Expertise, Gender, and Marginality among People who Inject Drugs

In fields without established credentials or training, how do people develop and perform expertise and how do they decide whose expertise is reliable? Bringing together theories of expertise, gender, and urban marginality, my dissertations answers these questions by analyzing uncredentialed expertise in a particularly high-risk context: assisted injection, a common practice in which one person injects another with illicit drugs. About half of all people who inject drugs engage in this practice, which doubles the risk of overdose or infection. In the U.S., the approximately 1.3 to 1.8 million people who currently inject drugs face high rates of overdose, HIV and Hepatitis C infection, and other harms. One third of this population are women, and there are significant gender disparities in infection and overdose rates that are not yet well understood. Further, injection drug use is increasing due to the opioid epidemic. Despite this growing public health crisis, there is little information on how people, particularly women, protect against these risks while engaging in this activity. While most existing literature focuses on the impact of structural violence, or on behaviors that increase infection and overdose risk, my research instead examines how people engaged in high-risk practices try to reduce their risk. My dissertation centers people who inject drugs as experts in their own lives who are doing their best to avoid injury or death. My work is based on 16 months of ethnographic observation in San Francisco and interviews with 80 people who either receive injection assistance, provide injection assistance, or both. Using the case of assisted injection, I examine how people develop, perform, and assess uncredentialed expertise, which I define as expertise in practice that arises outside of professional institutions to address the needs of laypeople. I consider assisted injection providers as potentially possessing expertise because providing injection assistance can require skill, knowledge, and trustworthiness. I begin by examining how injection providers develop and perform uncredentialed expertise, with a focus on “hit doctors,” people who provide injection assistance for compensation. I find that successfully providing injection assistance can require many of the competencies of trained medical practitioners, including care work, trustworthiness, sterilization practices to reduce infection risk, and significant technical skill. I then show that people seeking injection assistance assess uncredentialed expertise through trust mechanisms to reduce their risk, which increases the chance that providers are motivated to help recipients. However, this strategy offers little protection against technically unskilled providers and it may increase health risks because people employ few self-protective strategies in trust-based relationships. Furthermore, despite their efforts, recipients are vulnerable in these interactions. Counter to assumptions in the public health literature, I argue that power dynamics in assisted injection interactions increase the recipient’s vulnerability, regardless of whether they are a man or a woman. However, my research does reveal one important gender difference among injection providers: women practice uncredentialled expertise by developing robust anatomical knowledge and performing care work, while men perform expertise by dominating recipients. This study contributes to the literature on drug use, gender, expertise, and marginalized communities by examining how people navigate high-risk situations when codified knowledge and certifications are not available. In addition, this research contributes to actionable culturally sensitive and gender congruent interventions for reducing overdose and injection-related risks based on the existing practices of people who inject drugs