The Everyday Violence of Hepatitis C Among Young Women Who Inject Drugs in San Francisco

Abstract

A theoretical understanding of the gendered contours of structural, everyday and symbolic violence suggests that young addicted women are particularly vulnerable to the infectious diseases caused by injection drug use—especially hepatitis C. Participant-observation fieldwork among heroin and speed addicts in San Francisco’s Haight Ashbury neighborhood reveals that extreme levels of violence against women are normalized in the common sense of street-youth drug culture. Physical, sexual and emotional violence, as well as the pragmatics of income generation, including drug and resource sharing in the moral economy of street addicts, oblige most young homeless women to enter into relationships with older men. These relationships are usually abusive and economically parasitical to the women. Sexual objectification and a patriarchal romantic discourse of love and moral worth leads to the misrecognition of gender power inequities by both the men and women who are embroiled in them, as well as by many of the public services and research projects designed to help or control substance abusers. Despite deep epistemological, theoretical and logistical gulfs between quantitative and qualitative methods, applied public health research and the interventions they inform can benefit from the insights provided by a theoretical and cross-methodological focus on how social power contexts shape the spread of infectious disease and promote disproportional levels of social suffering in vulnerable populations.

Prince’s Fieldnotes August 1, 2001

“The other night Heather’s boyfriend beat her up so bad that it woke everybody up. He was hitting her with a tent pole and nearly killed her.”

I ask Nate why no one in the camp intervened. “It’s the code, Bridget. It’s her fight, that’s the deal. We can’t get involved”

Prince’s Fieldnotes August 3, 2001

Calamity tells me that her boyfriend beat her up last night in their camp in China Basin. She is angry about it, but her friends reassure her. “The harder he hits you, the more he loves you.”

The Haight-Ashbury neighborhood of San Francisco was the symbolic epicenter of the US anti-Vietnam War and hippie movements during the 1960s. Associated with sex, drugs, and rock-and-roll, “the Haight” continues almost half a century later, despite gentrification (Cavan 1972; Godfrey 1988) and an aggressive war on drugs to be a mecca for counter cultural youth. Even at the height of the popularity of psychedelic drugs in the late 1960s, however, the “Haight” hosted significant numbers of homeless amphetamine and heroin injectors of primarily working-class and lumpen origin (Howard and Borges 1970). Homeless injection drug users from poor backgrounds continue to have a visible public presence in the early 2000s. They range in age from their early teens to their early 40’s, with most being in their mid-to-late twenties. Despite the Peace/Love hippie symbolism of the neighborhood, they are enmeshed in a lifestyle in which violence against women is considered normative, as the opening fieldnotes suggest. Almost all the youth are white, and most consider racism and homophobia to be commonsensical.

Everyday Violence in the Haight

As part of an epidemiological hepatitis C prevention project for youth injectors the second author (Bridget Prince), conducted long-term participant-observation fieldwork primarily among a half dozen overlapping social networks of homeless young women in the Haight.¹ Attempting to document the everyday pragmatic logics and cultural context for why injectors engage in risky injection practices, the ubiquity of violence against women emerged as her central focus. Simultaneously the third author (Andrew Moss) directed an epidemiological project known as the UFO (not an acronym) that documented an almost 50% higher hepatitis C seroconversion rate among women. Females represented 30 percent of the overall sample of 844 under-30-year-old injectors that the UFO recruited at storefront sites in three neighborhoods—including the Haight—where youth congregate (Evans, Hahn, Page-Shafer, Lum, Stein, Davidson, and Moss 2003; Hahn, Page-Shafer, Lum, Bourgois, Stein, Evans, Busch, Tobler, Phelps, and Moss 2002).² In the conclusion, we discuss how the distinct theoretical and epistemological disciplinary traditions of ethnography and epidemiology made it difficult for us to combine our findings in a complementary manner in order to propose applied suggestions for interventions that prevent the spread of infectious disease among street-based youth injectors (see also Bourgois 2002; Moss 2003).

To make sense of our ethnographic data on the relationship between gendered violence and the heightened vulnerability of young women to hepatitis C infection, we draw on three theoretical categories of violence—symbolic, structural and everyday. This allows us to link individual risky behavior that is commonly associated with ignorance, psychopathology, or immorality to larger social power relations as well as to pragmatic constraints for survival as a street addict. The medical anthropologist Nancy Scheper-Hughes began using the term everyday violence in order to counter psychological-reductionist and individualistic understanding of social pathologies that blame victims for their self-destructive behaviors. She draws on the psychiatrist Franco Basaglia’s phrase “peace-time crimes” (Basaglia, Scheper-Hughes, Lovell, and Shtob 1987) in order to call attention to the institutionalized brutalities that are normalized and rendered invisible because of their routine pervasiveness (see also Scheper-Hughes and Bourgois 2004). She refers to everyday violence as the “small wars and invisible genocides” that plague the socially vulnerable and cause them to suffer inordinately (Scheper-Hughes 1996). This could characterize both the sexual and physical abuse regularly experienced by women on the street (once again conveyed in the opening field notes) as well as the fact of their disproportional hepatitis C infection rates (hence the title). A focus on everyday violence is especially important in anthropology because our participant-observation method often becomes embroiled in fine-grained observations of individuals that miss the invisible structures of power and historical context that are taken for granted by people when they are trapped in them (Wolf 1982). At the same time, by focusing on the phenomenological details of social suffering as it is lived by individuals, Scheper-Hughes’s concept avoids the economic reductionist and linear tendencies inherent to the related term, “structural violence” most prominently elaborated by the physician anthropologist Paul Farmer to demonstrate how social inequality is embodied by the poor in disproportional patterns of infectious disease (Farmer 2004, 1999). Structural violence has also been applied to gendered experiences of illness and disability in the public health literature in order to reveal its cultural and historical dimensions (Walter, Bourgois, Loinaz In Press).

To elaborate how macro-forces of structural violence affect intimate relations we take the term everyday violence in an explicitly political-economic direction in our analysis of substance abuse and interpersonal violence in the US inner city. Drawing on Bourdieu’s theory of symbolic violence as the mechanism whereby the socially dominated naturalize the status quo and blame themselves for their structural subordination in society’s hierarchies and injustices we suggest that the everyday violence pervading the lives of substance abusers exacerbates their misrecognition of the structural violence propelling their abusive behaviors (Bourdieu 2001). The socially vulnerable tend to lash out physically and emotionally against those closest to them—their loved ones and even against themselves. Consequently suffering in the inner city is often interpreted as being caused by immoral individuals living there rather than by political economic forces and/or by cultural belief systems such as patriarchal definitions of romantic love that legitimize the domination of women by older men (Bourgois 2003; Bourgois 2001).

Many of the youth injecting drugs in the Haight report personal childhood histories, not just of neglect, but also of dramatic physical and/or sexual abuse (Gloeckner 2002; Goldberg 1995; Ringwalt, Greene, and Robertson 1998). Most were expelled from high school and from their families, and a significant number have been institutionalized in foster care, group homes and/or juvenile hall. They consider violence to be a commonsensical way for resolving problems and for asserting hierarchies of prestige and belongingness. For example, an injector trying to impress an outreach worker about his commitment to harm reduction outreach messages, bragged in front of us about how he “beat up” an acquaintance for throwing his dirty needles, uncapped, on the ground in his shooting encampment in the park. Care and concern are frequently communicated violently; hence a young injector who was just beginning to switch from injecting speed to injecting heroin was proud of the fact that her speed-using friends were so worried that she was going to become addicted to heroin that they “beat me up when they found out I had started using heroin.” Merely the presence in the scene of a new, young unattached woman is enough to spark fights between the older men scrambling to for control:

Prince’s Fieldnotes October 30, 2001

As I walk into the front of the park I enter into the aftermath of yet another fight. There is a man, probably in his early 40s lying on the ground knocked out by the bathrooms. His nose and mouth are bleeding. Jack tells me that he was “coming on” to some much younger girl--“So we decided to deal with him.”

I have never met the woman before. She is new to the scene: blonde, maybe 18, in a flowery halter dress.

As the phrase “so we decided to deal with him” implies, violence is understood as an effective way to assert moral values. Bourdieu’s concept of misrecognition, which is the crucial component of symbolic violence whereby oppressive social relations are disguised so that they appear to be the natural order of things, applies to the common sense of relying on violence as an honorable and effective means for resolving problems and achieving goals.

Initiation and the Misrecognition of Sexual Predation

In this violent context, entering the street scene can appear terrifying to a newly arrived young woman. Simultaneously, however, she can also experience life on the street as exciting and welcoming—something she chooses. Young women are sought after by older males as potential sexual, romantic and income-generating partners. Consequently, immediately upon stepping into a new street scene, inexperienced women they are able to mobilize money, drugs, food, offers of shelter, etc. Most commonly this takes the form of casual, friendly offers of free drugs by acquaintances, and/or lecherous, predatory strangers. As Kate, a woman who ran away from home at age 16 and survived on the streets of the Haight for almost six years explains to Prince, the street offers a teenage girl more than merely a refuge from abuse, neglect and social rejection. It represents an exciting new world where she can feel accepted and even excel for the first time in her life:

In Texas where I am from I felt like such a loser, such an outcast. It’s just like I didn’t fit in my high school. And my mother she’s crazy. She couldn’t help me; she’s suicidal.

And when I came out here I wanted to be involved in the lifestyle. I thought it was cool and I knew I could do it well.

When I first started using, people were always giving me drugs. All the tweakers [speed injectors] in the front of the park treated me like a big thing. It’s the way people do stuff.

Of course the converse of this attention and these gifts are the manipulative power dynamics of males preying sexually on neophyte girls. Men occasionally talked openly and almost self-critically about the male competition for control:

I see a lot of guys getting young girls loaded so they can have sex with them. The guys like it when the girls can’t fix [inject] themselves. It’s power; the guys have power over the girls.

Like when I met my wife she had never tried heroin yet. She convinced me to fix her for the first time.

I didn’t want to at first but you know because of all those people I just told you about who fix little girls and fuck them…all I could see was her going off with one of these two other guys who we both knew and getting overdosed and raped if I didn’t fix her.

So I went off and fixed her. She wasn’t my wife yet.

Vulnerability to sexual predation, however, is not as transparent as this account implies. On the contrary it is often experienced as a form of power and agency on the part of the woman who finds herself competing with other young women to be the center of attention of older males. For example, after six years injecting in the Haight, Kate is critical of sexually abusive males but she remains trapped, nonetheless, in the logic of objectifying women’s bodies. She participates in the symbolic violence whereby women, as well as men, take for granted the legitimacy of a female competition to be sexy for men. This dynamic is imbued with moral judgment and individual blame:

“All the guys swarm around a new girl acting like they want to help her. They all want to be the first one to show her how to shoot up—hoping they will be the one that gets to sleep with her first.

When junkies see a young innocent girl they totally like to have that control thing. And if she is still pretty they are going to fuck her. They are going to use her until they don’t want her any more.

And then you start to get older; your body hurts. No one wants you.

Like look at Hurricane, she is 20 now. Have you seen a picture of her when she was 16 out here? She looks so different now. She was so cute then.

I remember when she used to come to the front of the park and say, “Have you seen Jason?” I was sleeping with Jason at the time and Hurricane was hella cute—she stole him from me.

Now she is so tore back. She will never, ever look the same again. Her teeth are rotting out, she picks at her face.

Similarly, Calamity, a charismatic 17 year-old who Prince watched arrive in the Haight at age 15, experienced her dramatic transitions into homelessness, speed, and then heroin addiction as a series of teenage love affair adventures. She complained once to Prince almost with a pout, “a new young girl just came into town and now all the boys are giving her attention instead of me.” A young woman like Calamity who basks in being one of the most sexually desired women in her social network and who is effective at hustling drugs because of her popularity, is alternately envied or condemned as a “ho” [sex worker]. The sexual naiveté or immorality of women becomes the subject of condemnation on the street, while the predatory behavior of men who demand sex in exchange for their gifts of drugs remains unexamined.

Extreme Vulnerability to Hepatitis C upon Initiation to Injection

From the public health perspective the risk of hepatitis C infection is especially high for neophyte women during their initiation phase into intravenous drug use (Doherty, Garfein, Monterroso, Brown, and Vlahov 2000). Patriarchal cultural scripts for behavior around the gender and sexual power dynamics translate into specific micro practices of risky syringe handling and ancillary paraphernalia sharing. An intimidated/excited adolescent girl who has only minimal knowledge of how to earn money and how to inject drugs does not yet understand or recognize the various potential infection vectors in the mechanics of drug preparation and injection. Most women can remember quite vividly their first injection episode. Kate, for example, is critical both of herself and the drug culture she had otherwise proudly embraced when she recollects her first time injecting:

I remember my first time getting high. It was with little Tommy—they say he is HIV positive now. It is not a good situation not knowing how to hit [inject] yourself. He had to prepare the shot and hit me. He grabbed the only syringe we had- it was already fucking used. I didn’t know what to do.

But back then I used to trust people more than I do now. And first he used the syringe before me and then he handed it back to me with a bottle of water pretending it was bleach telling me to rinse it.

I have bad veins like every other girl. I couldn’t hit myself. He had to hit me but he can’t find a vein at first so he hits in my foot and collapsed a vein in my foot.

Most fucking guys who go out with girls who don’t know how to hit themselves-who just started getting high are going to take advantage of those girls. I mean junkies are junkies. And I mean girls are dumb and everybody wants to be in love with someone and junkies are scandalous.

A straightforward demographic dynamic following the patriarchal logics of gender relations (older men dominating younger women) exacerbates the hepatitis C risk faced by young women during initiation.

The guys don’t care enough about the girls to make sure they have clean equipment. They just want a piece of ass.

And they are always older and most long-time IV drug users have Hep C. I could probably count the people that don’t on one hand.

With seroconversion rates of over 25% per year in San Francisco, injectors with several years experience on the street are more likely than not to be hepatitis C positive.³

Men are not necessarily solely interested in manipulating inexperienced women sexually or in displaying them as objects of prestige, and desire. They also often seek to control the material resources that women are able to generate. For example, Karla, who prides herself at having a boyfriend who is not abusive and who is seen on the street as an effective strong woman in control of her life, reflects back on her extreme vulnerability when she first began injecting. Her boyfriend was a veteran street injector and manipulated her artfully to obtain more than his share of the drugs they purchased together. At this point in the relationship Karla was not yet homeless on the street. She still had access to an apartment and was employed. She only frequented the drug scene initially in order to pursue her new boyfriend. It is common to see this kind of gradual initiation by young women seeking the companionship of a street-wise boyfriend. In contrast we never saw this occur among young neophyte men. In fact, in the Haight in the early 2000s it is rare to see boys in their teens among heterosexual drug injectors: ⁴

I remember the first time I fixed, I might have ended up using a dirty [syringe], I’m not sure. I didn’t know anything about it or about hep C at all. I was with my boyfriend; he was the first junkie I ever met. He made me pay for it. He met me downtown and we went up into this bathroom in this big skyscraper building that he knew about. I think he fixed first. He didn’t really let me see what he was doing.

As a matter of fact, for a long time he didn’t want me to know how to cook the dope up, how to prepare it and all. For months and months, maybe six months.

I wasn’t using that much. He would do most of the dope and just save me a small rinse of the cotton [used to filter the heroin as it is drawn up into the syringe out of the cooker] or whatever.

He was doing all the preparing and I think probably most of the time I ended up using the same needle as him.

The vulnerability of newcomer women to becoming infected with hepatitis C by an older, domineering boyfriend is exacerbated by the dynamic of sexual objectification and competition described earlier that divides women from one another:

Prince’s Fieldnotes May 14, 2001

A young girl walks by us in the park who we have never seen before. Melissa laughs at how young and naïve she looks. “I used to be like that; now I’m just a washed up 20 year old.”

The girl is walking fast up Hippy Hill with a man, presumably to share drugs. Melissa frowns, muttering “Hill ‘ho’” [park sex worker]. “There are a bunch of young girls out here now like that.”

I ask her why a girl cannot ask another girl on the street for information on how to inject safely. She says there is a very strong rivalry between the girls.

She tells me that it is hard to get information from other girls because there are fewer women on the street than men and that those who are around are in closed-off relationships. Most are caught in relationships where they are only allowed to use drugs with their partner. They cannot break away to shoot up with another girl and show her how to do it.

“I think women learn not to trust other women for some reason. I’m not sure how that happens or why. Maybe it is something that men do.”

Jealous Sexual Running Partnerships and Violence

It is difficult and dangerous for young women to remain independent and autonomous on the street. Their vulnerability to direct violence and sexual predation obliges them to enter into an exclusive “running partnership” relationship with a man. The stakes of violence are high as Calamity’s initiation into intravenous drug use illustrates.

Prince’s Fieldnotes December 15, 2000

I go to the hospital with an outreach worker to visit Calamity in the Intensive Care Unit. She was raped, strangled, stabbed and left for dead in Buena Vista Park last night.

When we arrive she is sitting up in bed and seems incredibly composed and physically stable even though the doctors tell us that she was very nearly killed.

I saw Calamity the day before her rape when she stopped by the Youth Outreach office obviously depressed. Her boyfriend, Panic, had “just dumped” her. She talked about wanting to get high on speed.

From her hospital bed she now explains in greater detail without showing any emotion or vulnerability:

“I was thinking about Panic, my boyfriend. I thought, ‘Fuck it! I’m not going to get really high if I just smoke this speed. So instead I decided to shoot it—my first time ever.

We headed to Buena Vista Park to camp for the night. Along the way we picked up our friend Tony. I’d known Tony for a few months so I felt pretty comfortable with him. Big mistake! Around 7:00 AM Tony went into my jeans pocket and took my pocketknife. I was sleeping. He then stabbed me four times in the throat and raped me.”

Several women with more extensive street experience than Calamity recognize consciously the imperative of finding a male running partner who behaves jealously in order to be protected from violence and sexual harassment. 20-year-old Hurricane, a four-year veteran of the streets, explains this dynamic without ambiguity:⁵

Girls are afraid that if they don’t fucking kick it with a guy then fucking like the next guy is going to come along and like…. you know hassle them.

Look at Emma. She is kicking it with Spun. He’s not a very good-looking guy at all. I mean he’s an older tweaker dude. He’s scary looking. But Emma will stay with him so that men like Gary and fucking Jon and all the other like younger guys won’t get to her, y’know?”

Gendered Contours of Police Enforcement

Most of the men in the Haight earn their money from selling small quantities of marijuana to upper middle class tourists and wealthy local residents. The escalation of the war on drugs in the early 2000s has increased the frequency of police sweeps. Within a matter of months most male street dealers have been arrested several times. The judges usually give arrested men probation sentences with conditional “stay-away orders” that exclude them from returning to the neighborhood. If they are caught returning, they are automatically incarcerated for two-to-four years. Often the women involved with men who are serving probation sentences take over the responsibility for selling marijuana.

Karla: I volunteered to start selling because Spike kept getting arrested. So I told him “Well the cops don’t really notice me. I’ll be able to sell and that will keep you out of jail. You don’t have to worry about it.

I just thought I was doing a really good thing for both of us. But he totally had very little regard for what I was doing for him. And he would steal from me in the middle of the night the money I had made selling weed—leaving me without a wake-up shot.

As Carla’s comment indicates, “…The cops don’t really notice me…” there is greater tolerance on the part of law enforcement officials for the illegal activities of young women on the street. Conversations with veteran police officers in the neighborhood suggest that it is harder for them to recognize the women as drug sellers. They identify young women as manipulated victims of older men and in an almost jealous concern over their sexual exploitation, they focus law enforcement on the men. Even officers hostile to public health approaches to substance abuse almost sound like liberal social workers when they talk about specific underage girls who they attempt to redeem rather than arrest:

Officer Saroyan: We know that they are preyed upon. I have heard of girls getting raped, girls selling themselves for the next high, you know. That’s how women get into prostitution. They get hooked on heroin and they are selling themselves. So I think they are very vulnerable from that standpoint.

They make unholy alliances with people. And it’s a shame to see. There is one girl I can think of right now, she just turned 18. She’s got an older boyfriend, she’s hooked on heroin and they’re selling marijuana to get by…I see her and every week she gets a little bit worse.

I try to talk to her.

“Why don’t you go back home; visit your mother; get yourself together; finish high school…stop hanging out with homeboy

A public defense lawyer who was extremely critical of arbitrary police repression of youth in the neighborhood specifically notes that women are treated more leniently than men:

If you are a young woman… there seems to be a little bit more general empathy from police officers.

[The judges] are also definitely easier on the girls. You got mostly male judges and they look and say, “Oh, my god. That could be my daughter.”

Notwithstanding paternalistic tendencies of sympathy for women the police usually do not intervene in public outbreaks of domestic violence. Instead, the overall strategy of law enforcement in the Haight revolves around expelling street people rapidly from the gentrified neighborhood.⁶ This has the unintended consequence of rendering youth injectors less accessible to the historically well-developed and youth-targeted social services operating in the neighborhood. Instead young street people flee to poorer, less policed neighborhoods, such as the dilapidated warehouse district known as China Basin. This is part of a larger pattern of contradiction between public health initiatives and law enforcement: The right hand of the public sector confiscates syringes to enforce the war on drugs, while the left hand attempts to increase access to syringes to promote public health. The effects of law enforcement are particularly hard on women because the isolation of a neighborhood like China Basin exacerbates violent dynamics among couples. Displacement to China Basin also increases the contact between youth-culture identified injectors with the older long-term homeless addicts and ex-convicts residing there. For example, all of the most extreme descriptions of boyfriends beating up girlfriends—such as the incident reported in the opening fieldnotes—took place in China Basin. Our fieldnotes contain several accounts of particularly vulnerable women disappearing from the radar screen of social services in the Haight when law enforcement forces them to move precipitously to China Basin.

Bourgois’ fieldwork notes May 25, 2001

At the youth needle exchange, Hurricane proudly announces that she was the first person in the Haight to hear that Jennifer, who now camps in China Basin, is pregnant. She says she is going to be the godmother and starts talking about loving families.

She halts abruptly in the midst of this upbeat conversation and bursts into spontaneous tears, wiping them silently from her eyes.

She then tells an outreach worker who is distributing clean cookers at the needle exchange that she is going to bring the pregnant Jennifer to see him because she is sure Jennifer will be happy to see him. She switches to telling Bridget--but for all of us to hear--that Heather is also now camping in China Basin where she has met a new boyfriend who beats her very badly: “He is even worse than her old boyfriend Cad.” She repeats this loudly several times, presumably hoping that one of the outreach workers or someone overhearing may be able to help Heather.

After the needle exchange closes, Bridget [Prince] explains that a judge issued Jennifer a stay-away order from the Haight last year for selling marijuana. The Haight Ashbury Youth Outreach Team has sought to provide Jennifer with pregnancy services when Hurricane alerted them to her condition a few weeks ago, but “we have gone out looking for Jennifer in China Basin, and we can’t find her camp.”

Some women switch to sex work when they are forced by the police to stop selling marijuana in the Haight. They usually move with their boyfriend to the Capp Street Stroll in the Mission where they are socialized into the even more physically abusive inner city-style of Latino pimp/prostitute relationship described in the ethnographic literature on that neighborhood (cf. Epele 2002) and critiqued in the larger literature on the violent subordination of sex workers to pimps in the U.S. inner city (Bourgois and Dunlap 1993; Maher 1997; Milner and Milner 1973).

Interpersonal Control and Hepatitis C

The relationships between young, moneymaking women and older men are often fraught with the intense jealousy and social isolation described in the domestic violence literature on batterers (Herman 1992). Men often attempt to increase their control over the resources generated by their female partner by refusing to allow her to inject with anyone else – whether male or female. Cat, for example, identifies this dynamic of social isolation and control in her relationship and generalizes to the women around her:

“Spike didn’t want me to talk to other people or hang out with other people. I would invite other people over and he would get mad.

Once you are in a relationship like that, it is really hard to meet new people. It’s a weird cycle. You end up just being by yourself.

Once Spike just freaked out and strangled me. He would not let me leave the hotel room. That was scary, because afterwards he would say how much he wasn’t into violence.

But I came to accept it and get used to it. It just becomes normal, y’know your standards of what you’ll take and what is acceptable really go down.

I mean like already you are homeless. People who aren’t on the streets treat you like shit. It is like second nature for you to be in a relationship where people treat you like shit.”

Control over the logistics of the injection process and over the dynamics of purchasing drugs takes on a special symbolic importance in relationships where the man survives off the income and drugs generated by his female partner:

Prince’s Fieldnotes March 29, 2001

Laura and Rob have been together three years and he is still the one who goes and buys the heroin. She isn’t even allowed to know the phone number of the connection. Rob also prepares the heroin.

Laura is currently earning all the money for heroin, cigarettes, food, rent—everything. She is stripping and turning tricks [prostituting] on the side and the money is sometimes good. She has a cell phone and often in the middle of the night she will get a call and have to go out and meet someone. She says Rob “kind of knows what I am doing but we don’t talk about it. I mean he can’t complain seeing as it’s not like he is going to go out and get a job.

Although she knows how to inject herself she lets her boyfriend do it every time. “Rob needs to control something so I let him control the drugs.” She explains that his mother abused him as a child and that he could not handle it if she was in control of everything—the money and the drugs. “It would mess with his self-esteem. So I just let him fix me. You can think of it as being like letting your husband choose the restaurant you are going to go eat at. It lets him feel like he has power… And it prevents a fight.”

Typically, the more violent and jealous the male partner, the more control he insists on maintaining over the logistics of the injection process:

For three years, I didn’t even watch my boyfriend prepare the drugs. He would just present me with a loaded syringe and fix [inject] me every time.

It’s the same with everyone out here. The guys like it this way. They like the feeling of having all that control over somebody. I mean it’s a really big amount of control. You are controlling how high someone gets; how sick someone gets. It makes the guys feel that the girl won’t leave. They are bound into that relationship.

From the public health perspective of preventing hepatitis C, these forms of jealous male control result in women being forced to engage in riskier injection practices. One of the strongest statistical associations with risky injection practices on our epidemiological project is “having an injection partner who is also a sexual partner” (Evans, Hahn, Page-Shafer, Lum, Stein, Davidson, and Moss 2003). One of the predictors of actual seroconversion to hepatitis C for both men and women is “sharing needles with an hepatitis C infected sex partner” (Hahn, Page-Shafer, Lum, Bourgois, Stein, Evans, Busch, Tobler, Phelps, and Moss 2002:1558).

Youth injectors usually treat male control over the logistics of injection as a natural fact of gender relations. It is dismissed as yet another case of boys will be boys. Cat conveys how the protective—and often physically abusive—man understands this expression of gender power relations to be an act of chivalry that justifies ongoing control:

Sometimes guys don’t even realize what they are doing. It is just instinct. It’s just the way society is: real patriarchal.

If you’re a guy, it’s like [raising and deepening her voice]: “I’ll take care of this”

It’s as if they think they are doing a good thing by being in charge of the drugs. They say they are trying to make sure their girlfriend doesn’t OD [overdose] or whatever.

The Symbolic Violence of Romantic Relationships

As several of the quotes and fieldnotes have suggested, most of the young women construct their relationships romantically. They see themselves as falling in love. As Carla notes above at the end of her description of the injection risks faced by novice women, “everybody wants to be in love with someone.” Unlike most of their middle-class adolescent counterparts in the suburbs, girls in the Haight are not simply pursuing harmless crushes. Instead they are mired in abusive relationships that are cemented by physical and psychological addiction. Their surrounding environment is shaped by physical and sexual violence as well as by an inconsistent level of police enforcement that keeps them unstable and intermittently on the run. Romantic love, consequently, becomes a central mechanism of the symbolic violence that misrecognizes male domination and violence against women and renders it the woman’s fault.

Heather’s account of trying to break up with her boyfriend emphasizes how her choice becomes one of tolerating the direct physical violence of her lover versus chronic sexual harassment or rape from street-based acquaintances, but she still insists on asserting that she loves her boyfriend:

Prince’s Fieldnotes August 30’ 2001

Cad beat Heather up so badly last week that she actually left him. It was nighttime and she had no blankets. She eventually found someone willing to share his blankets with her, but she woke up halfway through the night with the guy’s hands up her shirt and had to run away.

The next morning she made up with Cad and when she told him about what happened the night before he went and beat up the guy, but his battered victim turned out to be the wrong person.

This then caused another huge fight between Cad and Heather, which took place right in front of me. They were yelling into one another’s faces.

At one point Cad turns to me and hisses, “I want to kill her.” Heather shouts back defiantly “You are crazy.” Worried that it was going to escalate to blows I manage to get Heather to walk away with me by offering her an ice cream cone.

She is upset repeating over and over “I love him, Bridget I really do”

When Prince visited Hurricane while she was in jail for burglary for six months they conducted a soul-searching interview about addiction, violence and recovering from drugs. Hurricane, however, made sure to periodically pepper the serious and otherwise moralistic interview with adolescent girl talk. Once again, if the stakes were not so high and the class setting so different she might sound like any of her middle class counterparts in the suburbs: a bored adolescent girl with boys on her mind:

Prince Fieldnotes December 5 2001

Hurricane is enrolled in a GED program in the jail and has earned the privilege of going to the Law Library twice a week. She seems excited by that and when I ask her to elaborate her eyes light up and she says “BOYS!”

Hurricane identifies as a strong woman who refuses to be controlled by her boyfriends. Nevertheless, she considers it to be a sign of love and commitment when one of her boyfriends beats her up for going off with a female friend to inject heroin without him. She speaks almost with pride about the fact that “He doesn’t like it if he catches sight of me with somebody else: Once he strangled me until I passed out. He grabbed my shirt and threw me on the ground and started choking me.” Even though Hurricane is often critical of the way other women submit to violence in their relationships she sees herself as deeply in love with her violent man. Her romantic vision is a contradictory survival strategy under conditions that make it difficult for her to leave the relationship. Being in love shields her from acknowledging the abuse of the relationship while simultaneously trapping her inside it.

The everyday interpersonal violence that all the young women participate in forces them to try to appear to be tough, streetwise addicts. Consequently it is easy to forget the adolescent emotional turmoil that embroils the youngest ones. For example, we watched Calamity’s substance abuse patterns change a half dozen times when she broke up with boyfriends. On one occasion, she actually ceased using drugs for several weeks by establishing a relationship with a boyfriend who violently disapproved of injection drug use:

But he wound up dumping me for this junkie prostitute named Duchess, who he met on Polk Street. Last I heard they had gotten married in Reno.

So there I am single again. I move back into my dads trailer. That’s when I met Lee and started using heroin on a regular basis…

In these love-torn abusive conflicts the women start to appear almost as though they deserve the violence of the men that they fall in love with because they do it over and over. It is easy to forget about their childhoods of abuse and economic marginalization; as well as their current context of addiction and the omnipresent imperative of police repression exacerbating their social isolation:

Prince’s Fieldnotes March 5 2002

I see Hurricane for the first time since my last visit to her in jail three months ago where she was stalking “boys” in the jail library. She has just bought heroin. She immediately tells me that she broke up with Cad because he blackened both her eyes; hit her over the head; and then held her at knifepoint in the camp for six hours.

“But I’m sort of thinking of going back to him. We’ve been hanging out together again. He knows now that I will leave him if he does it again. It was only the speed that made him do it.”

I tell her that she “deserves better than that” and I am about to discuss her pattern of violent lovers when a police car passes.

“See you, Bridget. I gotta get out of here right now before that cop car turns around. [Calling over her shoulder as she runs] Come see me in China Basin!”

Outreach workers often discuss with frustration the equation between love and violence that Calamity epitomized in the opening quote: “the harder he hits you, the more he loves you.” They often despair of being able to help women and girls who keep returning to abusive boyfriends in the name of love. It is easy in this context to give up and leave a woman to the self-destructive vagaries of her heart. It almost becomes a defense mechanism for social workers facing burnout (Connolly 2000). When a woman or girl insists on remaining with an exceptionally violent man she is generally left alone because, as Prince is told in the opening epigram, “It’s her fight, that’s the deal. We can’t get involved.”

Romantic Agency and Hepatitis C Risk

The discourse of romance provides many women in the Haight with a sense of order and control over their lives. Even though it is rare for young women to remain physically autonomous and independent on the street this does not mean that they do not have agency within the context of poverty, racism and overwhelming oppression (Maher 1997; Measham 2002).⁷ Despite an evident lack of free choice over getting involved with men, women pursue very different survival strategies within the constraints of their income generating options and their cultural models for romantic love. Many women, for example, assert independence by entering into serial short-term monogamous relationships that they terminate rapidly. As Kate explains, “I change men faster than I change socks. I like being on my own. But I really do love Nate…” Even the strategy of serial monogamous relationships, however, is justified by a commitment to passionate love and redemptive romance. Kate and Calamity who strongly criticize women who remain in relationships with abusive, dominant men understand their own agency in rejecting and choosing men as a romantic act rather than an instrumental one:

Calamity: One time Sketch raised his hand to me I took out my smiley [bicycle chain with padlock] and told him if he ever raised his hand to me again I would fucking kill him, that and just about every other person in the park.

That’s why he broke up with me too, because I wouldn’t let him do that. I wouldn’t let him control me like that. He’d be like [making the motion of trying to stick a needle into Prince’s arm]

I was like “Dude, I can hit [inject] myself bro’. I don’t need you to do this.”

It used to piss him off. I think he liked the power control over it. I think that is why he is with Duchess now, dude because he beats her like crazy.

A side effect of refusing to tolerate abuse by having serial boyfriends is greater risk of hepatitis C infection.

In dramatic contrast to the women who assert their agency by changing their boyfriends, some women consciously exercise their agency by remaining in exclusive monogamous long-term relationships. The woman is generally exploited economically and abused physically, emotionally and sexually by her stable—usually jealous—lover. Women in these relationships do not spend time on the street socializing with friends. Once they earn their money they generally return to their boyfriend. This is certainly the case for Cat who earns her money selling marijuana and who supports her boyfriend, Spike, approximating the old-fashioned pimp/prostitute relationship. Cat however had a very different perspective. She interpreted her stable relationship with Spike as a rational strategy for bringing stability and companionship into her life on the street. She saw herself as minimizing unpredictable abuse by remaining subordinate to Spike. She identified and carried herself on the street as a strong, street-wise, effective hustler, but stayed faithful to her parasitical man. After attending a court-mandated drug treatment program for several months, she reflects on her long-term relationship with Spike during her previous four years on the street as an effective way of managing survival—despite his opportunistic behavior. She is explicit about the undesirability of remaining independent from a man:

It’s really not viable being alone. It gets freaky, y’know. There are a lot of predators out there. There are not really a large variety of guys on the street. You kind of pick the lesser evil.

I mean when Spike was in prison I was alone. I would run into all these fucked up people who were obviously just wanting to take advantage of the fact I was alone. Wanting me to get loaded or me to get them loaded or whatever, especially when I was smoking crack…it’s just hard.

So I just figured it wouldn’t be that much different if I left Spike. I felt really comfortable in that relationship, because he was someone I really knew well. Like maybe it was shitty sometimes, but I knew what to expect. He knew a lot about me. We really understood each other.

A side effect of these longer-term, socially isolated and often abusive relationships is a reduction in hepatitis C risk for the woman when she is lucky enough to have “chosen” an uninfected partner.

Conclusion: Linking Hepatitis C Prevention and Gendered Violence

The epidemiological public health model for applied research focuses on developing interventions that change the behaviors of individuals. We found, however, that most of the street injectors, with the exception of newly arrived adolescent girls, are knowledgeable about the biological transmission mechanisms of hepatitis C. They are not able to act on that knowledge, however, because they are too overwhelmed by everyday gendered violence. A hepatitis C intervention that strives to reduce the disproportionate seroconversion rate of women might be more effective if it begins by focusing its messages and programs on the social dynamics of gendered violence before attempting to address the micro practices of injection that physically transmit virus molecules. Public health outreach workers must understand how people experience their romantic relationships and their social hierarchies and moralities. They also need to be fully conversant with the pragmatic logics for taking risks in the context of everyday violence. This is not an impossible challenge. As Prince documented, women prefer to talk about sexual power relations rather than about the details of the hepatitis C injection risks they engage in when they inject every day. They were eager to talk to Prince for hours on end about love, betrayal and violence among their friends and enemies. Sometimes this unfolded in the context of gossip and at other times as intense confession.

Safe injection messages are usually delivered almost without reference to the social context of power relations in which risky behaviors occur. Little connection is made between the forces constraining the lives of injectors and their risky practices. Most notably, discussions of safe injection practices are rarely linked to gendered violence. Outreach workers find themselves obliged to talk about violence with women on the street because that is what most overwhelms women on a day-to-day basis. These discussions, however, are not considered relevant to hepatitis C prevention. Time spent on women’s issues is understood as time not spent promoting sanitary injection practices when in fact the reverse may be true from a practical perspective. Prior to conducting the ethnography, Prince was employed for two years as an outreach worker for youth injectors, and she experienced this conflict directly. She was sensitized personally and humanely to the importance of violence in the hierarchies of risk confronting women. She even organized an intervention to specifically address intimate partner violence. Nevertheless, she did not make a purposeful connection between that work on violence and the primary goal of her outreach program, which was defined as promoting safe injection to prevent the spread of infectious diseases (HIV, hepatitis C, abscesses) and of overdoses.

The hepatitis C prevention literature does not identify gender as an independent variable capable of predicting seroconversion or serostatus because the vulnerability of being a woman on the street is embedded in too many complicated logistical practices that all have risky consequences (Bastos and Strathdee 2000; Evans, Hahn, Page-Shafer, Lum, Stein, Davidson, and Moss 2003; Hagan and Des Jarlais 2000). Specifically, the UFO epidemiological project we collaborated with identifies the acts of “sharing injection equipment” and “pooling money to buy drugs” to be the principal risk factors for hepatitis C infection (Hahn, Page-Shafer, Lum, Bourgois, Stein, Evans, Busch, Tobler, Phelps, and Moss 2002). Although the UFO documents an elevated risk of seroconversion among women (34.4% versus 23.4% for men), the elevation is not large enough, given the size of the study, to reach what epidemiologists call “statistical significance.” Statistical significance is calculated according to a set of mathematical assumptions about both the data and the world, and is the conventional way of distinguishing empirical observations that will be considered important or valuable from those that are thought to be merely due to chance variation. Thus in the UFO data, the relationship between HCV seroconversion and gender is suspected of being a coincidence caused by statistical noise. The theoretically-informed ethnographic findings on gender violence reported here that anthropologists would consider important to explain the heightened vulnerability of young women to hepatitis C appear only as tentative speculation in the reports published by the UFO. Instead, the epidemiologists report the variable “being first injected by a sex partner” as a statistically significant predictor for hepatitis C seroconversion among both men and women (Hahn, Page-Shafer, Lum, Bourgois, Stein, Evans, Busch, Tobler, Phelps, and Moss 2002). Similarly, “having an injection partner who is also a sexual partner” has a strong statistical association with self-reporting the kinds of risky injection behaviors that spread hepatitis C, i.e. “borrowing a used needle” and “sharing drug preparation equipment” (Evans, Hahn, Page-Shafer, Lum, Stein, Davidson, and Moss 2003), consequently, from a strictly quantitative perspective the everyday violence of gender power relations can easily be overlooked in favor of a focus on micro injection practices. The quantitative literature on Hepatitis C is full of unexplained findings. For example, even though the virus is not transmitted sexually a similar strong statistical association between having a sexual partner who injects drugs and heightened risk of hepatitis C seroconversion has been published by several other major epidemiological studies across the United States (Hagan and Des Jarlais 2000; Johnson, Gerstein, Pach, Cerbone, and Brown 2002; Montgomery, Hyde, De Rosa, Rohrbach, Ennett, Harvey, Clatts, Iverson, and Kipke 2002). Gendered findings on HIV infection have also often been dissonant in the quantitative literature, suggesting the need to contextualize socially the associations that survive the test of statistical significance. For example, long-term retrospective analyses of HIV seroconversion among heterosexual injectors identify “having a sexual partner” as risky for women but protective for men (Collier, Kotranski, Semaan, Lauby, Halbert, and Feighan 1998; Strathdee, Galai, Safaiean, Celentano, Vlahov, Johnson, and Nelson 2001).

The epidemiological literature does not interpret the added risk of the variable “having a sexual partner” within the context of the everyday violence of gender power relations because of how statistical data is collected and analyzed.⁸ They look carefully at the mathematical size of the effect which is difficult to measure in relatively small samples. Does the fact that the UFO did not find a statistically significant increased hepatitis C seroconversion risk for women contradict our ethnographic findings? Not necessarily. The fifty percent increased risk of seroconversion among women documented by the UFO is data that epidemiologists would consider “non-negligible” and worthy of further examination even when it is not statistically significant. They find it more reasonable to focus on statistically significant findings based on variables that are more amenable to quantification. Consequently, many of the epidemiological conclusions are driven by the logistics of managing sample sizes. The UFO study, for example, observed only 48 seroconversions among 195 people who had follow-up blood tests. Its “statistical power” consequently is relatively low, rendering its findings on gender only tentative. More importantly, social or cultural processes like gendered violence are complex to operationalize quantitatively via questionnaires and are difficult to measure with quantitative precision. As a result, epidemiological investigations of blood-borne pathogens tend to focus on the micro details of injection practices, which are easier to quantify as discrete variables. Furthermore, the emotional nature of violence as a subject is difficult to explore in a structured interview and requires the provision of psychological support for respondents. Epidemiological studies need long lead times and this prevented violence and the relationships between gender power relations and injection behavior from being included in the UFO study even after we began reporting our ethnographic findings to our epidemiological colleagues.

Epidemiologists “follow the numbers” and when social processes are not identifiable or are only “marginally significant”—such as the association between gender and hepatitis C seroconversion on the UFO project—they become marginal to the epidemiological analysis. Thus they may not be subsequently translated into applied public health recommendations. Instead, messages and programs are developed primarily around the logistics of micro-behaviors that are more amenable to quantification and that usually do not engage the structures of social power that from an ethnographer’s perspective promote the spread of hepatitis C among the socially vulnerable, but which from an epidemiologist’s perspective, are hard to study. As a result, public health messages often contradict the hierarchies, reciprocities--and in this case the everyday violence--that prevent injectors on the street from following safe injection practices that appear to be rational and straightforward in a clinical or office-based setting.

Everyday violence needs to be addressed directly by public health outreach otherwise safe injection messages may remain just another sanitary admonition that at best is ignored and at worst become a mechanism of symbolic violence whereby women living on the street blame themselves for their high infection rates. Hepatitis C is especially vulnerable to this kind of normalization because it is highly infectious and prevalence rates among older addicts in most cities in the United States hover around 80%. Many injectors consider infection with hepatitis C—like the everyday violence of gender relations--to be part of the natural, inevitable order of things in their world of street-based addiction

To create pragmatic interventions public health has to rise to the theoretical and logistical challenges of cross-methodological dialogue and engage with the social power categories that tend to be erased by epidemiology’s focus on quantifiable micro-practices rather than larger “webs of causation” (Krieger 1994). This raises an interesting science studies contrast with political and practical implications. In anthropology ethnographic data that is consistent with a theoretical understanding of larger social categories (like gender) is considered more persuasive. In epidemiology assertions based on theories of power relations that do not translate into statistically significant numbers are distrusted for being potentially ideologically biased. Disagreements over these epistemological and political issues are not usually discussed openly—or even recognized. Instead they become complicated arguments over techniques of appropriate statistical calculations. Combining Michel Foucault’s understanding of the way populations internalize disciplinary power in the name of science and progress (1981) with Bourdieu’s analysis of how oppressive structures of inequality are systematically misrecognized, public health’s goal of providing young women on the street with detailed information on how their micro-practices infect them with Hepatitis C, inadvertently hides the brutality of everyday violence on the street at the same time that it does little to reduce infection rates.