Time and again the researchers heard that drug injecting is a 'shame job' for Indigenous Australians, and that for many Indigenous IDUs secrecy and anonymity are crucial issues in relation to injecting behaviour and use of services. (Similar points are frequently made in the earlier studies discussed in Appendix C.)
Shame and the need for secrecy have several implications. For example, some Indigenous IDUs may be extremely reluctant to visit any NSP outlet, and will try to find friends or acquaintances – possibly including people who do not themselves use drugs – who will collect clean equipment for them. Time after time, in diverse locations, those consulted by the study team spoke of Indigenous IDUs wanting friends or acquaintances to collect injecting equipment on their behalf, so that they themselves did not have to 'front' the NSP. In Mildura, for instance, it was said that some Indigenous IDUs' shame and embarrassment make it 'really difficult for them' to go to the NSP at the Community Health Centre. (One advantage of a secondary service, on the other hand, was that you were not 'labelling yourself' as a drug injector by walking in the door.)
It was said by people consulted in a number of different locations that young Indigenous injectors were likely to be especially hesitant about using NSP services. 'We have young kids crouching down in cars to avoid being seen', said an NSP worker in Cairns. Among other things this has clear implications for the desirability of a flexible approach to the amounts of injecting equipment that NSPs issue.
Second, Indigenous IDUs may particularly seek to avoid services (eg an outlet located in a main street, near a fast food outlet or near a busy agency such as Centrelink), where they believe they may be readily seen or identified. Thus the NSP outlet should preferably present a nondescript or understated appearance – there should be 'no flashing lights'. In western Sydney it was noted that the existing, youth-oriented NSP in Mt Druitt is located quite close to the Police Station – not a very desirable situation, especially from an Indigenous perspective given that 'most of our fellas have got warrants out for them'.
Privacy is a particularly difficult issue in small population centres. Truly confidential access was described by one observer as 'pretty much a nonsense' in a town the size of Alice Springs, for example. Outreach or mobile services were one possible response to this issue, but even with these it was likely to be quite difficult to offer a genuinely discreet service. A worker described the WAAC mobile service in Perth as 'anonymous, but not particularly private' – that is, it was hard for clients to ensure they were not observed by others. 'The van does a great job', said another stakeholder, but 'it's almost too visible'.
Third, Indigenous IDUs may avoid Indigenous-specific services (in particular, Aboriginal health services) on the basis that these involve greater risks of their being seen and identified as drug users by family members or others in the Indigenous community. As a result, some existing NSP services based at Aboriginal health services attract mostly non-Indigenous IDUs. Thus it is not easy for NSP program managers to know what priority should be given to encouraging Indigenous-specific health services to offer NSP services.
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Some of those consulted drew a comparison between the issues that could arise for IDUs and for lesbians or gay men in making use of AMSs. A health worker in Cairns, who commented that 'gay guys and sistagirls' may tend to avoid going to the local AMS on sexual health matters, also believed that this group included relatively high numbers of IDUs (more so, for example, than non-Indigenous gay men), and that this reflected 'double' marginalisation (being part of a minority within a minority), low self-esteem, and possibly separation from home or family34.The reference to injectors who are homosexual is a reminder that among Indigenous IDUs there is a range of subgroups who may each have their own particular characteristics and needs.
In Mt Isa, health workers made the point that in a small population centre with a significant Indigenous population, the chances of an Indigenous client encountering a family member or friend were almost as great at mainstream health services as at an Indigenous-specific service. In this kind of situation, therefore, mainstream services did not in practice afford anonymity. Somewhat similar comments were made in Taree, where it was said that an IDU could encounter relatives, neighbours or acquaintances in any busy waiting room or reception area – not just at the AMS.
Certain groups were mentioned as having special concerns with regard to secrecy. In Darwin, for example, the comment was made that Aboriginal women with child care responsibilities may attach great importance to keeping their drug use secret from their children or other family members, and that this tends to discourage them from actively using NSPs or similar services. Fear of intervention by the welfare department is a related concern.
Consultations made it clear that the importance attached to keeping one's drug-using to oneself is more than simply a matter of self-protection. The other side of this coin is a respect for family and community which does not want them to be exposed to things they would find embarrassing or distressing ('We don't want to give our family a bad name', said a young Sydney woman). Staff at a metropolitan AMS similarly commented that part of the reason that injecting drug use in the community is 'behind closed doors' or 'hush hush' is a matter of showing 'a bit of respect' for family and elders. It was suggested that this was also a reason for Indigenous IDUs taking care to safely dispose of used needles.
34 Meyerhofff's 2000 literature review for Danila Dilba Health Service (see footnote 24) refers to illicit drug use among gay/bisexual/transgender Aboriginal people.