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Journal of Ethnicity in Substance Abuse

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Scars, Harm and Pain

Maria Esther Epelea

a
Universi-dad Nacional La Plata, Buenos Ares., USA

To cite this Article Epele, Maria Esther(2001) 'Scars, Harm and Pain', Journal of Ethnicity in Substance Abuse, 1: 1, 47 69
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Scars, Harm and Pain:

About Being Injected
Among Drug Using Latina Women

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Mara Esther Epele, PhD

ABSTRACT. The practice of being injected by others is one social

vector that promotes a higher vulnerability to HIV among injector drug
using (IDU) women. This paper suggests that this practice can be interpreted as a strategy used by these women to avoid the bodily damage
caused by muscle injection, and thus to reduce its political and economic consequences. Abscesses and scars that are more frequent with
muscle injection lead to further subordination within the hierarchies of
their social networks, and deteriorate the womens precarious strategies
of income production. Although being injected by another increases the
probability of HIV infection, it simultaneously prevents the visible
physical damage that subjects these women to greater vulnerability. In
the street ideology of this network the moral devaluation arising from
the bodily damage implies a moral anatomy that reproduces in this
setting the politics of self-care that dominate in mainstream society.
This local practice was studied through interviews of Latina IDU
women and ethnographic immersion into a social network of drug
consumption in the Mission District, San Francisco, California. [Article

copies available for a fee from The Haworth Document Delivery Service:
1-800-342-9678. E-mail address: <getinfo@haworthpressinc.com> Website:
<http://www.HaworthPress.com> E 2001 by The Haworth Press, Inc. All rights
reserved.]

KEYWORDS. IDU women, injection process, bodily damage, Latin minority

Maria Epele is an Argentinean medical anthropologist with a PhD from Universidad Nacional La Plata, Buenos Aires. She is a postdoctoral researcher at CONICET-Consejo Nacional de Investigaciones Cientficas y Tcnicas--Argentina, and visiting
scholar at the Department of Anthropology, University of California--Berkeley.
Journal of Ethnicity in Substance Abuse, Vol. 1(1) 2002
E 2002 by The Haworth Press, Inc. All rights reserved.

47

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INTRODUCTION
Studies about women who inject drugs have identified several social vectors by which gender inequality is transformed into HIV vulnerability. The principal vectors include the following: the reduced
accessibility of syringes (Goldstein, 1998), the dominance of sex for
drugs and sex for money exchanges (Tortu, Mc Coy et al., 1998), the
subjection to situations of physical and sexual violence (Weeks, Grier,
Romero-Daza et al., 1998), the reduced accessibility to medical treatment (Rockwell, Friedman, Sothernan et al., 1998), the tendency to
consume drugs with other people, and the tendency of being injected
by others (Connors, 1994).
Many Latina IDU women express the need to be injected by another
because they have weaker veins or they lack the skill to locate
their veins. Far from being an anatomical or logistical problem only, I
suggest that an analysis of this practice of being injected reveals a
political economy and morality of caring that dominates the treatment
of the female body in the social networks of drug consumption.
Injection leaves lesions and scars on the body. I argue that for those
women who are drug users, being injected by another person is a
practice that allows them to continue injecting in their veins, thus
avoiding the visible cosmetic harm following intramuscular injection.
Abscesses and scars deepen female subordination within street hierarchies and hinder womens strategies of income production.
Further, I suggest that in this setting there exists a moral anatomy
which is defined by valuations of the injection process and of resultant
bodily damage, and which reproduces the politics of the self-care of
the body prevalent in mainstream society. Moreover, the practice of
being injected by others clarifies the limitations and inconsistencies of
the individualistic technology of self-care in settings characterized by
social exclusion. Such self-care appears not only as a moral value
within social networks, but is reinforced by HIV prevention and also
therapeutic programs.
Through the analysis of this practice, it is possible to reconstruct
one of the paradoxes that characterizes the lives of Latina women who
live under conditions of social exclusion and scarcity of resources. I
argue that while being injected by others increases the possibility of
HIV acquisition (because of the possibility of syringe transference),
not being injected implies the potential of bodily damage (such as

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49

abscesses, lesions and scars), which, directly or indirectly, affects

income production.
Moreover, the minimization of cosmetic damage not only has
physical and emotional consequences but also influences the construction of a body image and the level of objectification these women
suffer in their everyday life. Therefore, in spite of the HIV risk of
being injected by others, the practice tends to reduce global vulnerability and increases the very possibility of survival in the streets.

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THE STUDY
The current research was conducted over a period of eight months
with an active IDU population in the Mission District, San Francisco,
California. The objective of this study was to determine through a
qualitative methodology the risk conditions and the care practices
related to HIV in the everyday life of drug users, specifically women,
who belong to the Latino minority.
The Mission District has long been the traditional Latino workingclass neighborhood in San Francisco. The category of Latino conceals
considerable ethnic diversity including the following: Mexican, Mexican Americans and minority groups from Central American (Guatemala, El Salvador, Nicaragua) and Latin American countries. During
the last few years, the composition of the Mission neighborhood has
started to change because of the progressive displacement by middle
class North Americans. This gentrification process has increased the
prices of housing and excerbated ethnic conflicts and law enforcement
problems. These conflicts are inherent in the everyday life of areas in
which poverty, homelessness, illicit drug dealing and sex work are
concentrated. My fieldwork was carried out in approximately 10
square blocks of one of these areas.
With respect to the ethnicity of the members of the social network
settled in this area, the majority of these women have roots in Mexico
(68%), while others originate in different countries of Latin America
(Colombia, Ecuador, etc.) and Puerto Rico. Some women have arrived
through international migration, but others belong to the first or second generation that have often undergone internal migrations within
the U.S. (see Table 1).
The research was based on a qualitative methodology consisting of
in-depth interviews, observations and participation in everyday life

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settings. The initial phase of the field research involved the recruitment of participants at one of the sites of the Needle Exchange Program. The snowball technique was used in order to recruit other members of the social network.
Interviews took place in such places as: coffee shops and hotel
rooms where some of the respondents live. A total of 35 in-depth
interviews were conducted among 25 women and 10 men. Eighty-five
percent of the interviews were taped and transcribed, and the rest were
recorded as field notes. The majority was conducted in Spanish and
the rest in English. With half of the participants, there were two or
three more interviews in order to probe certain topics. Informal conversations and observation in the streets, hotels and hangout places
were recorded as ethnographic field notes.
The interview protocol considered several topics, including: demographic and personal data, ethnic situation and migration history, strategies of income production, characteristics of gender relationships,
drug use history, current drug use, drug treatment history, injection
practices, sexual practices, HIV-related prevention practices, experiences in violent and abusive situations, characteristics of everyday life
in the streets.
This research focused on those people who practically live in the
streets. In spite of this, they do not consider themselves as homeless.
The majority of them obtain their resources through illegal activities
that take place in this area of the neighborhood. Fifty-two percent
were sex workers, 16% drug dealers, 12% petty thieves and 20% used
mixed strategies.
The age of the women varied between 22 and 54 years old. Their
mean age was 34. All used heroin intravenously and intramuscularly,
but around half injected a combination of heroin and cocaine. Eightyfour percent of the participants consumed other drugs, including
crack, cocaine, speed and marihuana.
The Injection Process
Since the emergence of HIV-AIDS, the practice of drug injection
has been one of the central issues in the research and prevention of the
epidemic. Studies based on an anthropological critical perspective
have conceptualized drug injection as complex practices co-determinated by social, economic and political-legal processes (Singer, 1998).
These processes include: the scarcity of resources and extreme social

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Mara Esther Epele

51

marginalization (Bourgois, 1997); the strategies of income production,

values and hierarchies in the street culture (Carlson, Siegal & Falck,
1994; Bourgois, 1998); the laws that regulate the purchase and possession of drug paraphernalia (Singer, Irizarry & Schensul, 1991; Koester, 1994, 1996); the drugs that dominate the market and the way they
change (Page et al., 1990); the level of institutionalization of shooting
galleries (Page, 1990; Warldorf, 1990; Bourgois, 1998); the patterns of
drug consumption of each geographical area and diverse ethnic minorities (Singer, Jia, Schensul et al., 1992; Singer, 1992). In such studies
local practices of injection are subject--directly or indirectly--to the
trends of the political and social processes dominating mainstream
society.
The cultural interpretation of the drug injection process as a ritual
has been analysed by some authors. The interpretation of shared syringe use as a strategy simply to fortify the bonds of an isolated drug
subculture has been demystified and rejected as a valid explanation
because of the victim-blaming mechanism that it involves (Carlson,
Siegal et al., 1996; Singer, 1994).
Several studies have shown that female injection practices have
some particularities including the tendency to inject with other people,
the reduced accessibility to sterile paraphernalia, and the practice of
being injected by another person. This tendency of being injected by
others has been described not only as an HIV high-risk practice but
also as one of the ways in which female subordination by the malecentered street network is expressed. Because drug use with other
people involves the possibility of syringe transference, it is one of the
ways in which IDU women are more vulnerable to HIV infection
(Connors, 1994; Bourgois, Lettiere & Quesada, 1997; Freidman, Curtis &
Neaigus et al., 1999).
While help during injection has been related to HIV infection, this
relationship is not always so clear and linear. Being injected promotes
the sharing of syringes and the spread of HIV because the consumption takes place with other people. But the inverse is not always true.
Drug consumption among more than two people does not suppose the
availability of any help during the injection process. Therefore, the
possibility of HIV infection by syringe transference exists even
though nobody helps another person.
During the current fieldwork, this practice and its implicit complexity became a problem to resolve.

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In the social network of drug use, being injected by other people is a

practice that goes beyond gender. However, what is gendered is the
expression of the necessity of being injected. I suggest that this necessity should be linked with the difficulty women report of finding a
vein, their rejection of muscle injection and the consequences of abscesses, lesions and scars, as interpreted by the street network. In
addition, the practice can be related to womens subordinate position
within street hierarchies and the importance of a healthy body to
womens daily survival.
While the majority of IDU women express the need to be injected
by another, in fact, this practice is not widespread unless it is in
exchange for something else. Even though their unstable survival
strategies force these women to associate with others for buying and
consumption, only a few said that they generally counted on help
during drug injection.
Since being injected is not an exclusively female practice, why is it
presented as female-centered? Why do these women describe the
practice in terms of necessity? Why is being injected not as widespread as the expression of its necessity?
Female Subordination and Bodily Care
The point of departure in analyzing this issue consists of considering injection by others as a part of a treatment of the female body
found in networks of drug consumption; specifically, those which
suffer a scarcity of resources and extreme social marginalization.
Following Foucault (Foucault, 1980; Dreyfus & Rabinow, 1982), I
consider this local practice upon the body as a part of a micro-politics
in which power strategies of the dominant society find their expression. The logic that supports being injected by another as a female
bodily practice is linked to power relations and income production
strategies of these street scenarios. Within the street ideology, injection
in the arms is viewed differently than that in the neck. Likewise,
distinct moral values are given to intra-muscular versus intravenous
drug use and to solo injection versus that administered by others.
Within these moral valuations of the injecting body, there is no uniform perception of the hierarchical values of these practices.
What is clear, however, is that intra-muscular injection leaves
marks on the body. Even though these marks do not vary with gender,
the corporal deterioration they engender have different effects on

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53

women. Lesions, marks and scars have consequences in the stigmatization, subordination, and even exploitation to which IDU women are
exposed daily.
Because of the objectification process suffered by women in the
street network, the female body is treated as a marketable resource
to obtain other resources, an object of transactions, an object of
power and place where diverse forms of male violence are exercised.
In other words, the demand for being injected could be related to the
logic of objectification and the alienation of the female body that
dominates in the street culture, the moral evaluation of the health of
the body, and the construction of the female body as capital to
obtain resources. Although these processes are not exclusive to this
social space and they spread into different social worlds, their reproduction under conditions of marginalization imply particular outcomes
(Carlson, 1996; Friedman, Jose, Stepherson et al., 1997). These circumstances are also closely related to the womens possibility of survival.
In the streets where female subordination is omnipresent, the affirmation of Irigaray that Commodities, women, are a mirror of value
of and for man (Irigaray, 1997, p. 178) becomes reality. According to
this author, the woman as a commodity is divided into two irreconcilable bodies: her natural body and her socially valued, exchangeable body, which is a particularly mimetic expression of masculine
values (p. 180). This commodification is not confined to sex workers. Those IDU women who live from drug dealing, shoplifting or
from mixed survival strategies are also subjected to this male-centered
logic. Consequently, the body for all these women is transformed into
a space through which they suffer, denounce and express the inconsistencies of being women, IDUs, and Latinas who spend the majority
of their time in the streets.1
Moral Anatomy in the Street Ideology
The part of the body (arm, leg, neck or breast), the way in which the
injection is carried out (vein or muscle injection), and its consequences (infections, lesions or scars) are everyday health problems in
the narratives of IDU women. Given the consequences of the injection
process on the female body, women explain the necessity of being
injected by another with expressions, such as for women it is more
difficult to find the vein or we women have veins more difficult to

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be found or I have no more veins. They explain their demand for

help during the injection as the result of a female anatomical peculiarity and/or by their lack of skill in the management of their own injecting process.
This combined difficulty of successful intravenous injection and the
necessity of obtaining it are tied up with the street ideologys values
concerning the body. According to male-centered street ideology, the
body is divided into parts through imaginary and real lines. In the
resultant anatomy this evaluative differentiation of injecting practices and the parts involved in them assigns specific values and concomitant moral connotations. In other words the resultant moral anatomy makes the body a space in which the care, the selfdestruction and the good or the wrong injection practices are
evaluated. Even though the symbolic violence wrapped in these valuations affects both women and men, they have deeper effects and more
diverse consequences among women.
According to the streets moral anatomy, injection in veins is better
than in the muscle. Several reasons explain this preference. IDU
women report the following: the stronger cocaine or heroin high
achieved through the vein, the increased speed of reaching the high
and strategy of caring for the body. Conversely, muscular injection is
wrong because of its potential infections, abscesses, marks and
disfigurements, especially injections taking place under unhygienic
conditions.2 Therefore, injection in the muscle is not only avoided but
also has negative connotations related to the absence of care of the
body, lack of economic resources and dirtiness.
-Where do you inject?
-In my arms. I do not like to do it in the muscle. I used to . . . but
I had a lot of abscesses. I can inject in my veins again, because I
am using drugs only once a day. Some women do not care, they
are sick, they do not clean anything. Their bodies are not very
pretty. They do not have respect for themselves. They do not
care. (Laura)
Women who inject only in veins (20%) are mostly young (between
20 and 30 years old) and with an average of six years drug consumption. They utilize two main strategies of drug injection. Some customarily inject in an exclusive part of their body (for example, in their
arms), and after a while change to other places. Others vary the injec-

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55

tion sites so that none will be completely damaged. These inject in

arms, legs, neck, feet, even breasts and genitals.
I shoot in different parts, I move around, legs, my neck, and
arms. You must move around, because you cannot hit in the same
place, one time and another. Veins blow out. I prefer the neck.
Because the mark is like a bite. (Mara)

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Even for those injecting in veins, the different places of body are
valuated differently. The majority prefers to inject in arms and legs
rather in the feet or breasts. However, only two women injected solely
in the veins of their arms.
I do no want to do it in all places. I do not like it. There are a lot
of women who died because of it. When I was in jail, my friends
told me, What is the matter?, I said, it is my life. I really do
not like in the neck nor in legs. (Rita)
In this group of intravenous injectors, comments for women it is
more difficult to find the vein or women have less veins are
frequent.
Before I used to do other drugs and snorted heroin. But since one
year ago, I have been injecting speedball. I have good veins. But
my boyfriend helps me because I can not do it without help.
Sometimes I hurt myself. (Victoria)
However, most (52%) drug using women inject in the muscle or in
the vein according to the circumstances. The majority is older than
thirty years, and they have an average of fifteen years injection history.
Among this group, the difficulties of drug administration, the necessity of being injected and moral anatomy valuations are omnipresent.
Their explanations of the difficulties are diverse and sometimes contradictory, including weak veins, obesity, thinness, propensity of veins
to blow out, particularities of the injection history. All seem to assume
these difficulties are natural to women.
I have problems finding the vein. The majority has weak veins or
does not have more veins. It takes too much time, more than men.
(Claudia)

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The marginal conditions of their everyday lives determine the characteristics of the injecting process. Unstable dwellings promote the practice of injecting in public places, including public or coffee shop
restrooms, and even in the streets. Not only do they sometimes share
syringes or other elements (like cookers); they also lack both clean
water and alcohol to clean the skin. Some women spend days in the
streets before they can rest in a hotel room and take a shower. This
situation increases the possibility of getting infections, abscesses and
death by septicemia. Neither are infection problems caused by drug
injection limited to the bodys surface. Some women have or have had
endocarditis and heart failure because of the recurrent infections related to intense drug use.
On the other hand, those few women who have a place to live can
spend more time on the injection and it is carried out under more
hygienic conditions. Only two of the women of this study formerly
injected in shooting galleries. In the Mission as in other San Francisco
neighborhoods, shooting galleries are less institutionalized than in
other U.S. cities (Bourgois, 1998).
Now, I am not consuming so much and I have some veins. But I
also do hit myself in the muscle. When I am in the street and I do
not have anywhere to go, I cannot do it so well. But I hate the
abscesses. The last year I went to the hospital and they did a cut
in my arm (showing the scar). Look what they did. I do not want
to go anymore to the hospital. When I got an abscess I put
something hot on it, nothing else. (Sylvia)
The lack of availability of a safe place to inject and the permanent
police threat restricts the time women have to locate and inject in
veins. However, the majority of the women also recognize withdrawal
symptoms as another factor that prompts muscle injection. Here, the
impossibility of delaying the drug consumption is coupled with not
having the pulse to obtain it.
It is difficult for old users, we do not have veins. Sometimes it
takes me one hour to find a vein and get it. So when I am with the
mala (withdrawal symptoms) I inject wherever. I know that it is
bad, but I cannot help it. (Rosario)
These women try to maintain the practice of venous injection by
seeking help during the injection process. Such help can be given by

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57

running partners, friends and acquaintances or even by people who

offer this help as a paid service.
Finally, some women shoot exclusively in the muscle (28%) because, as they say, they do not have more veins. Among them
abscesses and infections are everyday health problems.

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I do not have veins. It is hard. Now I am shooting on my back.

But in each place where I hit me, I have a new abscess. It is really
hard to look at myself like this, with scars and this body . . . .
destroyed. (Susana)
Most women who exclusively inject in muscles are sex workers and
are accustomed to injecting themselves. However, this situation does
not imply individual drug consumption. Occasionally, they shoot
drugs with other women and men as a result of the frequent sex for
drugs exchanges and as a result of the circumstantial associations
made in order to buy substances.
Within the male-centered street hierarchy, women are placed in a
subordinated situation. However, those women who inject in the
muscle and who are alone and sometimes by themselves are occasionally more marginalized and rejected even by members (women also)
of the street network. This position puts them outside the circle of
transactions, specifically beyond the help or service of being
injected.
The moral anatomy that differentiates and assigns values to the
body is not an idiosyncratic value system of a drug world. Rather,
the view of the female body dictated by the consequences of injection
is a reflection of the morality of bodily care from mainstream society.
Nevertheless, in this particular setting, the moral valuations are not
absolute but vary gradually between two extremes: the care, expressed
by intravenous injection in the arms, and the self-destruction, expressed by intramuscular injection in different parts of the body. In a
practical sense, womens necessity of being injected expresses their
intention to avoid being a muscle shooter and in this way forestalling the consequences--not only physical and symbolic but also political-economic--of this practice in the marginalized street setting.
Seeking Injection Help
Within male-centered street social networks, gender inequality is a
category that defines IDU womens everyday positions. Although this

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subordination (also exploitation) is omnipresent, women do not inevitably assume a passive attitude. Frequently, they develop various strategies to reduce or avoid violent situations and to obtain daily subsistence. If passivity were the case, being injected should be an
exclusively female practice; it should also be a regular and a dominant
one. In their narratives being injected is presented, instead, as an
ideal sought; to obtain this assistance, a strategy is required.
Three injection settings that include this practice can be differentiated: (1) with running partners, boyfriends or husbands; (2) with
those people recognized and paid for their skills at injecting (also
called hit doctors); (3) among acquaintances or friends who occasionally buy and inject together.
Running partners have been defined as couples who spend time and
resources and shoot drugs together (Connors, 1994; Friedman, Curtis,
Neaigus, 1999). Running partners, boyfriends and husbands sometimes help women during the injection. However these relationships
are affected by the subordinant place of the women in the street ideology, their inequality in access to resources (almost all resources are
provided by women) and different kinds of everyday violence. Between running partners, transactions are basically about subsistence
resources (drugs and money), a place to live, even protection and
respect. While women provide most resources, protection and respect
are male goods, which are basics to survival in the precarious daily
struggle.
Between running partners, help during the injection is not a regular
practice. Among those women who have a male partner, only a few
(28%) said that they are helped by their partner during the injection
process. Specifically, only two are always injected by their partners;
the others receive help only occasionally.
--I have my boyfriend. I only hit with him, always with him. I do
not like to do it with strangers or people to whom I do not know
so well. We women have more problems, because we do not have
veins or like me, veins are too thin.
--How do you inject?
--I only hit in this vein of my arm. My boyfriend helps me,
because when I do it, it swells up. (Rita)
The principal reasons these women express for the unhelpful behavior of their partners are the time that takes to inject the other person

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and the consequences (withdrawal symptoms and high) of drug consumption.

--In which part of the body do you inject?
--Where I can, because I do not have more veins . . . in feet, and in
the neck. Now I have started in the breast. But almost always I
shoot in muscle. The veins of my arms do not function anymore.
I had too many abscesses in my arms, look . . . When I can not
hit, I cry, but he (her boyfriend) leaves me alone. I ask him for
help, but when he shoots himself, he becomes one pendejo, you
know. So he does not want any more. I start to cry because I can
not do it by myself.
Sometimes men help women, but when they think that it
would take too much time, they do not want to do it. Sometimes
one or other friend could help you. But usually you must pay for
it. When we started to stay together, he made me get the high
first. Now, he wants first and he leaves me crying. Because of
that I ended, shooting in the muscle. (Vernica)
Outside these relationships, the possibility of finding help during
the injection is even more random. In some cases, someone injects
others among couples or groups of friends or acquaintances who usually buy and shoot together (17%). However, this situation generally is
part of a sort of transaction. For example, the help of being injected is
sometimes in exchange for a place to sleep, for sharing drugs, or even
for a drug taste.
--Sometimes when I am using too much drugs, I need someone to
help me. The problem is that veins do not resist, they are too
weak. If I want that someone helps me, I buy and share the drugs
with him. But because I know about AIDS, we try to carry
bleach. Sometimes, my friends help me . . .
--Among women?
--Yes, but sometimes someone spoils it. I had a Cuban friend . . .
we shoot together. But once, It took me a while to hit her. But she
was angry because I could not do it. (Cecilia)
Another regular way to obtain help during the injection consists in
paying people (men and women) who are recognized on the street for
their skill in finding and injecting in veins. (See also Page, Chitwood &

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Smith, 1990; Friedman, Curtis & Neaigus et al., 1999.) In this scenario,
only those women who have more resources (12%), specifically those
who work in street level drug dealing or even shoplifting can occasionally pay for this service.

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--Here, there are some who know how to do it, but you must pay.
That guy to whom I was talking when you came, he is good.
When I have extra money, I call him and he injects me. But he
only wants money.
--How much?
--It varies. Ten, eight, five, it depends on the circumstances, you
know. But eventually I do not have enough money to pay my
drug; rarely I can afford it. (Viviana)
Just as syringes are a product sold on the street black market, help
during the injection has been transformed into a product subject to a
system of transactions. While the syringe costs two dollars, injection
help can be paid in different ways: drugs, money, even in other kind of
products (for example, clothes). The usual situation involves giving or
sharing drugs as an exchange for being injected.
--Nobody wants to do it for free. Here everybody is in the same
situation, looking for the same. Nobody wants to spend his (her)
time for nothing, except with women.
--Why women?
--When you work selling your body, much people think that you
have more money, so that you can pay anything. (Irene)
In this way, moral anatomy not only imposes care/destruction values on the body; this valuation also transforms these womens bodies
into a sort of capital that defines their levels of subordination or
independence, their levels of marginalization and the availability of
material and human resources they have.
These womens efforts to find injection help might be interpreted as
a form of dissent (even a fragmented resistance), expressed through
their bodies, against inequalities that they suffer in their everyday
lives. It is also possible to interpret this necessity as a denouncement
of female subordination and inequality in the transactions with which
they survive in the street economy. However, in the context of the
male-centered street ideology and female subordination, this de-

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61

nouncement, dissent or resistance is more likely a coping mechanism

than a conscious effort to resist authority or this oppression (Kleinman, 1991, 1992).

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Objectification and Body Image

The moral field defined by scars, lesions, deterioration and care is
central to the experiences these IDU women narrate about their bodies. The embodiment of a domain that integrates subject/object and
self/body duality (Csordas, 1990, 1991) is replaced in this context by a
clear objectification of the female body. This objectification is expressed in the way in which these women talk about their body, particularly in the distance from which they describe their body experiences,
even the painful ones.
One of the more important bases of the womens objectification
process is the construction of the female body as a commodity in the
street economy.
I live by selling my body. This is the only thing that I can do to
pay for my habit. But I need to cover my body, to avoid that my
clients can notice that I have marks. I try to inject in hidden
places, but I have a lot of abscesses and the scars are big, my
arms are completely damaged. (Carmen)
This everyday and dominant experience of having an objectified
body is a result of the diverse violence that plagues these womens
lives. Structural violence is expressed in the impossibility of maintaining a healthful diet, regular clothes, a place to live or everyday hygiene. There is physical and sexual violence both as a part of sex work
and as varieties of domestic violence or random street violence, with
women as a target. Moreover, in several cases women have experienced sexual or physical abuse during their childhoods or neglect and
solitude because of drug addicted parents. Their narratives also include the consequences of the migration process to U.S.: poverty and
discrimination.
Each of these experiences has been recognized as a traumatic situation that promotes dissociation and distance of the bodily experience
(Frazier, 1990; Thompson Fullilove & Smith et al., 1993; Winkler,
1994; Weissman & Brown, 1995). Considered together, they explain
the distance and objectification of the body related to these womens

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narratives. Following Scarry, this objectification can be read as a

specific strategy of pain avoidance and resolution (Scarry, 1985; Jackson, 1994).

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Sometimes I try to think that my body belongs to another. When

I must do something disgusting, I close my eyes and I try not to
think in anything, only in the money that I am earning. (Mara)
In her analysis of drug-withdrawal and its relations to risk taking
behavior, Connors (1994) has shown how withdrawal symptoms can
be understood as the legitimated expression of emotional pain through
the physical body. (See also Clatts, Davis, Deren et al., 1994.) In the
case of lesions and scars, which are a product of infections and abscesses, it is possible to recognize a similarity. But to the emotional
and physical pain unified in the experience of physical deterioration, it
is necessary to add a consideration of the moral connotations the
lesions have for the survival struggle in these marginal settings.
Even though this objectification and distance from bodily experiences helps these women to minimize certain everyday pains, it fails
when women try to distance themselves from one of the ways that
physical deterioration produces emotional suffering: I mean the body
image (Scheper-Hughes & Lock, 1987; Fisher, 1986).3 A recurrent
reference in womens narratives was related to the body image and
constant allusions to feelings of dirtiness and self destructiveness linked to their identity of their self-body.
I do not visit my girls any more. My sister does not want to. But
really I do not want to either, I do not want that they have to see
me like I am now. I left some pictures to my sister, pictures of the
past, when I did not have this life, really vicious that I have. I do
not want to make them feel sad because of me. Because I am thin,
with this face, this hair. My appearance keeps at a distance from
them. (Carmen)
On the one hand, aspects like weight, hair, and facial lesions are
also indicators of deterioration, but they are considered as reversible
features, changeable with enough time. Yet, lesions (such as the abscesses) that are consequences of drug injection are physically and
metaphorically signs of the level of deterioration the women have
reached. This irreversibility of body damage sometimes is a factor that

Mara Esther Epele

63

make it impossible for them to think about the possibility of changing

their lives.

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I will never quit the heroin. Look at me, look at my body. I am

destroyed. I do not have a clean place to inject myself without
having abscesses. Look at my arms. I prefer to die instead of quit.
Where could I have a different life? (Soledad)
The body image of these women is subject to the streets moral
anatomy, under forms of symbolic violence inherent to failure and
incompetence in the care of their bodies. In this setting, deterioration
means self-destruction, and most women experience the body as
something dirty. This dirtiness--impossible to clean--appears as an
explicit reason to avoid contact with relatives, doctors and other representatives of mainstream society.
-My mother told me give me the girls, before police catch you
with drugs or something else . . . My girl writes me letters and
so do I. She tells me, Mommy, I want to stay with you and
asks me When are you going to visit us? Actually, I do not
want to stay there.
--Why?
--Because, even though I take a bath daily, I feel dirty, right? I
feel too garbage to stay with them. Here in the street, touching
drugs and dirty money, and then staying with your girls, I feel
like a pinche garbage, I do not want to even touch them.
(Nancy)
In summary, in this social space, self-care as self-control takes the
form of suffering produced by the symbolic violence contained in the
moral anatomy. Throughout the moral anatomy, a valuation of the
bodys deterioration is imposed upon drug-using women and causes
shame and guilt.
From Moral Anatomy to Survival Strategies
While bodily deterioration does not vary with gender, its moral significance has deeper effects among women. Thus, the moral reading of
bodily damage has practical ramifications in these womens uncertain
subsistence strategies (Weeks, Grier & Romero Daza, 1998).

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Among those who are sex workers, the body damage negatively
affects directly values of the transactions (specifically, sex-for-money
and sex-for-drugs exchanges). The reduction of the exchange values
transforms the usual gender inequality into exploitation, more abusive
situations, frequent physical and sexual violence and even death. This
is the case of those women who are called too used or too wasted.
Excluded from the street transactions system, sometimes they can only
obtain drugs by begging. On the other hand, those who are younger,
with a short history of drug injections, have the possibility of obtaining larger quantities of drugs through the street exchanges. Such is the
case of Patricia.
All the time these dealers (the crack dealers) offer me money or
drugs in exchange for spending some time with them. Others
want to be my boyfriend, and they say to me, I want to take care
of you. So when I have the mala I sometimes do it, but I do not
like to be a hooker. I prefer to help my boyfriend in selling drugs.
In fact, bodily deterioration reduces the possibility of finding running partners and participating in the transaction system of protection,
respect, credit, alliances of buying and selling and also help during the
injecting process. Although IDU women have subordinant positions,
these transactions--that allegorically reproduce those of the capitalist
market--are the means that allow them to hold on to their precarious
life in the streets.
Given the womens survival strategies, the necessity to be injected
introduces another level of suffering: that of being trapped in a vicious circle without escape and with a progressive devaluation of
their transactions. While, drug injection is not the only cause of body
deterioration and being injected by another cannot stop this process
indefinitely, for these women the practice is viewed as a preventive
strategy against bodily damage.
In synthesis, bodily damage promotes global vulnerability that involves the following: the possibility of producing income, the level of
marginalization, the way of valuing themselves through body image,
and the possibility of acquiring HIV and other infections.
However, there are a few women who do not want to be injected by
others and who resist being placed in the stereotypic subordinant
female position through having a male partner. The majority of them
are alone and are used to injecting themselves in the muscle. That they

Mara Esther Epele

65

defend the property of their body and the possibility of obtaining

resources only for themselves shows a level of autonomy unknown by
others. However, they are objects of criticism and segregation even in
the streets social network. Not only do they inject under more random
circumstances; they are also more exposed to infections and the everyday violence that dominates this part of the neighborhood.

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Survival and Care

Between subordination and resistance concerns about bodily care
appear in the voices of these women. They relate their ideas about
appropriate care to the moral implications of being injected and also
point out the inconsistencies and contradictions of some HIV prevention programs:
Everybody says that I am a sick person, that the addiction is a
disease. But I was wondering, if I am a sick person why they do
not let me go to the doctor, and let him give me my medicine? He
can control that everything is clean; I can not here. He could
inject me, so I do not have AIDS, abscesses, or this appearance.
The doctors should do it.
But, no. They condemn me to stay in the streets. They treat me
as a criminal and I became one. (Sylvia)
For middle class Americans, self-care as discipline and self-control
has become the dominant model of bodily care. According to this
model, the healthy body represents morality, responsibility and wellbeing and has become one of the central dimensions of mainstream
identity (Crawford, 1994; Fee & Krieger, 1993). From Sylvias perspective, analysis of injection by others highlights the limitations,
insufficiencies and inconsistencies of the cultural politics of self-care
translated to disempowered and marginalized contexts.
In the street setting, with its moral anatomy and its symbolic violence the politics of self-care has colonized the social space of IDU
women. Self-care values are implicitly or explicitly included in the
provision of health services (preventive, therapeutic or even harm
minimization), however, the availability of resources (for example,
of syringes) must be complemented by the will power of the individual at risk (Auerbach, Wypijewska & Brodie, 1994: Abdulrahim,
1998). As Bateson (1972) said in his studies of alcoholism, there is a

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contradiction and a reification process in demanding will power

from people subject to an addiction. This is even truer when people
live under conditions of extreme social vulnerability. Therefore, sometimes and even frequently, health care requires the assistance and the
clear intervention of another person in this setting.
Consequently, the importance these women place upon their need to
be injected shows a role that most health programs do not offer:
someone who can give care and reduce harm; someone who is impossible to encounter under the everyday conditions seen in this study.
Finally, this analysis implies that harm that has social origins requires
a social relationship in its restoration process.
NOTES
1. Probably, the preoccupation about the consequences of the injection were
increased by the damages produced by the flesh-eating bacteria (Clostridium
perfringens). During the fieldwork, members of the neighborhood network died
because of this bacterium, while others suffered amputations and disfigurements. The
consequences in the body and even the possible death related to this infection were
part of these womens narratives.
2. In the epidemiological and biological studies about injector drug users, it has
been established that injection in the muscle and a long history of drug injection is
linked to abscesses (Spijkerman, van Ameijden, 1996). Also women are more exposed to having abscesses than men, especially those who have fewer resources
(especially sex workers) and a long history of drug injection (Vlahov, Sullivan &
Astemborski et al., 1992; Herb, Watters, Case & Pettiti, 1989).
3. The definition of body image belongs to the psychological and psychiatric
field. It means the representation of our body (shape, size and form) that we have in
our mind (frequently unconscious) and the feeling associated to it. It has two principal dimensions: the perceptual and the cognitive/affective (see, Fisher, 1986; Sheper
Hughes & Margaret Lock, 1987; Wenninger and Heiman, 1998; Gainotti, 1999).

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SUBMITTED: 3/30/00
REVISION SUBMITTED: 10/30/00
ACCEPTED: 11/30/00