From safety to belonging: The essential elements of gender-responsive harm reduction
As the toxic drug crisis continues to devastate communities across Canada, available supports are dwindling. In Ontario, many supervised injection services (SIS) have been shuttered by regressive and dangerous government policies. This attack on evidence-based care limits opportunities to expand and diversify harm reduction services, which is especially harmful to women, trans and non-binary people who use drugs (WTNB-PWUD) as their gender-specific needs are already often overlooked in harm reduction services. Only a small number of SIS have provided dedicated spaces for WTNB-PWUD. Looking more closely at the lessons learned from these effective models can help inform where the harm reduction movement can grow in the future.
The Women, Trans and Non-Binary Day program
The Women, Trans and Non-Binary Day (WTNB Day) program was based out of Regent Park Community Health Centre in the downtown east neighbourhood of Toronto. It provided a range of integrated supports and was much more than a space offering supervised injection and overdose prevention. It opened one day per week from within a gender-neutral SIS and provided additional gender-responsive drop-in programming such as testing and treatment for hepatitis C and HIV, support for sex workers, healthcare and social work services, dedicated access to shower and laundry facilities, as well as workshops and educational sessions.
Our University of Toronto research team explored the experiences of participants in this program and produced a community report that reveals three interconnected principles of effective gender-responsive harm reduction. These include the critical role of trust-building in wraparound service engagement, safety that goes beyond overdose prevention, as well as the therapeutic power of community connection and belonging.
Wraparound services work when trust is built first
Our study found that the need for relative safety while using drugs was what led service users to come through the door, and meeting this immediate need allowed program staff to slowly build relationships of care. Once that trust was built, service users often felt ready to meet with social workers, doctors, nurse practitioners, HCV/HIV specialists and dentists within the community health centre to address other unmet needs.
Service provision begins with recognizing that the trust of marginalized people must be continually earned and not taken for granted. Almost all of the study participants reflected on past experiences of stigma and discrimination as major barriers to service access, and commonly mentioned that the warmth and respect they received at WTNB Day made them willing to ask for longer-term supports. They were much more likely to engage with the other services available at the community health centre when they felt assured that the WTNB Day staff would not knowingly refer them to professionals who were likely to cause them further harm. Co-location and service availability was not enough to make wraparound services genuinely low barrier. Rather, it was the cultivation of strong trust-based relationships grounded in mutual respect that reduced barriers and enabled meaningful engagement.
Safety means more than overdose prevention
SIS respond to many crucial safety needs of WTNB-PWUD, but the harms that these communities experience on a daily basis require more than just overdose response. Our findings showed that WTNB service users returned to the program because it was a space where they reported an intuitive sense of safety from sexual harassment, unwanted advances and gender-based violence. Some participants reported attending WTNB Day for respite from their abusive cis male partners. It was also a place where service users could share vital information with each other about which sex work clients, service providers and other community members had been harmful or helpful to them.
Participants who engaged in sex work reported that they were regularly harassed and solicited for services when they accessed other harm reduction programs. WTNB Day was a space of reprieve in which they could actually let their guard down and rest. The program also encouraged many participants to take significant steps in accessing testing and treatment for HIV, hepatitis C and other health conditions. Participants frequently told us how they rarely felt comfortable enough elsewhere to sleep, express their genders and sexualities, or simply enjoy their high without fear. For many, WTNB Day offered a rare and cherished opportunity to experience that safety.
Community connection is healthcare
Over the course of completing this study, we were struck by the fact that almost all of the WTNB-PWUD participants referred to the program as a “family” and a “home”. The deep sense of belonging and connection with WTNB Day staff and other service users was significant and powerful. People who had experienced homelessness, disconnection from family, violence from trusted individuals and social isolation described the program as a place where they felt seen, valued and understood.
Belonging is a key social determinant of health with striking positive and protective effects, and an essential goal that service providers must foster. Participants’ sense of belonging was strengthened by welcoming staff with lived experience of injection drug use, homelessness and sex work, who built connections through shared experience and empathy.
The medical model of healthcare doesn’t adequately meet the needs of most marginalized communities, including WTNB-PWUD. Connection and belonging are lifelines that motivated service users to repeatedly access healthcare and services through the WTNB Day program that they may not have accessed otherwise. This community-building is essential for engaging individuals in care and maintaining continuity of care. Although many supportive relationships built among WTNB Day participants endured beyond the program itself, its closure increased participants’ isolation by removing regular, structured opportunities for connection.
Service shutdowns and shifting landscapes
It is bittersweet to reflect on the victories, large and small, of the WTNB Day program in a time of precarity for harm reduction services. The program itself was paused in 2020 at the start of COVID-19 and the SIS it was embedded in was permanently closed in 2025 when the Ontario government passed new legislation and funding cuts that prevented the site from operating. These forced closures took place in spite of overwhelming evidence that SIS are a highly successful healthcare service and a sanctuary for communities which have been pushed to the margins. In this new era of increased repression and war on drugs politicking, harm reduction services are being blamed for the very social issues they respond to. WTNB-PWUD and all other people who use drugs will feel the repercussions of these shifts and shutdowns.
The WTNB Day program was a service that fostered a unique sense of access to safety and care. The significant impacts that participants described as a result of this program indicates the need for and importance of gender-responsive services and spaces, in addition to conventional ones. The loss of these spaces is an attack on healthcare, on community and on relationships of trust that take years to build. We grieve the disappearance of these spaces, and of our brilliant program participants who have passed away as a direct result of the war on people who use drugs. In their memory, we call for resistance to unjust policies and to fight for spaces that reaffirm the fundamental dignity and inherent worth of women, trans and non-binary people who use drugs.
Phoenix Babiak (she/her) is a first-generation white settler on Turtle Island, a long-term harm reduction advocate and a person with lived experience. She worked and volunteered at sanctioned and unsanctioned overdose prevention sites from 2018 to 2025, and has worked with several community research initiatives focused on service access for people who use drugs. She has organized with various liberatory grassroots organizations and initiatives since her youth, and currently collaborates closely with the Harm Reduction Advocacy Collective. She currently works in a frontline role at a downtown Toronto community health centre. Her work is always informed by a deep commitment to ending the war on drugs and advancing drug user liberation.
Katherine Rudzinski is an adjunct assistant professor and research associate in the School of Social Work, University of Windsor. She also works as a research associate at the Dalla Lana School of Public Health, University of Toronto. As a community-based researcher, Katherine’s work focuses on how criminalization, gender-based violence and structural inequities shape the health and well-being of people who use drugs, with a focus on reducing service barriers and improving access to harm reduction programs.
Lindsay Windhager is a social worker with over 20 years of frontline and leadership experience in community-based settings and a PhD candidate at the Dalla Lana School of Public Health, University of Toronto. Her work focuses on advancing low-threshold, harm-reduction programs that reduce barriers and expand access to health care and support.
Charlotte Smith is a researcher and PhD candidate in sociology at York University in Toronto, Ontario. Their research focuses on health service and harm reduction access for women who use illicit drugs, with particular attention to the regulation and surveillance of mothers who use drugs by child welfare systems. Charlotte’s research is grounded in working toward the abolition of the drug war and the promotion of justice, autonomy and drug user liberation.
Carol Strike is a professor at the Dalla Lana School of Public Health, University of Toronto. She is a social scientist who, for over 25 years, has studied HIV prevention and harm reduction services with the goal of improving health services for people who use drugs.