Beyond Vulnerability: Breaking the Link Between Violence and HIV Risk for Young People

A growing body of research reveals a link between young people's exposure to violence and their risk for HIV.¹ Connecting the dots can help us better understand the various ways in which violence and stigma are linked to HIV risk in the lives of youth, and how policies and programs that address this violence constitute key prevention strategies.

A Multi-Headed Beast

Youth may face diverse forms of violence, from overt physical to more subtle kinds of aggression, from systemic exclusion to interpersonal violence. These include the following:

• Family violence -- physical, sexual and emotional abuse, as well as neglect and the rejection of being kicked out of their family and home.
• Peer violence -- the mean things people do to each other, such as verbal and physical bullying and deliberately shunning, humiliating or excluding a person.
• Sexual violence -- sexual harassment, assault, abuse and exploitation, which can put youth at direct risk for contracting HIV.²
• Hate crimes -- including homophobic, misogynist and racist verbal or physical violence.
• Institutional violence -- discrimination and the use of social power and control over groups to undermine their opportunities. For example, the legacy of residential schools or the way that heterosexism can exclude LGBTQ (lesbian, gay, bisexual, transgender and queer) people from some types of employment. Institutional violence can also limit official responses to bullying or hate crimes.
• War and other forms of armed conflict -- from wars between countries to violent government responses to their own citizens, or even gang wars in cities.

All types of violence occur in the context of societal structures that indirectly justify the oppression of less powerful groups, and sometimes turn a blind eye to acts of direct violence against them.³

The Impact of Violence: Stress and Trauma

Experiencing any type of violence causes stress and trauma physically, psychologically and socially. Profound or repeated trauma can activate the central nervous system's chronic stress responses and can cause a person to experience severe anxiety, insomnia, post-traumatic stress disorder and depression.⁴ The emotional impact of trauma -- including feelings of fear, shame and rage -- can also alter the way a person thinks about themselves and others.⁵ For example, a person might feel worthless as a result and think, "This is what I expect and deserve." He or she may withdraw from relationships and isolate themselves, finding it hard to trust other people or care about them. This can remove a person's support networks, making them feel alone and that they have nobody to turn to. This may be compounded by the reality that others sometimes avoid a young person who has experienced violence, for fear of being stigmatized themselves.

How do youth deal with the trauma and social isolation that can result from violence? Unfortunately, some coping strategies can increase a person's risk for HIV. Youth may use sex to seek love and support or use substances to try to manage their pain and distress.⁶ may be more likely to have unprotected sex because the low self-esteem and feelings of powerlessness that can result from a traumatic experience may make them less able to negotiate safer sex^2,7,8 or take measures to protect themselves.⁵ Using substances to cope can affect one's thinking and judgment and result in unprotected sex and young people may end up trading sex for drugs.⁹ These activities can all put a person at risk for HIV.

Unequal Risks for Violence and HIV

Young people who belong to stigmatized groups -- including youth who are Aboriginal,^10,11 who identify as LGBTQ^12,13 and/or who are homeless or street-involved⁸ -- are more likely to be targeted for violence and are also more vulnerable to HIV.^2,14 Consider the following:

• Aboriginal youth who have experienced the legacy of trauma within their communities (such as institutional violence that parents and grandparents experienced in the Indian residential schools) are at higher risk for sexual abuse and substance use.¹⁵ Among BC Aboriginal students, these risks are also linked to higher rates of sexually transmitted infections.¹⁰
• LGBTQ youth are also more likely to be exposed to HIV as a result of violence. They are over three times more likely to have experienced childhood sexual abuse than heterosexual youth, and more likely to report physical abuse by a parent.¹² This history of sexual abuse (and not sexual orientation) explains why lesbian, gay and bisexual high school students report higher levels of HIV risk behaviours than heterosexual students.¹³ When compared with other LGBTQ youth, those who experienced high levels of bullying in school are more likely to report HIV risk behaviours as young adults.¹⁶
• Street-involved and homeless youth are also more likely to experience violence, and a history of sexual abuse or neglect as a child or adolescent can lead to running away from home or being kicked out.¹⁷ Being homeless or street-involved is linked to trading sex, having unprotected sex and using injection drugs, all of which increase the risk for HIV. Abused youth may then experience more physical and sexual violence on the street,⁸ including sexual exploitation.¹⁴

Intersecting Vulnerabilities

Sexually abused or exploited youth -- who are often Aboriginal, LGBTQ and/or street-involved -- are particularly vulnerable to HIV.^2,14 These intersecting vulnerabilities put youth at greater health risks because they belong to more than one stigmatized group and are more likely to experience multiple kinds of violence. For example, youth who experience sexual abuse are also more likely to experience other kinds of maltreatment and witness more violence, which increases the likelihood that they will make sexual decisions that put them at risk for HIV.⁷ This is true for both girls and boys: sexually abused boys are much more likely than non-abused boys to have sex without condoms, to have multiple sex partners, and be involved in teen pregnancy.^17,18

Protective Factors in the Lives of Youth

Not all youth who experience violence end up with HIV; some survive or even thrive, thanks to positive influences in their lives. One of the most important of these is a sense of connectedness: feeling cared for by friends, family, teachers or other adults in the community. Supportive family members or other caring adults can help youth who have experienced violence feel connected and learn positive coping strategies.^10,18

Having one's basic survival needs met -- including food, stable housing and opportunities for education and employment -- can also help lower risks for HIV by reducing the pressure to trade sex for these basic needs.

It's also important for youth to have healthy ways to relieve stress; this includes physical activities (such as sports) as well as creative activities (such as theatre, visual art and music),¹⁸ which can help youth deal with difficult emotions and develop a sense of positive self-worth.