International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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Page 108 of 153

R. McNeil et al. / International Journal of Drug Policy 25 (2014) 608–615 609 of violence that is rendered invisible due to its pervasiveness (Scheper-Hughes, 1992), and is often embedded within gendered power relations (Bourgois, Prince, & Moss, 2004). Finally, symbolic violence is the product of social forces that lead vulnerable groups to misrecognize their subordination as the natural order of things and often blame themselves for the suffering experienced due to their social position (Bourdieu & Wacquant, 1992). Epidemiological data underscore how intersecting structural inequities that impact upon street-based drug scenes, including homelessness (Duff, Deering, Gibson, Tyndall, & Shannon, 2011; Shannon et al., 2009) and drug and sex work law enforcement (Kerr, Small, & Wood, 2005; Shannon, Rusch, et al., 2008), increase exposure to violence. Ethnographic and qualitative studies further underscore how social norms operating within drug scenes perpet- uate everyday violence (Bourgois et al., 2004; Epele, 2002; Shannon, Kerr, et al., 2008). Previous research has described how the subor- dination of women within street-based drug scenes is expressed through violence, particularly that directed from 'boyfriends' (i.e., men who control the resources women generate through exchang- ing sex) and sex work clients (Bourgois et al., 2004; Bungay, Johnson, Varcoe, & Boyd, 2010). Furthermore, the tendency among PWID to identify women's subordination as natural underscores the symbolic dimensions of drug scene violence (Bourgois et al., 2004). Violence among PWID is an urgent public health concern given its direct impacts and association with drug-related harm. Pre- vious studies have primarily concentrated on drug-using women (Braitstein et al., 2003; El-Bassel et al., 2005; Vlahov et al., 1998), linking violence to elevated rates of syringe-sharing (Braitstein et al., 2003), inconsistent condom use (El-Bassel et al., 2005), and accidental overdose (Braitstein et al., 2003). Furthermore, violence or the threat of violence in settings where drug-using women exchange sex have been found to undermine their ability to nego- tiate safer sex work transactions (Shannon, Kerr, et al., 2008). Although male PWID are also likely to experience drug scene violence, comparatively less attention has been paid to the associ- ated risks and consequences outside of studies linking experiences of violence among male PWID with an increased likelihood of depression (Curry, Latkin, & Davey-Rothwell, 2008) and death due to homicide (Clausen, Waal, Thoresen, & Gossop, 2009). The limited attention to violence among drug-using men reflects an empha- sis on gender-based violence in the drug use literature, which is viewed primarily as violence perpetrated against women by men (Marshall et al., 2008). Epidemiological studies of drug scene vio- lence have tended to concentrate on biological sex or define gender as a binary, and have emphasized women's vulnerability to inter- partner violence or violence in the context of sex work (El-Bassel et al., 2005; Shannon et al., 2009). Whereas several ethnographic and qualitative studies have linked violence against women within drug scenes to gendered power relations, and examined how it is produced by gender norms that subordinate women (Bourgois et al., 2004; Bungay et al., 2010; Shannon, Kerr, et al., 2008), they have not considered the role of a wider range of 'gender positions' in shaping violence. An alternative view may consider how gendered violence is pro- duced by hegemonic forms of masculinity that operate within street-based drug scenes, which render women and 'marginal men' vulnerable to violence due to their marginal positions within gen- dered hierarchies. Hegemonic masculinity may be understood to be a set of practices occurring within any particular context, in this case the street-based drug scene, through which some men subor- dinate or control women and 'marginal' masculinities (Connell & Messerschmidt, 2005). Violence toward those occupying marginal positions within gendered hierarchies is one of the 'practices' through which hegemonic masculinity is expressed and reinforced (Stoudt, 2006). Although limited, evidence suggests that the structure of street- based drug economies reflects and reinforces gendered hierarchies, in that men occupying more prominent roles (e.g., drug deal- ers) subordinate women and marginal men. While some women occupy roles within drug economies that allow them greater claims to agency (Maher, 1997; Shannon, Kerr, et al., 2008), women are nonetheless largely confined to marginal positions (Maher & Hudson, 2007). Moreover, the marginal positions of some men are often determined by the lower status accorded to their income- generating strategies within the street-based economies (e.g., panhandling, recycling) (Bourgois & Schonberg, 2009). Follow- ing Connell and Messerschmidt (2005), we extend this view of marginal men within the context of street-based drug scenes to also include men who do not—or cannot—occupy dominant roles due to age, disability, health status, social isolation (e.g., limited social ties within the drug scene), and specific drug use practices (e.g., requir- ing help injecting). While recognizing that women and marginal men's experiences of violence are complex and unique, evidence from other settings suggest that dominant forms of masculinity increase vulnerabilities to violence and adverse health outcomes among women (Jewkes & Morrell, 2012) and marginal men (Canetto & Cleary, 2012; Courtenay, 2000), but this has been under- explored as a driver of violence within the context of drug scenes. The Downtown Eastside (DTES) neighbourhood in Vancouver, British Columbia is the site of Canada's largest street-based drug scene (Strathdee et al., 1997; Wood & Kerr, 2006), with an estimated 5000 PWID living in this approximately ten-block area (Wood & Kerr, 2006). This neighbourhood has been shaped by the interplay between entrenched poverty, homelessness, and drug use (Wood & Kerr, 2006). Whereas numerous environmental supports are avail- able to PWID in this neighbourhood, including North America's only sanctioned supervised injection facility (Insite) and safer sex work environments (Krusi et al., 2012), research has documented the sig- nificant impact that violence has on neighbourhood PWID (Lazarus, Chettiar, Deering, Nabess, & Shannon, 2011; Marshall et al., 2008; Shannon, Kerr, et al., 2008). Notably, in a social mapping study among drug-using women who exchange sex, Shannon, Rusch, et al. (2008) found that women commonly avoided main streets and core areas of the DTES with high concentrations of health services due to violence and police harassment. However, there remains a need to explore how injection drug- using women and marginal men's understandings and experiences of place and gendered violence shape their spatial practices—that is, how they actively negotiate space in the context of their everyday lives (de Certeau, 1984). Furthermore, studies into how gendered hierarchies frame the violence experienced by women and men who inject drugs, and the consequences of this violence, are needed. We undertook this study to explore the spatial practices of women and marginal men who inject drugs in the DTES, and how these are shaped by gendered violence. We were particularly concerned with how their spatial practices impacted their access to health and harm reduction services, including Insite. Methods This study is based upon qualitative interviews and mapping exercises conducted with PWID in the DTES between September and December 2011. This research was undertaken in partnership with the Vancouver Area Network of Drug Users (VANDU), with whom members of our research team have collaborated for more than a decade. Two research team members (McNeil and Small) conducted semi-structured interviews with twenty-three PWID who regularly accessed VANDU. We aimed to oversample women relative to their representation within the local drug scene to facilitate the study of gendered patterns of risk and harm. We also prioritized the recruitment of participants whose specific injecting

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