“Bed bugs and beyond”: an ethnographic analysis of North America’s first women-only supervised drug consumption site
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This entry is our analysis of a study considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original study was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. The summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

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“Bed bugs and beyond”: an ethnographic analysis of North America’s first women-only supervised drug consumption site.

Boyd J., Lavalley J., Czechaczek S. et al.
International Journal of Drug Policy: 2020, 78, p. 1–10.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Boyd at jade.boyd@bccsu.ubc.ca.

‘How can the design of drug consumption rooms be optimised to maximise their benefits?’ – a question that has tended to be overlooked in the wider debate about whether consumption rooms should be established in the first place. The featured study goes inside North America’s first women-only safer injecting facility, which emerged in response to an epidemic of fatal drug overdoses and an epidemic of violence against women.

Summary Overdose deaths were declared a public health emergency in British Columbia (Canada) in 2016. In response, a range of novel community-driven public health initiatives were expanded, including injectable opioid substitution therapy (eg, pharmaceutical heroin), distribution of the ‘overdose antidote’ naloxone, and drug consumption rooms which provide hygienic and supervised spaces for people to inject or otherwise consume illicit drugs.

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Key points
From summary and commentary

Study investigates the subjective value of North America’s first women-only drug consumption room, SisterSpace.

Based on 100 hours of fieldwork, the researchers established that its setting, operational policies, and environment gave clients a temporary reprieve from stigma, discrimination, violence, and drug-related harms.

Drug use, drug policy and drug interventions have historically tended to be narrated and evaluated through men’s experiences. Putting women’s needs and experiences at the centre, the featured study identified barriers (and facilitators) to women accessing substance use support services that may be overlooked if the assumption of typical support services is that they are ‘gender neutral’.

Drug use, drug policy, and drug interventions have historically been narrated and evaluated through men’s experiences, which has minimised the visibility of women as people who use drugs and the potential recipients of drug use interventions, and by extension has minimised the visibility of experiences that women may need substance use interventions to respond to, including forms of violence that affect women disproportionately and can overlap with their drinking and drug use (eg, domestic violence, sexual violence, and harassment).

The featured study helped to address this void in information and understanding through investigating the experiences of women accessing SisterSpace – North America’s first women only safer injecting facility, based in Downtown Eastside, the urban epicentre of the Vancouver’s overdose crisis, and also the site of North America’s most comprehensive harm reduction services.

The study took place between May 2017 (when the doors of SisterSpace first opened) and June 2018, and involved researchers observing and interacting with service users for 100 hours. It was enriched by the lead researcher being familiar with the specific setting, and having several years’ experience conducting research with and for communities such as the one studied.

During the study period, 65–75 women visited the site each day, and interviews were conducted with a total of 45 women. As this was not the only drug consumption room many of the participants had visited and used, this gave the opportunity to compare and contrast their experiences of SisterSpace with drug consumption rooms that supported both men and women.

Roughly half of interview participants identified as white (53%) and half as Indigenous (51%), despite Indigenous people comprising only 3% of metro Vancouver’s population. The age of participants ranged from 24–60 years old. Most participants were unhoused or homeless at the time of the interview (62%), and had been incarcerated at some point in their lives (64%). Nearly half of participants had spent time in the foster care system (49%) and just under a third of participants engaged in sex work (31%). Some participants (7%) were transgender.

Main findings

The findings provide a story of the perceived benefits of a women-only drug consumption room, as told by women currently attending the service, and highlight some of the barriers to accessing this and other harm reduction services, particularly among pregnant and parenting women (click on the links below to skip to a section):

  1. It provided a ‘less institutional’ service
  2. It recognised women’s agency
  3. It responded to gender-based violence
  4. But it still didn’t exist as a ‘safe space’ for all women

It provided a ‘less institutional’ service

Women’s accounts of using the service suggested that the site provided a welcoming, non-chaotic environment in which to help to prevent (fatal) overdoses, and was perceived to address their wider needs to a greater degree than mixed-sex or mixed-gender drug consumption rooms. Addressing these wider needs was a conscious decision by the creators of SisterSpace, and was reflected in its operational policies. Overall, women valued SisterSpace for facilitating the prevention of overdose deaths in a less institutional or formal environment than other drug consumption rooms they had used:

“It feels like you’re not in an injection gallery. When you’re at SisterSpace it feels like you’re at a friend’s or your place or wherever. Like it’s not like a facility. It’s more open. It’s not isolated. You can converse when you’re using.” (Rose, a 35-year-old Indigenous woman)
“It’s not as regimented, it’s just more relaxed.” (Mireya, a 40-year-old white woman)

Like other drug consumption rooms in Vancouver’s Downtown Eastside, SisterSpace provided harm reduction equipment such as clean needles and syringes, needle disposal boxes, cookers, filters, single-person tourniquets, alcohol swabs, sterilised water packs, and fentanyl-testing strips. SisterSpace also provided tampons, and food including cereal, yogurt, juice, and pastries. Previous fieldwork confirmed that food was not routinely provided at other drug consumption rooms in the Downtown Eastside, and in this case, the presence of food seemed to increase participant engagement, engender a sense of support, and mediate the impacts of poverty, at least in the short term:

“[It’s] pretty nice and cozy and they have snacks and stuff like that there for the ladies, so I think that’s an extra privilege…” (Kiley, a 39-year-old Indigenous woman)
“For me it’s nice and quiet, relaxing… They feed you. It’s huge. Especially when you’re starving you know.” (Doro, a 32-year-old Indigenous woman)
The physical space of SisterSpace was deemed to be more welcoming than other drug consumption rooms

The physical space of SisterSpace was deemed to be more welcoming than other drug consumption rooms

Overall, the less regimented, more social atmosphere gave some women a better sense of having their basic needs met. Getting “your own nice space”, as described by Lauren above, garnered greater significance in the context of poverty and homelessness; for this group of women, the deprivation they personally experienced would often extend to the stark, stripped down spaces of low-income housing and more medicalised harm reduction services operating in Vancouver’s Downtown Eastside.

Participants’ views about the site’s atmosphere were consistent with fieldwork observations of SisterSpace’s physical set-up, which consisted of an uncluttered, open-concept space, with soft chairs, a couch, plants, a few movable screens for privacy, and a large communal table, as well as wallpaper depicting a nature setting along the side wall. Upon entering the site, participants could see the colourful handmade artwork by clients and staff displayed on the back wall, many with cultural and political references, including feathers, which have symbolic meaning for some Indigenous nations in Canada, and slogans such as ‘women just want to have fun-damental rights’ and ‘she persisted’. Such images, representing women’s creativity and input into the production of the physical space further established the setting as both non-institutional and inclusive.

Participant accounts also emphasised appreciation for the relaxed time limits. One participant explained that she had been to all of the drug consumption rooms in the area, which, in comparison, were over-crowded, chaotic, and occupied by men – attributes that seemed to run counter to a space designed for reflection, agency over drug consumption, and pleasure, which SisterSpace more explicitly sought to cultivate:

“The other ones, they just cattle you in like you’re a cat, like a cow, and they just want you to do your thing and go. Like, they just, like, shuffle, shuffle. …there is chill spaces, but, I mean, they’re overcrowded. There’s always guys there and, I don’t like them, like, the men with the ego thing, and they… they’re always, like, really aggressive, and it’s really, It’s like a shit show in there, in those [consumption] galleries. And, like, most places you want to be quiet, and, like, you know, you just want to collect your thoughts, and just, like, do your thing and enjoy it. Those other places, they’re just fucking chaotic, man. Like, who wants to be in a chaotic spot when you’re getting high on speed? It’s like double-whammy, you know?” (Ayesha, a 38-year-old Indigenous woman)

Researchers observed that relaxed time limits accommodated diverse drug-using practices, particularly for women preferring to stagger the consumption of their drugs (repeatedly consuming small amounts of their drugs over a longer period of time) during a single visit to the site in order mitigate the risk of overdose. SisterSpace did not have as high a volume of clients as other drug consumption rooms in the area, which made this possible, although numbers increased over the course of fieldwork.

It recognised women’s agency

A key aspect of its service design and delivery was the demarcation of SisterSpace as a women-only space (transgender and non-binary inclusive), supported by an all-women peer staffing model. These specific policies increased women’s feelings of agency and expression, and elevated these women – who use illicit drugs – to the status of ‘knowledge-producers’ within a broader experience of stigma and marginalisation.

Participants expressed unequivocal appreciation for the site’s women-only policy and operational efforts towards cultural safety and inclusion, for example diversity among peer staff and specific cultural practices such as ‘smudging’, a cleansing ceremony practiced by many Indigenous communities involving the burning of a small bundle of sacred herbs.

Women emphasised that there was a particular level of comfort that couldn’t be achieved or delivered in presence of men. One participant said that the absence of men enabled woman to be less defensive and more vocal:

“[SisterSpace is] more down and personal. And not only that; when you get a group of women together, there’s a certain lingo in the air, you know, with the… just being a woman, the essence of woman, right? So it’s a little bit more comfortable, more open space. We’re more open to each other. We don’t feel we have to be defensive or hide, you know? That sort of thing.” (Loretta, a 45-year-old Indigenous woman)

The same participant noted that because of the heighted sense of comfort she experienced at SisterSpace, she no longer frequented other drug consumption rooms:

“I just go to SisterSpace now. That’s it … Every day. Every day. Morning and night.”

Participants not only respected that peer workers had knowledge and expertise garnered from lived experience, but they perceived that this gave them greater capacity for empathy and a lack of judgement. Participant accounts demonstrated that peer staff and service users were responding to the overdose crisis in a careful and sensitive manner. After trying other drug consumption rooms, one participant said that she began only frequenting SisterSpace for its women-only setting, and less stigmatising staff:

“I like SisterSpace. You know, for all girls, I liked the vibe there. It was good. Like for just women only. Like I thought it would be more… I thought it would be different. But no, I liked it. It was good. … The other injection sites, they’re more regimented. Like and the staff are rude, I find, to you. It’s more personable there [at SisterSpace]. … The staff. They’re really caring. I think they go out of their way to make you feel good. Which is good, because people look down their nose a lot at addicts, and they kind of just… they’re there to make you feel comfortable. Like it’s good for everything, really.” (Lottie, a 43-year-old white woman)

Interactions between women actively established the site as a space that centred women’s voices, experiences and needs – for example, providing space to communicate how SisterSpace could better address their health and wellbeing (ie, the need for food, overnight hours, and more Indigenous-focused programming). A greater ability to be vocal and participate in the space was particularly significant for Indigenous women who often described feeling undervalued and/or socially excluded in other service settings.

Although transgender women and non-binary people represented a minority in the space, Diane (a 32-year-old white, transgender woman) described experiencing SisterSpace as more transgender-inclusive than other services:

Participant: “Well being trans … you know like it’s, it can be really uncomfortable in a lot of places even though Vancouver’s great, accepting … we didn’t want to try or expose yourself to that, uh, hate. SisterSpace is a safe place.”
Interviewer: “It’s a safe place … because it is trans inclusive?”
Participant: “Very inclusive… The ladies that are there in the morning are awesome, they’re so awesome … I’ve always felt great and welcomed and you know it was really hard for me to go there to be honest cause when I started going there I was just still kind of figuring everything out and where this is all going and, uh, and yeah and then seeing girls that I know, that know me I guess or whatever and being whole and being super positive about it was nice and it’s cool and yeah, I mean it’s a great place.”

Another participant spoke about feeling cared for in a manner distinct from other drug consumption rooms:

“Honestly, for me, I just really like the girls that work there, they are really nice. They’re different than any… like all the rest of the people that work at any of those [other] places in the entire city, the ones they have there [at SisterSpace) are like awesome… They just feel like, I don’t know, it’s just like my mom kind of. Reminds me of my mom.” (Cherry, a 35-year-old white woman)

An important outcome of participants associating the women-centred, peer-led environment with comfort was knowledge-sharing between clients and staff. Researchers observed women regularly sharing experienced-based information in non-stigmatising ways on a range of health-related topics including drug toxicity, accessing withdrawal services and opioid agonist therapy, housing and shelter, and safer sex work tips.

Due to peer involvement from women in the local community, conventional power hierarchies within services (eg, between staff and service users) were less apparent, though still existed. This had a positive impact on women using the service, but also on staff who can be affected by conventional power hierarchies too.

It responded to gender-based violence

Participants’ experiences were shaped by different forms of gender-based violence, which overlapped with and sometimes superseded the need to access overdose-related harm reduction services. A number of participants linked the overdose epidemic to the missing and murdered women epidemic in Canada (1 2), with one participant expressing frustration with both the general public and law enforcement for their apathy in relation to both.

A central component of wellbeing in SisterSpace was the absence of unwanted men’s attention and violence encountered in other settings. SisterSpace was perceived to give women a non-threatening space in the absence of predatory male violence:

“[SisterSpace] is quiet and nonthreatening, there is no anxiety.” (Max, a 30-year-old white woman)
“Yeah [I feel safe]. Even their [client’s] boyfriends, the staffs’ boyfriends aren’t even allowed in there [SisterSpace]… because like guys will fucking prey on fucking chicks that are high.” (Amira, a 28-year-old white woman)

One participant explained that men not being present at SisterSpace “makes [me] feel safe”. When asked if she had experienced men’s violence at mixed-sex or mixed-gender drug consumption rooms, she explained that she hadn’t, but that past negative experiences with men led her to prefer SisterSpace. Other participants described having been or felt threatened by men they knew when at mixed-sex or mixed-gender drug consumption rooms.

Whereas the interior of SisterSpace represented a haven from men’s violence, the building was not entirely divorced from it. For instance, on some occasions, disparaging comments could be heard from men outside, and shortly after it opened a man threw a brick through the site’s front window in a fit of anger. One participant noted that, while some men’s responses were inappropriate and disrespectful, SisterSpace functioned as a private site of pleasure for women:

“Don’t think you can stop here and check out the girls and that. No, this is their private space and this is their pleasure space. Please keep on moving, right?” (Loretta, a 45-year-old Indigenous woman)

But it still didn’t exist as a ‘safe space’ for all women

Although SisterSpace staff said they made an effort to increase support for pregnant women accessing the site, substantial barriers remained for pregnant and parenting women in the form of stigma and fear of legal repercussions. One participant explained that even a women-only site cannot ensure equitable engagement as pregnant women and women with children may refrain from using the service for fear of their children being taken away by social services:

“I’ve never seen a pregnant woman in [SisterSpace], first of all, and I never seen anyone I know who has their kids. I think they would be discouraged because they don’t want people to see them and call [social services] on them.” (Rose, 35-year-old Indigenous woman)

Something not encountered during fieldwork at other drug consumption rooms, but vocalised among women at SisterSpace, was the ongoing struggle and heartbreak incurred from child custody issues, including dealing with ex-spouses and social services, as well as the lack of housing and treatment options for pregnant or parenting women. Indeed, as one leaves SisterSpace, generally accompanied by the mantra “be safe” from staff, it is near impossible to overlook the neighbouring graffiti on walls and doors commenting on a range of marginalised women’s and Indigenous issues, particularly violence and child apprehension:

“I miss my sisters”.
“I wish I was with my kids instead of here. I miss them so much”.
“Foster care operates in [British Columbia] as the new name for residential school”.

The authors’ conclusions

SisterSpace, North America’s first women-only drug consumption room, was found to give its clients a temporary reprieve from stigma, discrimination, and violence at the same time as reducing drug-related harms, and achieved these benefits through its:
• setting (non-institutional);
• operational policies (no men; inclusive of all women);
• environment (diverse group of women who use illicit drugs interacting).

The calm, quiet environment was significant for this group of women who were vulnerable to everyday gender-based and racialised violence, and often unhoused or precariously housed in male-dominated settings (1 2). The use of peer workers was also significant given the pervasive stigma and discrimination encountered in Vancouver’s healthcare services among women who use drugs, especially Indigenous women, transgender women, and women involved in outdoor sex work (1 2 3 4).

Based on 100 hours of fieldwork, the featured study found that there was value in engaging with social problems beyond overdose prevention inside a drug consumption room. Participants’ accounts highlighted the severe level of deprivation they were living with, and the imperative of establishing interventions to meet their basic human needs as the norm rather than the exception. The casual conversations within SisterSpace during fieldwork conveyed the ability of women accessing the space to give voice to how women who use illicit drugs were dealing with discrimination and stigma, everyday male violence (eg, intimate partner, predatory) and poverty on an on-going basis outside of the site.

The study, of course, also had limitations. As participants were recruited solely from SisterSpace, the views of women who could not or did not wish to access the site were not represented. The study was also undertaken in an urban location with alarmingly high rates of overdose deaths, and might have produced different findings or come to different conclusions under less life-threatening and challenging circumstances. Finally, SisterSpace may have created a relatively safe space, but the threat of children being taken into ‘protective custody’ remains a constant fear and barrier to marginalised women accessing harm reduction services (1 2 3), including low-barrier drug consumption rooms such as SisterSpace.

Findings logo commentary The featured paper analysed the subjective value of a women-only drug consumption room, and in doing so showed how a substance use service ‘open to everyone’ (ie, women and men) could inadvertently exclude or marginalise women by failing to make provisions for their specific needs.

Time for safer injecting spaces in Britain?

The Scottish Government has recognised mounting harms to the health, wellbeing, and dignity of people who use drugs, and supports trialling drug consumption rooms as part of an approach to substance use based on public health objectives and human rights principles. However, the UK Government based in Westminster (London) has repeatedly“We have no intention of introducing drug consumption rooms, nor do we have any intention of devolving the United Kingdom policy on drug classification and the way in which we deal with prohibited drugs to Scotland” (Home Office Minister Victoria Atkins, January 2018, House of Commons debate on drug consumption rooms).

“There is no legal framework for the provision of drug consumption facilities in the UK and we have no plans to introduce them” (Prime Minister Theresa May, July 2018, Prime Minister’s Questions).
blocked any such action. This stalemate provides the backdrop for an Effectiveness Bank hot topic exploring the following questions:
• In communities dealing with the consequences of public injecting, could drug consumption rooms be part of the solution?
• Knowing the human cost of unsafe public injecting practices, would it be negligent for governments not to consider them at this point?

The UK has yet to see a legally-sanctioned drug consumption room within its borders (see side panel). However, the debate continues on home ground about the potential benefits, and the featured study represents a useful extension to the evidence base, in particular probing how the design of drug consumption rooms can be optimised to maximise their benefits for women. Overall, the findings didn’t suggest that women wouldn’t use mixed-sex or mixed-gender drug consumption rooms, but they did suggest that the outcomes for women were enhanced when the intervention was deliberately crafted to cater to women’s needs.

A ‘bottom-up’ response to two epidemics

SisterSpace represented a bottom-up response to two epidemics in British Columbia: an epidemic of fatal drug overdoses; and an epidemic of violence against women. As the featured paper described, it sought to mitigate the effects of both through the following:
People: Central components of wellbeing in SisterSpace were the absence of violence and unwanted men’s attention, things reportedly encountered in other settings, and the presence of women as peer workers, who were able to demonstrate being in caring roles and in positions of authority, flowing directly from their own lived experience.
Place: The less regimented, more social atmosphere gave women a better sense of having their basic needs met. The “nice space” in SisterSpace took on greater significance in the context of lives shaped by poverty and homelessness. The level of comfort was also increased by the absence of men, which helped cultivate the feeling that women could take up space and spend time there.
Provisions: Like other drug consumption rooms in Vancouver’s Downtown Eastside, SisterSpace provided a range of harm reduction resources, such as clean needles and syringes, needle disposal boxes, cookers, filters, single-person tourniquets, alcohol swabs, sterilised water packs, and fentanyl-testing strips. Unlike other drug consumption rooms, it also routinely provided tampons, and food including cereal, yogurt, juice, and pastries.

However, despite the SisterSpace service model seeming to improve the accessibility and impact of a drug consumption room for women, it could not overcome one particular barrier: the study found that pregnant women and women with children may still not access the site due to fears of their children being taken away by social services. This finding is backed up by the wider evidence base. Mothers or pregnant women who use drugs commonly report that they are reluctant to access healthcare and harm reduction services because of the risk of losing custody of their children (1 2 3). Due to the fact that women tend to be the primary caregivers and bear the responsibility of pregnancy, women have more reasons and more occasions than men to ‘avoid detection’ by healthcare, criminal justice, and social services. This might lead pregnant women to hide or deny their pregnancies, and delay or avoid prenatal care, as well as not seek help for their substance use problems.

Different risks, different needs

Men use illicit drugs in greater numbers than women, experience drug-related harm in greater numbers, and make up the majority of those in treatment. UK-based sources bearing out these patterns include the following:
• The 2018/19 annual crime survey results for England and Wales, published by the Home Office, indicated that the rate of illicit drug use was higher among men than women (13% vs. 6%).
• The NHS Digital survey of mental health and wellbeing in England, last completed in 2014, showed that signs of dependence are higher among men than women (4% compared to 2%).
According to the annual accounting of the treatment caseload from Public Health England, over two-thirds of people in treatment in 2018/19 were male (69%), and nearly three-quarters of those in treatment for opiates were male (73%).

However, viewing substance use problems and solutions through the lens of men’s experiences, as has tended to be done, is problematic as it obscures the unique needs that women have and the unique barriers they may face in accessing services. A paper published in 2018 by the same lead author as the featured study in the journal of Addiction adds more insight into the way women may differently (and in some ways disproportionately) be affected by drug-related harms.

Based on 185 hours of observation and in-depth interviews with 35 women recruited from three drug consumption rooms, this sister study found that women were at increased risk when injecting in public due to the risk of sexual violence from men. This risk had been amplified since fentanyl (a very strong opioid, sometimes mixed with heroin or cocaine) entered the market – causing severe intoxication and overdose to occur more quickly, and from the consumption of smaller amounts of opioids. Fentanyl or drugs mixed with fentanyl were also being offered to women in extreme poverty for the purposes of “knocking them out” to sexually assault them. One participant had recently accepted a stranger’s offer of “a hit of down” (opioids) and subsequently lost consciousness due to its potency, later awakening to discover that she had been sexually assaulted and robbed.

By giving women a safe space to inject ‘off the streets’, the study indicated that drug consumption rooms in general had an important role to play in addressing the overdose crisis and violence against women crisis. However, drug consumption rooms were also seen as “masculine spaces”. The services were primarily accessed by men, and women were routinely subjected to harassment, which both reinforced their marginalised status within drug consumption rooms. Furthermore, the services were sometimes accessed by men who had previously victimised women outside the drug consumption room. Taken together, the findings of this and the featured study affirm the potential benefits of drug consumption rooms for men and women who would otherwise be injecting in public places, but also underscore the fact that drug consumption rooms may not provide equal benefits for men and women unless concerted action is taken to meet women’s gendered needs and address gender inequality within the service walls.

Everyday violence

Another group of researchers in Canada further interrogated the theory that unequal power relations can magnify the level of risk during the overdose crisis, asking whether violence operating within street-based drug scenes also renders some men vulnerable to violence – specifically, men who do not (or cannot) occupy dominant roles due to age, disability, health status, social isolation. Through in-depth interviews they found that: both women and “marginal men” experienced violence, which tended to be concentrated in high-traffic drug market locations; participants actively avoided these “dangerous” areas to limit their exposure to aggressive and violent men; and reasons for needing to cross into dangerous areas included for income (eg, nearly all the women interviewed were engaged in sex work) and to get drugs when they could not access them through usual or preferred means.

Harm reduction services can provide respite from everyday violence as well as a way to mitigate the harms of drug use.

The researchers found that violence was a normal and pervasive part of the lives of vulnerable men and women who use drugs, and that harm reduction services can serve to provide respite from this everyday violence as well as a way to mitigate the harms of drug use.

The paper encouraged readers to think beyond the binary of ‘men as perpetrators’ and ‘women as victims’. However, if the aim was to facilitate a more nuanced discussion, it seemed to do just the opposite – obscuring the different and disproportionate ways that women are exposed to harm. The study operated on the simple classification of men as either ‘dominant’ or ‘marginal’. This enabled the researchers to illuminate the unequal distribution of power and status among men in this drug scene, and the violence that some men were exposed to by other men. However, by stopping there in their analysis, the researchers merely introduced another binary (‘dominant men as perpetrators’ and ‘women and marginal men as victims’). This painted over the fact that even men occupying a relatively marginal position could also be perpetrators of violence towards women, and in mixed-sex or mixed-gender drug consumption rooms, women may not get the respite from harassment, violence and fear of violence that men might get, remembering that the sister study in Addiction found that drug consumption rooms were sometimes accessed by men who had previously victimised women. In the study of everyday violence, “marginal men” included men who were sleeping outside and/or socially isolated – descriptors that would presumably be common among the target population of drug consumption rooms.

Drug consumption rooms: reaching their harm reduction potential

Drug consumption rooms are designed to reduce the risks of injecting drug use by providing hygienic and supervised spaces for people to inject their illicit drugs. Evidence suggests that women who inject drugs may face higher levels of injecting-related risk than men (1 2 3), but are less likely to access harm reduction programmes. A study in Sweden investigated barriers and facilitators to needle exchange use among women, finding that while women were primarily motivated to access the needle exchange for sterile injecting equipment, knowing that staff would treat them in a respectful way and that they could access a multitude of other health and women’s health services (eg, contraception and cervical cancer screening) were factors that bolstered their attendance. Reasons given for not wanting or not being able to attend included fear of losing custody or visitation rights to children, male partner jealousy and violence, unwillingness to spend time in the waiting area, fear of receiving positive test results for HIV or hepatitis C, limited opening hours, and too far to travel to the needle exchange. To strengthen the programme, most participants proposed some form of women-only access to the needle exchange to strengthen the feeling of it as a safe space.

Getting people through the door and feeling comfortable enough to stay the other side is patently very important if drug consumption rooms are to reach their harm reduction potential. In 2014, the European Harm Reduction Network published a paper detailing some of the barriers people who use drugs face in accessing drug consumption rooms. The most obvious barriers are created by admission criteria – put in place and justified on the basis that they protect clients and staff, and enable staff to run a safe facility. Studies of existing facilities also suggest that there are hidden barriers, meaning that drug consumption rooms may unintentionally be excluding or failing to explicitly include all groups at risk from public injecting, including pregnant women, people who cannot self-inject, and people whose patterns of drug use mean that they need 24-hour access.

The Effectiveness Bank hot topic “Time for safer injecting spaces in Britain?” goes in-depth into the evidence base around drug consumption rooms, including whether they produce sufficient benefits, without the feared countervailing problems.

Last revised 08 March 2021. First uploaded 05 January 2021

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