International Journal of Drug Policy 87 (2021) 103012 Available online 6 November 2020 0955-3959/© 2020 Published by Elsevier B.V. The Cedar Project: Historical, structural and interpersonal determinants of involvement in survival sex work over time among Indigenous women who have used drugs in two Canadian cities Richa Sharma a , Sherri Pooyak b , Dr. Kate Jongbloed a , Dr. David Zamar c , Dr. Margo E. Pearce d , April Mazzuca a , Dr. Martin T. Schechter a , Dr. Patricia M. Spittal a, * , For the Cedar Project Partnership a School of Population and Public Health, 2206 East Mall, Vancouver, BC, V6T 1Z3 b AHA Centre/ Canadian Aboriginal AIDS Network, 6520 Salish Dr, Vancouver, BC, V6N 2C7 c BC Children’s Hospital Research Institute, 950 W28th Ave, Vancouver, BC, V5Z 4H4 d BC Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4 A R T I C L E INFO Keywords: Survival sex work Indigenous women Canada Substance use Social determinants ABSTRACT Background: Indigenous women involved in survival sex work face multiple layers of discrimination, criminali- zation and alarming levels of intergenerational and lifetime trauma. This longitudinal study examined historical, structural and interpersonal factors associated with survival sex work involvement among Indigenous women who have used drugs in British Columbia (BC), Canada. Methods: The Cedar Project is an ongoing cohort study involving young Indigenous people who have used illicit drugs in Vancouver and Prince George, BC. Data was collected every 6 months from 2007 to 2016. Generalized linear mixed-effects modeling was used to model survival sex work involvement, defned as exchanging sex for money, drugs, food or shelter in the previous six months. Results: Among 292 participants, 34% reported their family always/often lived by traditional culture and 37% reported their family always/often spoke their traditional language. In contrast, 48% had a parent in residential school and 72% were removed from their biological parents. In total, 55% of women were involved in survival sex work at baseline. In adjusted analyses, those who were single (ARR: 1.91; 95% CI: 1.50–2.35), identifed as two-spirit (ARR: 2.16; 95% CI: 1.36–2.91), experienced sexual assault (ARR: 1.90; 95% CI: 1.22–2.58), were denied access to shelter (ARR: 1.71; 95% CI: 1.18–2.28), used crack daily (ARR: 2.85; 95% CI: 2.36–3.31), used injection drugs (ARR: 2.52; 95% CI: 1.98–3.07), and were unable to access substance use treatment (ARR: 1.58; 95% CI: 1.15–2.05) were more likely to be involved in sex work. Conclusion: Indigenous-governed, wellness-based harm-reduction interventions, and structural reforms address- ing housing insecurity and normalization of a culture of violence against Indigenous women, especially those involved in survival sex work, are urgently needed in Canada. List of abbreviations TRC – Truth and Reconciliation Commission Background Indigenous leaders in Canada are concerned that young Indigenous women and girls involved in survival sex work face structural threats and barriers to their wellness, rooted in discrimination, criminalization and intergenerational and colonial traumas (Christian and Spittal, 2008; NWAC, 2014). First Nations, Inuit and M´ etis women comprise 4% of the female population nationally (Arriagada, 2016). Yet, they are over-represented in sex work. Estimates of Indigenous women among all women involved in sex work vary, up to 50% in Vancouver, British * Corresponding author. E-mail addresses: richa.sharma@bcchr.ca (R. Sharma), sherrip@caan.ca (S. Pooyak), david.zamar@bcchr.ca (D. Zamar), april.mazzuca@alumni.ubc.ca (A. Mazzuca), martin.schechter@ubc.ca (M.T. Schechter), spittal@sm.hivnet.ubc.ca (P.M. Spittal). Contents lists available at ScienceDirect International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo https://doi.org/10.1016/j.drugpo.2020.103012