Contents
Introduction
Ritual Aspects of Needle Sharing: A Review of the Literature
Needle Sharing and Conditions for Ritualization
Who Propogate the Needle Sharing Ritual
Conclusions
References
The exchange of infected blood from user to user during the injection process is currently believed to be the primary means of transmission of the Human Immunodeficiency Virus (HIV) among injecting drug users (IDUs).(1, 2, 3, 4) Such blood-blood contact can be established through various routes, of which needle sharing has received the bulk of attention in both the mass media and the scientific literature. As is established in the previous two chapters, this has blurred the view on other, distinct, potentially hazardous parts of the process of preparing and self-administering an injection of drugs. Sharing water, used for cooking and rinsing, sharing of other drug injection paraphernalia, and, most notably, sharing of collectively prepared drug solutions can all include risks of viral transmission. But, needle sharing is a limited concept for more reasons. While lending, borrowing, passing on and renting a syringe may be covered by the term, from a semantic point of view, picking up a needle that another user left behind (as Dirk did in chapter 12.2) can hardly be called an act of sharing. After all, sharing requires at least two participants.
This subtle, but important semantic distinction is also of main interest to the question dealt with in this chapter: Is needle sharing a ritual? In the context of this dissertation this question cannot be omitted. But besides theoretical, there are also pragmatic public health considerations. For one thing, if needle sharing is a ritualized behavior, this should have consequences for education and prevention campaigns aimed at IDUs. And in fact, the argument that needle sharing is a ritual is often put forward in objections to harm reduction oriented approaches towards the HIV epidemic among IDUs, such as needle exchange. This chapter will explore the question whether or not the sharing of needles is a self-perpetuating ritualized part of injecting drug use. First, it will review the existing literature on ritualized needle sharing. In this review special attention will be directed at the terminology and definitions used. It will critically examine statements and conclusions made and extensively screen data presented and the references these are supported with. Secondly, needle sharing will be discussed in light of the definitions and theories of ritual and the findings reported in this thesis. From the preceding linguistic discussion it can already be derived that not all events that are generally included in the term needle sharing are expressions of ritual. Picking up and using a left behind fit can impossibly be considered a ritual. The coincidental nature of such an event excludes the development of a stereotypical sequence--a basic requirement of ritual. Furthermore, a symbolic goal cannot be distinguished in this incident, as sharing requires more than one person. It takes two to tango. The primary focus of this discussion will be if, and under what conditions needle sharing can be regarded a ritual behavior. Finally, the chapter will investigate who herald the notion of ritual needle sharing--on what do they base their statements; what are their motives.
Ritual Aspects of Needle Sharing: A Review of the Literature
In preparing this review it was surprising to learn that little is written about actual needle sharing events in their socio-cultural context. Even less studies discuss or mention ritual in relation to needle sharing. An extensive review produced 13 papers which discussed ritual or symbolic aspects of needle sharing. Eight of these were published by (US) American, one by Canadian and four by European authors.
The first two highly derivative articles, by Tempesta and Di Giannantonio, discuss the relations between needle sharing and the high prevalence of HIV among Italian IDUs. Despite the alleged absence of restrictions for over the counter sale of syringes and needles, the HIV-seroprevalence in Italy is among the highest in Europe, which is, as Moss writes, indeed alarming.(5) This so-called Italy argument has also been put forward against needle exchange and other efforts to liberalize the availability of injection equipment, e.g. in the USA. Tempesta and Di Giannantonio explain the high Italian HIV seroprevalence rates in terms of "insufficient knowledge" and "ritual and special patterns of behavior." (6) The authors claim that in their study, HIV-seropositive IDUs tended to share needles for ritual and habitual reasons, while the HIV-seronegative IDUs shared because of temporary difficulties in finding a syringe. In both groups promiscuity was common, but, according to the authors, in the former group this behavior had ritualistic characteristics, while in the latter group promiscuity seemed due to circumstantial reasons. It is unclear what the authors mean with this statement. A study into the sexual practices of 1214 Italian heterosexual IDUs did not mention such peculiarities.(7) They describe the former group as "heavily conditioned to the ritualistic and social use of drugs in which needle sharing has a high symbolic meaning." (8) "[T]heir peculiar psychopathology prevents them from being sensitive to prevention-promoting campaigns. Moreover, for this group, every injection is a symbolic challenge to death. Thus, these subjects feel a drive for drugs which is stronger than any other consideration."(6)
In neither article do the authors define the terms they use and their bold statements are not supported by the presented data or by references. The impression of IDUs they present bears more resemblance to a tabloid caricature than a scientific representation of research results.
The paradoxical Italian situation--absence of official restrictions on needle availability and a high infection rate--may well be explained by a combination of alternative, more down-to-earth, factors. For example, Rezza et al. found that almost half of their IDU subjects affirmed to have shared needles because of unavailability.(9) Furthermore, apparently citing the Rezza et al. study (without reference), Tempesta and Di Giannantonio add that nine percent shared "because syringe purchase presented problems." (8) This suggests a discrepancy between the official availability in pharmacies and drug stores, and the actual availability, as experienced and perceived by IDUs. Tempesta's and Di Giannantonio's allusion that pharmacists might refuse to sell syringes to IDUs may be an important factor underlying the discrepancy between official syringe policies and IDUs' perceived availability of injection equipment. Several Italian heroin users at the Rotterdam Central Railway Station denied that syringes can be purchased without prescription in pharmacies and drug stores.(10) This situation is not specific for Italy, as in both the Netherlands and in most parts of the United Kingdom syringes and needles have never been scheduled, but significant numbers of pharmacists are, both before and after the consequences of needle sharing for the AIDS epidemic became apparent, reluctant to sell syringes to IDUs.(11, 12, 13) The Italian situation is presumably exacerbated by a disastrous combination of a lack of knowledge about HIV and AIDS and an insufficient or too late educational intervention. Feldman and Biernacki compared the Italian situation with the San Francisco gay scene in the first stage of the epidemic:
[C]ondoms were available to gay men in San Francisco during the period when the virus was spreading through the homosexual population. The fact that they were not used seems more the result of gay men not knowing that unprotected sex, particularly anal intercourse, allowed the virus to enter their bodies. The missing ingredient, we are suggesting is the concerted education campaign ...(14)
In the Rezza et al. study nearly 20% of the people, who reported that they never shared needles, were seropositive.(9) Therefore, other risk behaviors conceivably have played a role in the rapid spread of HIV among Italian IDUs. These may be sexual practices, such as high levels of unprotected sex, or drug use related, such as frontloading or similar drug sharing practices.
In Britain, the ethnographer Power noted that "there is no ritualism associated with the sharing of needles and syringes. ...Sharing in Britain results from the shortage of freely available needles and syringes."(13) The needle exchange evaluation studies by Stimson et al. confirmed this view. They showed that in Britain needle sharing is largely determined by availability problems, situational and social factors (e.g., homelessness).(15, 16, 17) However, Ghodse et. al. doubt the positive effect of an increased availability of syringes on needle sharing, "[b]ecause sharing of syringes is associated with a feeling of community among drug users and not only with a shortage of needles."(18) This statement is, however, not based on their findings, but references a letter to the editor of the New England Journal of Medicine by the American researchers Black et al.
In their report on a study at the Dallas Veterans Administration Hospital Black et al. also question the effectivity of increased syringe availability without educational interventions, "since needle sharing has been found to be associated with socialization, communal feelings, and protection in the drug subculture, not merely with shortages of needles." (19) Again, this is not an empirical finding of the research reported, but a reference to a 1970 study by Howard and Borges(20) (in the letter the two references are mixed up).
Likewise, Newmeyer et al. refer to "the ritual of needle sharing"(21) and Newmeyer writes "[E]ven if rigs are abundant, there remain social and psychological reasons for sharing (for example, the expression of interpersonal trust or bonding)."(22) The authors, however, fail to explain what they mean by ritual and do not support their statements with empirical evidence or references.
Smith claims that "needle sharing is an integral part of the drug taking ritual" and that "sterile needles will not eliminate that ritual, but it will reduce some of theassociated medical risk."(23) However, just as the preceding publications, this article does not present empirical data to support this statement. Smith also doubts the effectivity of needle distribution:
The assumption that distribution of free needles will change the ritual and that each individual will use their own outfit except when they are really high or junk sick is questionable at best, because addiction is characterized by a compulsion to use, the loss of control and continued use in spite of adverse consequences.
This articleis confusing and inaccurate in several aspects. The supposed awareness of street addicts "of the risk of AIDS associated with needle sharing" is supported with a reference to the Howard and Borges article (20), published in 1970, well before the onset of the AIDS epidemic in the USA. A clear mistake. The above mentioned Black et al. study is extensively cited. Smith uses the same quote on symbolic meanings of needle sharing as Ghodse (which as already demonstrated, is based on the Howard and Borges article). Some percentages of the Black et al. study are presented, but two of the cited percentages on needle sharing do not match the original report in the New England Journal of Medicine. Furthermore the impression is created as if two distinctive studies are cited, because not only the original study is mentioned, but also a review of this study, without connecting the two.(24) For a large part these mistakes and inaccuracies may be the result of the author's casual reading.
But after reviewing both sources carefully one cannot but conclude that Smith's writing displays carelessness of plagiaristic proportions. Many sentences have the (almost) exact wording of the review without quotation marks, one time referencing the original paper, the other the review. This also explains the mistakes to a great degree. The sentences that give the (wrong) percentages on needle sharing are exact copies of the review, but reference the original report. One of these percentages is a copy of a mistake of the reviewer, in the other the integers are transposed. The inaccurate AIDS awareness reference to the Howard and Borges article is also a copy of a mistake of the reviewer. Likewise, the quote on the symbolic meanings of needle sharing also leans heavily on the wording of the review. Surely in these last two instances the author should have known better, as in 1972 he himself edited a book in which the Howard and Borges article was reprinted.(25)
Three of the discussed articles refer to the Howard and Borges article.(20) This article is one of the very few empirical studies into the ritual aspects of needle sharing. It discusses the results of fifty interviews held in the Haight-Ashbury district of San Francisco in 1968. The article is frequently cited in contemporary publications on the relationship between needle sharing and HIV transmission. Therefore it was reviewed with extra attention. According to the methods section, the study subjects were non- randomly selected based on appearance and interviewed by a student interviewer.
People that denied injecting drug use and, with a few exceptions, IDUs who denied needle sharing were excluded from the sample. Females were deliberately oversampled. Of a subsample of 36 (18m, 18f), 11 subjects (8 f, 3m) had injected drugs less than ten times altogether. The median ages were 20.5 for males and one and a half years younger for females. The overwhelming majority of subjects had life time experience with narcotics, sedative hypnotics, amphetamines, LSD and other synthetic or botanical hallucinogens, cannabis and other psychoactive preparations, either orally (swallowing or smoking) or parenterally.
The study showed that almost all subjects were aware of the negative consequences of needle sharing and they tried to counter these by a variety of measures and techniques. Pragmatic considerations were found to be the dominant incentives for sharing needles: The shortage of needles and syringes was most often mentioned as reason for needle sharing, followed by fear of arrest and economic incentives --"it saves the cost of outfits and because sharing can be tantamount to sharing drugs" (one has the dope, the other the works).(20) Sharing was found to be part a more general pattern, as food, lodging and drugs were frequently shared. Subjects said they generally shared needles at home or at a friends residence, with friends or intimates, rarely with strangers.
Females shared needles more often than males. 65% of the women had never shot alone compared to 25% of the men. 56% of women compared to 17% of the men always shared needles. 68% of the males compared to 29% of the females had at one time or another injected themselves. These differences are explained in terms of socialization into injecting drug use and traditional sex role differentiation. Traditional sex roles can thus be seen to restrict women's availability of both drugs and works, as one of the female subjects expressed, "My husband would not get me a new point. The only way I can get the dope is by sharing with him."
Only after being prompted, 20% of the sample mentioned "a feeling of closeness" in sharing. However, when discussing group shooting in general 20% spontaneously mentioned the importance of relating to others and feeling a sense of community, while 32% emphasized communicational aspects and the sharing of experiences. When discussing "means of protection" the distinction between needle sharing and group shooting was blurred by the respondents, but 18% of the sample mentioned feelings of security and protection provided by the group. The authors argue that "sharing needles leads to a greater protection than shooting in a group with one's own fit, because sharing conveys a greater sense of identification, bondage, and responsibility." This argument is, however, not really supported by their data or by preferences. Moreover, the argument that needle sharing leads to shooting the same amount of the drug, which is perceived safer by the authors, is inaccurate for two reasons. First, shooting the same amount is not very likely as the injected dose highly depends on individual tolerance levels. In particular in mixed groups of experienced and unexperienced users or in initiations such a practice may even be dangerous. And second, titration of individual doses does not require needle sharing.
The article also discusses status achievement and the findings indicate that status is allocated with drug tolerance, needle tracks and injecting skills, and the willingness to share drugs. Ensuing, the sexual connotation of sharing needles is addressed and the authors suggest sexual overtones to needle usage. Finally, the authors discuss self-destructive and masochistic aspects of injecting drug use. They speculate that such tendencies may help explain endured needle sharing in spite of knowledge of the negative consequences. However, the results presented on the last three items (status achievement, sexual connotations and self-destructive/masochistic refer to needle usage and not to needle sharing and can therefore hardly be used in explaining the latter.
This article provides a unique view of the social setting of injecting drug use in a group of San Franciscan hippies. But its results are not definitive, as it has some important limitations. In particular the findings on the often cited "community feelings," "security/protection" and "socialization" must be considered with considerable caution. It is rather ambiguous if the presented data on these items exclusively refers to needle sharing or to group injecting in general. Not only the subjects seemed to mix them up, but data on group drug use are used to support statements on needle sharing. Therefore, the presented results do not convincingly show that needle sharing is a self-perpetuating ritual in the study sample. As the article indicates, needle sharing often appeared in the context of drug sharing, which, as chapter nine demonstrated, is an important part of group drug taking and often does have symbolic functions. The quote of one female subject, "In some circles there's a social stigma if you don't share," may well address the wider practice of drug sharing.
A second, and more important, shortcoming is the generalizability of the results. As the authors suggest, it is indeed important to know how (a)typical their sample is for other IDU populations. In the present decade, the second in the AIDS-era, this question is more opportune than ever. The second half of the 1960s was an atypical and turbulent time. The hippie subculture, the Vietnam war and the anti-war movement, the sexual revolution and upcoming drug use among white (middle class) youth all fused in a juncture of which the main, and lasting, characteristics were the emancipation of youth and the diffusion of drug use into large segments of most Western nations. Since then, things have changed rather drastically. For the AIDS generation the day-to-day worries of the love generation have lost most of their validity. Make love not war has been replaced by a more sabre-rattling slogan: War on Drugs. In the western hemisphere drug use has become a stable phenomenon, while in many drug producing countries and the former socialist countries drug use is booming as new consumer markets develop. (26, 27, 28) More than half of the sample in the Howard and Borges study never self-injected drugs.(i) Combined with their drug use characteristics, this strongly suggests that many of this study's subjects were in a beginning, experimental phase of their drug use careers. Moreover, their sociodemographic characteristics only minimally match those found among current IDU populations.(7, 15, 29, 30, 31) Finally, the specific ideology and spirit of the times of the
late 1960s may have influenced the self-images and assessment of drug use variables by the research subjects. As the authors write in their conclusion, "the relative importance of the various possibilities involved in sharing is yet to be determined."
Des Jarlais and his colleagues reported on needle sharing in the social setting of the pre-AIDS drug subculture in New York City. Their well documented descriptions of the social context of needle sharing emphasize the subcultural context of injecting drug use. They describe a highly repressed social structure around the procurement and use of drugs in which "interpersonal trust is in precarious balance with a generalized mistrust."(32) This deviant subculture shares values, rules and language, and functions as a communication network spreading oral information about drug availability, police actions and other valuable information.(33) In general, their findings match the results presented in chapter nine, although the level of repression, due to the ongoing drugs war, seems to result in more extreme situations and behaviors. They found that in the pre-AIDS period, needle sharing was usually associated with initiation into use--the person to be inducted normally did not carry a syringe--, the use of shooting galleries, and practical utility and social bonding between running partners.(32) In particular "the sharing of needles within such running partner relations symbolizes a social bonding that makes it very difficult for one or more group members to use only his or her own set of works ..."(34) Regarding pre-AIDS needle sharing Des Jarlais et al. write:
Prior to concern about AIDS, the sharing of drug injection equipment was normal behavior among IV drug users. There were multiple reasons for sharing, from the social norms within the small friendship groups to greater availability of used equipment when a person had drugs to inject. While there was some concern about hepatitis, there were no overriding reasons not to share drug injection equipment.(33)
Finally one recent report from Canada claimed that needle exchange and similar strategies "would be generally ineffective, because [among other reasons] sharing needles communally [w]as part of the sexual ritual of fixing."(35) Data to substantiate this bold statement was, however, not presented.
Based on this literature review it is clear that scientific support for the thesis that ritual is a self- perpetuating ritual is scanty. None of the discussed studies utilized explicit definitions of ritual. All but two studies fail to support statements regarding the alleged symbolic properties of needle sharing with empirical data. Some authors just present the argument without reference. In other papers references are mixed up or inappropriate. A questionable practice of chain-referencing has been found, leading back to the in 1970 published study of Howard and Borges. Reading the original study makes it clear that many of those referencing it failed to do so. The findings of this study must, however, be interpreted with reticence. Moreover, both this study and those of Des Jarlais and colleagues on the ritual and symbolic aspects of needle sharing reflect drug use situations (long) before the onset of AIDS. It can thus be concluded that the studied literature does not give a decisive answer to the question whether contemporary needle sharing is a ritualized part of drug using behavior and if so, under what conditions such rituals develop.
Needle Sharing and Conditions for Ritualization
The reviewed literature offers thus little empirical evidence to support the idea of a needle sharing ritual, independent of other social, psychological, cultural and economic influences. But, as the extensive literature review on the concept of ritual (chapter two) suggested, in essence all behavior may be subject to ritualization processes. From that perspective needle sharing is not an exception. In order to determine the ritual dimensions of needle sharing, it must be examined in light of the relevant definitions of ritual and ritual objects. In particular, the conditions regarding injecting equipment and those regarding illegal drug use in general must be considered. In short, these definitions state the following requirements: For an event to be a ritual event it must follow a prescribed sequence of psychomotor acts which has special meaning for the performer.(36) The condition of special meaning has a double meaning, referring to instrumental and symbolic goals. The ritual value of an object--its capacity for ritualization--is determined by the subjective importance it has gained due to its scarcity.(37, 38, 39) Through a low availability, objectively important objects are transformed into subjectively important objects. This may lead to the appendage of symbolic elaboration (social importance) to the object, increasing the ritual value. (For a detailed discussion see chapter two).
Needle sharing Compared with Drug Sharing--Different Objects, Different Statuses
As has been demonstrated in chapters nine and eleven, drugs were often shared among the research subjects and, in general, these sharing events fulfilled the definitional requirements of ritual interaction. Not only standardized interaction sequences were observed in these drug sharing events, but these interactions served both instrumental and symbolic purposes. In contrast, needle sharing as a planned or stereotypical sequence in which two or more people share a syringe was not ever observed. A typical pattern of needle sharing was non-existent. The recorded cases of needle sharing could not be interpreted in terms of ritual interaction and were mainly determined by situational variables (see chapter twelve). This difference is explained by the disparate statuses of the two objects in regards to the definitional requirements of ritual and ritual objects. Drugs, such as heroin and cocaine, not only have a recognized objective importance among their users, but due to prohibition and the resulting exorbitant black market prices they have become scarce objects. Therefore, they gained substantial subjective importance and have become the instrumental imperative for the formation of a drug-centered community.(40) Not surprisingly, drugs are the most important incentive for, and subject of, interaction in this community. Sharing drugs has both short term and long term instrumental advantages. It prevents instances of intensive withdrawal experiences, as there is normally a fellow user willing to help with a betermakertje. This has created a network of mutual obligations which surpass debts between individual users. Drug sharing is also inundated with symbolic meaning. Sharing drugs facilitates contact and communication, smothers conflict and reinforces enduring relationships among individuals of equal (deviant) status. Strict norms have developed around the sharing of drugs. Drug sharing sanctions the integration into normatively regulated social behavior of the activities which the users' desire for drugs urge them to perform.(41) Ultimately, drug sharing is aimed at maintaining the subculture. In contrast, needles have never been restricted in the Netherlands and due to the exchange programs, sterile injection equipment can normally be easily obtained. Although needles hold a recognized objective value in the IDU subculture, the easy availability of new needles precludes the regular sharing of used ones. Because needle sharing is not a regular event, there is no room for the development of stylized, stereotypical behavioral sequences. The absence of scarcity likewise prevents the development of subjective importance and the addition of community values.
The Netherlands v.s. the USA--Different Drug Policy Contexts, Different Outcomes
In the United States drug sharing has also been documented, representing similar community values.(14, 33 36, 42, 43) The legal status of heroin and cocaine is not essentially different in the USA and the Netherlands--in both countries these drugs are illicit. However, the enforcement policies can be seen to diverge substantially. While the Dutch approach has resulted in rather stable and less violent drug subcultures, the work of Des Jarlais et al. and other research groups indicate that in America the subcultures surrounding these drugs are volatile and violent.(32) Generalized feelings of mistrust, though not completely absent among Dutch users, seem more normative among American users. The, compared to the Dutch situation, lower and less stable drug availability has not only induced a more elaborated monetarization of mutual services (for example commercially exploited shooting galleries, needle rental and paid house doctors) (32, 44, 45), but sharing behaviors, symbolized by the sharing of drugs, seem less consistent and limited to smaller groups or networks around the individuals, exemplified by the dyadic relationship of running partners.(14, 46) When sharing is limited to only the most significant other(s), the event increasingly becomes distinguishing and revered, thereby increasing the binding force of the ritual.
In contrast with that of drugs, the legal status of injection equipment in the USA and the Netherlands is significantly different. In the Netherlands injection equipment has never been scheduled, while in most states of the USA they are. After the development of the Model Drug Paraphernalia Act by the Drug Enforcement Administration in 1979, thirty-eight states and the District of Columbia have passed laws based on the model act, while an additional nine states have passed similar laws. With a broad range of other drug paraphernalia, these laws prohibit the distribution and possession of drug injection equipment. The Federal Mail Order Drug Paraphernalia Control Act, enacted in 1986, criminalized the interstate transport of these objects.(47) These laws did not criminalize up to then unscheduled objects, but merely streamlined the existing legislation. It is therefore not surprising that the little empirical evidence for ritualization or symbolic elaboration around needle sharing comes from the USA comes, to be concise, from New York City and San Francisco. Both cities are located in states with legal restrictions on the availability and possession of hypodermic syringes and needles.
These legal restrictions have limited the overall availability of injection equipment significantly, while fear of arrest on possession charges often discourages IDUs to carry their personal set which further reduces their on-the-spot availability. The low availability has turned needles into scarce commodities in the American drug subculture. This structural scarcity increased their (subcultural) economic value and inspired several expressions of monetarization around the provision of needles. Hopkins documented a structural black market in needles.(48)(ii) In addition to new needles, needle sellers not infrequently sold resealed used needles as new. Such profiteering may put IDUs unknowingly at risk for HIV infection. Used needles are often anonymously used at commercial shooting galleries, which are documented sources of HIV spread.(3, 49) In a shooting gallery individuals pay an entrance fee and rent a (mostly used) needle. Both needle selling and running a shooting gallery are motivated by economic incentives. For a considerable number of users these activities are an important source of income.(iii)
Nevertheless, the low needle availability has created a situation in which ritualization processes around needle sharing could develop. But renting a needle at a commercial shooting gallery cannot be interpreted in terms of ritual. Galleries mostly serve transient populations and proprietor and visitor have a foremostly (short lasting) monetary relationship. Use of shooting galleries is primarily determined by pragmatic factors and the use of these venues has been associated with homelessness, lack of financial resources and the absence of (friends that could supply) a place to get off.(16, 45) In general, interactions in such places do not meet the definitional requirements for ritual interaction.
As Turner pointed out, the closer the bond outside the potential, ritualized situation, the more meaning the ritual act will have.(50) Thus, ritualized needle sharing is more expected among IDUs with multiplex relationships--(sexual) partners, friends and other close relationships. Although, the preceding literature review produced little empirical evidence to substantiate this expectation, the finding that the majority of IDUs generally only shares with people they know well (19), is perhaps an indication of social ritualization processes. On the other hand, this selectivity is probably better explained as a rational attempt to asses HIV infection risks, given the available information. Sharing in tight friendship groups is generally perceived as a lower risk than sharing with strangers, by both users(51) and researchers (19), and there is some evidence to support this idea.(9) But this protection is of course limited. It only gives protection as long as the virus has not been introduced in the group among which injection paraphernalia are shared. When introduced, it may, by the same token, spread very rapidly. That may well have been the case in the group of early seroconverters in Scotland, reported on by Robertson et al., who, "due to a failure of the supply of clean equipment, formed an intimate equipment sharing community".(52)
Murphy suggested that in couples, needle sharing may substitute feelings of sexual intimacy and represent an intimate part of their relationship. Just as in the Howard and Borges study, some of her female subjects were dependent on their male partners to inject the drug for them.(53) In such cases needle sharing is part of the couples shared use of drugs, whereby the male exercises authority over the female by controlling her access to drugs, works, and her veins. Needle sharing has frequently been related to initiation into injecting drug use.(20, 32) First injection of an illicit drug is seldom a planned event and the novice does not carry a syringe around. If this event is subject to ritualization, it is not so much the sharing of injection equipment (on such occasions drugs are mostly also shared) which is the object of the ritual process, but the event itself. The event signifies the transition of non-user or, more specific, non-IDU, to the newly acquired status of IDU. In such cases needle sharing is merely part of this rite of passage.(54) The most pronounced indications of ritualization processes around needle sharing were found among dyads.(32) But, here again it is not an isolated phenomenon, but part of a larger sharing pattern, which is the cement of a highly entrained relationship.(55)
Primary vs. Secondary Ritual Value
A factor that may limit ritualization of needle sharing is the indirect relationship between the goal (the drug high) and the means (the needle). Drug use facilitates interaction and when drugs are shared they induce feelings of solidarity and produce a common mood. These are intrinsic features of ritual and a main reason for drug use.(55) Use of drugs (irrespective of their legal status and resulting availability) is thus directly associated with positively valued altered states of consciousness. Chapters two and nine contended that the intensity of ritualization is subject to factors that influence availability. For example, draughts and the absence of reliable water distribution systems limit the availability of water and thereby have an impact on the ritualization of this necessity of life among certain tribal peoples. Likewise, prohibition and the uncertainties of the resulting underground or subcultural drug distribution system limit the availability of drugs, contributing to the level of ritualization of drug use. However, with or without these deterrents, drugs are, and throughout history have been, used for ritual purposes. Their use is inherent to human (and animal) nature.(56) Therefore, it was argued in chapter nine that drugs have intrinsic or primary ritual value. In contrast, the ritual value of syringes and other drug paraphernalia is merely derived from their association with the drugs. Hence, needles and syringes can only obtain secondary ritual value. To make a bold comparison, in the Sahara people ritualize water, not the bucket (but they might if these should become scarce).
Ritualization is a Dynamic Process
It must be understood that ritual is not a static condition, but a dynamic process. The significance or coercive power of ritual--the power performers ascribe to, and feel forced upon themselves by the performance of ritual--can be seen to vary with the intensity of ritualization. This intensity may vary with several factors. Social factors define the situation in which the ritual interaction is performed. As Goffman explained, different faces, statuses and relationships delimit what is appropriate behavior in a situation.(57) Ritual is furthermore embedded in, and an expression of a wider set of cultural values, which also determine the pertinence of behavior. Personal factors (perceived availability, religion, etc.) may account for variations in perception, interpretation and evaluation of what is and is not (part of the) ritual or what the meaning (ranging from purely instrumental to highly symbolic) is of certain acts.(36) The symbolism of blood brothers, reported by some subjects in the Howard and Borges study, can therefore best be interpreted as personal expressions of symbolism of experimental drug users. As Cleckner writes, "The symbolic content of shared customs is not regarded as terribly significant. What is significant is the concrete results of effects of any action, not its reality status. The actual texture of street activity is dealing with reality as it is. Street customs are predominantly pragmatic and rational with little room for symbolic elaboration. A dope fiend can almost always give a practical explanation for anything he does."(58) Most committed IDUs are thus too busy taking care of business for such conscious symbolic elaboration of their daily activities.(46) On a conscious level, their activities are generally driven by pragmatic, especially economic considerations--related to the object that largely determines their daily life.
Adaptation to the Changing Functionality of Needle Sharing
Pragmatism is an essential feature of the lives of IDUs. Maintaining regular injecting drug use requires considerable coping skills and the flexibility to adapt to obstacles that (potentially) interfere with drug use management. From this functionalistic perspective needle sharing is simply a rational adaptation to the legal restrictions on injection equipment. Under these conditions, needle sharing has become the rule. Although sharing has always been associated with diseases as hepatitis, abscesses and endocarditis, these were only part of the many hazards IDUs had to cope with, and, not unjustly, many others were experienced as far more threatening. From the perspective of the IDU, the cost benefit analysis of needle sharing has thus always been in favor of this behavior. Until the advent of the HIV epidemic. HIV has tipped the balance towards the negative. IDUs are increasingly aware of the threats HIV poses on them and they are looking for ways to protect themselves, partners, family and friends. Being denied access to services which may support such changes in many countries, in particular in the USA, this is not an easy task. However, a large number of recent studies established that under the influence of the AIDS threat all over the world IDUs are adopting less risky injecting practices(59, 60), even in the American epicenters of AIDS.(61, 62) New needles are in great demand(48) and when shared, used ones are often cleaned with bleach.(21) This underlines the instrumental imperative of needle sharing. In the AIDS era, the functionality of needle sharing is challenged by the information on the threats it poses on the user and her/is relationships--it has gradually become dysfunctional. But due to HIV's long incubation period, the consequences of needle sharing have been underplayed, obscured and denied for a long time. For many IDUs HIV was only an intangible remote threat, which could simply not compete with more immediate needs and threats. As Stern made painfully clear, "AIDS is just not the biggest problem on the block."(63) Reduction of personal risk behaviors can only be maintained if these are supported by cultural change, and this is a slow process, hampered by prohibition of drugs and injection paraphernalia. As it is much harder to break the rule of sharing with close relationships than with strangers and loose acquaintances(32, 64, 65), one may expect that the process of change started with the latter and will end with intimates, presumably before the sharing of other body fluids is terminated.
Who propagates the needle sharing ritual?
Conducting the literature review it became apparent that several authors put ritual or symbolic aspects of needle sharing forward to support their doubts about the effectivity of needle exchange. In particular Smith went far beyond what is scientifically acceptable. Elsewhere he made an even more unrealistic claim. In his opinion, needle exchange programs would not have an effect on the spread of HIV through needle sharing, because such practices are simply part of the drug culture. He furthermore alleged that if ten addicts in a room had their own needles, they would all use the same one and simply pass it around.(66) Apparently, this quixotic depiction appeals to the public's imagination as some years later it was recorded in an interview with a top rank law enforcement officer in New York City:
You are dealing with an addict who is at best very, very unreliable. He does not bathe, he does not wash, he wakes up every morning with the purpose of kicking the drug habit and at the same time he is going to get some drugs. ... By nature drug addicts, street people, they share things. They share their beds, their bottles, they share their women: they share their needles. ... Drug users lie, steal, cheat. That is the make-up of a drug addict. ... They have always shared needles, that is their nature, that is their make-up, they share things. What is the reason for it? I don't know, but that is their nature. ... We have seen cases where addicts were in a room and had needles, that were stolen from a hospital or a pharmacy, in its package, sterile, all on the floor and they were sitting around sharing one, probably contaminated, needle among each other.(67)
These portrayals are false for at least two reasons. As was explained above, needles are solely instrumental in the act of getting high and sharp new ones fulfill this function of getting the drugs into ones system best. For what reason would an IDU--who is eager to get off--wait for nine others to finish using the same dull needle (which can take a while), while sharp new ones are available? With all respect, such simplistic analyses may be expected from an ill-informed and frightened lay audience, but not from professionals. As Fiddle pointed out, those working in the area of drug law enforcement ordinarily see drug users at their worst.(68) Likewise, Smith is a clinician and his view may be biased by overexposure to poorly coping clinical populations, but as he also is involved in research, some reservations in his statements would be appropriate.
However, such narrow and ungrounded analyses are not limited to clinicians and law enforcement officials. On the contrary, the mythical needle sharing ritual is frequently used to block harm reduction approaches against the spread of HIV in this population. In particular, the American administration has consistently been using this bogus argument in opposing needle exchange programs and defending restrictive needle legislation. For example, Herbert Kleber, former deputy director for demand reduction of the Office of National Drug Control Policy (the pentagon of the war on drugs), recently published an editorial in which he reflected on the issue of needle exchange. Among several other ungrounded statements, and without any references, he claimed that "many addicts would continue to share even if clean needles were available; it has become part of the ritual of taking drugs that accompanies an illicit and socially condemned activity."(69) Likewise, Charles Schuster, former director of NIDA, affirmed that "[a]lmost all intravenous drug users sometimes share their works, for reasons that include convenience, friendship and ritual." He wrote this in the foreword of the recent NIDA Research Monograph on needle sharing, which determined that the reality of needle sharing situations is far more intricate than suggested.(70)
The literature review raised no conclusive empirical evidence to support the notion that needle sharing among IDUs is a stable ritual, independent of other factors. The two empirical studies that suggest symbolic functions of this behavior were conducted before awareness of the HIV-epidemic came about and therefore generalization from pre-AIDS to current populations of IDUs may be invalid. The other articles add little relevant information, and some of these even spread misinformation about the discussed phenomenon. Perhaps the only definite evidence of ritual the review brought up, reflects on the scientific culture itself, as a questionable example of ritual referencing was established.
By comparing the conditions of drug and needle use with the relevant definitions of ritual event and ritual objects it was demonstrated that the attachment of symbolic elaboration to the use of such objects is principally subject to their perceived availability. This explained the ritualization of drug use found in this Dutch research and in American studies. In both countries, decreased drug availability has created a situation in which the attachment of symbolic meaning to primarily instrumental acts became possible. The different levels of ritualization and monetarization around drug use activities between the two countries can be attributed to gradual differences in drug availability due to different enforcement policies. The same factors explained the absence of a pattern of ritualized needle sharing in the Netherlands and the assumed presence of needle sharing rituals in the USA, prior to AIDS awareness. While the easy availability in the Netherlands prevented this process, the restrictions on sale and possession in the USA made the addition of symbolism to the primarily instrumental act of sharing needles possible. As Carballo and Rezza write in their discussion of factors that may restrain the perceived availability of needles and syringes:
Placed in th[e] broader social framework in which drug injecting has been stigmatized, actively prosecuted and associated with a range of other social problems, the sharing of needles and syringes may have gone on to represent, for some individuals, a symbol of group cohesiveness and solidarity and may have enhanced the process as well as the experience of drug injecting.(71)
However, even in the USA there is no substantial evidence in support of ritual needle sharing practices, despite these favorable conditions. The assumption that IDUs will not change or reduce their needle sharing practices in response to an increased availability, because it is a ritualized behavior pattern cannot be supported by scientific data.
This myth is further falsified by a growing number of scientific publications that show significant behavior modification towards safer injecting practices, in particular in places where needles and syringes are sufficiently available. These studies show furthermore that needle sharing is essentially adaptive behavior, induced by unavailability and unfavorable socio-economic conditions. The same conclusions are reached on the basis of the current analysis of determinants of ritualization. That is, through input of AIDS information and experience, the instrumental imperative of needle sharing is becoming increasingly overruled by the potential negative consequences for the individual, his network and the subculture as a whole. Knowledge of the current risks of needle sharing is, nevertheless, not a guarantee for (the maintenance of) safe injection behavior. Sufficient availability of syringes and needles does prevent the development of stereotypical needle sharing patterns. Moreover, it limits the number of situations in which needle sharing may, besides abstaining from or postponing a drug injection, become the only choice. But, just as the availability of condoms will not entirely stop unprotected sex, it cannot reasonably be expected that easy access to needles will eliminate all unsafe injecting. After all, injecting drug use remains a highly criminalized, but (for the performers) imperative activity.
The idea of ritualized needle sharing and other stereotypical portrayals of drug users are actively propagated by the highest rank executives in the hierarchy of the War on Drugs. Presented as scientific facts, they essentially are deceptive political soundbites--the argot of the war on drugs rhetoric. These political opportunistic myths fuel addictophobia and obstruct a rational assessment of the drug problem, blocking alternative (and more efficient) approaches to stop the spread of AIDS among injecting drug users and their relationships. Ultimately, they obstruct peace in the civil war on drug users.
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