A ‘bottom up response to two epidemics’ and a discussion for International Women’s Day 2021 on the need for women-only and gender-responsive services.
By Natalie Davies (co-editor of Drug and Alcohol Findings)
“Women-only services are a legacy of the women’s movement. In 1970s Britain, nearly 200 domestic abuse and sexual violence refuges were established where previously there were none”
There was a flurry of activity in Canada between 2016 and 2018 to address the opioid crisis, which notably included a step change in the provision of hygienic and supervised spaces for people to inject illicit drugs in. The country went from having two drug consumption rooms to 26 over a short period of time, one of which was SisterSpace, North America’s first women-only safer injecting facility.
A study analysed by Drug and Alcohol Findings found that SisterSpace gave women a temporary reprieve from stigma, discrimination, violence, and drug-related harms, against the backdrop of two epidemics: an epidemic of drug overdoses; and an epidemic of violence against women (see box).
Violence against women
The term ‘violence against women’ unifies a number of issues that are disproportionately perpetrated against women, including domestic abuse, rape and sexual assault, forced prostitution, female genital mutilation, so-called ‘honour-based’ violence, and sex trafficking.
The United Nations defines violence against women as “any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life”, and furthermore as “violence that is directed against a woman because she is a woman or that affects women disproportionately”.
During the study period, researchers spent 100 hours observing and interacting with the roughly 70 women who visited the site each day, and conducted in-depth interviews with a total of 45 women. Overall, participants felt that SisterSpace responded to their gendered needs in ways that other drug consumption rooms either could not or had not sought to achieve. SisterSpace fostered feelings of safety, comfort and belonging through its setting, its operational policies, and its environment. Central to this was the demarcation of the drug consumption room as a women-only space – staffed by women with similar lived experience.
Women-only services are a legacy of the women’s movement. In 1970s Britain, nearly 200 domestic abuse and sexual violence refuges were established where previously there were none, providing desperately-needed support to victims and survivors, and signifying a collective challenge to male violence against women. In the context of substance use services, some of the reported benefits of women-only interventions include women feeling more at ease discussing sensitive or women-specific issues, services paying attention to women’s needs as the norm rather than the exception (e.g. being trauma-informed and providing practical assistance with childcare), an opportunity to build relationships with other women around shared experiences, and the absence of men who women may associate with unwanted sexual attention, harassment, abuse and violence both inside and outside of substance use services.
While it does not necessarily follow that all women will want or need to access women-only services, the opportunities these services create to meet women’s specific needs can help to inform discussions about how mixed services can become ‘gender responsive’.
“The overlapping harms of public injecting and violence against women, which are often intensified by poverty, homelessness, and sex work, require a pragmatic and compassionate response.”
A sister study published in 2018 in the journal of Addiction described how women may be differently and in some ways disproportionately affected by drug-related harms. Based on 185 hours of observation and in-depth interviews with 35 women recruited from three drug consumption rooms, this study found that women were at increased risk when injecting in public due to the risk of sexual violence from men – a risk amplified since fentanyl (a very strong opioid, sometimes mixed with heroin or cocaine) had entered the market. Fentanyl was causing severe intoxication and overdose to occur more quickly, from the consumption of smaller amounts of opioids, and there were reports that women in extreme poverty were being offered drugs laced with fentanyl for the purposes of “knocking them out” to sexually assault them. One participant described how she had recently accepted a stranger’s offer of opioids and subsequently lost consciousness due to its potency, later awakening to discover that she had been sexually assaulted and robbed. Her story touched on a neglected part of the conversation about the opioid crisis, which is the qualitatively different kind of vulnerability that exists for a woman who is dependent on drugs, and the qualitatively different definition of what constitutes drug-related harm.
We can anticipate that some will see a women-only drug consumption room as a “luxury” in the midst of the overdose crisis. However, it is not the only public health emergency facing women who inject drugs. The overlapping harms of public injecting and violence against women, which are often intensified by poverty, homelessness, and sex work, require a pragmatic and compassionate response. One approach is to implement women-only services of the kind illustrated by SisterSpace, and another touched upon above is to institute gender-responsive operational policies.
Violence can be a normal and pervasive part of the lives of vulnerable men and women who use drugs, and drug consumption rooms have the potential to provide respite from this everyday violence, as well as serve to mitigate the harms of drug use. However, women may not get the respite from violence that men get without concerted action to address gender-based violence and other forms of gender inequality. Reminders of women’s vulnerability to male violence and their marginalised status within substance use services can include unwanted sexual attention, harassment or abuse from men going unchallenged by staff and other service users, and finding themselves in a space with men who have previously victimised them.
The global call to action for International Women’s Day 2021 is #ChooseToChallenge – “to show your commitment to choose to challenge inequality, call out bias, question stereotypes, and help forge an inclusive world”.
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