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A qualitative study of the perceived effects of blue lights in washrooms on people who use injection… Crabtree, Alexis; Mercer, Gareth; Horan, Robert; Grant, Shannon; Tan, Tracy; Buxton, Jane A Oct 8, 2013

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RESEARCH Open AccessA qualitative study of the perceived effects ofblue lights in washrooms on people who useinjection drugsAlexis Crabtree1,2*, Gareth Mercer1, Robert Horan3, Shannon Grant4,5, Tracy Tan5 and Jane A Buxton1,2AbstractBackground: Blue lights are sometimes placed in public washrooms to discourage injection drug use. Theireffectiveness has been questioned and concerns raised that they are harmful but formal research on the issue islimited to a single study. We gathered perceptions of people who use injection drugs on the effects of blue lightswith the aim of informing harm reduction practice.Methods: We interviewed 18 people in two Canadian cities who currently or previously used injection drugs tobetter understand their perceptions of the rationale for and consequences of blue lights in public washrooms.Results: Participants described a preference for private places to use injection drugs, but explained that the needfor an immediate solution would often override other considerations. While public washrooms were in many casesnot preferred, their accessibility and relative privacy appear to make them reasonable compromises in situationsinvolving urgent injecting. Participants understood the aim of blue lights to be to deter drug use. The majority hadattempted to inject in a blue-lit washroom. While there was general agreement that blue lights do make injectingmore difficult, a small number of participants were entirely undeterred by them, and half would use a blue-litwashroom if they needed somewhere to inject urgently. Participants perceived that, by making veins less visible,blue lights make injecting more dangerous. By dispersing public injection drug use to places where it is morevisible, they also make it more stigmatizing. Despite recognizing these harms, more than half of the participantswere not opposed to the continued use of blue lights.Conclusions: Blue lights are unlikely to deter injection drugs use in public washrooms, and may increase druguse-related harms. Despite recognizing these negative effects, people who use injection drugs may be reluctant toadvocate against their use. We attempt to reconcile this apparent contradiction by interpreting blue lights as aform of symbolic violence and suggest a parallel with other emancipatory movements for inspiration in advocatingagainst this and other oppressive interventions.Keywords: Harm reduction, Injection drug use, Public injection, Fluorescent blue lights, Internalized oppressionBackgroundThe use of injection drugs in public spaces is associatedwith individual (physical, psychological) and societalharms. Physical harms, such as abscess and damage toveins, become more likely in settings where injecting isrushed and hygiene is compromised [1-8]. Lack of priv-acy compounds the shame that many people who usedrugs feel [9,10] and communities where public druguse occurs become marked and subject to stigma[11-13]. Strategies to reduce public injection drug use,or to reduce the harms associated with injecting in pub-lic, could benefit people who use injection drugs and thecommunities where they live.Attempts to reduce harms associated with publicinjecting include strategies that support people who useinjection drugs (supervised injection sites, provision ofhousing) and dispersal strategies (intensified policing,changes to the built environment). In this article we* Correspondence: alexis.crabtree@alumni.ubc.ca1University of British Columbia, Vancouver, Canada2British Columbia Centre for Disease Control, Vancouver, CanadaFull list of author information is available at the end of the article© 2013 Crabtree et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Crabtree et al. Harm Reduction Journal 2013, 10:22http://www.harmreductionjournal.com/content/10/1/22focus on a single dispersal strategy, the installation ofblue lights in public washrooms. Here we define theterm “public washroom” as including washrooms locatedin not-for-profits, community facilities, and privatelyowned businesses, but not in private homes. Blue lightsemit an intense blue-coloured light, with the purpose ofvisually obscuring superficial veins [14]. A qualitativestudy from the United Kingdom of people who use in-jection drugs' experiences with blue lights suggestedthat, while blue lights do make it more difficult for themto find their veins, for some this would not deterattempted injection. Potential reasons for this lack ofdeterrent effect included scarcity of alternative injectionlocations and confidence in their injecting ability [15].Theoretically, blue lights could compound the risk ofinjecting in public washrooms by increasing the prob-ability that people who use injection drugs will miss thetarget vein and inject into surrounding tissue and bypromoting other unsafe practices such as deep veininjecting (which is done without visual identification ofthe vein and therefore is not deterred by blue lights)[16]. Aside from the United Kingdom study, there is noformal research into the harms of installing blue lightsin public washrooms. The existing research has indeter-minate applicability to the Canadian setting, since thecontext of injection drug use differs between the UnitedKingdom and Canada. In particular, in one of our studysites, the existence of a supervised injection facility (SIF)provides an alternative to injecting in washrooms, andthe existence of blue lights in nearby washrooms mayinfluence people who use drugs' decision-making aboutvisiting the SIF.The purpose of this study was to engage people who arecurrent and former users of injection drugs from two cit-ies in British Columbia, Canada, to share their perceptionsof the potential harms and benefits associated with bluelights in public washrooms. We aim for our results toinform harm reduction practice regarding blue lights.MethodsBetween January and March, 2011, a sample of peopleidentifying as current and former users of injectiondrugs was recruited purposively through drug user com-munity advocacy groups in Vancouver and Abbotsford,British Columbia (the Vancouver Area Network of DrugUsers (VANDU) and the BC Yukon Association of DrugWar Survivors, Abbotsford Chapter). Board members ofthese organizations identified individuals who had ex-perience injecting drugs in public places and invitedthem to speak privately with the researchers to learnmore about the study. This recruitment method waschosen over the use of intensive screening questions orobservation of track marks in order to create a respectfulresearch environment in which people feel they areparticipants rather than subjects, and to take advantageof the expertise of the collaborating advocacy organiza-tions. Participants were required to be aware of the issueof blue lights in public washrooms, though they werenot required to have personally experienced injecting ina bathroom fitted with a blue light. This allowed us toexplore reasons why a person who encounters bluelights might chose to inject elsewhere, in addition to ex-ploring perceptions and decision-making among thosewho have injected under blue light conditions. We hadnot planned to explore how people who use injectiondrugs view themselves in relation to people who do notuse drugs, but this was a persistent theme identified inour interviews and we explore it in this article to theextent allowed by our data.Participants’ perceptions of the impacts of blue lights inwashrooms were gathered using approximately half-hourlong, semi-structured interviews conducted by the firstfive authors. Interviews were conducted in private roomsmade available by the two community advocacy groups.At the beginning of each interview, written informed con-sent was obtained and participants were offered contactinformation for the study principal investigator and for acounselor who would be available to speak with them fol-lowing their interview. Participants were offered a nominalhonorarium to thank them for their involvement in thestudy. All names presented are pseudonyms.Interviews were recorded and transcribed verbatim,then organised using qualitative analysis software(NVivo 9). The analytic approach of interpretive descrip-tion was followed [17], whereby vocalized thoughts werecoded into a set of concept categories. Concept categor-ies were further clustered into an overarching set ofthemes. These themes were presented to representativesof the drug user advocacy groups in Vancouver andAbbotsford for member checking and their commentsincorporated into the final analysis. This method waschosen with the aim that the “interpretive description”derived from the final thematic structure could be usedto inform harm reduction practice and policy.Initial transcripts were coded together by all five inter-viewers so that consensus could be reached on the assign-ment of thoughts to concept categories and the structureof these categories within the overarching themes. Laterinterviews were coded by each individual interviewerusing the existing thematic structure, adding new conceptcategories and themes where they emerged. Interviewswere conducted until there was general agreementamongst all interviewers that data saturation had beenachieved, defined as the point where no new themesemerged from the most recent round of interviews.Approval for this study was obtained from the Behav-ioural Research Ethics Board of the University of BritishColumbia.Crabtree et al. Harm Reduction Journal 2013, 10:22 Page 2 of 8http://www.harmreductionjournal.com/content/10/1/22ResultsCharacteristics of the participantsEighteen participant interviews were conducted. Eightinterviews were conducted in Abbotsford and 10 inVancouver. Eight participants reported current injec-tion drug use, while ten reported no longer using in-jection drugs. Six participants were women and 12were men; the sex distribution was similar amongparticipants from the two cities. All participants knewabout the practice of blue lights being installed inpublic bathrooms, and 16 described situations inwhich they had personally attempted to inject in ablue-lit bathroom.Preferred geographic locations for using injection drugsTo contextualize the participants’ perceptions of theimpacts of blue lights, we first sought to explore thecriteria that made particular geographic locations pre-ferred places for them to inject drugs. The majorityof participants described cleanliness and being in-doors as important factors. Two participants specific-ally mentioned preferring locations with “properlighting.” Two key themes to emerge from our ex-ploration of preferred injection location were “pri-vacy” and “immediacy.”PrivacyA majority of participants told us that finding a locationthat afforded privacy was a priority. Reasons includedwanting to avoid interruption and wishing not to be judgedby others or “labeled as a junky” [Daniel, Vancouver]. Thedesire for privacy was strongly tied to a sense of shameabout being observed while using illicit drugs. Bruce(Abbotsford) in response to a question about being seenwhile injecting, answered, “I don’t know, I feel kind of badfor them, actually, you know, like, I shouldn’t be thereshooting dope, like, you know, it’s just-- it’s not right,I don’t think.” Bruce's response includes a moral judgment("it's not right") as the basis for his discomfort with beingobserved injecting, and includes an implication thatnon-injectors should not have to witness his actions.Several participants mentioned being seen by childrenas a particular concern, reflecting an assumption thatsimply witnessing drug use would cause childrenharm:“I’m invading their space and I’m doing somethingthat’s not sociably acceptable. And I almost feel badabout it, felt bad about it, you know, a little bit. Had achild or something like that walked in and-- Iimpacted their life somehow by them experiencingseeing me doing it or the after effects of me doing it,which has never happened, but if it did I would feelworse about it than I do.” [Greg,Vancouver]For most, a desire for privacy was expressed as a pref-erence for locations where they could be alone. Peterexplained that having someone else there “kind of de-stroys the feeling of getting high,” while Sally told us: “Itwas a personal thing to me. I didn’t want that image inanybody’s head of me… sitting there injecting.” However,more than half of the interviewees also included loca-tions where there are other people around in their dis-cussion of private places. Places mentioned includeddrop-in centers, like VANDU, and the supervised injec-tion facility in Vancouver, Insite. The sense of privacy atthese places was linked to feeling less exposed to judge-ment when using injection drugs. For example, describ-ing VANDU, Natalie (Vancouver) explained, “When I’mcoming here I don’t feel like I’m being treated like justanother junky. I feel like I’m just being treated like I’mjust another human being.” Only three participants toldus that they specifically preferred injecting in the com-pany of other people, but it is notable that one partici-pant mentioned needing to be around other peoplewhen he injects because he sometimes requires assist-ance. Vancouver's SIF does not accommodate assistedinjecting, so needing assistance to inject further limitsoptions for places to consume injection drugs [18].ImmediacyAlthough the vast majority of participants had definitecriteria for preferred injection locations, most (15/18)made it clear that the locations where they use injectiondrugs are often suboptimal and selected under pressure.This is particularly the case when they are experiencingwithdrawal symptoms (“dope-sick”):“I mean, whatever-- if I’m dope-sick then it reallydoesn't matter where I do it. I mean, I would do it infront of a cop car, fix myself.” [Natalie,Vancouver]“Oh, when I’m heavy in my addiction I don’t care,right. It’s just -- I try to get it in me. I don’t care. I’vedone it right on Main Street and Hastings [a majorintersection in Vancouver], actually. Even done it outhere [in Abbotsford] on the street, right.” [Bob,Abbotsford]“I never do decide [where to inject]. Just wherever,right. If I score here, and, you know, the obsession isthere…I always go around the corner from where Iscored and use.” [Bob, Abbotsford]In our analysis of participants’ perceptions of the im-pacts of installing blue lights in public washrooms, wefound it critical to keep in mind the apparent conflictbetween the ideal of accessing private, non-judgmentalplaces to use injection drugs and the frequent reality ofCrabtree et al. Harm Reduction Journal 2013, 10:22 Page 3 of 8http://www.harmreductionjournal.com/content/10/1/22accessing the closest, easiest location. Participantssuggested that in circumstances when they feel theyurgently need to inject, they would be more likely touse public spaces like bus stops, alleys, and publicwashrooms.Washrooms as a compromise between privacy and urgencyFinally, in considering preferred locations for using in-jection drugs, we sought to specifically understand par-ticipants’ beliefs about using public washrooms. All ofthe participants had accessed public washrooms as loca-tions for using injection drugs, but about half specificallysaid that these were not preferred places for them. Inter-estingly, two participants described public washrooms ashaving the benefit of being relatively private:"…it's private, you know what I mean. There's oneplace where you go, just where you go in there, no oneelse can. You know what I mean? You're okay in there'till you come out, right.” [Daniel,Vancouver]“No, I don't see any harm in using drugs in thebathroom 'cause you're only there and then you'regone, right. It's better than letting people use them outin the alley, out in front of kids….” [Pierre,Vancouver]Conversely, three participants described public wash-rooms as feeling “unsafe” because of a lack of privacy.As an example, Sam from Abbotsford told us: "I feeltrapped in a public washroom. You come out and you'reall wasted and there's people standing around...."The majority of participants described public wash-rooms as locations they would use for their accessibility(“it’s easy and handy” [Sam, Abbotsford]), but usually onlywhen they need somewhere to inject urgently (“…if I wasout and I was sick, I’d go to a public washroom.” [Marg,Abbotsford]). Based on the perceptions of a smaller num-ber of the participants, public washrooms may also be im-portant locations for people who do not have a privatespace of their own, especially people who are homeless."If I was homeless, which happened from time to time,I would go to, like, the church bathroom or theCarnegie [library] bathrooms a lot." [Greg,Vancouver]Understanding public washrooms as locations for ur-gent injecting and as places used by people with fewprivate alternatives helped us to interpret participants’responses to blue lights.The perceived effectiveness of blue lights as a deterrentto injecting in public washroomsOne aim of this study was to explore what people whouse injection drugs understand to be the purpose ofinstalling blue lights in public washrooms, and whetherthey think that purpose is being effectively achieved.Except for one of the participants who had notattempted to inject in a blue-lit bathroom, there wasunanimous recognition that the aim of installing bluelights is to make it difficult to do injections, thereby to“deter people from using [intravenous] drugs in [the]bathroom.” [Marg, Abbotsford] About half (7/18) of theparticipants explicitly described the aim of blue lights asbeing to make it “so you can’t see your veins.” [Daniel,Vancouver] The remainder gave more general descrip-tions such as, “…it makes everything hard to see anddisorienting,” [Greg, Vancouver] “everything looks thesame colour,” [Steve, Vancouver] and they make it“…hard to make the injection work.” [Bob, Abbotsford]In interpreting the discussions about the effectivenessof blue lights we observed an important distinction: theireffectiveness at making it difficult to inject versus theireffectiveness as a deterrent. All those who had triedagreed that it is more difficult to inject under blue lights.The discussion of their deterrent effect was much morecomplex, often requiring consideration of the situationin which injection drug use is taking place. A majority(15/18) of participants said that they would generally tryto avoid public bathrooms where they knew blue lightshad been installed. At the opposite extreme, threeparticipants made comments suggesting that they wereentirely undeterred by blue lights. For example:"It didn’t really make a difference for me. It’s almostlike a challenge." [Alice, Abbotsford]“It doesn’t seem to bother me because I always knowwhere I’m going. …You get used to it after awhile.”[Peter, Abbotsford]Even among those who said they would try to avoidblue-lit bathrooms, almost half (6/15) described strat-egies they would use to overcome some of the incon-venience imposed by blue lights. These strategiesinclude: preparing drugs and loading syringes before en-tering the bathroom; bringing other light-sources likecandles, lighters, or flashlights with them into the bath-room; injecting by “feel”; relying on the “flash” of bloodentering the needle to know when they were in a vein;injecting into a muscle rather than a vein; or even “step[ing] out into the hallway and do[ing] it there.” [Richard,Abbotsford] Importantly, women and veteran injectors,who were described as having smaller or more difficultto access veins, were identified by participants as havingparticular difficulty adapting their practices to success-fully inject under blue lights.A key finding was that half (7/15) of those whosaid they generally avoid bathrooms with blue lightsCrabtree et al. Harm Reduction Journal 2013, 10:22 Page 4 of 8http://www.harmreductionjournal.com/content/10/1/22explained that they would not be deterred from injectingin these bathrooms if they perceived that they had noalternative.“When push comes to shove, it would mean nodifference to me, really. If I needed the bathroom andit was there and it was, like, my only choice in thearea, I wouldn’t think twice about going there again.I’m sure I could do what I needed to do in thereagain.” [Greg,Vancouver]“If I could find something better, yes [I would avoidblue lights]; if it was my last resort, I’d try. Simple.”[Marg, Abbotsford]In interpreting these assertions it is useful to remem-ber that most of these statements came from partici-pants who described a preference for avoiding publicbathrooms as injection locations, but acknowledged thatthey offer a reasonable compromise between privacy andaccessibility in situations when they need somewhere toinject immediately, especially when they are experien-cing withdrawal symptoms. Taken together these find-ings suggest that blue lights, while effective at makinginjecting more difficult, would not deter most of ourparticipants from injecting if the need were urgent -- inother words, blue lights would not deter injecting in pre-cisely those moments when injectors are most likely tobalance privacy and immediacy by using a washroom forinjection in the first place.The perceived negative consequences of installing bluelightsThe next step in our exploration of the perceived effectsof installing blue lights in public washrooms was to askparticipants whether they felt there to be any negativeconsequences to the practice. The responses can gener-ally be organized as relating to either the direct effectsof making injecting more difficult or to the effects ofdispersing injection drug use to other public places.About half of the participants believed that, by makingit harder to see veins, blue lights could make injectingmore dangerous. A number suggested different waysthat a person struggling to find a vein while injectingunder blue light could be more likely to damage her/hisbody, including causing more needle scars, damaging anartery or nerve, starting an abscess or over-dosing. Inparticular, many felt that a person who is desperateenough to inject in a bathroom with a blue light is notgoing to give up easily, and is thus especially vulnerableto harming her/himself. These findings suggest that bluelights may hinder people’s ability to observe the safer in-jection practices promoted by harm reduction practi-tioners. One participant also suggested that blue lightscould make a person more likely to spill blood or leaveher/his used needle in the washroom. Although a minor-ity opinion, we feel it is justified to raise it because anumber of other participants felt that installing needle-disposal bins in public washrooms, (as opposed to focus-ing on deterring use in that location with interventionssuch as blue lights) would be a more effective means ofreducing drug-use-related litter.About one third of participants spoke about the dis-persal effect of blue lights. These individuals tended torespond to the question of whether blue lights deterinjecting with variations on the idea that, if blue lights“inhibit people from successfully I.V. drug using in the[washroom]– they just go somewhere else where theycan [inject].” [Daniel, Vancouver] These participantsappeared to share the perception that washrooms offersafer injection locations than the alternatives for peoplewho are in the situation of needing to access a publicplace for injecting. The following quotes clearly demon-strate this concern:“The alley. That’s the thing, you know, doing that, yousend them out to unsafe-- really unsafe places.” [Sally,Vancouver]“…outside-- it’s just sometimes, it’s not a very cleanthing to do outside-- water wise, you know. I’ve seenpeople suck up mud puddle water and stuff like that.”[Ben, Abbotsford]In addition to making injection drug use more difficultand potentially harmful than in public washrooms, theselocations offer less privacy. Blue lights may, therefore, beexpected to make public injection drug use a morevisible, shameful experience.Almost all Abbotsford participants mentioned theirdesire for a local supervised injection facility anddiscussed the role it could play in providing a safer alter-native to public washrooms (especially those that areblue-lit). For example, when asked what could be donein addition to blue lights to reduce drug use in publicwashrooms Emma [Abbotsford] told us: “Well, a safe in-jection site, definitely. But Abbotsford, I mean…it’s amillion miles away from, you know, for that to happen.”None mentioned potential problems or drawbacks tosuch a facility. In contrast, Vancouver participants sug-gested the supervised injection facility did not usuallyprovide an adequate alternative to the dispersal effectsof blue-lit washrooms. Although generally valuing thefacility, they suggested several barriers to its use: dis-tance or the need for more than one facility in severalareas of Vancouver; wait times to use the facility (poten-tial clients are asked to wait in queue if the facility is atcapacity); rules against assisted injecting; and lack ofCrabtree et al. Harm Reduction Journal 2013, 10:22 Page 5 of 8http://www.harmreductionjournal.com/content/10/1/22privacy. Regarding the experience of injecting at the su-pervised injection facility, Steve [Vancouver] commented,"A private bathroom is the best ‘cause at Insite, even, I feelperfectly safe but I always feel like someone’s watchingme. Which they have to, right." Overall, Vancouver-basedparticipants' statements suggest that the supervised injec-tion facility does not consistently meet the need for imme-diacy and privacy that encourages individuals to usepublic washrooms for injecting.These findings, taken together with those presented inthe previous section, suggest that installing blue lights ina public washroom is unlikely to have the desired effectof preventing all drug use there, but it may preclude theuse of that washroom as a safe place for injecting bythose who need it most.Participant recommendations in favour of blue lightsdespite their negative effectsAlthough a number of negative effects of blue lights inwashrooms were identified by participants, most (13/18)indicated they were not opposed to their use or evenrecommended them. Reasons given included supportingbusiness owners' rights to use their property as they seefit and purportedly making washrooms safer for patrons:“I don’t believe when a person goes out to a publicplace that they should have to be worried-- if aperson’s going to be that blatantly open about, like,about using drugs in public, then they’re sometimesnot going to be worried about leaving theirparaphernalia behind. And they’re going to endangerother people as far as I’m concerned.” [Emma,Abbotsford]Implicit in this statement is that once a personchooses to use an establishment’s washroom for the pur-poses of injecting drugs, they cease being a “patron" andthus give up the privilege of using the washroom. Kevin(Vancouver) told us, “it’s not for that purpose. It’s for pa-trons. It’s for, you know, people in the restaurant or inthe gas station. It’s not for injecting.”Almost half (7/18) of participants both identifiedharms from blue lights and made positive statementsabout their use. This is an important finding, as shows adevaluing of people who use injection drugs' health infavour of the experience of non-drug users.DiscussionThe use of blue lights in public washrooms has beeninterpreted by others as a form of symbolic violenceagainst people who use injection drugs [15]. Symbolicviolence describes how power is used to control and dis-cipline people in ways that seem natural to both suf-ferers and perpetrators [19]. Our results support thisinterpretation and highlight how people who use injec-tion drugs may come to accept and even support suchpractices through a process of internalized oppression.Symbolic violence reinforces existing axes of oppres-sion and serves a political purpose. When attention is di-rected to drug use as criminal, shameful, and a potentialvector of disease, it is directed away from the harms ofthe drug war and from those who benefit economicallyand politically from its continuation [20]. As well, bymaking exclusion seem natural or for the benefit ofpeople who use drugs, actions of symbolic violence cancause them not to resist their own oppression and evento perpetuate it.In keeping with the practical and incremental goals ofharm reduction, many practitioners would laud peoplewho use drugs for choosing a location to inject that ispotentially quiet, unrushed, well-lit, and equipped withrunning water (while, of course, working towards theday when injecting drugs in public washrooms is no lon-ger the best of a constrained set of choices). In our re-search, participants advocated for the use of blue lightsdespite identifying harms from this practice. Their supportof blue lights was based not on fear of speaking outagainst them, but of a deep-seated sense of shame in theiruse of public washrooms to inject. We therefore identifythis as an example of internalized oppression in keepingwith the symbolic violence of blue lit washrooms.This research has several implications for harm reduc-tion practitioners. First, participants identified significantharms from blue lights in public washrooms, includingphysical damage to veins and surrounding tissue anddisplacement to riskier spaces for injection. The lattermay increase the psychological harms of public injectiondrug use by making it more visible, enhancing the ac-companying sense of shame. Those working in harm re-duction should be aware of the negative impacts of bluelights and be prepared to advocate against their use.Second, confirming other qualitative and quantitativework [21-24], we found that supervised injection facil-ities do not always meet the needs of people who use in-jection drugs for privacy and immediacy. This meansthat the deterrent effect of blue lights will not necessar-ily result in injecting in safer locations, even when super-vised injection facilities are available. Therefore, whilethe expansion of supervised injection facilities is desir-able to reduce other drug-related harms (and was calledfor strongly by our participants in the community thatlacked a SIF), the presence of SIFs should not be seen aseliminating the harms imposed by blue-lit washrooms.Finally, our results indicate that internalized oppres-sion may inhibit people who use injection drugs fromacting to challenge practices that cause them harm, suchas installing blue lights in washrooms. Self-advocacy bypeople who use drugs has been an important force inCrabtree et al. Harm Reduction Journal 2013, 10:22 Page 6 of 8http://www.harmreductionjournal.com/content/10/1/22the harm reduction movement [25-31], but has beenlimited by lack of funding, legal concerns, and theprioritization of survival needs by people who use drugs[32-36]. We suggest that internalized oppression adds tothese difficulties by discouraging people who use drugsfrom engaging in self-advocacy and even leading them todefend the use of harmful practices. Other liberatorystruggles (for example, the women's movement) have in-volved a process of consciousness-raising to challenge in-ternalized oppression [37,38]; those working with peoplewho use drugs may benefit from exploring how similartechniques could be incorporated into their practices.Several limitations to this research should be noted. Therecruitment strategy selected for participants who wereconnected to other people who use drugs and to drugusers' advocacy organizations. People who use drugs inrelative isolation (i.e. without others having knowledge oftheir injection drug use) possibly have more complexneeds regarding privacy and choices of injecting location.In addition, we recognize those without access to privateplaces to inject (particularly homeless people) may experi-ence blue lights and their effects differently; few partici-pants in our sample were homeless, and further researchwith this population may yield additional insights.In summary, the installation of blue lights in publicwashrooms is an example of a structural interventionaimed at reducing public injection drug use, which,superficially, may appear less oppressive than manyother drug-use dispersal strategies. Our analysis of theperceptions of people who use injection drugs supportsprevious findings that installing blue lights is unlikely todeter injection drugs use in public washrooms, and mayincrease drug use-related harms. Importantly, we sup-port the suggestion that blue lights are a form of sym-bolic violence: they aim to tacitly control people whouse injection drugs, forcing them to make choices aboutplaces to inject that are not in their best interests, andimposing upon them the belief that their own well-beingis secondary to the interests of those responsible for in-stalling the blue lights. We encourage harm reductionpractitioners to consider the potential harms of bluelights and to advocate against their use. Practitionersworking on advocacy projects with people who use in-jection drugs may find it valuable to facilitate opportun-ities to promote their clients' sense of self-worth and toillustrate the ways in which harmful drug-use dispersalinterventions are forms of oppression.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAC and JB conceived of and designed the study. AC, GM, RH, SG, and TTcollected and analysed data and wrote sections of the manuscript. JBoversaw data collection and analysis and revised the manuscript. All authorsread and approved the final manuscript.AcknowledgementsThe authors gratefully acknowledge the assistance of the Vancouver AreaNetwork of Drug Users and the Abbotsford Chapter of the BC-YukonAssociation of Drug War Survivors.This study received funding from the Social Accountability and CommunityEngagement Initiative of the University of British Columbia Faculty ofMedicine. AC is supported by a BC Centre for Disease Control-CIHR-UBC MD/PhD studentship. GM is supported by a CIHR Vanier Graduate studentshipand a Child and Family Research Institute-CIHR-UBC MD/PhD studentship.Author details1University of British Columbia, Vancouver, Canada. 2British Columbia Centrefor Disease Control, Vancouver, Canada. 3University of Saskatchewan,Saskatoon, Canada. 4University of Calgary, Calgary, Canada. 5MemorialUniversity of Newfoundland, St. John's, Canada.Received: 29 March 2012 Accepted: 28 September 2013Published: 8 October 2013References1. DeBeck K, Small W, Wood E, Li K, Montaner J, Kerr T: Public injectingamong a cohort of injecting drug users in Vancouver, Canada.J Epidemiol Community Health 2009, 63(1):81–6.2. Gibson EK, Exner H, Stone R, Lindquist J, Cowen L, Roth EA: A mixedmethods approach to delineating and understanding injection practicesamong clientele of a Victoria, British Columbia needle exchangeprogram. Drug Alcohol Rev 2011, 30(4):360–5.3. 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Commun Stud 2004, 55(4):535–52.doi:10.1186/1477-7517-10-22Cite this article as: Crabtree et al.: A qualitative study of the perceivedeffects of blue lights in washrooms on people who use injection drugs.Harm Reduction Journal 2013 10:22.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitCrabtree et al. Harm Reduction Journal 2013, 10:22 Page 8 of 8http://www.harmreductionjournal.com/content/10/1/22

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