large northern region. Conversely, an AIDS support worker stressed how
hanging a rainbow flag in the emergency room in a hospital in a large
metropolitan area was an important symbol of acceptance for the large
gay, lesbian and bisexual population served by the hospital.
End-of-Life Decisions
Lack of acceptance of the sexual orientation of a gay man with
HIV/AIDS can, together with the stigma of HIV/AIDS, create conflict
within his family of origin or between his family of origin and his
lover or partner.174 In the event of a crisis (such as
decisions about health care for a person who is incapacitated) or death,
the law privileges the family of origin. As the Final Report on
gay and lesbian legal issues and HIV/AIDS notes:
If a person living with HIV or AIDS has not planned in advance of
his/her death or incapacity, his/her same-sex partner will have almost
no recourse for making decisions about that person's health care,
administering finances and property, or claiming a share in the deceased
partner's estate. The partner of the deceased may have a claim based on
common law remedies (such as resulting or constructive trusts) or a
claim for compensation for having cared for the deceased, but there is
no statutory right to a share of the estate or to be appointed to
administer the estate.175
Same-sex partners can take steps to protect their position, and laws
in Newfoundland, Nova Scotia, Québec, Ontario, Manitoba, and British
Columbia specifically permit individuals to designate who can make
health-care decisions when they become incapacitated.176 But
the law still substantially privileges biological families over same-sex
partners.
Transgendered People
Like many of my sisters and brothers I have felt like a freak of
nature, and had a sense of not belonging anywhere. When on the streets,
I was accepted and validated, and was able to escape from the realities
of being transgendered. I did not need to adjust to the real world and
the expectations of others. In the straight world we were abandoned,
forgotten, and occupied a social status reminiscent of earlier times. In
the real world there was no human rights protection, and no dignity for
the transgendered.177
Transgendered people - a term that applies to transsexuals,
transvestites, drag queens, and cross-dressers178 - are
exposed to humiliation, degradation, and discrimination at almost every
turn. Many transgendered people are rejected by their families. They are
not universally welcome within the gay and lesbian communities. Few
workplaces are accepting and accommodating of their identity and dress.
Police tend to be polite until they see identification papers, at which
point their attitude changes.179 Health care and social
service providers may be insensitive, referring, for example, to
transgendered people by their sexual identity, not their gender
identity. In hospitals and prisons transgendered people are lodged with
people of their sex rather than their gender. In prison the risk of
violence and coercive sex is high, particularly for those whose sex is
male but whose gender is female. In short, transgendered people are
rejected, isolated, closeted, and vulnerable within society.
This has numerous consequences in the context of the HIV/AIDS
epidemic. Because of their rejection by society, many transgendered
people end up on the street as sex workers or injection drug users. On
the street, their risk of HIV infection is high. It is estimated that 70
to 80 percent of transgendered people on the streets in Vancouver are
HIV-positive.180 Many HIV-positive transgendered people do
not attend HIV clinics because their gender is not acknowledged and
affirmed.181 Health-care providers may not be sufficiently
knowledgeable of and sensitive to the hormonal and psychosocial needs of
transgendered people with HIV/AIDS.182 Transsexuals with
HIV/AIDS are refused at gender clinics if they disclose that they are
HIV-positive. In one case, a physician agreed to perform the surgery
requested by a transsexual, but for a surcharge of $5000 over the
regular fee. It can be difficult for HIV-positive transgendered people
to obtain services they require to maintain their physical appearance,
such as electrolysis. Protecting and preserving one's gender in
hospitalization and in making funeral arrangements is difficult.183
Recognizing the consequences of isolation and discrimination against
transgendered people in the context of HIV/AIDS, health-care providers
and community workers have developed peer-driven programs for
transgendered street people and clients of HIV clinics. Such programs
have provided support to transgendered people who otherwise would not
approach more traditional organizations.184 One initiative, a
support group for transgendered people with HIV/AIDS at a primary care
clinic, reports:
Transsexual patients stated a dramatic increase in trust for their
health care providers over the 2 years. The number of clinic
appointments missed by all the group decreased from 64% in 1994 to 12%
in 1995. The group developed their own community within the clinic,
shared HIV and transgender information, provided mutual support, and
fought discrimination.185
However, targeted programs and specialist health care must be
accompanied by protection from discrimination in law, policy, and
practice. Currently, there is no explicit protection for transgendered
people in human rights legislation in Canada; transgendered people lodge
complaints on related prohibited grounds, such as sex, mental and
physical disability, and sexual orientation.186 Only if
transgendered people enjoy the same rights, freedoms, and opportunities
afforded others in Canada, and are not ostracized by society, will the
conditions that place transgendered people at risk of HIV infection be
ameliorated.187
Injection
Drug Users
I don't like the abuse people take whether it's because they drink
rice wine, use drugs or because they are mentally ill. Poor bashing is
easy to get away with. The poor don't have the ear of the press.188
Why should people be homeless, sick, beat up, etc. because they use
drugs? It's not important if people use or not - they deserve to be
treated compassionately. When wealthy people use drugs it is private
because they are not homeless shooting up on the streets.
The illegality of the drugs causes damage, not necessarily the drug
itself. Did I have to be degraded and criminalized to stop? I think I
felt worse about my self and may have used more and longer as a result.
People have to see a reason to stop and degradation is not a reason to
stop - it's often a reason to use.
A non-judgmental place is the key to a successful place for users. A
place where we can help each other. We can say to each other, "It's okay
to be who you are and I accept you where you are now whether you are
using or not."
When does the addict see anything ever happening? Only when we
overdose or get HIV or endocarditis - the rest is a lot of gum flapping.
Addicts are considered the lowest of the low. My name is mud. I used
to teach elementary school and was a psychologist assistant. The
assumptions made about me because I am identified as a drug addict are
that I have no self-esteem, no respect for my body and that I am not
capable of anything. No one listens to me - nothing I say is taken
seriously. I have a problem. I am an addict. I don't need to be
insulted, discredited, humiliated and ignored.
Current Epidemiology
Health Canada reports that "[i]n 1996, approximately half of the
estimated 3,000-5,000 HIV infections which occurred in Canada were among
injection drug users, illustrating the significance of this group in the
current Canadian epidemic":189
• For men, the proportion of AIDS cases attributed to injection drug
use has increased from 1.0 percent during the period before 1989, to 2.6
percent during 1989-92, to 5 percent during 1993-96. For women, the
proportion of AIDS cases attributed to injection drug use during the
same periods has increased even more dramatically, from 6 percent to 15
percent to 25 percent.
• Prevalence of HIV infection among injection drug users in Toronto
has increased from 4.5 percent in 1991-92 to 7.6 percent in 1993-1994;
in Montréal, from 5 percent prior to 1988 to 19.7 percent in 1996; and
in Vancouver, from 4 percent in 1992-93 to 23 percent in 1996-97.
• Estimates of the incidence of HIV infection among injection drug
users, as reported in various studies, are as follows: 5-6 new
infections per 100 injection drug users per year (100 person-years) in
Montréal during the early 1990s; 5 new infections per 100 person-years
in Vancouver in 1992-93; 18.6 new infections per 100 person-years in a
cohort in Vancouver in 1996-97; and 5.4 new infections per 100
person-years among needle exchange attenders in Ottawa and Québec.
Recent studies indicate that lending and borrowing of needles and
other injection equipment is relatively common among injection drug
users in Canada:190
• Among 1006 injection drug users enrolled in a study in Vancouver,
40 percent had either borrowed or lent needles, and 11 percent of
HIV-positive users and 25 percent of HIV-negative users consistently
used bleach.191
• Among 2458 injection drug users recruited at needle exchanges in
Ottawa and in the province of Québec, 40 percent had injected with
borrowed used needles in the preceding six months.192
Injection drug users also report unprotected sex with regular,
casual, and commercial sex partners.193 Among injection drug
users recruited at needle exchanges in Ottawa and in the province of
Québec:194
• 79.3 percent of women and 73.6 percent of men never or only
sometimes used condoms with regular partners. Of the men, 4.4 percent
had a regular male partner, and of these 72.5 percent never or only
sometimes used condoms.
• 54.9 percent of women and 56.7 percent of men never or only
sometimes used condoms with casual partners. Of the men, 6.8 percent had
casual male partners, and of these 75 percent never or only sometimes
used condoms.
• 40 percent of women and 7.1 percent of men reported having male
commercial sex clients, and of these 35.5 percent of women and 63.9
percent of men did not consistently use condoms.
Patterns of Stigma and
Discrimination
Drug use is a powerful source of stigma, and people who have acquired
HIV through injection drug use, like those who have acquired HIV through
same-sex activity, live with a double stigma. A study of public
attitudes in Australia in 1990 found that drug users who contracted HIV
through needle sharing attracted the most blame (92 percent), the least
sympathy (18 percent), and the most calls for them to pay for their own
treatment (70 percent).195 Similarly, a random-sample survey
conducted in the United States in 1990-91 found that 20.5 percent of the
respondents thought that "people who got AIDS through sex or drug use
have gotten what they deserve."196
The stigma of drug use is reinforced by the illicit status of drug
use in law, and by the application of coercive measures, including
police surveillance, criminal prosecution, and criminal penalties,
against illicit drug users. The legislation is, arguably, itself
discriminatory. When one compares illicit drugs with similar licit drugs
in terms of their pharmacological action, their psychotropic effects,
the damage they may cause to the user's health, their potential for
dependency or abuse, and their social consequences, the criminal
penalties applied to illicit drug use are not proportional to the harm
incurred and do not match comparable penalties to comparable offences.197
In addition, the legislation is discriminatory in its effects. The
prohibition of drugs and the application of criminal sanctions,
compounded by existing patterns of discrimination based on race and
income, has a disproportionate effect on impoverished and minority
populations. The greater availability, lower price, and increased use of
heroin and cocaine in poor, minority ghettos in the United States, for
example, can be traced to the longstanding practice of white
middle-class authorities to contain "vice" in its successive forms -
prostitution, gambling, alcohol, marijuana, heroin, and cocaine - to
minority ghettos.198 Today, although as many whites as blacks
use drugs in the United States, blacks are overrepresented among the
users that require treatment for drug abuse or drug dependence.199
Blacks and Hispanics are also vastly overrepresented among prisoners
convicted of drug felonies in the United States. As a report on drug
sentencing in New York State observes:
In New York state, almost 30,000 people a year are indicted for drug
felonies, and 10,000 are sent to prison; approximately 90 percent of
them are blacks and Hispanics. In New York, as throughout the United
States, drug felonies are the single most significant factor underlying
the remarkable growth of the prison populations.200
Canada has its own parallels in this regard. Currently Aboriginal
peoples are overrepresented among inner-city injection drugs users and
among attenders of needle exchange programs.201 Likewise,
both Aboriginal peoples and injection drug users are overrepresented in
prison populations.202 Many drug users are socially and
economically disadvantaged. A study of 582 injection drug users in
Toronto found that 12.7 percent had an elementary school education, that
72.2 percent had a high-school education, that only 22.5 percent were
permanently employed, and that only 36 percent lived in their own
residence, while the rest lived in a shelter (14 percent), a room rented
on a daily or weekly basis (16 percent), or had no fixed address (11.5
percent).203 Similarly, among injection drug users enrolled
in a recent study in Vancouver, 81 percent had less than a high-school
education, 62 percent were living in unstable housing, and 28 percent
had a high level of depression.204
The marginalized status of drug users profoundly affects the way they
are treated by others. Users attending meetings of the Vancouver Area
Network of Drug Users (VANDU) attest to numerous discriminatory and
degrading experiences:
My brother and sister couldn't get a hold of me at my hotel. We had a
death in the family and when they came to pick me up they wouldn't let
them upstairs to get me or go up to tell me they were here to get me. I
missed the funeral. It makes me mad. I have no where else to live.
[A certain hospital] is a nightmare! They throw people out. I've
really behaved well and I still get thrown out. Every time I go there
they treat me like shit. Recently I broke my ankle. I was given crutches
and told to leave. The next day they called my mom and asked her to
contact me to tell me to come back as my ankle was broken. They wouldn't
believe me.
I also need a family physician. They won't take users.
Some police are really dirty. ... I've been beaten up a few times.
They sometimes pepper spray you and leave you in the alley.
What about cops helping us with landlords evicting us when we've paid
our rent? I've had a very bad experience with this. Police could really
be of help to people down here in this way and they aren't.
Does anything ever happen to hotel owners as a result of these
violations [room violations, guest fees, illegal evictions]? Where is
the City in all this? Where are the by-law enforcement officers?
In other words, drug users find that they are denied the legal
protections, health services, and social supports that others enjoy.
Impact of Stigma and
Discrimination
Vulnerability to Infection
The high-risk injecting and sexual behaviours among injection drug
users are, in part, an effect of the illicit status of drugs and other
restrictions on drug users.205 The illicit status of drugs
drives up their price, leading users to take the drugs in the most
efficient manner possible (injection) rather than by less efficient but
safer means (oral consumption). Substitutes that could be taken orally
are either prohibited (heroin) or, if they are available, are medically
regulated (methadone). As a result of both policies and practices
governing the sale of syringes, drug users do not have ready access to
syringes in community pharmacies,206 and needle exchanges may
impose limitations that do not meet the needs of drug users (such as
limits on the number of syringes exchanged at one time).207
To this must be added other features of the illicit drug market, such as
having to use drugs of uncertain quality and purity, being vulnerable to
coercion or violence, or in some cases resorting to property crime or
commercial sex to pay for drugs.
Socioeconomic disadvantages contribute further to the risk of HIV
infection among drug users. The Vancouver study, noted above,208
found that HIV-positive injection drug users were disproportionately of
Aboriginal origin, and were significantly more likely to have less than
a high-school education, to live in unstable housing, and to reside in
the poorest postal district in Canada. The sociodemographic
characteristics of low education and unstable housing - along with the
behavioural characteristics of commercial sex work, borrowing used
needles, injecting with others, being an established injection drug
user, and attending a needle exchange program more than once per week -
independently predicted HIV-positive status among injection drug users.
Programmatic barriers in the form of inadequate or inappropriate
services, as well as professional attitudes and practices that are
controlling and demeaning, are also factors in the HIV epidemic among
drug users. Noting that Vancouver has an HIV incidence of 18.6 percent
among injection drug users despite the fact that Vancouver has the
largest needle exchange program in North America, the authors of the
Vancouver study comment:
In Vancouver, NEP [needle exchange programs] were introduced early,
but access to drug and alcohol treatment, methadone maintenance and
counselling services remain inadequate. As early as 1990, the lack of
appropriate services for addictions treatment in British Columbia,
especially for cocaine users, was identified as a major barrier
encountered by Vancouver's NEP attenders, among whom there was already a
marked demand for HIV-related counselling. This situation continues at
present. Our results do not argue against the overall effectiveness of
NEP as an HIV intervention, but rather, they lead us to propose that
without adequate and appropriate community-wide interventions such as
addictions treatment, detoxification and counselling, stand-alone NEP
may be insufficient to maintain low HIV prevalence and incidence for an
indefinite period.209
The importance of providing a broad range of interventions is
reinforced by evidence from Amsterdam, where, as the authors of the
Vancouver study note, "a continuum of harm-reduction activities was
associated with lower HIV incidence and needle-sharing behaviours, but
there was no evidence of a protective effect for single interventions
like NEP or methadone maintenance."210 Providing such a range
of interventions requires, as the Task Force on HIV, AIDS, and Injection
Drug Use recommends, eliminating the barriers that professional and
public attitudes, as well as the design and delivery of programs, place
in the way of integrated, accessible, suitable, flexible, and respectful
services for drug users.211
HIV/AIDS Care, Treatment, and
Support
A recent report on the care, treatment and support of drug users with
HIV/AIDS describes the difficulties that they often encounter when they
seek drug treatment, health care, or social support.212
Service providers may be reluctant to offer service or may do so with an
attitude of disrespect because they consider injection drug users to be
disruptive or manipulative. Professionals may be unwilling to accept a
drug user's choice to continue using drugs or may be reluctant to work
with what they consider to be difficult clients. Organizations that are
not experienced in working with injection drug users - including
established HIV/AIDS organizations - may offer programs that are
inappropriate or may be less ready to serve them relative to other
populations with which they have more experience or more success. Health
and social programs may be designed to address a single problem, rather
than the multiple problems that drug users present, and consequently may
have neither a sufficient range of services nor a flexible enough set of
criteria to be able to serve drug users well.
The clinical care of drug users with HIV/AIDS is complicated by the
need to attend to both drug treatment and HIV/AIDS treatment. There are
a number of areas where the care that is delivered may be
discriminatory. One is the area of pain medication. Drug users
frequently report that they are not given adequate pain relief. Pain
medication that is offered to other people with HIV/AIDS is not
available to them. Another area of concern is antiretroviral therapy.
There is considerable fear that drug users will not be offered the
current standard of care because it is assumed that they will not be
able to maintain the demanding drug regimens. Abstinence as a condition
of treatment and care is another area where drug users may experience
discrimination. Physicians may be unwilling to provide treatment unless
a drug user agrees to discontinue using and enter drug treatment.
Similarly, restrictions on drug use in residential facilities may
effectively exclude or deter drug users from care.
As the report on the care, treatment and support for injection drug
users with HIV/AIDS observes,213 there are numerous legal and
ethical issues involved in providing care to injection drug users, in
large part owing to the illicit status of the drugs used, concern for
professional safety and liability, and prevailing norms and attitudes
among health-care providers. For example, health-care providers may
perceive an irreconcilable ethical contradiction between preventing
illicit drug use and enabling or permitting a drug user to continue to
inject. Physicians may be liable to professional discipline or criminal
prosecution if they do not follow professional guidelines or government
regulations in the prescription of psychoactive drugs. Health-care
facilities may face legal problems if they allow illicit drugs on the
premises.
While these ethical and legal dilemmas require careful deliberation,
it is not acceptable to make decisions without considering the full
range of options available (including innovative approaches), obtaining
accurate information about the real (rather than stereotypic or
imagined) risks to drug users, and, most importantly, recognizing the
rights of drug users to health care and treatment. This is especially
pertinent in decisions about antiretroviral treatment of HIV in drug
users, given the requirements that current drug regimens place on people
with HIV - regimens that are demanding by any standard, and not only for
drug users. As the Task Force on HIV, AIDS, and Injection Drug Use
states:
It must be recognized that injection drug users living with HIV are
individuals, suffering in a myriad of ways, and in need of the best
possible interventions, tailored to their unique situations. They retain
all the rights of every other citizen, and must therefore be given equal
access to a continuum of services, as well as the dignity of making
their own decisions. If lack of compliance with a drug treatment is
feared, then the patient must be supported to ensure adherence to the
treatment regime, just as any other individual is, whether diagnosed
with diabetes, epilepsy or another condition. Bias against treating
[injection drug users] is unjustified and unacceptable.214
Research and Information
The care and treatment of drug users in general, and of drug users
with HIV/AIDS in particular, is limited by gaps in research and by
difficulty in getting accurate information about illicit drugs. The gaps
in research are a result, among other things, of norms and practices
that effectively exclude drug users from research, neglect areas of
research that are relevant to drug users, or prevent innovative research
on drug use. For example, drug users may be excluded arbitrarily as
participants in clinical research, without due consideration to the
individual characteristics of drug users and potential support for their
participation. Research into such questions as the interactions between
approved therapies and illicit drugs may be hindered by the stigma
associated with drug use, lack of interest in the pharmaceutical
industry, and the illicit status of the drugs. Innovative research, such
as clinical trials on the prescription of heroin and cocaine, is
difficult to initiate, given the prevailing models of drug treatment and
public and professional attitudes toward illicit drugs.215
HIV, Drug Use, and Disability
Human rights legislation and human rights commissions in Canada have
afforded protection to people who have been or are dependent on alcohol
or drugs. The Canadian Human Rights Act recognizes previous or
existing dependence on alcohol or a drug as a disability within the
meaning of the Act,216 and the Ontario Human Rights
Commission, in a complaint against Imperial Oil Limited, determined
"that drug abuse and drug dependence both constitute a handicap within
the meaning of the [Ontario] Human Rights Code."217
However, in an environment that regards drug use as a choice, a vice,
and a crime, considerable education and advocacy will be required to
ensure that the rights of drug users are protected and that drug
addiction is recognized as a disability. For example, Bill 142 in
Ontario, an Act to amend the law related to social assistance, excludes
persons whose only substantial restriction in activities of daily living
is attributable to the unauthorized use or the cessation of use of
alcohol, a drug or some other chemically active substance, from
eligibility for income support.218 The first draft of the
bill excluded persons whose impairment is the result of unauthorized use
of alcohol, drugs or other substances from the definition of disability,219
but this was subsequently amended to exclude such persons only from
eligibility.
Bill 142 makes an exception for a person "who, in addition to being
dependent on or addicted to alcohol, a drug or some other chemically
active substance, has a substantial physical or mental impairment,
whether or not that impairment is caused by the use of alcohol, a drug
or some other chemically active substance."220 In Vancouver,
drug users report that "[s]ome people are getting HIV on purpose to get
the increased welfare for the disabled."221 The terms placed
on the eligibility for income support in Bill 142 may have the same
perverse effect in Ontario.
Participation of Drug Users
One of the guiding principles of the report of the Task Force on HIV,
AIDS, and Injection Drug Use is that "[t]hose using the services must be
involved in the processes which affect them - the development of policy
and programmes."222 This is fundamental to health promotion -
"the process of enabling people to increase control over, and to
improve, their health"223 - and is reflected again and again
in what drug users say:
People are not empowered - they have no control over their lives.
Administered welfare treats people like children. It's insulting and
disempowering. Too many service agencies take the same approach. There
are no services around to really help you get a life. The main way to
get empowered is to get decent housing.224
If we're such garbage, why are we still alive? Because we believe
we're not garbage. Junkies have strong spirits despite being called
everything bad you can think of.225
Well, we know that users aren't going to go away. Nothing to force
users to stop using works - not beatings, pepper spraying, arresting -
not hate, overdoses, poison in the drugs - nothing stops a person using
drugs unless they decide to quit.226
The marginalization of drug users, combined with individual
preferences of drug users and the predominantly criminal or medical
perspective applied to drug users, creates many barriers to health
promotion, to the organization of drug users, and to including drug
users in developing policies and programs. Simply disclosing drug use is
unsafe. Drug users who are employed risk losing their job and other
benefits, such as the opportunity to obtain a mortgage or insurance.
Drug users who are unemployed and are dependent on social assistance may
lose income support (as, for example, under Bill 142 in Ontario) or may
be required to enter into treatment with little or no choice as to the
kind of treatment that they believe will be best for them.
Involving drug users is, however, essential if patterns of
discrimination, exclusion, and coercion are to be broken. As the Task
Force on HIV, AIDS, and Injection Drug Use recommends, drug users must
be actively involved in policy development, program planning,
implementation, and evaluation. In addition, community-based
peer-support and advocacy groups for drug users must be developed. These
are first steps, among others, in any strategy to overcome
discrimination against drug users among professionals, service
providers, and the general public.227
Aboriginal People
I work on the reserve. On the reserve they don't understand at all
about HIV. They're afraid of HIV. I'd lose my job and they'd run me
right off the reserve. They believe you can catch HIV by kissing. But
they believe it will never happen to them. Some friends who know my
daughter is on the street but don't know she is HIV-positive say to me
they pray she doesn't contract HIV.228
In 1994, I believe it was the Assembly of First Nations and the Royal
Commission who did a report on First Nations Suicide Issues. I believe
it was called, Bridging the Gap. And in this report, I wanted to find a
mention of First Nations homosexuality, of Two-Spiritedness, a mention
of it. And unless you knew what you were looking for, unless you could
read very small print between the lines, it was mentioned, but not very
strongly. And I found an injustice in that. It is unjust that we as
First Nations people, have become so suppressed by the Roman Catholic
Church, by colonialism and a lot of other things, by the residential
schools. So we no longer respect Two-Spirited people for who they are.
That we no longer revere them for the spiritual people that they are,
that we are, and we always will be, we always have been.229
Many Aboriginal people experience racism in health care and social
assistance settings. Some people do not trust Western medicine and
practitioners. Some people are not comfortable using mainstream testing
facilities. In some cases this reflects cultural difference rather than
direct racism.230
One person who works for an AIDS organization related a story about
waiting for a doctor for half an hour after the time of her appointment.
When asked why she was being passed over in favour of other patients,
the receptionist replied, "Oh, I thought you didn't have a job."231
Current Epidemiology
Health Canada reports that, although there are limits to the
information available on the HIV epidemic among Aboriginal people, "it
is clear that some Aboriginal communities are at increased risk for HIV
infection because of their low socioeconomic status, poor health
condition, and high rates of sexually transmitted diseases."232
• The proportion of AIDS cases among Aboriginal people, as a
percentage of all AIDS cases, has risen steadily over the past decade,
from 1.5 percent before 1989 to 3.1 percent during 1989-92 and 5.6
percent during 1993-96.
• Sex with men and injection drug use account for the majority of the
210 Aboriginal male AIDS cases, and injection drug use and heterosexual
sex account for the majority of the 39 Aboriginal female AIDS cases.
• Aboriginal AIDS cases are more likely to be younger, to be women,
and to be attributed to injection drug use than non-Aboriginal AIDS
cases.
• Recent data from British Columbia and Alberta show that Aboriginal
people account for 15 to 26 percent of newly diagnosed HIV-positive
cases, and that injection drug use and heterosexual activities are the
most significant risk factors.
• Aboriginal people are overrepresented in groups at high risk for
HIV infection, including injection drug users, clientele using
inner-city services, men who have sex with men, and prison inmates.
Patterns of Stigma and
Discrimination
Aboriginal people with HIV/AIDS live with many layers of stigma and
discrimination. These may include, in addition to being HIV-positive and
being an Aboriginal person, being a woman, a two-spirited person, a
substance user, a sex worker, or in prison.
Aboriginal Status
As Stefan Matiation observes, what differentiates discrimination
against Aboriginal people living with or affected by HIV/AIDS is the
history of oppression and social disintegration that has been meted out
to First Nations, Métis, and Inuit in Canada.233 This history
has resulted in a maze of interconnected spiritual, communal, social,
economic and political problems that strain the resources, the will, and
the spirit of Aboriginal communities. Therefore, improving the health
and well-being of Aboriginal people (including those with HIV/AIDS)
means addressing the causes of cultural dislocation, ruptures within
families, violence within families, substance use, chronic poverty,
unemployment, poor housing and utilities, environmental destruction,
lack of information and services, and lack of control over resources and
programming.234
Gender Disparity
Women have been doubly disadvantaged as a result of the influence of
colonial attitudes and the restrictions of the Indian Act upon
Aboriginal society. For much of this century, Aboriginal women were
denied a vote in band elections, could not own or inherit property, and
lost their Aboriginal status upon marrying a non-Aboriginal man.
Aboriginal women have been subject to degrading sexual and racial
stereotypes in both non-Aboriginal and Aboriginal communities, and they
continue to experience high levels of emotional and physical abuse from
Aboriginal men. This violence is itself related to the disastrous
consequences of racism and oppression within Aboriginal communities, and
in particular among Aboriginal men - high unemployment, poor housing,
poor self-esteem, self-hatred, and substance use.235
Two-Spirited People
Sixty percent of known Aboriginal AIDS cases in Canada are among men
who have sex with men, and an additional 14 percent are among men who
have sex with men and who are injection drug users.236 There
is little acceptance of or support for two-spirited people in many
Aboriginal communities. Many two-spirited people have lived away from
their communities for years and feel rejected because they are
two-spirited or because of their HIV status.237 The effects
of this are felt by both two-spirited people and heterosexual Aboriginal
men. Because many two-spirited people feel unwelcome, they do not care
about their own lives and engage in unsafe behaviours. Because many
heterosexual Aboriginal men regard HIV/AIDS as a "gay disease," they
also do not practise safer sex.238 In addition, homophobia is
one of the main barriers to Aboriginal leaders taking action on HIV/AIDS
issues.
Substance Use
The rupture of family and community bonds, personal histories of
abuse, lack of opportunity and employment, displacement in a
non-Aboriginal environment, poverty, and despair have led many
Aboriginal people into substance use. Currently in Canada, Aboriginal
people are overrepresented among inner-city injection drug users and
among clientele using inner-city services.239 This not only
contributes to a greater risk of HIV infection; it also introduces a
further layer of stigma and discrimination.
Impact of Stigma and
Discrimination
Poor Health and Well-Being
The effects of two centuries of racism, oppression, and displacement
are evident in the current health status of Aboriginal people. As the
Royal Commission on Aboriginal Peoples notes:240
• life expectancy at birth is about seven to eight years less for
registered Indians than for Canadians generally;
• the death rate among Aboriginal infants is twice as high as the
national average;
• infectious diseases of all kinds are more common among Aboriginal
people than others;
• the incidence of life-threatening degenerative conditions
(previously uncommon in the Aboriginal population) is rising;
• overall rates of injury, violence, and self-destructive behaviour
are disturbingly high; and
• rates of overcrowding, educational failure, unemployment, welfare
dependency, conflict with the law and incarceration all point to major
imbalances in the social conditions that shape the well-being of
Aboriginal people.
Vulnerability to HIV Infection
Many of the factors that contribute to higher risk of HIV infection
relate directly or indirectly to the patterns of discrimination noted
above. These factors include:241
• high rates of sexually transmitted diseases;242
• high rates of teenage pregnancy, indicating a lack of safe-sex
practices and a higher risk to youth;
• low self-esteem, particularly among two-spirited people;
• high rates of sexual and physical violence;
• drug and alcohol abuse;
• lack of access to health information and facilities; and
• poor health in general.
Denial and Avoidance within
Aboriginal Communities
Aboriginal leaders have been slow to recognize and respond to the
presence of HIV/AIDS among Aboriginal peoples. There have been a number
of reasons for this. HIV/AIDS has been seen as "a disease of gay white
men in the cities."243 Band councils have many pressing
issues to deal with, and few resources with which to do so.244
The majority of Aboriginal people with HIV/AIDS are not living on
reserve, and are therefore not within the jurisdiction of First Nations
and Inuit leaders. As a result, there is considerable concern at present
that, as authority for health services is transferred to First Nations,
funding and programs for services for people with HIV/AIDS will be
inadequate.245
People within Aboriginal communities have also been reluctant to
address HIV/AIDS because of the shame and stigma associated with
homosexuality and other sexuality issues. These attitudes themselves
compound the problems of trying to reduce the risks of HIV infection
among Aboriginal people. As one individual put it:
In our communities, we have been doing workshops on HIV/AIDS and we
have tried so many ways: a doctor, an [Aboriginal person with HIV/AIDS]
and a two-day workshop with youth, young adults, and elders. The first
time the kids were horrible. We are having a hard time, especially with
the elders, it is so sad we really don't know what to do. This is a very
touchy subject. Risk behaviour is very high around here.246
Moreover, as Matiation reports,
HIV/AIDS workers cannot simply go into communities and talk about
HIV/AIDS. All the issues around HIV and public health in Aboriginal
communities must be addressed, including the impact of a foreign culture
on community practices and traditions, residential schools,
assimilationist policies, health problems, sexual and physical abuse,
and alcohol. All these topics make it difficult to talk about sexuality
issues.247
Disclosure and Rejection within
Aboriginal Communities
Because of the shame and stigma associated with HIV/AIDS in
Aboriginal communities, confidentiality of HIV status is very important.
However, it is often hard to ensure confidentiality in Aboriginal
communities, not only because of improper disclosure by health-care
providers, but also because of word spread by relatives, friends and
acquaintances in small communities.248
The reaction, upon finding out that someone is HIV-positive, has
included ostracism, avoidance, and denial of services.249 In
the face of these kinds of reactions, one of the three priorities cited
most often (after the issues of funding and poverty) in the Aboriginal
consultations on Phase III of the National AIDS Strategy was "access to
home communities with adequate services, and without fear of
discrimination."250
Treatment in Non-Aboriginal
Settings
The majority of Aboriginal people with HIV/AIDS live in cities, not
in remote communities. Although more services relating to HIV/AIDS or to
substance use are available in cities, these may be provided in ways
that are discriminatory, particularly to those who are at greater risk
of HIV infection, such as drug users or sex workers:
A study in Alberta revealed that Aboriginal people using emergency
facilities at a hospital in Edmonton were given sub-standard treatment.
Aboriginal people face systemic discrimination in health care. This is
particularly acute for inner-city and street-involved people.251
The first step to treating Aboriginal people - including those with
HIV/AIDS - with dignity is, clearly, to provide them with services of
the same quality as those provided to others. But it also means
affirming the insights and practices of Aboriginal cultures (which are
diverse) in developing and delivering programs, as well as incorporating
traditional healers and healing practices into those programs.252
Jurisdictional Barriers
The Royal Commission on Aboriginal Peoples found that the belief in
the interconnectedness of all the elements of life and living is central
to Aboriginal perspectives on health and healing:
The idea brought forward perhaps most often was that health and
welfare systems should reflect the interconnectedness of body, mind,
emotions and spirit - and of person, family, community and all life -
which is essential to good health from an Aboriginal point of view.253
However, as many of the presenters to the Commission observed, the
separation of resources and programs into isolated streams according to
jurisdiction (federal or provincial/territorial, on-reserve or
off-reserve, health services or social services, etc), as well as the
Western approach of specialization and expertise in health care and
social services (each problem with its particular specialist), has
presented many barriers to a holistic and interconnected approach to the
health and social problems within Aboriginal communities.254
The lack of coordination and collaboration due to jurisdictional
divisions has been a major and persistent problem for HIV/AIDS
programming in Canada.255 There are a number of initiatives
under way that are intended to improve coordination and collaboration in
HIV/AIDS programming - multilateral working groups, provincial
Aboriginal AIDS strategies, the Canadian Aboriginal AIDS Network.256
To the extent that these initiatives result in HIV/AIDS programs
designed by, appropriate to, and controlled by Aboriginal people
(recognizing the diversity of First Nations, Inuit and Métis cultures),
they move beyond the discrimination (lawful though it may be) inherent
in the bureaucratic structures (federal, provincial, and Aboriginal)
that are the legacy of the Constitution Act and the Indian Act
- structures designed for, rather than by, Aboriginal people.
Sex
Workers
Because women involved in street prostitution are stigmatized by
society, they cannot count on basic rights such as confidentiality,
health care, protection by the police or access to other services.257
In relation to HIV/AIDS, prostitute women are usually viewed as
vectors of transmission rather than people in need of treatment/support.258
The well-being of women involved in street prostitution depends as
much on access to adequate legal and social counselling and education
resources as it does on safety tips and health care.259
Current Epidemiology
There is considerable variation in the practices of sex workers and
the conditions affecting their health and safety. Studies of HIV
infection among sex workers often draw on samples that are not
necessarily representative of all types of sex workers. As a result, it
is difficult to generalize about the risks to the health of sex workers,
including the risk of HIV infection, from one locale to another.
Nevertheless, recent reviews of the literature offer the following
observations:260
• In Canada, as in other parts of the developed world, the prevalence
of HIV infection among female sex workers who do not use drugs is lower
than the prevalence of HIV infection among male sex workers and among
sex workers who use drugs.261
• Risks to health and safety, including risk of HIV infection, vary
with the type of sex worker: street prostitutes, escorts or prostitutes
who work indoors (often in so-called brothels), and women who work in
bars or saunas and provide sexual services, usually on a part-time
basis. Street prostitutes have tended to be overrepresented in studies
of sex workers, so that one must be cautious in generalizing on the
basis of such studies about the risks to the health of other types of
sex workers.
• There is a high rate of condom use with clients among female sex
workers who do not use drugs. This practice, already established before
the onset of the HIV epidemic, has contributed to relatively low rates
of HIV infection among these sex workers. However, factors such as
inexperience on the streets, threats of violence, economic pressure, and
drug use can affect sex workers' ability to refuse clients who do not
wish to use a condom. In addition, familiarity with regular clients,
which can blur the lines between commercial sex and private sex, can
lead to inconsistent condom use.262
• There is a much lower rate of condom use with personal partners
among female sex workers. There are a number of reasons for this:
condoms are associated with "work" and are a barrier to intimacy;
condoms represent a breach of trust in the relationship; the woman may
be attempting to become pregnant; there may be a threat of violence in
the relationship. As a result, sex workers may be more at risk in their
private lives than through their work.263
• Poverty, socioeconomic discrimination based on gender and race, a
history of sexual abuse, homelessness, lack of education, and drug use
are factors in people's decisions to provide sexual services and in
people's risk of HIV infection in providing such services. People
consulted in the preparation of this Discussion Paper observed,
for example, that single mothers tend to work the streets at the end of
the month, when their income from social assistance has run out. In
Toronto, the disproportionate number of street prostitutes who are black
is thought to be an effect of racial discrimination and lack of
employment for blacks.264 A study of male sex workers in
Vancouver found that, relative to other gay and bisexual men, male sex
workers were significantly more likely to be younger, non-white, less
educated, live in unstable housing, have a low income, and report
non-consensual sex, sex at a younger age, and drug use.265 An
investigation into the determinants of trading sex for drugs among 6004
drug users in the United States found that trading sex for drugs was
significantly associated (in order of decreasing statistical strength)
with being female, homelessness, lack of employment, and crack cocaine
use.266
Patterns of Stigma and
Discrimination
Sex workers live and work in an environment that stigmatizes and
marginalizes them in many ways. Personal and public disapproval of sex
work is expressed in the attitudes of communities, politicians, and
service providers, in local by-laws and police surveillance, and in the
criminal status of prostitution. Many sex workers are further
marginalized by involvement with the street, poverty, race, alcohol and
drug use, and, as with bisexual or transgendered sex workers, sexual
identity.
Street prostitutes are often the most marginalized of sex workers.
Street prostitution is illegal, whereas escort services are not - a
discriminatory feature of the law that has an adverse effect on poorer
sex workers. Street prostitutes are more vulnerable to harassment, and
are more likely than other types of sex workers to be arrested for
soliciting and imprisoned.267
The HIV epidemic has heightened and exposed the vulnerability of sex
workers to discriminatory attitudes, attention, and regulation. Sex
workers have been characterized as "vectors of transmission," a phrase
that ignores the fact that many sex workers use condoms more
consistently than other populations, that they frequently exercise more
responsibility than their clients, and that they are generally at a
higher risk of infection from their clients than vice versa.268
Research on sex workers has focused more on their working lives than
their private lives, even though many sex workers may be more at risk in
the latter than the former.269 Certain countries, such as the
United States, have introduced regulatory regimes comprised of mandatory
HIV testing and detention, overemphasizing, disproportionately, the role
that sex workers play in HIV transmission.270 Confidentiality
of HIV status is often breached, particularly for street prostitutes.
Word of HIV status is spread not only by other prostitutes, but also by
public officials. In the consultations for this Discussion Paper,
an incident was reported, for example, in which police, when detaining
an HIV-positive prostitute, loudly announced for all to hear that she
was HIV- positive.
The prospect of criminalizing HIV transmission is ominous for sex
workers:
[A]s a prostitute, you could be blamed as an easy scapegoat for
someone else's unsafe behaviour. You're an easily identifiable target
and the potential for this is really high.271
Indeed, in the Thissen case an HIV-positive prostitute was
charged with aggravated assault for biting a police officer, although
the risk of infection from biting was extremely small.272 As
Elliott observes, the charge was a misguided overreaction by police and
prosecutors: "while there is no question that biting someone constitutes
an assault, the HIV-positive status of the accused does not render a
mere bite an 'aggravated' assault."273 Media reports of the
case did not question the charge or the sentence; in fact, a Toronto
radio host suggested that the accused should have been executed rather
than given a sentence of two years in prison.274
Impact of Stigma and
Discrimination
Such attitudes, laws, and policies regarding sex work affect the
health, well-being and safety of sex workers, particularly street
prostitutes, and increase their vulnerability to HIV infection. Sex
workers are often disinclined to access health and social services on
account of the stigma associated with their occupation.275
By-laws regulating their activity, along with police surveillance, may
push them into less safe neighbourhoods, away from drop-in centres, and
beyond the range of outreach workers.276 Consequently, as one
person in the workshop on discrimination and HIV/AIDS reported, sex
workers are driven away from needle exchanges and other services aimed
at protecting their health. The illegal status of their activity can
prevent sex workers from prosecuting abusive clients and protecting
themselves from HIV infection:
The criminalization of sex for money means that hookers who are
subject to abuse from their customers are less able to report their
abusers. It also makes it difficult for them to insist on condom use
with their customers, and thus increases their chances of becoming
infected. In conversations I had with a number of women who were raped
by their customers, without condoms, they said that because their work
is illegal they are not willing to prosecute these men. Instead, they
maintain a "bad date" list and disseminate it to other hookers.277
Decriminalization and Protection
from Discrimination: Key to Effective HIV Prevention
According to a recent review of international policies and programs,
there have been three strategies to control HIV infection among sex
workers: regulating sex workers by mandatory HIV testing, treatment, and
in some cases detention; providing accessible and appropriate services
for sex workers through targeted programs and specialist clinics; and
enhancing the ability of sex workers to safeguard their health and
improve their position in the industry.278 The review
observes that there is no evidence that the first strategy, regulation,
has prevented HIV transmission:
Indeed, it has been argued that repression exacerbates the problem
since sex workers are further marginalized from health services in the
attempt to evade state restrictions on their work.279
Decriminalization and anti-discriminatory measures, on the other
hand, have been effective in reducing the risk of sexually transmitted
diseases and HIV infection:
[D]ecriminalisation of prostitution and anti-discriminatory measures
have been associated with low levels of infection and almost universal
condom use. In New South Wales, Australia, and in the Netherlands, legal
and social changes appear to have paved the way for more effective
health interventions within the sex industry.280
The review concludes that a combination of the second and third
strategies is required:
Targeted programmes are important in the short term for those with
higher prevalences of infection, including groups of prostitutes.
Specialist health care is an important occupational service for sex
workers, regardless of the relative prevalence of infection. However,
targeted control programmes and specialist health services can only
complement, not replace more broadly based interventions to the sex
industry as a whole and a general health infrastructure.28
FOOTNOTES
133 C Waldby et al. Epidemiological Knowledge and
Discriminatory Practice: AIDS and the Social Relations of Biomedicine.
Australian and New Zealand Journal of Sociology 1995; 31(1):
1-14.
134 Mann & Tarantola, supra, note 56 at 431-432;
Fisher et al, supra, note 5.
135 Federal Centre for AIDS Working Group on HIV Infection
and Mental Health, supra, note 73 at 44. Unless otherwise noted, the
stories and reports that follow were provided by individuals interviewed
in the preparation of this Discussion Paper or by participants in
the 15 January 1998 workshop on discrimination and HIV/AIDS.
136 Canadian AIDS Society. Critical Work: Sustaining
Men Who Have Sex With Men Programs in Canada. Ottawa: Canadian AIDS
Society, 1997, at 24, 26.
137 Health Canada. HIV/AIDS Epi Update: HIV and AIDS
Among Men Who Have Sex with Men. Ottawa, November 1997.
138 P Yan et al. Estimation of the Historical Age-Specific
HIV Incidence in Canada. XI International Conference on AIDS, Vancouver,
July 1996. Abstract no. Tu.C.573.
139 SA Strathdee et al. HIV Prevalence, Incidence and Risk
Behaviours Among a Cohort of Young Gay/Bisexual Men. 6th Annual Canadian
Conference on HIV/AIDS Research, May 1997. Canadian Journal of
Infectious Diseases 1997; 8(Suppl A): 24A. Abstract no. 204.
140 Fisher et al, supra, note 5.
141 Pryor et al, supra, note 36; Pryor et al, supra, note
37; Fish & Rye, supra, note 35; BA Le Poire. Attraction toward and
Nonverbal Stigmatization of Gay Males and Persons with AIDS: Evidence of
Symbolic over Instrumental Attitudinal Structures. Human
Communication Research 1994; 21(2): 241-279; Peters et al, supra,
note 33; Johnson et al, supra, note 33.
142 T O'Hare et al. Fear of AIDS and Homophobia:
Implications for Direct Practice and Advocacy. Social Work 1996;
41(1): 51-58. See also Le Poire, supra, note 141.
143 Adam & Sears, supra, note 80 at 67-70; T Myers et al.
Variations in Sexual Orientations Among Men Who Have Sex with Men, and
Their Current Sexual Practices. Canadian Journal of Public Health
1995; 86(6): 384-388; E Nonn et al. Dimensions identitaires,
appartenance à la communauté gaie et prévention contre le virus du sida.
6th Annual Canadian Conference on HIV/AIDS Research, May 1997.
Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 9A.
Abstract no. 104; E Nonn et al. Construction de l'échantillon à partir
d'une population difficile à définir: Diversité versus représentativité.
6th Annual Canadian Conference on HIV/AIDS Research, May 1997.
Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 9A.
Abstract no. 107.
144 See, eg, JP Stokes et al. Comparing Gay and Bisexual
Men on Sexual Behaviours and Attitudes Relevant to HIV/AIDS. XI
International Conference on AIDS, Vancouver, July 1996. Abstract no.
Tu.C.2404.
145 PGA Cornelisse et al. A Comparison of Risk Factors for
HIV Transmission Between Two Cohorts of Gay Men (1982-84 vs. 1995). XI
International Conference on AIDS, Vancouver, July 1996. Abstract no.
Tu.C.2393.
146 Ibid; Strathdee et al, supra, note 139; A Dufour et
al. Risk Behaviour and HIV Incidence among Omega Cohort Participants:
Preliminary Data. 6th Annual Canadian Conference on HIV/AIDS Research,
May 1997. Canadian Journal of Infectious Diseases 1997; 8(Suppl
A): 23A. Abstract no. 201; T Myers et al. Bisexual Men and HIV in
Ontario: Sexual Risk Behaviour with Men and with Women. 6th Annual
Canadian Conference on HIV/AIDS Research, May 1997. Canadian Journal
of Infectious Diseases 1997; 8(Suppl A): 23A. Abstract no. 203. For
evidence of continuing high risk behaviour in the United States, see LA
Valleroy et al. HIV and Risk Behaviour Prevalence among Young Men Who
Have Sex with Men Sampled in Six Urban Counties in the USA. XI
International Conference on AIDS, Vancouver, July 1996. Abstract no.
Tu.C.2407.
147 SL Martindale et al. Evidence of Psychologic Distress
in a Cohort of Young Gay/Bisexual Men. 6th Annual Canadian Conference on
HIV/AIDS Research, May 1997. Canadian Journal of Infectious Diseases
1997; 8(Suppl A): 8A. Abstract no. 102. These findings are comparable to
those of other studies on the risks faced by gay youth, as reviewed in
Health Canada. The Experiences of Young Gay Men in the Age of HIV.
Ottawa: Minister of Supply and Services, 1996, at 12-13.
148 Martindale et al, supra, note 147. Similarly, a survey
of 1314 bisexual men in Ontario found that 26.4 percent of the men had a
history of nonconsensual sex, and that, among those who had had sex with
both men and women in the year prior to the survey (1013), men with a
history of nonconsensual sex were significantly more likely to report
unsafe sex with both male and female partners; see C Strike et al.
Nonconsensual Sex and Unsafe Sexual Behaviour: Results from the Bisex
Survey. 6th Annual Canadian Conference on HIV/AIDS Research, May 1997.
Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 14A.
Abstract no. 124.
149 T Myers et al. The Canadian Survey of Gay and
Bisexual Men and HIV Infection: Men's Survey. Ottawa: Canadian AIDS
Society, 1993, at 57. In a subsequent report of the findings, the
researchers report that study participants with a positive attitude
toward being tested had a 40-45 times greater odds of intention to be
tested compared with those with a negative attitude. Low and high
intenders differed on each one of the four items included in the
"reasons for not taking the test" scale: "I do not want to know," "I do
not want my name on a government list," "It could affect my career or
insurance," and "It could affect my relationships." See G Godin et al.
Understanding the Intention of Gay and Bisexual Men to Take the HIV
Antibody Test. AIDS Care 1997; 9(1): 31-41.
150 Myers et al, supra, note 149 at 71.
151 Jürgens & Palles, supra, note 4 at 60-63, citing
extensive literature at nn 164 and 165.
152 I Hertz-Picciotto et al. HIV Test-Seeking Before and
After Restriction of Anonymous Testing in North Carolina. American
Journal of Public Health 1996; 86(10): 1446-1450.
153 Laryea & Gien, supra, note 81 at 254.
154 RB Hays et al, supra, note 75 at 425.
155 Ibid at 427-428; G Kadushin. Gay Men with AIDS and
their Families of Origin: An Analysis of Social Support. Health and
Social Work 1996; 21(2): 141-149, at 143, and the literature cited
there; JM Simoni et al. Disclosing HIV Status and Sexual Orientation to
Employers. AIDS Care 1997; 9(5): 589-599, at 591, and the
literature cited there.
156 Hays et al, supra, note 75 at 429-430.
157 Kadushin, supra, note 155 at 143-144, and the
literature cited there.
158 Adam & Sears, supra, note 80 at 105.
159 Ibid at 102-106.
160 Ibid at 95.
161 GM Powell-Cope, MA Brown. Going Public as an AIDS
Family Caregiver. Social Science and Medicine 1992; 34(5):
571-580 at 575-576.
162 Ibid.
163 Supra, note 155.
164 Pryor et al, supra, note 37.
165 Adam & Sears, supra, note 80 at 125.
166 Ibid.
167 Ibid at 132-133.
168 Jalbert, supra, note 81.
169 Simoni et al, supra, note 155.
170 Fisher et al, supra, note 5.
171 LH Calabrese et al. Physicians' Attitudes, Beliefs,
and Practices Regarding AIDS Health Care Promotion. Archives of
Internal Medicine 1991; 151(6): 1157-1169.
172 B Tremble et al. Health Care and Social Service Needs
of Gays, Lesbians, Bisexual and Transsexual Communities in Ontario. XI
International Conference on AIDS, Vancouver, July 1996. Abstract no.
Pub.D.1465.
173 Eighty-nine percent of the physicians who responded in
the study of Heath et al, supra, note 93, had provided care to gay or
bisexual men.
174 Kadushin, supra, note 155 at 144-145.
175 Fisher et al, supra, note 5 at 90.
176 Ibid.
177 D Brady et al. Transgendered People, Discrimination,
and HIV/AIDS. Canadian HIV/AIDS Policy & Law Our Sponsors 1996;
2(3): 6-7 at 6.
178 As Brady et al, ibid, explain, transsexuals are people
who are born with a core gender identity that is not congruent with
their external genitalia. Some transsexual people choose hormone
treatment and/or sex-reassignment surgery to bring their genitalia into
line with their core gender identity. Cross-dressers are people who
dress all the time as members of the opposite gender. Transvestites
dress in clothes of the other gender usually in the context of erotic
play. Drag queens are often performance artists. Transsexuals,
cross-dressers, and transvestites may be gay or straight; drag queens
are all gay men. The discussion that follows focuses primarily on
transsexuals.
179 Given the process required to change name and gender
in official documents, transgendered people often carry identification
that does not correspond to their gender identity and their chosen name.
180 Brady et al, supra, note 177 at 7.
181 This was reported in consultations for this
Discussion Paper. See also JM Grimaldi, J Jacobs. HIV/AIDS
Transgender Support Group: Improving Care Delivery and Creating a
Community. XI International Conference on AIDS, Vancouver, July 1996.
Abstract no. Tu.D.2953.
182 MJ Bennett et al. An Ethnographic Study of HIV
Infected Male-to-Female Transgendered Clients. XI International
Conference on AIDS, Vancouver, July 1996. Abstract no. Tu.D.2954.
183 Grimaldi & Jacobs, supra, note 181.
184 Brady et al, supra, note 177.
185 Grimaldi & Jacobs, supra, note 181.
186 Brady et al, supra, note 177.
187 See also the recommendations in Fisher et al, supra,
note 5 at 56.
188 This comment and those that follow are from minutes of
meetings of drug users in Vancouver.
189 Health Canada. HIV/AIDS Epi Update: HIV/AIDS Among
Injection Drug Users in Canada. Ottawa, November 1997.
190 Ibid.
191 SA Strathdee et al. Needle Exchange Is Not Enough:
Lessons from the Vancouver Injecting Drug Use Study. AIDS 1997;
11(8): F59-F65, at F61.
192 R Parent et al. HIV Among IDUs: Second Surveillance
Year of the Survidu Network. 6th Annual Canadian Conference on HIV/AIDS
Research, May 1997. Canadian Journal of Infectious Diseases 1997;
8(Suppl A): 27A. Abstract no. 220.
193 Health Canada. HIV/AIDS Epi Update: Risk Behaviours
Among Injection Drug Users in Canada. Ottawa, November 1997.
194 Ibid, with reference to Parent et al, supra, note 192.
195 New South Wales Anti-Discrimination Board, supra, note
22 at 68.
196 GM Herek, JP Capitanio. Public Reactions to AIDS in
the United States: A Second Decade of Stigma. American Journal of
Public Health 1993; 83(4): 574-577, at 575.
197 Mitchell, supra, note 60 at 221-237.
198 W Kornblum. Drug Legalization and the Minority Poor.
In: R Bayer, GM Oppenheimer, eds. Confronting Drug Policy: Illicit
Drugs in a Free Society. New York: Cambridge University Press, 1993,
at 115-135.
199 DB Kandel. The Social Demography of Drug Use. In:
Bayer & Oppenheimer, supra, note 198, 24-79 at 63-67.
200 Cruel and Unusual: Disproportionate Sentences for New
York Drug Offenders. Human Rights Watch 1997; 9(2), from a
summary posted on the Internet at http://www.hrw.org
201 Health Canada, supra, note 189.
202 Ibid.
203 P Millson et al. Prevalence of Human Immunodeficiency
Virus and Associated Risk Behaviour in Injection Drug Users in Toronto.
Canadian Journal of Public Health 1995; 86(3): 176-180.
204 Strathdee et al, supra, note 191 at F61-F63.
205 E Oscapella. Criminal Law and Drugs. In: Second
National Workshop on HIV, Alcohol, and Other Drug Use Proceedings.
Edmonton, Alberta. February 6-9, 1994. Ottawa: Canadian Centre on
Substance Abuse, 1994, at 38-40.
206 For variations in provincial policies, professional
practices, and professional views concerning dispensing syringes to
injection drug users, see T Myers et al. The Role of Policy in Community
Pharmacies' Response to Injection Drug Use: Results of a Nationwide
Canadian Survey. AIDS & Public Policy Journal 1996; 11(2): 78-88.
207 In Montréal, a policy of one-for-one exchange,
intended to encourage multiple visits and binding to a multifaceted
prevention program, was abandoned when it was discovered that frequent
attenders of needle exchange services had a higher rate of
seroconversion than non-attenders. See J Bruneau et al. High Rates of
HIV Infection among Injection Drug Users Participating in Needle
Exchange Programs in Montreal: Results of a Cohort Study. American
Journal of Epidemiology 1997; 146(2): 994-1002 at 1001.
208 Strathdee et al, supra, note 191 at F61-F63.
209 Ibid at F63-64.
210 Ibid at F64, citing EJC van Ameijden et al. Injecting
Risk Behaviors among Drug Users in Amsterdam, 1986 to 1992, and Its
Relationship to AIDS Prevention Programs. American Journal of Public
Health 1994; 84: 275-281. See also Bruneau et al, supra, note 207 at
1001.
211 HIV, AIDS and Injection Drug Use: A National Action
Plan. May 1997, at 18-21.
212 D McAmmond. Care, Treatment and Support for
Injection Drug Users Living with HIV/AIDS. A Consultation Report.
March 1997, at 9-12
213 Ibid at 9-15.
214 Supra, note 211 at 22, noting, in this regard, that
"[t]he Portland Hotel in downtown Vancouver is an excellent model of how
adherence to drug therapies can be facilitated. 60% of residents are HIV
positive. A nurse visits three times a day to ensure proper medication
is distributed: needles are available at the front desk."
215 These and other recommendations are included in the
report of the Task Force on HIV, AIDS, and Injection Drug Use, supra,
note 211 at 23.
216 Section 25.
217 Entrop and Ontario Human Rights Commission v
Imperial Oil Limited (1997), Ontario Court of Justice, Court File No
597/96.
218 Bill 142, 28 November 1997, Sched. B, section 5(2).
219 Bill 142, June 12, 1997, Sched. B, section 4(2): "A
person is not a person with a disability if the person's impairment is
caused by the presence in the person's body of alcohol, a drug, or some
other chemically active substance that the person has ingested, unless
the alcohol, drug or other substance has been authorized by prescription
as provided for in the regulations."
220 Supra, note 218, Sched. B, section 5(3).
221 Comment from minutes of a meeting of drug users in
Vancouver.
222 Supra, note 211 at 12.
223 J Epp. Achieving Health for All: A Framework for
Health Promotion. Canadian Journal of Public Health 1986; 77(6):
393-424 at 400.
224 Comment from minutes of a meeting of drug users in
Vancouver.
225 Ibid.
226 Ibid.
227 Supra, note 211 at 18.
228 Goldie et al, supra, note 65 at 75.
229 Healing Our Nations, supra, note 68 at 68.
230 S Matiation, supra, note 7 at 4.
231 S Matiation, supra, note 6 at 5.
232 Health Canada. HIV/AIDS Epi Update: HIV/AIDS
Epidemiology among Aboriginal People in Canada. Ottawa, November
1997.
233 Matiation, supra, note 6 at 3-4.
234 Royal Commission on Aboriginal Peoples. Report of
the Royal Commission on Aboriginal Peoples. Vol. 3: Gathering
Strength. Ottawa: Minister of Supply and Services, 1996.
235 Ibid at 54-86.
236 Health Canada, supra, note 232.
237 A McLeod. Aboriginal Communities and HIV/AIDS. A
Joint Project with the Canadian AIDS Society and the Canadian Aboriginal
AIDS Network. Ottawa: Canadian AIDS Society, 1997, at 10.
238 Healing Our Nations, supra, note 68 at 22.
239 Health Canada, supra, note 189.
240 Royal Commission on Aboriginal Peoples, supra, note
234 at 108.
241 Matiation, supra, note 231 at 6-7.
242 Health Canada, supra, note 232.
243 McLeod, supra, note 237 at 12.
244 Matiation, supra, note 6 at 12-13.
245 S Matiation. HIV/AIDS and Aboriginal People:
Problems of Jurisdiction and Funding. A Discussion Paper. Montréal:
Canadian HIV/AIDS Legal Network, 1998, at 21.
246 Canadian Aboriginal AIDS Network. Report of the
Aboriginal Consultation of the National AIDS Strategy Phase I-II.
September 22 - October 10, 1997. Ottawa: Canadian Aboriginal AIDS
Network, 1997, at 12.
247 Matiation, supra, note 6 at 29.
248 Matiation, supra, note 7 at 23-27.
249 Matiation, supra, note 6 at 5-6.
250 Canadian Aboriginal AIDS Network, supra, note 246 at
21.
251 Matiation, supra, note 6 at 6.
252 Royal Commission on Aboriginal Peoples, supra, note
234 at 209-215.
253 Ibid at 205.
254 Ibid at 207.
255 Matiation, supra, note 245.
256 Ibid at 29-34.
257 K Herland. Mobilisation/Intervention - What Have We
Learned? - Commercial Sex Workers. In: C Hankins, L Hum, eds. Women
and HIV National Workshop. Montréal, 13-14 March 1995. Montréal:
McGill AIDS Centre, 1995, at 24.
258 Ibid.
259 Ibid.
260 LA Jackson, A Highcrest. Female Prostitutes in North
America: What Are Their Risks of HIV Infection? In Sherr et al, supra,
note 74 at 149-162 (which presents information obtained through
extensive discussions with current and former female prostitutes in
major cities in Canada); S Day, H Ward. Sex Workers and the Control of
Sexually Transmitted Disease. Genitourinary Medicine 1997; 73:
161-168.
261 Jackson & Highcrest, supra, note 260 at 154-155; Day &
Ward, supra, note 260 at 163. For a summary of seroprevalence studies
among sex workers in Canada, see Division of HIV Epidemiology,
Laboratory Centre for Disease Control, Health Canada. Inventory of
HIV Incidence and Prevalence Studies in Canada. May 1997, at 31.
262 Jackson & Highcrest, supra, note 260 at 152-154,
155-156; Day & Ward, supra, note 260 at 165.
263 Jackson & Highcrest, supra, note 260 at 156-158.
264 Jackson & Highcrest, supra, note 260 at 153-154.
265 ML Miller et al. Characteristics of Male Sex Trade
Workers Enrolled in a Prospective Study of HIV Incidence. 6th Annual
Canadian Conference on HIV/AIDS Research, May 1997. Canadian Journal
of Infectious Diseases 1997; 8(Suppl A): 8A. Abstract no. 101.
266 WN Elwood et al. Powerlessness and HIV Prevention
among People Who Trade Sex for Drugs. AIDS Care 1997; 9(3):
273-282 at 282.
267 Jackson & Highcrest, supra, note 260 at 152.
268 K Bastow. Prostitution and AIDS. Canadian HIV/AIDS
Policy & Law Our Sponsors 1996; 2(2): 12-13 at 12.
269 Jackson & Highcrest, supra, note 260 at 149.
270 Day & Ward, supra, note 260 at 163-164; Elliott,
supra, note 3 at 19.
271 Elliott, supra, note 3 at 50, citing B Wolgemuth.
272 Elliott, supra, note 3, Appendix B at 13-14. For an
up-date, see R Elliott. Justice Delayed and Denied in Biting Case.
Canadian HIV/AIDS Policy & Law Our Sponsors 1997/98; 3(4)/4(1): 44.
273 Ibid at 73
274 Ibid at 17.
275 K Herland. Stella: Addressing Sex Workers' Risk for
HIV/AIDS in Context. XI International Conference on AIDS, Vancouver,
July 1996. Abstract no. Th.C.4640.
276 Bastow, supra, note 268 at 13.
277 Ibid.
278 Day & Ward, supra, note 260 at 163.
279 Ibid at 164.
280 Ibid at 166; see also Bastow, supra, note 268 at 13, n
18.
281 Ibid at 167.
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