Participant characteristics
The sample consisted of 26 women, ranging from 22 to 63Â years, with an average age
of 43.2Â years. The racial-ethnic composition was 48% Caucasian, 36% African American,
and 16% Latina. The sample was poorly educated, less than half graduated high school,
and the entire sample were unemployed. Sixty-four percent were single/never married.
Six women reported childhood sexual or physical abuse by male family members.
Four WIDUs were not participants in the SEP but receiving services in the HRC. All
participants reported a period of illicit non-injecting drug use prior to injecting.
The mean age of initial drug use was 16.2 years (r?=?9–29). First injection mean age was 23.8 years (r?=?12–58). Most injected heroin, with a few cocaine and speedball injectors. Average
duration of injecting drug use was 18.2Â years. Sixty percent were identified as self-injectors,
20% as assisted injectors, and remaining women were reported self and assisted injections.
Themes from the cross-case analyses
Three main themes emerged in the interviews with respect to the social, behavioral,
and contextual domains of WIDU practices and risks: (a) transitioning from non-injection
to IDU, (b) patterns and variations of initiation to injecting, (c) shifting toward
autonomy or reliance on others. These themes, along with illustrative quotes from
participants, will be discussed below.
Theme 1: transitioning from non-injection to IDU
Reasons why women transitioned from non-injection to IDU at any given point in time
were complex. The expense of sniffing or smoking drugs was the primary reason many
decided to begin injecting. For many women, drug use was often a social network experience
shared with friends, partners, and spouses. Most women expressed the importance and
safety of using drugs around people they knew and trusted. In many cases, the decision
to transition to IDU was influenced by a combination of factors.
Women non-injectors were advised by their peers about the benefits of transitioning
from non-injection to IDU. Examples included the following: they would use less drugs,
spend less money, and get a better, quicker high compared to sniffing. Prior to their
first injection, it was a common belief among participants that injecting would be
a way to get their expensive habit under control.
It was gettin’ expensive by sniffin’ and so my friend said it holds you longer and
you don’t have to be doin’ as much bags … by sniffin as injecting like they say, which
is what’s true (23).
For some women, the shift from intranasal to IDU to their first injection was based
on her need to increase the high and desire to go along with others or fit in with
IDU social network.
I sniffed heroin at 21 years old. I was 23 and basically wasn’t feeling it at all
anymore, and I was now with a crowd of shooters that looked at me like I had four
eyes because I sniffed (21).
It was common for experienced WIDUs to encourage their non-injecting friend to change
the route of their administration to injection by explaining the benefits of IDU such
as the better quicker high than the intranasal route of administration:
Me and her was together one day and she was like “Why don’t you shoot it? It’ll hit
you better and you’ll feel it much betterâ€, and I was real scared and she was like
“I’ll hit you, I’ll hit you, I’ll hit you.†That was the first time, she hit me, and
I started shooting drugs (1).
The transition to IDU was often motivated by curiosity and self-gratification. Women
were not always passive in the transition process. Often, they had an active role
in their shift to injecting. Some women stated that injecting for the first time was
their own idea, curious about injection but unable to inject themselves. This woman
wanted to inject heroin so badly that she “blackmailed†someone to inject her.
I got curious…one night I was like I want to try it, and he’s like, absolutely not
happening, and I’m like, listen let me tell you something. I’m the one that’s bringing
it [heroin] back up here and you ain’t going to find anybody else who’s gonna do it
who’s as young as I am, so either you turn me onto it or I go…He actually hit me before
he hit himself the first time (18).
Theme 2: patterns and variations of initiation into drug injecting
Most often, the first injection was prepared and administered by someone they knew,
usually through a well-established social network of IDUs. An important finding was
that again, a WIDU who was a friend or relative injected more than half the women
their first time. Most of the initiates had only one other person present at initiation
and in a private indoor venue; home, apartment, or bathroom. None of the women were
alone the first time they injected.
Experienced WIDUS very often served as instructors by explaining the injection process
and in almost most cases, the injector prepared the drugs and injected themselves
before injecting the other women. The skill of the injector was important to women
receiving their first injection. A skillful injector was thought to be anyone that
could inject them without any complication or marking. Some initiators would take
their time and be gentle, careful and patient and others already high may miss or
go through the vein.
This woman was already in withdrawal, experiencing symptoms and not fearful of being
injected the first time. She expressed how good she felt after the injection and no
longer in withdrawal and continued IDU following their first injection.
So she explained to me how it works… she told me not to be scared. I wasn’t. I really
was feeling sick. I needed to get straight. I saw how she did it, she tied me up with
her belt and she told me to relax and then she put the needle and got the vein real
fast and she told me that as soon as you…pushed the syringe back and you see the blood
floating, that’s how you get the vein. That’s all it took, just one time. The experience
was amazing. I instantly felt ok (10).
Only two women in the study self injected their first time but after they observed
another injector who served as their instructor, usually a female friend, acquaintance,
or relative. They both thought they had good veins.
Well, I injected myself. I watched somebody inject themself and since I had good veins,
at the time, I had no problem injecting myself…they showed me how to do it and that
was it (24).
Conversely, a quarter of the women reported a male sexual partner, spouse, or friend
initiated their transition to their first injection.
At first I snorted for a couple of years. Then after that I was seeing how…I’m snorting
five bags to their equal to two and they’re like stoned…I said to myself, you know
what? I never stuck a needle in my arm.’ I didn’t like needles. My sexual partner
did everything for me…injected me. The first time it was, ‘I’m home! This is it!’
And I never stopped from then (26).
In most urban areas where rates of IDU are high (NYC), there are common neighborhood
locales for purchasing and using drugs. Among the highest risk locales are “shooting
galleries†or “safe houses†places where people go and inject and usually pay in order
to be able to inject. Hit doctors are frequently male and known within the IDU community
for their skill as injectors. Some women who required assistance with their first
injection went to safe houses belonging to IDU friends who lived alone and would serve
as a place for a group of close friends to inject together.
For this woman, being reassured by an experienced, knowledgeable hit doctor who blew
on her skin as the needle was pushed in to reduce stinging when being injected. Often,
these decent experiences of assisted injecting ensured dependency on the hitter and
injecting at the same time.
I was young, 13 and down the block was what you’d consider a crack house and it was
really dirty in there and they had 10 cats. I sat on the couch…he had a ponytail and
he was really cool, he kissed my arm, before he did it and, I looked away and he did
it for me and it was quick (15).
Theme 3: shifting towards autonomy or reliance on others
Most women in this study identified as self-injectors. For these women, the shift
to becoming a self-injector is related to many protective strategies; independence
from other injectors, self-sufficiency, choice of body injection site, and control
over the time, place, and relative safety of injecting practices.
After learning how to self-inject, this woman expressed a strong sense of independence
and autonomy of her ability to learn how to self-inject.
I learned how to hit myself. A lot of people say, ‘oh well I need somebody to hit
me,’ not me. I close, I drew it, and I put it back in. I didn’t need nobody to help
me draw up. I didn’t need nobody to help me do that no more because I do everything
myself. Everything (11).
This woman described the process of teaching herself to self-inject. Her ability to
self-inject also instilled feelings of competence, independence, control of oneself,
and prevention of harmful, noticeable scars on her body.
First time I self-injected was in my hand, and I fucked it up, like twice. But you
know, then I got the hang of it. I didn’t push it in. I knew it wasn’t in because
the blood wasn’t registering…I have no track marks. I felt a hell of lot more independent
and more in control. …. Now I can do it everyday (18).
Another woman strongly described her choice to self-inject as a competent and safer
practice.
I watched somebody inject herself. I had good veins, at the time. I had no problem
injecting myself. They showed me how to do it and that was it. I think it’s safer.
I don’t want someone else injecting me. I can tell when I register. I shoot up in
my own way. That’s when I made the choice. I chose to be a self-injector because I
do it my way (24).
These experiences of self-injectors described above sometimes triggered women to contemplate
the intrinsic worth of self-injecting. Many of the women who were self-injectors expressed
a sense of autonomy and control in utilizing the SEP as a protective and safer measure.
I always use clean syringes from here, I shared one time in my life, and I was very
nervous, I got an HIV test after that. I was very scared to get that test, cause,
this person was a junkie, and dirty. I always carry cleans. If my friends didn’t have
cleans, I gave them cleans. If I use the same one more than once, I made sure I knew
it was mine, I had a little makeup case that I carried all my needles (26).
However, several women did describe requiring assistance with injecting because they
lacked knowledge, uncomfortable self-injecting, or small veins making self-injection
complex. Women who were injected by others experienced a lack of autonomy, reliance
on others, and fear of causing harm to themselves. People sometimes injected women
in areas of their body, or, they were people they would not ordinarily choose out
of an urgent need to alleviate withdrawal. These risks of being injected by others;
transmission of blood-borne viruses, bacterial infections, damage to the circulatory
system, and overdose were rampant among this group.
This woman appeared to be unaware regarding the potential risks associated with being
injected by another, until after she realized she was infected with hepatitis C.
I didn’t know how to hit myself. Then after a while she would do it for me, I would
have to call her. I started having to go to the shooting gallery…I learned when they
would hit you…That’s how I think that I contacted the hep C, you only get it blood
to blood. Then, I really did wanted to learn how to hit myself, but I never did learn
how to do that (1).
An implicit understanding existed for some women that they should not question the
injector’s skill or knowledge when being injected, for example, about which vein to
inject into. Women injected by others were clearly much less in control of their injecting
situation. Skillful and experienced injectors however did not always successfully
inject others. Women had experienced harm from injectors and often compared the abilities
of different injectors.
He was injecting me. At first, because very, very hard for me to hit myself. I had
these little girly veins. They roll. It’s really hard, so I used to let him hit me
in my neck because I had bad veins. It’s really hard (21).
Women requiring injecting assistance often spoke about being second on the needle.
It was common for the women to receive their injection after the injector had self
injected. The injector’s condition often affected the injection technique particularly
if they had already self injected. Injectors being heavily intoxicated when injecting
women placed them at an increased risk of physical harm.
Some women thought people who self injected before injecting them were selfish and
impatient for drugs.
I was asking do I need my own set? She would say no. She always went first and she
was mainlining and did me second and it was actually hell because I always had to
wait for her and then sometimes she didn’t clean the needle. [She] done die of AIDS (8).
For others, experiencing withdrawal affected their ability to assess risks or take
precautions. This woman describes how she just wanted to get high.
I didn’t think about safety…I didn’t think about nothin’. All I wanted was to feel
the heroin run through my veins. There was a needle that was shared and at the moment
I don’t even think about it. I didn’t think about this person, how well do you know
him or did somebody else use it and if he just cleaned it (7).
Women’s experience of physical harm and damage to their veins as a result of being
injected by others was common. Women spoke about the injector “missing†as a result
of the needle not going into the vein or being pushed through the vein were frequent
which often resulted from the injector rushing when injecting them due to their own
withdrawal. The injector’s condition often affected the injection as they took less
time and care when injecting the women if they had already self injected. Several
participants described harmful and risky syringe-sharing behaviors with IDU partners
who provided injection assistance:
He would have to hit me cause I couldn’t hit myself. Sometimes we would get I into
arguments over who would go first. We had this thing between us that we used to call
it I say I’m first on the case. But if I call I’m first on the case first, he would
get angry cause he had to hit me first. He would do it in a rough way (13).