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“Like a lots happened with my whole childhood”: violence, trauma, and addiction in pregnant and postpartum… Torchalla, Iris; Linden, Isabelle A; Strehlau, Verena; Neilson, Erika K; Krausz, Michael Jan 12, 2015

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RESEARCH Open Access“Like a lots happened with my whole childhood”:violence, trauma, and addiction in pregnant andpostpartum women from Vancouver’s Downtownand human rights.Torchalla et al. Harm Reduction Journal 2014, 11:34http://www.harmreductionjournal.com/content/11/1/342255 Westbrook Mall, Vancouver, BC V6T 2A1, CanadaFull list of author information is available at the end of the articleKeywords: Substance use, Women, Pregnancy, Trauma, Gender-based violence* Correspondence: itorchalla@cheos.ubc.ca1Centre for Health Evaluation and Outcome Sciences (CHÉOS), St. Paul’sHospital, 588-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada2Department of Psychiatry, University of British Columbia, Detwiller Pavilion,levels and from issues of drug use and reduction of drugEastsideIris Torchalla1,2*, Isabelle Aube Linden1, Verena Strehlau1,2, Erika K Neilson1 and Michael Krausz1,2,3AbstractBackground: Women living in poor and vulnerable neighbourhoods like Vancouver’s Downtown Eastside (DTES)face multiple burdens related to the social determinants of health. Many of them struggle with addiction, areinvolved in the sex trade and experience homelessness and gender-based violence. Such evidence suggests thatpsychological trauma is also a common experience for these women.Methods: The purpose of this qualitative study was to explore themes and subjective perspectives of trauma andgender-based violence in women who lived in an impoverished neighbourhood and struggled with substance useduring pregnancy and early motherhood. We interviewed 27 individuals accessing harm reduction services forpregnant and postpartum women in Vancouver, Canada.Results: Key themes that emerged from these women’s narratives highlighted the ubiquity of multiple andcontinuing forms of adversities and trauma from childhood to adulthood, in a variety of contexts, through a varietyof offenders and on multiple levels. Both individual and environmental/structural conditions mutually intensifiedeach other, interfering with a natural resolution of trauma-related symptoms and substance use. Women were alsoconcerned that trauma could be passed on from one generation to the next, yet expressed hesitation when askedabout their interest in trauma-specific counselling.Conclusions: In offering harm reduction services for poor and marginalized women, it is clear that anunderstanding of trauma must be integrated. It is recommended that service providers integrate trauma-informedcare into their programme in order to offer this service in a trusted environment. However, it is also necessary toshift the focus from the individual to include environmental, social, economic and policy interventions on multiple-related harms to include issues of gendered vulnerabilities© 2014 Torchalla et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.Torchalla et al. Harm Reduction Journal 2014, 11:34 Page 2 of 10http://www.harmreductionjournal.com/content/11/1/34BackgroundExtreme poverty neighbourhoods have been defined bypoverty rates of at least 40% [1]. Such neighbourhoodshave received increasing attention by researchers andpolicy makers because concentration of poverty is asso-ciated with additional social problems that are in turnlinked to negative health outcomes for their residents[2]. The Downtown Eastside (DTES) of Vancouver,British Columbia, is a small geographical area of about17,000 people [3] that has often been described as thepoorest neighbourhood in Canada [4]. Many communitymembers experience unemployment, precarious hous-ing, violence and crime. A plethora of readily available,low-cost, illicit drugs also exist there, resulting in highrates of crack cocaine, crystal methamphetamine andheroin use [5], and the mortality rates for drug-induceddeaths are seven times greater than the provincial rates[6]. Involvement in sex work and the drug trade arecommon means for the DTES residents to make endsmeet, and many struggle with mental illness, medicaldiseases such as HIV/AIDS and hepatitis and substanceuse disorders (SUDs) [6]. Researchers have also identi-fied the significance of traumatic experiences such aschildhood maltreatment, sexual assault and family andpartner violence for individuals with substance use prob-lems [7,8]. Such evidence suggests that people residingin the DTES face multiple burdens related to social de-terminants of health and that psychological trauma isalso likely a common experience.About 38% of the DTES population are women [3]. Ina community health survey of DTES residents, 78% ofthe women reported recent use of illicit drugs and aboutone third reported injection drug use [9]. Female injec-tion drug users in Vancouver have mortality rates almost50 times that of the province’s general female population[10]. Researchers have pointed out how the numericalsuperiority of men in the DTES has created a domin-antly male street culture and gendered risk environmentsin which women experience particular marginalization, ex-ploitation, increased safety risks [11] and gender-based vio-lence [8,12]. Gender-based violence against women hasbeen defined as any act “that results in, or is likely to resultin, physical, sexual or psychological harm or suffering towomen, including threats of such acts, coercion or arbi-trary deprivation of liberty, whether occurring in public orin private life” [13]. In practice, it includes an array of of-fenses against girls and women such as sexual and physicalviolence, psychological abuse, violence in pregnancy, co-erced sex/rape, sexual slavery, sexual harassment andforced prostitution conducted by family members, intimatepartners and other perpetrators [14]. Women who use sub-stances generally tend to report more sexual victimizationand multitype trauma [15,16] and greater rates of posttrau-matic stress disorder (PTSD) [17] than men. In a study ofhomeless people with SUDs from British Columbia, PTSDcomorbidity was significantly more prevalent in womenthan men; PTSD and gender were both associated withvariables of psychopathology, and the most severe patternwas found for women with PTSD [18]. Women from theDTES also have high rates of pregnancy and poor preg-nancy outcomes [19,20]. Studies among mothers living inpoverty found that histories of abuse and maltreatmentwere associated with greater psychological distress anddrug use severity [21], low parenting satisfaction and phys-ical punishment and neglect of their own children [22,23].It must be pointed out that reports on the deficits andproblems in the DTES represent only one side of thecoin and do not reflect the strength, resilience and cour-age of many individuals living in this neighbourhood.The DTES has an energetic and creative community ofadvocates and activists that initiate and support change.For example, an organization was formed in 1997 byVancouver drug users and activists to address the healthcrisis among intravenous drug users in the DTES by or-ganizing public demonstrations and discussions, operat-ing various educational and support programmes,advocating for changes in drug policies and participatingin council and policy planning meetings [24]. Otherwork has focused on developing affordable housing, pro-moting harm reduction services and creating safe spacesfor women. In 2000, the City of Vancouver released itsFour Pillars Drug Strategy (prevention, treatment, harmreduction and enforcement), a pragmatic approach todrug issues to reduce the health, social and economiccosts of legal and illegal substance use without necessar-ily reducing the consumption [25]. Vancouver’s currentharm reduction programmes include a supervised injec-tion site, needle exchanges and low-threshold commu-nity housing and health services. For example, pregnancyoutreach programmes with a harm reduction philosophyhave been established to respond to a growing under-standing of the complex health and social needs of preg-nant women and new mothers who use substances. Theoverall goals of these programmes are to improve preg-nancy outcomes, increase the women’s well-being andhelp them reduce their risk behaviours, support mothersin their capacity as parents and promote the health anddevelopment of their children. However, despite existingevidence highlighting the importance of trauma in thelives of women with SUD, the majority of research pro-jects and programme planning in the DTES has focusedon injection drug use and infectious diseases whereasmental health issues and trauma have often been neglected[26]. The goal of the current paper is to complement theexisting work by exploring themes of trauma, violence andmental health in pregnant and postpartum women whostruggled with substance use and accessed harm reductionservices. Staff who are working with these women mightTorchalla et al. Harm Reduction Journal 2014, 11:34 Page 3 of 10http://www.harmreductionjournal.com/content/11/1/34not fully understand the associated challenges or have thetraining to address the complexity of problems among in-dividuals with substance use issues [27]. Understandingtheir perspectives can offer insight into the complexities ofproviding services for marginalized individuals; feeding thisinformation back to the harm reduction services couldhelp to improve service access and intervention outcomesfor these women.MethodsThe study was conducted in Vancouver between June2009 and March 2010. Eligible participants were adultwomen who were struggling with substances duringpregnancy and/or early motherhood. They had to be 19years of age or older and have given birth in the past 5years. Participants were recruited from three communityprogrammes which provided harm reduction services forsubstance-using mothers: 1) ‘Sheway’ is a drop-in centrein the DTES that offers prenatal and postnatal care, sex-ual health counselling, addiction counselling and metha-done maintenance treatment, practical support, foodand nutrition counselling, parenting classes, and FirstNation specific services for about 120–160 women.2) ‘Fir Square’ is a residential programme at a Women’sHospital dedicated to providing care for substance-usingwomen and their newborns in a single unit. Theprogramme helps women and their newborns stabilizeand withdraw from substances, while keeping mothersand babies together and continuing to provide care fromantepartum to postpartum and between hospital andcommunity. 3) ‘Crabtree Corner Housing’ is located inthe DTES and provides transitional housing for pregnantand parenting women who use substances. The centrealso offers meal programmes, child care, support groupsand programmes related to parenting, family activities,health prevention and child development.Study recruitment posters were placed at these ser-vices. Recruitment was slow, partly due to the slow rela-tionship building the researchers experienced with theservices. The research team also presented the study de-sign and recruitment strategy to the staff of Sheway be-cause it is the primary service provider for substanceusing mothers in Vancouver. From this meeting, it wassuggested that the interviewers become more familiarwith the study population by engaging in some of the ac-tivities during Sheway’s drop-in hours. In the initial re-cruitment period, the interviewers helped with childminding, organizing and distributing donations, foodand other supplies, as well as accompanying somemothers and children to the park. The interviewers alsoset up a display booth during high volume drop inhours, presenting information about the study andscreening interested mothers. Furthermore, at the endof each study interview, participants were given cardsdetailing the contact information of the study coordi-nator and asked to share that information with any otherwomen they thought might be eligible to participate.The original target number for the study was 50 women,but during data analysis, it became clear that after inter-viewing 27 women, no new knowledge was being gener-ated and therefore data saturation was reached.After providing written informed consent, participantscompleted several quantitative questionnaires and a semi-structured qualitative interview. All interviewers had pre-vious experience working with marginalized populationsand had performed similar interviews before. Interviewswere conducted and audiotaped in private rooms atSheway, Fir Square or in participants’ homes by three fe-male research assistants. Child care was offered when theinterviews were conducted at the services. All participantsreceived an honorarium of $20.A total of 33 women met the inclusion criteria andconsented to participate in the study. Only 31 partici-pants completed the quantitative questionnaires becausetwo women were unable to attend their scheduled ap-pointment and could not be reached to re-schedule. Thequantitative measures assessed sociodemographic char-acteristics and information related to substance use,childhood maltreatment, adult abuse experiences andgeneral and PTSD-related distress. The results have beenreported elsewhere [28].Qualitative methodology was employed within thispopulation specifically because of the sensitive nature ofthis topic and the lack of available in-depth information.This article describes the qualitative component of thestudy aimed at giving a voice to the women, obtainingtheir personal and subjective experiences and perspectiveson trauma and addiction and appreciating individual di-fferences in addition to collecting standardized data.The qualitative interviews were guided by pre-identifiedthemes (i.e. the context of substance use, the context oftrauma and violence and the interplay of trauma and sub-stance use) which prompted the following questions: Canyou describe to me how your drug use started? Can you tellme how your drug use developed when you learned youwere pregnant? How was your mental health, how did youfeel? Did you experience any significant life event that mayhave affected you? The interviewer also asked questionsabout the women’s relationships with their family mem-bers and partners, explored their interest in trauma treat-ment and encouraged women to discuss other issues thatwere important to them but have not been addressed bythe interviewers. Interviews took between 1 and 4 h. Theinterviewers determined in repeated discussion with theprincipal investigator (M.K.) that data saturation wasreached after interviewing 27 women.These women were on average 32.0 years old andabout half of them self-identified as aboriginal. Nineteenwomen had a foster care history, more than half of themhad no high school diploma, and 24 received their currentincome from governmental support. The women were upto 1 year postpartum and 21 women had more than onechild. Sixteen women reported that they had no partner atthe time of the interview (see Table 1 for detailed sociode-mographic information).All interviews were transcribed verbatim and enteredinto NVIVO. The goal of the analysis was to provide athematic description of key elements involved in ourparticipant’s lifetime experiences. The interviews werefirst examined for content through multiple readingsand thematic analysis. Themes were identified by tworaters (I.T. and I.L.), a clinical psychologist and re-searcher with a Master of Public Health, by extractingcentral topics that were recurring within and across theindividual interviews. Initial coding was conducted inde-pendently, with codes being applied incident by incident.After an initial coding phase, a codebook was created,incidents were pooled and redundant codes were collapsed.Table 1 Sociodemographic information of the studysample (n = 27)M SDAge 32.0 5.7Maternal age 22.4 5.3N %EthnicityaWhite 13 48.1First Nations/aboriginal 13 48.1Torchalla et al. Harm Reduction Journal 2014, 11:34 Page 4 of 10http://www.harmreductionjournal.com/content/11/1/34Asian 3 11.1Marital statusSingle 14 51.9Partnered 7 25.9Married 4 14.8Divorced 2 7.4EducationNo high school diploma 15 55.6High school diploma 2 7.4Some college education 3 11.1College graduation 4 14.8Graduate studies 1 3.7Other 2 7.4Total number of children1 6 22.22 4 14.83 10 37.04 3 11.15–8 4 14.8aThe numbers add up to 29 because two women declared two ethnicities.The findings are presented narratively. The study had re-ceived approval from the University of British Columbiaand Providence Health Care ethics boards.ResultsSix key themes were found; the themes are as follows:(1) women spoke of adverse and traumatic experiencesin early childhood, (2) the continuation of adversitiesand trauma in adulthood, (3) intimate partner violence,(4) structural violence, (5) transgenerational trauma and(6) their interest in trauma counselling. The results illus-trate the complexities of the target population, all ofwhich are important considerations when offering harmreduction services.Adversities and trauma during childhoodThe vast majority of women described difficult circum-stances and multiple problems in their families whenthey were growing up. Often, one or both of the parentsor primary caregivers used substances themselves and/orsold drugs to make a living, and they were exposed orintroduced to drugs by their families and peer groups atan early age. The majority of participants reported thattheir drug use started in very early adolescence. Someparticipants reported that their parents had mental ill-nesses. Some participants mentioned that they have hadmental health problems themselves from very early on.Exposure to domestic violence, sexual, physical and emo-tional abuse and neglect was common. All of the womenreported childhood maltreatment experiences; more thanthree quarter (n = 24; 77.4%) reported sexual abuse andeach of the other types of childhood maltreatment(i.e. physical and emotional abuse and physical and emo-tional neglect) was reported by at least 17 of the women(see [28] for detailed results of the Childhood TraumaQuestionnaire). In most cases, the participants had experi-enced multiple forms of adversities and trauma.“I was heavily abused as a child. Mentally andphysically by my mother. And, sexually by herboyfriends. And I watched her getting raped. And Ihad, I watched her get beat the crap out of her, Iwalked in on her slitting her wrists. And the blood wasjust, spraying everywhere. And, uh, yeah, it, I had, uh,a traumatic childhood” (White woman, 36 years).These experiences led some participants to drift intosubcultures and peer groups where exposure to familydysfunction, abuse and neglect was the norm. Partici-pants also ran away from their parents, were evicted bytheir parents and/or were placed in foster homes. Thisabsence of a stable home resulted in further disruptionof normal developmental processes, making participantsmore likely to engage in deviant behaviours such as drugAnd then I met my boyfriend and we moved out. AndTorchalla et al. Harm Reduction Journal 2014, 11:34 Page 5 of 10http://www.harmreductionjournal.com/content/11/1/34use, criminal and violent behaviours and prostitutionand exposed them to further risk.“My grandparents raised me part, on a small reserve.And I was in foster care since I was 13. I moved myselffrom the reserve. Then my father called and asked fora visitation. At the time I was trying to get out of thefoster system. Having to be in somebody else’s care, itwas a lot of rules. I’d never had rules growing up. So Iran away. I moved here and I ended up in the Mainand Hastings area” (Aboriginal, 30).“I was like a full, crack head. I put myself in fostercare. And uh then, I’d run away, and stay out for 30days, at a time until, the um, kiddie cop car, wouldpick me up and, take me back to my foster parents’house. Or my group home. Um, and, uh, like I wasprostituting on the streets at that point too. Uh,starting at 12” (White, 33).Continuing adversities and trauma in adulthoodNormality and daily routines were missing in the lives ofmost participants, and many of them were unable tocomplete school, get an education and take up employ-ment. Their childhood was often chaotic and character-ized by abuse and neglect and it continued to be so inadulthood. Twenty-seven women (87.1%) indicated theyhad experienced emotional abuse, 23 (74.2%) reportedphysical abuse and 16 (51.6%) reported sexual abuse inadulthood, oftentimes by multiple perpetrators. Environ-mental and structural factors contributed to the dangersand threats that dominated the women’s everyday life.For example, all of the women reported experiences ofhomelessness or precarious housing at some point intheir lives; many of them early in their career, multipletimes and/or for long periods of time. Life on the streetsin combination with drug use often involved engage-ment in risky activities (e.g. prostitution) and exposureto high risk and traumatic situations (e.g. sexual andphysical assault) which typically deteriorated theircondition.“I had ended up in a building in Vancouver that wasone of the worst places you could rent from, full ofhookers and drug addicts. And it was a nightmare. Iwas selling myself on the street. I had no income at allwhatsoever. There was no beds for me to go to. Therewas no detoxes at the time. I was suicidal and I justwanted to die” (White, 37).“I ended up back in escort. And I was datingsomebody and he showed me how to deal. But I endedup using coke and heroin again. I started drinking. Iwas making mad cash back then. I’d work and workI found out he was an alcoholic and a crack user. Hewould get violent, and I was so bruised that I couldn’tgo to work, I couldn’t speak. He locked me up andstole all my bank cards and fed me crack cocaine andgot me addicted. For seven days and nights straightthe first time, I didn’t know my name, I didn’t knowanything, and then …yeah, I lost my job because ofthis man, and I lost all my life savings, and I lost myhome” (Southeast Asian, 32).Intimate partner violenceWomen’s narratives of their relationship with intimatepartners reflected gendered relations of power betweenthe women and their intimate partners. Male partners,rather than female friends, were mentioned as significantsources of influence throughout their lives. Some womenwere introduced to drugs by their boyfriends. Often-times, their partners used substances as well and wereinvolved in criminal activities. Although several womenperceived their partners as supportive—emotionally aswell as in their daily struggle and their efforts to reducetheir substance use or take care of the children—the ma-jority experienced exploitation and repeated physical,sexual and/or emotional abuse by their partners. Preg-nancy was a time of hope for many women. Several par-ticipants indicated that they were hoping for a newbeginning and turning point in their lives and their rela-tionship. They expected that parenting a baby will helpthem and their partners to abstain from substances, stoptheir partners’ violence and bring them someone whoand work, seven days a week, and I’d stay up for threedays and I’d sit there and get high. And my kids wouldbe, in the other room, and it was, just crazy. Dope wasalways in front of me now” (Aboriginal, 31).Most women were victims of violence, trauma and con-tinuing and multiple adversities from very early on and, asa consequence, never had a regular and ‘normal’ life. How-ever, a minority of women indicated that they hadcompleted their education and obtained a job, but losteverything after experiencing trauma and/or addiction.“I have been abducted by a psychopath. He had me forseven months, and he was giving me, GHB, PCP and25 other pharmaceuticals. I went from being asupervisor in a mental health facility to, a homelesscrack head. Lost my apartment, lost everything Iowned” (White, 36).“I had a stable job. And I was a university graduate.would love them. But in most cases, their hopes for abetter life were not fulfilled. The women often did notTorchalla et al. Harm Reduction Journal 2014, 11:34 Page 6 of 10http://www.harmreductionjournal.com/content/11/1/34receive much support by the fathers of their childrenand carried all the responsibilities themselves. Theirpartners did not stop the abuse, the women and the ba-bies continued to be exposed to violence and harm andthe trauma continued.“We moved to Vancouver because we wanted to, raisethis baby and, get away from the drugs and alcohol.This is where we came to start fresh and I thoughtmaybe he would be better. And then, he was gettingworse, physical, verbal abuse, you know, emotional,everything. When the baby was two and a halfmonths, I just had enough, because I kept ending upwith black eyes and a fat lip. And I was just tired ofbeing, abused and my daughter seeing that”(Aboriginal, 29).“After six months pregnant I put him in jail, because Iwas beaten so bad I was hospitalized. I had big bruiseson the side of my stomach. So I had to keep gettingchecked, cause if he damaged the baby’s head in anyway, there could be brain damage” (Aboriginal, 30).Raising children in the context of drug use, violence,homelessness and prostitution led to most babies beingapprehended from their mother’s care; some women hadseveral children in the care of foster families or relatives.The experience of their children being taken away fromthem was upsetting for all women, and they felt it wasunfair and wrong.“Losing him, was my biggest, downfall. Cause I wasclean when I lost him. And, to lose a child afterraising him for two years has absolutely destroyed me”(Aboriginal, 37).“I always, talked to her in my belly and said, we’regonna, mommy’s gonna really gonna do good andmommy’s gonna love you. And, keep you and, you know.So, that was one hard thing when um, when yeah, whenshe was taken away from me” (Aboriginal, 29).Structural violenceSome women reported experiences of stigmatization andgender-based psychological violence from the health caresystem. This type of experience reinforced the treatmentthat the women had made from their personal relation-ships and on the streets.“I did have a family doctor for some time, until I toldher I was escorting for work. And she totally turnedher nose up at me. I wanted to get a pap smear and ablood test, but she basically sent me out. So I wentsomewhere else and got it done. My safety and mywellbeing is still, huge. I might be a drug addict, but,like, regardless I want to make sure that I’m healthyand get checked. Because, you know, it’s a dangerouslifestyle. And you would expect your doctor to helpyou” (White, 37).One woman was brought to the hospital afterbeing raped during her pregnancy. The police werecalled and arrived at the hospital to question herabout the rape. “When I came in, they didn’t wantto check me right away. I was bleeding, I was in alot of pain, I was crying, but they just said ‘No, theofficers are here.’ And the cops kept harassing me,saying ‘Oh, were you using drugs? You deserve…’well not to get raped, but they were basicallysaying ‘oh, you asked for it.’ And all I kept sayingwas that I wanted to get checked for the baby, andthey kept saying, ‘You have to wait, the officerswant to talk to you’ and I kept saying ‘Check mybaby, I’ll talk to them later’, right? I was reallyupset – I just got raped, and they’re trying toquestion me?” (White, 36).In contrast, many women explicitly stated that theyexperienced no stigmatization at Sheway, Fir Square andCrabtree Corner.“But even when I checked myself in [at Fir Square], thenurse that intook me to, was really good. Cause Istarted crying - and she said, I’m glad you’re here. Thestaff, at Fir is, so amazing! Like no, judgment at all”(White/Aboriginal, 31).Transgenerational traumaReflecting on their experiences, several women ob-served patterns between their parents and themselvesor themselves and their own children—trauma beingpassed on from one generation to another—and severalmentioned how important it is for them to “break thecycle”.“I look healthy. I’m normal. But I don’t know.Sometimes I feel a little wacked up here. You knowand that could just be, my upbringing right? It wasreally violent so I can have violent tendencies. So fromchildhood to pre-teen and then pre-adult and thenadult it’s just been an ongoing cycle that I haven’tbroke” (Aboriginal, 32).“Even though you’ve been living on the streets,or you know, come from a very unhealthy background,with a very unhealthy childhood like I did, it ispossible to turn things around and break that cycle”(White, 20).Torchalla et al. Harm Reduction Journal 2014, 11:34 Page 7 of 10http://www.harmreductionjournal.com/content/11/1/34Interest in trauma counsellingThe vast majority of women have never been offered anytreatment that specifically addressed the trauma thatthey had experienced. When being asked about theirinterest in receiving trauma counselling, the majorityexpressed ambivalence, reluctance or refusal; many an-swered with a simple “No”. Few women stated that theywished to see or currently saw a trauma counsellor.“I haven’t done trauma counseling. I should. I don’tthink I’m, ready right now. Like a lots happened withmy whole childhood” (Aboriginal, 32).“I was very traumatized. I still am, right now. I wasafraid, I would never sleep, I had insomnia – I wouldstay up and hold a bat by my door, cuz I was scared.And now that I’ve had trauma counselling, I’m hopingthat I am able to recover” (White, 35).DiscussionThis study explored themes of trauma, violence andmental health in pregnant and postpartum women whostruggled with substance use and accessed harm reduc-tion services, in order to offer insight into the complex-ities of the target group and elucidate potential pointsfor improvement of and access to services. The key themesthat emerged from the women’s narratives highlighted theubiquity of multiple and continuing forms of adversitiesand trauma, often in form of gender-based violence, in avariety of contexts, from a variety of offenders and on mul-tiple levels. The definition of gender-based violence againstwomen is based on an understanding that such violence isinfluenced by gender roles and discrepancies in power andstatus and supports the legitimization and perpetuationof gender inequalities [14]. Gender-based violence isnot only a serious human rights problem but has alsobeen identified as a public health issue that is associ-ated with a variety of adverse psychological, physicaland social consequences [29].The majority of our study participants talked about ex-periencing multiple adverse events and conditions inchildhood, and all of the women indicated having experi-enced one or more forms of childhood abuse and neg-lect on the Childhood Trauma Questionnaire [28]. Formany years, studies on childhood adversities have fo-cused on one or two specific types of maltreatment, typ-ically sexual and/or physical abuse. However, researchhas shown that sexual and physical abuse often co-occurwith neglect, emotional maltreatment and other child-hood adversities [30-32]. The self-medication model isoften used to explain how individuals who have expe-rienced trauma use substances to regulate the result-ing distress [33]. The self-medication model appearsto reflect accurately the experiences of our own studyparticipants, but their stories also suggest that the riskybehaviours and conditions that are associated with illicitdrug use (e.g. intoxication, prostitution, homelessness,etc.) increased the risk for revictimization—as reflected bythe “high-risk hypothesis” [34], and once the relationshipbetween both factors was established, they reinforced andmaintained each other.The self-medication model and similar models [35,36]developed to explain the long-term sequelae of child-hood adversities focus on individual factors. Our resultssuggest that environmental and structural factors con-tribute to the harm participants experienced as well, be-yond individual factors. Rhodes [37] conceptualized the‘risk environment’ as comprising different types of envi-ronments—physical, social, economic and policy—whichinteract on both the micro- and the macro-level to pro-duce drug-related harm. Micro-environmental parame-ters include factors such as locations of drug use and sexwork, social and peer-group risk norms, income gener-ation, access to social housing, etc. Macro-environmentalparameters include gender inequalities and gendered risks,stigmatization of drug users, public health policy govern-ing harm reduction and drug treatment, etc. The riskenvironment framework shifts the responsibility for drug-related harms from the individual to include the structuresin which they have developed, and it extends the focus ofharm-reduction activities from the individual to includesociopolitical and structural changes [37].Women who have experienced childhood adversitieshave a greater risk of being a victim of intimate partnerviolence in adulthood [38], and many of our study partici-pants had experienced abusive relationships and violenceby their intimate partners. Researchers have highlightedhow violence, including intimate partner violence, wasconsidered a “normal” experience in the everyday life ofinner city women who use drugs [39]. Epele extended thefocus from the individual level to include social factors onthe micro-environmental level by discussing how a male-centred street ideology places women in a subordinateposition, pointing out that in her study, only a few drug-using women defined their relationship with their malepartner as equal sharing. Instead, the relationship pro-vided them with protection from street-based violence atthe risk of experiencing domestic violence [40]. In a fieldobservation in the San Francisco street drug scene, the au-thors described how women sought older male partnersto protect them from violence and sexual harassmentwhereas men sought young women as sexual, romanticand income-generating partners, and how these relation-ships were usually abusive and exploitative to the women[41]. Given this, gender-focused violence prevention pro-grammes in the city may benefit from components on themicro-level that address the social networks of substance-using women. One possibility may be to incorporate theinvolvement of peers to allow the exploration of unequalTorchalla et al. Harm Reduction Journal 2014, 11:34 Page 8 of 10http://www.harmreductionjournal.com/content/11/1/34gender relations and peer norms. Such a model has for in-stance been successfully employed by Oxfam with thegeneral female population in Africa and South Americathrough women-specific social services [42].Our results also suggest that structural (e.g. economicand policy) factors contribute to the dangers and threatsthat dominate the women’s everyday life. Many of ourparticipants have lived on the street or in precariousconditions; some of them even became homeless asteenagers. Homelessness during adolescence may disruptthe youth’s developmental processes and expose them tofurther harm once homeless [43]. Researchers have pro-posed a risk amplification model where intrafamilialchildhood maltreatment places adolescents at risk forbecoming homeless, and subsequent events and behav-iours on the street exacerbate the effects of adversechildhood experiences and resulting psychological dis-tress and increase the risk of revictimization and retrau-matization [44]. Homelessness and marginalized housingcontinued to be problematic in adulthood for our partic-ipants, and many of them experienced violence on thestreet. In their qualitative study, Lazarus and colleaguesdiscuss how—within the gendered risk environments ofthe male-centred housing models—low-income and tran-sitional housing resulted in marginalization, sexual andeconomic exploitation and increased safety risks forwomen [11] which is consistent with our participants’accounts. Many of our own study participants were en-gaged in street-based sex work for some period of theirlives, a dangerous business that involves a high risk ofvictimization, especially for women who are homeless[12]. In a synthesis of the literature of women in the streetdrug economy, Maher and Hudson pointed out howwomen remained marginalized with respect to opportun-ities for income generation, being confined to the harsheconomy of street-based sex work [45]. Such findings onstructural factors promoting violence against womenhighlight the need for structural (e.g. economic andpolicy-based) interventions on the micro- and the macro-level. These could include creating safe and innovativehousing models for women, implementation of victimsupport services for sex workers and homeless womenand reducing economic inequities to reduce the need forworking in the sex trade. Furthermore, our participant’sreports indicate that structural violence is reproducedthrough interactions in the health care system, suggestingthe need for training programmes for all professionalsworking with women who use substances.Women also described the distress that they experi-enced of their children being apprehended by the childwelfare system. Perspectives on the issue were that theprocess was unfair and wrong. The apprehension ofchildren may compound an overlaying of trauma inadulthood for these women. Aligned with this thought,in 2003, an article discussed children being taken fromVancouver drug-using mothers and stated that Canadiandrug users are afflicted by the government’s neo-liberalrepressive drug policy combined with a patronizing andpaternalistic social and child welfare system [46], whichsuggests that policy reforms on the macro-level may benecessary to improve the situation of drug-using mothersand their children. Furthermore, innovative models of careare needed on the micro-level which aim at increasing thewomen’s well-being and resilience, supporting them intheir capacity as caregivers, improving their economic andsocial position and ultimately helping them to retain cus-tody of their children.In summary, our findings suggest that drug use andtrauma follow complex patterns among women seekingharm reduction services in the DTES, where womenhave experienced multiple and often severe early child-hood adversities in the form of both single traumaticevents and chronic stressors; they experienced distressresulting from these adversities and used substances toself-medicate their distress. Once regular substance usewas established, they entered a vicious cycle of engagingin high-risk behaviours and situations to secure drugsupply, resulting in more trauma exposure and a lifestylethat was characterized by gendered risks, ongoing adver-sities and violence. All of these conditions mutually in-tensified and maintained each other and interfered withnatural, healthy resolution of trauma/PTSD symptomsand substance use. Our study provides an exploration ofthe gendered nature of violence and trauma and the needto create the environmental conditions for reducing healthinequalities on multiple levels.In our study, women spoke of concerns of passing ontrauma from one generation to the next, which confirmsa desire to address their trauma, and yet women also ar-ticulated hesitancy towards seeking trauma specific sup-port. In offering harm reduction services, it is clear thatan understanding of trauma must be integrated. It is rec-ommended to health care providers and policy makersthat women with concurrent substance use and traumaissues receive comprehensive and integrated treatmentthat addresses both conditions within the same servicein order to better meet the needs of this population.This study contributes to a growing body of literaturethat can be found in support of this recommendation[47,48]. In recent years, a number of integrated treatmentprogrammes for trauma and addiction have been deve-loped and tested and yielded some promising results,although the majority of these programmes involve treat-ment components to promote stabilization and safety ra-ther than trauma processing [49]. Our participants’hesitation or refusal when asked about their interest in re-ceiving trauma counselling raises questions about howtheir experiences can be best addressed. It is possible thatTorchalla et al. Harm Reduction Journal 2014, 11:34 Page 9 of 10http://www.harmreductionjournal.com/content/11/1/34trauma-specific interventions would not be well utilized.Researchers and clinicians have advocated for adopting acomprehensive trauma-informed approach in all harmreduction facilities providing services for women [50].Trauma-informed interventions are distinct from trauma-specific interventions such that the care delivery practicestake into account an understanding of the impact oftrauma on an individual’s life, development and substanceuse but do not necessarily require disclosure of trauma. Incontrast, trauma-specific interventions address trauma ex-periences directly and facilitate trauma recovery throughcounselling and treatment [50,51]. Our participant’s re-sponses suggest that trauma-informed approaches may bemore appropriate than trauma-specific interventions inlow-threshold harm reduction services for women in theDTES. They can be offered even to clients who choosenot to work on their trauma issues immediately and mayalso pave the way for considering additional steps towardsrecovery from trauma and proceeding to trauma-specifictreatment.A few important limitations should be considered inevaluating the findings of the study. All qualitative stud-ies are limited in terms of making generalizations aboutthe entire population from a small, non-random sampleof respondents. The self-selected sampling procedureslikely excluded the voices of many women in the DTES,such as women who do not seek out any services orthose living in other residential neighbourhoods. The ex-periences of women who do not have children and thosewho are younger than 19 years were also not repre-sented. Furthermore, the study was conducted in a veryspecific setting: harm reduction services in a progressivecity at the West Coast of Canada.ConclusionsIn summary, interventions for women who use sub-stances need to account for the complex needs of theirclients. In recognition of the continuing impact that ex-periences of trauma, violence and abuse have on poorand underserved women in Vancouver’s DTES, the rec-ommendation is made that presently trusted and suc-cessful service providers could integrate trauma-informedcare into their programme in order to offer this crucialservice in a trusted environment. Trauma-specific treat-ment should be offered to women who are ready to en-gage in this intervention. However, it is also necessary toshift the focus from the individual to include environmen-tal, social, economic and policy factors on multiple levelsand from issues of drug use and reduction of drug-relatedharms to include issues of gendered vulnerabilities andhuman rights.AbbreviationsDTES: downtown Eastside; PTSD: posttraumatic stress disorder;SUD: substance use disorder.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsThe current study idea and research question was developed by IT whoalso conducted the literature review and took the primary role in draftingthe manuscript. The data analytic plan was developed by IT, IL, VS, EN andMK. IT and IL were responsible for data management and analysis of results.IT, IL, VS and EN were involved in the interpretation and discussion of results.All authors critically reviewed and revised multiple drafts of the manuscriptand approved the final manuscript.AcknowledgementsThis study was made possible through a grant from the Carraresi Foundationin Memory of Augusto Carraresi. We also would like to thank the St. Paul’sHospital Foundation for their ongoing commitment. Dr. Torchalla wassupported by an HSBC fellowship. The Carraresi Foundation, the St. Paul’sHospital Foundation and HSBC had no role in the study design, in thecollection, analysis and interpretation of data, in the writing of themanuscript or in the decision to submit the paper for publication.Author details1Centre for Health Evaluation and Outcome Sciences (CHÉOS), St. Paul’sHospital, 588-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.2Department of Psychiatry, University of British Columbia, Detwiller Pavilion,2255 Westbrook Mall, Vancouver, BC V6T 2A1, Canada. 3School of Populationand Public Health, University of British Columbia, James Mather Building;5804 Fairview Avenue, Vancouver, BC V6T 1Z3, Canada.Received: 20 May 2014 Accepted: 20 November 2014Published: 12 January 2015References1. Gabe T: (2013) Poverty in the United States: CRS Report for Congress.Washington, DC, US: Congressional Research Service; 2012.2. Kawachi I, Berkman L (Eds): Neighborhoods and Health. New York, NY:Oxford University Press; 2003.3. 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Vancouver, BC: British Columbia Centre of Excellencefor Women’s Health, and British Columbia Ministry of Health; 2013.doi:10.1186/1477-7517-11-34Cite this article as: Torchalla et al.: “Like a lots happened with my wholechildhood”: violence, trauma, and addiction in pregnant and postpartumwomen from Vancouver’s Downtown Eastside. Harm Reduction Journal2014 11:34.

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