Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2023 Jan 1.
Published in final edited form as: Crit Public Health. 2020 Nov 13;32(3):382–391. doi: 10.1080/09581596.2020.1844151

“That’s what I’m supposed to do at work”: Gendered labor, self-care, and overdose risk among women who use drugs in Vancouver, Canada

Alexandra B Collins 1, Ryan McNeil 2,3, Sandra Czechaczek 4, Jade Boyd 4,5
PMCID: PMC9268005  NIHMSID: NIHMS1690487  PMID: 35812810

Abstract

Through rapid ethnography undertaken in Vancouver, Canada’s Downtown Eastside – one of Canada’s overdose epicenters – this article examines how gendered expectations of labor shape overdose risk for structurally vulnerable women and gender diverse people who use drugs. Drawing on two participant narratives, we explore how structural, symbolic, and everyday violence frame the lives of women and gender diverse people who use drugs in ways that drive their overdose risk as they balance self-care with caretaking, paid work, and basic survival. This article underscores the need for structural reform of peer overdose response work and funding for gender-attentive harm reduction and ancillary supports to better mitigate overdose risk for these populations.

Keywords: overdose, women who use drugs, social violence

Background

In this article, we demonstrate how the experiences of structurally vulnerable women (cisgender and transgender inclusive) and gender diverse people who use drugs (PWUD) amid an overdose crisis are framed by gendered labor and gendered expectations within cisgender, heterosexual relationships. Narratives of women being burdened by gendered divisions of labor, including household labor (e.g. cleaning, cooking), care work (e.g. crisis management, emotional support), and often feminized paid labor such as caretaking, have long been examined in relation to how women experience and manage social-structural inequities (Herzberg, 2010; Hochschild & Machung, 1989; Van Every, 1997). Some of this work has drawn attention to the role of drugs – both illicit and prescribed – in helping women cope with meeting gendered norms around success, domestic roles, and beauty (Campbell, 2000; Herzberg, 2010; Metzl, 2003). From the marketing of valium to women to cope in the 1970s (Campbell, 2000; Herzberg, 2010), to instrumental uses of methamphetamine and nonmedical use of stimulants to juggle unpaid labor within the home (Brecht et al., 2004; Carbone-Lopez & Miller, 2012; Hansen, 2017), research has documented how experiences of gendered social and economic marginalization are framed as individual pathology. Recently, attention has turned to the impact of stress and anxiety management attending overdose events for women amid North America’s overdose crisis (Hansen, 2017; Knight, 2017; VanHouten et al., 2019).

Of importance is how experiences of overdose and overdose risk are racialized, classed, and gendered (Hansen, 2017; Knight, 2017; Netherland & Hansen, 2016). Exploring the compounding impacts of labor on structurally vulnerable women and gender diverse individuals is imperative, as women experience approximately 25% of overdose deaths in Canada (Special Advisory Committee on the Epidemic of Opioid Overdoses, 2019), and are experiencing an increase in overdose deaths in the US (VanHouten et al., 2019). However, the factors contributing to fatal overdose among women are not well understood. As such, there remains a need to examine the social and structural factors that frame the daily lives of structurally vulnerable women and gender diverse PWUD to better inform overdose prevention interventions.

Examining how women and gender diverse PWUD negotiate formal and informal labor both within (e.g. care work) and outside (e.g. peer overdose response work) of the home is important in British Columbia (BC) Canada, which is experiencing an overdose crisis driven by illicitly manufactured fentanyl. Since 2016, more than 4,500 overdose deaths have occurred in BC, with 87% of fatal overdoses happening in indoor environments, including single room accommodations (SRA) housing (i.e. buildings in which tenants rent a small room and share washroom and, if available, kitchen facilities) and shelters (BC Coroners Service, 2019). While women have accounted for approximately 20% of overdose deaths in BC (BC Coroners Service, 2019), Indigenous women have been disproportionately impacted, experiencing eight times as many non-fatal overdoses and five times more overdose deaths than non-Indigenous women (First Nations Health Authority, 2017, 2019).

Vancouver’s Downtown Eastside neighborhood is the epicenter of BC’s overdose crisis, and characterized by a highly visible drug scene marked by poverty and ongoing gendered and racialized violence epidemics (Boyd et al., 2018; Culhane, 2003; Martin & Walia, 2019). Understanding how women and gender diverse PWUD in Vancouver are experiencing these overlapping crises crisis is important for mitigating drug-related harms framed by gendered and racialized inequities (e.g. being ‘second on the needle’) (Bourgois et al., 2004; Boyd et al., 2020; Harris & Rhodes, 2013; Iversen et al., 2015). Research has documented the gendered experiences of women accessing and working at overdose-related interventions, illustrating the presence of heteronormative gendered expectations (e.g. caretaking, tidiness) and how these reify gendered inequities for women (Boyd et al., 2018). Turning attention to how women and gender diverse PWUD navigate and cope with the competing demands of drug use, gendered expectations in the home, and paid work within a street-based drug scene is critical to understanding the social-structural forces shaping overdose risk for these populations.

In this article, we draw on dynamic and relational conceptualizations of gender, in which gender is actively produced, reproduced, and enacted through everyday social performances and relations (Connell, 2012) while intersecting with social categories (e.g. race, socio-economic status) and structuring political and social-cultural contexts (Campbell & Herzberg, 2017; Connell, 2012). We argue that social violence exacerbates labor responsibilities for structurally vulnerable women and gender diverse PWUD, reinforcing their health inequities as they seek to mitigate their marginalization. In what follows, we focus on paid and unpaid labor within and outside of the home, and how opioids are used as a way of managing gendered responsibilities. Within the home, we examine gendered expectations related to household labor (e.g. cooking, financial management) and care work – here, referring to unpaid labor involving managing the wellbeing of others, such as emotional support, crisis management, and caregiving (Eichler & Albanese, 2007). Outside of the home, we emphasize paid labor (formal and informal), focusing predominately on the role of peer overdose response work (i.e. people who use(d) drugs trained in overdose response) (see Kennedy et al., 2019). We draw on the narratives of two participants to illustrate how drug use practices are mediated by, and respond to, the social violence of poverty and racialization among women and gender diverse PWUD. In doing so, we aim to reveal how labor is navigated by women and gender diverse PWUD in unequal ways amid an overdose crisis. While these following accounts are unique to each participant, the gendered labor expectations were shared by participants.

Methods

Our findings are drawn from a larger rapid ethnographic research project that explored the impact of overlapping housing and overdose crises on women who use drugs in Vancouver’s Downtown Eastside. Rapid ethnography operationalizes researchers’ familiarity with a particular context to enable the rapid collection of data through focused fieldwork undertaken within a briefer timeframe (e.g. months vs. years) (Pink & Morgan, 2013). Similar to traditional ethnographic approaches that involves ongoing engagement within the lives of participants, rapid ethnography allows for a nuanced understanding of lived experiences while prioritizing efforts to inform interventions and decisions that address urgent health and social issues (Handwerker, 2001; Pink & Morgan, 2013). This approach has been successfully implemented within public health emergencies to illustrate complex social-structural dynamics (Johnson & Vindrola-Padros, 2017).

From 2017–2018 the lead author and two women-identifying peer researchers recruited 35 women and gender diverse PWUD to participate in the larger study, which included baseline and follow-up (n=20) in-depth interviews, and approximately 100 hours of ethnographic fieldwork in the spaces where women and gender diverse PWUD lived, socialized, and accessed health and ancillary services. Fieldwork sessions were conducted in neighborhood areas (e.g. street vending market, drop-in centers, parks), participants’ SRA rooms, overdose prevention sites, and attending medical and support service appointments with participants. Participants were recruited through fieldwork and study posters placed in non-profit-operated SRAs and women-focused services in the neighborhood. More detailed recruitment methods for this study have been described elsewhere (see Collins et al., 2020).

Participants ranged from 21 to 57 years of age at baseline. Approximately 51% of participants self-identified as Indigenous, with 43% self-identifying as white, and 6% self-identifying as Black, Asian, or multiracial. The majority of participants were cisgender (91%), 3% were transgender women, and the remaining 6% were gender diverse (Two Spirit1, non-binary, or gender nonconforming). At baseline, 54% of participants lived in non-profit-operated SRAs, 26% in privately-operated SRAs, and 20% in privately-owned, non-profit-operated SRAs. While no participants were unhoused at baseline, 15% reported being unhoused at follow-up. Approximately 49% of participants reported having experienced at least one overdose in the year prior to baseline, with a total of 34 overdoses reported by Indigenous participants compared to 14 overdoses among non-Indigenous participants.

All interviews were transcribed verbatim and uploaded to NVivo which was used to manage interview and field note data. Data were analyzed thematically to examine participant’s relationships, social and health outcomes, and work-related experiences. Analysis focused on participants’ variegated experiences of the overdose crisis on the bases of social locations (e.g. ability, sex, race), and how these operated in relation to social, historical, environmental, and operational contexts (Collins, Boyd, et al., 2019; Rhodes et al., 2012). Our analysis employed theoretical constructs of social violence to frame gendered labor expectations of participants. We use social violence to describe the overlapping impacts of violence occurring at structural (Farmer, 1997, 2003), symbolic (Bourdieu, 2001; Epele, 2002), and everyday (Scheper-Hughes, 1996) levels. Structural violence are institutionalized inequities (e.g. neoliberal ideologies, limited economic opportunities) that are embedded into social structures in ways that maintain the unequal distribution of power (Farmer 1997). When internalized, it results in symbolic violence where individuals blame themselves for their marginalization which is seen as ‘inevitable’ (Bourdieu 2001; Epele 2002). Structural and symbolic violence can also be operationalized through everyday experiences of interpersonal violence that are rendered invisible given their ubiquity (Scheper-Hughes 1996). Social violence was operationalized throughout the analysis to situate women’s spatial and drug use practices, social relationships, and work within gendered social and structural contexts, and how these differed based on social locations. Analysis was further enriched by the team’s many years of community-engaged research within the setting (e.g. Boyd & Boyd, 2014; Boyd et al., 2018; Collins et al., 2018; McNeil et al., 2014; McNeil et al., 2015). All study participants provided written informed consent and received a $30 CAD honorarium for each interview and fieldwork session. Ethics approval for this project was received from Simon Fraser University and Providence Healthcare/University of British Columbia Research Ethics Boards.

The analysis for this article employs a case study method, which has been utilized by feminist drug researchers to provide deeper insight into the gendered dynamics of drug use (Boyd et al., 2016; Farrugia et al., 2019; Murphy & Rosenbaum, 1997). Case studies are useful for gaining insights into how participant experiences are profoundly shaped by real-life contexts in ways that may have not been previously recognized (Farrugia et al., 2019). The two stories presented below (‘Tina’ and ‘Donna’) involve ‘thick description’ of overlapping social, structural, and spatial contexts and social locations from the perspective of the participant (Creswell, 2009; Hesse-Biber & Leavy, 2011). Their narratives illuminate some of the themes identified across interviews and during fieldwork. Both Tina and Donna completed baseline and follow-up interviews, as well as several one-on-one fieldwork sessions with the first author. Their cases are particularly significant because they reflect intersecting gendered, racialized, and classed inequities and draw attention to the labor expected of women within a public health crisis.

Love, labor, and drug use

Donna

Donna was a 50-year-old white woman who had lived in the Downtown Eastside for about two decades. For the last seven years, she had been living in the same non-profit-operated SRA – a place that she said she would “never leave” because, at roughly 250 sq. ft., her room was much larger than most. Donna had been in what she described as an “on/off” relationship with her partner for almost 10 years. Although he rented a room in a nearby privately-operated SRA, she described him as a “permanent guest” because of how regularly he stayed with her. During an interview, she explained: “I kick him out of my room during the day. He’s not going to just be hanging around my place all day when I’m at work – not my fault he lives in a shithole.”

Donna worked as a peer overdose response worker and supplemented her income as needed with recycling and sex work. Unlike other participants, Donna had regular peer shifts, working four nights a week. “We only get $12 an hour to save a life – sad isn’t it?” she said rolling her eyes, drawing attention to the pressure of the job and lack of appropriate compensation, especially for people like Donna who receive social assistance or disability benefits. Like other participants, Donna’s peer work was compensated under the provincial standard minimum wage at that time and the fixed amount people on benefits are allowed to earn each month, which she perceived as belittling her expertise as a woman who used drugs – a common sentiment amongst peer overdose response workers (Kennedy et al., 2019).

Like most participants who were on social assistance or disability benefits, Donna had to regularly balance accessing poverty management systems and drop-in services to meet basic needs (e.g. food, clothing, showers) with staving off withdrawal symptoms and working. In many ways, these systems structured Donna’s days as she had to function within the confines of extreme poverty, while also fulfilling work responsibilities. For Donna, such overlapping labor converged to create what she characterized as a ‘long day.’

During fieldwork and in interviews, Donna often stressed the importance of managing her withdrawals around her work schedule to avoid having to use opioids while at work. She expressed her ability to maintain this routine as reflective of being what she described as a “dependable” worker and used it to distance herself from other peer workers. While Donna typically used heroin, work responsibilities often necessitated using methamphetamine: “Most days I just use heroin. If I mix [with methamphetamine] it’s because sometimes I just want to nod off, but I gotta go to work. I just need it [methamphetamine] to get up and go.” For Donna, methamphetamine was described as something she used instrumentally to manage poverty (i.e. the drug provided energy to work), as well as out of desperation when experiencing withdrawal symptoms. By taking her opioids with methamphetamine, she was able to both slightly curb heroin withdrawal while also counteracting the opioid’s depressant qualities with the stimulant.

Donna’s insistence on separating drug use and work was critical as it allowed her to regain pleasure in her drug use and solace from her intense work. A key piece of this reprieve, however, was using drugs alone – a routine choice that afforded her both agency and the ability to relax as she was not also responsible for attending to her partner’s overdoses. “My boyfriend has overdosed seven times in the last year or so, and he doesn’t even use heroin,” she explained during fieldwork, blaming his overdoses on unintentional mixing of substances. Donna noted that all of his overdoses have been in her room and she has reversed them all: “I hate it! Fuck, I hate it. That’s what I’m supposed to do at work. Oh, I hate fucking doing that. I just hate the whole process of having to do it.”

For Donna, this persistent risk of having to deal with her partner’s overdoses, even when he used stimulants, was burdensome: “It’s a really horrible relationship. It sucks,” she explained. While Donna described herself as “lucky” given her lack of overdoses, she also suggested that differing approaches to drug use between she and her partner was also key: “I practice what I preach! You can’t take back what you did but you can always do more, and that’s what I do.”

Tina

Tina, a 40-year-old Indigenous woman, was born in Alberta. After a childhood of sexual abuse, she left home when she was 15 years old. Tina reflected on difficulties she experienced after leaving home, including being “on the streets for 12 years.” She explained that her efforts to deal with her childhood trauma led to heavy alcohol use, followed by “essentially non-stop crack use” while she cycled in and out of prison for the next two decades.

Tina and her husband moved from Alberta to Vancouver in an attempt to “cut back,” and eventually stop, using drugs. Tina explained that about five years ago she started using heroin and then fentanyl: “The first time I tried heroin I was like, ‘oh yeah, that’s the drug I want to use forever.’ I went from 0 to 100 just like that.” However, following a period in which she and her husband experienced numerous overdoses, they decided moving was critical to staying alive:

My husband overdosed like 12 times. We didn’t think he was going to live any longer. Me too, right? We had really bad habits and I mean we had to leave Alberta because we just couldn’t get off of it [i.e. fentanyl]. And we didn’t even want to come to Vancouver, we wanted to go to Victoria, but we ran out of money. We literally had $4 to our name so we just stayed.

Since relocating to Vancouver, Tina and her husband had experienced periods of homelessness, bouncing between shelters before securing a room in a privately-operated SRA. “We are paying $875 for one room,” Tina explained. “It’s steep [expensive]. And then we are on social assistance right now, which gives us $945 or something like that.” After rent, she and her husband had less than $100 for the month.

Soon after their move, Tina and her husband started methadone in an effort to stop using illicit opioids. However, Tina continued using illicit fentanyl several times a day, hiding it from her husband. “I go for little hoots at a time,” Tina explained, noting how this was both easier and quicker than injecting and did not leave physical marks on her body so it was easier to hide from her husband. Tina referred to fentanyl as her “little treat,” clarifying that she no longer used fentanyl to get high: “I just want to get the feeling,” she explained. Her characterization of fentanyl as a “treat” illustrates how she viewed it as something she could reserve just for herself.

Tina juggled multiple peer worker jobs, including working at an overdose prevention site, cleaning up harm reduction supplies from alleys, and working as a peer support worker at a community clinic. This work was precarious and underpaid, with shifts contingent on who else showed up that day: “You fish for shifts. When you go there you kind of wait until a certain time and then we all cut cards to see who goes on that shift.” For Tina, a lack of affordable housing and intense poverty necessitated that she worked multiple jobs to try to make ends meet, especially as the lottery system used for shift work was unpredictable. As there were limited opportunities available for PWUD within the formal economy, those that were accessible were at times challenging:

I’m still in early recovery, but I’m working at these OPS. I kind of get triggered a little bit there. Don’t know if it’s the safest environment for me to be in, but it’s cash, right? And it kind of helps not only for that little treat [i.e. fentanyl] but like I mean for food and stuff cause we’re kind of struggling.

Such forms of work impacted Tina’s wellbeing as she felt triggered by peer work due to seeing people injecting – something she actively tried to avoid.

For Tina, paid work responsibilities overlapped with efforts to minimize her drug use, cope with health challenges, and deal with an unstable relationship. She characterized her stress as resulting from having “too much happening at once” and positioned her drug use as providing pleasure amid the stress of multiple forms of labor and an unsteady relationship. In many ways, Tina’s stress was interconnected with pressure resulting from gendered responsibilities prevalent in the drug scene – namely, who held the burden of care both in the home (e.g. household work) and outside the home (e.g. meeting subsistence needs). During fieldwork, Tina explained that her husband quit doing peer overdose response work with her: “He didn’t like it, so he stopped going. He does the OPS once in a while, but he has other things too.” In her follow-up interview, Tina explained that while husband had gotten a more stable part-time job, he quit not long after, so she was solely responsible for their income: “I mean, there are things that like take us out almost, like stress us out so much, because I’m like ‘Oh my god. There’s no more money. How are we going to eat?’”

Discussion

Researchers and popular media have examined gendered expectations of labor in the home (e.g. Hartley, 2017; Hochschild & Machung, 1989; Hofman et al., 2003; Marcoux, 2019; Van Every, 1997), documenting how women are frustrated and exhausted by additional roles they must assume within the heteronormative family structure (Hartley, 2017). While this attention to varied forms of gendered labor in and outside of the home and its impact on women’s health is important, Donna and Tina’s experiences underscore how these responsibilities are further impacted by everyday gendered violence and gendered power differentials that are normalized within this context. Notably, these narratives demonstrate how structural (e.g. neoliberal discourses, socio-economic marginalization), symbolic (e.g. internalization of poverty, normalized gendered violence), and everyday (e.g. gender power relations, violence against women) violence can converge in ways that adversely impact women and gender diverse PWUD. As women and gender diverse PWUD shouldered the burden of household labor, care work, and paid labor (often multiple peer overdose response jobs), using drugs was a way to cope with burnout and frustration related to these overlapping demands amid an overdose crisis. Specifically, using drugs alone provided participants with a break from the caretaking responsibilities placed onto them by their partners in the home, as well as outside the home through work.

Being tasked with multiple forms of labor was common among participants and was framed by heteronormative gender roles within their relationships. Household labor, caretaking, and economic responsibilities coalesced with participants’ active roles in the overdose response, directly influencing their wellbeing. The narratives above illustrate how structurally vulnerable women and gender diverse PWUD are overwhelmed by the expectation to fulfill gendered responsibilities in the home while working to make ends meet. While feelings of responsibility to respond to overdose events within the context of a public health emergency are not limited to women and gender diverse individuals (Bardwell et al., 2019; Foreman-Mackey et al., 2019; Kennedy et al., 2019), social violence manifested in gendered ways to frame how participants experienced this work. Importantly, this paper illustrates how the task of overdose response in the home can fall to women and gender diverse individuals given gendered drug scene dynamics (e.g. men use first, control of drug use by partner) (Bryant et al., 2010; Harris & Rhodes, 2013; Iversen et al., 2015) and gendered assumptions of ‘risk taking’ and ‘responsibility’ within the context of drug use. In these instances, participants explained how they viewed their partners – and men in general – to use drugs in ‘risky’ ways because they “think that they can handle it” as opposed to women and gender diverse individuals who used in what they viewed as more responsible ways (e.g. spacing out injections, using small amounts at a time). While previous research has detailed how men can engage in gendered caretaking roles related to drug use of their partners (Syvertsen & Bazzi, 2015), participants framed overdose response expectations as one-sided and not always reciprocated by their partners. For participants, this culminated in distress, resentment, and exhaustion of having to engage in care work, leading them to use alone as a form of self-care. Such coping mechanisms (using alone), while framed by inequities reinforced by social violence, increase women’s fatal overdose risk (BC Coroners Service, 2020).

In this article, we demonstrate how women and gender diverse PWUD experienced burnout related to the multiple forms of labor they were responsible for; a materialization of structural violence in which drug use criminalization, limited income generating opportunities, and gendered inequities often placed the burden of income generation onto women and gender diverse individuals. As a result, participants were not always focused on their own overdose vulnerability as they were often managing that of their partner (or other individuals when at work). Specifically, women and gender diverse PWUD were tasked with responsibilities of caretaking in the home in lieu of caring for themselves. By navigating these complexities, Donna and Tina’s practices were at odds with broader narratives of ‘recklessness’ that are often spoken vis-à-vis PWUD. As these narratives illustrate, drug use practices – and specifically, using alone – are framed by pressures (e.g. gendered expectations, work-related stress), time, and caretaking. However, the compounding impacts of stress and responsibility adversely impacted participants’ health, where using drugs alone was a way to cope. Tina and Donna’s experiences of using alone in locked bedrooms or washrooms underscore the increased risk of fatal overdose women and gender diverse individuals face. However, public health overdose messaging largely focuses on behavior (e.g. do not use alone, use smaller amounts), which overlooks the social-structural inequities that shape the drug use patterns of structurally vulnerable women and gender diverse individuals. Overdose thus becomes a marker of individual ‘risk’ and ‘irresponsible’ drug use behavior (Moore, 2004). However, we argue that ‘risky’ drug use practices, including using alone, can be a rational strategy within a context framed by social-structural violence.

Research has highlighted how gendered assumptions can manifest within peer overdose response work (Boyd et al., 2018). While we highlight the compounding impacts of peer overdose response work in addition to unpaid labor for structurally vulnerable women and gender diverse individuals, the aim of this article is not to critique peer overdose response work, as the integration of peer workers within harm reduction settings has been shown to be integral to utilization (Bardwell et al., 2019; Foreman-Mackey et al., 2019; Kennedy et al., 2019). Rather, we point to the urgent need to increase occupational supports (e.g. training, education, counselling) and funding for peer-led services, as well as other programs and institutions who employ peer workers, so they can receive adequate compensation and health supports that prioritize their well-being. Furthermore, as evidenced by Tina, peer work can be triggering, particularly for individuals who have transitioned from injecting. This points to an urgent need to increase employment opportunities and support for structurally vulnerable women and gender diverse PWUD that addresses their socio-economic marginalization while staying cognizant of their wellbeing. Providing access to such supports are critical as low wages and mental fatigue related to overdose response can contribute to adverse health outcomes (Bardwell et al., 2019; Kennedy et al., 2019).

Moreover, participants detailed the extent to which they were experiencing ongoing trauma and burnout related to the continual loss of friends, family, and acquaintances. However, due to participants’ structural vulnerability, as well as a lack of supports offered as part of peer work positions, they were unable to grieve and cope with loss related to the overdose crisis. Rather, participants pointed to a gap in services available that provided health supports for women and gender diverse PWUD (including women-focused support groups and Indigenous-specific services), opportunities to debrief after peer overdose response shifts, and empowerment programs. Given this lack of support, participants managed their physical and mental health largely through their drug use and some arts-based activities (e.g. coloring, journaling). This underscores the urgent need to develop and fund health supports for women and gender diverse PWUD and integrate these supports into programs across the neighborhood.

In particular, this article echoes calls for Indigenous-focused supports that are for, and led by, Indigenous women and gender diverse individuals that address intergenerational trauma, systemic discrimination, experiences of violence, while providing opportunities for empowerment and support (Martin & Walia, 2019). This is critical because the lives of Indigenous participants, such as Tina, were strongly shaped by ongoing colonialism and systemic racism. Such systems have continued to drive inequities for Indigenous women, including disproportionate rates of poverty, violence, housing instability, incarceration, and overdose (First Nations Health Authority, 2017; Martin & Walia, 2019; Oppal, 2012). Tina’s narrative illustrated how her ongoing experiences with interconnected systems of oppression had impacted her health and wellbeing, including burnout and overdose risk. Supporting Indigenous women and gender diverse individuals with culturally appropriate supports that provide access to community, healing, and support within the context of an overdose crisis is fundamental to addressing their needs.

In this article, we have explored how structurally vulnerable women and gender diverse PWUD negotiate and handle the intersections of intimate partnerships, paid and unpaid labor, and health amid an overdose crisis, and how these are framed by social violence. Overdose response efforts and interventions need to be attuned to the variegated risks that can result from social violence, and be better suited to the needs of structurally vulnerable women and gender diverse PWUD (Boyd et al., 2018; Collins, Bardwell, et al., 2019; Collins et al., 2020). Structural reform is also needed to address ongoing structural violence faced by these populations, including increased pay for overdose response work, access health supports, higher social assistance rates, and access to livable, affordable housing. Without a commitment to addressing the social violence that frames the lives of women and gender diverse PWUD in the context of an overdose crisis, these populations will continue to shoulder the burden of care and experience increased risk of overdose as they cope with these inequities.

Acknowledgements:

This article is dedicated to Sandra Czechaczek who passed away prior to publication. We want to extend our sincerest thanks to the participants of this study for their expertise and willingness to share their insights. This work took place on the unceded territories of the xwməθkwəyə̓m (Musqueam), Skwxwú7mesh (Squamish), and selílwitulh (Tsleil-waututh) Nations. This research was supported by the Canadian Institute of Health Research (CIHR) (PJT-155943 and CBF- 362965) and the US National Institutes of Health (NIH) (R01DA044181). ABC was supported by a Vanier Canada Graduate Scholarship. RM was supported by a CIHR New Investigator Award and a MSFHR Scholar Award. JB is supported by funding from NIH (R01DA044181).

Footnotes

1

Two Spirit is a fluid and non-binary umbrella (English) term coined in the 1990s that denotes Indigenous persons with both masculine and feminine spirits (Ristock, Zoccole, & Passante, 2010; Robinson, 2017). While definitions continuously change, Two Spirit is often used by individuals to describe having a sexuality and/or gender that varies from others (Robinson, 2017).

Declaration of interest: None.

References

  1. Bardwell G, Fleming T, Collins A, Boyd J, & McNeil R (2019). Addressing intersecting housing and overdose crises in Vancouver, Canada: opportunities and challenges from a tenant-led overdose response intervention in single room occupancy hotels. Journal of Urban Health, 96(1), 12–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. BC Coroners Service. (2019). Illicit drug toxicity deaths in BC January 1, 2009 - June 30, 2019.
  3. BC Coroners Service. (2020). Illicit drug toxicity deaths in BC January 1, 2009 - December 31, 2019.
  4. Bourdieu P (2001). Masculine domination. Stanford University Press. [Google Scholar]
  5. Bourgois P, Prince B, & Moss A (2004). The everyday violence of hepatitis C among young women who inject drugs in San Francisco. Human Organization, 63(3), 253–264. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Boyd J, & Boyd S (2014). Women’s activism in a drug user union in the Downtown Eastside. Contemporary Justice Review, 17(3), 313–325. [Google Scholar]
  7. Boyd J, Collins A, Mayer S, Maher L, Kerr T, & McNeil R (2018). Gendered violence and overdose prevention sites: a rapid ethnographic study during an overdose epidemic in Vancouver, Canada. Addiction, 113(12), 2261–2270. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Boyd J, Fast D, & Small W (2016). Pathways to criminalization for street-involved youth who use illicit substances. Critical Public Health, 26(5), 530–541. [Google Scholar]
  9. Boyd J, Lavalley J, Czechaczek S, Mayer S, Kerr T, Maher L, & McNeil R (2020). “Bed Bugs and Beyond”: an ethnographic analysis of North America’s first women-only supervised drug consumption site. International Journal of Drug Policy, 78:102733. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Brecht M, O’Brien A, Von Mayrhauser C, & Anglin M (2004). Methamphetamine use behaviors and gender differences. Addictive Behaviors, 29(1), 89–106. [DOI] [PubMed] [Google Scholar]
  11. Bryant J, Brener L, Hull P, & Treloar C (2010). Needle sharing in regular sexual relationships: an examination of serodiscordance, drug using practices, and the gendered character of injecting. Drug and Alcohol Dependence, 107(2–3), 182–187. [DOI] [PubMed] [Google Scholar]
  12. Campbell N (2000). Using women: gender, drug policy, and social justice. Routledge. [Google Scholar]
  13. Campbell N, & Herzberg D (2017). Gender and critical drug studies: an introduction and an invitation. Contemporary Drug Problems, 44(4), 251–264. [Google Scholar]
  14. Carbone-Lopez K, & Miller J (2012). Precocious role entry as a mediating factor in women’s methamphetamine use: implications for life-course and pathways research. Criminology, 50(1), 187–220. [Google Scholar]
  15. Collins AB., Bardwell G, McNeil R, & Boyd J (2019). Gender and the overdose crisis in North America: moving past gender-neutral approaches in the public health response. International Journal of Drug Policy, 69, 43. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Collins AB., Boyd J, Cooper H, & McNeil R (2019). The intersectional risk environment of people who use drugs. Social Science & Medicine, 234. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Collins AB., Boyd J, Damon W, Czechaczek S, Krusi A, Cooper HLF, & McNeil R (2018). Surviving the housing crisis: social violence and the production of evictions among women who use drugs in Vancouver, Canada. Health & Place, 51:174–181. [DOI] [PubMed] [Google Scholar]
  18. Collins AB., Boyd J, Hayashi K, Cooper HLF, Goldenberg S, & McNeil R (2020). Women’s utilization of housing-based overdose prevention sites in Vancouver, Canada: an ethnographic study. International Journal of Drug Policy, 76:102641. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Connell R (2012). Gender, health and theory: conceptualizing the issue, in local and world perspective. Social Science & Medicine, 74(11), 1675–1683. [DOI] [PubMed] [Google Scholar]
  20. Creswell J (2009). Research design: Qualitative, quantitative, and mixed methods approaches (3rd ed.). Washington, DC: Sage. [Google Scholar]
  21. Culhane D (2003). Their spirits live within us: Aboriginal women in Downtown Eastside Vancouver emerging into visibility. American Indian Quarterly, 27(3–4), 593–606. [Google Scholar]
  22. Eichler M, & Albanese P (2007). What is household work? A critique of assumptions underlying empirical studies of housework and an alternative approach. Canadian Journal of Sociology, 32(2), 227–258. [Google Scholar]
  23. Epele M (2002). Gender, violence and HIV: women’s survival in the streets. Culture, Medicine and Psychiatry, 26(1), 33–54. [DOI] [PubMed] [Google Scholar]
  24. Farmer P (1997). On suffering and structural violence: a view from below. In Kleinman A, Das V, & Lock M (Eds.), Social suffering. University of California Press. [Google Scholar]
  25. Farmer P (2003). Pathologies of power: health, human rights, and the new war on the poor. University of California Press. [Google Scholar]
  26. Farrugia A, Fraser S, Dwyer R, Fomiatti R, Neale J, Dietze P, & Strang J (2019). Take-home naloxone and the politics of care. Sociology of Health & Illness, 41(2), 427–443. [DOI] [PubMed] [Google Scholar]
  27. First Nations Health Authority. (2017). Overdose data and First Nations in BC.
  28. First Nations Health Authority. (2019). The impact of the opioid crisis on First Nations in BC.
  29. Foreman-Mackey A, Bayoumi A, Miskovic M, Kolla G, & Strike C (2019). ‘It’s our safe sanctuary’: experiences of using an unsanctioned overdose prevention site in Toronto, Ontario. International Journal of Drug Policy, 73, 135–140. [DOI] [PubMed] [Google Scholar]
  30. Handwerker W (2001). Quick ethnography. Altimira Press. [Google Scholar]
  31. Hansen H (2017). Assisted technologies of social reproduction: pharmaceutical prosthesis for gender, race, and class in the white opioid “crisis”. Contemporary Drug Problems, 44(4), 321–338. [Google Scholar]
  32. Harris M, & Rhodes T (2013). Injecting practices in sexual partnerships: hepatitis C transmission potentials in a ‘risk equivalence’ framework. Drug and Alcohol Dependence, 132(3), 617–623. [DOI] [PubMed] [Google Scholar]
  33. Hartley G (2017, September). Women aren’t nags - we’re just fed up. Harper’s Bazaar. https://www.harpersbazaar.com/culture/features/a12063822/emotional-labor-gender-equality/
  34. Herzberg D (2010). Happy pills in America: from Miltown to Prozac. Johns Hopkins University Press. [Google Scholar]
  35. Hesse-Biber S, & Leavy P (2011). The practice of qualitative research (2nd ed.). Washington, DC: Sage. [Google Scholar]
  36. Hochschild A, & Machung A (1989). The second shift. New York: Avon. [Google Scholar]
  37. Hofman NG., Strenski TA, Marshall PA, & Heimer R (2003). Maintaining respectability and responsibility: gendered labor patterns among women injection drug users. Health Care for Women International, 24:794–807. [DOI] [PubMed] [Google Scholar]
  38. Iversen J, Page K, Madden A, & Maher L (2015). HIV, HCV and health-related harms among women who inject drugs: implications for prevention and treatment. Journal of Acquired Immune Deficiency Syndrome, 69(0–1), S176–S181. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Johnson G, & Vindrola-Padros C (2017). Rapid qualitative research methods during complex health emergencies: a systematic review of the literature. Social Science & Medicine, 189, 63–75. [DOI] [PubMed] [Google Scholar]
  40. Kennedy M, Boyd J, Mayer S, Collins A, Kerr T, & McNeil R (2019). Peer worker involvement in low-threshold supervised consumption facilities in the context of an overdose epidemic in Vancouver, Canada. Social Science & Medicine, 225, 60–68. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Knight K (2017). Women on the edge: opioids, benzodiazepines, and the social anxieties surrounding women’s reporduction in the U.S. “opioid epidemic.” Contemporary Drug Problems, 44(4), 301–320. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Marcoux H (2019, June). The invisible labor of motherhood is real-and it’s burning us out. Motherly. https://www.mother.ly/news/invisble-labor-motherhood-mental-load
  43. Martin C, & Walia H (2019). Red Women Rising: Indigenous women survivors in Vancouver’s Downtown Eastside.
  44. McNeil R, Kerr T, Lampkin H, & Small W (2015). “We need somewhere to smoke crack”: an ethnographic study of an unsanctioned safer smoking room in Vancouver, Canada. International Journal of Drug Policy, 26(7), 645–652. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. McNeil R, Small W, 2014. ‘Safer environment interventions’: a qualitative synthesis of the experiences and perceptions of people who inject drugs. Social Science & Medicine, 106, 151–158. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Metzl J (2003). Prozac on the couch: prescribing gender in the era of wonder drugs. Duke University Press. [Google Scholar]
  47. Moore D (2004). Governing street-based injecting drug users: a critique of heroin overdose prevention in Australia. Social Science & Medicine, 59(1547–1557). [DOI] [PubMed] [Google Scholar]
  48. Murphy S, & Rosenbaum M (1997). Two women who used cocaine too much: class, race, gender, crack and coke. In Reinarman C & Levine H (Eds.), Crack in America (pp. 98–112). University of California Press. [Google Scholar]
  49. Netherland J, & Hansen H (2016). The war on drugs that wasn’t: wasted whiteness, “dirty doctors,” and race in media coverage of prescription opioid misuse. Culture, Medicine and Psychiatry, 40(4), 664–686. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Pink S, & Morgan J (2013). Short-term ethnography: intense routes to knowing. Symbolic Interaction, 36(3), 351–361. [Google Scholar]
  51. Rhodes T, Wagner K, Strathdee S, Shannon K, Davidson P, & Bourgois P (2012). Structural violence and structural vulnerability within the risk environment: theoretical and methodological perspectives for a social epidemiology of HIV risk among injection drug users and sex workers. In O’Campo JR, Dunn P (Ed.), Rethinking Social Epidemiology: Towards a Science of Change (pp. 205–230). [Google Scholar]
  52. Ristock J, Zoccole A, & Passante L (2010). Aboriginal two-spirit and LGBTQ migration, mobility and health resaerch project: final report. Winnipeg. [Google Scholar]
  53. Robinson M (2017). Two-spirit and bisexual people: different umbrella, same rain. Journal of Bisexuality, 17(1):7–29. [Google Scholar]
  54. Scheper-Hughes N (1996). Small wars and invisible genocides. Social Science & Medicine, 43(15), 889–900. [DOI] [PubMed] [Google Scholar]
  55. Special Advisory Committee on the Epidemic of Opioid Overdoses. (2019). National report: apparent opioid-related deaths in Canada (January 2016 to March 2019).
  56. Syvertsen J, & Bazzi A (2015). Sex work, heroin injection, and HIV risk in Tijuana: a love story. Anthropology of Consciousness, 26(2), 182–194. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Van Every J (1997). Understanding gendered inequality: reconceptualizing housework. Women’s Studies International Forum, 29:411–420. [Google Scholar]
  58. VanHouten J, Rudd R, Ballesteros M, & Mack K (2019). Drug overdose deaths among women aged 30–64 years - United States, 1999–2017. Morbidity and Mortality Weekly Report, 68(1), 1–5. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES