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Health experiences of women who are street-involved and use crack cocaine : inequity, oppression, and… Bungay, Victoria Ann 2008

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     HEALTH EXPERIENCES OF WOMEN WHO ARE STREET-INVOLVED AND USE CRACK COCAINE: INEQUITY, OPPRESSION, AND RELATIONS OF POWER IN VANCOUVER’S DOWNTOWN EASTSIDE  by  Victoria Ann Bungay    B.Sc.N., St. Francis Xavier University, 1989 M.N., Dalhousie University, 1994       A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY   in   THE FACULTY OF GRADUATE STUDIES  (Nursing)     THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)     June, 2008  © Victoria Ann Bungay, 2008    ii ABSTRACT Women who live in Vancouver’s Downtown Eastside experience some of the most devastating health problems among residents of British Columbia. While crack cocaine use has been associated with many of these problems, we lack an understanding of how women who use crack cocaine experience these health problems and what they do to manage them. Informed by tenets of intersectionality and social geography, a critical ethnographic approach was used to examine the scope of health concerns experienced by women who are street-involved and use crack cocaine, the strategies they used to manage their health, and the social, economic, political, personal, and historical contexts that influenced these experiences. Data were collected over a seventeen month period and included a cross sectional survey (n=126), participant observations, and interviews (n=53). The women described experiencing poor physical and mental health throughout their lives; many of which were preventable. Respiratory problems, anxiety, sadness and insomnia were the most frequent concerns reported.  They endured severe economic deprivation, unstable and unsanitary housing, and relentless violence and public scrutiny across a variety of contexts including their homes and on the street. These experiences were further influenced by structural and interpersonal relations of power operating within the health care, legal, and welfare systems. The women engaged in a several strategies to mitigate the harmful effects of factors that influenced their health including: (a) managing limited financial resources; (b) negotiating the health care system; (c) managing substance use; and (d) managing on your own. These strategies were influenced by the types of concerns experienced, perceptions of their most pressing concern, the nature of interpersonal relations with health care providers, and the limited social and economic resources available.   iii Changes in the organizational policies and practices of the welfare, legal, and health care systems are needed to improve women’s health. Possible strategies include increased access to welfare and safe, affordable housing, safer alternatives to income, and improved collaboration between illness prevention and law enforcement programming. New approaches are required that build on women’s considerable strengths and are sensitive to ways in which gender, race, and class can disrupt opportunities to access services.    iv TABLE OF CONTENTS ABSTRACT ....................................................................................................................................... ii TABLE OF CONTENTS ...................................................................................................................... iv LIST OF TABLES ............................................................................................................................. vii LIST OF ACRONYMS ...................................................................................................................... viii ACKNOWLEDGEMENTS.................................................................................................................... ix DEDICATION .................................................................................................................................... x CHAPTER ONE: INTRODUCTION........................................................................................................ 1 Situating the Problem.................................................................................................................. 1 Research Purpose and Objectives ............................................................................................... 3 Conceptual Issues and Definition of Terms................................................................................ 4 Organization of the Thesis .......................................................................................................... 8 CHAPTER TWO: REVIEW OF EXISTING KNOWLEDGE...................................................................... 10 Introduction............................................................................................................................... 10 Crack Cocaine: The Substance ................................................................................................. 11 Locating Women and Crack Cocaine Use within a Historical Context.................................... 12 The Magnitude of Health Concerns.......................................................................................... 17 The Contextual Factors Influencing Experiences of Health ..................................................... 22 Smoking Practices............................................................................................................. 23 Sex Practices ..................................................................................................................... 24 Violence ............................................................................................................................ 26 Health Care ....................................................................................................................... 28 Women’s Health Management Strategies................................................................................. 31 Summary ................................................................................................................................... 32 CHAPTER THREE: RESEARCH DESIGN AND IMPLEMENTATION ....................................................... 34 Introduction............................................................................................................................... 34 Intersectionality......................................................................................................................... 35 Systems of Oppression and Inequity......................................................................................... 37 Gender............................................................................................................................... 38 Class.................................................................................................................................. 40 Race................................................................................................................................... 41 The Domains of Power ............................................................................................................. 43 Groups and Individuals ............................................................................................................. 46 Social Geography: Place ........................................................................................................... 48 Critical Ethnography: The Research Approach ........................................................................ 51 Selecting the Place .................................................................................................................... 54 Negotiating Entry: Positionality and Relationships.................................................................. 57 Participants................................................................................................................................ 59 Data Collection: Methods and Process ..................................................................................... 60 The Cross Sectional Survey .............................................................................................. 60 Sampling strategies ..................................................................................................... 61 Observations ..................................................................................................................... 64 Sampling strategies and locations............................................................................... 67 Recording Observational Data as Field Notes .................................................................. 68 Formal and Informal Interviews ....................................................................................... 70 Sampling strategies ..................................................................................................... 71 Supplementary Sources of Data........................................................................................ 72   v Analysis..................................................................................................................................... 72 Ensuring Scientific Quality....................................................................................................... 74 Usefulness of the Research ............................................................................................... 79 Ethical Considerations .............................................................................................................. 79 Informed Consent.............................................................................................................. 80 Confidentiality .................................................................................................................. 81 Respectful Research Relationships ................................................................................... 83 Financial Honorariums...................................................................................................... 86 Summary ................................................................................................................................... 87 CHAPTER FOUR: “DOWN HERE” IN THE DTES: PLACE MATTERS.................................................. 88 Introduction............................................................................................................................... 88 The Participants ........................................................................................................................ 89 Survey Participants ........................................................................................................... 89 Kit Making and Interview Participants ............................................................................. 91 Patterns of Substance Use......................................................................................................... 93 Down Here: Representations of the DTES ............................................................................... 94 A Place of Escape ............................................................................................................. 95 No Place Else to Go .......................................................................................................... 96 A Place of Exploitation and Abuse................................................................................... 98 A Place of Positive Possibilities ....................................................................................... 99 Women’s Day-to-Day Lives: Intersectionality and Place ...................................................... 101 Home: A Complex Place ................................................................................................ 101 Home: Structures and Locations..................................................................................... 103 Home: A Temporary Place ............................................................................................. 104 Home: “It’s Not Your Own Place” ................................................................................. 106 Home: The Place Where “Police Don’t Do Anything” .................................................. 109 Home: A Place of Possibilities ....................................................................................... 110 Finding Places of Shelter: The Challenges ............................................................................. 112 Out in the Open....................................................................................................................... 115 “Always a Target”........................................................................................................... 116 Moving between places............................................................................................. 117 Working out in the open ........................................................................................... 119 Dealing...................................................................................................................... 121 Using out in the open ................................................................................................ 123 Place of Possibilities ....................................................................................................... 124 Summary ................................................................................................................................. 126 CHAPTER FIVE: WOMEN’S EXPERIENCES OF HEALTH.................................................................. 128 Introduction............................................................................................................................. 128 Experiences of Health: A Beginning Snapshot....................................................................... 128 Women’s Experiences of Physical Health.............................................................................. 131 Respiratory Health Concerns .......................................................................................... 131 Musculoskeletal Health Concerns................................................................................... 135 Immune Function and Health Concerns ......................................................................... 137 Reproductive Health Concerns ....................................................................................... 140 Women’s Experiences of Mental Health ................................................................................ 141 Feeling Nervous and Anxious......................................................................................... 142 Feeling Sad and Blue ...................................................................................................... 143 Problematic Substance Use and Mental Health Concerns...................................................... 145 “Why” Women Get Sick: An Overview................................................................................. 148   vi Exemplar One: “Underclass,” Gender, and Relations of Power..................................... 148 Exemplar Two: Crack Use and Relations of Power ....................................................... 155 Summary ................................................................................................................................. 160 CHAPTER SIX: TAKING CARE OF YOUR HEALTH: MANAGING THE DAY-TO-DAY........................ 161 Introduction............................................................................................................................. 161 Managing Limited Financial Resources ................................................................................. 161 Managing the Money you Have...................................................................................... 162 Seeking Opportunities for Income.................................................................................. 165 Negotiating the Health Care System....................................................................................... 168 Negotiating the Place and the People.............................................................................. 169 Working within the System ............................................................................................ 174 Managing On Your Own ........................................................................................................ 181 Dealing with the Basics .................................................................................................. 181 Substance Use to Manage Health ................................................................................... 187 “Doing Nothing”............................................................................................................. 193 Managing Substance Use........................................................................................................ 196 Summary ................................................................................................................................. 203 CHAPTER SEVEN: CONCLUSIONS, DISCUSSIONS, AND SOME FINAL THOUGHTS ON INTERSECTIONALITY .................................................................................................................... 205 Introduction............................................................................................................................. 205 Overview of Key Findings...................................................................................................... 206 Discussion............................................................................................................................... 210 Dominant Ideologies and Women’s Health.................................................................... 211 Domination and Subordination: Economy, Health Care, and the Law........................... 214 Economic resources: The costs, benefits and women’s health ................................. 214 Health services and health concerns ......................................................................... 221 The illegal context: Costs, benefits, and women’s health......................................... 225 Health Management and Women’s Resistance to Oppression ............................................... 231 The Strengths and Challenges of Intersectional Research...................................................... 234 Multiple Locations and Multiple Systems of Oppression............................................... 234 The Nature of Knowledge............................................................................................... 237 Combining Intersectionality and Social Geography ....................................................... 240 Thinking about Nursing .......................................................................................................... 241 Conclusion .............................................................................................................................. 243 REFERENCES ................................................................................................................................ 245 APPENDIX A: SCHEDULE AND SEQUENCE OF DATA COLLECTION ACTIVITIES ............................. 266 APPENDIX B: PROJECT DESCRIPTIONS ......................................................................................... 267 APPENDIX C: CONSENT FORMS.................................................................................................... 270 APPENDIX D: RESEARCH INSTRUMENTS: SURVEY AND INTERVIEW GUIDES ................................ 276 APPENDIX E: CERTIFICATES OF ETHICAL APPROVAL.................................................................... 257 APPENDIX F: FIGURE 1. MAP OF DTES NEIGHBOURHOOD ............................................................. 259   vii LIST OF TABLES Table 1 Demographic Characteristics of the Survey Participants.......................................... 90 Table 2 Profile of Drug Use among Survey Participants....................................................... 94 Table 3 Shelter and Safety among Survey Participants ....................................................... 104 Table 4 Prevalence of General Health Concerns Over Past Year........................................ 130 Table 5 Self-reported Health Status ..................................................................................... 131 Table 6 Crack Smoking Practices ........................................................................................ 159 Table 7 Other Smoking Practices......................................................................................... 159    viii LIST OF ACRONYMS  Community Health and Safety Evaluation Project………………………………………...CHASE Downtown Eastside……………………………………………………………………….....DTES Hepatitis C Virus……………………………………………………………………………...HCV Human Immunodeficiency Virus………………………………………………………………HIV International Society for Equity in Health………………………………………………….ISEQH Pivot Legal Society…………………………………………………………………………PIVOT Pre-Kit Distribution Survey………………………………………………………………….PKDS Safer Crack Use Coalition…………………………………………………………………...SCUC Safer Crack Use, Outreach, Research and Education Project……………………………...SCORE Safer Crack Use, Outreach, Research and Education Project Women’s Advisory Committee…………………………………………………………………………………..SWAC Sexually Transmitted Infections………………………………………………………………..STI Vancouver Area Network of Drug Users…………………………………………………VANDU Women’s Information Safe House Drop-In Centre.……………………………. …………..WISH World Health Organization…………………………………………………………………..WHO      ix ACKNOWLEDGEMENTS  I am eternally grateful to all of the amazing women in the DTES who took the time to share with me their thoughts, experiences, laughter, and tears. They have taught me so much about strength, courage, and perseverance, and have transformed my life. In particular, I would like to thank Jules and Jackie for their thoughtful contributions and encouragement. I am forever indebted to my supervisor, Joy Johnson, and committee members Colleen Varcoe and Susan Boyd. Joy’s constant optimism, encouragement, support, and clarity made this work a possibility. I am particularly thankful for her ability to encourage students to follow their passions in research and to allow them learn at their own pace and in their own way. I am in awe of all that Colleen had to contribute. Her insightful questions, feedback, and willingness to just let me ramble until my thoughts became clear were so important in helping to put this work together. I am most thankful however for her unending support and feel lucky to have had this opportunity to learn with her. I am very grateful for Susan’s incredible encouragement and willingness to listen and share resources and ideas. Her compassionate understanding of the challenges inherent in this type of work helped to make it achievable. To my friend Bobbi-Jo, I am forever indebted. Nobody else would spend six hours on a bike ride helping me figure out how to make it all work. I am also thankful to my classmates Heather and Heather for their friendship, warmth, and support. I wish to express my thanks to my mom Marie, my brother Chris, and my sister Marj for their relentless belief that I could accomplish this goal. And finally, I thank my husband Tobe. I am humbled by his belief in me. He truly makes it all worthwhile.   x DEDICATION               In loving memory of my dad, Murray Augustus Bungay (1934-2004)   Because you taught me that everybody matters.   1 CHAPTER ONE: INTRODUCTION Situating the Problem Women who live in Vancouver’s inner-city neighbourhood known as the Downtown Eastside (DTES) experience serious inequities with regards to their health. They die at twice the provincial rate from potentially treatable illnesses including cervical cancer, bacterial infections, and pneumonia (BC Vital Statistics Agency, 2005).1 Aboriginal women are significantly overrepresented and many live in poverty and unstable housing. Women in the DTES are at greater risk than men for trauma-related health issues and blood-borne infections and are more likely to be treated disrespectfully by health care providers (Community Health and Safety Evaluation Project [CHASE] Report, 2005). Additionally, despite the increase in health care clinics implemented by the regional health authority to serve the neighbourhood (Vancouver Coastal Health), women’s access to health care remains a substantial problem which further exacerbates their likelihood of experiencing poor health (CHASE Report). The DTES has gained international notoriety for its open drug scene. Crack cocaine is the most commonly used illegal substance and smoking is the most common method of consumption (Buxton, 2007; CHASE Report, 2005). Additionally, recent research indicates that women are more likely than men to use crack cocaine (CHASE Report). Crack cocaine use among women has been correlated with a myriad of health concerns that ultimately affect their health status including cardiac and respiratory health issues, acute psychosis, sexually transmitted infections (STI), unplanned pregnancies, HIV, hepatitis C (HCV), and increased violence against women (Butters & Erickson, 2003; Goodman, 2005). Research in the field of crack cocaine and women’s health has focused almost exclusively on cocaine pharmacology, smoking practices, and women’s sexual behaviours as factors influencing their health concerns. Conversely, research in the fields of sociology and criminology have emphasized the negative experiences of  1 It is of significance to note that men in the DTES also die at twice the provincial rate from preventable illnesses.   2 sexism, racism, and economic deprivation as factors influencing the day-to-day lives of women who use crack cocaine (Mahan, 1996; Maher, 1997; Murphy & Rosenbaum, 1992; Sterk, 1999). Many women who are street-involved experience severe economic and social deprivation including absolute and relative poverty, unstable housing, and increased arrest: experiences that often precede the use of crack cocaine (Maher; Sterk). Women have reported that they perceive biases and assumptions on the part of health care providers regarding crack use and poverty as the main causes of disrespectful and demeaning interactions with health service providers (Butters & Erickson, 2003; Goodman, 2005). In an attempt to avoid these experiences, women often try to manage health concerns independently, and do so with relative degrees of success (Ensign & Panke, 2002). Despite evidence pertaining to the complexity of health experiences among women who use crack cocaine and knowledge related to the detrimental effects of poverty, sexism, and racism for women’s health in general, few studies have specifically focused on women’s experiences of health concerns in a manner that has served to expand our understanding of the influential factors that contribute to women’s overall health. Substance use has remained the central factor in research almost treating the health experiences of women as a result of the substance itself rather than substance use as one of the contextual factors influencing women’s lives. Women who use crack cocaine continue to experience severe health problems, are less likely to access health care, and are actively involved in managing their own health. How these experiences play out in women’s lives is less well known. There are significant gaps in knowledge, for example, concerning the range of health concerns experienced by women who use crack cocaine that may or may not be related to their crack use. There are additional unknowns with regards to the influential factors that shape these experiences or how women make decisions with regards to managing their health. While not discounting the significance of the research that has preceded this project, it was timely to explore the health concerns and   3 health management strategies of women who use crack cocaine. It was also worthwhile to shift the emphasis from crack cocaine as the predominant factor influencing women’s health to incorporate a broader perspective encompassing the social, economic, political, personal, and historical factors that may contribute to women’s experiences of health and their health management strategies. This knowledge is essential for changes in research, education, policy, and practice aimed at reducing the influential inequities experienced by those who carry the greatest burden of illness (Frolich, Ross & Richmond, 2006). Research Purpose and Objectives The overarching purpose of this study was to more fully understand the health experiences of women who are street-involved and use crack cocaine, the strategies these women use to manage their health, and the relations of power that influence their experiences. Situated specifically within DTES, I drew upon select aspects of intersectionality, social geography, feminist theory, and critical ethnography as a method of inquiry to critically examine the social, economic, political, personal, and historical aspects of women’s day-to-day lives that both influenced and were influenced by their experiences of health. The specific research questions explored were: 1. What are the nature and the scope of day-to-day health concerns experienced by women who are street-involved and use crack cocaine? 2. What strategies do women use to manage their day-to-day experiences of health? 3. How are women’s experiences of health and health management strategies influenced by relations of power, systems of oppression (e.g., sexism, racism, classism) and spatial relations? The specific research objectives were to: 1. Critically examine women’s experiences of health within the wider social, economic, political, spatial, personal, and historical contexts of their day-to-day lives.   4 2. Generate a broader understanding of the strategies that women who are street-involved and use crack cocaine use to manage their health including the influential power and spatial relations that contribute to these experiences. 3. Analyse the interrelationships between relations of power, systems of oppression, spatial relations, and women’s health experiences and health management strategies to understand the implications of these interrelationships for women’s experiences of health. 4. Generate recommendations in the areas of education, research, and practice to optimize women’s opportunities for health. Conceptual Issues and Definition of Terms  Language and its inherent meanings are frequently problematic. To enhance clarity I provide a brief overview of key terms that were used in the design, implementation, and analysis of this project. The meanings that I ascribed were chosen in part from the language that the participants used to describe their experiences as well as from related literature.  The terms woman or women were not defined according to secondary sex characteristics but were conceptualized based on how the participants self-identified their gender. Participants who self-identified as female were descriptively categorized as women. Although a small number of participants self-identified as transgendered, they regularly accessed women-only services including housing and drop-in centres, and several had undergone surgical procedures to alter their appearance (e.g., breast implants or sex-reassignment surgery). Thus, the term woman was used to capture those who self-identified as female and transgender male-to-female.  Street-involvement was the term used to describe an inner-city context of housing, activity, and visibility among women who experience marginalization in housing and financial security. Women who are street-involved usually experience serious economic deprivation and may circulate between home and the street, have no connection to home, and/or have inadequate or insecure shelter (Caputo, Weiler & Anderson, 1997; Peressini & McDonald, 2000). They are   5 often highly visible within the public domain. Women who are street-involved may or may not have ties with mainstream society and may or may not be involved in criminal activity or substance use (Higgit, Wingert & Ristok, 2003). Street-involvement, as a descriptor, was not used to imply a homogenous population or experience among all women. Women were recognized as having individual characteristics, histories, skills, and resources.  Health concern was the term applied to describe women’s experiences and perceptions of mental and physical health problems that contributed to their overall well-being, an experience that was described by the participants’ perceptions of their health and my application of knowledge within the health sciences (e.g., pathophysiology). Mental and physical health concerns were not necessarily equated with medically diagnosed disorders (e.g., schizophrenia, osteoarthritis). Additionally, as recommended in the 2001 World Health Organization (WHO) Report on Mental Health, the category “mental health” incorporated a broad perspective including women’s experiences of emotional and subjective well-being and a recognition that these experiences are influenced by biological, psychological and social factors (WHO, 2001). Women’s experiences of health concerns were also positioned within the realm of inequities in health (International Society for Equity in Health [ISEQH], 2005). As a concept, inequity implies injustice and unfairness (Frolich et al., 2006). Within the context of experiences of health concerns, inequities in health pertain to the “systematic and potentially remedial differences” (ISEQH, para. 2) in social, economic, political, and personal factors that negatively influenced women’s experiences of health (Adelson, 2005; Frolich et al., 2006; Reimer Kirkham & Browne, 2006). Positioning women’s experiences of health within the arena of inequities was important to highlight that women’s experiences of health concerns were disproportionate in relation to other women within British Columbia and that an individualized notion of equality, or the state of being equal, was an insufficient conceptual tool to explore the injustices that influenced women’s health concerns (Farmer, 2005; Reimer Kirkham & Browne, 2006).   6 Additionally, as noted by many who are concerned with inequities in health, rhetoric of equality has served to neutralize resistive discourses by rendering arguments against the racialized, class based, and sexist organization of social institutions as mere “complaints” and have diminished the aims of a social justice call to action that incorporates civil, social, and economic human rights (Collins, 2000; Crenshaw, 1991). Members of dominant groups have drawn upon assumptions of equality that are now integrated in many of our social institutions to argue that because equality is now “guaranteed,” individual’s experiences of poor health must represent individual failures, a tactic that effectively permits them to sidestep more meaningful social change within relations of power (Crenshaw; Farmer). Application of inequity as a conceptual tool was necessary to explore relations of power that justify and reinforce women’s experiences of poor health.  Relations of power is, necessarily, a significant concept in a project concerned with inequity in women’s experiences of health. Although described in greater detail in Chapter Three, briefly stated, relations of power refer to the social, spatial, economic, personal, and political processes, ideologies, and practices that sustain and resist domination and subordination, and advantage and disadvantage among members of society. Relations of power are historically situated and operate across multiple and intersecting racialized, gendered, and class-based systems of oppression. Health management strategies referred to the actions, experiences, and decision-making processes employed by women as they sought to prevent and/or manage their experiences of specific health concerns. Women’s agency to actively engage in managing their health and the relations of power that influenced their options, and the interrelationships between relations of power and their decision making were integral ideas within the conceptualization of this term.  As a theoretical construct, poverty lacks cohesive conceptual clarity. Quite often it is expressed solely in terms of income in which a predetermined income level such as the Low   7 Income Cut Off (LICO) is viewed as an indicator for poverty (Reid, 2007). Within the context of this project, poverty was conceptualized as not merely a representation of income, but also as a deprivation of multiple dimensions of life including a long and healthy life, knowledge, and a decent standard of living (Krieger, 2001). Poverty was reflected through inadequate material possessions such as food, clothing, and shelter (absolute poverty) as well as social exclusion in terms of opportunity for employment, education, and full participation in community life (relative poverty) (Reid).  The language concerning substance use is inherently challenging. Few researchers within the health disciplines have historically differentiated between addiction and non-problematic use in relation to crack use (and other illegal substances). Drawing upon the voices of the participants, I recognized that not all use of substances could be considered addiction, an experience that was defined by the participants as the compulsive need to use to avoid serious experiences of withdrawal. I therefore chose to situate substance use within the context of the relationship between the person who is using, families, society overall, and the substance being used. Incorporated within this relationship were the route of use, contextual factors associated with use, and the pharmacological properties of the substance. When negative relationships were experienced with crack or other substances I applied the term problematic substance use. Problematic use was the use of any substance (e.g., legal or illegal) that contributed to individual and/or social harms which may have included but was not limited to dependence and addiction, crime, violence, employment difficulties, and other mental health issues (MacPherson, 2000; MacPherson, Mulla & Richardson, 2006).2  2 Note that the term illicit is intentionally not used to describe illegal substances or the use of illegal substances as this term is often value laden and implies a negative moral judgment concerning people’s use of illegal substances.   8 Organization of the Thesis Having introduced the purpose and research questions addressed in this dissertation, the remainder of this work is organized around a central line of argument which illustrates how the experiences of health concerns and health management strategies of women who are street- involved and use crack cocaine are influenced by relations of power that operate across racialized, gendered, and class-based systems of oppression. In Chapter Two I review literature that was germane to the research. I begin with an overview of knowledge concerning crack cocaine and its physiologic properties and move forward to provide a brief historical perspective of critical and feminist work in the field of women, experiences of health, criminal justice practices, and crack cocaine use. In the final half of the chapter I emphasize the Canadian context and literature specific to health experiences to describe select aspects of the state of current knowledge about women’s experiences of health and their health management strategies and include the identification of areas that require further investigation. In Chapter Three I outline the theoretical foundations that underpin the research and explicate the research design that I employed. Positioned within the emerging body of nursing and related social science scholarship, I delineate the central tenets of intersectionality and social geography that influenced my understanding of relations of power, systems of oppression, and inequities in health. Drawing from these perspectives I explain my application of critical ethnography as a research approach and outline the methods and activities that were used to collect and analyse data. I specify the ethical considerations that were necessary within the scope of this project and provide rationale for choices that I made regarding the nature of research relationships with participants, participant codes, and my use of financial honorariums. Chapter Four represents the first analytical chapter in relation to the data collected within the project. The overarching purpose of this chapter was to provide the backdrop against which women’s experiences of health concerns and health management strategies could be better   9 understood. I provide an overview of the participants and highlight the day-to-day economic, personal, social, historical, and political context in which women live. Of particular relevance are the experiences of women living within the neighbourhood of the DTES, the continual threats to their personal safety, poverty, and the positive attributes they associated with the neighbourhood. In the fifth chapter I present an analytical discussion of women’s experienced health concerns and critically examine these experiences as inequities in health within the context of relations of power and systems of oppression. The discussion highlights the magnitude of chronic and acute physical and mental health concerns that occur throughout the course of women’s lives and incorporates how women perceive of and experience these health concerns on a day-to-day basis. In Chapter Six I describe the strategies that women employ to manage and/or prevent health concerns. Through the analysis, I illustrate the effects that perceived negative interactions with service providers have for women’s health management strategies and also identify the positive and creative strategies that women employ on a regular basis. Within this chapter I draw upon the experiences of women to demonstrate the complexity of women’s use of illegal substances and the wide range of experiences with crack and other substances used by individual women themselves and across women as a social group. The final chapter is devoted to my discussion of the analysis, the broader meanings and the implications of this work for future research, policy making, education, and practice. Within the scope of this chapter I illustrate the damaging effects that ideologies of deviance housed within relations of power designed to advantage some social groups at the expense of others, have for women’s overall health and their opportunities for more equitable experiences of health. In the final conclusions, I highlight some of the limitations of this work and methodological challenges along with recommendations for change.   10 CHAPTER TWO: REVIEW OF EXISTING KNOWLEDGE Introduction  To situate this project within the realm of historical and current knowledge concerning the health experiences of women who are street-involved and use crack cocaine, I conducted a review of relevant health and social science literature. Given the breadth of research within this area, I reviewed literature published primarily between 1990 and 2007 with a specific emphasis on the Canadian context. For the most part, I limited the review to studies that had addressed health concerns and/or self-regulated health management strategies of women who use crack cocaine as their primary topics. In some instances, studies that focused more generally on women’s issues within the context of illegal substance use and studies that involved both men and women were included as the study approaches, topics, and findings of this work were relevant within my overall project purpose. I have organized the results of the review into several themes within the realm of women who are street-involved and use crack cocaine: (a) the historical context of crack cocaine use and related discourse; (b) women’s health concerns; (c) women’s health management strategies; and (d) the spatial, economic, social, and political influences affecting women’s health. In reviewing this literature I was able to explore the state of current knowledge concerning study populations, methodological approaches, and general findings and identified topics that require further investigation. Because this project was also concerned with relations of power as influential factors for women’s health, I also critically examined the mechanisms by which the arguments put forth in this literature challenged or resisted a homogenous, essentialized perspective of women who use crack cocaine.   11 Crack Cocaine: The Substance Cocaine is a powerful central nervous system stimulant and its effects include feelings of increased alertness and energy, inhibited appetite, and euphoria (Erickson, Adlaf, Smart, & Murray, 1994). The feelings of euphoria are directly related to the ability of cocaine to interfere with the re-absorption of dopamine, which is the chemical messenger in the brain that is associated with pleasure (Snyder, 1996). The physiological effects of cocaine include vasoconstriction (the constriction of blood vessels) which may contribute to increases in heart and respiratory rates and blood pressure and in some instances cause muscle spasm and vertigo (Volkow, 2004). Crack is a relatively inexpensive form of cocaine that is made by processing powder cocaine with baking soda or ammonia and crystallizing it into a salt (Goodman, 2005; Ratner, 1993). Few impurities are removed during this process and it is possible to add other substances at some point in the manufacturing process. Recent Canadian research indicates that the majority of crack bought “on the street” usually has small amounts of cocaine and is mixed with a variety of other substances (e.g., lidocaine, crystal methamphetamine) (Goodman). Smoking is the predominant method of using crack cocaine although injection also occurs (Fischer, Rehm, Patra, Kalousek, Haydon, Tyndall, El-Guebaly, 2006; Leonard, DeRubeis, & Birkett, 2006). The crystallized cocaine, referred to as “rock,” is heated in a makeshift pipe made of glass or metal and the resulting vapours are inhaled (Goodman, 2005). Crack cocaine is quickly absorbed into the bloodstream which often results in a quick and intense “high” that is relatively short-lived (Porter, Bonilla, & Drucker, 1997; Ratner, 1993; Volkow, 2004). There is minimal empirical evidence to support reports within American and Canadian media that crack cocaine is immediately addictive (Erickson et al., 1994). Instead researchers have demonstrated that patterns of crack cocaine use vary considerably among people from occasional use (e.g., once per month) to a binging pattern of using large amounts in a relatively short period of time   12 and problematic use including addiction (Erickson et al., 1994; Decorte, 2000; Waldorf, Reinarman & Murphy, 1991). The exact prevalence of crack cocaine use in Canada is unknown. In the 2004 Canadian Addiction Survey (CAS), which included a sample of Canadians over the age of 15 (n=13909) from the ‘general’3 Canadian population, lifetime cocaine/crack use was recorded at 10.6% and use in the past year was 1.9% although rates in British Columbia were noticeably higher at 16.3% and 2.6% respectively (Adlaf, Begin, & Sawka, 2005). Recent Canadian data with people who were street-involved and lived in economic deprivation indicated higher rates of use. The data from a Canadian cohort of people who use illegal opioids in five Canadian cities for example, indicated that 54.6% of baseline participants had used crack in the past 30 days although there was some variation among prevalence according to sites ranging from 86.6% in Vancouver to 3.4% in Quebec City (Fischer et al., 2006). Data from recent work with 4000 people who were street-involved and had accessed community health services in the DTES illustrated that 55% reported using crack in the past six months and women were more likely than men to use crack (34% versus 27%) (CHASE Report, 2005), although the rationale underpinning this finding was unclear. Although people of all socioeconomic backgrounds use crack, as evidenced within the CAS results, researchers have suggested that the inexpensive cost of crack production and purchasing, has contributed to increased spread of use within city neighbourhoods characterized by severe economic deprivation (Mahan, 1997; Waldorf et al, 1991). Locating Women and Crack Cocaine Use within a Historical Context The discourse concerning women’s use of illegal substances in general and crack cocaine in particular has a complex and at times conflicting history that has influenced how women have  3 To highlight that data was collected primarily with people who had a place of residence with phone access thereby limiting participation of those living without these resources, the term general is placed in single quotation marks.   13 been positioned within the health care and social science disciplines concerned with illegal substance use and addictions. Early medical and anthropological research focused on illegal substance use within the discourse of addiction which portrayed addiction as a disease entity that contributed to people’s inability to control their actions (Keane, 2002). Moral claims about addiction and illegal drug use revealed a hierarchy within substances used in which illegal “drugs” such as heroin and cocaine were perceived as more socially deviant than legal substances such as alcohol or tobacco and were touted as contributing to the destruction of society (Brook & Stringer, 2005; Ettore, 1992). Proponents of prohibition argued that there was a direct link between criminal acts and the use of illegal substances, an ideology that remains prevalent today (Boyd, 2008). People who experienced addictions with illegal substances were portrayed as deviant, weak, and unable to act in their own best interest, and as such required that their actions be governed by others, particularly medicine and the criminal justice system (Boyd, 2004; Brook & Stringer; Cooper, 2004). As noted by several feminist researchers, this ideology concerning addictions and illegal substance use has been significantly damaging for women. Women who use illegal substances historically have been positioned within health and social science discourse as a homogenous group incapable of self-control who have abdicated their nurturing and mothering roles within society and as individually weak and of poor moral character, particularly with regards to their sexuality (Boyd, 1999, 2004; N. Campbell, 2000; Ettore, 1992, 2004; Maher, 1997). This dominant ideology has served to legitimate an increased regulation of women by medicine and the state including the social service and criminal justice systems. For example, women who use illegal drugs, particularly those who experience economic deprivation and are Aboriginal (within Canada) or African-American (within the US) are more likely to be incarcerated for substance- related crimes and are also more likely to have their children apprehended into protective   14 custody than women within the “general” population (e.g., White women, women of greater economic resources) (Boyd, 1999). Several researchers have highlighted that the dominant ideology is further influenced by intersections of race, class, and gender and that these relationships have had significant implications for women’s day-to-day lives (Boyd, 1999, 2004; Campbell, 2000; Cooper, 2004; Ettore, 1992; Maher, 1997). In her analysis of 297 health-related articles dated during the periods 1880-1920 and 1955-1975, Cooper demonstrated how oppressive assumptions of gender, race, and class played out within the realm of health research and theory development concerning the etiology of opiate addiction. She reported that health professionals attributed experiences of addiction to individual psychopathology such as immaturity, weakness, and regressive characteristics in relation to women from the working class or who were poor and/or men and women who were described as Latino, African-American, and indigenous. External factors such as the stressors associated with “living in the modern world” were cited as the primary cause of addiction experienced by affluent White males (Cooper, p. 441). Drawing upon theories of oppression and intersectionality, she further argued that how health professionals defined the root cause of addiction was not accidental, but instead reflected the inequitable social relations of these eras and was a deliberate attempt to “ratify this group’s supremacy over others” (p. 442). Today the dominant ideology concerning women and illegal substance use permeates social science and health care research concerned with the lives of women who use crack cocaine. For example, several social science ethnographic studies have focused almost exclusively on issues of crack use and commercial sex work, exploring women’s experiences of sex-for-money or sex-for-crack exchanges with a specific emphasis on the location and types of sexual acts involved.4 Researchers such as Inciardi, Lockwood, and Pottieger (1993) and Ratner  4 Commercial sex work involves work with the explicit purpose of exchanging sex activities for resources. Resources may include but are not limited to money, substances, food, protection, and shelter. Commercial sex work provides a more comprehensive approach to examining sex-for-resource exchanges than housed within traditional   15 (1993) studied the experiences of African-American women living in extreme economic deprivation within specific drug houses where sex-for-resource exchanges occurred. The researchers documented their observations of women’s actions and experiences and presented their findings in a manner that decontextualized women from the rest of their lives. Women were described as “doing anything for the drug” and the economic or gendered forces influencing their lives were never discussed, despite the overwhelming literature that has demonstrated the link between survival commercial sex work, oppression of women, and severe economic deprivation (e.g., Kearney, Murphy & Rosenblaum, 1994; Maher, 1997). In more recent ethnographic projects within two separate economically deprived American inner-city neighbourhoods’ researchers E. Anderson (1999) and Bourgois (2003) perpetuate the sexist stereotypical discourse of women who use crack cocaine as amoral, self- serving women who have abdicated their responsibility to the family. In his work that primarily targets African-American men and women, Anderson discusses crack cocaine use solely in the context of women’s behaviours. He blames women’s use for the destabilization of the family unit and draws upon stereotypes of Black matriarchal figures to reinforce his point. One of the worst hazards is crack. Once a family member ‘hits the pipe,’ a process begins that destabilizes an already weak unit…it starts when the daughter gets in with the ‘wrong crowd’…the grandmother often unintentionally aids and abets the daughter’s fall into this life by babysitting for the children and helping out financially and in other ways, thus giving the daughter the freedom to pursue a good time (pp. 215-216).  Bourgois (2003) in his work with Latino men and women, describes men who engage in drug selling and violence as being victims of the economic circumstances within the United States and attributes their actions to a loss of masculine identity. Despite an acknowledgement of the difficulties women face in accessing social assistance programming, women’s actions as dealers and people who use are described as “destroying the family.” Drawing solely on his own  ideas of prostitution and permits critical examination of the relations of power underlying the sex-for-resource exchanges.   16 experiences in the neighbourhood and interviews with only one woman he states, “she finally came to the realization that she was destroying herself and her family through her drug dealing” and that “her aggressive, street-wise single mother persona did not inspire credibility at the welfare office” (p. 245). Over the past 25 years critical and feminist ethnographic and qualitative researchers have critiqued this dominant discourse as problematic.5 While it is beyond the scope of this project to review all of these studies, a key number that reflect this resistive discourse should be highlighted. Beginning in the early 1980s, Rosenbaum (1981) acknowledged the lack of empirical work that accurately reflected the experiences of women and sought to critically examine aspects of women’s lives that pertained to illegal substance use from the standpoint of women themselves. Although her project focused upon women who used heroin, Rosenbaum was the first researcher that specifically identified the need to examine women’s experiences of their day-to-day lives and illegal substance use within the context of race, gender, and social class. Maher (1997) engaged in ethnographic work to examine the economic context of drug use and dealing among women within an impoverished inner-city setting and demonstrated the intricate relations between poverty, race, and gender as factors influencing the economic opportunities available to women who use crack cocaine. In their work with pregnant and parenting women, Murphy and Rosenbaum (1992, 1999) demonstrated that women were concerned for the welfare of their children and capable of enacting a variety of strategies to mitigate the harmful effects associated with substance use. In her qualitative work, Boyd (2004) demonstrated that women’s lives and actions related to mothering and substance use were significantly influenced by social, economic and criminal justice policies as powerful structural forces that shaped women’s experiences. As a result, significant advances were made in  5 Drawing from work of feminist sociologist Dorothy Smith (1987) the term problematic refers to inquiry that examines the social organization of experiences as they occur in the day-to-day lives of women and the discourse and knowledge that pertains to these experiences.   17 understanding the context of women’s lives as they pertained to illegal drug use, poverty, race, motherhood, and violence. These researchers challenged assumptions regarding homogenous “woman’s” experiences of initiation to drug use, patterns of drug use, resources and support needs, pregnancy and mothering, and women as both victims and perpetrators of violence (Boyd, 1999; DeCorte, 2000; Waldorf et al., 1991). These same researchers have brought to the fore the importance of examining the intersection of gender, race, and class in any study seeking to develop a better understanding of the experiences of women’s lives and the social and structural forces shaping these experiences (Boyd, 1999; Mahan, 1996; Maher, 1997; Sterk, 1999). Some researchers (Boyd, 1999; Maher, 1997; Murphy & Rosenbaum, 1999; Taylor, 1993) expanded work in the area of women and illegal drug use to include a critical exploration of women’s agency. Through their findings, they demonstrated that theoretical descriptions of women who used illegal drugs as “deviant” and “hypersexual” and “out of control” are inherently problematic. Instead, these researchers were able to demonstrate that many women who use crack cocaine and other illegal drugs are rational, active people making decisions based on the structural and personal factors influencing their lives (Taylor, 1993). In the remaining review of the extant literature, I draw upon more examples of this work as they pertain to the topics under review. The Magnitude of Health Concerns Canadian research concerned with the health experiences of men and women who use crack cocaine has grown over the past 20 years.6 Studies concerned with the typology and prevalence of health concerns predominated much of this work. In the early 1990s researchers explored health issues among people who reflected a socio-recreational pattern of use  6 Due to the breadth of research in Canada and the US and the overwhelming emphasis within US-based literature on the sexual practices of women who use crack cocaine and the resultant narrow scope with which women’s health concerns are identified, I emphasize the Canadian literature as the focus of this discussion concerned with prevalence of health concerns. Comparisons with US and European-based research are made when deemed appropriate to the topic of discussion. More of the US-based literature is incorporated in the review of literature relevant to contextual factors influencing health.   18 characterized as infrequent use and use as a component of social activities (Erickson et al., 1994). More recently the focus has shifted to inner-city settings where high rates of unemployment, unstable housing, arrest for criminal activities, and more frequent use patterns predominate (Butters & Erickson, 2003; Fischer et al., 2006; Goodman, 2005; Leonard et al., 2006; Malchy, Bungay, & Johnson, 2007; Shannon, Ishida, Morgan, Bear, Oleson, Kerr, & Tyndall, 2006). Regardless of the setting or the social demographics all of the studies’ findings reflected that people who used crack experienced a variety of health concerns. Poly-substance use defined as the use of substances in addition to crack was the most common pattern of use. Erickson and her colleagues (1994) conducted one of the first Canadian studies that incorporated people’s experiences with crack cocaine. As part of a larger study concerned with health concerns among people who used powder cocaine, they included items in their questionnaire that specifically targeted people’s experiences with crack cocaine including crack use patterns, perceived risks, and negative and positive experiences associated with crack use. Of the 111 people who participated in the cross sectional survey, 78 reported having used crack at least once in the previous three years (59 men; primarily of Euro-White descent; all employed full time for at least six of previous 12 months). The researchers reported their findings about health concerns experienced during cocaine use within the context of the larger study and did not differentiate these findings according to the presence or absence of crack use. The most frequent concerns included increased heart rate, dry mouth and throat, nervousness, acute insomnia, paranoia, and hallucinations, most of which intensified with an increased frequency of use. Long-term negative reactions that participants associated with cocaine use included the inability to relax, chronic insomnia, physical and mental exhaustion, and weight loss. Those who reported crack use were also asked in an open-ended question to identify what they least liked about crack use. “Adverse physical effects” was the most common response (43.6%). “Adverse physical effects” was a generic category applied by the researchers to describe experiences of nausea,   19 sweating, painful breathing, and tachycardia (increased heart rate). These same participants responded “unlikely” when asked if they would seek health care attention for these concerns. The findings reported within this Canadian project were consistent with those of a US-based study concerned with general cocaine use among participants of similar demographics (e.g., primarily Euro-White men, who were employed full time). Insomnia, hallucinations, paranoia, frequent colds, sore throats, and nervousness were identified as the most common health concerns among participants who had also reported using crack (Waldorf et al., 1991). More recent Canadian research has shifted the emphasis from powder cocaine use with people who are regularly employed to engage in study with people who are street-involved, experience poverty and unstable housing, and use crack cocaine. As with the earlier research, mental health concerns were frequently reported among the participants. For example, in a Toronto-based study with men and women who reported current crack use (n=108; 49% women, 44% men, 7% transgender; 50% Euro-White, 18% Aboriginal, 32% Other; 10% involved in paid work) “mental health issues” was rated at the most frequent health concern reported by the participants (41%) (Goodman, 2005). Unfortunately, what this term encompassed was not explained. Researchers from another Canadian study with people who were street-involved, unemployed, and used opioids noted that 54.6% of all participants (n=679) also reported crack use in the past 30 days (Fischer et al., 2005, 2006). Although fewer crack use participants scored significantly on the Composite International Diagnostic Interview (CIDI)-Short Form (Depression) Scale (43.7% versus 51.2%), it was apparent that depression was a common mental health concern for both groups (Fischer et al., 2006). Within a US-based study with 430 not-in- treatment people who used crack and shared similar demographics with this Canadian study, significant incidence of depression was reported with 55% of respondents scoring at a moderate- to-severe level (Falck, Wang, Siegal, & Carlson, 2003).   20 Unlike the research of the 1990s that emphasized the physiologic effects of cocaine (e.g., tachycardia), current research has highlighted a myriad of other physical health concerns among men and women who use crack. The differences in these findings may be due in part to the recent emphasis on health concerns that pertain to blood-borne infections (e.g., hepatitis C virus [HCV] and human immunodeficiency virus [HIV]), concerns attributed to the smoking practices associated with crack use (e.g., cuts and burns), and specific health concerns related to poverty and unstable housing (e.g., foot problems and malnutrition). For example, Goodman (2005) identified health concerns that were specific to infections, mental health, malnutrition, and diabetes in her survey with men and women who use crack; HCV, foot problems, diet/malnutrition, and chronic lung infections were the four dominant physical health concerns reported. In another Ontario-based study that targeted people who injected as a route of use and who identified crack cocaine as one of the substances used, researchers investigated prevalence of HIV, HCV, and smoking-related burns and/or cuts to the lips and mouth (n=112; 77% male, 9% Aboriginal identity, and 91% Other; 65% unstable housing in past six months) (Leonard et al., 2006). HCV (62.5%), HIV (12%) and cuts or burns (51.8%) were significant health issues experienced. Researchers have reported similar findings in their research with people who use crack in the DTES. In one cross-sectional survey pilot project, 74% of participants who reported current crack use experienced burns associated with smoking (n=97; men 51%; Euro-White 46%, Aboriginal 32%) (Malchy et al., 2007). Shannon and her colleagues (2006) reported high incidence of HIV (27%), HCV (69%), and burns (40%) among study participants in their project aimed at assessing potential public health impacts of medically supervised smoking facilities for people who smoke crack (n=437; 67% male; 45% Aboriginal; 43% homeless). Thirty-five percent of the participants did not inject as a route of use. Within the five-city Canadian study mentioned previously that focused primarily on people who were street-involved, unemployed, and used opioids, people who used crack were more likely than those who did not to report   21 physical health problems (78.2% versus 64.7%). HCV and pain were the most commonly reported concerns for both groups (Fischer et al., 2005, 2006). Testing of salivary antibodies illustrated that a greater number of those who used crack were HIV (17.7% versus 13%) and HCV (56.4% versus 46.6%) positive. I could find only one Canadian study that specifically examined the health concerns of women living in poverty who regularly used crack cocaine (n=30; 17 Euro-White; 7 First Nations; 6 Black; 1 East Indian) (Butters & Erickson, 2003). In this qualitative study, researchers reported findings similar to those in other Canadian research. HCV, respiratory illness such as asthma and pneumonia, and mental health issues such as anxiety, depression and suicidal ideation were the common health concerns experienced by women. Women’s reproductive and sexual health concerns were also significant. Sixteen women reported their health status as poor to fair, 15 had experienced an STI at least once in their lifetime and 14 of the women reported lifetime experience of miscarriage during at least one pregnancy. While each of these studies have provided important information concerning the general health problems experienced by people who use crack cocaine, there are specific challenges in generalizing this research to women who are street-involved within the DTES. In several of the research projects for example, inclusion criteria was specifically targeted towards people who injected (Leonard et al., 2006) and/or used opioids (Fischer et al., 2005, 2006). Other studies predominantly targeted people who used cocaine powder (Erickson et al., 1994; Waldorf et al., 1991). People who used crack were often a sub-study of interest and not the primary target group. Although poly-substance use has been well documented among people who use crack cocaine (Goodman, 2005), it is reasonable to assume that some people who use crack may not use opioids or cocaine powder or inject as a route of use and therefore their concerns may be underrepresented within the findings of the current research concerned with the health experiences of those who use crack cocaine.   22 Men were frequently overrepresented in several of the Canadian projects (e.g., Erikson et al., 1994; Fischer et al., 2005; Leonard et al., 2006; Malchy et al., 2007). In some instances researchers reported that there were no statistically significant sex differences but the testing for differences was not consistently reported. Several studies overlooked the addition of women- specific health concerns in the construction of their instruments. Health concerns were not consistently defined or measured within the projects and only one project used a standardized instrument to assess depression among study participants (Fischer et al., 2005, 2006). The context of people’s experiences of health concerns was often not fully explored. For example, only Goodman (2005) identified health concerns that have been associated with poverty and unstable housing as items to be measured (e.g., malnutrition and foot problems).  While seeking to lessen the knowledge gaps concerning health concerns associated with crack use, it is apparent that current research has not yet fully explored these issues within the larger social, economic, political, and historical context of women’s health and the full scope of health concerns experienced among women who are street-involved and use crack cocaine remains unknown. The Contextual Factors Influencing Experiences of Health In more recent years, Canadian researchers have begun to examine a variety of social and economic factors as well as crack use practices that may contribute to the magnitude of health concerns experienced by women (and men) who use crack cocaine. This area of research is of particular importance in light of the growing empirical research that indicates that people who use crack cocaine and experience economic and social marginalization are more likely to experience poorer health and require more frequent medical attention when compared to people of similar life circumstances who use other forms of cocaine and/or other illegal substances (Ferri & Gossop, 1999; Fischer et al., 2006; Ottaway & Erickson, 1997). Within the literature previously discussed that targeted people within impoverished neighbourhoods, the vast majority of all participants who reported crack use were unemployed, relied on social income assistance,   23 and had experienced unstable housing over the past year (Butters & Erickson, 2003; Fischer et al., 2006; Goodman, 2005; Leonard et al., 2006). For example, 12 women in the Toronto-based study reported living in shelters at the time of the interview and none were regularly and/or legally employed (Butters & Erickson). Within the Canadian five-city project, people who used crack were significantly less likely to have stable housing or to have had paid work in the previous 30 days than those who used other illegal substances (Fischer et al.). Similar findings have been reported within a Brazil-based project with women (10%) and men (90%) that compared demographic characteristics based on route of cocaine administration – snorting powder (n=113) or smoking crack (n=95). Significantly more of the crack using respondents were unemployed and had lived on the street at some point throughout their lives (Ferri & Gossop, 1999). Although significant evidence exists demonstrating the increased likelihood of reduced opportunities for health among women and men who live in poverty and unstable housing (e.g., see Frankish, Hwang, & Quantz, 2005 for a review of the Canadian literature), the rationale for why women and men who use crack experience such high rates of unemployment and unstable housing and how these experiences may contribute to the health concerns within this population remains for the most part an under investigated area of research. Smoking Practices The practices associated with smoking crack cocaine versus injection have also come under recent scrutiny as a contextual factor associated with health concerns. As noted previously smoking cocaine usually involves the use of a makeshift pipe made of glass or metal. There is growing evidence that the majority of these pipes contain splits or cracks which may contribute to cuts, particularly of the fingers and lips (Goodman, 2005; Leonard et al., 2006; Malchy et al., 2007). In recent project in Vancouver’s DTES for example, 81% of respondents reported using pipes with splits or cracks (Malchy et al.). In addition, the heat required for crack vaporization and the inhalation of steel wool particles that break apart from the filter used to hold the crack in   24 place have has also been associated with lip and mouth burns (Goodman, 2005; Moettus & Tandberg, 1997; Shannon et al., 2006). Determining the underlying cause of oral lesions however is complex. In a US-based study with youth who were street-involved (47.6% female; 77.9% Black), significantly more oral sores were present among those who smoked crack than those who did not although recently having syphilis and being HIV positive were also strongly correlated with the presence of oral lesions (Faruque et al.,1996). Given the high incidence of HCV among people who use crack cocaine, many researchers have hypothesized that in the presence of oral lesions due to burns, the sharing of smoking equipment may be a route for possible infection (Tortu, McMahon, Pouget, & Hamid, 2004), particularly given the high incidence of pipe sharing documented within the literature (Leonard et al., 2006; Malchy et al., 2007). In light of the empirical evidence concerning increased likelihood of other activities associated with HCV infection (e.g., injection use, unprotected sex activities) that are prevalent among people who experience economic and social marginalization who use crack, other researchers have cautiously noted that it would be difficult to effectively demonstrate that pipe sharing would be the sole source of HCV transmission (Fischer et al., 2008). In a recent investigation that involved sampling of pipes for HVC- antibody, 2.0% of the pipes tested (i.e., one pipe out of 51) positive and in this instance, the pipe had been used by someone known to have HCV (Fischer et al.). The researchers caution that given the small sample size the results should be interpreted cautiously and further investigation is warranted. Sex Practices The sexual practices of women who use crack cocaine, including numbers of sexual partners, condom use, and engagement in commercial sex work have also become topics of interest among researchers concerned with factors that influence women’s opportunities for health. The interest in these topics has been due in part to the abundance of extant research that   25 indicates increased risk for STI, HCV and/or HIV infection among women who experience greater numbers of sex partners, are less likely to use condoms, and engage in commercial sex work (see Remple, 2007 for a review of this literature). Within the context of women’s health, crack use has been correlated with increased numbers of sexual partners and less frequent condom use when compared to women who use opioids (Cohen, Navaline, & Metzger, 1994). In comparisons between men and women who use crack however, greater condom use by women has been reported (McCoy & Wasserman, 2001; Tortu et al., 1998). High rates of STI, particularly syphilis have also been documented although the correlation with crack use appears to be less well understood (Butters & Erickson, 2003; DeHovitz et al., 1994; Goodman, 2005; Logan & Leukefeld, 2000; Ward, Pallecaros, Green, & Day, 2005). Within Canada, researchers have reported that crack use is significantly associated with engagement in commercial sex work (Butters & Erickson, 2003; Fischer et al., 2006; Shannon et al., 2006; Spittal et al., 2003). In a two-city Canadian study with women who were street involved and used injection as a route of administration (n=591), crack cocaine smoking was independently associated with commercial sex work (adjusted OR = 3.3) although no significant differences among HIV rates were found in relation to the presence or absence of sex work (Spittal et al.). Spittal and colleagues (2003) caution against drawing generalized conclusions concerning a causal relationship between sex work and crack use as the majority of participants involved in commercial sex work reportedly did so out of economic necessity due to limited options for income generation. These findings were consistent with two US-based qualitative projects with women who used crack cocaine and engaged in commercial sex work that demonstrated the presence of complex interrelationships between crack use, class, and gender (Kearney et al., 1994; Maher, 1997). The women in these projects, the majority of whom were African-American and living in economic deprivation, experienced less financial autonomy and   26 fewer options to generate legitimate paid income than men within the same neighbourhoods (Kearney et al.; Maher). By contrast, many US-based research projects have examined commercial sex work as a health-influencing factor from the perspective of sex-for-crack exchanges and these studies appeared to be informed in part by ideologies and stereotypes concerning women’s sexual behaviours in relation to crack use (e.g., Inciardi et al., 1993). Crack use was consistently portrayed as a negative behaviour and in most instances all crack use was equated with addiction despite the lack of evidence included in the reports to support such claims. Factors that may intersect with women’s engagement in sex-for-crack exchanges were often overlooked. These assumptions underlying women’s health research are inherently problematic as they portray an individualized, behavioural approach to complex issues such as condom negotiation, commercial sex work, economic deprivation, and crack cocaine use. Although the association between crack use and “riskier” sexual practices has been documented, the complex interrelationships between these factors and other economic and social circumstances (e.g., housing) as they pertain to women’s experiences of health are not well understood. More sensitive and nuanced investigation is required. Violence Much of the empirical literature has noted that women who are street-involved and use crack cocaine are often victimized by violence (Butters & Erickson, 2003; Erickson, Butters, McGillicuddy, & Hallgren, 2000; Falck, Wang, Carlson, & Siegal, 2001; Goodman, 2005; Liebschutz, Mulvey, & Samet, 1997; Mahan, 1996; Maher, 1997; Sterk, 1999). For example, in Goodman’s (2005) Toronto based study, 64% (n=69) of participants cited violence as a significant concern and 44% reported sexual assault with women suffering significantly more sexual assaults than men (mean = 0.58 versus 0.19; p = 0.000). Despite the high frequency however, few research projects have specifically explored the interrelationships between   27 violence, crack use, and women’s experiences of health. This is somewhat surprising given the abundance of other health-related research indicating the serious mental and physical health implications that have been associated with violence including HIV (Gielen et al., 2000), traumatic injuries (J. Campbell, 2002), and mental health concerns (Morrow, 2002). One US-based study was carried out in an attempt to address some of these gaps. One hundred seventy one women (57% Black, 43% Euro-White; impoverished urban neighbourhood) were interviewed about their experiences with physical assault and rape “since they had begun using crack cocaine” (Falck et al., 2001, p. 81). Data concerning women’s arrest history for commercial sex work was also collected based on the researchers’ stated assumption that commercial sex work increased the likelihood for violence, a finding that has been well supported elsewhere (see Lowman, 2000). Physical attacks were reported by 62% of the women since initiating crack use and 32% had been raped. Fifty-seven percent of the women who reported physical attacks stated they sought medical care to deal with injuries associated with the attack although the nature of the injuries was not included in the report. Although these statistics represent a very real concern regarding the violence experienced by women, there were serious flaws in the study design. First, the women were asked if they sought medical care because of the attack; they were not asked how badly they perceived themselves to be injured or if they perceived themselves as needing medical care. Therefore, the severity of the injuries suffered by the women may be under-represented. Also, the women were not asked about injuries associated with being raped or whether or not they required medical care due to injuries suffered from the rape. Although statistical analysis demonstrated increased odds of being raped if a woman had been arrested for sex work, being arrested is not an adequate measure of engaging in sex work nor the complexity of what constitutes sex work. Not all women who engage in sex work get arrested and the findings could under-represent the number of women engaging in commercial sex work within this study sample.   28 In addition to prevalence research, researchers in the field of violence against women have noted that it is important to examine violence as an influential health-related factor within the broader context of other socio-political and economic factors including race, gender, and poverty (Crenshaw, 1994; Razack, 2002a, 2002b; Smith, Varcoe, & Edwards, 2005). Within Canada for example, it has been well documented that Aboriginal women experience high incidence of violence (Razack, 2002b; Smith et al., 2005). Researchers have also demonstrated that the factors contributing to this violence are related to relations of power within society that have legitimated violence against Aboriginal women as reflected in the longstanding history of residential schooling (Smith et al.). Given the overrepresentation of Aboriginal women within the Canadian empirical literature concerned with crack cocaine use, the interrelationship between commercial sex work and violence, and the reported high incidence of commercial sex work among women who are street-involved and use crack cocaine, much more complex investigation is warranted to examine how race, class, and gender intersect with regards to violence as a factor influencing women’s health. Health Care It is generally accepted that health service access and utilization are significant factors that influence the health of all Canadians. Although a full review of the literature relevant to health care access and utilization are beyond the scope of this study, it is worthwhile to examine some of the literature particularly in light of the growing body of research that indicates barriers to adequate health care and/or social services may contribute to health inequities among men and women who use crack cocaine (Fischer et al., 2006; Shannon, Bright, Duddy, & Tyndall, 2005). Researchers have recently begun to explore the dearth of harm reduction programming specific to people who are street-involved and smoke crack cocaine (Fischer et al., 2006). A meta-analysis of 33 US-based HIV intervention studies for people who are street-involved and use illegal drugs, for example, revealed that only 21% reported recruitment of people who   29 smoked crack while 94% focused on people who injected as a route of use of illegal drugs (Semaan et al., 2003), despite the previously noted increased prevalence of HIV among people who smoke crack cocaine (Fischer et al., 2005, 2005; Shannon et al., 2006). In Canada, harm reduction programming concerned with the health of people who use illegal substances has focused almost exclusively on “safer” injection including needle exchange programs and a safer injecting site, and opiate replacement therapy (e.g., methadone) all of which are connected to other essential health and social service programs. Strategies to enhance harm reduction programming for people who use crack cocaine (e.g., the distribution of less harmful smoking equipment, educational programming) have been met with significant socio-political resistance in many Canadian cities, so much so that such programming was recently cancelled within the city of Ottawa (Leonard et al., 2006). Law enforcement practices have further exacerbated problems with harm reduction programming. In all Canadian cities in which research has occurred, participants have consistently reported that their smoking equipment has been confiscated and/or smashed by police; a practice that one could reasonably assume may result in increased sharing of equipment and infectious disease transmission (Malchy et al., 2007; Shannon et al., 2006). In addition to the loss of supplies, enforcement strategies of increased arrest have contributed to less safe practices such as smoking in known areas of increased risk of violence in order to hide from police and smoking crack more quickly, a factor known to increase aspiration of the hot steel wool filter (Shannon et al.). Experiences of discriminatory or disrespectful interactions with health service providers have also been identified as a potential barrier to health care (Butters & Erickson, 2003; Ensign & Panke, 2002; Goodman, 2005). Although Canadian-based research has not been explicit with regards to how discrimination was defined or measured, one study in particular noted that 50% of all survey respondents (all of whom use crack) reported discrimination due to poverty, substance use, and/or sex work as a barrier to receiving health care (Goodman). Within the   30 qualitative focus groups of the same study, participants described that they were denied service or made to wait specifically because they were people who used illegal substances and that the attitudes of health care professionals were often derogatory (Goodman). The experiences reported by these participants are consistent with those reported in a US-based study with adolescent and young women who were also street-involved and in some cases involved in illegal substance use (Ensign & Panke, 2002). Lack of respect and judgmental attitudes by service providers were reported among the women as significant barriers to health services, so much so that the women in Ensign and Panke’s project reported that they avoided health care agencies and often attempted to manage a health concern without any health care intervention. In another US-based study situated within several inner-city areas in Miami involving 624 participants, women reported using health care services (defined as medical clinics, emergency rooms, family planning and STI clinics) more often than men overall but women who used crack cocaine were less likely to use services than those who did not (Metsch et al., 1999). The findings of this work must be interpreted cautiously however as the sampling strategies used in this work were problematic. First, the sample was predominantly of African-American ethnicity and the researchers did not report how this categorization was measured and whether any sampling strategies were used to represent greater variance in ethnicity within the study population. The researchers also chose to study HIV seropositive status and history of STI as factors influencing use of health care services. This choice of health concerns overlooks other research that has identified many other relevant health concerns experienced by women who use crack cocaine, specifically those associated with violence (Falck et al., 2001) and other general health concerns such as respiratory illness and burns or lacerations (Falck et al., 2003; Leonard et al., 2006; Malchy et al., 2007).   31 Women’s Health Management Strategies The literature pertaining to the health management strategies of women who use crack cocaine is limited and much of this work has focused on pregnant or early parenting women (Kearney et al., 1994; Murphy & Rosenbaum, 1999). In the early 1990s a large-scale US-based mixed methods study was conducted with hundreds of predominantly African-American women who use crack cocaine, were not in drug treatment, and were either currently pregnant or had used crack at least weekly during their pregnancy. Several sub-studies have arisen from this work and researchers have reported findings associated with women’s health management strategies (Kearney et al.; Murphy & Rosenbaum). These strategies included harm reduction practices such as using less crack, eating well, taking vitamins, avoiding stressful situations by distancing themselves from social situations known to be stressful, finding secure housing, and getting more sleep. Kearney and colleagues reported that many of these practices were also associated with reducing the amount of stigma (defined as social derision and rejection) women experienced and frequently included women choosing to have less contact with health services and a desire to manage their own and the fetus’ health. While the findings reported by the researchers shed light on important strategies employed by women, in both instances the focus of the research was identifying women’s practices with regards to the health of their fetus. How this information is related to women outside of the context of pregnancy or in the context of general health concerns remains largely under-investigated. This is increasingly important given the findings in other studies non-specific to crack cocaine use that demonstrated that women make conscious decisions regarding the substances they use (e.g., stimulant versus depressant) depending on the desired effect and a careful weighing of risks and problems associated with a specific substance (Boyd, 1999). Bungay and colleagues (2006) in their work with street- involved youth who use crystal methamphetamine demonstrated that the youth were knowledgeable about their drug use and recognized when they required time to take care of   32 themselves including taking a break from the drugs, sleeping, eating well, and avoiding people with whom they did drugs. Other foci within the empirical literature have included women’s efforts to reduce crack use or maintain abstinence (German & Sterk, 2002; Pursley-Crotteau & Stern, 1996; Roberts, 2001), social networks and relationships as a source of support in women’s lives (Brown & Trujillo, 2003; Pottieger & Tressell, 2000), and condom use practices to prevent STIs and HIV (McCoy & Wasserman, 2001). Much of this work has occurred in the US and the participants in these studies have been predominantly African-American women living in inner-cities rife with high unemployment rates, poverty, single-parent households, unstable housing, and violence. The researchers of studies in the areas of support and crack use reduction or abstinence reported the importance of stable housing, family or friend support, and distance from people with whom they usually shared crack as strategies that reduced their crack use (Brown & Trujillo; German & Sterk; Pottieger & Tressell). None of the findings, however, were discussed in the context of managing one’s health, addressing health problems, or women’s health in general. While it seems reasonable to assume that factors such as housing, support, and reduced drug use would be significant for women’s health, the nature of the interrelationships between these factors and what they mean for women’s health experiences and health management strategies requires further investigation. Summary Although there is a significant amount of empirical literature within a variety of disciplines that demonstrates a myriad of health concerns among women who are street-involved and use crack cocaine, less is known about the full breadth of concerns experienced, how these concerns play out within the realm of women’s day-to-day lives, or how women manage these particular concerns. Research indicates a high prevalence of crack use in Canada among women who are street-involved and living in poverty, but few projects have examined use within the   33 context of women’s health with an eye to a comprehensive exploration of how class, race, and gender intersect to influence women’s experiences for health and the options available with regards to self-regulated health management. Given these gaps within the health-related literature, it was timely to undertake a project focused on the health concerns that women experienced and the strategies that women employ to mitigate inequities in health within the context of the socio-political and economic relations of power at play in their day-to-day lives.   34 CHAPTER THREE: RESEARCH DESIGN AND IMPLEMENTATION Introduction In order to address the research questions and overarching objectives I required a research design that could create an account of women’s experiences of health concerns and health management strategies situated within the relations of power and systems of oppression that influence women’s lives. To help orient me in designing a study concerned with relations of power and social justice, I drew from select theoretical perspectives located within the tradition of critical theory, specifically intersectionality, social geography, and feminist theory (e.g., Collins, 1998, 2000; Harding, 2004; Massey, 2005). I selected critical ethnography as the research approach as it best supported the use of methods that would lead to a rich description of women’s experiences including the integration of information concerning relations of power as key factors influencing their experiences of health (Quantz, 1992). A critical ethnographic design enabled recognition of women as essential sources of knowledge, critical examination of my role as researcher within the research process, and when combined with the theoretical perspectives, supported me to implement an analytical approach congruent with making visible the interrelations between women’s experiences of health, health management strategies, systems of oppression, and relations of power. Before presenting a full discussion of the relevant theoretical perspectives, their integration into the research design and implementation, and the actual research process, several points of clarification are warranted. First, I recognize that there are many varying perspectives congruous with critical theoretical traditions including feminism, critical social theories, post- colonialism, and post-structuralism (among others) (Browne, 2003). My use of ‘critical’ refers to the shared position within all critical perspectives that relations of power influence the processes by which “…groups of people are differently placed in specific political, social, and historic   35 contexts characterized by injustice” (Collins, 2000, p. 298). I also adhere to the commitment to justice that is a part of critical traditions and as such have engaged in this work to make visible, and thereby create the potential to alter, the oppressive circumstances of people’s lives (Weber & Parra-Medina, 2003). This project follows in the tradition of many nursing scholars who have embraced critical perspectives within diverse substantive areas that have contributed to a greater understanding of the landscape of inequity that permeates women’s health across the globe (e.g., J. Anderson, 2004; Browne, Smye & Varcoe, 2007; Reimer Kirkham & Browne, 2006; Varcoe, Hankivsky & Morrow, 2007). Much of this work has also contributed to the development and implementation of effective strategies to reduce these inequities. Intersectionality Intersectionality, as an analytical perspective, is a particular way of understanding social locations (e.g., the “groups” to which people belong) among multiple intersecting systems of oppression and inequity (McCall, 2005). Intersectionality refers to the perspective that “…systems of race, social class, gender, sexuality, ethnicity, nation, and age form mutually constructing features of social organization” (Collins, 2000, p. 299). Each of these systems of oppression are historically situated, socially constructed, and mutually interrelated in that they have the capacity to co-construct one another in a manner that further contributes to inequalities and inequities. Systems of oppression are not merely conceptual entities but represent social processes embedded within relations of power that translate directly into actual experiences (Crenshaw, 1991). These experiences are constructed in part in a manner that contributes to domination and subordination, and advantage and disadvantage among members of diverse social groups within society. I used intersectionality as a heuristic device to provide me with direction concerning the identification of systems of oppression (e.g., race, gender, age, class, and sexuality) to be considered within the realm of women’s experiences of health. I applied it as a framework to   36 critically examine how inequities in health are created, sustained, and transformed by power relations operating within society. Although a singular unified theory of intersectionality does not exist, there were several key attributes of this scholarship that I used to inform this study. These attributes reflect the work of feminist sociologist Patricia Hill Collins (1993, 1995, 1998, 2000) particularly as it relates to Black feminist epistemology. I also drew from other scholars dedicated to developing a greater understanding of the social relations that contribute to women’s experiences of health particularly among women who face multiple and intersecting barriers to better health (e.g., J. Anderson, 2002, 2004; Boyd, 2004; Browne, Smye & Varcoe, 2005, 2007; Crenshaw, 1991; Weber & Parra-Medina, 2003). The key tenets of intersectionality applied in this project are that: a) systems of oppression exist and are simultaneously socially constructed within specific social and historical contexts; b) power relations that contribute to domination and subordination among and within groups are situated within both macro (e.g., institutional) and micro (e.g., interpersonal) relations that sustain social hierarchies; c) social justice and social transformation are the underlying goals of intersectionality; d) the perspectives and experiences of those who suffer from inequities are a fundamental component of the transformative knowledge necessary for social justice; e) each individual will not necessarily have the same experiences or agree upon the significance of varying experiences; f) multiple systems of oppression are not inevitably equivalent or additive; g) systems of oppression translate into palpable experiences; and h) dichotomous binaries of oppressor/oppressed are problematic and therefore oppression needs to be explored within specific contexts.   37 Systems of Oppression and Inequity Systems of oppression and inequity refer to the unjust situations “where, systematically and over a long period of time, one group denies another group access to the resources of society” (Collins, 2000, p. 299). These systems, while mutually constructive, are neither additive nor equivalent (Collins, 1993, 2000). Conceptualizing oppressions as additive versus co- constructive and intersectional is problematic in that an additive approach contributes to a perspective of binaries in which systems of oppression such race, gender, and class are considered in terms of opposites (e.g., male/female; Black/White; rich/poor). When applied to theories of oppression, the creation of binaries results in everyone being classified as either oppressed or not oppressed and discounts the structural and interpersonal nuances of how oppression and human agency operate in the everyday (J. Anderson, 2004; Collins, 1993). Thus, an intersectional perspective directs us to examine specific oppressions within specific contexts. Collins (1993) argued that although many systems of oppression exist, “race, class and gender are all present in any given setting, even if one appears more visible and salient than the others” (p. 29). In doing so, she draws particular attention to the significance of race, class, and gender as dimensions of analysis for an intersectional approach to understanding women’s experiences of health concerns and the contextual factors influencing their health. Race, class, and gender, however, do not necessarily play out in an equivalent manner among diverse social groups. It is not that one system is consistently and hierarchically more oppressive than another, but that the salience of a system is often situational and differences exist with regards to how systems of oppression actually play out among different social groups (Collins, 1995; 1998; 2000). As she eloquently points out, “treating race, class, and gender as if their intersection produces equivalent results for all oppressed groups obscures differences in how race, class and gender are organized, as well as the differential effects of intersecting systems of power on diverse groups of people” (Collins, 1998, p. 208).   38 At the outset of this project, it was infeasible for me to determine a priori which systems of oppression would be most salient for the various individuals and groups of women who participated. Being true to the tenets of intersectionality, my theoretical responsibilities were to approach this project in a manner that allowed for consideration of how each of these systems of oppression operated in the women’s daily lives in a manner that co-contributed to their health status, health experiences, and opportunities for health. Based on previous empirical work highlighting the social and economic inequities experienced by women living in the DTES and the complex and dynamic mix of socially constructed racial and ethnic groups (e.g., Aboriginal, Latino, White, African American) within this location, I foresaw that, as noted by Collins (1993, 1998, 2000) gender, class, and race would require particular consideration and other systems of oppression, such as age, sexuality, and disability, would be considered as the project unfolded. For this reason, I briefly outline my understanding of these three concepts in the paragraphs that follow. Each of these descriptions is not intended to be exhaustive, but instead provides background regarding my theoretical positioning in relation to these constructs with regards to how these systems of oppression were considered in studying women’s experiences of health. Gender For the purposes of this project I conceptualized gender as a dynamic social process concerned with “the many and complex ways in which social differences between the sexes acquire meaning and become structural factors in the organization of social life” (Braidotti, 2003, p. 3). Thus, gender is relational and extends beyond the social properties of an individual person or interpersonal relations to include the broader structural relations of power of which we are part (Harding, 1987; D. Smith, 1999). Gender as a relational process required that I “direct attention to, and take up analytically, how what people are doing and experiencing in a given local site is hooked into sequences of action implicating and coordinating multiple local sites where others are active” (D. Smith, p. 7).   39 Gender relations are intricately connected to hierarchical power relations within multiple intersecting domains of power (discussed below) that influence norms, role expectations, and attitudes about men and women. These norms, role expectations, and attitudes further influence how men and women identify themselves as “man” and “woman”, act individually and in relation to one another, and how societal institutions such as health care clinics and hospitals respond to their health concerns (Krieger, 2003). The consideration of gender as a system of oppression required that I analyse norms, interpersonal relations, and institutional processes from the perspective of determining the impact that patriarchal ideologies and practices operating across intersecting systems of oppression had for women’s day-to-day lives and their experiences of health.7 In Canada, during the year 2000-2001, women represented over 63% (16,214 of 25,908) of all non-death related hospital visits where illegal substance use was the primary diagnosis and an additional 14,502 non-death hospital visits in which illegal substance use was identified as a contributing factor (Dell & Garabedian, 2003). A full appreciation of the factors influencing the inequities within experiences of substance use related illness requires a more nuanced analysis than an examination of biological sex differences would allow (Doyal, 1995, 2000; Weber & Parra-Medina, 2003). Writing specifically about the gendering of drug treatment, Ettore (2004) highlights the significance of gender relations as a factor contributing to women’s experiences of inequities in health: While both women and men drug users will experience the damaging effects of gender whether as a social process or an institution, women are at a greater disadvantage because ‘masculinist’ (i.e., male privileging) more than gender-sensitive structures and paternalistic epistemologies predominate (p. 330).  7 Patriarchy has been defined as a relation of power between men and women in which men dominate women (Smith, 1987). As applied here, this notion of domination has been extended beyond the relationship between men and women to include male-centered ideologies that dichotomize male and female based on ideologies of domination and control that privilege the masculine as the dominant way of being and therefore relegate the feminine and women to the position of subordinate.   40 Class Traditionally, within the health literature, class has been conceptualized according to income status and other related factors such as access to education, housing, and community services and it has long been recognized that people with relatively low incomes tend to experience poorer health than those with higher incomes. It has also been argued that although the relationship between income and health exists, the tendency to describe this relationships in terms of narrowly defined constructs of class has led to an epidemiological focus on behavioural, environmental and psychological characteristics described as risk factors, and has contributed to notions of class as a fixed entity or something one possesses (Farmer, 2005; Krieger, Williams & Moss, 1997; Weber & Parra-Medina, 2003). Conceptualizing class within an intersectional perspective required that I understand class as a social relation influenced by hierarchical power relations and socially grouped concentrations of economic power (Collins, 1998; Krieger et al., 1997). Class as a social relation is expressed within unequal distributions of economic power that contribute to the construction of specific social groupings known as the upper, middle and ‘under’ classes (Collins 1998; 2000).8 These groupings and inherent social processes are interdependent in that the maintenance of the economic power among those with greater concentrations of power is dependent in part on the economic deprivation of those with less (Krieger et al.). Class, as system of oppression, operates in the day-to-day to produce experiences of segregation and exclusion often at the expense of the underclass. Those with less economic power experience less access to material resources necessary for health including access to income, food, shelter, and health care (Weber & Parra-Medina, 2003). In keeping with class as a  8 The notion of ‘underclass’ is a term coined by Black feminist theorist Patricia Hill Collins (1998). Underclass refers to people who are particularly economically disadvantaged such as those who have no source of income or receive public assistance and move between paid labour and no employment.   41 social relation, the access to these resources afforded to the upper and middle classes is dependent on the exclusion of those within the underclass. I applied this conceptualization of class as a system of oppression embedded within economic inequities to explore the experiences of health among women in the DTES who use crack cocaine not only from the perspective of the distribution of resources necessary for health (e.g., food, shelter, health care sites) but also in relation to how the construction and maintenance of social groupings based on concentrations of economic power contributed to women’s experiences of segregation and exclusion, and their health concerns (Weber & Parra-Medina, 2003). As noted by Krieger and colleagues (1997), “class understood as a social relation correspondingly helps explain the generation, distribution, and persistence of – as well as links between – myriad specific pathways leading to social inequities in income, wealth and health” (p. 346). Analysis of class relations also helped me to explore how class as a system of oppression intersected with other systems of oppression to maintain and protect the interests of those with greater economic power and how those with lesser economic power resisted these circumstances in an attempt to promote their health. Race  Within health research, race as an analytical construct has frequently been conceptualized as a fixed, biological entity and therefore used as an explanatory or predictive category with regards to understanding health and illness. It has been argued that assumptions of race as a fixed, biological entity are related to the process inherent in racialization whereby “race” is assumed as a natural and neutral means of physiological and behavioural categorization (Ahmad, 1993). Conceptualizing race within an intersectional perspective challenges these assumptions and requires an understanding of race as a social relation that is influenced by power relations that reinforce the construction of hierarchical racial social groupings (e.g., Asian, Aboriginal,   42 White, Hispanic) embedded within the oppressive practices of both racialization and colonization (J. Anderson, 2002, 2006; Browne, 2003; Collins, 2000; Harding, 2006). Racialization as a social process “takes its power from everyday actions and attitudes and from institutionalized policies and practices that marginalize individuals and collectives on the basis of presumed biological, physical, or genetic differences” (Browne et al., 2005, p. 21). This ideology and resulting practices contribute to the construction of “Other,” which includes the projection of assumed differences and identities onto members of racialized groups that are founded on stereotypes and biased assumptions (Browne et al., 2005, 2007). The construction of the “Other” supports an uneven distribution of social, economic, and political resources on the basis of racialized groupings in a manner that supports the position of power for dominant social groups (J. Anderson, 2006; Browne, 2003; Collins, 2000). Colonization, while not limited to the oppressive practices of racialization, has deep- seated historical connections with these practices (Jacobs, 1996). Maori scholar Linda Tuhiwai Smith (1999), for example, defines colonization as an imperialist process designed to conquer, exploit, and appropriate indigenous peoples and their lands for the purpose of not only economic gain but to establish the dominance of a Eurocentric political, cultural, and scientific way of being. Within Canada the social group identified as “Euro-White” has been historically linked to the colonization and resultant segregation, exclusion, and creation of the Other that has contributed to severe social, economic, and political inequities particularly among Aboriginal peoples (Razack, 2002a). Although gains have been made to reduce the impacts of colonization, many scholars have demonstrated that colonial practices continue but are often insidious and difficult to identify (J. Anderson, 2004; Browne, 2003; Browne et al., 2005). These insidious power relations, subsumed within what has been termed a neo-colonial ideology, are embedded within the relations of power to perpetuate the subjugation and domination of many racialized groups and support white middle-class privilege.   43 Understanding the interrelations between racialization and colonization bring to the fore the importance of understanding how history has influenced the experiences of the women who participated in this project as well as how current neo-colonialist and racialized ideologies and practices operate to contribute to social and economic inequities and inequalities that exist within the DTES. Conceptualizing race as a social relation enmeshed within the processes of racialization and colonization helped me to consider race as an intersecting system of oppression and to explore the processes by which race played out in the day-to-day lives of women in the DTES who use crack cocaine and how such processes influenced their experiences of health (J. Anderson, 2004). The Domains of Power Intersectionality is founded on the premise that relations of power that support the processes involved in domination are significant factors in all social organization (Collins, 1993, 1995; Crenshaw, 1991, 1994; McCall, 2005). Relations of power operate across intersecting systems of oppression to exert “pressure” so that dominant group ideologies replace and/or restructure the ideologies of those groups considered less dominant. This pressure is exerted in such a way that justifies the practices of the dominant group to maintain a position of control (Collins, 2000). The specific social relations that reinforce this “pressure” are situated within a complex web of interrelated structural and interpersonal relations that operate across intersecting systems of oppression. Collins (2000) describes the interrelations between relations of power and intersecting systems of oppression as a matrix of domination. Within this matrix, she identifies four specific yet interrelated domains of power: structural, disciplinary, hegemonic, and interpersonal. These domains of power encompass both macro and micro relations and are historically and socially specific. The structural domain of power encompasses social institutions such as law, politics, religion, the economy, and the health care system as well as how these institutions are organized   44 to reinforce systems of oppression over time (Collins, 2000). The organization of social institutions serves to exclude members of particular social groups who are constructed as Other from the full citizenship rights afforded to members of dominant groups (Collins). The structural domain of power operates to organize oppression and to ensure that the greater concentrations of wealth and privilege remain among the dominant. Structural institutions give rise to specific organizations and inform related policies and practices that serve to justify exclusion and segregation, advantage and disadvantage. These policies and practices are housed within the disciplinary domain of power. The disciplinary domain of power includes many aspects of social organization including schools, hospitals, industries, and banks. This domain manages power relations primarily through the creation, maintenance, and operation of bureaucracies. According to Collins (2000), “bureaucracies, regardless of the policies they promote, remain dedicated to disciplining and controlling their work forces and clientele” (p. 281). Within bureaucracies, systems of oppression are hidden under the rubrics of efficiency, rationality, and equal treatment. Wilson (1992) provided an excellent example of the disciplinary domain and related domination inherent in the inner-city antenatal clinics that she studied. Although these clinics were established to prevent birth-related complications, most clinics did not have the appropriate resources to address these concerns and instead functioned to socially monitor women regarding their use of substances, parenting abilities, and their spending of money received on income assistance. The hegemonic domain of power pertains to the construction of ideologies and the manipulation of ideas, images and symbols to justify the status quo in favour of the dominant groups. Ideologies symbolize bodies of ideas, assumptions, and beliefs that are historically situated, represent the interests of a particular social group, and are often used to depoliticize the inequities experienced by members of groups who are categorized as Other (Collins, 1998, 2000). Collins (2000) stated that, “by manipulating ideology and culture, the hegemonic domain   45 acts as a link between social institutions (structural domain), their organizational practices (disciplinary domain), and the level of everyday social interaction (interpersonal domain)” (p. 284). In earlier discussions concerning ideologies of deviance and substance use I noted that women involved in crack cocaine use are frequently labelled within the empirical literature and media as “addict”, “hypersexed, morally corrupt, disease carrying women” (Maher, 1997, p. 9) who lack any sense of agency or ability to act on their own behalf despite the growing body of empirical work that discounts this thinking. Hegemonic ideologies as they pertain to women who use illegal drugs, especially Aboriginal women and women who are poor have also been used to justify social practices of incarceration, increased surveillance by welfare services, and the domination over women’s bodies particularly during pregnancy (Boyd, 2004; Campbell, 2000). The interpersonal domain of power comprises the regular, and routinized day-to-day social interactions and personal relationships that people encounter throughout their lives which may include relations with friends, colleagues, partners, strangers, and health service providers to name but a few. The interpersonal domain of power is concerned with how people treat one another and the impact of these interactions for the perpetuation of, or resistance to, oppressive social relations (Collins, 2000). Situating interpersonal relations within a matrix of domination directed me to recognize that as active agents, each individual can be engaged in interpersonal relations that may promote their own subordination, resist and challenge unequal distribution of resources or contribute to the subordination of others. Individuals are neither fully oppressed or an oppressor and the majority of people experience degrees of both (J. Anderson, 2004; Collins, 1998; Meyers, 2000). Understanding the relational processes inherent within the domains of power that structure social organization supported me to explore in greater analytic detail the processes whereby structures, disciplines, ideologies, and interpersonal relations influenced women’s experiences of health across multiple and intersecting systems of oppression at both macro and   46 micro levels of society. In addition, application of an intersectional perspective required that I explore women’s relationships with others to make visible not only the ways in which systems of oppression intersect to subordinate women, but also how women’s own activities contribute to both their active resistance to, and the subordination of themselves and others. Groups and Individuals  Intersectionality emphasizes group versus individual as the unit of analysis (Collins, 1998; Weber & Parra-Medina, 2003). While each individual is recognized as having her own unique and evolving personal biography, intersectionality assisted me to explore the distinct social locations of groups within the context of power relations and systems of oppression (Collins, 2000). Groups are social entities constructed in part by ideas of difference that assign social categories to bodies such as Aboriginal, Black, White, male, female, poor and rich. The social construction of groups functions to create hierarchical categorizations and the Other. Individual “membership” is not necessarily based on individual choices and nor does a group automatically reflect collective decisions among members concerning what a group may constitute (Collins, 1998). Groups are shaped by relations of power and social practices that need to be understood within ethical (e.g., responsibility), political (e.g., power relations) and historical (over time) contexts (Collins, 1998). Groups are not fixed entities but are relational and as such, are malleable and fluid thereby creating the possibility for change. Many individuals are simultaneously associated with dominant and subordinate groups, the significance of which is influenced by their particular experiences within specific contexts (J. Anderson, 2004; Collins, 1993, 1998; Meyers, 2000). The women who participated in this project were initially identified in relation to their past and current experiences with crack cocaine. They were assumed to occupy, to some extent, shared social, economic, political, and geographical locations informed in part by power relations and systems of oppression. As such they comprised the “group” that was the focus for   47 the study (Collins, 2000). As stated earlier, intersectionality as a heuristic device supports critical consideration of multiple and intersecting systems of oppression as they directly influence the different concentrations of economic, political, and social power among groups. All members of a group may not share the same experiences or even agree upon the significance of varying experiences (Collins, 2000). Instead, intersectionality supported critical examination of the shared and diverse challenges that people might experience based on their social location within relations of power (e.g., domination versus subordination) (McCall, 2003). It prompted me to analyse the complexities by which the intersecting systems of oppression situated within the matrix of domination influenced and shaped the women’s experiences of health. Intersectionality facilitated an examination of the diversity of women’s experiences of health while simultaneously permitting me to make some observations about the unjust power relations that contribute to the poor health experienced by women who use crack cocaine.  The emphasis upon shared and different experiences of the women who participated raised several important issues that I needed to consider concerning the individual women who participated in this project. Although the group, defined broadly as women in the DTES who had a history with crack cocaine, was the primary unit of analysis, it was the complexity of each individual woman’s experiences and actions and the related influencing power relations that comprised much of the data for this project. The experiences, actions, feelings, hopes, and desires of each individual woman were valued as essential sources of knowledge (Harding, 2004; MacKenzie & Stoljar, 2000). I also recognized all of these experiences were situated within the specific historical, social, and political contexts of each woman’s life. As such, I viewed each individual (e.g., the women who participated, myself as a researcher) as a relational being and therefore as a person who exists in relation to others and the social processes (e.g., power relations) of which she is part. This view did not preclude my recognition of each individual’s autonomy to make choices and to act in particular ways, but incorporated a cognizance that   48 choices and actions are embedded within the broader interpersonal and social relations of the world which we inhabit (Boyd, 1999; MacKenzie & Stoljar, 2000; Maher, 1997; Sherwin, 1998). The attributes of intersectionality concerned with the ‘group’ and the ‘individual’ as relational entities provided me with important analytical strategies including: (a) privileging women’s experiences and actions as data; (b) exploring their preferences, feelings and desires in relation to these experiences and actions in the present and for the future; (c) critical consideration of the interrelationship between intersecting systems of oppression, relations of power, and women’s actions and experiences as they pertained to their health concerns and strategies employed to manage their health; and (d) critical analysis of the shared and diverse challenges experienced by women including how these similarities and differences intersected among systems of oppression. Social Geography: Place Until recently, social geography has been largely absent in investigations concerning women’s health (Dyck, Lewis & McLafferty, 2001). There is, however, a growing body of empirical evidence that demonstrates the importance of critically examining the mechanisms by which where women live, work, travel, seek health care, and carry out their day-to-day activities affects their health as well as how relations of power play out within specific geographical locales (for examples see Dyck et al.; Pratt, 2004). There is a diverse range of standpoints concerning what constitutes social geography and I chose to align myself with scholars who argue for a relational approach (Massey, 1994, 2005; McDowell, 1999). I drew specifically from the tenets that describe place as that which includes physical locations and recognizes place as spatial, temporal, dynamic, and relational and therefore of significance to an analysis of health concerns and related structural inequities organized across systems of oppression (Dyck et al.; Massey, 1994).   49 Conceptualizing place as physical, spatial, temporal, and relational requires some elaboration. First, because place is spatial and relational, it represents a constellation of processes that include human social relations and the natural (e.g., weather, landscapes, and water). As such, place is open and always in process due largely to the constant contestation and negotiation inherent within relations of power that contribute to the construction of place. As noted by Massey (2005), “place does – as many argue – change us, not through some visceral belonging but through practising of place, the negotiation of intersecting trajectories; place as an arena where negotiation is forced upon us” (p. 154). Place as temporal refers to the existence of multiple and simultaneous trajectories or experiences that individuals and groups experience as they live their lives within a place. Trajectories are processes that occur over time and are therefore historical (Massey, 2005). Trajectories do not infer a singular history but allow for consideration of multiple and sometimes competing histories that occur within a specific locale. Because trajectories are relational, the trajectories experienced among those within the locale are interrelated. Recognition of place as the site and experience of multiple and intersecting trajectories highlights the complexity of social relations from a spatial perspective and is particularly relevant for an analysis designed to tease out relations of power as they influence women’s experiences of health. Thus, identification of specific geographical locations as a focus for study necessitated that I conceptualize place as “an integration of space and time; places are spatio-temporal events” (Massey, 2005, p. 130). From either a global or local perspective, there are many relational, spatial, and temporal places that can be identified by a physical locale including countries, cities, institutions, home, the workplace, and a street corner to name but a few. Each of these places represents what social geographers refer to as a spatial scale. Scales are organizational tools to think about different kinds of places (McDowell, 1999). Scales are also representative of social relations within and   50 between places as the social and physical boundaries of scales are open and porous. As a result, the social relations inherent in one scale influence and are influenced by those in another (Massey, 1994, 2005). The domains of power operating across intersecting systems of oppression contribute to geographical and social segregation and exclusion. As noted by feminist geographer Linda McDowell (1999), “places are made through power relations which construct the rules which define the boundaries. These boundaries are both social and spatial – they define who belongs to a place and who may be excluded, as well as the location or the site of the experience” (McDowell, p. 4). I situated this project specifically within the place known as the DTES, which is an inner- city neighbourhood located within the City of Vancouver. Viewing women’s lives within the spatial context of the DTES required attending to the geography of this neighbourhood including how the boundaries of this place were produced, negotiated, and contested within the realm of women’s day-to-day lives. Combining place and intersectionality provided direction to explore how systems of oppression (e.g., race, class, and gender) and relations of power operated across the many scales (e.g., home, the street, the neighbourhood, the city and the province) to contribute to the health concerns experienced by women who use crack cocaine. Given the porous nature of boundaries and the complex interrelations across boundaries, place as an analytical perspective directed me to examine the relevant health and social policies that govern the types of resources available to women within this place, the degree of access these policies support, who is able to offer services to women, and other relevant forces that influence women’s experiences of health (Curtis, 2004; Gatrell, 2002). This does not suggest homogeneity of experiences of health across the spatial scales located within the DTES. Spatial relations are fluid and dynamic and people may have different experiences across different spatial settings or even with similar spatial settings (Conradson, 2003). Understanding these differences, and how   51 they play out in the context of women’s health, was essential to a study whose objectives included understanding the complexity of health concerns experienced by women who use crack cocaine. Critical Ethnography: The Research Approach  Informed by a variety of critical and feminist perspectives, critical ethnography is a research approach that incorporates a specific orientation for the design, methods, and analysis of a research project that enables the researcher to empirically investigate women’s day-to-day practices and experiences within the broader social, economic, political, and historical contexts of their lives (Carspecken, 1996; Madison, 2005; Quantz, 1992). Critical ethnography is predicated upon values that are congruent with compassion for human suffering and take up as the analytical purpose a commitment to social justice to alleviate this suffering (Carspecken; Madison; Quantz). The application of a critical ethnographic approach required that I employ the methods of observation, interviewing, and reflexivity to support the development of a rich description of people’s day-to-day lives drawn from the experiences of women who were street- involved and had experience with crack cocaine. This research approach also incorporates a relational approach to knowledge in that knowledge is viewed as an ongoing contestation within asymmetrical relations of power. As a result, the women’s experiences were analysed within the context of the historical, political, economic, and social relations of power that influence their lives.  Although there are some variations within the health and social science disciplines concerning what constitutes critical ethnography, I drew significantly from the work of Quantz (1992), Carspecken (1996), and Madison (2005) as key references that informed the types and sequence of research activities that I employed within the project (i.e., methods) and the ethical considerations underpinning these actions (i.e., reflexivity). I also drew from these researchers to identify several relevant theoretical tenets of critical ethnography. In the following discussion I   52 briefly review these tenets to demonstrate the relationships between critical ethnography as a strategy of inquiry and the theoretical perspectives of intersectionality, social geography, and feminism informing this work. In the upcoming discussions of the methods and the ethical considerations governing my actions, I elaborate more specifically to demonstrate how I used a critical ethnographic approach to carry out this work. As noted previously, critical ethnography as a strategy of inquiry is predicated upon compassion for human suffering and a commitment to social justice to alleviate this suffering (Carspecken, 1996; Madison, 2005; Quartz, 1992). This requires an understanding of social justice that extends beyond the emphasis on distributive (e.g., access to resources) and individualistic (e.g., focus on the individual) perspectives of justice that are commonly found within nursing literature, to include a commitment to a collective perspective that situates individual experiences within the broader asymmetrical relations of power (Reimer Kirkham & Browne, 2006). A commitment to social justice as defined here is congruent with an intersectional framework in that it requires an exploration of the mechanisms by which gender, class, and race as systems of oppression intersect to give rise to injustices such as poverty and how these injustices are reinforced through relations of power to maintain a status quo of domination and subordination. Projects that incorporate critical ethnography as a strategy of inquiry must also work towards the ultimate aim of social change that alters the relations of power that contribute to the construction and experience of inequities (G. Anderson, 1989). A second tenet of critical ethnography pertains to the purpose of this strategy of inquiry to support an empirical understanding of the contexts within which the women’s experiences and practices were situated. Traditionally, ethnographic researchers (for an example see Roper and Shapira, 2000) have identified the broader context of people’s lives as the “culture” or “cultural context” of experience. Cultural context was most frequently conceptualized within these traditions as an apolitical, pre-defined context comprising beliefs, practices, and values that were   53 often associated with particular ethnic groups (J. Anderson & Reimer Kirkham, 1999; Smye & Browne, 2004). Researchers concerned with social justice, colonialism, and racialization (e.g., J. Anderson & Reimer Kirkham; Hall, 1997; Quantz, 1992; Smye & Browne) have challenged the notion of “cultural context” as an apolitical entity and have argued that these depictions of “cultural context” are situated within relations of power that contribute to the creation and maintenance of Other. Within the realm of this project, I used the term cultural context to refer to the historical, social, economic, and political contexts of women’s lives as well as how these contexts influenced what women experienced and their perspectives of these experiences. The third tenet of critical ethnography is concerned with the integration of reflexivity, positionality, and power into the research approach. This integration required that as a researcher, I critically examine and reflect upon my location (position) within relations of power as an influential factor in the research process (G. Anderson, 1989; MacBeth, 2001; Madison, 2005; Maher, 1997). The premise underlying this tenet includes an understanding that relations of power, personal history, and individual values are an integral component of all social life and therefore influence not only what I take up as a topic of interest but also the approaches and methods by which I engage in research. I engaged reflexively throughout the entire process to explore how my position as a Euro-Canadian, middle-class researcher who had chosen to situate myself within the field of women’s health with women who are street-involved and use crack cocaine influenced my actions and experiences within this project, the processes by which I developed relationships with the women who participated, the methods I employed, the analysis, and the presentation of the findings (Madison). I was challenged to examine how my values and experiences within various social groups and the historical context of my life (e.g., previous experiences as a nurse working with critically ill women who were street-involved and used illegal substances) played out in my role as an active participant throughout this project.   54 Consideration of positionality within a critical ethnographic project also required reflexive consideration of the knowledge associated with the research and necessitated that I critically question the relationship of the knowledge generated within this research to those who participated (Madison, 2005). I was aware of the long-standing history of research projects that have resulted, albeit at times unintentionally, in the exploitation of women and have contributed to an incorrect and essentialized notion of women who use crack cocaine as morally corrupt and deviant which has further contributed to their regulation by law, politics, and medicine (Boyd, 1999; Maher, 1997; Rosenbaum, 1981; Taylor, 1993). To adhere to the tenets of critical ethnography it was essential that I continue to pose questions concerning the relevance of this research not only to other researchers and health providers working in the field of women’s health, but to the women who participated, and to the ultimate aims of social justice and social transformation. Another tenet of critical ethnography that I addressed was in relation to the nature of the methods that I used to collect data. Field work in the form of observation is the hallmark of critical ethnographic work. However, it has also been noted that a researcher is obligated to employ methods that best facilitate a rich understanding of relations of power as influential factors within the topic of interest (Carspecken, 1996; Madison, 2005). Therefore, I integrated several data collection strategies including observations, a survey, interviews, document collection, and reflexive journaling, each of which is described in greater detail in the upcoming discussion. Selecting the Place The application of critical ethnography informed by theoretical perspectives of social geography and intersectionality required that I position this research within a specific socio- spatial place in which women’s activities, experiences of health, and their related contexts could be more fully explored (Carspecken, 1996). Given my experiential knowledge and related   55 research work in the area, I purposefully chose to carry out this project within the inner-city neighbourhood known as Vancouver’s Downtown Eastside (DTES). Although the exact physical ‘boundaries’ of the DTES have been contested, the neighbourhood is most often identified by people who live and work in the area as a ten block radius that is bordered by historic Chinatown and Gastown to the south and west respectively, Railtown to the north, and Heatley Avenue to the east (Buxton, 2005) (see Appendix F). By contrast BC Stats (2005), the central statistical agency for the province of British Columbia, equates the DTES to Local Health Area 162 which extends significantly beyond these borders. Initially I chose to use the BC Stats description of the DTES to define the physical location, but as the project unfolded, it became apparent that the majority of research activities would occur within the ten block radius. The ten block radius was where the majority of the participants lived and engaged in their day-to-day activities, and opportunities for them to leave this area were limited. Construction sites with cranes and work crews dominate the landscape both surrounding and within the area as lofts, condominiums, retail centres, and office buildings are being erected, often at the expense of existing housing structures. Within the real estate industry, the area is positioned within the rubric of ‘investment properties’ whose value is projected to increase as the gentrification process continues. Local advertising encourages potential buyers to “get in early” and “watch your money grow.” The DTES is home to approximately 16,000 residents and is one of Canada’s poorest neighbourhoods. The neighbourhood is characterized by a concentration of low-income single room occupancy (SRO) hotels that originally provided accommodations for seasonal, resource- based workers (Wood & Kerr, 2006). As resource-based economies began to slow over the past several decades, the DTES became the epicentre for illegal drug and sex-based economies. The neighbourhood and its residents have achieved international notoriety for the open drug scene, poverty, survival commercial sex industry, and violence that shape the day-to-day relations among many of those who live, work, and visit the area (Buxton, 2005; Boyd, 2006; City of   56 Vancouver, 2004). Aboriginal people, people who are homeless, and those with mental health issues are overrepresented (Morrow, Frischmuth, & Johnson, 2006). The overrepresentation of Aboriginal peoples is neither accidental nor coincidental (Robertson & Culhane, 2005). The outcomes of the racialization and colonization of BC’s First Nations people that began in the eighteenth century continue to have devastating effects for many of their descendants including separation from families, poverty, violence, health disparities, and stigmatization (Browne, 2003). Furthermore, the recent fiscal cutbacks and decentralization within BC’s mental health services have contributed to reduced access to mental health care. This reduction in services coupled with cuts to income assistance has left many people with mental health issues with few or no options for housing outside the boundaries of the DTES (Morrow et al.).  Inequities in health plague the people who live in the DTES and more people within this neighbourhood die of preventable and treatable illnesses than anywhere else in the province (BC Vital Statistics Agency, 2005). The residents of the DTES are among those who have been the hardest hit by recent provincial and federal government changes to social income assistance programming, resulting in reduced access to financial resources and ever-increasing numbers of people living below the LICO (Wallace, Klein, & Reitsma-Street, 2006). Gentrification and lack of housing resources have contributed to a steady decline in safe and affordable housing and emergency shelter services (PIVOT, 2006). The DTES is also home to law courts, churches, heritage buildings, parks, community health clinics, drop-in centres, social assistance offices, Canada’s only supervised injection site, and the largest emergency shelter for people with mental health issues and/or addictions within the City of Vancouver. Law enforcement has a long and contested history in this neighbourhood dating back to the 1950s. Early reports (e.g., Stevenson et al., as cited in Boyd, 2008) described people in the neighbourhood who used illegal drugs as “criminal addicts” (p. 217) which contributed to increased prison sentencing and police violence against those who used. Today large-scale   57 enforcement activities such as increased surveillance and arrests occur under the guise that these activities function to disrupt the open drug market and reduce some of the problems associated with illegal drug use (Small, Kerr, Charette, Schechter, & Spittal, 2006). However, there is a dearth of empirical evidence to support that these are effective strategies to reduce substance use related social and health problems. Instead research has indicated that these activities are more likely to reduce users’ access to harm reduction and health related services, and as a result are more likely to contribute to harm (Cooper, Moore, Gruskin, & Krieger, 2005; Cooper, Wypij, & Krieger, 2005; Kerr, Small, & Wood, 2005; Small et al.; Wood et al., 2004). Research has also indicated that police violence against people who use is still of significant concern within the DTES (Csete & Cohen, 2003). Despite this evidence, law enforcement constitutes the bulk of resources directed towards addressing “problems” associated with illegal substance use (Small et al.).9 Negotiating Entry: Positionality and Relationships  Negotiating entry to the “field” or place where the participants are located and live out their day-to-day lives is a common aspect of research and it requires an appropriate, effective, and ethical approach (Madison, 2005). At the time that this project was being designed I was working in the capacity of Project Director for The Safer Crack Use, Outreach, Research and Education Project (SCORE) funded through the Health Canada Drug Strategy Community Initiatives Fund. The main research aim for the SCORE project was to assess the effectiveness and feasibility of several harm reduction initiatives among the residents of the DTES who use crack cocaine. SCORE entailed a variety of research activities including cross sectional surveys, a “women-only” activity of constructing harm reduction kits to be distributed to people who use  9 Illegal drug use has been associated with negative consequences that impact individual lives, families, and communities with serious health and social welfare implications. In Canada the bulk of resources dedicated to addressing these negative consequences have been within the realm of criminal justice interventions as 94% of the $454 million annual budget dedicated to addressing the negative implications associated with illegal use is spent on these criminal justice interventions (Brittain, 2001).   58 crack cocaine, and distribution of harm reduction kits as an outreach strategy to provide harm reduction education and equipment and to enhance access to health related services (Bungay et al., 2008). While simultaneously drafting the research questions for my dissertation it became apparent that the objectives of the SCORE project and funding for the project could not fully support a more critical examination of the complex interrelations between women’s experiences of health and relations of power. I began to work with two members of the SCORE investigative team and another researcher in the field of women’s health to draft a research proposal that would support an investigation congruent with my dissertation research objectives. I also worked with members of the Safer Crack Use Coalition (SCUC) of Vancouver, comprising community outreach workers, health service providers and men and women who used crack cocaine. It was largely through their input that the need to more fully explore women’s experiences of health and influential factors shaping these experiences was identified. The SCORE project included an advisory group comprising four women who were selected by members of a women’s drug user support group who were self-named as the SCORE Women’s Advisory Committee (SWAC). The development of an advisory group was supported by the recommendations put forward in the document “Nothing About Us without Us”, Greater Meaningful Involvement of People who use Illegal Drugs: A Public Health, Ethical, and Human Rights Imperative that highlighted a social justice imperative that people who use illegal drugs have the right to be involved in activities that affect their lives including research, policy development, and delivery of services (Jurgens, 2005). Members of SWAC worked closely with members of SCORE to design the women-only activities for that project including defining and describing meaningful involvement and research recruitment methods. As I worked closely with this team they also identified the gaps within the SCORE project concerning a more detailed study of women’s experiences of health, and as a result I negotiated with them that they would also participate in my dissertation in an advisory capacity. Given the support of SCUC and SWAC and my role within SCORE, I   59 was already situated within the neighbourhood and had developed a respectful and trustful rapport with women who lived within the DTES. With the aid of members of SWAC, I developed a one page summary of the project purpose and activities and its relationship to the overall SCORE project that was shared with the larger women’s support group and various community service providers (see Appendix B). The feedback to the project was overwhelmingly positive, an experience that was in some instances directly related to my identification as a nurse researcher. SCUC and SWAC members expressed that they believed that because of my experiences as a nurse who was involved in SCORE and had worked within the primary inner-city hospital where women were hospitalized, I would be able to understand the nature of the health concerns that women experienced as well as the context of their experiences of health. They also reported that my interest and commitment in learning more about these experiences from the perspectives of the women themselves would contribute to an interest in participation among women who lived and/or visited the DTES. The members of SWAC provided input into the research design and participated in instrument development, recruitment, and data analysis. As the project unfolded, two of the members of SWAC left the group due to personal life situations. One left the DTES to enrol in treatment and the other was unable to commit to the time requirements due to her responsibilities as caretaker for an ill family member. Participants As noted previously, the “group” of interest within this project were women who were street-involved within the DTES who had a history with crack cocaine use. Inclusion criteria for participation included: (a) self-identification of a history of crack use (current or past); (b) the ability to speak English; and (c) self-identification as street-involved within the DTES. The criteria were deliberately broad to support sampling and recruitment strategies to facilitate a sample of participants that varied according to age, ethnicity, experience with substance use, and   60 experiences of health. I employed a variety of data collection techniques that involved many different sampling strategies. For this reason, I have integrated a comprehensive discussion of the sampling strategies within the discussions pertaining to the various research activities involved in this project. Data Collection: Methods and Process  Data collection occurred over a 17-month period of time. During the initial five months I employed the methods of observation, reflexive journaling, document collection, and designed and implemented a cross sectional survey (in collaboration with SCORE). Once the survey was complete I added methods of participant observation, and formal and informal interviewing, all of which continued over the remaining 12 months. A timeline for the project is located in Appendix A. Each of the methods that I employed has been well substantiated within the empirical literature as rigorous methods for collecting rich, contextualized data (Spradley, 1979; Williams, 1996). The Cross Sectional Survey As noted in the previous chapter, only a few empirical projects have been undertaken that have specifically examined the general health experiences among women who use crack cocaine (Butters & Erickson, 2003). To further develop knowledge in this area and to better situate myself before I engaged with women to explore how they experienced these concerns on a day- to-day basis, I began data collection by conducting a brief cross sectional survey to empirically assess women’s common health concerns, their self-reported health status, contextual information (e.g., place of residence, stability of housing, safety of housing, age, cultural or ethnic background, economic status), and substance use practices with a particular emphasis on crack cocaine (see Appendix D). The cross sectional survey, referred to as the Pre-Kit Distribution Survey (PKDS), was a 52-item interviewer-administered survey that relied on self report. The survey was developed   61 within the scope of the SCORE project to gather information related to crack use practices, safer crack use knowledge, access to harm reduction services, health concerns, and harm reduction service needs among men and women using crack cocaine in the DTES. The items of the PKDS reflected measures of crack use practices, poly-substance use, safer crack use knowledge, health status, health concerns, service needs, support, and demographics. Although the survey was designed within the scope of the SCORE project, several items of relevance to my dissertation project were added or expanded upon based on input from SWAC and SCUC and the state of existing knowledge concerning health concerns, contextual factors, and health management strategies with women who use crack cocaine. Once data collection was completed, a separate SPSS® database from that of the SCORE project containing only women’s data was provided to me by the principle investigator for my use in analysis. The concepts of interest in my project included: crack use practices (items CU1-CU16), poly- substance use (items SU1-SU4), health status (item HP1), health concerns (item HP2), health management strategies (items HP3 and HP4), contextual factors such as safe places (items S3- S5) and demographic information including place of residence, stability of housing, safety of housing, age, cultural or ethnic background, and economic status (items D1-D8). Several of these items, particularly those related to demographic information and crack use practices were also of relevance to the SCORE project. Ethical approval for the sharing of data between the two projects was obtained from The University of British Columbia Behavioural Research Ethics Board and participants were informed that the data would serve multiple purposes. Sampling strategies Accessing a representative sample from the population of women who use crack cocaine was not feasible as it was impossible to identify the entire population of women who use crack cocaine within the DTES. Many people in the DTES are transient, lack a permanent address, or   62 are reluctant to identify themselves for the purpose of census taking or to participate in community-based surveys that would identify them as people who use illegal substances (Robertson & Culhane, 2005). As a result, the survey was conducted with a non-probability convenience sample of 126 women who could speak English and self-described as having used crack cocaine in the month prior to completing the survey.10 Although the sample was defined as convenient, several strategies were employed in an attempt to draw a diverse sample of women that represented a variety of perspectives. Drawing upon my experiences within nursing practice and research and input from members of SCUC, the Vancouver Area Network of Drug Users (VANDU) Women’s Group, SWAC, staff from women’s resource facilities such as the Women’s Information Safe House (WISH) Drop-in Centre, and street nurses, I strategically chose four different locations from which to access women. Initially I planned to work with peers11 who were members of SWAC to recruit half of the participants “on the street” at locations at which women were known to spend time (e.g., a park, outside particular agencies). The plan was that peers would assess women’s willingness to participate and if they agreed they would accompany them to a safe location (e.g., a private room in a drop-in centre) where a research assistant could explain the purpose and process for their participation and conduct the survey. The rationale underpinning street-based recruitment was that it would provide an opportunity to recruit a more diverse sample of women and their related experiences than if I relied solely on service agencies where women accessed health and social services (Shaver, 2005). This strategy has worked in previous research with youth who use crystal methamphetamine (e.g., see Bungay et al., 2006) and with women involved in the commercial sex industry (see Shaver). However, recruitment “on the street” was problematic. Members of  10 Convenience sample here refers to the selection of participants based on their availability to participate in the study (Henry, 1998).  11 Peers in this instance refer to women who have life experience related to street-involvement and substance use and who are part of the social relation networks within the community.   63 SWAC noted that approaching women on the street was not always appropriate particularly if they were engaged in activities such as sex work and selling drugs. During attempts to recruit “on the street,” peers were threatened on two occasions by residents of the neighbourhood who insisted they be given an opportunity to participate. SWAC members also identified that if women were engaging in work to obtain money on behalf of another person (e.g., partner, dealer), disrupting a woman’s work potential to generate income may be put at risk. Due to these experiences, survey administration occurred in four different agencies. Two agencies were drop- in centres frequented by women, one was a women-only low-barrier housing facility, and the fourth was located at a local drug user group agency. In each agency I worked with a specific staff member to organize the recruitment and implementation of the surveys. Each staff member was given a copy of the project summary, and the survey process was reviewed including inclusion criteria, time commitments required for participation (i.e., 15-20 minutes), and an assurance of confidentiality for the participants. The staff member then recruited women on my behalf by explaining to women the purpose of the project, the activities involved, and the mechanisms used to guarantee confidentiality. Each staff member generated a list of participants with appointment times for them to participate. The staff members were actively involved in SCUC and VANDU and some were employed as research assistants with the SCORE project. Women who agreed to an appointment met with a trained research assistant at the time the survey was scheduled to ensure their eligibility, review the study purpose and survey activities, and to ensure that participants provided informed consent. Each participant received a verbal and written explanation of the study purpose as well as their right to refuse participation throughout the entire research process (Appendix C). Women were not asked to provide signed consent. As demonstrated in other studies with people experiencing severe marginalization and vulnerabilities, verbal consent was an appropriate method of consent as it respected the rights of women who wished to keep their identity private and enhanced confidentiality, safety, and   64 anonymity among study participants (Bungay et al., 2006; Ensign, 2003). All participants received ten dollars for completing the survey which served to acknowledge their input and expertise with the issues being examined (Shaver, 2005). Observations In keeping with an ethnographic approach, direct and participant observations were significant data collection strategies that I employed throughout the course of the entire project. Direct observations included those with minimal or no verbal interaction between myself and potential participants or other people located within the neighbourhood (Roper & Shapira, 2000).12 These observations began with my first visit to the DTES in the role as Project Director with the SCORE project and were documented in the form of field notes in order to inform a “thick record” or a detailed description of the physical structures such as buildings, vehicles, construction sites, retail and coffee shops, agencies that offered health and social services to name a few; the weather; the people, and the nature of the interactions that I observed (Carspecken, 1996). I paid particular attention to interactions that I observed between women and men, women and law enforcement officials including security guards, women and health service providers, for instance emergency medical technicians or street nurses, and each other. Contextual information such as the type and location of signs posted throughout the neighbourhood, hours of operation of agencies, and the general feelings I experienced as I moved within the neighbourhood were also recorded. The use of direct observations was particularly helpful for me during the first three months of the project as these observations served to provide  12 I intentionally chose to use a direct versus passive observational strategy. Carspecken (1996) articulated that passive observation usually discounts any interaction within the research setting and he recommends that during the initial phases of ethnographic work, any interaction between the researcher and potential participants should not occur. I found this an unrealistic expectation as it was almost impossible not to interact on some level as I moved through the various places within the DTES. I was part of the relations occurring within the place by the mere fact that I was present. It was not uncommon for me to interact with people in some manner such as smiling to people who smiled at me, responding to requests for directions or a greeting or saying “excuse me” as I worked my way through a busy entrance way to an agency. Instead of assuming a passive stance, I reflexively engaged with these experiences within my journal to critically examine my role in the research process.   65 a rich description of the neighbourhood and the general patterns of activities, structures, and related contextual circumstances that I observed. During this period I spent approximately two hours per week engaged in observational activities as I walked through the neighbourhood on my way to meetings, sat in coffee shops, or had lunch with SWAC members. While surveys were being conducted, my time spent in the neighbourhood averaged six to twelve hours per week during which time I also maintained a general observations record. As the project unfolded, participant observation was employed as the primary observational method and continued for the remainder of the project. Participant observation involved more direct involvement between myself and the research participants as we engaged in shared activities (Roper & Shapira, 2000). These shared activities included travelling to agencies throughout the DTES to attend functions and meetings, and participation in the SCORE activity known as the kit making circle (Bungay et al., 2008). The kit making circle was a research activity that adopted a feminist approach to bring groups of women together to construct harm reduction kits for people who smoke crack cocaine. These kits contained essential harm reduction equipment such as glass stems (pipes), rubber tubing (mouthpieces), brass screens (filters), chopsticks (push sticks), a lighter, condoms, alcohol swabs, and a harm reduction information card that provided “tips” for people who use to help reduce some of the harms associated with smoking crack. The aim of this activity was to achieve a philosophical goal of a holistic, women-centred approach to harm reduction. On average sessions were held 10-12 times per month and over the course of six months I attended 18 sessions. Each session was scheduled to be an hour long but the time spent engaged with participants often lasted 90 minutes as many women continued to dialogue once the activities were completed. Four women (one of whom was a peer-facilitator from SWAC) who lived and/or visited in the DTES, a non-peer outreach worker who was also a member of the SCORE investigative team (referred to as the team facilitator) and I took part in the sessions. For each of   66 the sessions we tried to set up the room in a manner that was inviting and non-threatening. Usually there were six chairs around a table and each chair was treated as a work station. Each station was assigned a number as a means of recording the participants, and the numbers ranged from one through six in a counter-clockwise direction. Each person was assigned a station that involved specific kit making activities such as placing items into the harm reduction bag, cutting rubber tubing, and note taking. Two members of SWAC worked consistently with the project and alternated as peer facilitators within the sessions. My role within each session was as the note taker and I was responsible for maintaining field notes throughout the sessions. A small separate table in the room held information that the women could take with them including: a description of project activities; contact information for health care, advocacy, legal, housing, and income assistance services; and safety tips for women involved in sex work. Once the women were seated around the table, the team facilitator welcomed the women to the session and thanked them for coming. She reviewed the purpose of the project, explaining that we were involved in a project aimed at reducing harms associated with crack cocaine use and that the kit making circle was an opportunity for women to come together and share their knowledge and expertise with regards to women’s concerns and resource needs. She used statements such as, “we want to hear what women have to say so that we can ensure that your voices get heard” and “this is an opportunity for us to come together to talk about women’s concerns.” The peer facilitator explained the actual kit making process by walking the women through the task for each station and demonstrating how it worked. After welcoming the women I explained my shared roles with SCORE and as a doctoral nursing student and discussed with the participants how the information we gathered would be used for both projects. Once the sessions began and women became involved in the tasks, the dialogue flowed naturally. There was no established script of questions. Generally, the women were very receptive to having someone take notes. In many instances the women would stop talking to   67 ensure that I had written down something they said. During these sessions I both observed and participated in the activities including the dialogue and the kit making activities such as assisting with the completion of the kits. I was judicious regarding what I observed as it was impossible to pay attention to everything that was occurring. I paid particular attention to women’s general appearances, their clothing, and any data that pertained to their health and health management strategies as well as other contextual factors influencing their lives such as housing, income assistance, experiences within the health care system, food access, interactions with police, and relationships with other people in their lives. General observations concerning the location of the kit making circles and social interactions occurring within these agencies distinct from the kit making activities (e.g., interactions between staff and the women) provided other relevant contextual information regarding how women negotiate their day-to-day lives within the context of using the resources in these facilities. Data concerning specific demographic information such as age, race/ethnicity, housing, and marital status was not specifically collected from each participant, but instead was noted as women shared aspects of their lives. Sampling strategies and locations The kit-making sessions occurred at various locations throughout the DTES including drop-in centres, women’s housing facilities, emergency shelters, and community health centres. The drop-in locations were chosen strategically to enhance women’s access to services offered by these agencies. For example, one centre offered lunch, showers, and laundry and ran a “Grief and Loss” support group targeted towards women involved in commercial sex work. Another agency offered emergency mental health services including shelter. For half of the sessions, particularly those occurring at drop-in centres, women were recruited by peer facilitators who had been actively involved in establishing the inclusion criteria for the project. The peer facilitators underwent training concerning purposeful sampling techniques and actively   68 attempted to recruit women that could represent a diversity of experiences and life circumstances among women in the DTES. One peer was Aboriginal and the other was Euro-White and both had lived for extended periods of time in the DTES. Both were also well known in the neighbourhood and were involved in many community outreach activities. The peers approached women in the DTES and asked them if they would like to participate in a project about women’s health and harm reduction for people who use crack. Usually recruitment occurred prior to the session, often several days in advance, when the peers deemed it safe to approach women. These participants were often recruited from locations throughout the DTES where women spent their time socializing including a local park, on the street, or during social activities that were women-only. For the other half of the sessions women were recruited by staff members from the specific agencies where the sessions were scheduled to occur. These agencies included those designed to provide services to people living with AIDS and mental health and/or addictions health concerns, supportive housing, and drop-in centres. In these instances women received a “ticket” with their name on it and the time and location for their session. When women arrived at the session, a member of the investigative team explained the purpose of the project and why women were being asked to take part in kit making circles. If the women agreed to participate they were asked to take a seat at one of the stations at the table. Recording Observational Data as Field Notes All observational data were recorded as field notes, which were essential to the development of detailed accounts of women’s experiences of health and health management strategies and the contextual factors that influenced these experiences. Drawing from the work of Browne (1995, 2003) and Emerson and his colleagues (1995) I employed a series of strategies to organize the process of recording notes. Field notes were recorded as general observations that reflected what I observed during both direct and participant observation activities. Direct quotes from participants during kit making activities were included in these records although they were   69 noted as interview data. Methodological notes included notes that I made to myself concerning the research process and topics and questions for follow up in further observations and/or interviews. The third category of notes was contained within my reflexive journal. These notes represented my record of linking observational notes with existing theoretical and empirical literature as well as my self-reflexive notes in which I critically examined my role within the research process, my influence and some of the ethical challenges that I faced as I carried out this work. Documenting key words and phrases during the process of conducting observations and/or interviews is a common ethnographic process (Emerson, Emerson, Fretz & Shaw, 1995), yet on many occasions I diverged from this practice. Although documentation was viewed as acceptable among the study participants during kit making sessions it was not always feasible or appropriate during direct observation periods or during the course of the interviews. Members of SWAC and other women from the neighbourhood informed me that the taking of notes during a one-on-one conversation may be misconstrued as disrespectful as it conveyed a sense of not listening. Note taking in public venues also carried the risk of potential misinterpretation of my activities. Members of SWAC explained to me that because women are often in a situation where their information is being documented by someone in a position of influence (e.g., health care provider, social worker) being able to “just listen” was a better strategy to support the development of respectful relationships. As a result, particularly during periods of direct observation or within the context of one-on-one conversations and more formal in-depth interviews, I learned to make mental notes and did my jottings immediately following an activity, usually at a local coffee shop or community centre. These jottings were then expanded upon in greater detail as soon as possible following each individual data collection session.   70 Formal and Informal Interviews Interviewing is a common technique used in ethnographic research and contributes to the collection of what Carspecken (1996) has described as “dialogic data” (p. 154). Within the context of this project, interviewing served multiple purposes including giving voice to participants, learning more about participants’ perspectives of the experiences that I observed, and supporting more in-depth exploration of topics and experiences than feasible through other data collection techniques. Both informal and formal approaches to interviewing were included. Informal interviews were often combined with participant observation activities and were spontaneous events that occurred most often within the context of kit making sessions in response to something that I observed or something one of the participants had stated. For example, it was common for me to spend time with a woman after a kit making session to explore in greater detail a topic that she had raised within the session in conversation with another woman and it was also common for participants to pose questions to me as an active participant in these sessions. These informal conversations constituted a significant portion of field note data. Formal interviewing differed significantly from informal interviewing in that these were somewhat semi-structured, prescheduled, audiotaped, and later transcribed. As recommended within the ethnographic literature this research technique was not employed until I had spent a significant amount of time (i.e., eight months) collecting data in the DTES, had developed a richer understanding of the contextual factors influencing women’s experiences of health, and had established a respectful ongoing relationship with many of the participants in the project (Carspecken, 1996; Heyl, 2001). The interview guide was developed to allow for maximum flexibility and included several questions that were designed to generate dialogue concerning women’s experiences of health, their health management strategies and contextual factors influencing these experiences (Carspecken, 1996) (see Appendix D). The guide also included   71 several items of interest to remind me of areas that could be further explored if appropriate during the course of the interview. Key areas upon which I focused within these interviews included women’s experiences of health such as their overall feelings about their health, the types of health concerns they experienced, their experiences with the health care system, and the factors that influenced their health. Each participant also completed a brief demographic questionnaire which in most cases served to build rapport and establish a respectful dialogue (see Appendix D). In addition to the women who used or had a history with crack cocaine use, I engaged in formal semi-structured interviews with three service providers. Each of these providers worked consistently with the women who participated in this project and worked outside of the acute health care system. The decision to interview these providers was made as the project unfolded. Participants frequently identified the role that each of these providers played in contributing to women’s experiences of health and they provided rich contextual data concerning the factors that contributed to health concerns that the women experienced. Interviews were conducted in a variety of settings including women’s homes, at community drop-in centres and at city parks. All formal interviews were recorded and later transcribed verbatim. Interviews with women who were street-involved and used crack cocaine lasted from 30-90 minutes while interviews with providers lasted one hour. Sampling strategies Within the realm of both kit making and formal interviewing activities, I employed a purposive sampling approach. Maxwell (1998) defined purposeful sampling as “a strategy in which particular settings, persons, or events are deliberately selected for the important information they can provide that cannot be gotten as well from other choices” (p. 87). Of the ten women who participated in formal interviews, four were recruited directly from kit making sessions based on their varied experiences of health concerns, time spent living in the DTES,   72 ages, race/ethnicity, strategies employed to manage their health, and willingness to participate. The remaining six were recruited with the assistance of peer facilitators. These women were purposefully recruited as they represented the opportunity to engage with women who were not part of the kit making activities. These women tended to experience greater social isolation, and more complex health concerns when compared to many of the women who I had met thus far. Supplementary Sources of Data In the design of this project I had proposed that supplementary data would be collected to support critical examination of the interrelations among women’s experiences of health, their health management strategies, and relations of power. Supplementary sources of data included newspaper articles, press releases, health policies within sites where women accessed health care, other research protocols, signage at local agencies frequented by women, and reports concerning health-related vital statistics, Aboriginal health initiatives, enforcement activities, and critiques of current policies concerning cuts to income assistance and housing programs. These supplementary sources of data were essential to my understanding of contextual events that occurred over specific time periods to influence women’s opportunities for health (Roper & Shapira, 2000). Analysis Data collection and analysis occurred concurrently in an iterative manner and an interpretive thematic approach that incorporated strategies appropriate for ethnographic research was used (Sandelowski, 1995; Thorne, Reimer Kirkham, & O’Flynn-Magee, 1994). Analysis was complex and occurred in a non-linear fashion that integrated the following procedures. Observational data from direct and participant observations were transcribed into text documents and checked for accuracy as the activities occurred. Interview transcription was conducted by an experienced transcriptionist and I checked each transcript against the original   73 recording for accuracy. A database was constructed using SPSS® (a statistical software package) by a trained database expert and all survey data were entered and checked for accuracy against the original surveys. The data were then analysed. Descriptive statistics constituted the bulk of the analysis of the survey data (Duffy & Jacobsen, 2001). These analyses included frequency distributions for each of the health problems, self-reported health status, health strategies, and demographics reported among the participants.  As data were continually gathered, whole interviews and observational field notes (including informal interviews) were read repeatedly to identify any recurring patterns (similarities) or unusual events (differences) (Carspecken, 1996). I also reread the data for possible linkages to theory and began to highlight illustrative examples from the data that depicted patterns and unusual events. As participant observation and interview data were collected I compared this data with the descriptive results from the survey, noting similarities and differences concerning women’s experiences of health and contextual factors influencing these experiences and highlighted areas for further clarification in follow up interviews with participants. As more data were collected and reviewed I began to create codes based on the themes identified. Initially these codes were descriptive of the themes regarding women’s experiences and activities. As analysis progressed, codes were further refined to reflect a more theoretical approach to the analysis that sought to analyse the data in a manner that would illustrate how relations of power operating across multiple and intersecting systems of oppression within the specific place of the DTES influenced women’s experiences of health and their health management strategies. Once these codes were identified, the coded interview and observational data and my reflexive journaling entries were entered into NVivo®, a software program for organizing and grouping data into sets that can then be easily retrieved, compared and contrasted. As more data were coded, additional categories were added within the coding structure, some of which reflected the ethical challenges inherent in conducting this work. Other   74 categories were expanded or collapsed. The analysis also contributed to theoretical sampling to include four additional interviews; one with a woman who was street involved but had no experience with crack use and three with service providers who worked in outreach and support worker capacities. Each of these interviews contributed to additional angles for analysis. While the dynamic coding and categorizations were underway I met with members of SWAC on three separate occasions to discuss the analysis and to seek clarification regarding some of my reflexive journaling notes regarding my interpretations of events that I observed during kit making activities. During each meeting, they challenged some of my interpretations and provided enhanced refinement for some of the coding. They also identified categories that warranted further elaboration and assisted in purposeful sampling to accomplish these tasks. As the data collection period was drawing to an end, the analysis continued from a more theoretical position to generate broader theoretical constructs and propositions. The interpretive inductive approach required a level of abstraction that extended beyond the position of giving voice to participants (Browne, 2003; Thorne et al., 2004). The analysis continued until I achieved a synthesized account that represented the mechanisms by which relations of power operating across systems of oppression such as race, gender, and class influenced women’s experiences of health, including an analysis of how these relations of power maintained the status quo and the resistive actions of the women to challenge these relations. Ensuring Scientific Quality  Research activities do not result in absolute truths and the knowledge generated through research is contextual to the specific historical, social, economic, and political circumstances associated with the research process and the lives of the participants (Angen, 2000; Collins, 2000; Harding, 2004; Hammersley, 1992; Thorne et al., 2004). Additionally, given that there are currently no absolute or finite rules or formulas to guarantee valid social knowledge, we are constantly challenged to ascertain the appropriateness of our strategies to ensure that we can   75 provide a credible, accurate, and confident (versus absolute) representation of participants’ experiences and the contextual factors influencing these experiences (Angen; G. Anderson, 1989; Browne, 2003; Dyck, Lynam & J. Anderson, 1995; Hammersley). Throughout the course of this project I employed several strategies to enhance the scientific quality of the representation of women’s experiences of health concerns, health management strategies, and relations of power influencing these experiences and many of these strategies for rigour were embedded within the critical and feminist perspectives informing the project. The first strategy that I employed pertained to the actual research activities. As several researchers have noted, the processes used in the development of a ‘representation’ are crucial to ensuring scientific quality (Sandelowski & Barroso, 2003; Thorne et al., 2004). Multiple data collection techniques were used to capture “breadth” and “depth” concerning women’s experiences of health including a survey, interviewing, and observation (Lather, 2007). The use of multiple data collection strategies provided me with an opportunity to compare study findings that diverged or complemented one another and contributed to a much richer understanding of the similarities and differences among women’s experiences of health as well as the complexities of managing their health concerns. Additionally I continuously integrated these multiple sources of data with the theoretical perspectives informing the project (a process often referred to as triangulation), which supported an iterative data analysis and collection process that maintained an emphasis on relations of power influencing women’s lives (Lather, 1991). The research instruments I used were also important for scientific quality. The items of the cross sectional survey used within the context of the larger project and my dissertation were derived from a variety of sources including extant literature and existing research instruments related to crack use practices (Malchy et al., 2007), the VIDUS Study Follow-Up Questionnaire #9 (Kerr, Wood, Small, Palepu, & Tyndall, 2003), Short Form (SF-36) Health Survey (Falck, Wang, Carlson, & Siegal, 2000; Ware, 1993), and the input of experienced researchers in the   76 areas of substance use, determinants of health and health behaviour, sociology, and feminist theory. Two separate focus groups were conducted with men and women who use crack cocaine to review the draft questionnaire and ensure item relevance. Each item was reviewed in the focus group for clarity, relevance, appropriateness, and common understanding of the meaning of the item (Fowler, 1998). Revisions were made based on this feedback, including reframing some questions, deleting others and adding important questions pertaining to health concerns among people who smoke crack cocaine. No questions concerning HIV seroconversion status, Hepatitis (B or C), or STI were included as all participants in the focus groups expressed the concern that these health issues were too personal and private to be included in a short survey administered by a stranger or acquaintance and several large-scale studies were simultaneously underway within the neighbourhood by investigators from the BC Centre for Excellence of HIV/AIDS. The final survey was pilot tested with eight women and three men in the DTES who reported using crack. Several small revisions were made including appropriate language use and reframing questions pertaining to sharing practices so that participants did not perceive that they were being asked to identify who they were sharing with. The final version was administered by research assistants (RA’s) and myself. A PKDS instruction guide was developed and all RA’s underwent training prior to administration to enhance the likelihood of consistency in survey administration and to reduce the amount of variance obtained due to administration bias (Burns & Grove, 2001). Although these strategies enhanced content validity there were several limitations that warrant comment. Several key health concerns were not included on the survey (e.g., HIV, HCV, and cervical cancer) or were inadequately articulated (e.g., skin infections or lesions). For example, skin infections was too generic an item to fully capture the frequency with which women experienced abscesses and lesions. Although each of these concerns was documented within the scope of the formal interviews and participant observation activities, these concerns may be significantly underrepresented within the data. Additionally, the context of housing was   77 inaccurately assessed as no questions were posed that reflected the instability of housing that women experienced. Instead, the data was limited to whether the women had housing at the time of the survey, which does not accurately reflect the housing crisis within the DTES or the instability of housing that has been reported elsewhere (PIVOT, 2006). The amount of time I spent engaged in research within the DTES was another important factor in relation to developing a credible representation. Although there are no pre-established criteria regarding the amount of time an ethnographic researcher should spend in data collection, Carspecken (1996) noted that a sufficient time must allow for participants to become accustomed to the researcher and that she ought to remain in the field until she “finds herself recording the same basic routines over and over again” (p. 49). Over the course of 17 months with almost weekly visits to the neighbourhood, I became known to many of the participants and other people, therefore my presence was not an unknown or unexpected entity. As I went about my regular research activities I would often stop and chat with women I knew and on several occasions I accompanied women to various events such as memorial services, not all of which were activities that were specific to my research. In addition, while I recognize that there exist limitless possibilities for new ethnographic observations, in light of time commitments for project deadlines, the abundance of data collected with a diverse group of women, and the iterative data collection and analysis process used, I was comfortable exiting the field after 17 months as the analysis revealed sufficient breadth and depth to develop a credible representation of the women’s experiences of health concerns, health management strategies and the structural inequities that influenced these experiences. Equally important to ensuring scientific quality within critical feminist research is the relational process of reflexivity as was previously discussed within the tenets of critical ethnography. In addition to reflexive journaling and methodological field notes, I was particularly concerned that an ethnographic approach might contribute to what Maher (1997) has   78 described as a “colonizing act” (p. 209). Historically research that has contributed to essentialized notions of Other has frequently occurred within an ethnographic context (L. Smith, 1999). Maher argues that projects that contribute to colonization are unethical and of little scientific merit within the critical and feminist research traditions. She goes further to note that further contributing to the colonization of people who are poor or indigenous is often unintended and critical self-reflection regarding our actions within the research process can limit these effects. During each aspect of the research I explored sampling methods that would support a wide range of experiences among women who use crack cocaine and in the writing of the report I repeatedly checked the exemplars I chose to represent the data to ensure that the wide range of women who participated could be represented. I strove to avoid becoming the “transformative intellectual” (Lather, 1991, p. 109) speaking on behalf of women who used crack cocaine and instead integrated verbatim quotes. I remained constantly embroiled in the challenges of writing about the “group” as the focus of analysis within an intersectional framework with an eye toward avoiding an essentialist perspective. I read and re-read my journal seeking to identify similarities and differences not only in women’s experiences but their perspectives of these experiences while simultaneously recognizing that they shared legacies of discrimination, violence, and poverty (Collins, 1998, 2000). Because I maintained to some extent the power of representation by being the primary author of the written reports, I documented my feelings in response to what I heard and observed and strove to be open in my learning and reactions so as not to distort the representation (Carspecken, 1996). When I was particularly challenged, I engaged with members of my dissertation committee to assist in this process. I actively engaged with concerns regarding my position of influence as a Euro-Canadian middle class researcher and constantly re-examined my legitimacy as a researcher in this field. Adhering to the arguments put forth by Reimer Kirkham and Anderson (2002) I reflected on my legitimacy not as to whether or not I could be a researcher in the area of women’s health, but my   79 “…ability to explicate the ways in which marginalization and racialization operate” (p. 13). My issues was not to speak for women who are street-involved and use crack cocaine, but to make visible the interrelations between systems of oppression and relations of power that influence the health concerns they experienced. Usefulness of the Research  It has been argued that nurse researchers have a pragmatic obligation in that their research should be of relevance for the practice of nursing within the areas of research, education, clinical practice, or health policy (Thorne et al., 2004). This mandate is congruent with the critical and feminist aim of research to challenge the organization of dominant institutions (Harding, 2004) and transform current knowledge to better the lives of those experiencing marginalization (Carspecken, 1996; Collins, 1998; Madison, 2005). Evaluation of the utility is difficult to fully assess until the research is completed and the process of disseminating findings and developing plans are underway (Reimer Kirkham, 2000). In an attempt to begin this process however, the final discussion of this work highlights key recommendations for research, policy, education, and practice that are necessary to bring about social change to enhance women’s opportunities for health. Ethical Considerations There were many significant ethical considerations involved in the design, implementation, and completion of this project. First, in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (CIHR, NSERC & SSHRC, 1998), the research protocols for this project and SCORE including the sharing of data between the two projects were reviewed by the University of British Columbia Behavioural Research Ethics Board and a certificate of approval was obtained (see Appendix F). Research protocols, informed by feminist approaches to research ethics (e.g., McLeod & Sherwin, 2000; Patai, 1991), and the Tri-Council Policy Statement, included strategies to ensure confidentiality and informed consent,   80 data management and storage strategies, financial honorariums, and the establishment and maintenance of respectful research relationships. Informed Consent Feminist ethicists have argued that the social processes involved in informed consent are often problematic, particularly for women who experience multiple and intersecting systems of oppression as the relations of power that operate across these systems may undermine women’s autonomous decision making capacity by: (a) limiting options available; or (b) in some circumstances, limiting their opportunities to develop the autonomous decision-making skills (MacLeod & Sherwin, 2000; Sherwin, 1998). As noted previously many women who live within the DTES experience significant state regulation enacted through the criminal justice, social services (e.g., welfare), and health care delivery systems and as a result are often reliant on others to determine their fitness to receive services such as social income assistance, health service, or custody of their children (Boyd, 1999). This does not mean that women who experience oppression are incapable of autonomous acts but draws our attention to the need to “…examine how specific decisions are embedded within a complex set of relations and policies that constrain (or ideally promote) an individual’s ability to exercise autonomy with respect to any particular choice” (Sherwin, 1998, p. 32). Drawing from critical and feminist perspectives, I employed a relational approach to informed consent. A one page summary outlining the project purpose, the research activities, rights of refusal and participation, approximate time commitments, and participation honorariums was provided to women for the survey, kit making sessions, and interviewing procedures (see Appendix C). The information was reviewed verbally with each woman and I encouraged them to ask questions. No written consents were obtained. Previous research has indicated that people who are street-involved and experience significant state regulation and stigma associated with their income and drug use status are often mistrustful   81 of activities that require their signature and that verbal consent is a more appropriate and respectful approach (Bungay et al., 2006; Ensign, 2002). Research activities occurred in locations that were perceived as safe and comfortable for the participants including their homes, private rooms in drop-in centres, and for those concerned with potential retribution by partners and/or other people for participating, in community parks outside of the DTES. During kit making sessions I discussed with women that field note taking was a strategy that we could use to maintain a record of what they had to say. I also explained that I would be taking notes about the whole process of kit making. I reviewed that everything was confidential and that each woman had the right to request that a comment not be written down if she did not want it to be. At the end of each session women were reminded that they could request that their conversations be removed from the field notes but no women opted to do this throughout the course of the entire project. On several instances where women discussed painful life experiences including for example, rape, assault, and kidnapping, I often double- checked with women before they left to ensure that it was appropriate to record their comments. Women frequently thanked me for “checking” with them and on one occasion I was able to clarify with one woman aspects of her conversation that she wished to avoid being documented such as the location where the event had occurred and the other people involved. In some instances, I was able to support referral to counselling or outreach services that would assist women to address some of the concerns raised during our conversations. Confidentiality To ensure confidentiality, all possible identifying information was removed from the recorded data, field notes, computer files, and written reports. Each participant was assigned an identification number that pertained to the related research activity. Survey participants were assigned a three digit number and formal and informal interview participants were assigned a three digit number prefaced by the initials “IP” to differentiate them from survey participants.   82 Within the body of written reports, verbatim quotes were identified using this notation to demonstrate the use of exemplars from the entire data set in the analysis of the data. Additionally, descriptive data such as appearance, age, or self-identified ethnicity were only included in reports if they were deemed relevant to the underlying presentation of the findings. This practice is contrary to many other research projects that have integrated a feminist approach to research ethics where women have chosen pseudonyms. The choice of numerical representation was intentional. Many women who participated already use pseudonyms in other aspects of their lives, particularly when engaged in illegal activities or when seeking to avoid men and women who posed a risk of violence. Women expressed that these pseudonyms provided a sense of distance between these activities and who they were as friends, partners, and mothers in the rest of their lives and they did not want to add another pseudonym to their lives. In keeping with the feminist aim of supporting women to enact choices that enhanced their own moral worth as human beings, women were given an option regarding how they wanted to be “identified” within this project (McLeod & Sherwin, 2000). The overwhelming majority stated they did not want a “fake name” nor did they wish to have one assigned. The rationale was that in their experience, “fake names” often reflected an aspect of the person and as such could still potentially be used to identify them within the context of this research. Women who were worried about negative repercussions for participating in this project such as violence from their significant others for talking to a researcher or feared repercussions by service providers who might recognize them if they read the final written reports, were particularly concerned about identification. After consultation with numerous women and members of SWAC, the decision was made to assign numbers. Women reported that they viewed this as a sign of respect for their privacy. Confidentiality was also supported through data management strategies. All paper copies of data were stored in a secure location where I had the only key. Computer files were password   83 protected and again I was the only one with access to this password. Women were often asked if they wanted records of their transcripts, but all refused and reported that they would appreciate receiving a final report that summarized the key findings of the project. Respectful Research Relationships There are few explicit guidelines or codes of conduct that provide direction regarding how one engages in a respectful research relationship. Yet as Maori scholar Linda T. Smith (2005) noted, “while indigenous communities and other marginalized groups may not understand the history of the ethical code of conduct…they do understand breaches of respect and negative impacts from research” (p. 101). In my attempts to negotiate respectful relationships I drew upon the ethical principles outlined in the Guidelines for Ethical Research in Aboriginal and Strait Islander Health Research (National Health and Medical Research Council, 2003 ), as well as the tenet of positionality (Madison, 2005) and integrated the processes of consultation, negotiation, recognition, and involvement throughout the research project. Recognition involved recognizing my own strengths, limitations, and roles within the relationship. I was cognizant of the fact that I was a visitor in the lives of the participants and as such positioned myself largely in the role of “learner as researcher.” In developing relationships with women I acknowledged that through my experiences as a nurse in clinical practice and as a nurse researcher, I had learned a lot about women’s health, but that in reality, I had little experience regarding how women experienced their health on a daily basis or negotiated the multiple and intersecting systems of oppression. I also positioned myself as a nurse researcher concerned with supporting social, economic, and political change towards the improvement of the contextual factors influencing women’s experiences of health concerns. I was honest with women regarding the differences and similarities in our life experiences. Many women asked me throughout the course of the project, for example, if I had ever used crack cocaine and some questioned whether I could grasp what their lives were like if I had not experienced being street-   84 involved. I honestly answered that I had never used crack nor did I know what it was like to be street-involved, but I had, throughout my twenty-year career, worked with many women who shared similar life circumstances and that during this time I learned that women continued to suffer severe inequities in their health. I also expressed my belief that a concerted effort was needed on the part of all of us to initiate and maintain change to reduce social and economic inequities that influenced women’s health. Women responded positively with my position of learner as researcher and expressed that they “felt respected” by my approach to learn from them about their experiences and actions as they attempted to manage their health. Women also expressed that they were “happy to talk” to me and contribute in any way to a project concerned with their experiences of health. Involvement and consultation were negotiated in a variety of ways. SWAC was instrumental in providing advisory advice and support throughout the entire project, particularly regarding appropriate “rules of conduct” when working with women who are street-involved. They established recruitment strategies that were designed to support women’s safety while at the same time providing the opportunity for participation to a diverse sample of women. As peer facilitators within the kit making sessions they negotiated with their peers general “rules” of conduct within the sessions. These including providing a fair opportunity for each woman to speak if she so desired, confidentiality within the group, and some boundaries concerning appropriate topics if and when other women became uncomfortable with a topic. Additionally, the use of kit making sessions supported a feminist approach to create a space where women could come together in a safe place to share their experiences and “take a break” from the constant vigilance that was required on the street to protect themselves and others. Our goal was to learn from women in their own words about their harm reduction programming needs including the contextual factors shaping these needs. It was a chance to participate in what feminist scholar bell hooks (1988) refers to as talking back: “Moving from silence into speech is   85 for the oppressed, the colonized, the exploited, and those who stand and struggle side by side a gesture of defiance that heals, that makes new life and new growth possible. It is the act of speech, of ‘talking back’ that is no mere gesture of empty words, that is the expression of our movement from object to subject – the liberated voice” (p. 9). The key items addressed during interviews were reviewed with interview participants at the beginning of each interview. On some occasions I negotiated with women topics they considered “out of bounds” including any direct questioning on my behalf about their children. Women often raised the topic of children in the interview and they noted that this was acceptable but wanted to ensure that the interview in no way would be focused on their parenting abilities. Although I specified that I was not acting as a nurse engaged in clinical practice but as a nurse researcher, there were many situations where women posed specific questions about their general health concerns. I listened to these concerns and in many instances supported women to access health resources such as community health clinics, outreach workers, and street nurses so that women could have their concerns be addressed by a health provider who could ensure continuity in the care they received.13 The final aspect of developing respectful relationships involved gleaning from the participants their input regarding how the results of the project would be shared back to their neighbourhood. Two strategies were decided upon. The first was that when I completed the project, I would give a presentation at a VANDU Women’s Support Group meeting that provided an overview of the findings. This would be scheduled for an hour and I was to ensure that women would have time to participate in a discussion about the work. Second, a brief  13 Throughout this research I recognized that both the women and I were emotionally invested in our relationships. How we experienced the emotional aspect of our relationships shared many similarities and differences. Within the scope of this dissertation I have not included of full discussion of the range of emotional experiences from my perspective or the emotional challenges of engaging in research with women who experience the magnitude of suffering that many of the participants experienced. A comprehensive discussion of the ethical issues and emotional challenges in engaging in this project is currently being addressed in a separate manuscript under development for publication.   86 newsletter outlining the study findings will be circulated to the agencies that women frequent such as women-only drop-in centres and other community programs. Members of SWAC will also help in the compilation and distribution of this newsletter. Financial Honorariums Over the past several decades there has been ongoing debate, albeit largely within the realm of clinical trials for pharmaceutical products, concerning the moral appropriateness of the provision of financial honorariums to research participants (for examples see Anderson & Weijer, 2002; Grady, 2001; Macklin, 1981). Concerns have been raised that offers of payment may contribute to undue inducement or that the refusal to offer payment could be construed as disrespectful of the effort required for people to commit to these activities (for a more thorough discussion of these issues see Bungay, 2006). In this project, survey participants received ten dollars and kit making and interview participants received twenty dollars for their participation. SWAC members received additional fifteen dollar honoraria for their participation in advisory meetings. The decision to offer honorariums was multifaceted. First, I recognized that women experienced severe economic deprivation. At the beginning of the project I was advised by members of SWAC and outreach workers that women spent a significant portion of their time trying to determine additional sources of income, a finding that was reinforced during this project. Therefore, it was appropriate to provide women with financial honorariums as their participation in research activities limited their options for alternative income during the time we spent together. Second, women considered it respectful to have financial acknowledgement for their participation. Honorariums contributed to a sense that I perceived them as experts in their own lives who had something meaningful to contribute to a project aimed ultimately at improving women’s health. Finally, it has become common practice within the DTES for research projects to offer financial honoraria for participation. Spittal and her colleagues (2002),   87 for example, reported that “subjects were reimbursed CAN$20 for each study visit” (p. 895) and anecdotal reports from participants identified that this is common practice. Within the context of this project I followed the trend for amounts of payment that were currently in practice to support consistency. Summary Viewpoints drawn from intersectionality and social geography provided the interpretive perspectives through which I approached this research. Combined with critical ethnography as a strategy of inquiry, these theoretical perspectives were used to critically examine: (a) the nature of the health concerns experienced by women who use crack cocaine as articulated through the perspectives and experiences of women themselves; (b) the day-to-day circumstances that influenced women’s lives and opportunities for health; (c) the strategies employed by women to manage their health; and (d) the influential social, economic, political, and historical processes that shaped women’s experiences. I acknowledge that by applying these perspectives, there are some risks associated with focusing on aspects of the data and ignoring others. In reality, there are a multitude of analytical perspectives that could be used to examine the phenomena of interest within this project. My goal, however, was not to make the data fit the theory, but to critically engage in a reflexive manner regarding how these theoretical perspectives influenced the study and their strengths and limitations.   88 CHAPTER FOUR: “DOWN HERE” IN THE DTES: PLACE MATTERS Introduction In order to more fully understand the complexity of women’s experiences of health, the inequities that contributed to these experiences, and their related health managements strategies, I first analysed the actions and experiences of women as they occurred within the realm of living their day-to-day lives in the DTES. Within this chapter, I provide a comprehensive description of the women who took part in the various research activities, and highlight the similarities and differences among the women with regards to their age, income, places where they live, self- reported ethnicity, and substance use practices. In the remainder of the chapter I emphasize the meaning and attributes that women assign to the DTES as the place where they live (and in some instances visit) as well as how women’s experiences of racialized, gendered, and class-based systems of oppression operating within relations of power to influence what occurs within the context of their homes, shelters, and when outside in public places. Overall, I illustrate how the lives of the women are filled with relentless assaults on their personal safety, continuous public scrutiny, and an overwhelming sense of despair with regards to their perceived moral worth in society. In the midst of this they also incorporate creative and resistive strategies to circumvent oppressive life circumstances. In the next chapter I move from this ‘general’ description to more critically examine how the contextual factors and relations of power influencing women’s lives play out with regards to their experiences of health concerns. Before I go further, it is important to note that my analysis of women’s experiences is not intended to imply that all women in the DTES experience their everyday worlds in exactly the same manner. There were multiple experiences and varying degrees of experience among the women. In keeping with the tenets of intersectionality, I present an analysis to critically represent the shared and diverse challenges experienced by women on a daily basis.   89 The Participants  There were many similarities and differences among the women who took part in the various research activities. One hundred and twenty-six women completed the survey, 53 participated in kit making sessions and 13 women (three of whom were service providers) participated in lengthy, formal interviews. Many of the women represented the most marginalized women in the city as evidenced by their significant levels of poverty, homelessness, illness, violence, and reliance on illegal activities for income. Aboriginal women were overrepresented in all aspects of this project although only five percent of the Canadian population is of Aboriginal descent (Adelson, 2005). Survey Participants One hundred and twenty-six participants who self-identified as “female” or “transgendered” participated in the cross sectional Pre-Kit Distribution Survey. Six participants who self-identified as transgendered were included in the findings as they completed the survey in “women-only” locations such as a women’s drop-in centre and a women’s low barrier housing facility. 14 All women reported having used crack cocaine at least once in the 30 days prior to the survey and many were daily crack smokers. A general demographic profile of these participants is provided in Table 1.  14 Low-barrier in the context of housing, shelter, and health care services refers to supportive housing, shelter, and health care agencies that do not require abstinence from illegal substances or alcohol or enrolment in treatment programs to be eligible for these services. Strictly supportive services are not low-barrier and frequently require abstinence and/or enrolment in treatment programs including mental health services. Low-barrier and supportive housing services also have 24 hour, onsite staff whose purpose is to assist women in accessing services (City of Vancouver, 2007).   90 Table 1 Demographic Characteristics of the Survey Participants (N=126)15 Characteristic n %  Living in DTES    yes    no  126 117 9  92.9 7.1  Economic Status (LICO)    above    below 122 14 108  11.5 88.5  Primary Income Source    income assistance    other (e.g., family/friends; sex work; drug selling) 124 83 41 66.9 33.1  Age    mean (SD)  121 38.5 (8.53) Self-Reported Ethnicity16 124     Aboriginal-Canadian 58 46.8    Euro-Canadian 43 34.7    Other-Canadian 23 18.5   Within the survey findings I noted that 88.5% (n=124) of the women lived below the LICO. Of these women, 72.2% identified public assistance as their primary source of income while 27.8% (n=30) of the women identified “Other” as their main source of income. Of these 30 women, 22 listed sex work and/or dealing as their income source (both illegal activities), two reported no source of income, two refused to answer and six stated that they relied on family, friends, binning, and income assistance associated with continuing education. Of the fourteen women who reported living above the LICO, four reported “selling dope” as their primary source  15 The total number of women who participated in the survey was 126. The response sample size for these particular items ranged from 124 – 126.  16 Note: The ethnicity question in the original survey was open ended: What would you say is your main cultural and ethnic background? These responses were then collapsed into three categories based on participant’s responses. The Canadian suffix of each category reflects that the participant currently resides in Canada and is not a reflection of citizenship status.    91 of income, and six obtained income from commercial sex work activities such as street-based (working outside on the street) sex work and escort work (also known as “out-call”). None of the women reported having a “regular job.” Kit Making and Interview Participants Throughout the 18 kit making sessions that I attended, I met 53 women, many of whom I met on more than one occasion as there were no limits on the number of kit making sessions that they could attend. As I noted previously in the discussion of data collection strategies, I did not employ a standardized approach to collecting demographic information among kit making participants. As we engaged in kit making I listened to their stories and took notes regarding how they described themselves in relation to the social and economic contexts of their day-to-day lives. I also made observations regarding their physical appearance, how they interacted with one another, and their worries and concerns about themselves and the people they cared about. The women represented a diverse group, ranging in age from early 20s to late 50s although the majority were between 35 and 45 years of age. Their housing situations were also diverse: ranging from low-barrier and supportive housing, emergency shelters or single room occupancy units (SRO’s).17 Many were completely homeless (had no place to stay) and relied on friends to provide them with shelter. The economic circumstances of their lives was a common topic of discussion with the majority either receiving some form of social income assistance or having no formalized form of income. 18 Working within the commercial sex industry was common. Women were often involved in social and volunteer activities, for instance washing dishes at a drop-in centre, patrolling washrooms at a community clinic or doing peer-outreach in the alleys  17 SRO’s refer to single room occupancy units. Each unit typically consists of one room that measures about 10 by 10 feet. Residents share common bathrooms and sometimes cooking facilities. SRO’s are located in privately owned and managed buildings usually in the form of residential hotels or rooming houses (PIVOT Legal Society, 2006). 18 Welfare refers to “income assistance (money and/or benefits) provided by the provincial government to people considered eligible under a strict set of rules. Welfare is a program of last resort – it is available only to individuals and families who do not have the resources to meet their basic needs, have no employment, have used up their savings, and have exhausted all other options” (Wallace et al., 2006, p. 9).   92 of the DTES. There were also many who were involved with the criminal justice system, who had spent time in prison or were currently involved in dealing with a criminal charge against them (e.g., possession, property crimes such as break and enter and theft). Some women were in educational programs including taking university courses attending community college. The majority of women who participated were Aboriginal and identified themselves as such throughout the discussions. Other women were Chinese, Filipino, African-American, and Euro- White. Everyone spoke English although for several women English was a second language. French, Chinese and Spanish were some of the other languages spoken. Ten women, four of whom had also participated in kit making sessions, took part in lengthy, recorded, formal interviews. Each of these ten women completed a brief demographic information sheet similar to that included in the survey. Nine of them lived in the DTES and one lived in a supportive housing facility in a neighbourhood adjacent to the DTES. Eight of the women described themselves as single (two of these reported having been divorced), one reported having a common-law partner and one said that she was a widow. All of these women reported living below the LICO and income assistance was the primary source of income for nine of the women. While only one woman reported sex work as her primary source of income, six of the women reported having alternative incomes in addition to public assistance. These additional incomes included sex work, “selling dope,” and stipends associated with volunteer and research work. Three of the women lived in low-barrier housing, one was homeless and slept outside or “hung out” at agencies that were open throughout the day, evening and night (e.g., the Contact Centre and WISH), and the six other women lived in SRO’s. Two women expressed fear for their safety in their living arrangements due to threats of violence by men. Four women identified as Aboriginal, five as Euro-White and one as mixed Chinese and Hungarian. The women ranged in age from 38 to 59. Three women reported that their highest level of education   93 was between grades nine and eleven, two reported completion of high school, one had completed her GED, and four stated that they had some college or university. Three outreach and support service providers were also interviewed. These women were purposefully chosen based on their consistent working relationships with many of the women who participated in the various data collection phases of this project. One was an outreach worker with experience working with women who were living with HIV. One participant managed an evening program at a local women’s drop-in centre and the other coordinated a women’s support group within a local drug user organization. Patterns of Substance Use The patterns of substance use varied greatly among all participants who participated in the various data collection activities. It was common for women to be using more than one substance and many were receiving prescriptions for drugs such as Ativan, Valium and methadone from their physicians. Among the women who participated in the kit making sessions, some no longer used drugs other than those prescribed by a physician, some reported trying to quit using, others discussed using crack on a daily basis, while others talked about using different drugs depending on their mood: for example, crystal methamphetamine to feel energetic versus benzodiazepines to help them sleep. Among those who took part in the survey, they were asked to specifically identify substances that they commonly used, the results of which are outlined in Table 2.   94 Table 2 Profile of Drug Use among Survey Participants Drug Use Characteristic  (n = 126)  Frequency of crack use  %    daily 63.4    weekly 27.0    less than once per week 9.6  Regular drug use    tobacco 88.1    cocaine 77.6    alcohol 40.3    marijuana 38.7    methadone 37.1    pills 35.2    heroin 31.5   crystal methamphetamine 12.9   ecstasy 3.2   GHB 1.6  Route of drug use    injection 42.9    smoke 98.4    snort 24.6  Change in drug use? (past year) (yes) 58.7   Of those who identified that their drug use had changed in the past year, 48.6% said they decreased the amount of drugs they used while 31.9% reported an increase in the amount of drugs used. Just under 10% reported a change in their dominant drug or route for administration, while 4.2% stated they had started a methadone program. Down Here: Representations of the DTES The dynamic landscape of the DTES was where the women experienced much of their day-to-day lives and they described this neighbourhood as a specific place they called “down here”. “Down here” encompassed a physical scale as well as a socio-spatial place with open and porous boundaries. “Down here” represented a constellation of multiple meanings and experiences for women that reflected the often conflicting trajectories of their day-to-day lives   95 (Massey, 1994, 2005; McDowell, 1999; Razack, 2002a). Although “out there” was the term used by both service providers and residents to depict places outside of “down here,” it was apparent that “down here” and “out there” were not mutually exclusive or unrelated. “Out there” and “down here” represented a complex network of power relations that influenced many of the activities and experiences of the women that at times contributed to devastating consequences for their personal safety and health outcomes (Massey, 1994). To more fully comprehend the significance of the interrelations among place, systems of oppression, and relations of power for women’s experiences of health, I first critically examined women’s experiences of being “down here” to identify the multiple representations that women described and/or experienced in relation to the DTES. These representations included the attributes and meanings that women associated with the DTES and mirrored the ongoing negotiations and conflicts between class-based, gendered, and racialized systems of oppression; the relations of power that influence these systems; and resistance to the status quo of domination that were evident in their day-to-day lives. Each representation reflects the women’s experiences of “being down here” and is related to the reasons women reported regarding why they lived “down here” and how people from “out there” behaved towards them. The DTES was dynamically constructed as a place tied to social relations of the past, present, and what was envisioned for the future by those living out there and down here. As noted by Massey (2005), “neither societies nor places are seen as having any timeless authenticity. They are, and always have been, interconnected and dynamic” (p. 67). A Place of Escape In her work, The Sphinx in the City, Wilson (1992) documented the historical migration of women to cities beginning with the industrial era and argued that, for many women, their movement into a city represented a search for independence and freedom from oppressive social forces within their previous homes and neighbourhoods. This was the case for the vast majority   96 of women who shared their stories of how they had come to live within the DTES. Women reported running away, some as young as age 13, from violent home situations including childhood physical, emotional, and sexual abuse; intimate partner violence; and residential schooling. Many women had run away to other cities such as Edmonton and Winnipeg before moving to the DTES and there was sense of eventual migration to this particular neighbourhood. The movement to the DTES was a deliberate and intentional escape strategy and the city itself represented a place of freedom. IP(004): When I was 17, I left for good, on bad terms. There was a lot of emotional abuse going on from my adopted family. I went to Edmonton and lived with my brother for a while. From there I moved to Prince George. I eventually came out here by myself to get out of an abusive relationship…I came here because I like big cities…I was here once before and I knew this is where I wanted to live.  The loss of loved ones, having little or no support, and the break-up of marriages also contributed to a sense of “needing to get away.” Getting away helped women distance themselves from familiar people and places and enabled them to take a break from the scrutiny and to deal with their losses using their own unique strategies. As noted by one woman who experienced the loss of her mother while simultaneously involved in a divorce and custody hearing for her children: IP(002): I guess that’s what made me sort of end up moving down here. I needed to get away from being out there in that area because all the couples we knew and their kids were out there and they always said that they would be there if we ever broke up, but that’s bull, most of them sided with him.  No Place Else to Go Although it was apparent that the city represented a place to run to, for many women “down here” represented the only viable place to go within the City of Vancouver. Women were financially excluded from living elsewhere in the city as “down here” was the only neighbourhood where most could find “affordable” housing. Additionally, “out there” was perceived as problematic in that women believed that people “out there” did not want women   97 from “down here” living in their neighbourhoods. The comments of one of the service providers also illuminated the racialized underpinnings of the exclusionary relations of power, particularly for Aboriginal women, that maintained segregation within the city. Provider(003): People can’t move from these 10 blocks because people will treat you like shit. And it’s not like you know with [name], she is now renting somewhere uptown. She’s white, she looks healthy and she looks clean. She’s not living down here anymore. She is using heroin and is using crack a lot. But she can survive; she is a very skilled white woman, so she can survive in a better neighbourhood.  Among the women with mental health concerns, “down here” was one of the few places where they could access supportive and low-barrier emergency mental health services. “Down here” was also considered an acceptable place to go as there was a sense of compassion and tolerance among members of the community that was not experienced elsewhere in the city for people living with mental health concerns. This sense of belonging was also related to not belonging anywhere else. Provider(003): But people will look at you out there as if you are a leper, mainstream people the way they look at beggars. You see when people are taking the bus here, as high as the bus goes the population changes so you are left with one or two people who started this road, so you see how other people are, they won’t sit beside them. Yeah, I think the way people look at drug users it’s easier to be part of here, when everyone is a drug user and nobody will give you the evil eye. It must be a nightmare to be out there.  The DTES was a place where they could purchase substances at lower prices and in smaller quantities. As noted by one participant, “it took a while to get ‘down here.’ I just went where the drugs were and ended up down here. That’s the way it works when you are an addict” (IP007). The disciplinary organization of services including food banks, drop-in centres and low- barrier health services that were not accessible in other parts of the city, also contributed to the sense of having no place else to go. In many situations the services in the neighbourhood not only responded to some of the needs experienced by the women who lived there but also created a situation in which women could not leave if they needed to receive these services. This was   98 particularly evident among women receiving prescription methadone. Women described being “down here” in relation to their appointments with their “methadone doctor” and although they acknowledged that other physicians “out there” prescribed methadone, the wait lists for physicians and the perceived lack of knowledge among physicians unfamiliar with people from “down here” contributed to a perception that accessing appropriate methadone maintenance treatment or other health services would be problematic in another neighbourhood. A Place of Exploitation and Abuse In comparing the paradox of oppression and freedom for women within the city locale, Wilson (1992) noted that cities are increasingly becoming “playgrounds for the rich and dustbins for the poor” (p. 158). While the DTES was experienced paradoxically as a place of escape and an unavoidable place, it was also a place where women were violently abused and exploited. Men from “out there” and “down here” came to the DTES to buy and sell drugs and sex, and to engage in violent activities, frequently at the expense of women’s safety and dignity. The women’s stories reflected a recognition that violence and abuse existed “out there” beyond the DTES, but also demonstrated that women “down here” were considered more vulnerable and at greater risk for abuse than women elsewhere in the city. IP(001): Down here it’s [violence] rampant, and I’m not saying it doesn’t happen in other places but its just people from down here seem to attract it because men come down here that want to do it to women because they know they can intimidate them, because a lot of the women already have issues, you know, its sad, but that kind of a man loves an easy target, you know, they don’t want to have to fucking fight with a girl. They want to be able to intimidate her easily to get what they want, you know, if they want her to go make some money, you know, go sleep with some guys to get them high they just want to have to say ‘go do it’ and they do it right, they don’t want to have to argue with her, you know. Yeah, they want to be in control and a lot of, most of the guys that come down here are that kind of a man.  In the DTES women faced relentless harassment, public scrutiny, and threats of violence. The women reported that local services such as restaurants and corner stores often refused to serve them and that they were repeatedly chased away or forcibly removed by security guards.   99 They were also at times, mistreated by those whose job it was to protect them and/or provide important health and social services. It was a place where women believed that their concerns and life experiences did not matter to people from “out there” particularly health care providers, law enforcement officials, and government representatives. Women’s reflections about the criminal trial of Canada’s largest alleged serial killer, dubbed the “pig farmer,” who targeted women from the DTES illustrated that they believed that women were considered of less value than other women in society by others “out there.” IP(001): Do you know that the people that are there to help you are not even doing their jobs…a cop gets paid an awful lot of money but they do nothing to help you. Basically they’re worse, they’re the ones that we have to watch out for…when I was thirteen to sixteen I got raped by a cop…and you know what, until this fucking, oh sorry, till that guy got charged, the pig farmer, those cops they didn’t give two shits about us. They just thought, ‘ah, who cares, another hooker dead,’ I mean, you know, we’re not throw away people, we are human beings and we deserve to be protected, you know, not thrown away because some idiot thinks that its too much of a headache for him, you know? Who the hell are they to judge? It sounds like they’re the ones that are the criminals…they know what’s happening, they’re just as bad as that pig farmer. A Place of Positive Possibilities As noted by Massey (2005), places represent the social processes of contestation and negotiation and it is through these processes that positive experiences and meanings can simultaneously endure in the presence of more oppressive relations. Women were not passive players within the realm of their day-to-day lives and “down here” did not always represent a negative place, even among women who acknowledged that they lived in the DTES because they could not afford to live anywhere else. There was a sense of belonging experienced among many of the women who lived “down here.” Belonging was attributed to having a sense of identity within a group; women described being able to be with people who shared similar experiences, or being with other “drug users,” “addicts,” or “crack heads.” IP(010): People drive down here and you hear of them locking their doors and everything because they see us smoking. But we are the most harmless people you would ever meet…and when you’re on the skytrain or whatever going out to Surrey, you know you get these rude, ignorant people if you are dressed like this [points to her clothes] or   100 because of what it says on my shirt [Native]. But I am proud of who I am. And I’m a crack head. I don’t care, think what you want.  People who lived in the DTES frequently “watched out for one another” and “took care of each other” especially when avoiding harassment from members of social groups that represented positions of authority, for instance the police. Code phrases that specifically alerted people to a police and media presence were common. IP(010): But you know what, we have each other’s back. We will say ‘they’re filming, they’re filming’ or like when the cops are doing their sweeps or whatever, you know we are like ‘six up’ we’re not stupid, we help each other out.  The custom of helping each other out was also evidenced through the practices of sharing information and harm reduction supplies. Older women (e.g., between 40 and 60 years of age) shared strategies with younger women involved in sex work to help them try to be safer on the street. They told women to “trust their gut; don’t get in a car if it feels bad” and “try to have a spotter [someone to note a description of a date and licence plate of car] when you are out there.” They carried extra condoms for the specific purpose of giving them to younger women who may have been more hidden from regular outreach service patrols. “Down here” represented a place of familiarity and this contributed to a sense of feeling safer within the neighbourhood than elsewhere in the city. There were certain places that women could run to (e.g., a local store) if they ran into trouble and friends or outreach workers that would know if they went missing. This was particularly relevant for women who worked in street-based sex work. R: So it sounds like it’s important to know your space?  IP(001): Absolutely, your surroundings, yeah, absolutely, I mean, if I knew a certain area then I’d know that I could at least maybe run to someone’s place or maybe to a store that I’m familiar with or something I’d know the neighbourhood.   Women drew upon their knowledge and experiences of living “down here” to justify their position as expert knowers concerning the injustices that women experienced and attributed their   101 experiences of being “down here” to providing them with a sense of purpose. Several women were politically active in fighting for improved access to better housing and health services as well as making it a “safer place for women.” Women served on local community committees, participated in community forums, worked as volunteers at local drop-in centres, and I spoke with several women who were considered community spokespersons. IP(002): Yeah, I’m on a mission so now I have a reason to be down here. I ended up realising how big the issues were down here with social housing and I started to be quite an advocate. I got right into the politics of it all…I spent eight months on the street in the pouring rain in a one man tent…we were going to rallies…we had quite a strong voice…I want to make a difference, if I help only one other person, then it is worthwhile. Women’s Day-to-Day Lives: Intersectionality and Place The relational processes inherent with women’s representations of “down here” intersected with race, gender, class, and damaging stereotypes concerning people who use illegal substances to significantly influence the day-to-day experiences and activities of the participants. Of particular relevance was the impact these intersections had for women’s experiences within their homes, of finding shelter when they did not have a home, and of “being out in the open” (e.g., walking on the street, being in an alley, going to appointments). Home: A Complex Place Provider(001): Well, yeah, if you don’t have a home to go to, and so many of them if they have a hotel room, well they don’t turn the heat on all winter and it is like, ‘oh, somebody has been coming into my room’ and then you get the bugs, the bed bugs and the mice and the, whatever, and its like, you know, its not like us going home to our nice warm beds and feeling safe.  The preceding quote from one of the service providers eloquently illustrates the complex social relations embedded within women’s experiences regarding their homes. McDowell (1999) posits that home is one of the most complex words in the English language, particularly in relation to its many diverse symbolisms and meanings. Massey (1994, 2005) argues that beliefs about home as a private place of stability, security, nurturance, comfort, and permanence portray a romanticized version of home that discounts the power relations that shape home places and   102 the experiences of those within these locales.19 She and several others (McDowell, 1999; Pratt, 2004) argue that this romanticized version of home is gendered in that home places have been equated with a version of “feminine” that has served to maintain an oppressive stance in which home represents the place where women belong and whose purpose is to provide for others. It has also been argued that home places, particularly among those who have been colonized, are places of disruption, transience and segregation and have served to reinforce sexist, racist, and class based dominant ideologies (Collins, 2000; Razack, 2002a). By contrast, hooks (1990) viewed home as a site of resistance where Black women constructed a locale in which “…all black people could strive to be subjects, not objects, where we could be affirmed in our minds and hearts despite poverty, hardship, and deprivation, where we could restore to ourselves the dignity denied us on the outside in the public world” (p. 42). Within the realm of this project, home was used to refer to specific places where women lived and as such encompassed the physical structures and social relations that both produce and are produced within these places. There were multiple and varied home places and, “each of these home places [was] an equally complex product of the ever-shifting geography of social relations past and present” (Massey, 1994, p. 172). Home places reflected, to a large extent, the dynamic and complex sexist, racist, and class-based power relations inherent within the construction of the DTES and the experiences of the women who lived there. Home places were specific locations that afforded women little or no protection from harm. However, given the dynamic nature of place, home was occasionally a place of possibilities that contributed to a sense of comfort; be it through interactions with others, provision of food, or a place to escape from being out in the open.  19 The concept of locale includes a physical space that exists in relation to others (a location) as well as the relational attributes that make a place distinctive (Curtis, 2004).   103 Home: Structures and Locations  The majority of women (73.8%) who participated in the survey reported having a “regular place to live” (see Table 3), which was interpreted as women having a place they considered home at that particular moment in time. As illustrated in the narratives of women who took part in the kit making and formal interview activities, SRO’s, usually referred to as “hotels,” were the most common living arrangements. SRO’s were buildings that consisted of varying numbers of single occupancy units (e.g., ranging between 40 and 100), shared washrooms and limited kitchen facilities. Rent ranged from 325 to 375 dollars per month. Many of these buildings were in a state of decay and infested with bed bugs and mice. Low-barrier, affordable (e.g., rent supplemented) housing within the DTES was home for a smaller number of women and encompassed a diverse range of services including emergency shelter, self-contained apartments, and support staff to assist women to enhance their independent living skills (City of Vancouver, 2007). Supportive housing, such as housing designed for women receiving mental health care, addictions treatment, or care associated with HIV and AIDS was home for very few women and the majority of these homes were outside and/or on the border of the 10 block radius of the DTES.   104 Table 3 Shelter and Safety among Survey Participants Characteristic n %  Regular place to live  126     yes 93 73.8    no 33 26.2  Feel safe where you are staying 125    yes 92 73.6    no 33 26.4  Safe place to go in the day 125    yes 100 86.4    no 25 13.6  Safe place to go in the evening 124    yes 111 89.5    no 13 10.5  Safe place to go in the night 124    yes 97 78.2    no 27 21.8  Home: A Temporary Place  For the majority of women who took part in kit making and formal interviews, home was a temporary location. Women moved frequently from one SRO to another, in search of a safer, cleaner, and cheaper place to live. Eviction due to buildings being condemned or because women could not afford or neglected to pay their rent was common and violence, robbery, and exploitation among roommates also contributed to the need for relocation. IP(003): We lived together for three weeks. So what happened, I had all my stuff in the [hotel], right, and I had given it to her for safe keeping, to put away. So I’m going, ‘where is my big black hockey bag’, and she says ‘I will look for that stuff with ya when I get back from [name of city she was going to visit]’, okay, fine, and the minute she is out the door I am up looking for my stuff and not one thing was left. She stole everything and she told me after I confronted her on it that it was my own fault for being a mark. She said ‘If you are stupid enough to be a mark, you deserved it.’ I had a chicken burger in my hand and I launched it against her face. So it was the end of our friendship and I had to move out. I still don’t have a place to live.   Landlords’ abusive and exploitive actions were also a source of conflict that caused women to move. Many landlords charged guest fees to residents of the SRO in the amounts of   105 $10 to $25 per visitor. There was recognition that these charges were illegal but fear of having to relocate, in light of the lack of available safe and affordable housing in the DTES, resulted in many women paying the fees. Other women who tried to address these concerns were often punished and left with no option but to relocate. IP(101): I used to live in [name of SRO], but I made a complaint against the manager cause he was charging guest fees. He stopped accepting my mail and told people like my worker that I didn’t live there anymore. I had no choice but to move. That’s what happens if you are creating problems.  Women’s explanations regarding exploitation by hotel management reflected the mechanisms by which intersections among gender, poverty, and problematic substance use operating through disciplinary and interpersonal relations of power limited the options available to women to resist this exploitation. The sense of futility was readily apparent within the women’s narratives. IP(007): You know, for the longest time nobody did nothing. I mean when you’re a drug addict, I mean you don’t have time to fucking, you know, you’ve got, you’re too busy trying to make money for your next fix right so they take advantage of that kind of thing.   Gender, intimate partner relations, and the regulatory rules governing the policies of supportive housing also influenced women’s experiences of having a home place. Women discussed giving up their home when they lived in a facility that did not permit their “boyfriend” to live with them. In some instances, women gave up their supportive or low-barrier home places and eventually ended up without any place to call home. IP(123): I was the stupid one, I left Native Housing because of my boyfriend. They said he couldn’t be there so we moved home [back to their hometown] and he just used way more. Now I am down here again, alone and I have nowhere to live.   Despite the many negative experiences that contributed to frequent relocation, humour was a consistent strategy employed by women to deal with the temporary nature of home. Women joked and laughed about all of the different places they had lived and the events that occurred that contributed to their relocation. The story of a 59-year-old woman who had lived independently in the DTES since 14 years of age highlights this fact.   106 IP(008): Oh yeah, I lived in a lot of different places. I lived at, its not there no more, [hotel], I used to work downstairs in the bar and I worked upstairs too [laughs], I worked at the Sunrise, it’s not the Sunrise anymore either…Where I live now, I like it. We’ve got free cable. I don’t mind the ninth floor because it’s pretty quiet, people there don’t drink or do drugs…Yeah, I’ve lived in some places here, Main and Cordova…I was there when I first came to Vancouver, I only stayed there for about six months…The drunks knocked on my door and I said ‘get away from my door, I don’t want to see you.’ I had a sign ‘knock at your own at risk.’ [Laughter] Home: “It’s Not Your Own Place”  Massey (1994) argued that dichotomizing home as a private versus public locale is problematic as places produced through unequal power relations can rarely be reduced to either one or the other and in most cases reflect both of these attributes. This was the case for many of the women in relation to their home spaces. Most women reported that they lived alone and few had children or partners living with them on a permanent basis. Yet, a more complex analysis of the data revealed that living alone usually referred to a woman’s experience of being the sole name on a lease and the person responsible for paying the rent. It was a rare occurrence that home was a place where other people did not live (albeit temporarily) or have expectations of access. Homes were private places in regards to housing women’s belongings; they were also public places which other people could easily access and in some instances control what occurred. “Boyfriends” regularly moved in for periods of time and many women experienced a sense of having little control over this decision. Having a boyfriend was frequently equated with having protection from other men. This protection usually came at great expense including having boyfriends live in their homes, being forced to sell dope or engage in sex work to supply a boyfriend with money, being his sexual partner, and more often than not, being violently assaulted. The following two excerpts from interviews with kit making participants reflect these experiences. IP(054): I just can’t go home anymore. It’s like nowhere is safe. My ex is trying to get me and [name of another man] has been staying in my place the last couple of nights and I don’t want him there. I don’t know how to get him out. Now he is telling everyone he is my boyfriend and saying to me I’m your boyfriend now. I don’t want a boyfriend, I don’t want to go through all of that [e.g., beating, forced sex work] again.   107  IP(033): He [previous boyfriend] can get into my place where I live. He is out to get me, so I can’t go home. My new boyfriend doesn’t get home until one in the morning, so I have to find somewhere safe until then…And I will have to save 10 of this 20 dollars I got today here doing this [kit making] for him so he can get smokes or something.   Home places were also the site of harassment and exploitation by police and municipal city officials, whose actions frequently negated the notion of home as a women’s own place. Impromptu inspections by fire department officials were common and police frequently dropped by unannounced, particularly during the time period when welfare cheques had been issued. These practices demonstrated that women who were poor and labelled as drug users were not afforded the basic rights of notification prior to fire inspections or maintenance work and non- random visits by police. In essence, these practices reflected the dominant ideology concerning which members of which social groups are deserving of these basic rights. IP(006): Yeah, I was constantly harassed, by the police. Which totally mystifies me because the only housing that I could get at the time, that was clean and I could afford was here [in the DTES] in the apartment building above Pigeon Park, um, a really small building… As soon as they [police] knew I lived down here, they came over so much that on welfare day I left my door open for them because I knew they were coming.   R: Why did they come?  P: Because I’m a recovering addict. So they just came, to the point where the social worker because, obviously when [my daughter] was first born we had a social worker until she was, I don’t know six months and then they terminated it right, they didn’t consider me a risk. She had to phone them and say ‘if you do not stop coming to her place I will charge you with disruption, I will do it myself. I work with this family and if I don’t consider it fit for me to be going over there then you do not need to be there, have you found any drugs, have you seen any drug use, have you seen any people there’, ‘um, no, no, no,’ ‘then why are you there?’ ‘Because she’s an addict.’ Yeah, a recovering addict which gives you a right to invade my space and they said ‘we’re just here to help you, support you’, then can you do it open and honestly like ring my buzzer and not ring my neighbours and humiliate me by telling them you’re coming to see me so I walk out my door and all my neighbours are staring at me like I’m a freak.   In situations where police presence in the home was seemingly an attempt to assist women, it was apparent that these circumstances still bespoke a sense of police being able to enter women’s homes without their permission. Women could not necessarily expect that the   108 doors to their homes would not be opened unexpectedly or that they could experience a sense of privacy. IP(010): The police come to my house like maybe every third or fourth day since he beat me…yeah, they actually literally got the manager to unlock my door to see if I’m ok, but I was sleeping. I woke up when they were coming in.   R: So does it feel good though that they are looking out for you?  P: Oh yeah, I give the police a big hand because they even stopped me in front of the [name of hotel] last week and it was just after he beat me up and the officer said ‘you know [participant’s name], we don’t want to come over to your place and we have to identify you, …you know?’ Those are harsh words but coming from them…and this is funny, we were just talking about this at the women’s group, I said to my friend ‘I can’t even enjoy a toke anymore because I’m scared the cops are going to come there and smell it.’[laughs].   In addition to the lack of privacy women experienced within their homes, maintenance crews routinely worked at night, disturbing women’s sleep and removing their access to washroom facilities. There were limited options for women to fight against these disruptions for fear of retribution by landlords. IP(093): I am tired because I didn’t get much sleep. There were men in the building last night who were supposed to be fixing the bathroom. It was like midnight or early in the morning…They were supposed to be working, but you know, they are just in there doing dope. Yeah, this stuff happens in a lot of the hotels. The landlords don’t care. And you can’t call the police because then you will be a rat. And then you might not have anywhere to live or other stuff can happen.  The lack of privacy and the ongoing disruptions and harassment were experienced by all of the women, not just those living in SRO’s. Women living in supposedly secure buildings such as supportive and low-barrier housing with around-the-clock staff also experienced a sense that their homes “were not your own”. IP(171): People come into your room because you have housing, you know, a regular place to live. People come to sniff the place out, you know, see what you have. Men are always looking for some girl to put them up. Guys are always checking your place out. This happens with men that you don’t even really know, that they might just be there with someone else or they are some guy that you end up smoking with or something like that and then he won’t leave.    109 In some circumstances women attempted to reassert with men that this was their home place. More often than not, this resulted in violence. IP(010): Yeah, like we were together every single day in the last month and everything was going good right? And I just wanted my space at that time but he was high and I was high and I said ‘come on just go home. I can’t smoke no more. I want to go to bed.’ Right away he thought I was up to something. He just freaked out. That’s when it happened [the beating that resulted in her current legal action against him]. The last time it was this bad he kept twisting my arm until he broke it.  Ultimately, the experience of not having a home be “your own” was constructed in part by gendered and class-based systems of oppression that were reinforced through women’s interactions with men and people in positions of authority as well as the organizational practices of the disciplinary domain of power. Ideologies concerning women’s roles in relation to men, particularly with regards to creating a home and having the explicit purpose of serving the needs of men were evident and often contributed to exploitation and abuse (McDowell, 1999). The practices of municipal workers (e.g., law enforcement, fire department) represented a disconnect between women’s civil rights within municipal by-laws and what they actually experienced. The futility to resist these practices reflects the negative influence of domination for those constructed as Other. Home: The Place Where “Police Don’t Do Anything”  As noted previously, violence within women’s home places was common and took many forms including beatings, rape, and the constant threat of other people in the building “freaking out” and contributing to possible harm. The women’s stories illustrated a sense of futility with regards to being protected by police in that police often did not respond to women’s 911 calls for help, or when they did respond, their actions perpetuated the assaults experienced by women. This lack of protection and racialized violence at the hands of police was illustrated during discussions among a group of Aboriginal women with regards to the actions of police in their neighbourhood.   110 IP(032): I called the police because of my friend next door. I could hear her, and I knew that she was being raped. So I called the police. And when they came and interviewed her, I knew she was really scared and shook up. But they wouldn’t let me be with her while they talked to her. I don’t think this was very fair that she had to be alone. I waited out in the hallway until they were finished and then these two cops came out. One of them says, ‘what are we doing here anyway? How the hell can you rape an Indian?’ I know this is horrible, but it is not surprising given how Indian women get treated down here. That sort of stuff happens all the time. Prejudice still exists today but it is just more hidden, but it’s still there. The cops are all racist and they [the police] just don’t care.   The women perceived that the lack of police protection within the home and the exploitation the women experienced by men was influenced by their lack of worth within society; an experience that was attributed to their use of substances and involvement in commercial sex work. There was a belief that nobody cared what happened to them and a futility concerning the likelihood that these ideologies concerning women’s value in society would ever change. IP(113): That place is a bad hotel. I found it strange that the smoke detectors never worked. They were filming porno and women had no idea [she began to quietly cry]. I figured it out. It was weird you know, like what my boyfriend did and how he positioned me for sex. He would like, make me be a certain way. Like turning my head a certain way or how I was on the bed. And I talked to some of the other girls and they said the same thing. There is nothing you can do because if you said anything you could just end up in a dumpster if you did the wrong thing and that nobody would care. ‘It is just another junkie whore’ is what they’d say. Home: A Place of Possibilities  Given the dynamic nature of the social relations that produce and are produced by home places, it was not surprising that the experiences of women within their homes could not be dichotomized as simply “good” or “bad.” There were many positive facets of women’s home places. Home places, particularly when located within low-barrier and supportive housing facilities, provided a “roof over your head”, a place to gather with friends, access to food, supportive staff that could intervene on a woman’s behalf, and a “better place” where women could live with their children or partners. The processes by which these positive experiences played out varied among the women and were influenced by the location and structure of the   111 various home places. SRO’s for example, were considered a more positive home place among many women who had been recently homeless and who had been living outdoors. IP(104): I finally got a place to live. I have been on the street all summer but now I have somewhere to live. It’s not that great a place, but man it was nice to sleep in a bed for the first time in three months.  SRO’s and the low-barrier housing were also social places where women got together with their friends to “hang out.” Hanging out often took the form of smoking crack with friends and was considered a safer alternative to smoking crack alone or in an alley. Some low-barrier and supportive home places enabled women to have greater access to food. Women talked openly about being able to eat more regularly because they were living in particular housing facilities and that this contributed to their overall health. IP(001): Living in Bridge Housing, I tell you, they make sure we have food which is good, because I probably wouldn’t be so fat if I didn’t have food [laughter]. Well I wouldn’t be healthy if I didn’t have all the food that I have. Mind you, the peanut butter and jam sandwiches aren’t the most healthiest thing but the soups they give us, they are great.  Low-barrier and supportive housing also provided around-the-clock staff. The staff provided support services such as receiving prescribed medication from pharmacy deliveries, removing unwanted people from a woman’s apartment and “looking out for women” when they were feeling unwell or in some instances concerned about harming themselves. IP(172): My boyfriend is going to come and stay with me so I won’t be alone. I have a friend who will check on me too. The staff here (women’s housing) know I am scared of getting really sad and they will take care of me. I don’t really want to hurt myself but I am scared that I’ll be so sad on Christmas day that I might not think straight. I told them they had better put a trampoline outside my window on Christmas day. And they said they would make sure I was OK. That helps.  A few women with whom I spoke lived in supportive housing that was situated outside of the boundaries of the DTES. These home places were also places of positive possibilities in that provided women with more physical space within their apartments, which often permitted them to have separate bedrooms from their children. Being situated away from the DTES was   112 perceived as a positive experience that enabled women protect their children from the more violent aspects of living in the DTES. IP(006): The only place that I could have got into quicker was down here and I refused to live down here with her right? It’s not an appropriate place for her to be and I’m not going to shield her from the world but I certainly want don’t want her to have to view it on a daily, twenty-four hour basis either. I mean luckily now like we’re in subsidized housing so we have two bedrooms and so I can go have my own space in my own house and so can she. Finding Places of Shelter: The Challenges  As noted in Table 3, 26.2% of survey respondents reported having no regular place to live and 21.8% women noted a lack of safe places to stay between the hours of eleven at night and six in the morning. Because a lack of home places and safe locales exacerbated women’s risk for violence, harassment, exploitation, and illness, those without home places often spent considerable time and energy trying to “find shelter.” Women experienced significant challenges with regards to finding shelter that were influenced to a large extent by the high demand for shelter in a neighbourhood inhabited by people living in poverty who had no place else to find housing, and the unjust power relations that contributed to both gentrification and a dearth of low-barrier shelter facilities that provide services for women. Over the past several years, gentrification in the DTES has contributed to the steady decline in the number of low-income units for singles (PIVOT, 2006). Between 2003 and 2005 there was a net loss of 415 low-income units and rent increases in SRO buildings continue to surpass the $325 welfare allotment for rent. Although provincial and municipal strategies are being implemented to address these concerns, investigators reported that the number of facilities receiving government funding will not meet the demands of the residents of the DTES (PIVOT, 2006). It has been estimated that by 2010 the number of homeless people in the DTES will have doubled.   113 The participants recognized the declining state of affordable home places within the DTES and attributed these changes to the economic gains (e.g., increased rent) to be made by building owners and managers if they “renovated” an SRO. Renovations and rent increases were perceived as being related to the upcoming Olympic Games to be hosted by Vancouver in 2010. The women associated the declining housing with the Olympic games, based on their historical experiences of living in Vancouver during Expo in 1986 when they witnessed a considerable reduction in affordable housing. IP(007): Oh yeah, that housing thing, that’s ridiculous like what are they going to do? I mean I keep going to Expo right, these Olympics right, what are they going to do, you know...they will rip everything fucking down here...they’re going to sweep it under the carpet, these people eh? I like to throw that out, what are you going to do when what do you call it [the Olympics] is over? You saw it with fucking Expo. I was here, yeah. Lucky I had places that I lived…that’s when you got like double beds in the hotels and stuff, you know, like places, for instance, the St. Helen’s and I used to live there. They got double beds and carpeting. Then one year later, jack the prices up you know. It’s going to be a big problem, they might be able to cover it up for the time being, for the Olympics, stupid man, they are just asking for trouble…after that, there will be a lot of crime and shit.  Economic barriers also contributed to the challenges of finding home places in that women could not always afford to pay their rent. As noted earlier, the majority of women lived well below the LICO and income assistance in the form of welfare payments was the dominant source of income. A single person considered employable in BC who passes the welfare eligibility criteria receives a total of $510 per month, $325 of which is allocated for shelter and $185 for all other needs including food, clothing, and transit which averages to approximately six dollars per day (Wallace et al., 2006). The narratives of the service providers illustrated that while economic barriers were important, they needed to be understood within the scope of relations of power and systems of oppression that influenced the options available for women who are poor and use illegal drugs. Provider(002): And when a women’s only, like the Vivian Transitional Housing gets put up and really fights to have a women-only low barrier housing, there’s protests and people trying to shut them down and it’s so sexist. There is this whole thing around ‘oh it’s a brothel in there and it’s this and it’s that.’ It’s amazing, like there is all these hotels   114 that are doing the most insane stuff and nobody questions it. Or there is tons of transitional housing that gets established and nothing is said. But then this women’s one gets put up the community is like ‘you should have asked us,’ ‘we want cameras,’ ‘they’re hanging out outside.’ You know it’s totally crazy.  In addition to the challenges created by the reduction in the number of affordable home places to rent, accessing emergency shelters when without a home was tremendously problematic. “Down here” emergency shelters consistently operate at full capacity (PIVOT, 2006) and outreach staff and those working at women-only drop-in centres reported increasing challenges in assisting women to find shelter. Fewer beds were available for women within the gendered processes of shelter bed allocation in the neighbourhood and available places filled up quickly. IP(073): We have nowhere to go in the night. Men have the [Union Gospel Mission] but women have nowhere to go and sleep when it was cold. We aren’t allowed in there. We need a place to go get warm too. I was out the night before last and it was freezing. It is worse now that the weather is getting worse. And you know [name of residence] has 45 slots for men but only 12 slots for women. Why is that? Other places have no beds for women at all. Women are left out in the rain. There just isn’t enough housing for women. There are way more women down here than men but people think it is the other way around. There are lots of women with nowhere to go.  Too few of these available beds were low-barrier which prevented women who were using substances from being able to access these facilities. Women who were “using” were increasingly segregated from safe places to spend the night an experience that illustrates the oppressive ideological assumptions about women who are poor and use illegal substances that underpin the practices of shelter organizations. “And you see those, the ones that will take people who are using and are in the most fucked up state, are usually the ones that are fuller and faster” (Provider001). Rules limiting the length of time that one could remain at a shelter also contributed to women’s challenges in locating temporary shelters. Some shelters regulated their beds by requiring people to leave at 6:30 in the morning while others locked their doors at a specific time of night. If a woman arrived after lock-out time there was no option but to stay on the street. One   115 shelter limited the amount of time women could spend in the facility. After 30 days they were forced to leave regardless of whether or not they had a home place to go to. The following excerpt from one provider who was attempting to find shelter for a woman at her agency reflects these experiences. Provider(001): So, they’ll [shelter staff] be like ‘she can’t come back for thirty days’ because if you stay there for a certain amount of time then you have to wait thirty days before you’re allowed to come back. So one of the girls right now is sleeping in a garage because she used up all her time at one of the places and can’t go back so she has to wait out the thirty days and then try to get a bed again. She loved the place, it was great but now she can’t get in anywhere so she’s sleeping in a garage downtown somewhere. She’s like ‘I’ve got a headache from all the fumes of the cars’ and I’m going ‘oh dear, do you know how dangerous that is’ and she say, ‘yeah, but its warm right there.’ Like warm and waking up dead, you know, like you’ve got headaches from the fumes, you need to move so, so every day that she doesn’t come in or comes in late I’m just waiting for her to show up because I just have visions of, you know, her not waking up.   The fear associated with “other people” staying in a shelter and the actions of the shelter staff also contributed to barriers in finding shelter. Women expressed concerns for their own safety when housed with people considered violent or “seriously mentally ill.” In addition, reports of aggressive actions by staff were not uncommon. Out in the Open IP(160): The woman at the second station said that her biggest fear was being found dead in an alley naked, by the cops. She asked the others to promise to cover her if they found her.  Intersections between race, class, and gender embedded within relations of power also influenced women’s experiences outside of their homes in the places they commonly described as “out in the open.” “Out in the open” included the multiple and dynamic places within and outside their neighbourhood where women went about their regular day-to-day lives. These activities included but were not limited to attending appointments related to health care, income assistance, housing, and legal issues; visits to local drop-in centres; work related activities such as peer-outreach, sex work and drug selling; shopping; educational activities; attempts to find shelter by those who did not have a home place; buying and using crack (or other substances);   116 and obtaining drug using equipment. “Out in the open” inferred a certain degree of unavoidable visibility beyond what they experienced within their home places particularly in relation to the general public, the media, men from “out there” and the police. Being “out in the open” increased the accessibility of women to those who could harass, exploit and physically endanger them. Conversely, “out in the open” was also a place of escape to take a break from home places and violent partners, a place to socialize, and a place where a woman could find protection. These contradictory yet simultaneous processes associated with being out in the open were not surprising given the non-static nature of socio-spatial places. “Always a Target”  Cities as places of violence against women have been of increasing concern to social and feminist geographers over the past several decades. The majority of this work has focused on the “safeness” of city structures (e.g., location of buildings, lighting, and bus stops) as women move between places within a city locale. More recently, Listerborne (2002) has called for a more critical examination of the relations of power that construct city structures to more fully appreciate women’s experiences of fear and violence within the city. While little work has been done to examine violence within a geographical context among women who use crack cocaine, analysis of the experiences of the participants illustrated that violence and anxiety related to the constant threats of violence, were legitimate concerns for women when “out in the open.” The violence was associated with the specific activities in which women were engaged including moving between places, seeking shelter, working, and using out in the open. Although these activities are separated here for discussion purposes, overlap among these activities was common.   117 Moving between places Women’s mobility and visibility on the city streets contributed to their likelihood of being harassed. Women rarely walked from one place to another without being approached for sex, the offer of drugs, or for people to demand that they give up personal items such as cigarettes or food. On one occasion, for example, while a group of us were leaving an agency, one woman who was carrying a tray with two muffins was approached by a tall, heavy-set man. He called out to her and she smiled but kept moving and he simply stepped in front of her and asked for her food. She responded, “I need this. Look how skinny I am.” He kept walking in front of her and saying “come on.” The facilitator and I positioned ourselves on either side of her and walked out of the building. He followed us to the outside, but did not approach her again. Later when I asked her about the incident she commented, “oh yeah, that happens all the time. People are always trying to get something you have.” Women were also targeted by film crews from local television news stations and independent film makers. There was a sense of frustration related to “always being filmed” or “always having to watch out for a camera” and women were rarely asked for permission to be filmed. Film crews were often on the street and in alleys, and were usually accompanied by police. On one occasion I noted that there was a television news crew accompanied by police and talking to a woman who was standing on the street. She was an older woman, probably in her 60’s and she was swaying from side to side. I wondered if maybe she was starting to experience withdrawal. The light from the camera was almost blinding and they had a huge microphone directly in her face. There were two police officers standing off to the side in uniform. Policing practices were also a source of concern for women when they were out in the open. Women were frequently approached by police and detained for questioning while they attempted to go about their everyday business. Women described the harassment as “relentless”   118 and “unfair” and the data also reflected that harassment was at times targeted, purposeful, and racialized. IP(006): My daughter was three weeks old, she [my partner] walked from the apartment to the store which is like a half a block and they [POLICE] already nailed her and were hauling her back, ‘what are you doing with this kid’, ‘its my daughter’, ‘no it’s not’, ‘yes, it is my daughter.’ Yeah, and you know what she was told, ‘you don’t look like your child.’ ‘What because I’m fucking Native, like excuse me, you go do this in the west end and see what happens to you, right?’ So what about all these kids that are adopted, and stuff like that, I mean inter-racial marriages or whatever, I mean not everybody looks like their frigging kid. Yeah, and the thing is that it’s not just me it happens to so it makes it even fucking worse right? And I mean what happens when you can’t afford to live anywhere else, it’s a shitty area.   Targeting and harassment also took the form of men waiting for women outside their homes, drop-in centres, and community clinics. Men waited for women to bring food from women-only locales serving food and threatened women with violence if they did not give up their food. It was not uncommon during kit making sessions for men to interrupt a session to let a participant know he would be waiting for her when she was finished and this was most frequently associated with sharing a woman’s financial honorarium or her harm reduction supplies (e.g., pipe) obtained during the session. There was an ever-present concern for their safety particularly when women knew that “someone was out to get them”. Ex-boyfriends were the most common people identified as trying to find women and women expressed tremendous fear for their safety in relation to being found while out in the open. IP(054): I hate going outside because I know he is always looking for me and now he has his friends looking for me too. There is always one of his boys around saying things like ‘guess who I saw today’ or ‘he would love to see you’. It’s like people are always trying to get at me. I worry what he might do to the other girls [women who lived in her housing complex]. I don’t want anyone hurt because of me.  Later when the facilitator and I were alone and talking about our concerns for her, the facilitator sighed and said, “And the worst part is that we can try and do all these things to keep her safe, but eventually she is going to be out there on her own and he will probably get to her.”   119 Working out in the open  Street-based commercial sex work was the primary activity associated with working out in the open. This type of sex work usually involved women “out in the open” on particular city streets with the intent of engaging in sex for money exchanges with men who solicited these services. These streets were, more often than not, areas of somewhat less traffic than other busy streets. Women usually worked throughout the hours of the evening and well into the night. The action of participating in commercial sex work reflected intersections of gender, poverty, and substance use. As noted previously, street-based sex work was one of the few options available for women to obtain income or to supplement their $510 monthly income from welfare, and in some instances was an activity that was forced upon them by boyfriends. The need for money was also intimately connected to substance use. IP(004): I’ve been like working the streets for like five years since I have been down here. And, you know, for the most part its been okay, I mean I had one potentially bad date but, you know, its just that, you know, I am a drug addict so, you know, I have to do it, you know, and the hours are like you go out all night and I came in around five and sleeping like till two or three and it just screws up my whole day, you know?   The nature of sex work required that women regularly get into cars with unknown men or perform the activities in secluded alleys with little or no protection. Women suffered severe beatings, were raped, kidnapped and dumped out of town, robbed, not paid for services, and were victims of motor vehicle hit-and-runs. Bad date sheets that described women’s experiences of assaults and physical descriptions of the man (or men) and the vehicle were circulated weekly to local agencies frequented by women. These bad date sheets, which have been in place in the DTES for several years, were viewed as a tool to help women recognize these men with the hope that they could avoid doing a date with them. It was also apparent, however, that these sheets did not truly reflect women’s experiences. Provider(001): I mean there’s all kinds of different criteria what they consider a bad date or what they, whatever I mean there’s, what they go through on a daily basis, I mean where is your norm? It changes all the time depending on if you’ve been using or if you   120 need to be using or if you’re going to get beaten if you don’t do the date or maybe the date is not as bad as what you’re gonna get at home, there’s so many variables…but generally speaking, if they get their money, they have to be pretty bad to be a bad date.  Many women expressed feelings of constant anxiety due to fear for their personal safety, never knowing what might happen, and the possibility of being killed. The current trial of the “pig farmer” and the frequency with which women “go missing” from the DTES were regular topics of discussion in relation to risks associated with working out in the open. Provider(003): It’s a bit cliché now with the Pickton trial, but it’s like every day when I think whenever a woman gets into a car, she doesn’t know what will happen next, or whenever she gets some drugs, you have the hope that nothing will happen but you cannot really tell.  Within women’s stories, it was apparent that substance use, lack of money, and domination by men all contributed to the violence they experienced. These intersections were perceived as different from “everyday women” or other women in society who were not from “down here” and not visible on the street. IP(002): I think down here especially because there are a lot more, uh, I guess easier targets in the sense you’re a lot more vulnerable because there’s drug addiction, there’s a lot of sex trade workers. I think that any potential criminal activity happens a lot of time down here because you are such an easy target. I mean look at the pig farmer, for instance, he targeted women that were addicted street workers because he knew that they were vulnerable and he knew exactly what they needed in order to get through their day and used that to his advantage and that’s sick in itself. But I think that because of that, yeah, there’s some issues that might not be everyday women kind of issues like the working girls.  The changing drug market economy and related oppressive circumstances of women’s lives were also contributing factors that increased the risk for violence among women who worked out in the open in the sex industry. The relationship between declining drug costs, reduced costs for sexual activities, and the related temporal factors were of particular significance, as effectively demonstrated in the following quote: IP(134): Have you thought about the link between the sex work costs and the drug market. It used to be that it used to cost 40 dollars for a blow job and a rock costs that much. Now a rock is 10 dollars and so is a blow job. The cost for sex is going down and   121 that means women have to work more and are more at risk because they have to be out there longer and do more dates.  As in other places, women were not provided with protection from police when “out in the open.” Police failed to respond to their reports of violent dates, and instead, targeted women for arrest and harassment. IP(183): I went to the police when I had a bad date. He robbed me and beat me. You know I told the police this and they said to me ‘well, you shouldn’t be working.’ Like this guy just beat me up and it is all my fault because I am working?  IP(121): I’m on probation. Yeah, a john approached me and I said OK that I would do the date and we went to a bank machine so he could get money. I was out in Surrey. And then these cops came up and arrested me for working, but nothing happened to the john. I think it was a set up. I don’t know why they did that. The police set up women all the time who are doing dates.  R: What usually happens to the johns when women get busted?  IP(121): Nothing ever happens to them. They really only target the women.   Women had very few safe locations that they could access to escape or to simply “take a break.” The only drop-in centre that was specifically for women working in the sex industry closed at 11pm despite a three-year effort to open a 24-hour facility. Any other locations such as the Health Contact Centre or the Supervised Injection Site are open to both men and women. While some women felt safe in these locations, others reported not wanting to be there due to being hassled by men or not wanting to be at a site where people were “fixing”. Women were left with a sense of feeling exposed and vulnerable to assault, robbery, and potentially death. Dealing  “Selling dope” or “dealing” was also a means of working out in the open for a small number of the participants. Dealing usually occurred on busy city streets, in parks, alleys, hotels and local bars. Customers included both people from “out there” and “down here.” Lawyers, medical professionals, and police officers for example, were reported to be regular customers. IP(010): It’s just not downtown east side. My lawyer does it, I swear to God, my lawyer. When I used to deal at the hotel down the street he’d come there and score off of me. I’ve   122 known people, another lady she worked in a critical unit at Children’s Hospital and she did it.”  IP(003): Remember I was a dealer. My best customers were cops and their wives…you know, my middle-class customers. I had a lot of people that were real estate agents too.   Dealing, like sex work, was considered one of the few options available to women to generate income. Among some women, dealing was an activity forced upon them by boyfriends. Women who sold for their boyfriends were rarely permitted to keep any of the money they obtained and compliance with these rules was ensured by violence. Dealing out in the open also contributed to women being targeted during periods of intensified police activities (e.g., increased surveillance and arrests), commonly referred to as crackdowns, aimed at reducing drug availability, consumption, and related crime. Crackdowns occurred regularly and tended to exacerbate the violence inflicted upon women working out in the open. Provider(001): Yeah and its always the women, I mean how often do they pick up the guy, its always the women and then the guys are there waiting for them when they get out of jail and it just puts them that much further in danger really, yeah, its frustrating as hell…and then you have the police crack down so they don’t feel safe from that either because if somebody is forcing them to go out and deal and then they get picked up and then the police take the drugs and they owe that person the money because they’ve lost the drugs. That’s one of the things that’s happening right now is a lot of the cops are picking the girls up and then it makes life way worse for them because they do lose the drugs but they still owe the people and so they get beaten for that and then they’re out there and they’re having to work [sex work and dealing] more and it’s a vicious circle so that, that’s something that’s been escalating for the last little while for sure.   Not all women who sold drugs did so because of coercion by their boyfriends. The few women that I met who were “dealing” and were willing to discuss their activity, viewed “selling dope” as a means to achieve better financial stability. These women were perceived among other participants as “more dangerous than men” and someone who would “rip you off” or “beat the shit out of you if you fucked with them” (IP053). The aggression on the part of women who were dealing was portrayed as necessary to survive as a dealer. “Yeah, I have my own corner where I deal. Women are very aggressive dealers, they have to be” (IP162).   123 Using out in the open Smoking crack (and other substance use) out in the open was a common occurrence among participants. There were many specific places where women smoked crack including (but not limited to) doorways on city streets, alleys, parks, parking lots, and public washrooms. Smoking crack out in the open was associated with specific risks for women including being targets for rape, violence, and robbery; forced sharing of crack and crack smoking equipment; and harassment, humiliation, and arrest by the police. During the survey, for example, women were asked in an open-ended question to list some of the problems experienced by women who smoked crack. Representative responses included: “boyfriends - because they want half and if women don’t give it, they get beat up”; “at risk for rape or violence if they get too high”; and “being a target for men; guys hit on girls that are high.” Smoking out in the open increased women’s visibility and contributed to others, particularly men, harassing women to share smoking equipment and crack. Women reported that threats of violence were common when they expressed their preference not to share. Women were concerned about sharing equipment due to the possibility of contracting infectious diseases and wanted to be able to “use their own dope without hassle.” The desire to smoke without hassles or violence occasionally played a part in reducing women’s mobility out in the open so much so that they rarely left their home places. IP(171): You know, I have been an addict for over 40 years and that I don’t want to share anymore. This guy wanted to share but he had a sore on his mouth and I told him no way, I wasn’t sharing with somebody with a sore. I barely go outside anymore. Smoking in my room is more safe than outside. Then I don’t need to worry about sharing.  Certain locations were more problematic than others. Smoking in alleys was especially dangerous for women due to the lack of visibility within these particular locales. IP(001): Yeah, because guys are preying on girls in the alleys…this girlfriend of mine, she was in the alley, she was smoking and two black guys came up and tried to rape her right in the open, in the doorway. She said that if a car hadn’t driven by and got them to turn around and she bolted that they would have raped her.   124  Despite these risks, it was apparent that more women were smoking in alleys than in other outdoor locations and this was chiefly due to the increased crackdowns by the police. Police actions contributed to women not carrying their own smoking equipment which increased the likelihood of having to share thereby exposing them to risks associated with smoking with men. Police frequently smashed women’s smoking equipment or forced them to smash their pipes. Within the context of the survey data, 55 (43.7%) of women reported not carrying their own pipe or mouthpiece due to fear of being “jacked up” by police, 27% of women reported having their pipes smashed by police and 18.3% (23) women reported that the police made them smash their pipes. Women described these experiences with police as humiliating and degrading. IP(072): It is really humiliating because they hassle you in front of other people and they humiliate you with what they say and do…they take your stuff, smash your pipe and then you have to go and work [sex work] and make some money so you can buy your stuff, cause they just smashed yours. That’s hard.”  The actions of the police contributed to a reduction in the number of safe locations out in the open for women to smoke and also influenced women’s experience of the DTES as a place where people could “help each other out.” Using in less visible locations meant that women were unable to assist each other, and this was considered particularly problematic for women who were described as “too high and not knowing what was going on.” IP(123): Police are charging for possession if you are using outside now. It used to be that they would just ‘smash our pipes’. This is driving people way less out in the open and you won’t be able to keep an eye on people or check in and see how they are doing. Place of Possibilities  Women’s experiences of being out in the open were not always negative. When out in the open, women were able to assist other women to be safer or to give care such as identifying and acting on behalf of someone who needed to go to the Emergency Room. Women who engaged in peer outreach activities, which represented the majority of women who participated in the kit making sessions (and possibly the surveys, although there was no way to determine this), were   125 especially involved in providing assistance. Participation in peer outreach work included being on the street, in alleys and in areas where women worked. This work provided women with a sense of accomplishment in that felt they could be of some value to other people. It also provided a way to generate some additional income. IP(002): Some people say what’s outreach, I say ‘well turn around reach out’, outreach, its literally what it means, you’re reaching out, I think anybody that can benefit from something I’ve gone through and not have to go through it is a good thing…so to me its beneficial in so many ways like I believe that everybody has a mission in life and I think part of mine is to be here and to be doing what I’m doing and doing the outreach and touching people’s lives and realizing that I’m just a small, small spec in the big picture but I myself can have a huge influence on other people and that is like people say ‘what can one person do’, one person can do a whole lot.   In their everyday activities of moving between places, “out in the open” was also a place where women could accompany one another especially when a woman felt unsafe or worried. Women recognized the importance of “safety in numbers” and perceived being out in the open together as a means by which to build “a community of sisterhood.” IP(034): I was on the bus and a woman who got off the bus as the same time looked really nervous and asked where I was going and it turned out we were going the same way. I walked with her, because it’s important that women not be alone.   Out in the open was a place where women socialized with each other and shared information about upcoming events or resources, for instance upcoming self-defence classes and a change in hours at a local drop-in centre. Seeing friends “on the street” that they had not seen for a period of time was one of the most positive aspects of being out in the open. Due to the lack of mechanisms such as phone or e-mail to maintain contact with each other, and the infrequency of women visiting each other in their home places, women often experienced a sense of loss and fear if another woman was perceived to be “missing.” A woman was deemed missing if she was not seen for several days going about her usual activities of moving between places. Being missing was frequently due to admission to hospital, being ill at home, or in worse case   126 scenarios, being kidnapped or murdered. Being able to see a woman who had been missing was experienced as a sense of relief among other women who knew and cared about her.  There were also positive and supportive relations that occurred with men who lived in the neighbourhood. Many of the women reported having a “street brother” who helped to provide protection when they were out in the open. Street brothers were not necessarily blood relations, but men from the neighbourhood who volunteered their time and energy to enhance women’s safety in the DTES. IP(008): Street brother is, well I met him when I was about fourteen, its just like having a brother but he’s not your real brother and I always call him my street brother, say when he went to jail, he got, uh, his friends to keep an eye on me when I was down here so I was, if I had any problems, they were there…yeah, in case somebody jumped me or something.  “Out in the open” was experienced as a complex series of processes, both positive and negative. These processes were intricately connected to the relational attributes of the place known as the DTES and the systems of oppression operating within women’s lives. Summary  In this chapter, I presented a comprehensive analysis of the everyday circumstances of the lives of women in the DTES who use and/or have experience with crack cocaine. Although there was diversity among participants, the majority of women experienced relentless harassment and violence across a variety of spatial scales and in relation to diverse groups of people including other women, men who visited the DTES, boyfriends, landlords, and police. Women lived in both absolute (low-income) and relative (lack of opportunity for income) poverty (Krieger et al., 1997; Reid, 2007) that contributed to poor housing and homelessness, engagement in sex work, and reduced opportunities for alternative living arrangements or sources of income. By contrast women’s day-to-day lives were influenced by the positive possibilities that being situated within the DTES were perceived to offer including a sense of belonging and a sense of understanding among other women who shared similar life experiences.   127 Each of these circumstances of women’s lives were significantly interrelated and influenced by intersecting systems of oppression such as race, class and gender as well as women’s individual strengths and capacities to deal with these circumstances on a daily basis.    128 CHAPTER FIVE: WOMEN’S EXPERIENCES OF HEALTH Introduction  In this chapter I build upon the previous analysis to critically examine how the interrelationships among the women’s day-to-day life circumstances and relations of power contributed to the myriad of complex and at times devastating negative health experiences. To begin, I present the main health concerns reported by women who participated in the Pre-Kit Distribution Survey. I then draw on other data sources to more critically examine how women experienced these concerns and include an analysis of the relations of power that influenced these experiences. For ease of discussion I have divided women’s health experiences into the broad categories of mental and physical health concerns. This division functioned solely as a heuristic device for analysis. Mental and physical health were significantly interrelated, a fact that is apparent in the upcoming discussion. As I organized the analysis for presentation, it became readily apparent that it was unfeasible to address every possible interrelationship between life circumstances, relations of power and each health concern. As a result, I focused upon select exemplars that were highlighted in the data that best reflect not only the dominant health concerns experienced by the participants but also make explicit the processes by which the systems of oppression and relations of power influenced women’s opportunities for health. Experiences of Health: A Beginning Snapshot The women who participated in this project experienced a myriad of complex and interrelated mental and physical health problems that were both chronic (e.g., arthritis, asthma, depression) and acute (e.g., pneumonia, oral lesions, psychosis, withdrawal) in nature. Many women experienced their health as a continuous worsening of conditions that, as they aged, contributed to chronic physical and emotional pain, disability and eventual death. The cross-   129 section of women who were currently using crack cocaine and who had participated in the Pre- Kit Distribution Survey provided data that serves to increase understanding of the nature of the general health concerns that the women had experienced over the course of the previous year. Their responses provided a snapshot of women’s general health experiences and their self- reported health status, the results of which are presented within Tables 4 and 5 respectively. Both physical and mental health problems were identified within the top ten health concerns. Respiratory problems dominated the physical concerns while anxiety, feeling sad and sleep disturbances were the most frequently reported issues for mental health. Throughout the entire project it was apparent that there were similarities and differences in how women perceived and experienced their health concerns. These similarities and differences were influenced by dynamic relations of power operating across class-based, racialized, and gendered systems of oppression, and were reflected in women’s personal beliefs and assumptions regarding the meaning they attributed to their experiences of health concerns, the degree of access to material resources and health services necessary for health, pre-existing health issues, and the social interactions that they experienced with health service providers. The remainder of this chapter is devoted to these issues.   130 Table 4 Prevalence of General Health Concerns Over Past Year (n = 126)20 Health Problem n Valid %  Coughing up phlegm  99 79.8  Dry cough 93 75.0  Feeling nervous/anxious 92 74.2  Feeling sad/blue                                     83 66.4  Insomnia/trouble sleeping 82 65.6  Teeth/gum problems 81 64.8  Trembling hands/the shakes 74 59.2  Sore throat 73 58.4  Pains in your chest  64 51.2 Feeling paranoid 63 50.4  Burns on lips/mouth 59 47.2  Heart palpitations 55 44.4  Brillo® in mouth, throat, lungs 51 41.1  Skin infections/abscesses 47 37.6  Lung infections                                      45 36.6  Psychosis 38 30.6  Oral lesions (cracked lips/sores)  36 29.0  Broken bones/joint pain 18 14.4  Seizures 18 14.5  Other21  44 35.5  20 The number of participants ranged from 124-126 and therefore the reported percentage varies to reflect the differences within the number of participants in each item. The range of 124-126 is due to missing data based on participants’ non-response in some items.    131 Table 5 Self-reported Health Status (n = 119; non-response to item n=7) Health Status n Valid %  Poor/Fair  63 52.9  Good/Excellent 56 47.1  Women’s Experiences of Physical Health Women experienced a diverse range of physical health concerns. Some concerns were acute or short lived, while others were experienced as conditions that worsened as they aged and as a result contributed to chronic pain, disability and eventual death. The level of complexity among the women’s experiences of health posed many challenges in presenting a systematic yet comprehensive analysis. To enhance clarity I have organized the key exemplars of women’s physical health concerns according to the relevant body “system” including the respiratory, musculoskeletal, immune function and reproductive systems. Each system is discussed in relation to the actual health concerns that women experienced and the influential factors that contribute to these concern. Respiratory Health Concerns Respiratory health concerns were those that involved a woman’s mouth, throat, nose, and/or upper and lower airways including her lungs (Porth, 2005). Women experienced a multitude of respiratory concerns including burns to the throat, mouth, and lungs; infections; and coughs and colds. Within the kit making sessions, women often described chronic respiratory concerns as “breathing or lung problems” which referred to experiences of asthma, emphysema, and bronchitis. In some instances women were unaware of the diagnosis associated with their  21 Examples of other health problems included asthma, pneumonia, musculoskeletal problems (e.g., sore back; neck pain, arthritis), diabetes, endocarditis, HIV, HCV, weight loss, swelling in hands and feet, PTSD, and traumatic injuries (e.g., head injury, stabbing).    132 respiratory problems, and understood them solely in terms of the symptoms they experienced. As one woman noted, “My lungs – there is all this stuff in there. I take medication for it” (IP153). Recurring coughs, colds, and flu-like symptoms were common experiences for women involved in all aspects of this project. Statements such as: “I have had four colds in the last month” or “I’ve been sick for days with this cold” were common. Women complained of colds and flu-like symptoms in nine of the 18 kit making sessions, and six of the women who participated in the lengthy interviews had a cold at the time the interview was conducted. Women often became sufficiently ill that they were unable to leave their homes for several days to weeks at a time, which then contributed to them missing other essential health care appointments such as picking up prescriptions or following up with a physician to address another health concern. In most of these instances, the respiratory problem was more severe than a common cold, but women equated any new onset of “breathing problems” or sore throat with having a “cold.” Women described many scenarios in which they were at home “with a cold” only to have their health deteriorate to the point that required hospital admission, predominantly due to experiencing pneumonia. Although lung infections were among the lowest occurring respiratory problems noted in the survey data (36.6%), during the interview and kit construction portions of this study there was an outbreak of pneumonia in the City of Vancouver that primarily affected residents of the DTES. As noted in a memorandum from the Vice President of Medical Affairs for Vancouver to physicians working within the local health authority, many of the people infected “…presented in septic shock and nearly a third required intubation and admission directly to ICU. Lengths of stay in ICU are averaging two to four weeks” (Providence Health Care, 2006, p. 1). Many women had either been hospitalized or knew of a friend who was hospitalized during this outbreak. The impact of pneumonia for women’s health was articulated clearly in the description   133 of the experiences of a 45-year-old woman living with HIV, HCV, asthma, depression, and arthritis who had been hospitalized due to pneumonia. IP(005): My whole body was sick. Yeah, I didn’t even know what it was. I was out of breath, walking to the clinic to pick up my script [methadone], having to stop all the time. This whole side here, [pointing to the front of her chest on one side] was like on fire and really hurt…And it was both sides. I was like ‘check me out,’ and she [her doctor] said ‘[name] you are going to the hospital right away.’ She called the ambulance right away. I thought I would be there for four or five days [instead of three weeks]…Yeah and I didn’t even know that I was that sick. It came up slowly, I figured it was just a cough, you know getting worse. But it really hurt.   Among women who experienced colds, many also experienced rhinitis that contributed to excoriation around their noses. During our conversations, women described these experiences as “very painful” and attributed this problem to “blowing my nose so much.” It was not uncommon for me to observe severe chafing and dried blood around women’s noses and women described a sensation of their “skin ripping apart” when they had to blow their nose. Access to tissues often meant taking toilet paper from a public washroom or requesting tissues from a drop-in centre. Due to their limited economic resources, women could not afford to buy tissue paper that was softer or had moisturizers within. They reported instead that they had to buy the “cheap stuff” and that these tissues and the toilet paper were “harsh” on their faces. Women also could not afford to buy creams or moisturizers that would help to alleviate the pain around their nostrils or prevent the chafing from occurring.  My field observations and interviews with women supported the survey findings that sore throats and laryngitis were frequently experienced. Many women’s voices were raspy and on some occasions it was obviously painful for them to talk. Women reported getting a sore throat as frequently as once per month. While in many instances a sore throat was related to getting a “cold” or the “flu,” in some instances the experience of a sore throat was associated with immunocompromise such as occurs with HIV: “I’ve had tonsillitis for a few weeks. My count [CD4] is low and I get sick really easy” (IP143). Additionally, many of the women joked   134 amongst themselves that sore throats were due to smoking crack as reflected in the following dialogue between two of the participants. IP(092): I think I need some Halls or something, my throat really hurts.  IP(093): [Laughs and playfully taps the other woman on the arm] You smoke too much…that’s what is going on.  IP(092): It’s not smoking this time. I am coming down with something. My throat has been sore for a couple of days and it is really raw.  The experience of a sore throat associated with crack smoking was related to the drying of women’s mouths and throats, due in part to the pharmacology of cocaine (e.g., drying effect) as well as burns that resulted from the inhalation of hot particles such as steel wool or glass. As one participant noted: IP(104): Man, I swallowed my brillo and I just kept hacking and horking until I coughed it out, and that really hurt. I had this huge burn in my throat right here [she pointed to the side of her throat just below her chin]. It hurt really bad for about three weeks.  The inhalation of particles also contributed to the production of phlegm, the coughing up of which only further exacerbated throat soreness. Women expressed concern that the impurities associated with crack cocaine, a phenomenon referred to as “bad dope,” also contributed to respiratory problems. IP(010): My partner he deals with the Iranian guys out there, he works for them every day. When he comes home he has enough for us to get high. When I smoke that dope I’ll get this really nasty cough and it feels like I can’t breathe. It’s a dry cough. But when I score off of other people I don’t have that.  As women’s health deteriorated over the course of their lives, respiratory concerns were identified as one of the most significant indicators for worsening health and women often associated these concerns with the experience of dying. This was particularly relevant for women living with HIV as evidenced by the following quote from a woman who had been living with HIV for 21 years and who was quite ill at the time of our meeting. IP(171): I know that I am getting sicker all the time. I have been sick now for a while with my lungs. I know I might be dying and I don’t want to die. I don’t want to go   135 through that. [My doctor] said that if I don’t get better soon I am going to have to go into the hospital. I don’t want to do that. I don’t want to die there. She said something about PCP. What’s PCP?  Musculoskeletal Health Concerns  The majority of women experienced a myriad of concerns associated with their musculoskeletal health including bone infections, reduced bone density, arthritis, impaired mobility, fine hand tremors or “the shakes,” and traumatic fractures, sprains, and soft tissue injuries. Women’s general appearances illustrated that their bodies exemplified the realities of these health concerns. Many women walked with visible limps and several women over the age of 50 had noticeable facial drooping associated with having a stroke. Some women had mobility aids such as walkers, canes, or crutches, while other women reported needing such devices. Arthritis was prevalent among women over the age of 35 and was cited by women as the most significant factor contributing to their impaired mobility and chronic pain. Many women took frequent breaks during kit making to exercise “stiff joints” or to relieve pain particularly in their shoulders and lower back. There was significant frustration associated with impaired mobility, especially in terms of the impact on women’s abilities to engage in regular daily activities. IP(008): When I walk downstairs it takes me half an hour. If I go shopping I have to bring a, a cart for shopping or I ask my son to come with me…Arthritis is really hard.  Scarring was another physical attribute that exemplified women’s musculoskeletal health concerns. The majority of women had a wide range of visible scars including surgical scars of the shoulders, neck, legs, arms, hands, and feet; jagged scars on the inner aspects of their forearms and wrists; and circular scarring patterns on the backs of their hands. Health issues such as reduced bone density, bone infections, depression, and fractures were frequently associated with scarring as exemplified in the following excerpt from an interview with a 38-year-old woman who, at the time of our first interview, had recently recovered from osteomyelitis (a bone infection) that required multiple surgeries and six months of halo traction.   136 IP(002): So, they tried to do a bone graft and it wouldn’t take which makes sense because after having been a heavy user for so many years and my bones and teeth being compromised, why would it, uh, you know, why would my bones that are already weak and not the greatest to begin with? It makes sense that it wouldn’t hold a heavy head and do the job that it needed to keep my neck stable, so they ended up doing a second surgery and putting a little piece of metal in there.  In addition to scarring, many women had casts or ace ba