“Bed Bugs and Beyond”: An ethnographic analysis of North America's first women-only supervised drug consumption site

Abstract

Background

Attention to how women are differentially impacted within harm reduction environments is salient amidst North Americas overdose crisis harm reduction interventions are typically ‘gender-neutral’, thus failing to address the systemic and everyday racialized and gendered discrimination, stigma, and violence extending into service settings and limiting some women’s access. Such dynamics highlight the significance of North America’s first low-threshold supervised consumption site exclusively for women (transyender and non-binary inclusive), SisterSpace, in Vancouver, Canada. This study explores women’s lived experiences of this unique harm reduction intervention.

Methods

Ethnographic research was conducted from May 2017 to June 2018 to explore women’s experiences with SisterSpace in Vancouver’s Downtown Eastside, an epicenter of Canada’s overdose crisis. Data include more than 100 hours of ethnographic fieldwork, including unstructured conversations with structurally vulnerable women who use illegal drugs, and in-depth interviews with 45 women recruited from this site. Data were analyzed in NVivo by drawing on deductive and inductive approaches.

Findings

The setting (non-institutional), operational policies (no men; inclusive), and environment (diversity of structurally vulnerable women who use illegal drugs), constituted a space affording particioants a temporary reprieve from some forms of stigma and discrimination, gendered and social violence and drug-related harms, including overdose. SisterSpace fostered a sense of safety and subjective autonomy (though structurally constrained) among those often defined as ‘deviant’ and ‘victims’, enabling knowledge-sharing of experiences through a gendered lens.

Conclusion

SisterSpace demonstrates the value and effectiveness of initiatives that engage with socio-structural factors beyond the often narrow focus of overdose prevention and that account for the complex social relations that constitute such initiatives. In the context of structural inequities, criminalization, and an overdose crisis, SisterSpace represents an innovative approach to harm reduction that accounts for situations of gender inequality not being met by mixed-gender services, with relevance to other settings.

INTRODUCTION

Feminist scholars continue to articulate the ways gender, intersecting with race, ethnicity, class, sexuality and other social locations matter, demonstrating how intersectional analyses can serve to identify important gaps in the literature (Boyd, 2015; Boyd et al., 2018; Campbell and Collins et al., 2019; Herzberg, 2017; Iversen, Dolan, Ezard & Maher, 2015; Iversen, Page, Madden, Maher, 2015; Maher & Hudson, 2007). Women’s everyday lives are structured by socially constructed gender categorizations and identifications—gendered, classed and racialized stratifications that influence and are influenced by drug policies and practices that subject women to formal and informal regulation (Fraser & valentine, 2008; Boyd, 2015). This research has challenged biomedicai discourses about drugs and addiction by highlighting how such conceptions are shaped by historical, cultural, and social norms. Gendered discourses regarding risk shape the governance of drug use (i.e., policies and interventions) and the diverse ways in which women who use illegal drugs are penalized for transgressions of normative gender stereotypes, perceived as being victims (lacking agency) and/or inherently more deviant tnan men who use drugs and, in turn, subject to gendered, classed and racialized forms of regulation (e.g., the governance of reproductive and maternal rights) (Boyd, 1999, 2015; Campbell, 2000; Campbell and Herzberg, 2017; Ettore, 2010; Knight, 2015; Maher, 1990, 1992; Paltrow & Flavin, 2013). Documenting women’s lived experiences of drug use, drug policy and drug-based interventions, including women-only harm-reduction services, offers a distinctive vantage point for feminist and critical drug studies, while further recognizing women’s perspectives in an area historically narrated/documented and evaluated through men’s experiences (Campbell and Herzberg, 2017). In this article, we consider women’s experiences at a women-only (transgender and non-binary inclusive) supervised consumption site. Drawing on a critical ethnographic study, we analyze the ways in which these accounts on usage and impact of the site are co-produced within social relations, producing particular ‘affordances’ less often elucidated.

Approach

Women who use illegal drugs experience pervasive stigma and stereotyping that reduces them to a few fixed naturalized characterizations (Hall, 1997) that results in discrimination and health inequities, and is further distinct from that experienced by men. For example, some women who use illegal drugs are constructed as hyper-sexual, pathological, criminal, and as unfit parents (Boyd, 2015; Bungay et al., 2010; Campbell & Ettorre, 2011). Stereotyping produces stigma, which operates as a technology of power or means of social control that is politically productive (Fraser et al., 2017). Thus, the ubiquitous stigma related to ‘addiction’ has differential outcomes for women, while still further intersecting with other social locations such as race, ethnicity, sexuality, socio-economic status (Fraser et al., 2017).

The concept of structural, symbolic and everyday violence further provides a useful lens for examining the intersecting processes of discrimination, stigma, and exclusion in the lives of women who use illegal drugs. Structural violence describes the interconnected social structures, such as patriarchy, colonialism, capitalism, and drug criminalization, that contribute to the perpetuation and normalization of inequities (including health disparities), and the social (re)production of oppression, social suffering and risk (Farmer, 2004; Farmer, 2009; Rhodes et al., 2012). Symbolic violence is the legitimation of hegemonic norms by naturalizing, or rendering invisible, the mechanisms of social inequality (Bourdieu, 2001; Scheper-Hughes, 1996). Together they have embodied consequences which intersect to shape the ‘everyday’ violence experienced by women who use illegal drugs (Bourgois, Prince, & Moss, 2004; Bungay et al., 2010; Rhodes et al., 2012; Shannon, Kerr et al., 2008, Shannon, Rusch et al., 2008).

Some scholars have further extended critical analyses of drug consumption to interventional settings (Boyd at al., 2018a; Duncan et al., 2019; Fraser & valentine, 2008; Kerr et al., 2007; McNeil, Kerr, Lampkin, & Small, 2015; McNeil & Small, 2014; Rhodes, 2009). These spaces are shaped by a multitude of dynamics including largely unexamined gender, sex- and class-based and racial norms, the operationalizing of particular notions of care, and culturally specific assumptions around health. Such spaces are further produced as moral/immoral, normal/abnormal, healthy/unhealthy, medicalized/non-medicalized through everyday repetitive, performative acts that most often serve to regulate and work to naturalize dominant hegemonies (Butler, 1990; Farrugia et al., 2019; Hubbard, 2000). For example, most drug using spaces occasioned by structurally vulnerable people are coded as deviant, with the exception of some harm reduction settings (Fraser & valentine, 2008), while frequent illegal drug use is conventionally constructed as antithetical to health and the pursuit of, and strategies for, health and well-being (Moore et al., 2017).

However, substance use interventions, including but not limited to harm reduction and addiction treatment services, are not neutral. Rather, subjects, objects, and practices constitute and are constituted by these spaces through temporal assemblages of relationalities, particular practices and relations of iterations—that are not static (Fraser & valentine, 2008; Latour, 2002). Experiences of harm reduction services, including design, operating policies and relations of care, are co-produced within complex social relations, which together produce specific affordances, or possibilities of use, and therefore outcomes that bear on service uptake (Farrugia et al., 2019; Fraser et al., 2017; Latour, 2002). In the approach we take here, these affordances suggest that SisterSpace, a women-only harm reduction program, offers much more than its formal function—overdose reversal for women.

Background

Attention to the production of service settings within social relations, as well as how diverse women are constituted through structural violence (including drug policy and harm reduction initiatives), is particularly germane as Canada and the United States contend with overdose epidemics increasingly driven by a drug supply poisoned with illegally-manufactured fentanyl and related analogues (Ahmad et al. 2018; Special Advisory Committee on the Epidemic of Opioid Overdoses 2019). Preventable illegal drug overdose deaths are occurring at alarming rates, increasing more than 45% in both Canada and the US from 2016 to 2017 (Government of Canada 2019; Scholl et al. 2019). In Canada, there were over 4588 opioid-related deaths in 2018 with epidemiological data showing overdose deaths remain a serious epidemic, particularly in British Columbia (BC) (BC Coroners Service, 2019; Special Advisory Committee on the Epidemic of Opioid Overdoses, 2019).

Deemed a public health emergency in BC in 2016, an average of just under three people died of an overdose daily in BC between January and October in 2019 (BC Coroners Service, 2019). Vancouver’s Downtown Eastside is the urban epicenter oi the province’s overdose crisis and also the site of North America’s most comprehensive harm reduction services. In response to the overdose crisis, a range of novel community-driven public health initiatives have been expanded including, injectable opioid agonist treatment, naloxone distribution, peer health navigation, supervised consumption sites (SCS), as well as innovative low-threshold models (Kerr et al., 2017; Wallace et al., 2019). Supervised consumption sites are spaces where people can consume pre-obtained drugs under the supervision of someone trained to respond in the event of an overdose (e.g., administer oxygen, naloxone).

Unsanctioned, low-threshold SCS were first implemented in BC as community-led responses to the growing number of overdose deaths amidst government inaction (Collins, Bluthenthal, Boyd et al., 2018). By 2017, low-threshold SCS were approved provincially as a temporary measure of the emergency response and were rapidly implemented across the province (with over 20 implemented to date) (Wallace et al., 2019). Low-threshold SCS are less formal, clinical, and regimented than federally authorized SCS, focus more on overdose prevention rather than unsafe injecting more broadly, and are primarily staffed by people who use drugs (Boyd et al., 2018a; Kennedy et al., 2019). Evidence indicates low-threshold SCS are critical life-saving interventions (Irvine et al. 2019), and no deaths have occurred at these sites to date (BC Coroners Service, 2019). Similar to formal SCS, though to a lesser degree, some low-threshold SCS also provide a range of health supports that extend beyond overdose reversal, including linking people to health and social services, reducing disease transmission through the provision of harm reduction supplies and safer drug use education, and communitybuilding and peer employment (Kennedy et al., 2017; Kerr et al., 2007; McNeil & Small, 2014; Wallace et al., 2019). For women, as in the case of formal SCS (Fairbairn et al., 2008), low-threshold SCS have also served as temporary refuge from street-based violence (Boyd et al., 2018a). Understanding the dynamic complexity of SCS environments, beyond the prevention of overdose deaths, is a critical imperative towards fostering meaningful and equitable engagement in overdose prevention settings during an overdose epidemic.

While the intersections of social location can constrain access to health services, particularly among those negatively impacted by intersecting marginalizing forces (e.g., gendered violence, racialization, transphobia) (Bousgois et al., 2004; Campbell & Ettorre, 2011; Lyons et al., 2015; Maher, 1997), women remain underserved by harm reduction programs and women-focused and culturally-responsive harm reduction initiatives continue to remain underprioritized and underfunded (Boyd et al., 2018a; Collins et al., 2019; International AIDS Society, 2019; Iversen, Dolan, Ezard & Maher, 2015). This is significant as Indigenous women in BC, for instance, are disproportionately impacted by the overdose crisis, experiencing overdose rates comparable to that of Indigenous men and accounting for five times more fatal overdose events than non-lndigenous women (First Nations Health Authority, 2017, p. 7; First Nations Health Authority, 2018). Further, Indigenous, racialized and transgender women can experience some overdose interventional settings as discriminatory, as well as privileging traditional gender norms (Boyd et al., 2018a). However, harm reduction services typically claim to be gender-neutral and/or to accommodate women’s needs through the inclusion of women-only days or hours, rather than permanent services that are set up exclusively for women, such the SCS in Hamburg, Germany (Schäffer et al., 2014). Although some services that specifically target women have integrated syringe exchange/distribution services, for example, residential or sex worker outreach services, these interventions are rarely evaluated and few opioid agonist treatment (OAT) programs have been specifically designed to engage and support women who are pregnant and/or parents, despite the significant proportion of women on OAT who have children and the identification of pregnancy as a motivation for seeking drug treatment (Iversen, Page, Madden, Maher, 2015). Gender ‘neutrality in the provision of health/harm reduction services, compounded by a dearth of data on women who use drugs globally, fails to address gender inequities and does little to abate the systemic and everyday racialized and genderbased discrimination, stigma and violence that can limit some women’s access to service settings, including low-threshold SCS (Boyd et al., 2018a;Iversen, Page, Madden, Maher, 2015).

It is this context which demarks the significance of North America’s first, to our knowledge, low-threshold SCS exclusively for women (inclusive of transgender women and non-binary persons), which opened in Vancouver’s Downtown Eastside in May of 2017 - a unique micro-environment intervention that has yet to be studied. This is one of the poorest urban neighbourhoods in Canada, with residents characterized by their structural vulnerability (Boyd et al., 2018b; Collins, Boyd. Damon et al., 2018; McNeil et al., 2015) and experiences of exceptionally high rates of gendered and racialized violence, criminalization, poverty, housing precarity, and health disparities, which disproportionally impact Indigenous women, women engaged in sex work and gender diverse persons (Bennett & Larkin, 2018; Bungay et al., 2010; Collins, Boyd, Damon et al., 2018; Culhane, 2003; Krüsi et al., 2014, 2016; Lyons et al., 2017; Oppal, 2012; 2018; Shannon et al., 2008; Socías et al., 2016). While developing better understandings of barriers and facilitators to engagement with overdose prevention and harm reduction services is critical to addressing women’s overdose risk (Fairbairn et al., 2008; Schäffer et al., 2014), the experiences of those marginalized within, or excluded from, existing and emerging services remain underrepresented. In this study, we set out to highlight service user responses to a women-only low-threshold SCS, SisterSpace, and to explore what might be afforded by this novel space and its associated service design and delivery.

METHODS

This study draws on ethnographic research, an approach offering a lens to disentangle critical dynamics that both constrain and evoke intervention effectiveness in real-world settings and a way to generate data/evidence that is sensitive to gendered contexts. Ethnographic fieldwork was conducted at SisterSpace from its opening in May 2017 until June 2018. This ethnography was framed by critical and feminist perspectives (Campbell & Ettorre, 2011; Campbell et al., 2017; Hesse-Biber & Leavy, 2006; Maher, 2002) and involves naturalistic observation and conversation, textual analysis and qua itative interview as a basis for rich engagement, which is methodologically useful for investigating the responses, perceptions and experiences of particular populations in a specific context (e.g., during a public health emergency such as an overdose epidemic) (Creswell, 2009; Johnson & Vindrola-Padros, 2017). Fieldwork was further enriched by researcher familiarity with the specific setting, including several years of community engaged research (Anonymous), which increased ability to gather related data while also attending to the details and nuances that demarcate the complexities of women’s lived experience. This paper also builds on earlier qualitative research on women’s experiences of mixed-gender low-threshold SCS in this setting (see Boyd et al., 2018a).

The first author (xx) conducted approximately 100 hours of ethnographic observation in four hour sessions, which included unstructured conversations with women at SisterSpace and surrounding areas. Fieldnotes documented observations, interactions and conversations at the field site with staff and clients, as well as the insights of peer researchers (members of the Downtown Eastside community trained in research activities with lived expertise of drug use) frequenting the site. Forty-five participants were recruited and interviewed by a culturally, sexually and gender diverse research team. Two team members (peer researchers) (SC) recruited participants directly from SisterSpace. Those recruited were interviewed by team members at our nearby research office. In-depth semi-structured interviews, facilitated by the use of an interview guide eliciting responses to the low-threshold SCS, were audio-recorded and lasted approximately 30–60 minutes. Interviewees received a $30 CAD honorarium for their time. Recordings were transcribed verbatim, with identifying information removed. Participant s were then assigned pseudonyms using an online pseudonym generator to further facilitate confidentiality.

Data were analyzed thematically using NVivo while drawing on tenants of grounded theory (Glaser & Strauss, 1967; Corbin & Strauss, 2009). Analysis involved repeated readings of transcripts and fieldnotes with attention to both a priori (e.g. gende.ed experiences of the low-threshold SCS) and emergent themes (e.g., stigma, gendered violence). Deductive and inductive methods informed by theoretical concepts and insights gained from the literature were used to additionally refine themes.

FINDINGS

Participant Demographics

In total, interviews were conducted with 45 structurally vulnerable women residing in Vancouver’s Downtown Eastside who use drugs. Their experiences of health services, in this case overdose prevention interventions, were shaped by the intersections of poverty, gender inequality, transphobia, and racial and cultural discrimination, as well as the stigma of illegal substance use and sex work. Approximately half the participants interviewed self-identified as white and half as Indigenous (though Indigenous peoples make up only 2.5% of metro Vancouver’s population (Statistics Canada, 2016), two participants identified as ChineseCanadian and Latinx. Ages ranged from 24–60. Most participants were cisgender (three were transgender), unhoused or homeless at the time of the interview, and had been incarcerated at some point in their lives. Approximately half the participants had spent time in the foster care system and just under a third of participants engaged in outdoor sex work. More than half had experienced at least one overdose in the past year (see Table 1).

Table 1.

Demographics.

	n (%)
Participant Characteristics	N=45
Age
Mean	38 years
Range	24 – 60 years
Gender
Cis-gender	42 (93.3%)
Transgender	3 (6.7%)
Race/Ethnicitya
White	24 (53.3%)
Indigenous	23 (51.1%)
Latinx	1 (2.2%)
Chinese-Canadian	1 (2.2%)
Housing Status at Time of Interview
Housed	17 (37.7%)
Unhoused	28 (62.2%)
History of Foster Care
Yes	22 (48.9%)
No	21 (46.7%)
No answer	2 (4.4%)
Previous Incarceration
N/A	16 (35.5%)
Ever	29 (64.4%)
Past year	10 (22.2%)
Past month	1 (2.2%)
Income Generation in 30 days Prior to Interviewa
Full-time Employment	2 (04.4%)
Sex Work	14(31.1%)
Drug Dealing	16 (35.5%)
Boosting	13 (28.8%)
Recycling/Binning	10 (22.2%)
Social Assistance	23 (51.1%)
Overdose in Last Year Prior to Interview
One	9 (20%)
Two	3 (6.7%)
Three or more	5 (11.1%)

^aParticipants could select more than one.

The Space: Affording Basic Provisions in a Context of Social-Structural Marginalization and an Overdose Epidemic

SisterSpace is the first official women-only SCS in Canada and during the study period approximately 65–75 women visited the site each day (Atira, 2018). Many participants compared their experiences at SisterSpace to other mixed-gender SCS. Accounts located the site as significant, in that the space and emergent atmosphere, coproduced by the physical set-up, specific operating policies and practices and social relations, afforded possibilities beyond overdose prevention by attending to some of service users’ fundamental needs (e.g., the provision of a welcoming, non-chaotic environment, food, and relaxed time limits) that they described as not consistently attended to at other mixed-gender and sanctioned SCS in our setting.

De-medicalizing substance use service settings

Participant accounts demonstrated that women valued SisterSpace for facilitating the prevention of overdose deaths in a less-institutional environment than other SCS they had frequented. ‘Rose’, a 35-year-old indigenous woman, described the non-institutionalized setting as fostering social engagement.

It feels like you’re not in an injection gallery. When you’re at SisterSpace it feels like you’re at a friend’s or your place or wherever. Like it’s not like a facility. It’s more open. It’s not isolated. You can converse when you’re using.

‘Mireya’, a 40-year-old white woman, noted, “It’s not as regimented, it’s just more relaxed.” ‘Lauren’, a 33-year-old Indigenous woman, noted that she frequented SisterSpace because “it’s safe” as “it’s made for that” [overdose prevention when injecting (inhalation is prohibited)] but explained that compared to other SCS she had been to, SisterSpace was also more welcoming:

There’s a difference. [SisterSpace is] more friendly. This one, you get your own nice space and everything.

The less ‘regimented,’ more ‘social’ atmosphere enabled some women a sense of having their basic needs attended to. Getting “your own nice space,” as described by Lauren, garners significance in a context of deprivation (e.g., poverty; being unhoused) that is often mirrored in the stark, stripped down, spaces of low-income housing and more medicalized harm reduction services operating in Vancouver’s Downtown Eastside.

Participant sentiments regarding the site’s atmosphere were consistent with fieldwork observations of SisterSpace’s physical set-up, which consisted of an open-concept space, uncluttered, with soft chairs, a couch, plants, a few movable screens for privacy, a large communal table as well as wall-paper depicting a nature setting alongside the side wall. Most distinct (absent from other local SCS) when entering the site was the colourful hand-made artwork by clients and staff displayed on the back wall (many with cultural and political references: e.g., feathers, which have symbolic meaning for some Indigenous nations in Canada; slogans such as, ‘women just want to have fun-damental rights’ and ‘she persisted’). Such images, representing women’s creativity and input into the production of the physical space, further constituted the setting as both non-institutional and inclusive.

Food scarcity

Operational policies responding to women’s needs beyond overdose prevention further facilitated participant engagement at SisterSpace. We observed that, similar to other SCS in Vancouver’s Downtown Eastside (Boyd et al., 2018a), SisterSpace provided harm reduction supplies, e.g., clean dgs and needle disposal boxes, cookers, filters, single-person tourniquets, alcohol swabs sterilized water packs, and fentanyl testing strips. Unlike most other SCS in our setting, tampons were also available and food was provided, including cereal, yogurt, juice, and pastries. ‘Kiley’, a 39-year-old Indigenous woman, appreciated the atmosphere and characterized the provision of food, not routinely provided at other SCS in the Downtown Eastside (as observed in previous fieldwork, Boyd et al., 2018a), as a privilege:

[It’s] pretty nice and cozy and they have snacks and stuff like that there for the ladies, so I think that’s an extra privilege…

Similarly, ‘Doro’, a 32-year-old Indigenous woman, emphasised food as significant to economically marginalized women lacking food security.

For me it’s nice and quiet, relaxing… They feed you. It’s huge. Especially when you’re starving you know.

Sister Space responded to the structural and everyday violence shaping the lives of women who visited the site in myriad ways. While providing food seemed to increase participant engagement and engender a sense of support, it also mediated the impacts of, at least in the short term, women’s economic marginalization.

Accommodating diverse drug using practices

Participant accounts also emphasised appreciation for the relaxed time limits. ‘Ayesha’, a 38-year-old Indigenous woman, explained that she had frequented all of the SCS in the area and, when asked to elucidate some of their differences, described mixed-gender SCS as overcrowded, chaotic, and occupied by men She characterized these attributes as counter to spaces that allow for reflection, agency over drug consumption, and pleasure:

The other ones, they just cattle you in like you’re a cat, like a cow, and they just want you to do your thing and go. Like, they just, like, shuffle, shuffle…. there is chill spaces, but, I mean, they’re overcrowded. There’s always guys there and, I don’t like them, like, the men with the ego thing, and they… they’re always, like, really aggressive, and it’s really, It’s like a shit show in there, in those [consumption] galleries. And, like, most places you want to be quiet, and, like, you know, you just want to collect your thoughts, and just, like, do your thing and enjoy it. Those other places, they’re just fucking chaotic, man. Like, who wants to be in a chaotic spot when you’re getting high on speed? It’s like double-whammy, you know?

We further observed that relaxed time limits accommodated diverse drug using practices, particularly for women preferring to stagger the consumption of their drugs during a single visit to the site in order mitigate overdose risk. This was achieved by repeatedly consuming small amounts of their drugs over a longer period of time. SisterSpace did not have as high a volume of clients as other SCS in the area, although numbers increased over the course of fieldwork. As ‘Max’, a 30-year-old white woman, explained, “I just love the quietness.” A calm, ‘quiet’ environment was significant for structurally marginalized women in this setting, as they are particularly vulnerable to everyday gendered and racialized violence (experiences that do not foster tranquility) and are often unhoused or precariously housed in men-dominated settings characterized by gendered violence (Collins, Boyd, Damon et al., 2018; Collins, Boyd, Hayashi et al., 2020) and are, therefore, less likely to have a ‘quiet’ space of their own.

The wealth of service users’ accounts highlighting basic provisions in the context of an overdose epidemic emphasizes the acute impoverishment experienced by participants and the imperative of establishing such provisions as the norm, rather than exceptions. Possibilities for attending to basic needs materialized through the space, through service policies, and how it was configured, but also in relation to participant’s socio-structural marginalization, through which opportunities for basic necessities were both limited and constrained. As the following section elucidates, the service afforded other possibilities, including alternate ways of caring.

(Destigmatising) Possibilities: Affording agency, knowledge sharing and reciprocal relations of care

A key aspect of SisterSpace’s service design and delivery, marking it as distinct from other mixed-gender and sanctioned SCS in our setting, was the demarcation of the space as women-only (transgender and non-oinary inclusive) and the all women peer staffing model. The possibilities afforded by these two policies, highlighted in participant quotes below, include increased ability foi expression and agency, reciprocal relations of care and the situating of women who use illegal drugs as knowledge producers within a broader context of pervasive stigma.

Participants unequivocally expressed appreciation for the site’s formal attention to gender and its intersection with diverse social locations in a health care service provision. This was enabled by the woman-only policy and some operational efforts towards cultural safety and inclusion (e.g., a diversity of peer staff and Indigenous practices such as smudging—a cleansing ceremony practiced by many Indigenous communities involving the burning of a small bundle of sacred herbs). While participants articulated SisterSpace’s utility in protecting them from fatal overdose, their accounts indicate the service’s potential for the co-production of a non-misogynistic, intentionally socially and culturally supportive, and accepting women-centered environment.

Women’s descriptions of SisterSpace emphasized a particular level of comfort not being met at mixed-gender sites due to the presence of men, which they attributed to fostering space for increased expression among clients. ‘Loretta’, a 45-year-old Indigenous woman, explained that the absence of men also enabled woman to be less defensive and more vocal:

R: [SisterSpace] It’s more down and personal. And not only that; when you get a group of women together, there’s a certain lingo in the air, you know, with the… just being a woman, the essence of woman, right? So it’s a little bit more comfortable, more open space. We’re more open to each other. We don’t feel we have to be defensive or hide, you know? That sort of thing.

I: Have you felt that way at other [SCS] sites, that you had to hide or be defensive?

R: Not so much hide, but just not say so much or speak so much, you know what I mean? Or share so much.

Loretta noted that because of the heighted sense of comfort she experienced at SisterSpace, she no longer frequented other SCS “I just go to SisterSpace now. That’s it […] Every day. Everyday. Morning and night.” Similarly, ‘Brenda’, a 60-year-old Indigenous woman, expressed unequivocal appreciation for SisterSpace and peer staff rooted in feelings of safety and love:

It’s a really, really good environment. I feel comfortable. I feel safe. I eat a lot, you know what I mean, like they [peer staff] seem like they’re little hostesses and they’re just like ‘May I get you something?’ and they’re very kind and loving and compassionate. I love it there.

Interactions between women actively constituted the site as a space that centered women’s voices, experiences and needs; for example, providing space to communicate how SisterSpace could better address their health and well-being (i.e., the need for food, overnight hours, and more Indigenous-focused programming). Enhanced ability to be vocal and participate in the space was particularly significant for Indigenous women who often described feeling undervalued and/or socially excluded in other service settings.

A number of women located their heightened sense of wellbeing experienced at SisterSpace with it being a women-centered space, in that it fostered a sense of shared acceptance that itself was further enabled by the peer-led gender and racially diverse staffing model. As peer staff were women from the community who used drugs, participants emphasized respect for peer workers’ knowledge and expertise garnered from lived experience, their capacity for empathy and lack of judgement, and the sense of inclusivity it fostered. This is significant given research detailing the pervasive stigma and discrimination encountered in Vancouver’s health care/service settings by Indigenous, racialized and marginalized women and transgender people who use drugs and/or are involved in outdoor sex work (Boyd et al., 2018a; Goodman et al., 2017; Lyons et al., 2015; Socías et al., 2016).

‘Lottie’, a 43-year-old white woman, explained that after trying other SCS, she began only frequenting SisterSpace for a variety of intersecting reasons including the women-only setting, and less stigmatizing staff:

R: I like SisterSpace. You know, for all girls, I liked the vibe there. It was good.

I: Yeah. What do you mean, for all girls?

R: Like for just women only. Like I thought it would be more… I thought it would be different. But no, I liked it. It was good. [….] The other injection sites, they’re more regimented. Like and the staff are rude, I find, to you. It’s more personable there [at SisterSpace].

I: What makes it personable?

R: The staff. They’re really caring. I think they go out of their way to make you feel good. Which is good, because people look down their nose a lot at addicts, and they kind of just… they’re there to make you feel comfortable. Like it’s good for everything, really.

Lottie’s comments speak to the stigma impacting people who use illegal drugs, which is particularly heightened for women (Boyd, 2015; Campbell, 2000; Campbell & Herzberg, 2017; International Aids Society, 2019). Participant accounts demonstrate that peer staff with lived expertise of drug use, and the women who use the site, were responding to the overdose crisis “in a careful and sensitive manner” (Farrugia et al., p. 438). ‘Diane’, a 32-year-old white, transgender women, described experiencing SisterSpace as more transgender inclusive than other services, though transgender women and non-binary persons represented a minority in the space:

I: I’m curious actually what brought you to start using Sister Space?

R: Well being trans because I am trans, you know like it’s, it can be really uncomfortable in a lot of places even though Vancouver’s great, accepting […] we didn’t want to try or expose yourself to that, uh, hate. SisterSpace is a safe place.

I: It’s a safe place [Yeah] and because it is trans inclusive?

R: Very inclusive [….] The ladies that are there in the morning are awesome, they’re so awesome […] I’ve always felt great and welcomed and you know it was really hard for me to go there to be honest cause when I started going there I was just still kind of figuring everything out and where this is all going and, uh, and yeah and then seeing girls that I know, that know me I guess or whatever and being whole and being super positive about it was nice and it’s cool and yeah, I mean it’s a great place.

‘Cherry’, a 35-year-old white woman, also spoke about feeling cared for in a manner distinct from other SCS:

Honestly, for me, I just really like the girls that work there, they are really nice. They’re different than any… like all the rest of the people that work at any of those [other] places in the entire city, the ones they have there [at SisterSpace) are like awesome…. They just feel like, I don’t know, it’s just like my mom kind of. Reminds me of my mom.

Participants represented peer staff (and each other) as more diverse than conventional depictions of women who use illegal drugs—as simultaneously caring, as women in positions of authority and as having expertise in drug use.

An important outcome of high participant comfort with the women-centered, peer-led environment was engagement and knowledge sharing between SCS clients and staff, particularly in relation to toxic drug events and connection to services—providing crucial support for those most marginalized. Ethnographic observation documented women regularly sharing experienced-based information in non-stigmatizing ways on a range of health-related topics including drug toxicity, shelter, accessing detoxification and OAT, and safer sex work tips (e.g., avoiding bad dates).

Due to peer involvement by women from the local community, conventional gender relations and power hierarchies within care practices between service provider and clients were less apparent (though still existent), affording the possibility for reciprocal relations of care, as staff were also impacted by negative gendered discourses, discrimination, stigma and structural violence. In contrast to service and health settings where care is experienced by women who use illegal drugs as discriminatory (Boyd, 2015; Bungay et al., 2010; VANDU women’s care team, 2009), participants’ accounts highlight the conditions of care produced at SCS as having destigmatizing potential. Thus, enhancing the uptake of this particular low-barrier SCS.

Affording Safety: Attending to Intersecting Gendered Violence in Service Provision and Design

Participants’ experiences were shaped by a constellation of acute gendered violence, that coincided with and sometimes superseded attention to minimising overdose-related harm. Women who use illegal drugs, especially those that are poor, racialized and gender diverse and/or engaged street-based sex work, experience heightened incidences of everyday violence, framed by structural violence (Bungay et al., 2010; Boyd, 2015; Maher, 1990, 1992; International AIDS Society, 2019; Shannon et al., 2008). A central component of participant expressions of well-being in a women-centered space were also due to an absence of unwanted men’s attention and violence encountered in other settings. For instance, Max, a 30year-old white woman, experienced SisterSpace as non-threatening: “[SisterSpace] is quiet and nonthreatening, there is no anxiety.” Amira’, a 28-year-old white woman, more directly attributed her heightened sense of safety at SisterSpace to the absence of predatory male violence:

Yeah [I feel safe]. Even their [client’s] boyfriends, the staffs’ boyfriends aren’t even allowed in there [SisterSpace]… because like guys will fucking prey on fucking chicks that are high.

Similarly, ‘Sam’, a 32-year-old Indigenous woman, explained that the absence of men at SisterSpace “makes [me] feel safe.” When asked if she had experienced men’s violence at mixed-gender SCS, she explained that she hadn’t, but that past negative experiences with men led her to prefer SisterSpace:

No, I have had negative experiences with men in the past though. That’s why I’ll go to the SisterSpace because there’s just women there.

Some participants, such as Lottie, described being “threaten[ed]” by men they knew when at mixed-gender SCS. A number of participants further linked the overdose epidemic to the missing and murdered women epidemic in Canada (Bingham et al., 2014; Oppal, 2012), foregrounding the ways in which Indigenous women are particularly impacted by both. Ayesha, for instance, expressed frustration with both the general public and law enforcement for their apathy (symbolic violence) in relation to both epidemics. When asked about SisterSpace and its function during the overdose crisis, she explained that:

First Nation women that are alone, they’re the target [of overdose]. They’re the prime meat. It’s like Pickton [the serial killer infamous for targeting Indigenous women and sex workers in the neighbourhood]. They're the prime target of it all. [….] I’m like, you guys all know what the fuck’s going on. Why are you doing this stupid shit? (38-year-old Indigenous woman)

Ayesha’s comment speaks the intersections of racial and gender discrimination, framed by the structural violence of drug criminalization, gender inequality, poverty and colonialism, that (re)produce everyday violence and enable inadequate responses to women’s health, including overdose risk.

Whereas the interior of SisterSpace symbolically represented a haven from men’s violence, it was not entirely divorced from it. For instance, on some occasions, disparaging comments could be heard from men outside (e.g., ‘this is sexist too’) and shortly after it opened a man threw a brick through the site’s front window in a fit of anger. Loretta noted that, while some men’s responses were inappropriate and disrespectful, SisterSpace functioned as a private site of pleasure for women:

Don’t think you can stop here and check out the girls and that. No, this is their private space and this is their pleasure space. Please keep on moving, right?

The casual conversations within SisterSpace during fieldwork conveyed the ability of women accessing the space to give voice to how women who use illegal drugs were dealing with discrimination and stigma, everyday male violence (e.g., intimate partner, predatory) and, more acutely, structural violence on an on-going basis outside of the site (e.g., poverty). One staff jokingly relayed that it was suggested SisterSpace be named ‘Bed Bugs & Beyond’ during a naming brainstorm session -a play on words that simultaneously evoked gendered consumerism through the name of a popular domestic retail company, “Bed, Bath & Beyond,” contrasted with a space outside of (‘beyond’) the dire living conditions, housing precarity, and severe marginalization that most SisterSpace clients contend with. It is the cumulative impact of the intersection of these disparities which also served as barriers to SCS access for some women. For instance, Rose, 35-year-old Indigenous woman, explained that even a women-only site does not ensure equitable engagement as pregnant women and women with children may not access the site due to fears of child apprehension:

I’ve never seen a pregnant woman in there [SisterSpace], first of all, and I never seen anyone I know who has their kids. I think they would be discouraged because they don’t want people to see them and call the Ministry [of Children and Family Development] on them. So I don’t think… like I wouldn’t go there if I had my…[kids].

Though SisterSpace staff expressed efforts of increased support for pregnant women accessing the site, stigma and fear of repercussion, formalized through the legal regulation of women who use illegal drugs, particularly those pregnant and/or parenting and/or Indigenous, remains a substantial barrier to these life-saving services. Vocalized among women at SisterSpace, not encountered during fieldwork at mixed-gender low-threshold SCS in our setting (Boyd et al., 2018), was the on-going struggle and heartbreak incurred from child custody issues, including dealing with ex-spouses and foster care through the Ministry of Children and Family Development and the courts, as well as the lack of options offered women pregnant and/or parenting seeking housing and also treatment services. Indeed, as one exits SisterSpace, generally accompanied by the mantra “be safe,” it is near impossible to overlook the neighbouring graffiti on walls and doors commenting on a range of marginalized women’s and Indigenous issues, particularly violence and child apprehension: “I miss my sisters”; “I wish I was with my kids instead of here. I miss them so much”; “Foster care operates in BC as the new name for residential school."

DISCUSSION

Our findings outlined the value of initiatives that engage with socio-structural factors beyond the often narrow focus of overdose prevention and that account for the complex social relations that constitute such initiatives. Our findings also underscore that a women-oniy low-threshold SCS is a vital environmental intervention that can afford significant possibilities that include, but are not limited to, overdose prevention within a context where women are marginalized within a drug scene comprised predominantly of men, and contend daily with the intersections of structural (e.g., poverty, colonialism), social (e.g., discrimination, stigma), symbolic (e.g., normalizing disparity) and everyday gendered and racialized violence (e.g., interpersonal), heightened during an overdose epidemic (Bennett, Larkin, 2018; Boyd et al., 2018a; Collins, Boyd, Damon et al., 2018; Martin & Walia, 2019). Participants emphasized the significance of a welcoming substance use service setting that attended to experiences of food scarcity and accommodated diverse drug using practices. While not uniquely gendered, participants’ consistent highlighting of these basic provisions emphasizes: 1) these were not universally provided at other SCS, and; 2) that women participants experienced attention to basic needs as significant, precisely because of the uniquely gendered pervasive stigma and structural violence they experience. The women-only environment and diversity of women staff with lived experience of drug use afforded participants possibilities for agency (among those more often defined as victims), knowledge sharing (e.g., of drug-related experiences more often defined through or absent form men’s perspectives) and possibilities for reciprocal care and support, distinct from asymmetrical hierarchies of care present in other patient-provider-based relations (Boyd et al., 2016; Browne & Fiske, 2001). Most significantly, the service provided a temporary reprieve from some forms of everyday violence, stigma, and drug-related risks and harms, allowing for women to constitute the space in diverse ways—generating the potential for belonging while building resilience and resistance to ongoing structural violence and negative discourses about (racialized and gender diverse) women who use illegal drugs.

Structurally vulnerable women who use illegal drugs navigate an on-going complex matrix of institutional control as clients of a range of medical and social services and as subjects of the criminal justice system (Boyd, 2015; Campbell & Ettorre, 2011; Fraser & valentine, 2008;Greenfield, 2007; Paltrow & Flavin, 2013). Indigenous women’s experiences in our setting are further shaped by gendered colonial discourses that shape Canadian legislation (including the reserve system and the governance of the residential school system), and subsequent foster care and child protection services (Million, 2013, Denison, Varco & Browne, 2014; Turpel-Lafond & Kendall, 2009). It is therefore significant, though not surprising, that participants placed particular value on the non-medicalized setting of SisterSpace, addressing basic fundamental needs such as food (amidst entrenched poverty), temporary shelter (amidst housing insecurity) and overdose reversal (amidst an overdose crisis), as well as a reprieve from gendered and racialized violence, misogyny and punitive policing practices endemic within the neighbourhood (Bennett & Larkin, 2018, Collins, Boyd, Damon et al., 2018; Martin & Walia, 2019; Oppal, 2012; Shannon et al, 2008). These findings indicate compelling reasons for moving beyond conventional and gender-neutral interventions, towards ones that reflect frameworks that consider the underlying intersectional structural, social and environmental drivers of drug-related harms, including overdose (Campbell, 2012; Campbell & Herzberg, 2017; Rhodes, 2009; Dasgupta, Beletsky & Ciccarone, 2018; Reinarman & Granfield, 2015).

Feminist theorists have long discussed the importance of women- and populationspecific community-based spaces for women who use illegal drugs, specifically in response to the male-centeredness of prevention and treatment paradigms which fail to account for women’s diverse and unique social and health concerns, including increased stigma, often positioning women as deviant, non-conforming and at risk (Campbell & Ettorre, 2011). Women who use illegal drugs are “doubly” impacted by both service providers and men who access said services (Fraser & valentine, 2008). However, our study indicates that a women-only SCS affords destigmatizing potential, which we argue served to co-produce “different capacities for, and subjects of, care” (Farrugia et al., 2019, 433). Critical scholars argue that concepts of care are contested, complex, and not fixed; however, it is argued, analyses attentive to the politics of care can afford new possibilities and actions for overdose prevention (Boyd et al., 2016; Buse et al., 2018; Farrugia et al., 2019; Latimer, 2018). In our study, we argue that overdose prevention at SisterSpace is not divorced from the “social relations that give rise to it” (Farrugia et al., 2019, p. 439). Care was diverse, but afforded challenges to conventional conceptualizations of people who consume illegal drugs as uncaring (Farrugia et al., 2019), women who use illegal drugs as deviant and/or victims (Boyd & Boyd, 2014); and drug use as antithetical to health (Moore et al., 2017).

he involvement of people with lived experience working in overdose prevention has increased significantly in BC (Kennedy et al., 2019). Overdose prevention in ‘gender-neutral’ spaces can reproduce dominant gendered and intersecting racialized power relations, limiting access for women and gender minorities who fear violence and/or discrimination from men staff and clients (Boyd et al., 2018a). Significantly, participants described SisterSpace as a refuge from male violence. Recognizing that women-led peer spaces are not free of power hierarchies, our findings nevertheless suggest the potential of women staff with lived experience of drug use, as well as other diverse intersecting social locations (e.g., lived experience of sex work, poverty, racial discrimination, and/or transphobia), can potentially co-produce alternative environments that challenge societal stereotypes and discrimination against women who use illegal drugs as well as offer supports, as previous research on women peers in a drug user union (Boyd & Boyd, 2014) and the effectiveness of Indigenous peer-led interventions, has indicated (Carter & MacPherson 2013; Marshall, 2015; Mooney-Somers et al., 2015). Experiences of SisterSpace were not fixed, but rather co-produced by a set of changing relations (eg., participant experiences constituted and were constituted by operating policies), producing particular affordances such as safety and alternate relations of care (Fraser, 2017; Fraser, Moore & Keane, 2014; Farrugia et al., 2019).

This study has limitations. As participants were recruited solely from SisterSpace, women who could not or did not wish to access the site are not represented. Findings are therefore specific to a particular gender-specific low-threshold SCS in Vancouver and not representative of the experiences of all women who use illegal drugs nor transferable to all harm reduction/SCS settings. In particular, the experiences of transgender, two-spirit, gender fluid and non-binary participants are underrepresented and beg further analysis, particularly in relation to the potential essentialism “women-specific” spaces may incur. This study was undertaken in a localized urban location with alarmingly high overdose mortality, thus might yield different results under less life-threatening/challenging cicumstances. In addition, SisterSpace was not divorced from power hierarchies The threat of child apprehension, remains a constant barrier to marginalized women accessing harm reduction services (Boyd, 1999; 2015; Kenny et al., 2015), including low barrier SCS such as SisterSpace, while gaps in access for gender diverse people (Lyons et al 2015) and cultural relevance for Indigenous women remain salient in efforts towards Indigenizing harm reduction (First Nations Health Authority 2017; First Nations Health Authority, 2018; LaValley et al., 2018; Marshall, 2015). Having a voice is crucial for Indigenous women, who remain systemically socially excluded from health policies even though research indicates Indigenous autonomy is necessary to reduce health inequities (Belle-Isle, Benoit & Pauly, 2014; Million, 2013).

In conclusion, our findings highlight that under the constraints of prohibition and amidst pervasive structural, symbolic and everyday violence, SisterSpace represents an innovative, and effective non-institutionalized and potentially life-saving approach to women-centred harm reduction, including overdose. Women’s experiences of illegal drug use and institutional settings, including harm reduction services, are gendered, while gendered forms of stigma, structural and everyday violence inform the experiences of women who use illegal drugs (Bungay et al., 2010; Iversen, Dolan, Ezard & Maher, 2015; McNeil et al., 2014; Rhodes et al., 2012). Provision of and equitable access to SCS for diverse populations remains critical to overdose response, particularly during a crisis and without legal access to safe, unadulterated drugs. Supervised consumption sites, however, remain limited in scope if they fail to address the broader social and structural factors that comprise the root causes of harm associated with illegal drug use and politics of care (Farrugia, 2019; Dasgupta et al., 2018; Marshall, 2015; Rhodes et al., 2012). There remains an urgent need to reexamine how structural drivers (including drug laws and policies) contribute to the overdose crisis and the implementation overdose interventions, including increased attention to how gendered discourses on drug use, and the intersection of factors such as poverty, criminalization, systemic racism, gender inequality and transphobia, structure the lives, as well as the deaths, of women who use illegal drugs.