The Summit was pleased to host a special panel on intimate partner violence, sponsored by the Public Health Agency of Canada. Intimate partner violence is an emerging field of HIV research, with service providers increasingly aware of the role violence plays in HIV risk and health outcomes.
Experiences of Violence among Street-Involved Women in Canada
Kate Shannon, Director of the Gender and Sexual Health initiative at the BC Centre for Excellence in HIV/AIDS, presented the results of several studies related to female sex workers and other marginally-housed or street-involved women, explaining that these women experience an elevated risk for violence.
Shannon argued that the criminalization and policing of sex work can perpetuate violence against women by forcing marginalized populations into isolated places due to fear of police harassment. She emphasized that, in Canada, there is also serious concern over missing and murdered Indigenous women, who are overrepresented in street-involved populations.
Citing early results from the AESHA study, which was still in progress at the time of the Summit, Shannon reported that, of 800 Vancouver sex workers in the study sample, 25% or more reported sexual violence, 50% reported physical violence, and that the violence came from partners, clients, police and other authority figures. Violence had a negative impact on the women’s ability to negotiate condom use, and also shaped access to HIV care. Sex workers living with HIV also experienced treatment interruptions due to incarceration, which, together with violence, predicted poor treatment outcomes.
Shannon noted that a recent paper from Elena Argento et al. demonstrates a high prevalence of intimate partner violence among sex workers: 25% of sex workers in Argento’s study experienced moderate to severe physical and sexual violence, especially those who were dependant on partners for drug use or had a partner who was economically dependent on them.
Results from a 2011 paper, co-authored by Shannon, illustrate how male-dominated housing models, including single room occupancy (SRO) hotels, can be unsafe for street-involved women. In this qualitative study, women spoke about harassment and threats of violence, which led them to use strategies like couch surfing – which also put them at risk – to stay out of these environments.
Shannon concluded by noting that, in Vancouver, women-only supportive housing models have become a promising alternative. These environments have sign-in of visitors, condom distribution on site, supportive guest policies that allow women to bring partners and clients into their rooms, supportive managers who intervene in altercations and police who remove violent partners or clients from the building.
- The AESHA study
- Argento’s paper on violence among sex workers at Pols One
- The Lancet Series on HIV and Sex Workers
Violence and Stimulant Use among Homeless Women in the United States
Elise Riley, a researcher from the University of California, discussed the results of a study into homeless and unstably-housed women in San Francisco, emphasising that crack cocaine use is one of the strongest predictors of negative health outcomes among this population. Results from her study reveal that men and women have different experiences with crack and homelessness, and that violence against women mediates and influences their other health outcomes.
Riley and her colleagues used the SF36 measure to rank factors that influenced physical and mental health outcomes among 227 homeless and unstably-housed adults, and discovered that mental health outcomes for HIV-positive women were most influenced by:
- unmet subsistence needs (food, clothing, housing)
- high adherence to ARV
- having a close friend
- using crack cocaine
- sleeping on the street
- cocaine withdrawal
- adverse alcohol use
- and not having instrumental support (someone to borrow money from or provide a place to sleep).
The results for men were different, in that crack use, withdrawal and sleeping on the street were not among the strongest predictors for mental health outcomes, as they were for women.
Based on these findings, the research team began a qualitative study to understand this gender difference. Women who participated in the study were asked what they did when they didn’t have a place to sleep, and their answers revealed that negotiations for housing mirrored the drug-sex economy, in which housing was traded for sex and relationships were often violent.
Riley explained that many of the women she spoke to were trying to extricate themselves from the downtown Tenderloin neighbourhood, and deliberately tried to isolate themselves in the meantime by holding up in their rooms. Over 50% of women in the study reported some form of violence in the past six months from neighbours, strangers, ex-partners and family members. Violence was more common if the women used cocaine or if they reported adverse alcohol use, psychiatric diagnoses and unmet subsistence needs. Riley emphasized that these were bidirectional relationships, meaning that women who experience violence are at risk for cocaine use and women using cocaine are also at risk for violence. Among women who were not using stimulants at baseline, homelessness and sexual violence were both predictors of stimulant use within the next six months.
Screening for Intimate Partner Violence among Men Living with HIV
Intimate partner violence really knocks people off balance and interferes with their ability to keep themselves safe
Conall O’Cleirigh, of the Harvard University Centre for AIDS Research, described the experience of introducing an intimate partner violence screening questionnaire at Fenway Health. He explained that researchers have known for some time that people do less well managing HIV in the presence of depression, PTSD and active substance use, and that nearly 40% of gay and bisexual men have histories of childhood sexual abuse. Intimate partner violence has emerged as a related intersectional factor, especially given that people who experience trauma as children are more likely to experience trauma as adults.
O’Cleirigh explained that one challenge in implementing an intimate partner violence questionnaire is that violence is a structural, syndemic issue that psychologists cannot treat directly. He noted that it doesn’t always make sense for providers to spend time collecting information they aren’t able to act on, and that Fenway was able to develop a simple, four-question survey to meet this need:
- In the last year, have you felt isolated, trapped or like you are walking on eggshells in an intimate relationship?
- In the last year, has your partner controlled where you go, who you talk to, or how you spend money?
- In the past year, has someone pressured or forced you to do something sexual that you didn’t want to do?
- In the last year, has someone hit, kicked, punched, or otherwise hurt you?
Just under 10% of patients who’ve taken the screening survey answered yes to at least one of the questions, and O’Cleirigh noted that bisexual men and women were much more likely to answer yes than heterosexual or gay and lesbian patients. Based on preliminary data, it appeared that trans patients were also more likely to report intimate partner violence. Patients reporting intimate partner violence were less likely to adhere to their HIV medication and less likely to arrive for scheduled appointments.
In an interview with OHTN staff, O’Cleirigh was asked about differences in the way heterosexual women and gay or bisexual men experience intimate partner violence. “In heterosexual relationships the man is often the aggressor, if not almost always the aggressor,” he said. “Sometimes, in same-sex relationships that are characterized by violence, it’s not always possible or therapeutically important to identify an aggressor and victim. There’s generally maladaptive patterns that are present. That’s a complicating factor, and I don’t think we know enough about how that plays out.”
Introducing Routine Screening for Intimate Partner Violence in Clinics
John Gill, Medical Director of the Southern Alberta HIV Clinic, shared how the discovery that one of their patients had been murdered by her common-law partner led the clinic to adopt a new intimate partner violence screening protocol.
Gill explained that Alberta has the highest incidence of intimate partner violence in Canada, and that violence is prevalent not just among women living with HIV, but also among men living with HIV, particularly Indigenous men. He noted that research has demonstrated the negative impact violence can have on engagement with care, mental health and missed appointments.
After implementing the screening tool, which was developed by a sexual assault program, uptake expanded so that now 80% of the clinic’s 1600 patients are screened, and a protocol is in place to do an immediate safety assessment if intimate partner violence is reported.
Results from the screening tool have shown that 23% of the clinic’s patients report experiencing intimate partner violence as adults, and many were abused as children. Gill noted that this was an issue his team was still researching.
Gill explained that, at one point, concerns were raised about the danger of re-traumatizing patients during the interview, so the team asked patients for feedback on the questions – whether they should be asked at all and, if so, by whom and how often. Responses showed that patients were overwhelmingly in favour of including these questions once a trust relationship had been established. Patients emphasized that providers should continue to ask at every visit, as living situations can change.
Because the clinic also collects information on housing stability, Gill was able to demonstrate that unstable housing was twice as common among patients who reported intimate partner violence, and that housing instability itself was associated with lower CD4 counts, alcohol use, injection drug use and incarceration.