HIV disclosure without consent linked to increased violence against women living with HIV in a Canadian setting

Our study examined the association between HIV disclosure without consent and verbal and/or physical violence due to HIV status among women living with HIV (WLWH). This study draws on baseline data of a sample (N = 316) from SHAWNA, a longitudinal community-based open cohort with WLWH in Metro Vancouver, Canada (2010-2019). Bivariate and multivariable logistic regression was used to investigate factors associated with physical and/or verbal violence due to HIV status. Adjusted odds ratios (AOR) and 95% confidence intervals [95%CIs] are reported. In total, 46.5% experienced non-consensual disclosure of HIV status without consent and 34.2% experienced physical and/or verbal violence related to HIV status in their lifetime. In multivariable analysis, HIV disclosure without consent was associated with increased odds of experiencing HIV-related physical and/or verbal violence (AOR: 7.46[4.21-13.21]). Lifetime exposure to homelessness was also associated with increased odds of physical and/or verbal violence due to HIV status (AOR: 2.15[1.03-4.49]). This research underscores the reality of HIV stigmatization and criminalization and suggests a critical need to remove HIV disclosure from the reach of criminal law and ensure women's rights to confidentiality. Governments and organizations must work to identify and address the drivers of various levels of stigma and gender-based violence and invest in inclusive, trauma-informed, culturally safe support and care programs and policies designed in collaboration with WLWH.

CALD Communities as "Collateral Damage" in the Criminalization of Coercive Control: An Argument for Prioritizing Civil System Reform Over Further Criminalization in Victoria

When posing the question of whether Victoria should follow other Australian states in criminalizing coercive control as a form of domestic and family violence (DFV), there are many arguments in favor of and against in the literature. However, scholars and advocates from marginalized communities, or in allyship with marginalized communities, tend to be cautious of embracing further criminalization, particularly due to the risks such an approach poses for women from culturally and linguistically diverse communities. This paper argues that women from marginalized communities are treated as "collateral damage" in the campaign to eliminate DFV via criminal law interventions.

From a Criminal to a Human-Rights Issue: Re-Imagining Policy Solutions to Homelessness

Criminalizing homelessness is ineffective, costly, and immoral; yet it remains a dominant feature in the management of this global social issue. There has been little analysis investigating why punitive homeless policies have remained popular despite their ineffectiveness. In applying Bacchi's What's the Problem Represented to Be (WPR) framework to a Canadian encampment bylaw, our analysis demonstrated that public policies criminalizing homelessness continue to prevail because homelessness is fundamentally understood as a problem of deviant, criminal individual behavior. We argue that reframing understandings of homelessness from one of criminality to a human rights issue gives way to more dignified, just, and effective solutions, such as the Housing First Model. We suggest that community health nurses can serve a key role in disrupting these criminalizing discourses across domains of policy, research, and practice by advocating for holistic, rights-based, and equity-oriented policy solutions related to homelessness.

Overpoliced and Underrepresented: Perspectives on Cannabis Legalization From Members of Racialized Communities in Canada

Historically, overpolicing of some racialized and Indigenous groups in Canada has resulted in unequal application of drug laws contributing to disproportionate rates of charges and convictions in these populations. Criminal records severely and negatively impact an individual's life and can perpetuate cycles of poverty and socioeconomic disadvantage. On October 17, 2018, Canada legalized cannabis production, distribution, sale, and possession for non-medical purposes. Advocates of criminal justice reform have raised concerns that Indigenous and racialized people may not equitably benefit from legalization due to unequal police surveillance and drug enforcement. These groups are among priority populations for research on cannabis and mental health, but their views on cannabis regulation have been largely absent from research and policy-making. To address this gap, we asked self-identified members of these communities about their lived experiences and perspectives on cannabis legalization in Canada. Between September 2018 and July 2019, we conducted semistructured interviews and focus groups with 37 individuals in Québec, Ontario, Alberta and British Columbia. During this phase of early cannabis legalization, participants responded to questions about anticipated public health risks and benefits of legalization, how their jurisdiction is responding to legalization, and what community resources would be needed to address legalization impacts. We conducted a thematic analysis and identified five major themes in the data related to race and early cannabis legalization: overpolicing of racialized communities, severity of penalties in new cannabis legislation, increased police powers, and underrepresentation of racialized groups in the legal cannabis market and in cannabis research. Participants discussed opportunities to support cannabis justice, including establishing priority licenses, issuing pardons or expunging criminal records, and reinvesting cannabis revenue into impacted communities. This work begins to address the paucity of Indigenous and racialized voices in cannabis research and identifies potential solutions to injustices of cannabis prohibition.

Characterizing Arrest and Incarceration in a Prospective Cohort of Transgender Women

This study characterized arrest, incarceration, and risk factors for incident incarceration among transgender women (TW) in the northeastern and southern United States. During semiannual study visits over 24 months in a multicenter cohort study, TW completed HIV testing and self-administered surveys. In total, 1571 TW completed baseline survey; 1,312 HIV-negative TW enrolled in the cohort and contributed 2134.3 person-years to the analysis. At baseline, 37% had been arrested and 21% had been incarcerated. Incident incarceration was 23.4 per 1,000 person-years (95% confidence interval [CI]: 16.9-29.9). Sex work was significantly associated with baseline and incident incarceration (p < .01). A history of incarceration at enrollment was the strongest predictor of incident incarceration (adjusted odds ratio [aOR] 6.99; 95% CI: 3.43-14.24). Living in the South (aOR 2.69, 95% CI: 1.22-5.93), income below the federal poverty level (aOR 2.65 95% CI: 3.43-14.24), and having a recent partner who had been incarcerated (aOR 2.62, 95% CI: 1.20-5.69) also increased the odds of incident incarceration in multivariable modeling. Structural interventions to reduce poverty and decriminalize sex work have the potential to reduce incarceration rates among TW.

Self-managed abortion: Aligning law and policy with medical evidence

People have always and will always find ways to try to end their pregnancies when necessary. Many do so safely without the involvement or direct supervision of healthcare professionals by self-managing their abortions. In 2022, the well-established safety and efficacy of abortion medications prompted WHO to fully endorse self-managed medication abortion as part of a comprehensive range of safe, effective options for abortion care. But despite robust evidence supporting the safety and effectiveness of the self-use of medications for abortion, abortion laws and policies around the world remain at odds with clinical evidence and with the realities of self-managed medication abortion in the present day. The present article considers legal issues related to self-managed abortion and addresses the role of obstetricians, gynecologists, and other healthcare professionals in promoting clinical and legal safety in abortion care through support of self-managed abortion.

Harmful Alcohol Use and Associated Socio-Structural Factors among Female Sex Workers Initiating HIV Pre-Exposure Prophylaxis in Dar es Salaam, Tanzania

Harmful alcohol use is an important risk factor for premature mortality and morbidity and associated with increased HIV risk and lower uptake of and adherence to HIV interventions. This study aimed to assess the extent of harmful alcohol use and associated socio-structural vulnerability factors among female sex workers in Dar es Salaam, Tanzania, a key population in the HIV epidemic. Data from a study of female sex workers initiating pre-exposure prophylaxis (PrEP) recruited through respondent driven sampling were used. We assessed harmful alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) defined as having an AUDIT score ≥ 16. Associations between harmful alcohol use and socio-structural factors were assessed using logistic regression with marginal standardization. Of the 470 women recruited, more than one third (37.3%) had a drinking pattern suggestive of harmful alcohol use. Such use was independently associated with sex work-related mobility (aPR: 1.36, 95% CI: 1.11-1.61), arrest/incarceration (aPR: 1.55, 95% CI: 1.27-1.84) and gender-based violence (aPR: 1.31, 95% CI: 1.06-1.56). The high prevalence of harmful alcohol use and the interconnectedness with socio-structural factors indicate a need for a holistic programmatic approach to health for female sex workers. Programming should not solely direct attention to individual behavior but also include strategies aiming to address socio-structural vulnerabilities.

Violence against sex workers: Correlates and Changes under 'End-Demand' legislation in Canada: A five city study

Canada is among several countries to have implemented 'end-demand' criminalization frameworks for sex work. Drawing on interviews with sex workers (n = 200) in five cities, we employed multivariate logistic regression to identify associations with workplace violence. We also analysed descriptive data on trafficking and on workplace violence under end-demand legislation. In the past 12 months, being unable to call 911 in a safety emergency at work for fear of police detection (Adjusted Odd Ratio AOR: 4.307, 95% Confidence Interval CI: 1.697 -10.927), being unable to screen clients due to fear of police detection (AOR: 2.175, 95% CI: 1.074 -4.405), having experienced anti-sex work housing policy/eviction (AOR: 2.031, 95% CI: 0.897-4.598), and being Indigenous (Adjusted Odd Ratio (AOR): 2.167, 95% Confidence Interval (CI): 1.060-4.428) were all independently associated with workplace violence in the past 12 months. Of those who worked prior to the law change (n = 167), a majority of respondents (80.24% (134)) reported that violence in the workplace had increased or stayed the same compared to the previous criminalization model and 87.43% (n = 146) reported it was harder or the same to get help in an emergency.

Contextualizing the Experiences of Black Women Arrested for Intimate Partner Violence in Canada

This qualitative study was informed by critical race feminism and explored Black women's experiences with the police with a particular focus on how issues of race, racism, oppression, and subordination inform their experiences. It sought to answer three research questions: (1) What is known about Black women's experiences with the police in the context of intimate partner violence? (2) Given their experiences with the police, what is their perception of the police? and (3) To what extent do women construct counter-narratives of their experiences with the police and what does that involve? The sample was comprised of 25 participants, 15 of whom were arrested. The women were over the age of 18 and lived in the Greater Toronto Area and surrounding areas. Most women expressed that they had negative encounters with the police, which was influenced by the police's negative perceptions of them. Black women who called the police to intervene in an intimate partner violence incident were subjected to great scrutiny and vulnerable to racialized and gendered police violence. Consequently, women were fearful and distrustful of the police and were less likely to seek help from them in the future. The study answers the call for research that examines Black women's experiences with the police from their perspective. It has implications for social service providers and provides strategies to improve future police interactions with Black communities.

Actions needed to promote health equity and the mental health of Canada's Black refugees

OBJECTIVES

The overall goal was to synthesize knowledge on actions that need to be taken to promote health equity and the mental health of Black refugees in Canada.

DESIGN

Group concept mapping systems were applied to generate and organize action-oriented statements related to the different social determinants of health. A total of 174 participants from the cities of Calgary and Edmonton with experience working with Black Canadians participated in four focus groups: (a) 2 focus groups that engaged 123 participants in brainstorming 84 statements guided by the following focus prompt: 'A specific action that would improve the mental health equity of Black refugees living in Canada is … ' and (b) 2 focus groups of 51 participants who sorted the generated statements and rated them by order of 'importance' and 'ideas seen in action.' Data was further computed and analysed by the research team and a select advisory group from the participants.

RESULTS

A 10-cluster map generated included the following clusters: (1) promoting cultural identity, (2) promoting ways of knowing, (3) addressing discrimination and racism, (4) addressing the criminalization of Black Canadians, (5) investing in employment for equity, (6) promoting equity in housing, (7) facilitating self-determination, (8) improving (public) services, (9) promoting appropriate and culturally relevant mental health services, and (10) working with and addressing faith and belief related issues. Clusters 4 and 9 ranked as the most important clusters in promoting health equity and the mental health of Black Canadians.

CONCLUSIONS

Addressing the criminalization of Black Canadians through a range of rehumanizing interventions at institutional levels will provide a platform from which they can participate and engage others in developing appropriate and culturally relevant mental health services.

Criminalization of Care: Drug Testing Pregnant Patients

This article reveals how law and legal interests transform medicine. Drawing on qualitative interviews with medical professionals, this study shows how providers mobilize law and engage in investigatory work as they deliver care. Using the case of drug testing pregnant patients, I examine three mechanisms by which medico-legal hybridity occurs in clinical settings. The first mechanism, clinicalization, describes how forensic tools and methods are cast in clinical terminology, effectively cloaking their forensic intent. In the second, medical professionals informally rank the riskiness of illicit substances using both medical and criminal-legal assessments. The third mechanism describes how gender, race, and class inform forensic decision-making and criminal suspicion in maternal health. The findings show that by straddling both medical and legal domains, medicine conforms to the standards and norms of neither institution while also suspending meaningful rights for patients seeking care.

Engaging unhoused community members in the design of an alternative first responder program aimed at reducing the criminalization of homelessness

Police are often called to address concerns about people experiencing homelessness, with arrests often resulting from low-level, nonviolent crimes, and violations of minor nuisance ordinances. In Portland, Oregon, advocates lobbied for a new model of emergency response for 911 calls involving unhoused community members and people experiencing behavioral health crises. To ensure the program reflected the needs and perspectives of people experiencing homelessness, teams of researchers, community volunteers, and people with lived experience interviewed 184 people in camps, shelters, and parks. Teams asked unhoused people how the program should be designed, including who the first responders should be, how they should approach individuals in crisis, what resources they should provide, and how they should be trained. This article describes the methods, findings, and recommendations from our collaborative survey process aimed at ensuring that the voices of people experiencing homelessness informed the development of the Portland Street Response pilot program.

"I'm No Criminal, I'm Just Homeless": The Greensboro Homeless Union's efforts to address the criminalization of homelessness

This paper examines how homelessness is criminalized in Greensboro, North Carolina, and the ways in which the Homeless Union of Greensboro (HUG) has contested such criminalization. This paper draws on data from a participatory action research study conducted between 2018 and 2020 by a group of researchers from two local universities and members of HUG. Findings from our study suggest that law enforcement officers in Greensboro use a vast array of laws to harass, ticket, and arrest people experiencing homelessness, particularly those who are Black. Findings also suggest that when individuals experiencing homelessness seek help for citations or arrests, it is challenging to access quality, affordable legal representation. This paper illustrates how HUG takes a multi-pronged approach to address the variety of policies and practices that target homeless people, particularly people of color, recognizing that systems change requires a multifaceted approach that adapts to dynamic social and political contexts.

Promoting Mental Health and Criminal Justice Collaboration Through System-Level Partnerships

Recent high-profile deaths of unarmed individuals in police custody have raised concerns about the role of police officers in responding to people who are experiencing mental health crises. Of further concern, people with serious mental illness are highly over-represented throughout the entire criminal justice system including within jail, prison and community corrections populations. It is widely accepted that promoting mental health and criminal justice collaboration is a key to addressing these concerns. Promoting effective collaboration is challenging, however, due to fundamental differences in cultures and methods that exist between mental health and criminal justice service providers. To promote effective collaboration between service providers, a conceptual framework was recently published that divides the collaborative process into separate steps and outlines respective responsibilities at each step. Yet optimal collaboration between mental health and criminal justice service providers requires the support of their respective supervisors and agency heads. This paper extends previous work at the service provider level by applying the conceptual framework to promote effective collaboration at the systems level (i.e., between agencies). Barriers to inter-agency collaboration are discussed, and strategies for facilitating collaboration at each step of the collaborative process are presented.

When law and science part ways: the criminalization of breastfeeding by women living with HIV

Stigma and discrimination are a constant reality for the 37.7 million people living with human immunodeficiency virus (HIV) around the globe. Fear over vertical transmission has fuelled HIV criminalization: laws that target people living with HIV for acts deemed to be a transmission risk. Research has now shown that many of these behaviours, including breastfeeding, pose an extremely low risk of transmission when people have proper medical care, access to treatment and open relationships with medical professionals. Yet, we are witnessing a wave of criminal cases against women living with HIV for breastfeeding, an act which is actively promoted worldwide as the best infant feeding strategy. In this review, we will place the criminalization of breastfeeding within the context of current medical recommendations and cultural views of breastfeeding. We will highlight the criminal cases against women living with HIV for breastfeeding around the globe and the criteria for justifiable criminalization. Finally, we will provide recommendations for moving towards decriminalization, removing this barrier to HIV prevention, treatment and care.

Trends in Abortion Policies in Low- and Middle-Income Countries

The decision to terminate a pregnancy is not one that is taken lightly. The need for an abortion reflects limited sexual autonomy, ineffective or lack of access to contraceptive options, or a health indication. Abortion is protected under human rights law. That notwithstanding, access to abortions continues to be contested in many parts of the world, with vested interests from politically and religiously conservative states, patriarchal societies, and cultural mores, not just within local contexts but also within a broader geopolitical context. Criminalization of a women's choice not to carry a pregnancy is a significant driver of unsafe procedures, and even where abortions are provided legally, the policies remain constrained by the practice or by a lack of coherence. This review outlines the trends in abortion policy in low- and middle-income countries and highlights priority areas to ensure that women are safe and able to exercise their reproductive rights.

Criminalized Black Women's Experiences of Intimate Partner Violence in Canada

Canadian research examining the overlap between Black women's victimization and criminalization is sparse. This qualitative study addresses this gap by examining the ways in which criminalized Black women's intersecting identities of race, class, and gender influence how they perceive, experience, and respond to intimate partner violence (IPV). Semi-structured interviews were conducted with 25 Black women who experienced IPV. The findings focus on the women (15) who were also charged with an IPV-related offense. Critical race feminism was employed to analyze their narratives. This research has implications for policy, practice, and future research with Black women who are victimized and criminalized.

When biographical disruption meets HIV exceptionalism: Reshaping illness identities in the shadow of criminalization

Drawing on interviews with civil society actors in the AIDS Service Organization (ASO) sector in Canada, this article explores how these actors contribute to shaping the illness identities of people living with HIV/AIDS in the shadow of efforts to criminalize exposure to HIV. While the biographically disruptive qualities associated with an HIV diagnosis have been addressed in the medical sociology literature, we turn our attention to the key role played by ASOs as interlocutors in this process. Paying specific attention to the intersection of processes of medicalization and criminalization, we ask how they are re-stigmatizing a condition that has shifted in the public consciousness from its earlier association with deviance and moral culpability. One important implication of our findings concerns the need to take greater account of how the illness identity and experience can be shaped by a 'biography of telling', of a renewed pressure to disclose intimate details of one's health status as a way to perform responsible practices of citizenship.

Is criminalization the answer? Perspectives of community members and police on menstrual seclusion policy in Far-West Nepal

Chhaupadi is a form of menstrual seclusion practiced in Nepal in which women and girls are isolated during their menstrual cycles and follow numerous restrictions. The tradition dates back centuries and can have serious physical and mental health consequences. While the practice was criminalized in 2017 with fines and jail time, this legislative action comes after more than a decade of legal history, from an initial ban in 2006, to declaring it a form of violence against women in 2009, and finally, its criminalization in 2017. Exploring levels of awareness regarding the 2017 chhaupadi criminalization, perceptions of the legal penalties, and whether or not criminalization will lead to behaviour change are imperative next steps for informing the development of evidence-based interventions targeting chhaupadi. In this qualitative investigation conducted in Kalikot district, six focus group discussions and 33 in-depth interviews were conducted with a total of 81 participants. School-going girls, girls who have dropped out of school before completing twelfth grade, mothers, fathers, teachers, health care providers, religious leaders, traditional healers, grandmothers and police participated in the study. The results indicate that criminalization is generally perceived as a positive step for initiating chhaupadi behaviour change, and one-third of participants expressed that they plan to change their behaviours after learning that chhaupadi is publishable with fines and/or jail time. However, accurate information about the criminal code is extremely low and therefore interventions ensuring communities and law enforcement are informed of the criminalization and associated penalties are urgently needed. In addition, even after its criminalization, chhaupadi behaviour change is anticipated to be gradual and is expected to require long-term interventions targeting social pressure associated with upholding the tradition and raising awareness via appropriate trainings, engaging the media, and beyond.

"I'm Going to Stop Myself Before Someone Stops Me": Complicating Narratives of Volitional Substance Use Treatment

Background: Often people assume that entry into drug treatment is a voluntary action for persons who use drugs (PWUD). This narrative informs the organizational and regulatory structure of most treatment programs and consequently affects patients' ability to exert agency over their own treatment. Yet, this view ignores the complex interplay between individual and structural factors in peoples' decision-making processes, particularly among people who use drugs who are stigmatized and criminalized. Treatment programs that assume voluntary entry may lack appropriate services for the populations of treatment seekers that they serve. Methods: This paper uses semi-structured interviews with 42 participants in Opioid Substitution Treatment (OST) (including patients, clinic doctors and staff, and advocates) informed by one of the author's own lived experience in OST, to examine patients' treatment decisions, and in particular, if and how, the structural context of drugs' illegality/criminalization affected their willingness to pursue treatment. A Critical Discourse Analysis was used to identify key themes. Results: Interview data demonstrates that most people who use drugs enter treatment under constrained conditions related to drugs' illegality. Themes that emerged included: 1. A feeling of limited choices due to drugs' illegality; 2. Peer and family pressure; 3. Fear of losing children; and 4. Internalized stigma (i.e. feeling they are dirty or bad for using). Conclusion: Narratives that frame PWUD's treatment decisions as volitional provide political cover to policies that criminalize PWUD by obscuring their effect on PWUD's treatment decisions. Treatment models, particularly those that serve highly criminalized populations, should be re-conceptualized outside of normative narratives of individual choice, and be broadened to understand how larger structures constrain choices. By looking at macro-level factors, including the interplay of criminalization and drug treatment, programs can begin to understand the complexity of PWUD motivations to enter drug treatment. Recognizing the role of the War on Drugs as a force of oppression for people who use drugs, and that their treatment decisions are made within that setting, may enable people in treatment, and providers, to develop more productive ways of interacting with one another. Additionally, this may lead to better retention in treatment programs.

From trauma-blind to trauma-informed: re-thinking criminalization and the role of trauma in persons with serious mental illness

Trauma-informed approaches offer a new perspective for understanding how and why individuals with serious mental illness (SMI) become entangled in the criminal justice system. There is growing awareness that many individuals with SMI have experienced significant life trauma, and factors beyond SMI that contribute to criminalization are being identified; however, the role of trauma continues to be overlooked in many formulations. In trauma-blind systems, trauma-related behaviors are often misunderstood and met with responses that exacerbate psychiatric and behavioral problems. Trauma-informed approaches provide a richer understanding of underlying drivers of behavior, and view trauma as an integral component of risk management, case formulation, relationship-based care, and referral. Embedding trauma-informed principles across organizations promotes continuity of care, safety, and more compassionate cultures that help reduce the flow of individuals with SMI into the criminal justice system. An expanded view of the criminalization hypothesis is offered, which incorporates all factors addressed in current research.

A social history of serious mental illness

Despite medical, technological, and humanitarian advances, the criminalization of those with serious mental illness continues. This is not an isolated phenomenon. The benefits of treatment reform and innovation are difficult to maintain or sometimes outright harmful. Across time and geography, the care of those with serious mental illness tends towards maltreatment, be it criminalization or other forms of harm. We present a social history of serious mental illness, along with the idea that the treatment of serious mental illness is a Sisyphean task-perpetually pushing a boulder up a hill, only for it to roll down and start again. The history is provided as a basis for deeper reflection of treatment, and treatment reform, of those with serious mental illnesses.

A brief history of the criminalization of mental illness

This article traces the history of the way in which mental disorders were viewed and treated, from before the birth of Christ to the present day. Special attention is paid to the process of deinstitutionalization in the United States and the failure to create an adequately robust community mental health system to care for the people who, in a previous era, might have experienced lifelong hospitalization. As a result, far too many people with serious mental illnesses are living in jails and prisons that are ill-suited and unprepared to meet their needs.

Reimagining VAWA: Why Criminalization Is a Failed Policy and What a Non-Carceral VAWA Could Look Like

The Violence Against Women Act (VAWA) is the signature federal legislative accomplishment of the anti-violence movement and has ensured that criminalization is the primary response to intimate partner violence in the United States. But at the time of its passage, some anti-violence activists, particularly women of color, warned that criminalization would be problematic for a number of reasons, a caution that has borne fruit in the 25 years since VAWA's passage. This article critiques the effectiveness of criminalization as anti-domestic violence policy and imagines what a non-carceral VAWA could look like.

A longitudinal description of incompetent to stand trial admissions to a state hospital

OBJECTIVE

Evidence is clear that the nation is experiencing an increasing number of incompetent to stand trial (IST) admissions to state hospitals. As a result, defendants in need of treatment can wait in jail for weeks for admission for restoration. This study was conducted to better understand this growing population and to inform hospital administration about the characteristics of IST admissions.

METHODS

The study was conducted at the Department of State Hospitals (DSH) facility in Napa (DSH-Napa), a 1200-bed primarily forensic inpatient psychiatric facility located in northern California. The records of patients found IST and admitted to DSH-Napa for restoration of competence between the dates of 1/1/2009 and 12/31/2016 were eligible for inclusion in the study.

RESULTS

There were a total of 3158 unduplicated IST admissions available during the specified time period. Our data indicate that the number of admissions with more than 15 prior arrests increased significantly, from 17.7% in 2009 to 46.4% in 2016. In contrast, the percent of patients reporting prior inpatient psychiatric hospitalization evidenced a consistent decrease over time from over 76% in 2009 to less than 50% in 2016.

CONCLUSION

Our data add to the body of literature on the potential causes of the nationwide increase in competency referrals. The literature is clear that jails and prisons are now the primary provider of the nation's mental health care. Our data suggest that another system has assumed this role: state hospitals and other providers charged with restoring individuals to competence.

Competence to stand trial and criminalization: an overview of the research

Beginning in the 1960s, a steady decline in the number of inpatient psychiatric beds has occurred across the United States, primarily as a result of stricter civil commitment criteria and a societal movement toward deinstitutionalization. Concomitant with this decrease in psychiatric beds has been a steady increase in the number of mentally ill individuals who are arrested and processed through the criminal justice system as defendants. One consequence of this has been an explosion in the number of defendants referred for evaluations of their present mental state-adjudicative competence-and subsequently found incompetent and ordered to complete a period of competency restoration. This has resulted in forensic mental health systems that are overwhelmed by the demand for services and that are unable to meet the needs of these defendants in a timely manner. In many states, lawsuits have been brought by defendants who have had their liberties restricted as a result of lengthy confinements in jail awaiting forensic services. The stress on state-wide forensic systems has become so widespread that this has reached the level of a near-national crisis. Many states and national organizations are currently attempting to study these issues and develop creative strategies for relieving this overburdening of forensic mental health systems nationwide. The purpose of this article is to review the current state of the research on competence to stand trial and to highlight those issues that might be relevant to the issue of criminalization of individuals with mental illness in the United States.

Public Perceptions toward Kratom (Mitragyna Speciosa) Use in Malaysia

Kratom (Mitragyna speciosa), an indigenous medicinal plant of Southeast Asia, is believed to be harmful. We compared the perceptions toward kratom use among kratom users and non-users in Malaysia. 356 respondents (137 kratom users and 219 non-users) were recruited for this cross-sectional study. The majority of respondents were male (60%, n = 212/356), Malays (88%), and 51% were ≥37 years old. Non-users showed higher unadjusted odds of reporting a perception that kratom use can cause addiction (OR = 6.72, CI: 3.91-11.54, p < .0001), withdrawal symptoms (OR = 7.58, CI: 4.62-12.42, p < .0001), illicit drug use problems (OR = 10.12, CI: 6.14-16.68, p < .0001), impaired social-functioning (OR = 12.05, CI: 7.24-20.05, p < .0001), and health problems (OR = 10.44, CI: 6.32-17.24, p < .0001). Similarly, non-users viewed kratom policies differently from kratom users, displaying increased odds of reporting the belief that kratom use and sales must be regulated with stringent laws (OR = 5.75, CI: 3.61-9.18, p < .0001), and kratom should be regulated instead under the Dangerous Drugs Act 1952 to overcome kratom use problems (OR = 8.26, CI: 4.94-13.82, p < .0001). Because of the disconnect in kratom use perceptions and personal experiences between kratom users and non-users, hastily criminalizing kratom without investigating carefully its scientific merits can significantly impede future kratom research.

Skirting Around the Issue: Misdirection and Linguistic Avoidance in Parliamentary Discourses on Upskirting

Discourses on men's violence against women have long been associated with linguistic avoidance and communicative strategies that obscure the responsibility of male perpetrators. Linguistic avoidance does not only obfuscate the responsibility of male perpetrators; such strategies also hide the norms and attitudes that underpin much of men's violence against women. Such techniques represent a form of misdirection: communicative strategies that draw attention away from the true causes or nature of an issue. To demonstrate misdirection in action, I conduct a feminist critical discourse analysis of Australian parliamentarians' speech acts during the criminalization of upskirting in Victoria in 2007.

From Criminalized Patients to Risk-Exposed Agents: Reconceptualizing Carceral Involvement among Individuals with Psychiatric Diagnoses

Individuals with serious mental disorder diagnoses (SMD) are overrepresented in U.S. jails and prisons, returning to custody more often and more quickly than those without these diagnoses. This paper examines the strengths and limitations of existing theoretical interpretations of justice involvement among those with SMD and presents results from in-depth interviews (n = 23) in an effort to direct an alternative theoretical path. Findings indicate people with SMD are not simply subject to the whims of their psychopathology, and instead are risk-exposed agents whose arrests are related to early institutionalization, interpersonal conflict, and life circumstances punctuated by socioeconomic marginality. Such findings suggest longitudinal and multi-level theoretical orientations are most appropriate for understanding carceral involvement among individuals with SMD.

Made wrong, excluded, and ignored: Introduction to a special issue on lesbians and the law

For some time now, the specific experiences that lesbians have with the law have been considerably overlooked. This is because there is a focus on how gay males have contact with the law, as gay males are the group whose same-sex intimacies are most often criminalized in legislative frameworks. It is rare for the same-sex intimacies of lesbians to be targeted explicitly in legislative frameworks. This special issue therefore focuses on how lesbians have contact with the law. It features articles focused on what the guest editors conceptualize as how lesbians are being made wrong, being excluded, and being ignored by the law, and each of these are outlined in further detail in this introduction. The articles highlight the relational nexus between lesbians and different frameworks, processes, rules, policies, institutions and applications of law, and the far-reaching impacts this nexus produces in the lives of lesbians around the world.

The Paradox for Chem-Fun and Gay Men: A Neoliberal Analysis of Drugs and HIV/AIDS Policies in Hong Kong

Globally, there has been increasing public health and scholarly interest in chemsex, where the consumption of drugs is related to enhancing sexual pleasure, often in a group context, particularly among gay men or men who have sex with other men (MSM). Since the early 2000s, Hong Kong has witnessed the growth of a chemsex scene. In recent years, HIV/AIDs surveillance reports indicate that chemsex goers have contributed to the rise of HIV infections among MSM, and with increasing pressure from frontline workers, the government has recently acknowledged that this is an emerging issue. Drawing on neoliberalism as a policy framework, ideology, and mode of government, this article traces the adoption of neoliberal discourses of harm reduction in HIV/AIDS and drug policies in Hong Kong. We argue that this emergent issue is the result of two divergent policy orientations, thereby leading to a critical health service gap. This article examines the intersection between HIV/AIDS and drug policies in a particular cultural context to underscore health policy gaps and extend our understanding of the construction of neoliberal subjects in health policies beyond the West.

Quality of care and HIV service utilization among key populations in Zambia: a qualitative comparative analysis among female sex workers, men who have sex with men and people who use drugs

HIV epidemic control requires improving access and uptake of HIV services by key populations (KPs). In Zambia, the behaviors of female sex workers (FSWs), men who have sex with men (MSM), and people of who use drugs (PWUD) are criminalized, and little information exists about their HIV/STI service use. Using a quality of care (QOC) framework, we compared barriers to and opportunities for HIV/STI service access and uptake among the three KPs. We conducted in-depth interviews and focus group discussions with 314 KP members between July 2013 and September 2015 in eight districts. Poorer QOC was received at public health facilities compared to private, NGOs and traditional healers. Stigma and discrimination, confidentiality, and legal prosecution were barriers to service use and more salient among MSM than FSWs and PWUD. Invasive facility policies were barriers and more prominent among FSWs than MSM and PWUD. Service unavailability was of equally high salience among MSM and PWUD than FSWs. Comfort in the clinic and perceived treatment effectiveness were facilitators for all three KPs. The health care experiences of KPs are not monolithic; HIV/STI service improvement strategies should address the concerns and be tailored to the needs of each key population.

Expert consensus statement on the science of HIV in the context of criminal law

INTRODUCTION

Globally, prosecutions for non-disclosure, exposure or transmission of HIV frequently relate to sexual activity, biting, or spitting. This includes instances in which no harm was intended, HIV transmission did not occur, and HIV transmission was extremely unlikely or not possible. This suggests prosecutions are not always guided by the best available scientific and medical evidence.

DISCUSSION

Twenty scientists from regions across the world developed this Expert Consensus Statement to address the use of HIV science by the criminal justice system. A detailed analysis of the best available scientific and medical research data on HIV transmission, treatment effectiveness and forensic phylogenetic evidence was performed and described so it may be better understood in criminal law contexts. Description of the possibility of HIV transmission was limited to acts most often at issue in criminal cases. The possibility of HIV transmission during a single, specific act was positioned along a continuum of risk, noting that the possibility of HIV transmission varies according to a range of intersecting factors including viral load, condom use, and other risk reduction practices. Current evidence suggests the possibility of HIV transmission during a single episode of sex, biting or spitting ranges from no possibility to low possibility. Further research considered the positive health impact of modern antiretroviral therapies that have improved the life expectancy of most people living with HIV to a point similar to their HIV-negative counterparts, transforming HIV infection into a chronic, manageable health condition. Lastly, consideration of the use of scientific evidence in court found that phylogenetic analysis alone cannot prove beyond reasonable doubt that one person infected another although it can be used to exonerate a defendant.

CONCLUSIONS

The application of up-to-date scientific evidence in criminal cases has the potential to limit unjust prosecutions and convictions. The authors recommend that caution be exercised when considering prosecution, and encourage governments and those working in legal and judicial systems to pay close attention to the significant advances in HIV science that have occurred over the last three decades to ensure current scientific knowledge informs application of the law in cases related to HIV.

"We Now Have a Patient and Not a Criminal": An Exploratory Study of Judges and Lawyers' Views on Suicide Attempters and the Law in Ghana

This study explored the views of judges and lawyers of the superior courts of Ghana on the law criminalizing attempted suicide. Qualitative data were collected from 12 experienced legal practitioners of the superior courts (five judges and seven lawyers) using a semi-structured interview schedule. Thematic analysis of the data yielded three main perspectives: In defence of the Law, Advocating a Repeal, and Pro-Health Orientation. Although exploratory, the findings of this study offer cues for stepping up suicide literacy and advocacy programmes toward either a repeal of the law or a reform.

"I Was Not Sick and I Didn't Need to Recover": Methadone Maintenance Treatment (MMT) as a Refuge from Criminalization

BACKGROUND

Methadone Maintenance Treatment (MMT) in the United States (U.S.) has been undergoing a shift towards conceptualizing the program as recovery-based treatment. Although recovery is seen by some as a means to restore MMT to its rightful position as a medically-based treatment for addiction, it may not represent the experiences, or meet the needs of people who use drugs (PWUD), many of whom who use the program as a pragmatic means of reducing harms associated with criminalization.

OBJECTIVES

To examine alternative constructions of MMT in order to produce a richer, more contextualized picture of the program and the reasons PWUD employ its services.

METHODS

This paper uses semi-structured interviews with 23 people on MMT (either currently or within the previous two years).

RESULTS

Most participants linked their use of MMT to the structural-legal context of prohibition/criminalization rather than through the narrative of the recovery model. Responses suggested the recovery model functions in part to obscure the role of criminalization in the harms PWUD experience in favor of a model based on individual pathology. Conclusions/Importance: In contrast to the recovery model, MMT cannot be understood outside of the structural context of criminalization and the War on Drugs which shape illegal drug use as a difficult and dangerous activity, and consequently position MMT as a way to moderate or escape from those harms.

Social and structural factors increase inconsistent condom use by sex workers' one-time and regular clients in Northern Uganda

While sex workers (SWs) bear the brunt of the epidemic in Uganda, there remains a dearth of empirical research on the structural drivers of HIV prevention among SWs. This study examined the drivers of inconsistent condom use by one-time and regular clients of young women SWs in Gulu, Northern Uganda. Data were drawn from the Gulu Sexual Health Study, a cross-sectional study of young SWs, aged 14 years and older (2011-2012). SWs were recruited using peer/SW-led outreach, in partnership with The AIDS Support Organization and other CBOs. Multivariable logistic regression was used to examine the correlates of inconsistent condom use by one-time and regular clients. In total, 84.5% of the 381 SWs servicing regular clients and 76.8% of the 393 SWs servicing one-time clients reported inconsistent client condom use. In multivariable analysis, physical/sexual violence by clients (AOR = 5.39; 95%CI 3.05-9.49), low sexual control by workers (measured by the validated Pulweritz scale) (AOR = 2.86; 95%CI 1.47-5.58), alcohol/drug use while working (AOR = 1.98; 95%CI 1.17-3.35) and migration to Gulu for sex work (AOR = 1.73; 95%CI 0.95-3.14) were positively correlated with inconsistent condom use by one-time clients. Correlates of inconsistent condom use by regular clients included: low sexual control by workers (AOR = 4.63; 95%CI 2.32-9.23); physical/sexual violence by clients (AOR = 3.48; 95%CI 1.85-6.53); police harassment (AOR = 2.57; 95%CI 1.17-5.65); and being a single mother (AOR = 2.07; 95%CI 1.09-3.93). Structural and interpersonal factors strongly influence inconsistent condom use by clients, with violence by clients and police, low sexual control by workers, migration and single-parenthood all linked to non-condom use. There is a need for peer-led structural interventions that improve access to occupational health and safety standards (e.g., violence prevention and alcohol/drug harm reduction policies/programming). Shifts away from the current punitive approaches towards SWs are integral to the success of such interventions, as they continue to undermine HIV prevention efforts.

Community mapping of sex work criminalization and violence: impacts on HIV treatment interruptions among marginalized women living with HIV in Vancouver, Canada

Despite the high HIV burden faced by sex workers, data on access and retention in antiretroviral therapy (ART) are limited. Using an innovative spatial epidemiological approach, we explored how the social geography of sex work criminalization and violence impacts HIV treatment interruptions among sex workers living with HIV in Vancouver over a 3.5-year period. Drawing upon data from a community-based cohort (AESHA, 2010-2013) and linked external administrative data on ART dispensation, GIS mapping and multivariable logistic regression with generalized estimating equations to prospectively examine the effects of spatial criminalization and violence near women's places of residence on 2-day ART interruptions. Analyses were restricted to 66 ART-exposed women who contributed 208 observations and 83 ART interruption events. In adjusted multivariable models, heightened density of displacement due to policing independently correlated with HIV treatment interruptions (AOR: 1.02, 95%CI: 1.00-1.04); density of legal restrictions (AOR: 1.30, 95%CI: 0.97-1.76) and a combined measure of criminalization/violence (AOR: 1.00, 95%CI: 1.00-1.01) were marginally correlated. The social geography of sex work criminalization may undermine access to essential medicines, including HIV treatment. Interventions to promote 'enabling environments' (e.g. peer-led models, safer living/working spaces) should be explored, alongside policy reforms to ensure uninterrupted treatment access.

Negotiating Violence in the Context of Transphobia and Criminalization: The Experiences of Trans Sex Workers in Vancouver, Canada

A growing body of international evidence suggests that sex workers face a disproportionate burden of violence, with significant variations across social, cultural, and economic contexts. Research on trans sex workers has documented high incidents of violence; however, investigations into the relationships between violence and social-structural contexts are limited. Therefore, the objective of this study was to qualitatively examine how social-structural contexts shape trans sex workers' experiences of violence. In-depth semistructured interviews were conducted with 33 trans sex workers in Vancouver, Canada, between June 2012 and May 2013. Three themes emerged that illustrated how social-structural contexts of transphobia and criminalization shaped violent experiences: (a) transphobic violence, (b) clients' discovery of participants' gender identity, and (c) negative police responses to experiences of violence. The findings demonstrate the need for shifts in sex work laws and culturally relevant antistigma programs and policies to address transphobia.

The Loss of Boystown and Transition to Online Sex Work: Strategies and Barriers to Increase Safety Among Men Sex Workers and Clients of Men

Men sex workers in Vancouver have largely transitioned from street to online solicitation coinciding with losing "Boystown," the main outdoor sex work stroll for men. This article explores strategies and barriers to increase safety among men and trans sex workers and clients of men in Vancouver, Canada. Qualitative interviews were conducted (2012-2013) with 61 self-identifed men who currently buy and/or sell sex in a community-based research project known as CHAPS (Community Health Assessment of Men Who Purchase and Sell Sex). Drawing on a socioecological framework, thematic analysis of interview transcripts was conducted utilizing ATLAS.ti 7 software among men (39 workers; 8 buyers). Narratives indicate that gentrification and urban planning led to social isolation and loss of social support networks among men in the sex industry. Concurrently, the restructuring of sex work to online increased workers' safety and control. Narratives reveal how the Internet can provide greater opportunities to negotiate terms of sex work and enhanced screening using webcams, reducing risks of violence, stigma, and police harassment for both workers and clients compared with the street. This study highlights how losing Boystown led to a loss of community and solidarity: key protective measures for sex workers. Online solicitation increased workers' capacity to screen prospective clients and prevent violence. Recent legal reforms in Canada to further criminalize sex work raise significant concern for human rights and health of individuals in the sex industry, and point to the critical need to include voices of men and trans sex workers and buyers in policy discussions.

Models of Invisibility: Rendering Domestic and Other Gendered Violence Visible to Students Through Clinical Law Teaching

The proliferation of university courses about domestic violence includes clinical courses in law schools in which students represent victims in their legal cases. This essay advocates for a broader approach to teaching about the problem. Using examples from their clinic cases, the authors show how teachers can overcome pedagogical challenges and render domestic and other forms of gendered violence, including state and community violence, more visible to students by intentionally raising and placing it within larger frameworks of structural inequality. In this way, students learn to identify and address gendered violence even when it is not the presenting problem.

The impact of criminalization of HIV non-disclosure on the healthcare engagement of women living with HIV in Canada: a comprehensive review of the evidence

Introduction

In 2012, the Supreme Court of Canada ruled that people living with HIV (PLWH) must disclose their HIV status to sexual partners prior to sexual activity that poses a “realistic possibility” of HIV transmission for consent to sex to be valid. The Supreme Court deemed that the duty to disclose could be averted if a person living with HIV both uses a condom and has a low plasma HIV-1 RNA viral load during vaginal sex. This is one of the strictest legal standards criminalizing HIV non-disclosure worldwide and has resulted in a high rate of prosecutions of PLWH in Canada. Public health advocates argue that the overly broad use of the criminal law against PLWH undermines efforts to engage individuals in healthcare and complicates gendered barriers to linkage and retention in care experienced by women living with HIV (WLWH).

Methods

We conducted a comprehensive review of peer-reviewed and non-peer-reviewed evidence published between 1998 and 2015 evaluating the impact of the criminalization of HIV non-disclosure on healthcare engagement of WLWH in Canada across key stages of the cascade of HIV care, specifically: HIV testing and diagnosis, linkage and retention in care, and adherence to antiretroviral therapy. Where available, evidence pertaining specifically to women was examined. Where these data were lacking, evidence relating to all PLWH in Canada or other international jurisdictions were included.

Results and discussion

Evidence suggests that criminalization of HIV non-disclosure may create barriers to engagement and retention within the cascade of HIV care for PLWH in Canada, discouraging access to HIV testing for some people due to fears of legal implications following a positive diagnosis, and compromising linkage and retention in healthcare through concerns of exposure of confidential medical information. There is a lack of published empirical evidence focused specifically on women, which is a concern given the growing population of WLWH in Canada, among whom marginalized and vulnerable women are overrepresented.

Conclusions

The threat of HIV non-disclosure prosecution combined with a heightened perception of surveillance may alter the environment within which women engage with healthcare services. Fully exploring the extent to which HIV criminalization represents a barrier to the healthcare engagement of WLWH is a public health priority.

Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission

Male sex workers who sell or exchange sex for money or goods encompass a very diverse population across and within countries worldwide. Information characterising their practices, contexts where they live, and their needs is limited, because these individuals are generally included as a subset of larger studies focused on gay men and other men who have sex with men (MSM) or even female sex workers. Male sex workers, irrespective of their sexual orientation, mostly offer sex to men and rarely identify as sex workers, using local or international terms instead. Growing evidence indicates a sustained or increasing burden of HIV among some male sex workers within the context of the slowing global HIV pandemic. Several synergistic facilitators could be potentiating HIV acquisition and transmission among male sex workers, including biological, behavioural, and structural determinants. Criminalisation and intersectional stigmas of same-sex practices, commercial sex, and HIV all augment risk for HIV and sexually transmitted infections among male sex workers and reduce the likelihood of these people accessing essential services. These contexts, taken together with complex sexual networks among male sex workers, define this group as a key population underserved by current HIV prevention, treatment, and care services. Dedicated efforts are needed to make those services available for the sake of both public health and human rights. Evidence-based and human rights-affirming services dedicated specifically to male sex workers are needed to improve health outcomes for these men and the people within their sexual networks.

Ready for Retirement: The Gateway Drug Hypothesis

The psycho-social observation that the use of some psychoactive substances ("drugs") is often followed by the use of other and more problematic drugs has given rise to a cluster of so-called "gateway drug hypotheses," and such hypotheses have often played an important role in developing drug use policy. The current essay suggests that drug use policies that have drawn on versions of the hypothesis have involved an unjustified oversimplification of the dynamics of drug use, reflecting the interests of certain stakeholders rather than wise social policy. The hypothesis should be retired.

Time trends, characteristics, and evidence of scientific advances within the legal complaints for alleged sexual HIV transmission in Spain: 1996-2012

This article quantifies and characterizes existing legal complaints for the sexual transmission of HIV in Spain, describes temporal trends and whether advance of scientific knowledge is reflected in charging decisions, judicial reasoning, and sentences. Sentences and writs dictated by Spanish penal and civil jurisdictions between 1981 and 2012 were obtained through legal databases systematic search. Sixteen sentences and 9 writs belonging to 19 cases were included; 17 judged by penal and two by civil jurisdictions. The first sentence was pronounced in 1996, 3 between 1999 and 2000, 4 between 2001 and 2005, and 18 between 2006 and 2012. In 10 (53%) cases there was effective HIV transmission, there was not in 6 (32%) and in 3 (15%) directionality could not be determined. Of the defendants, 15 (79%) were heterosexual males, 1 of which was an injecting drug user (IDU), 3 were men who have sex with men (MSM), and 1 was a heterosexual woman. In the 10 cases of HIV transmission, the mechanism was heterosexual sex and index cases were males in nine occasions. Disclosure of HIV status, use of condoms and its frequency, and its possible breaks were mentioned in only some sentences/judicial decisions and fewer mentioned the use of antiretroviral treatment. Very few cases referred to plasma viral load (VL), and there are incorrect statements regarding HIV transmissibility. Only one 2012 sentence mentioned VL levels, adherence to ART, CD4 lymphocyte levels, concomitant sexually transmitted infections, and references to pertinent literature. The number of judicial decisions in Spain is increasing and the profile of the plaintiffs, largely heterosexual women, does not reflect the groups most affected by the HIV epidemic, largely IDU and MSM. Most judgments and writs do not reflect HIV scientific and technical advances. It is of utmost importance that these complex processes incorporate the most up-to-date knowledge on the subject.

HIV disclosure as practice and public policy

Responses to the largest surveys of HIV-positive people in Ontario show that most either disclose to or do not have partners who are HIV-negative or of unknown status. Non-disclosure strategies and assumptions are reported by relatively small sets of people with some variation according to employment status, sexual orientation, gender, ethnicity, and having had a casual partner. Interviews with 122 people living with HIV show that disclosure is an undertaking fraught with emotional pitfalls complicated by personal histories of having misread cues or having felt deceived leading up to their own sero-conversion, then having to negotiate a stigmatized status with new people. In gay communities, constructions of the self as individual actors in a marketplace of risk co-exist with the sexual etiquette developed throughout the AIDS era of care of the self and other through safer sex. Among heterosexual populations, notions of responsibility show some divergence by gender. The findings of this study suggest that the heightened pressure of criminal sanction on decision-making about disclosure in personal interactions does not address difficulties in HIV transmission and is unlikely to result in enhanced prevention.

"Patient Zero": the absence of a patient's view of the early North American AIDS epidemic

This article contextualizes the production and reception of And the Band Played On, Randy Shilts's popular history of the initial recognition of the American AIDS epidemic. Published over twenty-five years ago, the book and its most notorious character, "Patient Zero," are in particular need of a critical historical treatment. The article presents a more balanced consideration-a "patient's view"-of Gaétan Dugas's experience of the early years of AIDS. I oppose the assertion that Dugas, the so-called Patient Zero, ignored incontrovertible information about the condition and was intent on spreading his infection. Instead I argue that scientific ideas in 1982 and 1983 about AIDS and the transmissibility of a causative agent were later portrayed to be more self-evident than they were at the time. The article also traces how Shilts's highly selective-and highly readable-characterization of Dugas rapidly became embedded in discussions about the need to criminalize the reckless transmission of HIV.

The creation of the expected Aboriginal woman drug offender in Canada: Exploring relations between victimization, punishment, and cultural identity

This article illustrates how the Aboriginal female drug user is responded to as an expected offender based on the intersection of her gender, race, and class. Drawing on the findings of a national Canadian study documenting the lived experiences of First Nations, Métis, and Inuit female drug users, we argue that the strengthening of cultural identity can potentially disrupt this expected status at both the individual and social system levels. Within the framework of critical victimology, the challenge then becomes to translate this understanding into praxis. In response, we suggest advancing women's agency at the individual level in the face of disempowering images and practices related to the offender, the victim, and Aboriginality. For change at the system level, we return to Christie's notion of the need to dismantle the stereotypical construction of the Aboriginal female drug user. We illustrate both levels of change with an innovative form of knowledge sharing, which aims to evoke transformation with respect to individual and socially constructed conceptualizations of identity.