Between Care and Control: Examining Surveillance Practices in Harm Reduction.

As harm reduction programs and services proliferate, people who use drugs (PWUD) are increasingly subjected to surveillance through the collection of their personal information, systematic observation, and other means. The data generated from these practices are frequently repurposed across various institutional sites for clinical, evaluative, epidemiological, and administrative uses. Rationales provided for increased surveillance include the more effective provision of care, service optimization, risk stratification, and efficiency in resource allocation. With this in mind, our reflective essay draws on empirical analysis of work within harm reduction services and movements to reflect critically on the impacts and implications of surveillance expansion. While we argue that many surveillance practices are not inherently problematic or harmful, the unchecked expansion of surveillance under a banner of health and harm reduction may contribute to decreased uptake of services, rationing and conditionalities tied to service access, the potential deepening of health disparities amongst some PWUD, and an overlay of health and criminal-legal systems. In this context, surveillance relies on the enlistment of a range of therapeutic actors and reflects the permeable boundary between care and control. We thus call for a broader critical dialogue within harm reduction on the problems and potential impacts posed by surveillance in service settings, the end to data sharing of health information with law enforcement and other criminal legal actors, and deference to the stated need among PWUD for meaningful anonymity when accessing harm reduction and health services.

"The Law Doesn't Protect Me": Examining the Effectiveness of Good Samaritan Drug Overdose Legislation.

Background: Amid an unprecedented overdose crisis in Canada, the federal government passed the Good Samaritan Drug Overdose Act, which provides immunity from simple drug possession charges to overdose witnesses who phone 911. The law was meant to address the barriers posed by police presence and to encourage bystanders to seek emergency supports. Objectives: Our goal was to examine the effectiveness of the Good Samaritan law from the perspective of people who use drugs. We wanted to find out how aware they were of the law's protections and limitations, if first responders were adhering to the legislation, and if it ultimately had an impact on bystanders' helpseeking behaviors. Methods: We engaged a participatory research process that included surveys and focus groups with 109 people who use drugs in Ontario, Canada. This article focuses on the qualitative findings from focus group with 40 individuals in three cities. Results: Our results reveal that people who use drugs are confused about the law's safeguards, and based on their negative experiences with police, do not trust police to uphold the letter or spirit of the legislation. As a result, many engage in strategies to avoid contact with law enforcement. Conclusions/Importance: Greater knowledge of the law is beneficial, but even with such knowledge, mistrust of police and fear of criminal charges continue to deter people from calling 911. Good Samaritan laws would be more effective if they included a broader range of protections beyond simple possession and if police did not routinely attend overdoses.

Anti-trafficking saviors: Celebrity, slavery, and branded activism.

This article traces the development of popular forms of anti-trafficking activism in the United States through a social network and discourse analysis that focuses on NGO websites, celebrity advocacy, merchandising, social media campaigns, and policy interventions. This "branded activism," as we describe it, plays an important role in legitimizing an emerging anti-trafficking consensus that increasingly shapes both US foreign policy and domestic policing, and is frequently driven by an anti-sex work politics. Popular anti-trafficking discourses, we find, build on melodramatic narratives of victims and (white) saviors, depoliticize the complex labor and migration issues at stake, reinforce capitalist logics, and enable policy interventions that produce harm for migrants, sex workers, and others ostensibly being "rescued." Celebrity and marketing-driven branded activism relies especially strongly on parallels drawn between histories of chattel slavery and what anti-trafficking campaigns call "modern-day slavery." We challenge these parallels, particularly as they encourage participants to see themselves as abolitionist saviors in ways that reinforce neo-liberal notions of empowerment rooted in communicative capitalist networks.

Social service responses to human trafficking: the making of a public health problem.

Human trafficking has received considerable attention from policymakers, researchers and service providers globally, with resulting interventions often positioning trafficking as something that simply exists. Drawing on Bacchi's 'What's the Problem Represented to be?' approach, this article proposes that trafficking is continually made through efforts designed to eradicate it. We conducted 22 interviews with representatives from social service organisations funded by the government of Ontario, Canada, for anti-trafficking programming. These interviews provide insight into how trafficking is being represented and with what effects. Our findings suggest that organisational initiatives often rely on individualised health-related interventions, such as trauma-informed counselling and other mental health support, to address trafficking. In the process, various sex work activities are deemed 'symptoms' of trafficking, and perceived pathways to engaging in sex work (such as drug use/dependence, a history of trauma and low self-esteem) are produced as 'causes' or 'risk factors'. We contend that by pathologising sex work and sex workers, organisations are employing a contradictory neoliberal paternalism to advance a public health representation of human trafficking that simultaneously responsibilises and disenfranchises purported victims.

"That's why people don't call 911": Ending routine police attendance at drug overdoses.

Research has shown that police attendance and the corresponding threat of criminal charges are major deterrents to people seeking emergency medical assistance in the event of an overdose. In response to these barriers, Canada passed the Good Samaritan Drug Overdose Act in 2017, providing immunity from prosecution for simple drug possession to overdose victims or bystanders who phone 911. In theory, this should make people more comfortable seeking emergency supports, but in practice our research found that many remain hesitant because police continue to be routinely dispatched to the overdose site. Based on focus groups and surveys with 109 people who use drugs across Ontario, Canada, our findings show that the vast majority of participants have negative interactions with police, which discourages them from seeking medical assistance at future overdose incidents. Almost all questioned the necessity of dispatching law enforcement to a health emergency that requires medical intervention. As such, this commentary draws on the study's qualitative data to argue that ending routine police attendance at drug overdoses in Ontario would remove a major barrier to calling 911, and thus prevent the further, unnecessary loss of life in the ongoing overdose crisis.

Critical studies of harm reduction: Overdose response in uncertain political times.

North America continues to witness escalating rates of opioid overdose deaths. Scale-up of existing and innovative life-saving services - such as overdose prevention sites (OPS) as well as sanctioned and unsanctioned supervised consumption sites - is urgently needed. Is there a place for critical theory-informed studies of harm reduction during times of drug policy failures and overdose crisis? There are different approaches to consider from the critical literature, such as those that, for example, interrogate the basic principles of harm reduction or those that critique the lack of pleasure in the discourses surrounding drug use. Influenced by such work, we examine the development of OPS in Canada, with a focus on recent experiences from the province of Ontario, as an important example of the impacts associated with moving from grassroots harm reduction to institutionalised policy and practice. Services appear to be most innovative, dynamic, and inclusive when people with lived experience, allies, and service providers are directly responding to fast-changing drug use patterns and crises on the ground, before services become formally bureaucratised. We suggest a continuing need to both critically theorise harm reduction and to build strong community relationships in harm reduction work, in efforts to overcome political moves that impede collaboration with and inclusiveness of people who use drugs.

"It Goes on Everywhere": Injection Drug Use in Canadian Federal Prisons.

BACKGROUND: International and Canadian research on in-prison injection drug use has documented the frequency of its occurrence as well as some of the resulting consequences such as increased prevalence of HIV and hepatitis C virus. Access to prison-based harm reduction programing is thus important. OBJECTIVES: The aim of this study was to learn from former prisoner experiences and insights on in-prison injection drug use in order to advance and improve access to harm reduction options, in particular prison-based needle and syringe programs (PNSPs). METHODS: The qualitative and community-based study was conducted in 2014/2015 and included former prisoners from Ontario, Canada (N = 30) who had recent experience of incarceration in a federal prison and knowledge of injection drug use. Data analysis followed the deductive approach, drawing on the expertise of the academic and community-based research team members. RESULTS: Interview and focus group participants disclosed that drugs are readily available in Canadian federal prisons and that equipment used to inject is accessed in a variety of ways, sometimes gained through illicit means and sometimes made by prisoners themselves. Equipment sharing is a frequent occurrence, and disposal of such supplies is rare. Conclusions/Importance: While not yet available in Canada, PNSPs have led to positive outcomes in international contexts, including reductions in needle sharing and transmission of HIV and hepatitis C. Support for PNSPs among numerous Canadian organizations and associations, along with a recent change in government, could suggest a renewed opportunity for PNSP implementation.

Some like it mellow: on gay men complicating pornography discourses.

Despite the proliferation of writing on pornography generally, much of the literature that focuses on gay pornography specifically conforms to either a pro- or anti-porn framework. This overly simplistic dichotomy positions pornography as a homogeneous construct, albeit one that is either "good" or "bad." Even theorists who situate pornography on a continuum, with erotica at one end and hardcore at the other, tend to reify these discourses. Further, it is not uncommon for researchers to draw conclusions about the effects of pornography consumption without defining exactly what pornography is. This ethnographic research draws on qualitative interviews with 20 consumers' of gay pornography in Toronto, Canada. By using a thematic analysis to document the ways in which gay men define, distinguish, and conceptualize gay pornography, five definitional categories were developed: Mellow; Commercial; Raunch; Amateur; and Bareback. These broad conceptualizations are discussed in reference to writing on gay pornography. Our research results emphasize the importance of clear definitions of pornography within pornography research.

If you teach them, they will come: providers' reactions to incorporating pleasure into youth sexual education.

OBJECTIVES: Sexual pleasure and satisfaction are integral components of the human sexual experience, yet these crucial aspects of sexuality are rarely placed on sexual education agendas. The objective of this paper is to explore the ways in which various groups of Service Providers (SPs) participating in the Toronto Teen Survey (TTS) understand the role of pleasure in sexual education for youth, highlighting the challenges and benefits of teaching pleasure in diverse settings. METHODS: The TTS employed a community-based research (CBR) methodology. Between December 2006 and August 2007, 1,216 surveys were collected from youth in over 90 different community-based settings across Toronto by youth peer researchers. In 2008, 13 follow-up focus groups were conducted with 80 service providers from 55 different agencies around the Greater Toronto Area. All transcripts were input into qualitative data management software, NVIVO. Coding and analysis of data employed the constant comparative method. RESULTS: SPs had a number of competing opinions about the inclusion of pleasure in sexual health education and programming. These concerns can be divided into three major areas: placing pleasure on the agenda; the role of gender in pleasure education; and the appropriate spaces and professionals to execute a pleasure-informed curriculum. CONCLUSION: Access to resources, training and personal background determine SPs' willingness and ability to engage in the pedagogy of sexual pleasure. Medically trained clinicians were less likely to see themselves as candidates for instructing youth on issues of pleasure, believing that public health and health promotion professionals were more adequately trained and organizationally situated to deliver those services.

Improving health equity through theory-informed evaluations: a look at housing first strategies, cross-sectoral health programs, and prostitution policy.

The emergent realist perspective on evaluation is instructive in the quest to use theory-informed evaluations to reduce health inequities. This perspective suggests that in addition to knowing whether a program works, it is imperative to know 'what works for whom in what circumstances and in what respects, and how?' (Pawson & Tilley, 1997). This addresses the important issue of heterogeneity of effect, in other words, that programs have different effects for different people, potentially even exacerbating inequities and worsening the situation of marginalized groups. But in addition, the realist perspective implies that a program may not only have a greater or lesser effect, but even for the same effect, it may work by way of a different mechanism, about which we must theorize, for different groups. For this reason, theory, and theory-based evaluations are critical to health equity. We present here three examples of evaluations with a focus on program theories and their links to inequalities. All three examples illustrate the importance of theory-based evaluations in reducing health inequities. We offer these examples from a wide variety of settings to illustrate that the problem of which we write is not an exception to usual practice. The 'Housing First' model of supportive housing for people with severe mental illness is based on a theory of the role of housing in living with mental illness that has a number of elements that directly contradict the theory underlying the dominant model. Multisectoral action theories form the basis for the second example on Venezuela's revolutionary national Barrio Adentro health improvement program. Finally, decriminalization of prostitution and related health and safety policies in New Zealand illustrate how evaluations can play an important role in both refining the theory and contributing to improved policy interventions to address inequalities. The theoretically driven and transformative nature of these interventions create special demands for the use of theory in evaluations.