Harm reduction, like many radical philosophies, was co-opted by institutions of public health, social work, and the medical industrial complex (MIC). Activists fighting for the rights and safety of drug users; people in the sex trade, street economy, and involved in sex work; and people with chronic illness and disabilities sought to make the philosophy of harm reduction a part of the United States’ public health strategy in order to stem the spread of HIV/AIDS in the late 1980s. As a result of the successful work of these revolutionary organizers, some of you may have heard about syringe exchanges, the most popularized example of harm reduction.
What you may not know is that while the risk-reduction strategies embedded in harm reduction (condom distribution programs, syringe exchanges, etc.) did eventually become part of public health’s standardized approach to HIV prevention in most states, much of what actually makes up the daily practice of saving our own lives—the core values of the philosophy of harm reduction—was stripped away inside these institutional settings. The truth is that harm reduction was designed and created by drug users, sex workers, feminists, trans activists, people with chronic illness and disabilities, those of us working to end violence without the police, and those of us working to end prisons and the violent state. It is a practice steeped in joy, in living into the beauty of our lives no matter how messy they may (appear to) be.
We are not discussing “public health harm reduction” here. Instead we are talking about harm reduction’s origins as a liberation practice—Liberatory Harm Reduction—and how it intersects and pushes healing justice practitioners to find a place for all of us in the work.
Redefining “Risky” and Reclaiming Trauma-Centered Practice
In order to understand the philosophy of harm reduction, we have to interrogate our understanding of the idea of “risky behaviors” and reimagine our trauma-centered practice. The strategies survivors use to fight back, heal, cope, and, yes, seek pleasure are highly stigmatized and criminalized. Minimally, drug use and involvement in the street economy, the sex trade and sex work, self-injury, or not using prescribed (psychiatric or other) medication are often criminalized.
Survivors whose survival strategies have been deemed morally wrong or criminal are made even more vulnerable by healers and health care providers who lack a complex trauma analysis. We have become targets of a system that cannot make sense of us and seeks only to control us. Sometimes I think these systems have little help to offer, and other times I think these systems hoard resources from our communities intentionally and force us to fight each other for what little access we have. Depending on a person’s age, race, or gender presentation, the judgments of institutional representatives can and often do have carceral implications.
So we are forced to lie to our health care providers about our drug use, sex work, housing, medication adherence, and more to cover our tracks as much as we can. Even if we want to stop using drugs and seek out rehab or other forms of assistance, we are subject to humiliation and monitoring of our bodies that is designed to reduce caseloads and keep costs down.
When seeking medication-assisted treatment (MAT), like methadone or suboxone, the average person can wait months or even years to get into a MAT program, and then they must be free of other drugs to stay in the program. I have had several friends who intentionally became pregnant for the sole purpose of getting into rehab or on methadone because pregnant people have access to priority placement. If you felt shock or judgment come up when you read that statement, I invite you to answer it with curiosity and compassion. What is life like when becoming pregnant is the best option for someone who wants to get off drugs? What does it mean when the system is so violent that extremes become logical options?
When I was finally able to find a doctor who prescribed me suboxone, which is how I effectively stopped using heroin (but not all opioids) in my 30s, I was able to get into a program at my local syringe exchange. The program required a few hoops because it was in a harm reduction setting. This is far from a common experience, and I know that my community relationships are what kept me alive.
What Is Liberatory Harm Reduction?
This is the definition collectively created in the book Saving Our Own Lives: A Liberatory Practice of Harm Reduction:
Harm reduction is a philosophy and set of empowerment-based practices that teach us how to accompany each other as we transform the root causes of harm in our lives.
We put our values into action using real-life strategies to reduce the negative health, legal, and social consequences that result from criminalized and stigmatized life experiences such as drug use, sex, the sex trade / sex work, surviving intimate partner violence, self-injury, eating disorders, and any other survival strategies deemed morally or socially unacceptable.
Liberatory Harm Reductionists support each other and our communities without judgment, stigma, or coercion, and we do not force others to change. We envision a world without racism, capitalism, patriarchy, misogyny, ableism, transphobia, policing, surveillance, and other systems of violence. Liberatory Harm Reduction is true self-determination and total body autonomy.
Harm reduction disconnects the ideas of sobriety and healing. We center all of our lived experiences and don’t create false hierarchies with sobriety at the top. We honor decisions to be off medications, use herbs, or engage in the street economy though the sex trade or selling drugs. We hold each other close and fall in love with each other’s survival and survival strategies.
The idea of keeping our community safe from harm through the practices of abundance, love, joy, and welcoming each other as whole people is deeply rooted in the cultural practices of many Black, Indigenous, Latinx, and other people of color who find ways to survive in the United States. The impact of harm we are reducing results from the long-term impact of white supremacy, cisheteropatriarchy, ableism, and structural violence.
Where Does Liberatory Harm Reduction Come From?
Liberatory Harm Reduction focuses on transforming the root causes of oppression that cause the actual risk for illness, death, and incarceration.
In the United States, the story of the evolution of harm reduction predates the AIDS crisis. Parts of Liberatory Harm Reduction came through Marsha P. Johnson, Sylvia Rivera, and activists like Miss Major Griffin-Gracy, Trans Women of Color who were sex workers and street-based and who created shared housing, syringe exchanges, and sex work safety information. Liberatory Harm Reduction came through the Black Panthers creating free breakfast programs to feed and nourish a revolution, and from the Young Lords taking over Lincoln Hospital in the Bronx to demand—and ultimately create—community-accessible drug-treatment programs. It comes from underground abortion providers, Indigenous resistance fighters, and AIDS activists.
Liberatory Harm Reduction came to be because people in the sex trade; people of color; queer people; transgender, gender-nonconforming, and two spirit people; people with disabilities; people who were houseless; and fat people saved our own lives. It is a collective story of “Bad Date” sheets passed between sex workers to warn each other of dangerous customers. It is the story of clean syringes, “liberated” from empathetic doctors’ offices and then passed between punks in squats in the East Village by women like Isabel Dawson and Kelly McGowan—early AIDS activists—who made sure that everyone had syringes and knew how to use them in 1983.
While it is difficult to say for certain when it all began because of the underground nature of syringe exchanges, Catlin Fullwood in Seattle and Women with a Vision both began Black and queer/lesbian harm reduction projects led by people with life experience using drugs and in the sex trades in 1986.
Much of the mainstream harm reduction movement that operates alongside public health has historically treated people in the sex trade as an afterthought. As though the most important intervention ever contributed to the field of harm reduction is syringe exchange and that sex workers, even those of us like me who also shot drugs, are not a central part of the creation of this life-affirming philosophy. The few books that are written about harm reduction barely touch on sex work and focus entirely on drug use. People in the sex trade and sex work and survivors of all kinds are the breath of Liberatory Harm Reduction because, as uncomfortable as this sounds to many, as people with life experience in the sex trade and sex work, we place the importance of relationships and care work as a core practice in everything that we do. Liberatory Harm Reduction hinges on the depth of relationships we have with each other.
The Intersections of Harm Reduction and Healing Justice
Healing justice is rooted in the philosophy of Liberatory Harm Reduction. The lifeblood of each is self-determination, the belief that healing and growth happen best inside long-term relationships, and the right for people to choose how and when they engage the allopathic medical model. They both demand that healers and health care providers fight the systems of power, like the medical industrial complex, prison industrial complex, and carceral social work. These systems form a dangerous web that interrupts our ability to get care on our own terms.
Healing justice and Liberatory Harm Reduction are inextricably tied up together because they are both about the active strategies that people use to collectively heal and push back on the medical model and MIC. The MIC tells people that the only way to have an acceptable body is to be nonsick, nondisabled, nonfat, and non-drug-using. The MIC tells us that we cannot have a normative body if we use it to make money via selling sex or use our bodies to regulate our trauma via self-harm. We cannot have acceptable bodies if we decide to not take our psychiatric medication, if we accept (or struggle with) our eating disorders, or if we hesitate to buy whatever supplement or prescription we are told to without being called “noncompliant,” “in denial,” or “resistant to care.”
Liberatory Harm Reduction and healing justice both are largely ignored by activists and popular thinkers because it is uncomfortable. Both require doctors, social workers, legislative policymakers, healers, and organizers to make room for the fact that their ideas of bodies, safety, and health leave out enormous swaths of our communities. It requires us to make room for the reality of what it means to show up in our bodies exactly as we are without anyone asking us to leave, change, or conform. At this point, ideas of health, wellness, and self-care, which may have been ideas that initially existed outside the MIC, are now so intertwined with capitalism that they have become lost to those of us who are committed to dismantling the medical industrial complex and disconnecting it from carceral thinking and systems.
Empowerment means being in control of your choices—it means self-determination and body autonomy—regardless of whether those choices make healers uncomfortable. For healing justice strategy to live into its full intention, it must be able to hold me as a complicated person, as someone who wants to feel better and yet does not want to be cured, as someone who wants to be whole and yet cannot be forced to be “embodied,” as someone who wants to stay alive and may make choices you think are dangerous. Drug users, people in the sex trade and street economy, sex workers, those of us who self-injure or survive violent homes and relationships—we deserve strategies that value us. The ability to make change in our own lives and make change in the communities we live in—that is our power.
Excerpt from Healing Justice Lineages by Cara Page and Erica Woodland, published by North Atlantic Books, copyright © 2023 by Cara Page & Erica Woodland. Reprinted by permission of North Atlantic Books.
Shira Hassan is the founder of Just Practice, a capacity building project for organizations and community members, activists and leaders working at the intersection of transformative justice, harm reduction and collective liberation. She is the former Executive Director of the Young Women’s Empowerment Project, an organizing and grassroots movement-building project led by and for young people of color that have current or former experience in the sex trade and street economies. A lifelong harm reductionist and prison abolitionist, Shira is the author of Saving Our Own Lives: A Liberatory Practice of Harm Reduction; and along with Mariame Kaba, is the co-author of Fumbling Towards Repair: A Work Book for Community Accountability Facilitators.