Women’s crack consumption: an analysis on the meanings constructed by the street clinics’ consulting professionals of the city of rio de Janeiro, Brazil

This paper questions the meanings constructed by professionals of Street Clinics (eCnaR) on the consumption of crack by women and their implications to care practices. This is qualitative research carried out with four eCnaRs (eCnaR) teams working in three territories of the city of Rio de Janeiro, totaling 25 professionals. Produced from focus groups, the empirical data point to the several meanings in the understanding of crack, understood as the “death drug” or the “stone of happiness”. Discussion and analysis of data reveal that gender is incorporated controversially in the daily life of services: even if the discourses indicate different patterns of crack use between men and women, access to and use of psychosocial services and in the way of obtaining the drug, women continue to be thought of because of their reproductive capacity. They also point out that even in health care network services, female crack users are stigmatized because they are women who consume crack and because they live in the streets. They indicate that the mother-woman’s ideology prevails in the organization of the service network. It is advocated that the empirical-analytical reference of gender studies must be incorporated into the health care policy of crack users.


introduction
This papers questions the meanings constructed by health professionals incorporated into Street Clinics (eCnaR) teams, of the city of Rio de Janeiro, on the consumption of crack by women. Based on the concept of gender-related social relations 1,2 , we analyze how the discourses they construct guide the organization of health care and care practices for people living in the streets, especially women.
The Street Clinics 3 (eCnaR) are health services established within Primary Care, whose care for people living in the streets (PLIS) focuses more on the construction of citizenship than on drug use. As a health policy, the eCnaRs express a change vis-à-vis the prohibitionism-centered 4 model and practices, where drug use is understood as disease, moral failure or crime.
Organizing their actions with intersectoriality 5 as a guideline, the eCnaRs assume that the health sector alone is unable to cope with the complexity of care for PLIS who use drugs or not while, at the same time, it is configured as a device for managing, controlling and reducing damages and vulnerabilities in the context of streets or drug use. Thus, the role of the eCnaR almost always represents for the PLIS the gateway for access to public actions and services, as well as the construction of a vital link for the exercise of citizenship and mitigation of social vulnerabilities. There lies the potentiality of these teams: public, humanized and ethical-political case.
In Brazil, drug coping policies are a model marked by certain hybridism 4 . On the one hand, there is a set of policies that sign the international conventions and agreements that, in their origin, are aligned with the prohibitionist model, aiming to contain expanded consumption. On the other hand, we find the perspective of harm reduction 6 that stems from the recognition of human rights, including the use of the body, and from the view that not all drug use is necessarily detrimental; or that not all users are able to stop consumption immediately; or do not want to stop, at least at that moment.
Crack consumption by women is understood as a public health issue of concern that denounces symptoms of social unrest anchored in historical and unequal gender, class and race relationships 7 .
The field of sociological studies of the French school is used 1,2 to understand gender relations better and crack use. In it, "gender" is a political category that breaks with the biological determinism of genders by understanding the re-lationships between men and women as social constructs.
Bourdieu 1 observes that individuals are inserted in a society marked by the principle of sexual division, where the so-called "boys' things" and "girls' things" are present since childhood in the socialization process. It also emphasizes that the awakening of sexuality is experienced by the boys as a moment of demonstration of aggressiveness, virility, strength and domination, while, for the girls, as a moment of representation of romanticism and sensitivity.
Thus, productions of meaning 8 about women's crack consumption will be analyzed here, based on the concept of gender, since the way in which crack was socialized in the social imaginary -a "heavy drug", "aggressive" and lethal -is juxtaposed with the logic of the division between "men's drugs" and "women's drugs" 7 . Ethnicity and class are concepts that cross-reference the analysis, since, historically, drug abuse was considered, also in public policies, a matter of the male universe, and in certain aspects "black and poor men's problems", whose cause and effect is the underrepresentation/invisibilization of female consumption.
The first national epidemiological survey 9 on the use of crack and similar drugs dates from 2014, where data indicate that crack use is mostly performed by men, young adults with an average age of 30 years, single, black and brown, with low schooling, whose source of income consists of the sporadic development of informal activities. Around 370,000 people regularly use crack and similar drugs in Brazilian capitals 9 .
Concerning women crack consumption, Bastos and Bertoni 9 show similarities regarding the sociodemographic profile of male users as to skin color and low schooling. It also emphasizes that women are included in contexts of greater vulnerability, including for the occurrence of violence and that more than half of them have had at least one gestation since the beginning of crack use or similar.
From the biological viewpoint, women have specificities that tend to aggravate their vulnerability regarding their drug relationship. It is known, for example, that the female body has a higher concentration of fat cells, hindering the elimination of the drug 14 . Also, the use of certain substances not only compromises sexual health but can impair the formation of the fetus when they become pregnant. Schenker 18 believes that this association cannot trivialize the relevance of the multifactorial nature of fetal formation in women living in vulnerable contexts with poor, violent living conditions that combine to produce their pregnancy.
The challenge of this study was to carry out a sociological reading of gender on issues that mainstream the consumption of crack by women. Thus, it was necessary to think about the meanings constructed by professionals of the eCnaR on the consumption of crack by women and their implications to care practices.
The answers to this investigation are not simple and require a complex activity of articulation between realms of human life that are deeply intertwined, such as the processes of subjectivation to the economic and political interests of strategies of regulation and prohibition of drug use.

Methods
A qualitative study 19 supported by French discourse analysis (DA) 20 , in which discourse is conceived as a way of organizing social practices. The French DA emphasizes meaning as a relational, daily and fundamentally collective construction.
The interface between the concept of gender and DA is to unveil the power relations that traverse the conditions of production and social placement of the discourses that, in turn, reverberate in daily practices, conforming discourses, knowledge and social places to the subjects 20 .
Twenty-five professionals from four eCnaRs who work in three territories of the city of Rio de Janeiro, which received fictitious names: Agreste, Caatinga and Mata Atlântica, participated in this study. The participants were given names of precious stones. Agreste is a group of 12 favelas, in which the state is present predominantly through its military apparatus. Recently, it has been the target of major urban space reorganization projects, namely, the Growth Acceleration Program (PAC), which gathers an interdepartmental agenda, spearheaded by the federal government and the deployment of police units. The Caatinga comprises a territory with strong rural characteristics, marked by the low presence of state care services. It is currently disputed by drug trafficking groups and militiamen. The Mata Atlântica is a territory in which State policies are present ostensibly in the process of social organization, through the opening of routes for the flow of production and the revitalization of degraded areas, strategic for the city's economy. This is the only territory where two eCnaRs operate.
The project was presented to eCnaR professionals in their team meeting spaces, and such professionals were then invited to participate voluntarily.
Of the total number of professionals participating in the study, women accounted for 68% and men accounted for 32%. As for skin color, 56% considered themselves white, 20% brown and 24% black. Regarding education, 52% had completed secondary education and 48% had higher education, of which 75% have at least one specialization in some health area. Concerning the professional category of respondents who have a higher education level, 8% are dentists, 8% art educators, 25% nurses, 17% doctors, 17% psychologists, 17% social workers, and 8% did not respond [Chart 1].
The data were produced through the realization of three focus groups, one in each territory (FG) 21 . Barbour 21 says the FG is a collective interview technique that focuses on the analysis of interaction among participating members of the same group.
The focus groups were conducted according to a semi-structured script that focused on the meanings assigned by eCnaR professionals (a) regarding crack; (b) crack consumption by men; (c) crack consumption by women; (d) the challenges brought about care provided to female crack users in their professional practices. The FG did not include professionals who had a management position, to avoid that hierarchical relationships interfered in the production of data.
The focus groups were recorded in audio and transcribed in full. Data were organized in synoptic tables, distributed in columns, for later analysis. The columns identified the (a) analytical category, (b) discourse excerpts, (c) production of meanings (d) eCnaR. In the analytical category, one or two words were extracted from the discourses to summarize the dialogue. In the "production of meanings", we tried to capture what was between the lines of the dialogue.
The data shown here were organized into two categories: (1) workers' perception of crack and (2) gender marks, and they were questioned based on the analysis of discursive practices and production of meanings in daily life, highlighting the meaning core that structured the statements of the professionals in the eCnaRs.
The study followed the regulations outlined in Resolution 466/12 and was approved by the Human Research Ethics Committees (CEP). Also, authorization was requested from the management of the municipality's eCnaR, the District Coordination of Studies Centers, and the participants signed the informed consent form (TCLE).

results and discussion
the perception of workers about crack: from "stone of happiness" to "death drug" In order to understand the meanings produced by eCnaR health professionals about the use of crack by women, and how these meanings echoed in the daily service practices, we sought to understand conceptions, professional, personal, moral and ethical values that guided their behavior vis-à-vis the users of eCnaR services.
Summary Chart 2 questions the perception of eCnaR workers on crack and PLIS that use this drug or not. We can observe that the discursive production of professionals on the psychoactive is traversed by beliefs and stereotypes based on daily perceptions, which were either anchored in the experience of violence in the context of a great metropolis or based on discourses conveyed by the media.
As shown in the Summary Chart 2, professionals working in the Caatinga territory have consensually admitted to crack being "just another drug" that breaks/disables the user, whose only possible outcome is death; on the other hand, Agreste described it as a risky form of pleasure.  For eCnaR Caatinga, the meaning core is the idea that crack is synonymous with death. This conception is aligned with the first moment of the official campaigns promoted by the Ministry of Health between 2009 and 2010 22 , in which death was the only possible outcome of the users' linear path. This way of understanding crack as the drug of death is refuted by studies that show the increased survival of users from the onset of use 23 .
Subverting the meanings of crack as a metaphor for death, eCnaR Mata Atlântica conceptualized crack based on the relationship between this drug and the media (Chart 2). Regarding this chart 2. Analysis dimension: the perception of workers about crack.

Analytical category
Discourse excerpt Production of meanings ecnar

Crackmídia
Pérola-Azul: "I believe, it's one of the worst drugs ... it's devastating ..." Ametista: (...) "I think it's more than a drug, and yes, we know that it causes a more rapid dependence on others, but that it has been mediatically important that people end up ignoring the higher alcohol consumption ... Jaspe: And the media also see the crack user as a zombie, right? Diamante: "I think would I agree with the media issue, but I believe it extrapolates this thing" (...) Belief in the idea of light and heavy drugs. Crack as a byproduct of a culture marked by violence and lack of rights. Thus, the media appears as a disseminator of the idea "crack is death", "crack user is like a zombie. (eCnaR Agreste) Besides explaining the interface of drug use as a social and individual question, this fragment alludes to the understanding that there are no good or bad drugs, and that their effects are caused by the way they are used, contexts, intentionality and dosage 25 . These professionals believed that crack was not destructive to everyone, nor was it indiscriminately pleasurable (see Summary Chart 2).
The belief that there are "mild drugs" and "heavy drugs" emerged in the statements of some Mata Atlântica professionals. In the understanding of the group, the use path would be initiated by "mild drugs", and would reach "heavy drugs", in some linear scaling.
Peróla-Dourada: if we look at it, someone begins with the milder drug.
(eCnaR Mata Atlântica) By constructing discourses based on the dichotomy "mild drugs" and "heavy drugs", the equation subject (reason for use), drug (substances, biochemical properties, quantity, ways of use) and context (means of obtaining the drug, ways of dealing with it) 25,26 is simplified by professionals, who seem to value only "drugs", that is, their biochemical properties, making secondary other aspects that traverse their use, such as the social controls exercised by the user's social group 27 , that can lead to controlled consumption of the most diverse psychoactive substances 28 .
Recent studies contribute to an understanding of the equation subject, drugs and contexts of vulnerability, deconstructing the escalated use and linear progression towards death 28,29 .
When investigating in the city of Juazeiro (BA) to what extent the low labor qualification of so-called "crack users" for the legal labor market influences their permanence in the illicit market, as well as the maintenance of the compulsive use of this substance, Rodrigues and Ribeiro 30 have inferred that these two factors are mutually influential, also reverberating in other spheres of life, such as family relationships. On the other hand, people were also found to have controlled crack use and were in formal jobs, occasionally moving around scenes of use and acquisition of the sub-stance. Formal employees with harmful crack use employed the strategy of moving away from the scenes of use in order to regulate it, even with the help of the employers.
Marijuana has been repeatedly referred to in the media as a "gateway to heavier drugs", which has been deconstructed through qualitative and quantitative studies of its use. And in a longitudinal qualitative study with socially integrated individuals with high educational level and belonging to urban middle strata, MacRae and Simões 31 showed that they were willing to experiment with other psychoactive drugs; however, they tended to choose to stay with those more adjusted to their inclinations, interests, needs, moods, and wills.
Barry et al. 32 found that most people who use psychoactive polysubstances consume alcohol before consuming marijuana or tobacco; and those who start using alcohol prematurely have reported significantly higher lifetime use of illicit substances. The results of these studies indicate that social insertion and the context in which people find themselves are more decisive for self-control than the pharmacological properties of substances such as crack.

Women's crack consumption: the gender marks
By exploring the meanings produced by professionals about gender, we could observe different discursive formations on what it is to be a man and a woman, and this is the starting point of the debate. Chart 3 shows some of the categories that emerged from the discourses of the eCnaR professionals when the subject was the consumption of crack by women, in which it is possible to perceive that the discourse of the professionals of eCnaR Caatinga understand that male and female are flexible categories, which allow men to have female attitudes, like the care with the offspring, and, regarding women, to have behaviors attributed to men.
Gomes et al. 33 observed a certain relativization in representations about what it is to be a man and to be a woman. Flexibilization of gender boundaries implies "… the refusal to represent being a man as opposed to being a woman..." 33 means to admit multiple possibilities of living and perceiving the male feature, ranging from aggressiveness to the delicacy of acts of care identified as inherent to being a woman.
However, professionals of eCnaR Agreste argue that transformations of men and women roles were not enough to balance relations; despite referring to a particular perception of the flexibilization of gender boundaries, the transformations in the way of 'being a man' and 'being a woman' coexist with the maintenance of inequalities: Ágata Gender transition is expressed in the figure of "a new woman", capable of reconciling work in domestic (reproductive) and public (productive) space, controlling their fertility and managing their finances 34 . In turn, in this context, women chart 3. Analysis Dimension: Women crack use: the marks of gender.

Gender -Crack
Quartzo: "Being a woman in the streets, using crack is to be exposed to everything ... any danger that you can imagine, as I have already said here, uncountable violence abuse, having all your rights disrespected." Água-Marinha: "(...) I was in a discussion at the POP; they needed an absolute no-breastfeeding restriction orientation for mothers with a history of drug use. There is no such thing. .. I'm in pain' , a one-off thing. On the other hand, women seek us for a routine examination, such, 'I would like to do prevention because I know this is done annually' (...)". Rodrocrosita: "(...) Women are much more active in seeking care than men. I don't know, because of the situation they live, men seem to believe that it doesn't make any difference since they're already in the streets... They must value themselves." who consume crack are marked by the dialectic between the figure of a "new woman" who inhabits the public arena to make use of this drug, and the figure of the "classical woman", who reproduces in the scenes of crack use the roles assigned to women, such as caring for space cleanup and other users. Also with regard to gender conceptualization, if eCnaR Agreste understood gender as a social construction, on the other, eCnaR Caatinga conceptualized gender from the anatomical-physiological differences of men and women bodies. The latter believe that the construction of masculine was based on the belief of hegemonic masculinity marked by the idea of strength, vigor and courage. Thus, being a man or a woman is equivalent to: Rubi (eCnaR Caatinga) Bourdieu 1 says that the corporeal differences embodied in the specificities of men and women bodies "is the product of a construction carried out at the cost of a series of guided choices, or rather by the exacerbation of certain differences [childbirth], or the obscuration of certain similarities [social roles]" 1 . Put another way, no gender is built outside the body, just as there is no body outside gender. Both -body and gender -are mutually implicated, conditioning places, identities, and men/women social roles.
Romani and Roso 35 , in discussing the meanings attributed to the scars on the bodies of male and female crack users, observed that, in men, they translate the ideals of strength, virility, cour-age and power, whereas in women, scars are associated with the idea of the "ugly body", the body that is "non-pickable" by these men 35 .
In the Mata Atlântica team, we could observe the core of meanings antagonistic about what gender is. A first meaning core is organized from the conception that gender creates a system of differentiation that leads to the production of gender inequalities, and it is, therefore, necessary to avoid operating with this idea in the health sector. In the second meaning core, it is recommended to operate with the notion, since gender is related to the production of subjectivity, aligned with the perception of relativization of sex social roles. Finally, in the last meaning core, we evaluated that the notion of gender incorporated mechanically and in a depoliticized way in the flow of eCnaR administrative routine, during the completion of the register or the record for the medical visit.
Cristal (eCnaR Mata Atlântica) This fragment highlighted the low incorporation of the gender approach in the organization of the eCnaR, which may favor the non-recognition of the specificities of the groups of men and women in their relationship with drugs in the street context. Also, by failing to recognize gender specificities, there is a risk of assuming that men and women experience the street context and the use of crack in the same way.
On the other hand, the critical analysis of the discourses indicated that the street spaces, in which scenes of use of crack occur, far from being "no man's lands" 22  As for female PLIS crack users, the dialogue suggested that, even in the health service, guided by altruistic and humanitarian values, they are stigmatized and blamed: on the one hand, because they are women living in the streets; on the other, because they are female crack users.
The dialogue signaled that the ideal of woman as housewife, good wife and mother oriented the discursive production of professionals besides the organization of the healthcare network. The professionals' discourse showed that, in the culture of some services that underpin the healthcare network, the street was conceived as a space that favored the expression of masculinity and, in this context, the use of crack was aligned with this masculinity, making it morally more acceptable when performed by men than by women. This discursive formation was corroborated by the professionals of eCnaR Mata Atlântica, by understanding crack as a drug that masculinizes women, and, by masculinizing them, enables a better coexistence with the adversities imposed by living in the streets.
The fragment contains meanings that living with an extremely masculinized daily life, such as the streets, forces women to build strategies that favor addressing this potentially dangerous space. One of the strategies would be to "transvestite", erase "female marks", ultimately aiming to overcome the "easy victim/fragile sex" profile.
It is essential to register the paradox that marks the statement of Mata Atlântica professionals: on the one hand, crack consumption is referred to the male universe; on the other, when women are users, this consumption is also conceived as an act of resistance and contention against the social roles attributed to being a woman. (eCnaR Agreste) The perception of the differences regarding the search for and use of health services between men and women was shared by professionals. They said men made timely visits, while women tended to use services more routinely. The discourses of eCnaR Caatinga professionals showed that this trend was in line with the behavior also observed among men and women who did not use crack and were anchored in the social division of gender roles 1,2 , according to which women have reproductive work in the household environment and the health care of family members, and men had the "productive" work requiring physical strength. (eCnaR Caatinga) It is important to remember that in Brazil, historically, the organization of care services actions focus the mother-child dyad, which does not favor the participation of men in caring for themselves or even the other. It is therefore imperative to question whether there is a "non-presence of men" in the care setting or the way services are organized does not favor their pursuit by men. In this case, men do not perceive the recognition of their needs in health services and, thus, seek more objective ways of solving their demands, which may mean never returning to services 33 (Chart 3).
Concerning female crack users, the way services are organized favors the construction of bonds and the search for more routine and longitudinal care, such as preventive, prenatal care and other tests since these are part of the "primary package" approach to health care.
Concerning ways to obtain crack, the discourses indicated that women tend to use the body as a bargaining chip, offering sex in exchange for the psychoactive drugs or the amount to acquire such drugs; men tended to engage in petty theft, beg for money at traffic signs, collect cans for sale and organizing a "ground-shopping mall".
Focus groups emerged from the women-crack-maternity relationship (Chart 3). Historically, health services focusing the (good) mother-child dyad defines professional conduct protocols. However, no "differentiated" protocols established on the care of pregnant women or pregnant women in street situations are found within the municipality of Rio de Janeiro, which means that the organization of care always has creative and heterogeneous arrangements, given the ability to provide services installed in the territories.
In the daily routine of the eCnaR, the gestation period of women who consume crack allows a more individualized look on the part of the health professional. The case-by-case discussion allows eCnaR professionals to operate against the prohibitionist model, hold the maternity of these women as protection of life and the right to health.
It is important to note that the first legal framework to organize the care network for women and their babies dates back from 2016 36 ; this document reiterated that conditions of parental vulnerability and drug use are not grounds for family separation. Its guidelines are (a) promoting family and community interaction in line with the Statute of the Child and Adolescent 37 (ECA); (b) adoption as a last resort when the possibilities of family interaction are exhausted; (c) respect for women's autonomy over their bodies; and (d) the right to health, which, besides access and use of services, implies the non-submission to unnecessary and invasive procedures. This document was a response to the Public Prosecutor's Office of Minas Gerais, where the compulsory separation of mother and baby was adopted as a priority policy.
Unlike Minas Gerais, in the municipality of Rio de Janeiro, the Child Court and the Public Prosecutor's Office have different ways of operating when the subject is the maternity of these women. Thus, children are not always separated from their mothers, or the family of their parents, although the judicialization of these maternities is placed on the agenda as can be seen in the Chart 3.
Água Despite this, this moment does not escape the conflict that affects reproductive rights, and is inscribed as a bioethical dilemma: who and what rights should prevail: those of the woman to be a mother, even if she is a psychoactive drug user living in the streets, or those of the baby concerning family interaction?
Granada The discourses about the gestation of female crack users pointed to the existence of the ideology of a maternal love inherent in being a woman, an "instinctive" and "irrational" love that justified the belief of professionals in the possibility of leaving that context, since the street would be incompatible with what is expected of a "good mother" 38

Final considerations
This research identified a different production of meanings about crack consumption by eCnaR professionals. On the one hand, the consumption of this substance leads to self-destruction, which is described in the expression "death drug", with a little allusion to the context and motivations for its use. On the other hand, this same consumption is perceived as chemical support, triggered by the users subject to their psychic or psychosocial vulnerability to the "stone of happiness". The gender selection is incorporated controversially in the daily life of services. Even though the statements point to different patterns of crack use among men and women, access to and use of psychosocial services, and drug procurement, women continue to be thought of for their reproductive capacity.
On the political horizon, the conceptual framework of citizenship posed by harm reduction should be the guiding line not only for a legal review of drugs, but a structuring line for actions in the health and social care sector capable of combining the creation of shelter services for women, mother-baby, and the ongoing training of network professionals on the issue of women drug use.

collaborations
Authors GC Santos, P Constantino, M Schenker and LB Rodrigues worked together in all stages of the manuscript.