1. The Experiences of Women Receiving Injections from Others Charlotte Tompkins Nat Wright

2. Background Women more likely to be injected: –Lack knowledge & experience especially at initiation –Smaller veins make it harder to self inject –Men may be better, quicker and limit physical damage –Gender dynamics - men may control drug supply

3. Why does this matter? Receiving injections from others associated with –HCV and HIV risk and sero-conversion –Needle and paraphernalia sharing Those who inject others may have first use of shared needle Most literature not UK based IDUs unaware of the risks Implications for injector if recipients overdose

4. Qualitative Methods 45 in depth interviews 2 geographical areas Conducted in private, in services Written consent obtained Lasted 30 – 90 minutes Tape recorded, transcribed Grounded theory analysis

5. Women Participants 25 from North Notts, 20 from Leeds Age range 16 – 46 All but 2 white British Injecting histories range 5 months - 18 years All had been injected by others including friends, associates, partners and family Last time they had been injected ranged from that day to over 2 years ago

6. Main Findings Initiation into Injecting –All but one were injected by another the first time, mainly by males (usually boyfriends) –Often because there was not enough to smoke they did not know how to inject they feared needles

7. “I didn’t know what to do, like how to cook the stuff up and like put it in the pin and get myself. He (boyfriend) like showed me what to do, he told me to pull my sleeve up, put the tourniquet round my arm and then he injected me cos I just didn’t know how to do it.” (Anne, 19)

8. Injecting Order –Usually determined by the injector –Women mainly had to wait until injector injected self –Injector’s condition often affected technique, especially if they had already self injected –Heavily intoxicated injectors placed women at increased risk of physical harm

9. “We’d been brought up old fashioned, thinking ladies should go first, even though it’s a drug, thinking, ‘why cant you do me first?’ He’d (ex – boyfriend) done himself and then he’s hurting me afterwards. I used to get angry, very angry and it caused a lot of arguments and I ended up probably getting slapped and being told to wait and basically cos I couldn't do it myself, I had no choice.” (Hannah, 33)

10. “It used to right piss us off, because I used to always have to wait, do you know what I mean? When I was rattling and I was ill, for everybody else to have a dig before someone could help me, do you know what I mean? And I used to think, ‘God, if I could only do it myself, it would be a lot better.’” (Ella, 17)

11. “What annoys me with (boyfriend), he gets himself first, before me, where it should be the other way round, he should be getting me first before him because once he’s had a dig, he’s all gouchy, all over the place and then when it comes to try and get me, he’s all over the place.” (Sharon, 18)

12. Risk Perception –Confusion over the risks of being injected –Some thought there was no risk as long as the injector was careful and took their time –Linked to the injector’s skill –Increased awareness of potential trouble for injector if injectee overdosed

13. “There’s a lot of risks ‘cos they could hit anything, they could miss, they could do owt, couldn’t they?” (Sophie, 20)

14. “As far as I know, if you injected me, I can’t get nowt from you, just by you sticking a pin in my arm, do you know what I mean, unless, I don’t know, unless pin’s infected, but I can’t actually get anything off you by you doing it, ‘cos you’re not doing owt, all you’re doing is sticking a pin in my arm.” (Katy, 27)

15. Watching –Varying ideas about whether to watch when being injected –Watching had benefits: Checks what injector is doing Could learn skill Prevents deception –Some were afraid and could not watch so turned away

16. “I always have to be watching because you can never sort of a hundred percent trust anybody if you’re not looking, you know, I’ve got to be looking.” (Beth, 27)

17. “I used to watch them go into my arm and then turn away as they were going to put it in me.” (Michaela, 28)

18. Skill of Injectors –Based on: injecting knowledge & experience proof they can inject themselves and/or others without problems –A skilful injector: looks and feels for veins takes time when injecting someone –Women were dubious of being injected by those who previously harmed or marked them and/or missed their vein

19. “Some people are absolutely brilliant, like they say they’re a doctor kind of thing, they could just put it in straight away and get someone, whereas like me, I’d like be sat there for an hour trying to do it.” (Lucy, 22)

20. “He’ll like wipe me with it (steret) first and like, he’ll take the tourney off for me, and like he’ll blow on it as he’s pushing it in, and like he’ll do it gently ‘cos like some people, like they just push it in dead hard and it fucking hurts, but (boyfriend) makes sure he don’t, he’ll like do it softly ‘cos like he cares whether he hurts me like. Everyone else, they don’t care.” (Liz, 20)

21. Injector – Injectee Relationship –All had received injections from males –Being injected in mutually supportive sexual relationship appeared to minimise harm –Being injected by close female friends appeared to enhance quality of the friendship –Withdrawal put women at greater risk as some were injected by strangers or drug ‘associates,’ who they did not know very well

22. “Just anyone would try to get you, if someone can’t get me, other people would be trying to do it. But I mean, its horrible actually, like three or four people would have a go.” (Sonia, 25)

23. “I think my husband takes more care of me than anybody, you know just anybody would, ‘cos I’m just a person to anybody else, where my husband takes care.” (Kerry, 31)

24. Experience of Harm –Often resulted from being injected –Mainly experienced misses, some purposeful –Some reported bruising, hitting arteries and overdose –Concerns raised that injectors cant feel what they feel unless told –Linked to skill of injector (care and time taken) and order of injecting

25. “When he was out of it, my ex partner, he’d just stick the needle in and my arm would be purple, and he’d just be stabbing at me and sometimes I’d probably end up with about eighteen holes all up my arm before I even got the drug.” (Hannah, 33)

26. Reciprocity –Exchanging drugs as currency for being injected was common –Giving drugs (up to half) is usually expected, especially if injector is rattling –Proximity of injector – injectee relationship important - less direct exchange between close friends and partners –No evidence of sex in exchange for being injected

27. “As long as you’re dependent on someone injecting you, they’re going to want some of your fix, aren’t they, ‘cos nobody does nothing for nothing, not in this world anyway. So you’re going to have to share your fix with them and it means your gear’s going to run out and you’re going to have to go lifting again.” (Ella, 17)

28. Trust –Trusting injector was important for most –Often would not let a person they did not trust inject them –Some had previously been injected by people they did not fully trust and experienced harm or problems

29. “I trust them not to make a mess of me, not to miss my digs on me, not to butcher me, in other words, like keep stabbing the needle in and out of me every two seconds.” (Alice, 19)

30. Case Studies 3 real cases For each case think about: –What the issues are around peer injecting for this woman –How you would work with this woman –What the management responsibilities of your service are when working with this woman

31. Kerry, 31 Lives in flat with husband Was curious about husband’s heroin use so tried it Was clean for a while and started reusing recently Dependent on husband to inject her as marks self if tries to self inject Only lets husband inject her as trusts him He injects her first and then self so he can concentrate He is quick and doesn’t mark her when he injects her Would inject self if could as knows own tolerance Husband stems her blood flow with his finger afterwards Wants to stop using and start detox with husband

32. Ella, 17 Initiated into amphetamine injection by older family member (dealer) Started tooting heroin when living in squat but friend suggested injecting Pregnant On methadone. Smoking heroin on top as worried injecting may harm baby First injected with heroin by male she did not know. Went over Kept being injected as was scared of self injecting Relies on others to inject her as has problem with own veins Feels safer when injected by someone with injecting experience Wishes she could self inject so would not have to wait for others Gives others half of her drugs in exchange for being injected Only self injects (in ankles or breasts) when alone and rattling Also injected ecstasy, tranquillisers & crack cocaine Tries to protect self by unwrapping pins for others to use to inject her Waited for a male friend to self inject before asking him to inject her Doesn’t trust women to inject as thinks they are less experienced than men Wants to give clean urine at pregnancy clinic, go to college and be a good mother, away from heroin

33. Jess, 23 Lives with parents and her 2 week old daughter Using heroin 7 years, never smoked it, injected straight away On methadone so cut use down to £10/ night Occasional crack use. Always self injects crack as gets vein easily First injected with amphetamine by male, but didn’t like it Injected with heroin by the same male. Went over Used to self inject in groin but became worried about risk of blood clots Finds it hard to self inject as has poor veins Mainly injected in arms by female friend, after she has self injected Sometimes helps female friend inject Female friend is good injector, ‘like a doctor’ and is given gear in exchange Sometimes injects in groin to prevent visible marks on arms Boyfriend in jail and doesn’t agree with her injecting Experienced many overdoses, especially when self injecting Been injected by ‘whoever,’ mainly boyfriends, brother & other men but no longer asks ‘anybody’ as does not trust them as experienced harm Believes being injected by someone who does not care is main risk

34. Implications for Drug Services Provide staff training: –Increase awareness of factors influencing a move away from peer injecting –Regarding the reality and complexity of peer injecting Encourage workers in drug services to: –form empathic, trusting relationships with women users to discuss peer injecting –feel confident to actively question women regarding safe injecting –impart choice and assertiveness skills to women receiving injections

35. Explore the social situation and relationships between injectors and injectees Increase staff awareness about potential risks of moving from “safe” peer injecting to “unsafe” self injecting Discourage injectors initiating others Provide harm reduction information detailing increased: –HIV, hepatitis and bacterial infection risks from being injected –risk of circulatory system damage from being injected

36. Reinforce harm reduction messages Identify those who regularly inject others Consider providing explicit instruction on injecting Provide harm reduction information for injectors about safest and most considerate techniques Encourage regular injectors: –to take time and care when injecting others and communicate with them –to think about their withdrawal/intoxication status when injecting others

37. Client Recommendations Encourage women being injected to: –self inject if they may experience less harm –not be injected by people they do not know or trust –take responsibility for preparing their own drugs –watch the injector from preparation to injection –negotiate with injectors regarding injecting order –communicate with injector during injection process –stem their own blood flow from their injection site

38. Stress to women that self injecting: –often means they are more independent –is more economical Stress to injectors: –bacterial, BBV & overdose risks of injecting others –legal implications of injecting someone who subsequently overdoses and dies If women move to self injecting discourage them from: –groin injecting –injecting alone to avoid overdose risk

39. c.tompkins@leeds.ac.uk n.wright@leeds.ac.uk 0113 3436966