Concepts of time and conception only form one part of the discussion. Women who take the ECP may experience some form of bleeding and/ or discharge when they take the ECP (although not all women do), even if they do not consider that foetal 'personhood' is present until three months. For example, one woman noted of her experience with the pill that it made her 'expel blood', and another had a similar experience (although she identified this as an abortion, whereas the first did not). How do they make sense of this, for those who do not interpret it as an abortion?

Further, how do other women interpret the uterus' 'contents' if it is not perceived as 'life', and how do they account for the expulsion of blood that can accompany the ingestion of ECP (and misoprostol)? Hormonal contraception, including the ECP, has uses beyond pregnancy prevention. For example, a female art student studying at a public university, who supported a two-week 'pregnancy-test' time frame following a medical-scientific discourse, suggested that 'scientifically this is not a living human, it's a cell, nothing more, like so many cells that are born and die, I don't have a conflict with this'.

She recognised the development of living cells, even if they were not perceived as 'human' (yet) and recognised that there were cells that could be expelled. However, there are other explanations also. These pills can also be used to regulate and/or stop menstruation for purported health and lifestyle benefits, beyond pregnancy concerns alone (Sanabria 2016). Regulation of menses is an important health concept in parts of Peru, as retained menstrual blood can be interpreted as a sign of internal imbalance and illness (Bastien 1985; Hammer 2001). This finds expression through the ethno- and (increasingly) biomedical term *retraso menstrual* (menstrual regulation). This condition is identified by irregular or late menses, which is not always considered to be due to pregnancy (although there is room for ambiguity). Retained or delayed menses (*retraso menstrual*) are interpreted as a blockage of menstrual blood that forms a hard ball, much like a 'pregnancy', although it is not a given that a foetus would develop from this clotting. Unblocking this, through traditional methods such as herbal teas, or increasingly through biomedical methods such as hormonal contraceptive pills, is considered to be good for one's health (Hammer 2001).

To illustrate in the words of a 25-year-old office worker from the *conos* who had been prescribed the ECP by her gynaecologist for irregular menstruation (as per her medical complaint):

I used the ECP once because I had irregular menses and it was the gynaecologist herself who gave me the pill, she said it was necessary that I took it to make it come [my menstruation], to regulate myself, my month.

On discussing this further, it seemed that the gynaecologist may have mistaken her complaint of delayed or irregular menstruation (*retraso*) as a pregnancy scare and provided the ECP as an attempt at prevention. However, the informant herself did not consider it this way and had taken the ECP as she believed she could regulate her menses using the hormone.

Another informant, a 23-year-old *cono* rights activist, was also given hormonal contraception by her doctor when she complained of a delayed menses. Although she believed she had a hormonal imbalance and was not pregnant, when she went to the pharmacy they demanded the prescription as they apparently could not sell her the medicine without one, as it was considered abortifacient.

For more traditional methods, it is possible to obtain various plantbased medicines, commonly considered as abortifacient (*sangre de drago*, *japananchak*, *ruda*), from the weekly local market, by complaining of a *retraso.* For example, I was informed by an herbalist who sold me various plants, 'these will make you bleed', but without further explanation as to what blood (regular menses or abortifacient) that might be.

Such examples highlight the ambiguity within this concept. Without medical testing, delayed menses could be considered as an irregularity in the cycle, as *retraso* or as a potential pregnancy, depending on whether one believes oneself to be pregnant.

Thus, aside from clinical and at-home pregnancy tests that can provide an 'objective' answer, how do women differentiate a definitive pregnancy from an accumulation of 'matter' destined to end in a *retraso* treatment or a clot of blood in the body?

Pregnancy, and the process of becoming a parent, is not only a physical state, but a mental and emotional process also. It has been much discussed how the Cartesian dualism of this mind–body split can be found in Western contexts, where the physical development of a foetus can be separated from the psychological perception of that process (Goldberg 2002; Davis and Walker 2010). This is not the case for everyone in Peru. Through the various interviews regarding conception and contraception, the concept of will and development of a foetus was raised by several women.

For example, when a 31-year-old saleswoman and mother of two was talking about the moment of conception, she suggested: 'I believe that life begins in the form that you take it, if you want to have a child you become excited, but there are other people who it doesn't sit well with, and then it isn't [a life].'

For her, if two women had unprotected intercourse with their respective partners, but one desired to have a child and the other did not, their personal will is what could affect the reality of 'life' that could develop inside them. Another woman viewed this discrepancy in more concrete terms: 'You know what you're looking for, some [women] go to parties, they take antibiotics, it's not the same, they're not "pregnant" because one looks after one's pregnancy.'

Thus, if one perceives oneself to be pregnant, and has the will to be so, she will be more likely to care for her body and carry that pregnancy to term. If a woman does not want to be pregnant, her behaviour may reflect her choice and the pregnancy will not have the chance to develop. Hammer (2001) found a similar perspective among her Quechua informants, who she says may perform extra-strenuous physical tasks if they do not wish to be pregnant after unprotected sex (2001: 247). Whilst this could be seen as women's strategies to 'unconsciously' miscarry in order to prevent an unwanted pregnancy, that may be an oversimplification. Pregnancy may not be something that one's body 'does' by itself but something that begins in the emotions and will of the woman herself. Such an analysis further contributes to understanding menstrual regulation and *retraso* treatment, even in the case where a woman could be potentially pregnant (i.e. she recognises the consequences of unprotected intercourse). If she had not desired to become pregnant, she may see this delay as a health problem and deal with it accordingly. If she had wanted to be with child, then she may instead seek medical confirmation and take care *not* to miscarry. Further, if one sees ECP as preventative, then this may also translate into a lived reality as it being a contraceptive, rather than an abortive method, as the user is not considering or planning a pregnancy consciously. On the other hand, if one considers ECP to be abortive, and takes it anyway, then it could ontologically become abortive for that person's experience, due to their conception of life being formed from their unprotected intercourse. This supports the existence of 'multiple realities' as it is the process of using and understanding the ECP that creates the reality of a 'pregnancy' or not.

### Misoprostol and abortion ambiguity

ECP is not the only post-coital pill available to women in Peru, as there also exists an 'abortion pill' on the market (though it is not available for that purpose). As a pharmaceutical, misoprostol has been legally available on prescription in Peru to treat gastric ulcers since 1985, though use of this pill explicitly for abortion was not reported until the year 2000 (Ferrando 2006). If one considers that more invasive methods of abortion have been used in Peru for nearly 200 years (Necochea López 2014), the concept of aborting with a pill can be seen as relatively new in Peru's history. Lamas calls it 'the pill of the 21st century', highlighting its recent place in the timeline of pregnancy avoidance (2003: 140). Indeed, the most common forms of abortion in Peru continue to include the introduction of substances, medicines and tools into the vagina to extract the contents of the uterus (Ferrando 2006). Whilst a lack of access to misoprostol may be a factor in relative under-use compared to other abortion methods, the perceptions about what is an abortion, and whether a pill has the power to abort or not, must also be taken into consideration.

It is of interest to note that the recommended maximum number of weeks during which a woman can successfully abort with a pill is twelve (WHO 2012). Beyond this point there is the risk of incomplete abortion and infection, and so it is medically unadvisable. This time frame is noteworthy considering perceptions of foetal development in the Peruvian context. If taking the ECP was not considered abortifacient up to the three-month (or two-week) mark for some (regardless of whether the ECP would work until that point), depending on perceptions of whether there is discernible life or not, then how is taking misoprostol within these time frames also perceived?

One informant who suggested that there were only blood clots up to three months, and therefore the ECP could be taken until this point, was asked whether taking misoprostol also within this time frame would constitute abortion. She responded: 'Extracting blood, it's not abortion, a pill that can produce haemorrhage, it's not abortion. Abortion is the labour that a doctor does introducing things so that they can take "it" out, it's very different.'

From this perspective, *anything* taken before the cut-off point of three months was not abortion, and furthermore, the ability of a pill to abort at all was questioned.

Women who had suggested that two weeks was the point at which life begins were also asked about this. An informant who correctly identified the window of time for taking ECP as three days later suggested that no real life was identifiable until after two weeks. She was asked if, following from this reasoning, taking misoprostol at ten days after intercourse (still within the two-week limit) would be abortion or not. She answered: 'I don't think that it would be abortion in this case, there's no life, there are two cells that have joined, but they don't have the medium to develop themselves.'

Thus, depending on when a person perceives 'life' to begin after intercourse affects their perceptions not only of ECP as abortifacient, but also of misoprostol as abortifacient. If misoprostol is not abortifacient in some realities, what is it?

The answers given by informants included: 'really strong hormones', '[a] really strong dose of female hormones'; and 'I imagine that if the ECP is strong hormones, then this pill is even stronger'. Some women therefore consider misoprostol to be a stronger 'version' of ECP, yet essentially composed of the same kinds of hormones. This suggests that the local reality of misoprostol is not necessarily as a pill distinct from the ECP, even if medically speaking they are completely different things. Here, misoprostol can be seen as on a hormonal continuum, along with other contraceptive pills such as the combined oral contraceptive and ECP, as part of this 'family' of pharmaceuticals. As the ECP is understood as an incremented dose 'up' from the combined oral contraceptive, so is misoprostol seen as a higher dose of these same hormones. As such, it inhabits an ambiguous grey area: not quite contraceptive as it is taken post-coitally, but not quite abortifacient as it is not perceived as powerful enough to abort beyond the time-concept framings. Of course, this depends on the individual perspective and the way that a person uses it. Sanabria, studying hormonal contraceptives in Brazil, suggests that if 'the pregnancy is not interpreted as having generated a "person"' (2016: 92), then any intervention to clear the uterus of its contents cannot be interpreted as definitive abortion.

Then again, some women do use misoprostol to abort (see for example the feminist literature released by CLIM 2014 and Drovetta 2015). This again points not to a singular object that produces abortion, but to a pill that can be perceived to perform multiple, very different tasks (the fact that misoprostol is intended for treatment of stomach ulcers would further complicate the multiple realities of this pill, although it was not a focus of discussion in this study).

### A pill's ability to abort

Whilst some informants recognised misoprostol as potentially abortifacient, it was not considered to be effective at always doing the job on its own. For example, one man living in the *conos* spoke about his and his partner's experience with a misoprostol abortion. She was around three months pregnant when she took eight pills, four under the tongue and four inserted into her vagina. Whilst they had believed the pills were effective at first, she was later admitted to the hospital to have her uterus 'cleaned', as he termed it, because they did not perceive the pills to be completely successful at aborting. In this case, one could observe that this woman took the pills incorrectly (twelve pills are recommended, and either orally or vaginally but not both) and that she was at the maximum limit of the recommended time, and therefore the pills might not have functioned as they should. However, he mentioned no difficulties specifically, and the decision to visit the hospital was based on a perception about misoprostol's functionality, rather than an actual medical complication. If so, why would they not trust the pill on its own?

It is perhaps more enlightening to investigate cases where people actively *rejected* misoprostol, and their reasons for doing so. I discussed a clinical abortion with a male informant who had accompanied his partner to a *cono* 'clinic' when she was around one month pregnant. He knew about misoprostol, but they had decided not to use this method. When I asked why, he replied that these pills 'don't work' as they are not 'strong enough' to abort. He believed that a growing life 'stuck into the uterus' (referencing notions of the Andean 'aggressive foetus' that resists expulsion – Platt 2002), and that 'a mother's body' was incapable of expelling this entity on its own but needed an external force to enter the uterus and extract it. As far as he saw it, a mere pill would not have succeeded in aborting as the perceived will of the mother's uterus to protect the developing entity was stronger than anything that could be developed in a laboratory. His perception reflects the concept of *marianismo*, one could argue. First developed by Stevens (1973), *marianismo* is proposed as the female alternative to *machismo* (male dominance), with the 'ideal' woman emulating the Virgin Mary and motherhood being her most important and defining role. According to notions of *marianismo*, a woman's central role is to care for and nurture her children, to the exclusion of other pursuits. Motherhood is considered to be the most important social role that women have, and they are expected to act out this role with the same dedication as Mary is perceived to have done. As Anzaldúa states: 'Educated or not, the onus is still on woman to be a wife/mother: only the nun can escape motherhood. Women are made to feel total failures if they don't marry and have children' (1987: 17).

Another female informant made a comment that also reflects this idea: 'a mother is incapable of hurting her baby'. As misoprostol causes the uterus to contract and expel the entity 'from within', it relies on the 'mothering' body to reject the 'child' – which was viewed as an impossibility by some. According to the concept of *marianismo*, the female body is 'designed' to protect a baby, and certainly not to cause it any harm. Therefore, a pill that would cause the woman's body to 'aggressively' force out her 'baby' was perhaps not seen as a realistic possibility for some, resulting in the questioning of misoprostol as an abortion option. Because of this, misoprostol was not perceived to function completely, and a further external force was needed in the above-mentioned cases. If a woman's body was not perceived as able to abort by itself, then someone else needed to come along and pull the baby out. This may go some way towards explaining the prevalence of provider-led abortions over home abortions, and leaves room for ambiguity with misoprostol.

### Alternative solutions to post-coital pills

In the neighbourhood of Villa Cristo, on every single lamp-post, one can find an advertisement for *atraso menstrual* along with a telephone number (figure 4.1). These can be found throughout the poorer *conos*, but are nowhere to be seen in the wealthier districts of Lima. Whilst the concept of an *atraso menstrual* (menstrual regulation*/retraso*) itself can be seen as an ethno- (and increasingly bio-) medical illness, as previously discussed, when presented in the standardised, identifiable format that is found on signposts, it refers to clandestine abortion services, according to informants. But why are these advertisements found only in the *conos* and not wealthier districts? Two informants both suggested that women in poorer areas might be getting pregnant more frequently, and therefore need more abortions. The idea that poorer women are more fertile is common in Peru (Boesten 2010). It can be a troubling perception, as it has led to past population-control programmes in this demographic, such as the forced sterilisations under President Fujimori's anti-natalist national family planning programme in the 1990s (Rousseau 2009).

However, it is not true that only women in poorer areas of Lima are aborting (Ferrando 2006). What is true is that they have different available options. One could argue that in poorer areas abortion is simply more visible through public advertisements, as opposed to in private clinics. In the absence of state intervention, Matos Mar (2004) suggests that the informal economy has taken precedence in the Lima *conos*. In areas such as Villa Cristo, he states that 'there's the sensation of living abandoned by a good government' (2004: 143) and that because of this people effectively self-govern: the community collectively constructs and responds to unwritten rules of behaviour. The widespread advertisements, which everyone living in the area can identify as relating to clandestine

**Figure 4.1** *Atraso menstrual* advertisement (posters are misspelt). Photo by the author.

abortion, are not necessarily *legal*. However, because the state is perceptibly absent from Villa Cristo due to a lack of effective police surveillance or patrolling, such a practice becomes *legitimate*, as something that the people need and want, and the market provides (Matos Mar 2004). Goldstein (2004) further suggests that when a government's presence is not felt, people may resort to self-governance out of both necessity and resistance. Using this theory, he explains how illegal practices, in this case the lynching of thieves in the Bolivian Andes, become acceptable and commonplace. Whilst these adverts do not explicitly mention abortion, they are a code that everyone living in the area understands. In a similar fashion, one may recognise that shoes tied onto telephone cables indicate the house of a drug seller, or 'massage' advertisements indicate prostitution. However, these cultural codes are illegible to outsiders, and therefore indicate an informal economy outside the purview of the state and managed by the market in these neglected districts. Women living in wealthier districts do not access abortions in this way, because they have the financial freedom to access private clinics where surgical abortions can be performed safely. They may even be able to fly to the United States for an abortion, one informant suggested, an option that is both financially and practically unobtainable for poorer women due to travel costs and visa restrictions.

Whilst the informal economy may provide a solution for poorer women that the state does not, this in no way suggests that it is safe or viable. Clandestine abortions, such as those accessed through these advertisements, are a leading cause of global maternal mortality (Faúndes and Shah 2015).

A Lima psychologist who works with women who have aborted clandestinely commented:

It's in bad conditions, they have gone to hotels, the 'doctor' arrives with a dirty shirt with remains of blood, it's terrible, it's true that it's like a horror film. They have left them bleeding and left, it's almost always a man, and almost always with an ugly look, they do it really quickly.

Another informant, who had accompanied a friend, asserted:

Oh my god it's like a horror movie, I'd compare it to that movie *Hostel*, 5 something like that, but less healthy! Because that was for rich people to torture others [in *Hostel*]. For sure they have killed people, it's very gory, very bloody.

Methods of choice in these scenarios may include medication, aspiration, forceps or other tools inserted into the vagina. Because of the lack of regulation and lack of qualification of practitioners, women frequently perish as a result of clandestine abortions in Peru, from compilations and infections (Ferrando 2006), and therefore the risk inherent in the narratives of these women may not be far from the reality.

Yet for women living in Lima's poorer districts, there may not be many other options. As one male informant who had accompanied his partner to four abortions under such circumstances mused: 'You all in Europe, when you have an abortion you just fill in a form. For us? These advertisements you seen on the posts, that's our form.'

With a lack of state promotion and the illegality of abortion (and therefore lack of regulated and professional abortion services), clandestine and dangerous abortions offered on the informal market become a prime option for Villa Cristo women.

### Conclusion

Whereas scientific opinion views only misoprostol as abortifacient, widespread religious belief in Peru suggests that both the ECP and misoprostol can abort 'life'. Whilst it previously appeared as though the country was undergoing a process of change towards the ECP, with President Kuczynksi introducing the pill on the national health service in August 2016, his decision to officially pardon ex-president Fujimori (notorious for corruption and a policy of enforced sterilisations in the 1990s) and release him from prison in December 2017 led to wide criticism, and Kuczynksi's credibility (and policies) were thrown into question.6 This was followed by the successful Peruvian tour of Pope Francis in January 2018, reasserting sectors of the country as 'Catholic' once more and nudging the pendulum of 'context' back in the other direction (Lamas 2000).

However, drawing on the experiences and opinions of low-income women in Lima, this chapter has argued that the key factor in determining whether a pill can 'abort' or not is that of *time*, on which people hold opinions that differ from those dominant in health and religious discourses, among others. This suggests that women's interpretations of this process may be different from those presented by the mainstream institutions that control policy and public opinion, leading to unforeseen uses and understandings amongst women. It supports the argument that biomedicine is one of many cultural systems of understanding in health, and should not remain unchallenged, and as Menéndez (2016) has argued, this is especially relevant in Latin America where multiple medical systems coexist. Furthermore, in arguing that the post-coital pills should be understood within the theoretical framework of 'multiple realities' and a context of structural vulnerability, it has been shown how conflicting realities can potentially further deepen the marginality and poor health of women in vulnerable positions. As Mol observes, if incompatible objects (in this case, opposing discourses on pregnancy termination) do not meet, 'they are in position to confront each other' (2002: 118), but when it comes to the practicalities of competing realities, 'one of them wins. The other is discarded' (2002: 66). In the present context, it may be the dominant reality concerning 'abortion', that of the church for example, that wins out, at the sacrifice of the women's reality. This is particularly true for those women who live in structural poverty, such as the people of Villa Cristo and similar areas, where agency is limited through the conditions of structural violence. This is concerning not only for the health of women who may face death due to clandestine practices used because of their structural marginality, but also for their democratic freedoms; 'reproductive rights are intrinsically democratic rights: they stem from freedom, particularly sexual freedom' (Lamas and Bissell 2000: 21). It could be said that the lack of these freedoms is a form of 'reproductive governance' (Morgan and Roberts 2012), as women are restricted in their capacity to access the healthcare that they deem appropriate according to their understandings of their own bodies. Finally, if one considers Lock and Nguyen's (2010) theory of 'local biologies', where physical bodies may actually differ according to locale, this governance can be seen as attempting to homogenise bodies where the biological 'realities' may differ.

One further implication of this is that even non-governmental interventions intended to promote safe(r) abortion with pills may be unsuccessful for some women, if they do not accept that misoprostol is wholly abortifacient in the first place. The widely available do-it-yourself abortion manuals, such as those released by feminist groups in Peru and the southern cone (figure 4.2; CLIM 2014; Drovetta 2015; LFDI 2010; LFDI 2012) advocate at-home abortion with misoprostol as a less dangerous alternative to attending clandestine and invasive 'underground' abortions. However, these manuals may also need to attend to (mis)understandings about misoprostol and its ability to abort if they aim to speak to the widest possible range of Latin American women. Furthermore, they should be made more readily available among poorer women living in structurally vulnerable conditions (by a distribution of printed copies for those who cannot access the internet, for example). That said, Lamas (2009) suggests that feminist groups are key to pressurising Latin American governments into open debate about abortion and should be worked with in order to incite changes in the realities of women in the continent.

This is not to suggest that competing 'realities' cannot be reconciled, as suggested by the work of Campos-Navarro (2010) and Duarte-Gómez et al. (2004) on intercultural health models that successfully address indigenous concerns within biomedical hospitals in Mexico. However, while the dominant reality triumphs, low-income women may continue to have certain understandings of their bodies mistranslated into policy and be at risk from clandestine abortions or other complications. Returning to the political economy of health mentioned in the introduction, this chapter contributes to a deeper understanding of the local conditions in Lima that influence the reproductive health of the population with regard to the wider political and economic context.

Furthermore, the framework of CMA can begin to address these structural inequalities, and discussions such as this one can further

**Figure 4.2** Latin American abortion manuals: (left to right) Collective for Free Information for Women (CLIM, Peru, 2014); Lesbians and Feminists for the Decriminalisation of Abortion (LFDA, Argentina, 2012); Lesbians and Feminists for the Right to Information (LFDI, Chile, 2010). Source: Peru: http://abortoinfosegura.com, Chile: http://infoabortochile.org, Argentina: http://www.rednosotrasenelmundo.org.

develop understanding of them; however, further change at the policy level, which takes women's views into account, is needed to secure reproductive health for women in Lima.

### Notes

### References

Anzaldúa, Gloria. 1987. *Borderlands/La Frontera: The New Mestiza*. San Francisco: Aunt Lute Books. Bastien, Joseph W. 1985. 'Qollahuaya-Andean Body Concepts: A Topographical-Hydraulic Model

of Physiology', *American Anthropologist* 87 (3): 595–611. Berry, Nicole S. 2010. *Unsafe Motherhood: Mayan Maternal Mortality and Subjectivity in Post-War*

Stevens, Evelyn P. 1973. 'Machismo and Marianismo', *Society* 10 (6): 57–63.

Part II Globalisation and contemporary challenges of border spaces and biologised difference

### 5

### Migrant trajectories and health experiences: Processes of health/ illness/care for drug use among migrants in the Mexico–United States border region

Olga Lidia Olivas Hernández

This chapter discusses the subjective experience related to drug use from the perspective of Mexican migrant men in the US–Mexico border region. Some studies have argued that migrants increase drug use after leaving their places of origin; the purpose of this study is to examine the overlap between their migration trajectory and drug use practices and meanings, analysing how the migration experience and its social, economic and political conditions affects migrants' mental health.

Migration experience impacts daily life at interpersonal and structural levels. Leaving their places of origin and distancing themselves from family while lacking social networks may emotionally affect some migrants; the lack of language abilities acts as a barrier not only culturally but also economically; not having documents for a legal stay in a country criminalises people and makes them subject to deportations and detentions. Others are simply exploited by a capitalist system seeking cheap labour but offering precarious labour conditions. In general, being a migrant (undocumented or returned) can place a person at the margins of society.

California (CA) has the highest percentage of Mexican immigrants in the United States: they make up 69 per cent of the state's unauthorised immigrant population, and numbered more than 1.5 million in 2016 – the highest total of any state (González-Barrera and Krogstad 2019) – while Baja California (BC), specifically Tijuana, receives the most returned migrants (whether forced or voluntary) in Mexico. In 2018, BC registered 54,625 repatriations from January to October, and around 56 per cent (30,475) of these were repatriated at the receiving point El Chaparral in Tijuana (Secretaría de Gobernación 2018).

Both states (CA and BC) rank among the highest in their respective countries for prevalence of drug use. According to the National Survey of Addictions (Encuesta Nacional de Adicciones), drug use is increasing in the north-western region of Mexico, particularly BC (INPRFM 2012). In CA, specifically Los Angeles County, there has been an increase in methamphetamine use (Brecht 2014). San Diego shows a significant increase in heroin use and a growth in heroin overdose death rates since 2013 as well as an increase in methamphetamine use from 2015 to 2017 (Wagner 2014; Meth Strike Force 2018).

Even though it is possible to identify social conditions in the Western US–Mexico border region that affect the development of health problems related to drug use, in this work I focus on the analysis of the processes of health/illness/care (h/i/c) for drug use through studying people's life trajectories and focusing on their migratory experience. According to Menéndez (1994), the process of h/i/c constitutes a universal that operates differentially in each society and is diversely experienced among different groups. From Menéndez' perspective, health conditions – and the societal response to those conditions – generate representations, produce practices and structure specific knowledge of the appropriate ways to understand, treat and whenever possible cure what is socially defined as illness (Menéndez 1994: 71).

Focusing on migrants' experience to explore the process of h/i/c for drug use allows me to distinguish the different meanings that consumption practices have for Mexican migrants. At the same time, analysing their migratory trajectories makes it possible to identify their understandings, practices and forms of care related to drug use and how these may change throughout their lives in the US–Mexico border zone.

This chapter begins by discussing the theoretical perspectives approached in this study, mainly from psychological/medical and critical medical anthropology, followed by a summary of research studies conducted in Mexico relating to drug use and focused on social perceptions, policies and treatments. The third section describes methodological procedures, giving an account of the different settings where the study was conducted in the US–Mexico border region.

The chapter then analyses the overlap between migratory and drug use trajectories, discussing how the experience of migration from Mexico to the United States has affected drug use practices and meanings. From a qualitative perspective, some experiences analysed demonstrate an increase and diversification of drug use in the border region in comparison to their homeland, suggesting that in the first stages of their trajectory, drugs use is experienced as a resource to deal with the challenges faced in this context as undocumented migrants. The following section analyses how drug use became a health problem in the later stages of their trajectory, leading them to deportation, homelessness and seeking treatment at the margins of the healthcare system.

Finally, the chapter concludes by synthesising how migratory and drugs use trajectories overlap in the experience of undocumented and returned migrants in the border region. It highlights the processes of marginalisation that exacerbate their health condition as well as their active role in creating therapeutic communities for their peers.

### Theoretical perspective

The critical medical anthropology (CMA) perspective has made significant contributions to scholarly understanding of the social dimensions of health/illness/care processes. These contributions include analysing 1) the social construction of health and illness in relation to the world economic system; 2) health policies and the distribution of health resources; 3) the state's role in health fields; 4) contemporary understandings of medical pluralism; 5) the development of a critique of biomedical ideology; and 6) individual health behaviour as well as illness experience in the context of wider structures, processes and relations (Singer 1989). This chapter uses a life trajectories approach centred on the process of migration to analyse how the subjective experience of drug use is affected by the social, political, economic and cultural conditions experienced by migrants in the United States–Mexico border region.

Singer (1989) emphasises the importance of CMA prioritising the micro level of social analysis, specifically individual experience and behaviour, to discuss the conflict and struggles that happen at the macro social level, both inside and outside of healthcare systems. In accordance with this perspective, Scheper-Hughes and Lock (1986) emphasise the necessity of studying the subjective experience of illness and healing processes. In this case study, I examine the relationships people establish with others along their migratory trajectory, within different social contexts (e.g. the family, at work or among religious groups), as well as at institutions providing treatment for drug use. These relationships influence the lived experience of understanding, interpreting and reacting to drug use. According to Kleinman and Fitz-Henry (2007), this is an intersubjective process involving practices, negotiations and disputes. Therefore, by examining lived experience, I seek to understand collective realities as well as individual transformations and translations of those realities. Through engaging with migrants' life stories, it is possible to identify periods where their experiences of drug use are not understood as illness but rather as helping address the difficulties they face in daily life. Eventually, turning points in the lives of migrants (such as becoming homeless and starting to experience auditory hallucinations) affect the meaning of the experience as an illness and lead them to seek treatment.

Analysing the subjective experience of illness also requires consideration of gender and ethnicity, as they can affect the lived realities of health conditions (Jenkins and Schumacher 1999; Jenkins and Cofresi 1998; Jenkins 1997; Lerín 2004; Ramírez Navarro 2010). We can identify differences between men and women regarding drug use and its treatment processes. For example, in Baja California, 75 per cent of rehabilitation centres for drug abuse do not accept women, and the ones that do provide treatment for this group reinforce their gender role as mothers and caregivers since they incentivise internment by offering legal support to get back parental authority (Galaviz 2015). Thus, treatments for women are focused on the recovery of their social function as caregivers, giving special meaning to their role as homemaker, mother, and wife; while for men, the role of caregiver is oriented to their peers, especially to those who are part of their therapeutic community (Galaviz 2015). Women are less prone to following up rehabilitation treatments due to the social demand of taking care of their home rather than being in a process of internment. It is therefore important to point out that the participants in this study are Mexican men since it was more feasible to contact this population on both sides of the border.

The participants of this study have different migratory experiences that have brought them, from various places, to the US–Mexico border region. As part of their migration experience in the United States, this population often lacks housing, language skills, income and a social support network. Thus they often face specific difficulties related to being an undocumented immigrant, and disparities accessing health services (Holmes 2006). Following Holmes (2013), structural, everyday and symbolic forms of violence experienced by migrants, especially in relation to their ethnic origin and their migratory status as undocumented, make them more vulnerable to racism and unjust legal structures operating against them as conjugated forms of oppression, which often affect their health conditions. In some cases, undocumented migrants are blamed for their own health problems. The different forms of inequality and violence they are subjected to (in labour, health and justice systems) are not considered to affect their health condition, especially when talking about drugs use/abuse, since it has been criminalised rather than truly understood as a health problem. For example, under the Secure Communities Program,1 drug offences (in many cases, possession) have been one of the causes for deportation.

Therefore, the understanding of migrants' health problems is also affected by the marginalisation and discrimination they are subjected to, in addition to the stigmatisation that exists towards drug use/ abuse. Undocumented migrants have limitations accessing healthcare, and when it comes to drug use problems, the possibility of accessing a treatment is even more difficult: in some cases they are criminalised and blamed for their problem rather than perceived as needing help.

Active drug users face a different set of difficulties related to the social construction of addiction. Possession of illegal drugs sometimes implies that the person engages in illegal behaviours beyond drug use. For this reason, possession of or appearing to be under the influence of illegal drugs contributes to the stigma, marginalisation, criminalisation and social segregation of people who use drugs. The notion that drug use is an illness is sustained by the medical-psychological-psychiatric perspective embedded in the *Diagnostic and Statistical Manual of Mental Disorders* (*DSM*) as 'Substance-Related and Addictive Disorders', which is based upon a pathological set of behaviours related to the use of a substance (alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants or tobacco): impaired control, social impairment, risky use and pharmacological criteria (APA 2013).

The association of this health condition with impaired control resulting from drug use has resulted in the development of specialised, temporary residential treatment. The therapeutic models of these treatment centres range from biomedical and psychological to religious and mutual aid. Depending on where the centre is within the US–Mexico border region, patients may enter in-patient treatment voluntarily or involuntarily; however, later on in the treatment process they may move to out-patient care. Each of these therapeutic models represents a different institutionalised form of care based on a specific understanding of the problem to be treated, which leads to particular intervention strategies to support and guide the process of quitting drug use.

In order to discuss participants' experience through a critical lens rather than as having a psychological disorder, I use the notion of 'extraordinary conditions' proposed by Jenkins (2015). According to the author, instead of labelling someone as marginal or abnormal, the extraordinary can be recognised as vital and integral. Therefore, an analysis from the first-person perspective seeks to criticise the notion of mental health problems in categorical versus continuous terms, in order to consider the indeterminate thresholds between the ordinary and the extraordinary, the routine and the extreme, the healthy and the pathological (Jenkins 2015). Jenkins argues the critical need for engagement with individuals' experience, understanding their problems in terms of daily life struggles and not simply as symptoms defining illnesses.

Following Jenkins, I discuss extraordinary conditions as situations experienced at the limits of precariousness where, in some cases, drug use is involved. For example, the economic pressures experienced by some participants in the study led them to use drugs to do overtime at work. This situation is understood to be the result of a condition of precariousness, a struggle and an extraordinary condition experienced by undocumented migrants who have informal and low-paid jobs, while also having the responsibility of being home providers. Turning to drug use in this specific case can be discussed as a consequence of the structural violence exerted over them by the US immigration system.

The term structural violence is understood as a 'way of describing social arrangements that put individuals and populations in harm's way … the arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people' (Farmer et al. 2006: 1686).

The processes of criminalisation that undocumented migrants experience by being considered 'illegal immigrants' by the politicaleconomic system in the United States exacerbates their conditions of precariousness by restricting access to formal jobs, healthcare services, housing and other social and material resources. According to Armenta (2017), the immigration enforcement system has become increasingly punitive, and restrictive immigration policies are the primary mechanism through which people of Mexican descent are excluded and racialised in the United States, subordinating their status in the racial hierarchy, with consequences for their social, cultural, political and economic situation.

Even though some undocumented immigrants manage to get a job and find a place to live, their social rights are undermined due to their situation as undocumented; their labour and housing conditions may increase their fear of deportation, leading to other social and, in many cases, health problems related to poverty, marginalisation and discrimination. The jobs they acquire are often temporary, unskilled, low-paid, and do not provide healthcare or other work benefits. Some of the participants in this study reported that they have had jobs where they did not receive a salary, but instead were compensated with a place to live or with drugs (alcohol and marijuana). In some cases, they work extended hours or have two different jobs to earn enough money to cover their basic needs in the US as well as send some money to their families in Mexico. Using drugs may become a way to relieve the pressures of daily life. Such precarious conditions show how structural violence is embodied in the experience of people living in poverty or marginalised by social inequality (Farmer 2004).

The situation Mexican migrants face in the process of aiming to live in the United States affects their health. Thus it is relevant to discuss the way migration affects the h/i/c processes for drug use. Through this analysis, I argue it is possible to identify the hegemonic ways of understanding and caring for drug use. There are different forms of care configured by social structures and health institutions at the macro level, as well as the strategies that people living in socially and economically precarious conditions use to deal with problems related to drug use at the micro level. Menéndez (2003) suggests that it is possible to identify forms of care that individuals and groups use to address their illnesses beyond the biomedical, traditional or alternative perspectives used by health specialists, in what he describes as self-care. Therefore, analysing the h/i/c processes for drug use through life trajectories allows us to discuss the different interpretations of drug use as an illness, a habit, a vice and a self-care strategy to face the difficulties experienced under conditions of precariousness, among others. Likewise, it sheds light on the institutional forms of care sought by the participants.

Analysis of the life trajectory centred on the forms of understanding and caring for problems related to drug use allows us to identify how different healthcare and self-care practices intervene to reduce, solve or exacerbate health problems.

Self-care practices synthesise the activities developed by social groups regarding the h/i/c process (Menéndez 2003), that is, the different strategies they use to deal with and care for their health condition. In some cases, self-care practices are related to institutional healthcare practices, due to migrants' past experiences of specific forms of treatment, or to other drug users' self-care practices. When participants discussed their drug use prior to their migration, they did not consider it as problematic; it was not until they found themselves in certain critical situations in the United States as undocumented migrants or returned migrants in Mexico that they felt their drug use became problematic and sought out care for it. In this sense, it is relevant to analyse the way in which their condition as migrants in the border region has impacted their intersubjective experience related to drug use, not only associated with consumption but also the forms of care they turn to.

### Social perspectives on drug use practices, meanings and treatments in Mexico

Researchers have investigated a variety of problems related to drug use from both an anthropological and a sociological perspective. Some of these studies have analysed how different therapeutic models of treatment shape both conceptions of illness and the recovery or healing process. Although this paper is not focused on analysing a particular treatment model, it is relevant to review the studies that investigate the impact of cultural conceptions of the problem understood as drug abuse in Mexico, since it helps to understand personal, social, cultural, economic and political situations faced by people dealing with drug use problems in the border region between Mexico and the US.

Some scholars have studied residential self-help groups, in which people live together with the aim of mutually guiding each other's recovery process. This is one of the main forms of help for drug abuse problems in Mexico; it is modelled on Alcoholics Anonymous (AA), or the Twelve Steps.2 Since the early 1980s, Menéndez (1983, 2003, 2009) has analysed alcohol use and the role of AA therapeutic communities in Mexico. He discusses the relevance of religious aspects in the processes of h/i/c for drug use, highlighting the role these therapeutic communities have in the development of support networks for different stigmatised populations, from those labelled as 'drug addicts' to migrant populations. Menéndez (2009) also analyses the way AA as a therapeutic model understands the illness and recovery process through social and cultural aspects related to the alcoholic identity, which differs vastly from the biomedical perspective of drug abuse as brain disease. Módena (2009) specifically studies the group dynamics within AA therapeutic communities; she pays special attention to the processes of identity, power relations and differences in the meanings of treatment among groups in the process of recovery. Similarly, Palacios Ramírez (2009) discusses the self-transformations during the recovery process among an AA community. On the other hand, Rosovsky (2009) gives a historical account of AA in Mexico, analysing the fragmentations of this treatment model over the last century.

Self-help treatments have been the most extensively used and affordable source of help for people dealing with drug use problems. Living the process of recovery in a community setting is meaningful for the experience of quitting drugs and building new social and cultural contexts where this can be sustained. Thus, these models of treatment are relationally based, which is fundamental especially when the people going through this process are marginalised or stigmatised, not only due to drug use in itself but because of their cultural, economic, ethnic and political condition, such as being an undocumented migrant or returned migrant of Mexican descent in the border region.

Another kind of therapeutic community that has been analysed in northern Mexico, specifically in Tijuana, is religiously oriented: Evangelical-Pentecostal rehabilitation centres. García Hernández (2014) has studied the dynamic narrative identities of people undergoing religious conversion through analysing their testimonies of recovery, which are stories about personal transformation showing how a person reached sobriety with God's help. González Tamayo (2016) and Velázquez Fernández (2016) have analysed the process of recovery in relation to gender, while Kozelka (2015) has studied the way the social environment of rehabilitation centres contributes to certain cultural conceptions of the illness 'drug addiction' and the people who have it. Other scholars have analysed the processes of subjectivation through the paradigm of embodiment (Olivas Hernandez and Odgers Ortiz 2015) and the hope for the recovery during in-patient treatment in these religiously oriented centres (Galaviz and Odgers Ortiz 2014).

Both modalities of treatment, based on the Twelve Steps (AA) and religiously oriented, can be understood as self-help approaches offering alternative ways of understanding and treating drug users and drug use problems. In some cases, these therapeutic communities permit upward social mobility due to the role as guides or leaders that some people develop in the task of supporting others in their processes; this can positively benefit their own process of recovery.

Finally, some studies have discussed the problems associated with the social marginalisation of drug users. For example, París Pombo (2013) analyses the way the enforcement of legal policies against drug trafficking actually affects the human rights of drug users in Tijuana. She argues that poverty has increased drug users' vulnerability since the criminalisation of poverty has been added to the 'war on drugs'. In a similar sense, Cajas Castro (2013) analyses how drug prohibition in Mexico as a result of the 'war on drugs' has had a paradoxical effect of stimulating the use of illegal substances, highlighting the failure of prohibition policies. Thus, analysing drug use is not limited to the understanding of it as a health problem, but involves conceptions of it as a condition affected by social, cultural, economic and political issues embedded in the use of drugs.

Muñoz, Morales, Fernandez and Brower (in this book) analyse the conditions of vulnerability under which Central American migrants live in the southern border of Mexico and the inequalities they face in a system that marginalises them. These forms of economic, social and political inequalities place migrant people at risk in relation not only to their health (drug use, STI, interpersonal violence) but also to the spaces and networks they become linked to, undermining their social security as a result of the structural and interpersonal violence they are subject to as sex workers, migrants and drug users.

Thus, analysing migration in relation to drug use in the border regions shows the structural violence exerted towards those who, in the process of seeking life improvement through migration, are placed at the margins of nation states, and their health, social and political condition is worsened in these contexts. The aforementioned studies address different aspects and levels of analysis concerning the experience of drug use in contemporary Mexican society. Using migrants' experiences as starting point, this chapter aims to articulate, from a CMA perspective, the interactions between the migratory condition and the subjective experience of drug use (practices, meanings and forms of care) in the border region between Mexico and the United States.

### Methodological approach

This research is based on a qualitative longitudinal study that explores different participants' life stages related to the overlapping aspects of the migration experience, drug use and its forms of care, from leaving their places of origin until their settlement in the border region. This approach considers different variables (social, personal, cultural, economic and political, among others) as intertwined over a period of time, qualitatively paying attention to the subjective dimension of those variables from participants' experience. The study systematically analyses migrants' trajectories, from leaving their place of origin to settling in the border region between Mexico and the United States, and engaging with a form of treatment for drug use in California or Baja California.

The trajectory, as a theoretical and methodological tool, contributes to the systematisation of multi-spatiality during the migration experience (Rivera Sánchez 2012). It also aids understanding of changes, continuities and breakdowns in social, cultural, political, economic and personal aspects of individuals' life experiences. Specifically, the migratory trajectory approach permits the selection of an analytical period in the biography, allowing the order, systematisation and interpretation of drug use during a specific time interval, in this case migration between Mexico and the United States. Thus, this study discusses the relationship between personal situations and the context in which these experiences occur.

The study included 24 men between the ages of 25 and 65. Most of them reported methamphetamine, heroin or alcohol as the principal drug used. The majority of them were born in Mexico City and Tijuana, while a minority were from Nayarit, Jalisco, Michoacán and Durango. A few of those born in Tijuana emigrated to the United States with their parents or a relative during their childhood. However, the majority emigrated alone between the ages of 15 to 25, escaping from problematic situations in their places of origin, mainly drug use and violence, as well as economic and familial problems.

During the study, participants were recruited from three institutions providing low-cost self-help group services for drug use in the border region, which is the principal form of care in the Mexican side of the border (Galaviz and Odgers Ortiz 2014). Most of the people were of Mexican descent and treatment was provided in Spanish. Importantly, the people providing treatment have often had or are concurrently experiencing treatment as well. These self-help organisations outlined below were selected because they are more accessible for people with social and economic conditions of precariousness.

The first organisation is a religious rehabilitation centre located in Los Angeles that provides voluntary residential treatment for drug use. The religious approach to drug use rehabilitation understands the problem as spiritual and has the idea of God as saviour (Olivas Hernandez and Odgers Ortiz 2015). The second, located in San Diego, is a 24-hour AA group, which provides both out-patient and residential (in-patient) treatment. Even though it is an AA group, the users of this service have used drugs beyond alcohol, such as methamphetamine, alcohol, heroin and psychotropic pills, among others. The study participants attend out-patient self-help group sessions based on the Twelve Steps model. Finally, the third organisation located in Tijuana, is a rehabilitation centre also based on the Twelve Steps model, providing voluntary and involuntary residential treatment. The participants interviewed at this centre are returned migrants deported from the US.

During 2016, I conducted semi-structured interviews with 24 participants receiving treatment in each one of these organisations. In the interviews, I explored changes in their patterns of drug use and other familial, economic, emotional and social events that they had experienced after leaving their places of origin until their current involvement in the treatment. I specifically focused interviews on changes in drug use, their notions of health and illness, as well as the forms of care used to diminish their drug use, as most of the time they did not turn to specialised treatments. I also conducted observations of daily activities in the centres.

### The migratory process and drug use

Some quantitative studies that have focused on the experience of migration between Mexico and the United States in relation to drug use have argued that people migrating from Mexico increase drug use once they are in the United States, while among returned migrants drug use diminishes once they are back in Mexico (Caetano and Medina Mora 1988; Sánchez-Huesca et al. 2006; Sanchez-Huesca and Arellanez-Hernández 2011). However, the quantity of consumption in Mexico continues to be high compared with their drug use practices before leaving their home country.

Other studies have focused on Mexican immigrants settled in the US. For example, one study argued that labour discrimination and exclusion are associated with alcohol abuse and dependence. In this case, social support did not act as a source of help among the people living with high to moderate rates of labour frustration and feeling unsatisfied (Finch et al., cited in Alvarez et al. 2007). Other research has shown that Latin American people living in the US have unequal access to treatments for drug use (SAMHSA, cited in Alvarez et al. 2007). Even if the possibility of accessing healthcare exists, they wait long periods of time to receive care, which they ultimately find unsatisfactory (Wells et al. cited in Alvarez et al. 2007). Finally, some studies discuss treatments' characteristics, emphasising that culturally specific out-patient and residential treatments could have better results for drug use among Latin American people settled in the US (Cervantes et al.; Hohman and Gait; Waters et al. – all cited in Alvarez et al. 2007).

Although the condition of Mexican immigrants in the US or returned migrants in Mexico is different due to their migratory status, they share some difficulties related to the process of mobility (voluntary or forced) between Mexico and the US. As stated before, the majority of participants in this study migrated from Mexico to the US when they were 15 to 25 years old; most of them were using marijuana or alcohol at the time. Even though some of them had a relative or friend living in the US, they did not contact them, or if they did, the relationship was temporary.

Some of the reasons to migrate from Mexico to the US were related to family problems (mainly with parents), substance consumption, situations of violence in their places of origin and economic difficulties. In most of the cases analysed, moving to a new context was framed as an attempt to modify and improve their social, cultural and economic condition, in comparison to their lifestyle in their places of origin.

Nevertheless, undocumented migrants in the US face conditions of precariousness in terms of their labour, economic and social needs, which are reinforced by their experience of social isolation. In the border region, migrants deal with adversities that affect the possibility of gaining social and material resources to integrate themselves in their new context, ultimately impacting their mental, emotional and physical health.

Participants' migratory experiences were often characterised by a change in their drug use patterns. During the mobility from their places of origin and their first weeks in the border region, there was a decrease in drug use. However, once they became employed and established relationships with other users, their drug use increased. Additionally, most of them demonstrated a diversification of the type of drugs used, such as using methamphetamine, crack, psychotropic pills, cocaine or heroin for the first time. Valentin, for example, was born in Durango, México and emigrated to the US alone after ending a relationship, when he was 23 years old. He used to consume alcohol in Mexico, but in the US, crack was the main substance of consumption.

When I arrived [in the US], I was looking at everything differently. For example, it was easy for me to get into drug addiction here, because if you were on the street with a beer or a cigarette [marijuana], you just needed to hide it when the police were passing by, they were not aware of it … that made it easier for me (to use drugs) because being alone here is how I became addicted to marijuana. I was using meth, pills, PCP, crack, and I didn't know about all that until I arrived in this country.3

For most participants, their increased drug use was affected by their life circumstances in the border region, related to their working conditions, social isolation and living at the margins with other people in the same condition as undocumented migrants. Even though the kind of jobs they acquired have precarious conditions and low pay, most of them report an increased income, allowing them to have more access to drugs. They also find more social tolerance of drug use in the US, particularly among those sharing an apartment with other migrant men or in jobs where drugs were used to improve performance over long work shifts, like one of the participants describes.

Ricardo was born in Mexico State and migrated to the border region at 21 due to problems of gang violence in his neighbourhood. Even though the main drugs he used before starting rehabilitation were alcohol and cocaine, he describes the shifts from one drug to another and his experience with marijuana during his first employment in agriculture, where most undocumented migrants work in the US.

We arrived at a place called Oceanside, there were tomato fields and, well, I didn't know anyone, I had to stay working in the field. There I met more friends and that's when I got back into marijuana. While working in the field and picking tomatoes, they told me: 'Look, with this [smoking marijuana] you are going to work more quickly', and I said: 'Well, let's see.' Then I started using marijuana and stopped drinking alcohol. That is how my life has been [switching from one drug to another]. I started smoking marijuana [in Mexico] but I didn't like it, then I used inhalant drugs [volatile solvents] for a long time, later for a while I drank alcohol and I quit when I was working in the tomato field. I started with marijuana when I came here [to the US] because it was easier to get drugs here. I was working and having more money … I was smoking around ten cigarettes in a day.4

Ricardo did not have social networks when he first arrived in the US and he relied on other migrants to help him to settle in Los Angeles, California. The neighbourhood where he arrived was poor, with gang and drug use problems. Even though he met other undocumented migrant men in the US with whom he shared an apartment, he felt alone. Problematic emotional experiences on arriving at their migratory destination affected the increase and diversification of drug use among participants in this study, especially when settling into segregated neighbourhoods where drug trafficking is common. The feelings of loneliness and sadness experienced as a consequence of being away from their social networks in Mexico often caused an increase in drug use. In addition to the lack of affective bonds in the US, work stress, economic difficulties and marital problems influenced their emotional experience. For these men, drug use became a strategy to face the emotional challenges of living in these situations. As such, drug use could be understood as a form of 'self-care' in Menéndez's sense, to deal with the emotional pain, as another participant argues.

Dario was contacted in a rehabilitation centre in Mexico after being deported. It was his first experience of treatment. He was born in Tijuana and emigrated with an aunt to the US at the age of three months after his mother passed away. At the age of eight, he started to have problems with his aunt and left home. Later on, he started using drugs and was incarcerated many times, but not in rehabilitation centres, demonstrating how drug abuse is often criminalised but not understood as a health problem. Dario describes the experience of being away from his family as the reason for beginning and continuing his drug use:

When I started using more drugs, it was because I was falling into a kind of depression; I started missing my brothers, my aunt and my cousins. At the beginning with the marijuana, you are always laughing, but as it gets inside of you, you are more focused on your thoughts, and you will be there just thinking about the problem. Later I tried mushrooms and I would hallucinate … then the LSD, and later the pills. The pills (Rohypnol) started helping me more … in the way that they blocked my thoughts … I just started to think a little bit about my family and I would take three or four pills and that's how I was living.5

Even though many participants increased their drug use after the migratory experience, it was not perceived as problematic, because they felt capable of regulating their use by themselves. This notion was also associated with the benefits they were experiencing from drug use; it became a resource to deal with different situations in their lives. Moreover, some participants noticed that using drugs helped them to deal with their emotions. They registered an improvement in their social skills as they became self-confident and were able to work for longer periods under the influence of drugs, improving their income. They were also, however, spending more money on drugs, which later became a difficulty for some.

This situation gives an account of the levels of labour exploitation that some undocumented migrants face in the US. Since they have lowpaid and irregular jobs and are always at risk of being deported, some of them try to make the highest profit from their time in the US, sometimes at the cost of their health and safety. Even though they experienced challenges due to drug use, most of them developed strategies to diminish those effects, reducing the quantity and frequency of use. One of the strategies was to change their place of residence in the US, as some started to have illegal trans-border mobility between Mexico and the US (mainly those who were born in Tijuana), especially during the 1990s, before the militarisation of the border (Heyman and Campbell 2012). The mobility allowed them to move away from the drug users' networks, although sometimes only temporarily.

Another strategy was to manage their money differently, spending more on their family, homes and personal belongings and less on drugs. Entering into romantic relationships and having a child were other strategies related to more responsibility or being aware of it. Another strategy was to diminish the adverse effects of drug use. For example, when they felt a lack of control over their drug use, they replaced one drug with another, or diminished the use of one drug while increasing another. These adjustments in drug use patterns can also be understood as forms of self-care. These strategies were undertaken to avoid being in a critical condition, as one participant describes.

Martín was born in Mexico City and migrated to the US when he was 20 due to family economic problems. He used to work seasonally in the US and go back with his family (parents and brothers) to Mexico. But when the militarisation of the border was enforced after 9/11, he stayed in the US and never went back to Mexico. The jobs he got were in small markets, with precarious labour conditions, such as low payment and no access to healthcare, but with minimal supervision, allowing him to drink alcohol at work. He began consuming alcohol at the age of 15 and explains why he replaced alcohol with methamphetamine while working.

Here [in the US] I had the chance to drink at my job, there was a lot of freedom … since I used to work in small markets, I was able to do what I wanted in my place of work, and if the boss noticed, there was no big trouble. I used to drink a little bit, I never was falling [due to the alcohol use] and I drank more after my job, and I never fell, I could drink a lot and keep working. But when I started with meth, I had *tocado fondo* [touched bottom] with alcoholism, I was not able to work any more, it was very hard. On one occasion, I couldn't handle the hangover, I felt bad physically, but I was working, and someone told me that if I wanted to feel good, he had something for me to get better. I knew what he was talking about, but I had never tried meth; the guy left me some lines [of meth] on the table and I was so desperate because I was not feeling good, so the first time that I used it, I just started and immediately I was feeling good, the physical discomfort disappeared. That experience was what attracted me and captured me more. The meth consumption made me a sociable person, what I couldn't do or say I did it under the effects of meth. I remember that I quit alcohol and I started to use meth regularly … I turned to my normal activities again and I was feeling better because, in the beginning, that's how it was.6

From the participants' perspective, using drugs for some years without experiencing negative consequences shaped their perceptions of not considering drug use to be a problem. Rather, drug use was a means to deal with their problems. The use of as a form of self-care to address their needs and discomforts reveals their perception and experience of drug use as a solution to problems, not an illness. Even though they experienced difficulties related to their drug consumption, those were lived and understood as extraordinary conditions that they have to struggle with constantly, in efforts to improve their lives. However, not perceiving their situation with drug use as a health problem is in some cases a result of the indifference of employers towards undocumented workers' conditions, in addition to the difficulty of accessing healthcare.

### The notion of drug use as a problem

As mentioned earlier, the majority of participants identified different stages in their life trajectory where they managed drug use difficulties through self-care strategies, such as maintaining relative stability in their family relationships, job performance and economic position. However, in all the cases analysed, there are later stages where they experienced more difficulty in regulating the patterns of drug use, even if they were using the same self-care strategies, such as transitioning between different drugs or moving to a new context. These different conditions changed their perception and experiences related to drug use.

Once they were experiencing more difficulties in keeping a job or getting a new one if they were fired, they started to consider their drug use as a problem. In these cases, they were experiencing the situation of being at the margins of the system, which was expelling them once they were not economically functional for the employers. They often found themselves unable to provide for their families, which impacted their familial relationships and economic position. For participants in this study, the duty of being the worker and main provider is closely associated with gendered social expectations of them as the man of the house. Accordingly, when they were unable to perform their social role as provider, their family relationships broke down. Some of them found themselves in failing relationships, losing contact with their family members and eventually becoming homeless, as Alan recounts.

Alan was born in Guadalajara, Jalisco, and emigrated to the US at the age of 21. He tried to reunite with his wife in the US after having marital problems. His first employment in Texas was in agriculture, where he constantly experienced fear of deportation, leading him to live in precarious conditions in the field for some years. Later he reunited with his wife in Los Angeles, where he managed to get a job in upholstery. He was using alcohol in Mexico but began using meth in the US to do overtime and improve his performance at work. Eventually he started to lose control over his drug use.

In the beginning, I was using meth, and everything was fine. I even wanted to work and to be more active and used to do overtime at work. But as time passed, everything changed … When I started using meth I was able to work, I was not using too much, around \$20 per week. I was using just on Friday, Saturday and Sunday, when the party was over, and I was well rested and ready to work on Monday. For five years that's how it was, I didn't have economic or relationship problems. But when I started to spend the night with my friends drinking, I became more focused on drug use. That was when I began to have problems with my wife, and due to those problems with her, I increased my use. But what happened with that drug [meth] is that it is stronger than others. At the beginning I said, 'I control it', but later I lost control. I was using it to go to work and increased the quantity [of the drug]. Later, I started to miss work and had bad job performance. My social, labour and emotional responsibilities were affected. I said to my wife, 'I need help because I am not controlling it [the drug use]', and my wife said, 'That's your problem, don't count on me, because I didn't send you to use drugs', so I felt rebuffed. One time I heard her telling her sister, 'As long as he gives me what I need, he can do what he wants', but three years ago was when I was hitting bottom [having critical problems due to drug use]. My wife didn't want to be with me any more. I lost my job and became untrusty for other people and started falling down … I was still living with my wife, but our relationship was very hard, we were having economic problems, until the moment that she and her family threw me out of my house. I lived 15 days in the street and a friend of mine who was also using drugs let me stay in his garage. I got a job in an upholstery where I was known, but I was lost already. I continued using every day … to the point where in the morning if I got up, and I didn't drink a beer, I couldn't even walk. During the morning, I used to drink five beers and do meth at around noon, to reduce the beer effect so the boss couldn't notice. I was not using a lot of meth, the alcohol was what was disturbing me. The last 15 days were the heaviest because I started hallucinating and couldn't sleep at night. Those two weeks I was struggling with myself, due to the hallucinations.7

Alan's experience shows that failure as a provider (as a result of difficulties in keeping his job), and its consequences in the family context (being rejected by his family and becoming homeless), worsened his drug use problem, thereby exacerbating his conditions of precariousness. Most of the participants resorted to treatment once they were struggling with different problems or extraordinary conditions at the same time, such as the experiences of hearing voices, being homeless, lacking social support and suicidal ideation or attempting suicide.

The participants who had settled in Tijuana as returned migrants did not report seeking any treatment in the US. Compared with migrants arriving in the US for the first time, returned migrants with drug use problems experience conditions that are highly precarious once they are back in Mexico: a lack of social support networks, economic instability, limited employment and housing possibilities, as well as restrictions on receiving help in migrant shelters due to their drug use problems. This partially relates to their physical and mental health conditions stemming from their deportation (Rosales Martínez et al. 2017). Most of the participants interviewed on the Mexican side of the border reported that they become involved in treatment after their deportation. Their health conditions had worsened during their time in the US, due to their increased drug use. Once deported, they did not feel socially and economically able to integrate themselves in Mexico, leading them to voluntarily seek residential treatment as a temporary shelter.

From participants' perspectives, one critical consequence of drug use was the experience of auditory hallucinations, particularly when combined with suicidal ideation. For help with this they mainly turned to religious treatment, primarily because of social, economic and cultural difficulties in accessing any other sources of help. While some participants turned to psychiatric treatment, they did not feel comfortable being categorised as having a mental illness nor were they willing to begin psycho-pharmacological treatment. Therefore the preferred option was to seek religious support, where their hallucination experiences were interpreted as the presence of demons trying to bother them, rather than as a stigmatising mental problem. Alan recounted how he had turned to a charismatic Catholic group to take care of his problems related to drug use once he became homeless.

When I couldn't keep my job, was when the voices [auditory hallucinations] were bothering me more. I talked with a person from the Catholic group … he told me that he knew what was going on with me. Then, the same day, I heard the voices again, telling me that I had broken the rules, that I wasn't supposed to have talked with them [the Catholics], it was something between them [the voices] and me.  While reading the Bible, I found that seven demons attack us. I made sense of all that because I was listening to seven different voices by that time.8

All the participants sought institutionalised care based on the Twelve Steps or religious therapeutic models. This was in part because their economic condition prevented access to other kinds of treatments, since most of them only sought treatment once they became homeless. Furthermore, they identified with the community that constitutes those forms of care and the way they collectively addressed and understood their situation.

It is relevant to underline that Twelve Step treatments and religious models can be categorised as forms of care based on the self-help ethos, because service providers for those forms of care are often people who are also living through or have already undergone a rehabilitation process. In many cases, this caregiving community also provides social, cultural and sometimes economic support networks that migrants had been missing. This leads to two conclusions. First, turning to a form of low- or no-cost care sheds light on the conditions of social and economic precariousness that undocumented migrants with drug use problems often experience. Second, it allows us to analyse the way in which the social group that constitutes the therapeutic community has taken a position on understanding, defining and caring for drug use problems contrasting with other hegemonic forms (medical, psychological, psychiatric) of treating their health condition.

According to Singer (1989), analysing the life course both inside and outside the health arena reveals disputes between individuals and groups whose social interests conflict; further, the fact that these different social groups (i.e. therapeutic communities and biomedical/psychological professionals) have unequal abilities legitimises certain forms of care and meanings attributed to illness. From this perspective, Singer suggests that we need to pay attention to the implicit and explicit social struggles that manifest in illness meanings and experiences, clinical interactions and the relationship between health systems and healthcare providers, as well as organised efforts by patients, workers and oppressed populations, such as self-help groups.

The wide dissemination of alternative forms of care (religious and Twelve Step) categorised as mutual-aid groups, as opposed to statesponsored psychological services, makes visible the tension between the state as the provider of public healthcare services and its inability to meet the community's needs. Because of this, alternative forms of care have emerged within civil society (Galaviz and Odgers Ortiz 2014).

The difficulties experienced by undocumented and returnee migrants which ultimately lead to them accessing these forms of care reveal conditions of structural violence, social marginalisation and inequality. Being an undocumented or returnee migrant in the border region limits their labour possibilities to low-paid jobs with difficulties accessing healthcare, and with precarious housing conditions in segregated neighbourhoods, where drug use and violence are often community problems. These conditions worsen their problems with drug use, putting them in critical situations that make seeking treatment with mutual-aid groups a means to survive.

### Conclusions

The problems that Mexican migrants face in their efforts to achieve social, economic, political and cultural inclusion in the border region significantly shape their mental and emotional health. The lived experience of the migration process increased the problems that these men were already experiencing in their places of origin, such as drug use. It is important to highlight that the participants in this study migrated to the border region under conditions of extreme precariousness. Most of them were children or young adults experiencing social and economic problems that motivated their migration; thus, they did not have a network that could act as an emotional, social and economic support in the border region.

As mentioned previously, this chapter used a life trajectories approach centred on the process of migration to analyse the subjective experience of drug use (changes, continuities, practices and meanings) and to address its relationship with the social, political, economic and cultural environment in the United States–Mexico border region. In the first stages of their trajectory, mainly in their places of origin, drug use (mainly marijuana and alcohol) was perceived as a recreational practice, but in some cases it was causing family problems because their parents perceived such practices as immoral. Once they migrated to the border region and faced different challenges related to the process of economic and social integration as an undocumented migrant in the US, it is possible to identify drug use (mainly methamphetamine, alcohol, psychotropic pills and crack) as a form of self-care to manage the (emotional and social) difficulties they faced at their destination. They also found social tolerance and easy access to drug use in low-paid informal jobs, since it helped them to improve their performance by working for long periods of time, to the employer's advantage.

From participants' perspective, drug use was part of their coping strategies, and it helped them to achieve economic, social and emotional stability. Changing patterns of consumption, like increasing drug use or substituting one drug for another, facilitated their adaptation to their new context for some years. From this perspective, drug use in daily life was among the resources and strategies they had to cope with the challenges of living as an undocumented migrant in the US, such as the fear of deportation, the high cost of living combined with low wages, lack of healthcare access and difficulties with social and cultural integration beyond the margins.

Undocumented migrants in the US were trying to be functional in the economic system and deal with emotional instability – in some cases as a result of not being able to visit their family in Mexico due to the militarisation of the border. Analysing the subjective experience of drug use from the participants' perspective, I argue, reveals that their understanding of their condition escapes the social framing of drug use as an illness. Focusing attention on their struggles allows us to identify the precarious conditions they faced when settling in the border region. Moreover, their experiences illuminate the lack of support in this region and the easy access to drugs, which reduced the discomfort they experienced in the process of settling into a new context. Yet their drug use experience transforms in later stages after the settlement process in the US, when they experience adverse social, cultural, economic and personal consequences of drug use.

When the experience of using drugs started to lead to other problems, such as not being socially and economically functional, not being productive at any job and unemployed, unable to be a provider and accomplish the role of the man of the house, and finally becoming homeless, the participants started to seek help and the meaning of using drugs changed. The marginalisation they experienced, not only at structural levels but also interpersonally, led them to seek residential mutual-aid treatment. This was the main source of help that the participants of this study had access to in the border region. The intersubjective experience of treatments that were based on the Twelve Steps and/or religiously oriented shaped their notion of drug use as an illness or suffering related to a spiritual problem; they then realised that they needed help from a therapeutic community to overcome this condition. The social network aiding these people was composed of those who were also marginalised and discriminated against by the health, political and economic system in the US.

Since having a sense of belonging (to a therapeutic community or, in this case, a self-help group) has a significant meaning in the process of recovery, joining this kind of community has improved their experience of social inclusion at the border region. The cases presented in this chapter shed light on the processes of marginalisation that drug users undergo in contemporary society. Furthermore, it reveals migrant men's capacity to assume active roles in the process of managing the problems associated with drug use through self-care strategies, and their ability to be part of a community that delineates alternative forms of understanding and caring for their health conditions.

Analysing this phenomenon from a CMA perspective contributes to scholarly understandings of the meanings that drug use practices can have in the daily lives of people living in conditions of precariousness, such as migrants in the US–Mexico border zone. This chapter has provided a window on the process of pathologising or criminalising drug use practices alongside an account of how drug use can be a strategy for self-care under stressful and emotional extraordinary conditions. The systematic, structural violence experienced in the border region sheds light on migrants' lack of resources for help in relation to their mental and emotional wellbeing, leading to the embodiment of illness experiences related to drug use.

### Notes

1. The US Immigration and Customs Enforcement (ICE) implemented a Secure Communities Program from 2008 prioritising the removal of public safety and national security threats – people who have violated the nation's immigration laws, including those who have failed to comply with a final order removal. This deportation programme relies on partnership among federal, state, and local law enforcement agencies. Nonetheless, most of the people deported have committed minor offences and do not represent a threat to public safety and national security.

### References

Farmer, Paul. 2004. 'An Anthropology of Structural Violence', *Current Anthropology* 45 (3): 305–25.

### 6

### Border spaces: Stigma and social vulnerability to HIV/AIDS among Central American male migrants at the Mexico–Guatemala border

Rubén Muñoz Martínez, Carmen Fernández Casanueva, Sonia Morales Miranda and Kimberly C. Brouwer

*I travelled to the north and I was deported, then I tried one more time and I came back to Mexico.  There, they think I'm another person. Just by my haircut they think I belong to the Mara Chirizo, so Mara Salvatrucha and Mara 18 want to kill me by mistake. Sometimes you can be well dressed, beautiful, it doesn't matter, they kidnap you, and tomorrow you are in a plastic bag or floating in the river, dead.*

*(Honduran, 21 years old)*

*Listen, up to the north [of Mexico] there are the Zetas and* mareros*. When you try to get close to the border the leaders will not let you go if you don't pay some money. We are travelling, begging to have something to eat. If they catch you and you don't have any money … you can imagine!*

*(Honduran, 23 years old)*

The main purpose of this chapter is to share and discuss the findings of an exploratory research study1 conducted from a critical medical anthropology perspective. The study focuses on the processes of social vulnerability to HIV infection2 that are faced by Central American male migrants en route to the United States, who are undocumented during their transit through Mexico, who were residing near the Mexico–Guatemala border when interviewed, and who perform sex work under the influence of non-injected drugs. Considering migration and/or displacement as non-linear processes, we explore the transit and temporary sojourn of these migrants in the following four border cities: Tecún Umán and Quetzaltenango (Guatemala), Ciudad Hidalgo and Tapachula (Mexico).

Drawing on Latin American critical medical anthropology, this research contributes to the development of a relational approach beyond the framework of the dialectical debate on subject versus structure (Menéndez 2009), enabling us to challenge a structural analysis that erases the actor's points of view and praxis, as well as to overcome individual 'rational choice' perspectives that ignore structural, symbolic and ideological processes determining actors' social praxis and representations. Additionally, this research elucidates different levels of the political economy of sex work and HIV risk, as Maternowska (2006) and Farmer (2006) explored in the case of Haiti. At the Mexico–Guatemala border, the reification of bodies and social spaces are mutual and transfigured conditions, encouraged by current public policies and practices on migration that, at the meso and micro levels, determine susceptibility to, for example, stigma, discrimination and the threat posed by organised crime. In this context, the bodily economy of sexual practices' exchange value, as Viveros (cited in Wade et al. 2008) and Stolcke (1974) have shown in Colombia and Cuba regarding racism and sexism in gender relationships, arises at the intersection of the subject's social class, country of origin, sex/gender identity and ethnicity. Our critical medical anthropology approach highlights the need to combine theoretical contributions with ethnographic field results in order to contribute to transforming a social reality marked by unequal social relations; in this we follow, among other authors, Singer (1995) and Scheper-Hughes (1995).

Our main interest in this research is the stigmatisation and discrimination experienced by low-income, undocumented, drug-using migrants, analysed in terms of their social vulnerability at three levels: macro-spaces (regions), intermediate spaces (urban/rural areas), and micro-spaces (drug use and sex exchange locations). We conducted social mapping in each of the four cities examined, based on an understanding of 'territory' as plural and using the subjects' knowledge about the 'places/spaces' as a fundamental element of the social research (Diez Tetamanti and Escudero 2012).

Social mapping was implemented for two types of spaces – locations of sexual exchange and locations of drug use – analysed in terms of both their social configurations and specific uses: *puntos* (points) and *pasos* (steps). Within this framework, spaces are understood as locations where social vulnerability to HIV is produced in accordance with their characteristics of social and urban placement in terms of unequal access to resources and capital (Harvey 2007). In the specific case of *pasos*, we also analyse places as generating strategies as the application of survival praxis and the recreation of labour networks.

Our understanding of social vulnerability opposes the stigmatising characterisation of at-risk groups, emphasising the social determinants of illness/sickness/disease and its ideological, structural and historic dimensions (Muñoz Martínez 2018). Viewed in this light, every person is vulnerable to misfortune, although the susceptibility to heightened factors of social vulnerability and their consequences on health/illness/attention/ prevention varies based on one's position in the social structure (as a factor of ethnicity, social class, gender, age group or, as in the present case, migratory condition). We study the intersection of spaces, actors' viewpoints and strategies by documenting and analysing: 1) 'social representations' (Abric 2001) and practices surrounding the use of condoms, drug use during sexual exchange and HIV, and 2) the social use and configuration of the spaces where sex is exchanged under the influence of alcohol and other noninjected drugs. This is the first research study conducted at the Mexico– Guatemala border that documents and analyses these types of spaces from the perspective of health and migration-/displacement-related processes, as well as social vulnerability to HIV/AIDS of men engaging in commercial sexual intercourse with men and/or women.

The HIV epidemic in Mexico primarily affects vulnerable groups, and its main mode of transmission is sexual intercourse (CENSIDA 2015).  In 2014, the state of Chiapas documented the fourth highest prevalence of new AIDS cases per 100,000 inhabitants in Mexico (CENSIDA 2015). This data is analogous for Guatemala (MSPA 2014a), in which the San Marcos department – where Tecún Umán is located – ranked third for HIV prevalence (MSPA 2014b).

There is little data regarding the prevalence of AIDS among the migrant population at the border; the cases documented on the Mexican side correspond to a foreign migrant population composed mainly of Guatemalans, followed by Hondurans and Salvadorans (Secretaría de Salud 2009), with a higher prevalence (following a concentrated pattern) than in their countries of origin (Leyva-Flores et al. 2016). One study conducted at the border with migrants who abuse alcohol or use noninjected drugs found an HIV prevalence of 1.3 per cent in men and 2.4 per cent in women (Conners et al. 2017). The Mexico–Guatemala border is crossed by 200,000 migrants3 per year from the countries mentioned above, whose main destination is the United States (Rodríguez Chávez 2013); at the same time, mobile populations and circular and temporary migration are common.

The migrant route through Mexico toward the United States is considered one of the most dangerous in the world for undocumented migrants. Chiapas reports one of the highest rates of physical violence against migrants in Mexico (OIM/COLEF 2016), as well as rejection and discrimination against them (CIDH 2013), making migrants there particularly vulnerable to contracting HIV (Leyva-Flores et al. 2016) and/ or experiencing difficulties accessing available services (Ledón Pereyra et al. 2015). While some studies of social vulnerability to HIV among the migrant population in this border region have been undertaken (Infante et al. 2009; Bronfman et al. 2002), as well as some specific studies of sex work by migrant women (Fernández-Casanueva 2009) and the violation of their sexual rights (Infante et al. 2013), little is known about HIV vulnerability for migrant men who have sex with men (Conners et al. 2017) and, in particular, the impact of their undocumented status on their susceptibility to contraction (Goldenberg et al. 2012).

When the so-called 'war on drugs' was launched in Mexico in 2006 (ACAPS 2014), the drug trade underwent a process of national and international diversification and reconfiguration; both sides of the Mexico– Guatemala border experienced an increase in drug trafficking, with a reported increase in the use of cocaine, ecstasy, methamphetamines and alcohol (OPS 2009). This phenomenon is a reflection of a national trend in Mexico,4 where from 2008 to 2011 the number of those consuming methamphetamines, crack, cocaine and marijuana increased from 3.9 to 5.7 million people, and there was a rise in addiction rates from 450,000 to 550,000 people, according to the National Addiction Survey (Cacho Carranza 2015).

 'Crossing Borders'5 is the first study undertaken at the Mexico–Guatemala border that specifically focuses on migration, drug use and HIV exposure. The study is coordinated by researchers from the University of California, San Diego (UCSD), Mexico's Center for Research and Advanced Studies in Social Anthropology (CIESAS-Sureste) and the Universidad del Valle de Guatemala. This chapter forms part of that research, specifically focusing on the analysis of some of the sociocultural data collected from 2010 to 2013 and during fieldwork conducted in 2016.

### Geographic research context

There are three main routes for border crossing and migrant transit in southern Mexico: the route along the Pacific coast in Chiapas (Tecún Umán–Ciudad Hidalgo–Tapachula); one that borders the Gulf coast of Mexico (Tenosique, Tabasco); and one that crosses central Chiapas (La Mesilla, Comitán). The one most utilised by migrants is the Pacific coast route in Chiapas, since through it the train known as La Bestia (The Beast) is accessible. However, these routes have altered in recent years due to the pressure from immigration authorities and the violence of organised crime (Martínez et al. 2015).

Tecún Umán belongs to the municipality of Ayutla, Guatemala. Tecún Umán has 33,426 inhabitants and is located along the main Guatemala–Mexico border crossing (SEGEPLAN n.d.). According to official data, the municipality of Ayutla has a poverty rate of 37 per cent and an extreme poverty rate of 1.5 per cent (INE 2011).

With 300,000 inhabitants, Quetzaltenango is the second most populated city in Guatemala (CDUCIC 2016). It is located in the department of Quetzaltenango, and has an extreme poverty rate of 17.5 per cent (INE 2011). This city is a central crossing point along the migrant transit route to Tecún Umán/Ciudad Hidalgo or El Carmen (Guatemala)/ Talismán (Mexico); it is also the place of origin of many migrants crossing for temporary work in Chiapas or on their way to the United States (Anguiano Téllez 2008).

Tapachula is the most populated city of the southern Mexican border region, with one of the largest migrant populations living there temporarily or permanently, as well as a large mobile population in transit (Alfonzo Melgar 2008). Tapachula has a population of 351,165 and presents an intermediate level of socio-economic marginalisation, according to the municipal and national Marginalization Index6 (Gobierno del Estado de Chiapas 2017).

Ciudad Hidalgo neighbours Tecún Umán on the Mexican side of the border. It has 13,912 inhabitants and a high level of socio-economic marginalisation (Gobierno del Estado de Chiapas 2017).

#### Methodology

In-depth interviews were conducted with Salvadoran, Honduran and Guatemalan migrants (n = 28) and with professionals in the social, healthcare and migration sectors (n = 46)7 in the four cities on the main migrant routes on the Mexico–Guatemala border named above. In Tapachula,

participant observation was conducted in addition to secondary data analysis, contrasting and triangulating empirical data obtained through testimonies and direct observations with other sources of information. The qualitative analysis sought a typological and/or analytical generalisation of the results, exploring the articulations between sociocultural and political processes affecting the production of social representations (Abric 2001), the migrant or displaced subjects' practices regarding the use of condoms and HIV, and the social use and configuration of spaces where sex is performed in exchange for drugs and/or money.

The present study represents an analysis of 13 in-depth interviews with migrants or displaced men obtained between 2010 and 2013 in 'Crossing Borders' and 15 in-depth interviews conducted with migrants in 2016 during ethnographic fieldwork. In 2016, we also spent 20 days (6 hours per day) in two public parks in Tapachula known to be locations for the solicitation of sex work, so that we could talk to those engaged in such work and observe the sociocultural and spatial dynamics of these locations. Participants were between 18 and 45 years of age; 44 per cent were between 18 and 25 years old; 28 per cent were Guatemalans, 35 per cent Hondurans and 37 per cent Salvadorans. Our interviews focused on the type and frequency of drugs consumed; sexual practices during sex work; the use of condoms; social representations of HIV; and migratory and displacement trajectory, among other health determinants. For security reasons, we did not ask about or record answers regarding details of organised crime, such as people's names or the specific addresses of places where drugs are sold.

Eligibility criteria included: participant age 18 or older; willingness and ability to provide informed consent; consumption of an illegal substance in the two previous months or alcohol abuse; being an international (or internal, in Guatemalan cases) migrant from Central America en route to the United States and having lived in one of the study's cities for at least one month; having engaged in commercial sexual exchange under the influence of non-injected drugs in the previous three months. We conducted the interviews in safe spaces that ensured privacy for the interviewee and safety for other people involved. The participants were recruited by colleagues from local non-profit organisations at locations where they are solicited by clients for sex work.

One of the study's main methodological limitations was the high level of social vulnerability of participants, which affected access to the interviewees, especially on the Mexican side, since some participants mistook us for immigration officers. This situation has parallels in other studies conducted in this region, emphasising the need for a responsible local approach to human rights (Goldenberg et al. 2016). Two potential participants were contacted in the process of fleeing the Mexican city of Tapachula, since, as they narrated and as we inferred from their visible wounds, they had been attacked and their lives threatened. At the same time, field observation was formally and temporally limited by the security measures that the researchers were compelled to adopt (for example, conducting interviews only during the day, in public spaces, and trying not to be excessively visible). We tried to include non-mestizo participants but were only able to include one Afro-Honduran migrant, as during our fieldwork period most migrants were mestizos and non-mestizos refused to participate. The data this migrant provided was very relevant and in line with findings from other regional research studies.8

All interviews were conducted after obtaining participants' informed consent, with approval from the institutional review boards of the University of California, San Diego, the Instituto de Salud del Estado de Chiapas and the Universidad del Valle de Guatemala. Participants were assured of confidentiality and anonymity. Identifying personal data was not recorded: for every interview only code numbers were used as identifiers. Participants were treated with respect, avoiding situations or topics that could cause psychological pressure or pose a security risk, and emphasising that participation was completely voluntary. Those who required drug treatment, or who were victims of violence (extortion, discrimination, etc.) were referred to local available support programmes. Free condoms and health information were also provided by interviewers.

#### Reasons for migrating

All participants began using illicit substances in their country of origin and, at the time of the interview, used them more than three times a week. The most commonly used drugs were cocaine (71 per cent) and marijuana (64 per cent). Other drugs included crack (36 per cent) and methamphetamines (17 per cent);9 almost all participants combined the use of two or more substances. Alcohol was used more than three times a week by 82 per cent of the participants. Three participants had previously injected drugs, with two having injected only once. All injectors had had their first experience of intravenous use in the United States. Using and sharing crack pipes was also common in *puntos*, the spaces where drugs are purchased and consumed in a group.10 The interviewees who had crossed or lived at the border several times over the previous five years or more, as well as the experts interviewed, perceived that drug availability (mainly cocaine, crack, methamphetamines and marijuana) had increased during that period.

Reasons that led participants to migrate to the United States were similar to those of non-drug-using migrants. These included a context of scant economic opportunity and, for most, violence associated with organised crime experienced in their cities of origin. The latter was especially the case with youths (18 to 25 years of age), some of whom had applied for asylum in Tapachula on the basis of forced displacement.

We found that certain specific reported motives, as recounted by participants, were linked to structural and family violence, and correlated to problems in their neighbourhoods that had led them to drug consumption; such systems of violence were replicated, at the individual and collective levels, through marginalisation and the mechanisms of recruitment by organised crime, among others.

I came from El Salvador fleeing gangs, because death squads were about to start arriving […] So what they [gangs] most need are people to be able to fight the police. When you get involved in that, they recruit you and they make you sell drugs, they make you keep guard to make sure the police don't come, or they send you somewhere else to kill the rival gang.  That's what I was running away from […] no one has the right to take another person's life.

(Salvadoran, 18 years old)

I started [using drugs]; my dad used to beat me a lot and I was eight, seven years old. They would send me to do long errands and when I was about 12, 11 years old, I had many friends on the street and I started using drugs, marijuana and crack, in Honduras […] Here in Tapachula it's beautiful because you don't see too many armed people and as much violence as in San Pedro Sula.

(Honduran, 27 years old)

Under these circumstances, migration was perceived by many participants as an opportunity to stop using drugs and escape the problems stemming from the violence experienced in their countries of origin.

[I arrived] destroyed by drugs, I came here looking for help because I had many problems, I was involved in many things there […] I see that it's calmer here [Ciudad Hidalgo, Mexico] in terms of violence […] It's hard moving ahead. I would like to change my life completely and I see more opportunities here.

(Guatemalan, 32 years old)

Stigma and discrimination and the border as a temporary residence

There are four main transversal factors that cause participants to experience stigma and discrimination from the local border population, which associates them with criminal activity such as theft: a) having scarce economic resources and, in the case of Mexico, being undocumented; b) being an Honduran, Salvadoran or, in the case of Mexico, also Guatemalan migrant; c) using illicit drugs; d) being young and male.

According to our participants, the local population perceives that they are migrants from the Central American northern triangle because of their accents, appearance and attire – such as carrying a backpack – or practices such as begging. Skin colour, in the case of migrants of African descent, is a characteristic of 'otherness' in Mexico. Daily discrimination prevents their insertion in the formal job market because of their undocumented status or hinders their access to informal work or sources of income, such as begging.

They pay you a pittance as a migrant […] as soon as they look at you; in my case because of my colour, people who look at me know that I'm not Mexican. And others might be the same colour as they are, but [are identified as migrants] from the way they speak; we'll never get rid of our way of speaking.

(Honduran, 24 years old)

I was talking to them [government employees] about vulnerabilities and they said, 'Yes, we agree with these workshops, to be informed on how to orient migrants, but we're afraid because migrants are now sure of themselves, they think they have the authority to shout at us, to threaten us, everyone gives them priority, everyone believes that they are victims … but migrants murder, migrants steal.' I have heard this discourse everywhere.

(Director of Doctors of the World, Tapachula)

Exclusion is exacerbated for those who are recognised as drug users by the local population. According to participants, substance users are recognisable through their dirty clothes and a haggard, unshaven appearance: 'Because of our looks, people don't support us to work, because we look haggard, some of us thin, others dirty, unshaved' (Guatemalan, 32 years old); '[…] like thieves. Because that type of drug [crack and cocaine] makes you too addicted; the more you have, the more you want, so some people start stealing' (Guatemalan, 30 years old).

Age, in turn, plays an important role in the case of young migrants, since, according to their own perception, they are mistaken for *maras* (gang members) and excluded from jobs because they are suspected to be thieves.

Interviewees stated that two of the main reasons for their temporary residence in the cities at the border were migrants' perception of a high risk of physical harm and/or being deported during their journey through Mexico. An additional reason was access to informal work related to the flow of merchandise, mainly across the river at the border, in addition to activities such as sex work, car washing, street sweeping or rubbish collection, in a context characterised by exclusion from the formal job market. Migrants conceive of the border as a temporary residence while they obtain the money necessary for continuing their journey to the United States, money necessary for minimising the risk of aggression by paying protection money to criminal groups during their travel.

They're killing us up in the north […] In Reynosa, next to Laredo, things are uglier […] When I go north, I go through because I pay them [organised crime] \$300 to let me through, because if I don't, they kill me.

 Informal sex work consists of receiving goods such as food, lodging, money or drugs in exchange for sexual services of an occasional nature, in cases where another professional activity is the main source of income. Formal sex work consists of providing sexual services that are structured in location and time, within an economic framework of sex exchanged for money, with a frequency that results in a social 'professional profile', a designated location for the activity and, in the present case, the use of drugs during sex work as an end or a requirement for its performance.

While the analytical difference between formal and informal sex work is clear, the distinction is fuzzier in practice. The only empirical indicator observed that delimits one mode from the other is whether sex work is organised in groups and/or whether sex workers have to pay a pimp for working at a given location. From this standpoint, formal sex work is only performed by young participants, during their stopover on the way to the United States, in spaces such as the public park in the city of Tapachula.

There are two types of documented spaces where sex is exchanged for money or drugs. First, there are spaces for individual or collective consumption where drugs are not sold. Second, there are places where drugs are distributed and commercial sexual exchange takes place around that activity, mainly among consumers and, in some cases, with the seller.

In the first case, the spaces described are *pasos*, hostel rooms, repurposed rooms in abandoned buildings, public spaces away from roads (for example, temporary constructions among the shrubbery in dry rivers or ravines), public bathrooms and, in the cases of Tapachula and Ciudad Hidalgo, other public spaces where drugs are consumed and where the consumers are regularly or sporadically approached by people offering money in exchange for sex. Most of the time, the participants have not been previously contacted, since they do not have mobile phones or internet access.12 In the case of Tapachula, since formal commercial sexual exchange takes place at a public park, drug consumption is held in check as a form of collective protection and to keep discrimination and police harassment from hindering sex work. Informal encounters are relegated to other parts of the city, since those that take place in the park are regulated by organised groups that control the territory.

The second case is the so-called *puntos* and some discotheques defined by the interviewees as 'sexual diversity' nightclubs. The types of drug consumed at these locations depend on the place and its characteristics.

Consuming cocaine is good because you can do it anywhere, even in the restrooms, because it doesn't smell or require much [preparation] to be consumed […] Crack, on the other hand, is definitely consumed at home or they go to some abandoned house to consume it, because it smells, like marijuana also smells.

(Guatemalan, 28 years old)

Some spaces delimit a certain type of sexual practice for commercial exchange. Such is the case with Tapachula's public park, where the supply of sex is exclusively for local receptive men.13 Thus, the structure of formal sex work and its territorial and economic organisation also define supply and demand.

Most of the participants in this study, who perform formal or informal sex work, identify as heterosexual. Most of those who occasionally offered informal sexual services in order to obtain drugs mentioned that they did so only with women, and some participants (20 per cent) also with men. Others suggested the latter possibility without overtly stating it.  In all spaces documented, except for the park in Tapachula, informal sexual exchange takes place with either men or women.

Because of the need to get another dose […] I have to resort to those situations when a man offers you money for sex. I know […] that way I'll keep consuming, because there's no other option.

(Guatemalan, 32 years old)

Spaces for sale, consumption and sexual exchange: *Puntos* and *pasos*

*Puntos* and *pasos* merit analysis because of their characteristics as public/ private sectors of the city and their use by the study's subjects, as well as being the most representative spaces for sexual exchange and collective and clandestine drug consumption.

*Puntos* are spaces in the cities studied in Guatemala and in Ciudad Hidalgo (Mexico). In Tapachula, there are no such spaces. They are located on the outskirts or in under-developed locations (near rivers, for example) where drugs and alcohol are sold. They operate as informal bars with a guard at the entrance. Sugarcane alcohol and other drugs are usually sold in a separate section of the same space. Consumption on site is allowed and is, in fact, the main activity; the most common substances are crack, methamphetamines (in inhaled form) and marijuana. The interviewees mention that they consume alcohol to mitigate the effects of crack (called *paniqueo*, panicking).

[*Puntos*] proliferate quickly or are welcomed by consumers because they no longer have to hide themselves; they arrive at the place and there they can buy alcohol, which serves as a tranquilliser for the drugs, and there they have it, so obviously they are very welcome to the drug-consuming clientele.

(Guatemalan, 45 years old)

At some of these places, spaces for sexual exchange among men and women are improvised, for example, by hanging a bedsheet from the ceiling and walls. Sexual exchange (mainly among MSM) also takes place outside the *punto* where, according to all participants, condoms are not used.  'In one of those places there was a girl who had a partner, and when she would go in [to the *punto*] to get drugs and didn't get any for him, he would beat her badly' (Guatemalan, 30 years old).

*Pasos* are closed spaces similar to *puntos* but, in addition to being more improvised, these are places exclusively for drug consumption and not for sale. Another difference is that, in addition to consumption, people share other types of activities related to the space. *Pasos* are related to the spaces where *camareo* takes place (the transport of merchandise and informal trade across the border along the river). They are only present in Tecún Umán and Ciudad Hidalgo. Consumption takes place during the daytime; at night *pasos* are used as informal lodgings for those who have nowhere to sleep. One *paso* in Tecún Umán, located near a formal migrant shelter with a three-day maximum stay, is used as a refuge by the migrants who have reached this limit for staying at the shelter.

There people cook, people live. We call it a *paso* [passage]. There we pass the time, there many helpers who work on the rubber inner tubes [used to carry people and goods across the border] get together. There they smoke and drink. Most of us do drugs. We always have to hide from other people, we can't do it publicly. There is the *paso* of the Coyote, of the Cruz Blanca, the Rojos …

(Salvadoran, 44 years old)

The absence of police resistance to drug use in these spaces is one of the reasons for going there: 'In other words, it's because of the lack of pressure that we go there. You are free to smoke because there's no fear of the authorities' (Salvadoran, 44 years old).

 *Pasos* are also spaces to re-create labour networks: participants sometimes engage in remunerated informal activities, especially transporting merchandise across the river.

### Desire, body technologies, risk perception and condom use

Evidence obtained from fieldwork allows us to identify five correlated variables that affect condom use during the sex work carried out by participants: formal or informal sex work; the client's gender and sexual orientation; the need for money and/or drugs; the type and amount of drugs used; and space as a condition for the availability of condoms.

When we asked participants about modes of HIV transmission, they were aware of the risks involved, according to a biomedical explanatory model, in engaging in unprotected sex as well as using shared syringes.   None of the participants in the study carry condoms during sex work and they all report using them very sporadically. They acquire condoms in hotels, through a friend or client, or buy them in pharmacies.

Our data indicated more frequent condom use in formal as compared to informal sex work. In both cases, the client's gender and sexual orientation determined the perception of risk of contracting HIV. In this regard, the participants who use condoms reported a more frequent use with men than with women, since they relate 'promiscuity' and a greater risk of infection to MSM:

It's more dangerous, dirtier, and you can get it [HIV], they do it with anyone. A prostitute does it maybe to feed her child, to earn a living, she knows who to do it with, she kind of chooses. With gays it's different. If they see a guy, they don't care, they don't ask what he has. (Salvadoran, 22 years old)

Drug use during sexual exchange functions as a means and/or end for obtaining both drugs and money in the practices documented. In both cases, commercial sexual exchange takes place under the influence of drugs and is performed to obtain more drugs, to obtain money to buy drugs or to obtain money for a different purpose. While for some of the participants obtaining drugs is an end in itself, others reported not wanting to begin or continue consuming certain substances such as cocaine or alcohol, and considered its use a compulsory job requirement. This was the case with formal sex work performed to obtain money for continuing the journey to the United States with reduced risk of violence from organised crime (by paying protection money). Thus, sex work as a source of money for buying drugs was less frequent in interviewees aged 18 to 25 years. For this group, the main reason mentioned was to save money for the journey, purchase food or pay for lodging. However, it is necessary to analyse this data with a larger population sample to determine whether access to drugs during sex work, the structure of sex work and/or migration plans, among others, are intervening variables.

Drug use during sex work is an instrument, as well as an end, that creates unequal negotiating conditions and becomes a source of tension between the client and the sex worker. All interviewees mentioned that once they are under the influence of drugs, they commonly forget to use a condom. Some of them recount that their clients, whether drug users or not, try to force them not to use a condom, urge them to use drugs or offer them more money for unprotected sex. The interviewees who reported using condoms frequently recounted that they were able to assert more control over the encounters by refraining from using drugs or controlling the amount and type of drug consumed during the sexual encounter:

Some people tell you what you have to consume, and if you don't they get mad […] but I prefer not to. You tell them, "that's enough or I'll leave" […] Some invite you to snort cocaine […] sometimes I agree; as long as it's not too much I feel that it relaxes me.

(Honduran, 24 years old)

Although for some participants frequent or occasional consumption of some drugs acts as a sexual stimulant, several participants reported that one of the consequences of drug addiction, especially in the case of crack and cocaine,14 is a negative impact on virility. On the one hand, drug use is associated with what some participants call 'loss of manliness', since 'men end up having sex with other men'; on the other, they relate it to reduced vigour, by diminishing erection and sexual drive. These testimonies reveal a connection between condom use – and concern about it – and sexual desire, regardless of whether the encounter is insertive or not, and a decreased use when the sexual encounter is unrelated to desire.

With the exception of hotels, in none of the spaces analysed do participants describe having access to condoms. No condoms are available at either *puntos* or *pasos*, and none of the people who go there carry condoms with them. Furthermore, these spaces are far from urban zones and pharmacies where condoms can be acquired. In this regard, they operate as self-contained, clandestine universes, separated from public spaces by stigma and discrimination against drug use and, in the case of *puntos*, the illegal nature of drug sales, in which the ease of practising sex work is among the main currencies in the dynamics of drug purchase and/or consumption.

### The political production of inconsistent condom use and HIV exposure

The predominant approach by researchers and decision makers regarding drug use and HIV tends to focus on HIV prevention in the population that injects drugs, thus overshadowing attention from other modes of drug use. As a number of studies demonstrate, high-risk sexual behaviours associated with non-injected drug use can be an important contributing factor for HIV infection (Strathdee and Stockman 2010). The socio-economic, political and cultural conditions that affect HIV exposure at the Mexico–Guatemala border through high-risk sexual practices and under the influence of drugs, though specific to this context, exhibit characteristics that can be found in other settings that have not yet been studied. This is the first research study focusing on the Mexico– Guatemala border from this perspective, and one of the few that examines this problem in both countries as it is experienced by undocumented migrant men who perform sex work. It also contributes to the scant literature on HIV exposure and the effects of stigma towards drug users in Mexico (for example, in Tijuana, CONAPRED 2010) and Guatemala. Finally, it expands on studies that document the production of spaces of social vulnerability in places of drug consumption and/or sale and commercial sexual exchange in border regions of Central America and in the United States at large (Dickson-Gomez et al. 2012).