Infant rates of child protective services contact and termination of parental rights by first nations status from 1998 to 2019: An example of intergenerational transmission of colonial harm.

BACKGROUND: Rates of child removal by child protective services (CPS) in Manitoba are the highest in Canada with a profoundly disproportionate impact on First Nations families. Despite infants constituting the highest proportion of children affected, no research has examined population-level rates of infant contact with CPS. OBJECTIVE: We examined the incidence of infant contact with different levels of CPS, including termination of parental rights (TPR), according to First Nations status. PARTICIPANTS: We identified 217,261 infants (47,416 First Nations; 169,845 non-First Nations) born between 1998 and 2014 in Manitoba, Canada and residing in the province until at least age 5. METHODS: We used linked administrative data to calculate population-level rates of contact with different levels of CPS by First Nations status, including an open file before age 1, out-of-home placement before age 1, and TPR before age 5. RESULTS: Overall 35.8 % of First Nations infants had an open file, 8.5 % experienced out-of-home placement, and 5.4 % experienced TPR. Among other infants, 8.5 % had an open file, 1.3 % experienced out-of-home placement and 0.7 % experienced TPR. The rate of early-stage contact increased the fastest among First Nations infants, with a rise of 22.4 % in our study period, compared to a rise of 1.7 % among all other infants. CONCLUSIONS: CPS contact was exceptionally high among First Nations infants compared to other infants, with early-stage contact accelerating most dramatically over time. Findings support calls to greatly reduce the disruption of system contact in the lives of First Nations families.

"Everybody is impacted. Everybody's hurting": Grief, loss and the emotional impacts of overdose on harm reduction workers.

BACKGROUND: The emotional impacts of witnessing and responding to overdose and overdose-related deaths have been largely overlooked during the drug toxicity overdose crisis in North America. Scarce research has analyzed these impacts on the health and well-being of harm reduction workers, and the broader determinants of harm reduction work. Our study investigates the experiences and impacts of witnessing and responding to frequent and escalating rates of overdose on harm reduction workers in Toronto, Canada. METHODS: Using semi-structured interviews, 11 harm reduction workers recruited from harm reduction programs with supervised consumption services in Toronto, Canada, explored experiences with and reactions to overdose in both their professional and personal lives. They also provided insights on supports necessary to help people cope with overdose-related loss. We used thematic analysis to develop an initial coding framework, subsequent iterations of codes and emergent themes. RESULTS: Results revealed that harm reductions workers experienced physical, emotional, and social effects from overdose-related loss and grief. While some effects were due to the toll of overdose response and grief from overdose-related losses, they were exacerbated by the lack of political response to the scale of the drug toxicity overdose crisis and the broader socio-economic-political environment of chronic underfunding for harm reduction services. Harm reduction workers described the lack of appropriate workplace supports for trauma from repeated overdose response and overdose-related loss, alongside non-standard work arrangements that resulted in a lack of adequate compensation or access to benefits. CONCLUSIONS: Our study highlights opportunities for organizational practices that better support harm reduction workers, including formal emotional supports and community-based supportive care services. Improvement to the socio-economic-political determinants of work such as adequate compensation and access to full benefit packages are also needed in the harm reduction sector for all workers.

Identifying newborn discharge to child protective services: Comparing discharge codes from birth hospitalization records and child protection case files.

PURPOSE: Newborn removal by North America's child protective services (CPS) disproportionately impacts Indigenous and Black families, yet its implications for population health inequities are not well understood. To guide this as a domain for future research, we measured validity of birth hospitalization discharge codes categorizing newborns discharged to CPS. METHODS: Using data from 309,260 births in Manitoba, Canada, we compared data on newborns discharged to CPS from hospital discharge codes with the presumed gold standard of custody status from CPS case reports in overall population and separately by First Nations status (categorization used in Canada for Indigenous peoples who are members of a First Nation). RESULTS: Of 309,260 newborns, 4562 (1.48%) were in CPS custody at hospital discharge according to CPS case reports and 2678 (0.87%) were coded by hospitals as discharged to CPS. Sensitivity of discharge codes was low (47.8%), however codes were highly specific (99.8%) with a positive predictive value (PPV) of 81.4%, and a negative predictive value (NPV) of 99.2%. Sensitivity, PPV and specificity were equal for all newborns but NPV was lower for First Nations newborns. CONCLUSIONS: Canadian hospital discharge records underestimate newborn discharge to CPS, with no difference in misclassication based on First Nations status.

Medical Professional Reports and Child Welfare System Infant Investigations: An Analysis of National Child Abuse and Neglect Data System Data.

Background: Medical professionals are key components of child maltreatment surveillance. Updated estimates of reporting rates by medical professionals are needed. Methods: We use the National Child Abuse and Neglect Data System (2000-2019) to estimate rates of child welfare investigations of infants stemming from medical professional reporting to child welfare agencies. We adjust for missing data and join records to population data to compute race/ethnicity-specific rates of infant exposure to child welfare investigations at the state-year level, including sub-analyses related to pregnant/parenting people's substance use. Results: Between 2010 and 2019, child welfare investigated 2.8 million infants; ∼26% (n=731,705) stemmed from medical professionals' reports. Population-adjusted rates of these investigations stemming doubled between 2010 and 2019 (13.1-27.1 per 1000 infants). Rates of investigations stemming from medical professionals' reports increased faster than did rates for other mandated reporters, such as teachers and police, whose reporting remained relatively stable. In 2019, child welfare investigated ∼1 in 18 Black (5.4%), 1 in 31 Indigenous (3.2%), and 1 in 41 White infants (2.5%) following medical professionals' reports. Relative increases were similar across racial groups, but absolute increases differed, with 1.3% more of White, 1.7% of Indigenous, and 3.1% of Black infants investigated in 2019 than 2010. Investigations related to substance use comprised ∼35% of these investigations; in some states, this was almost 80%. Discussion: Rates of child welfare investigations of infants stemming from medical professional reports have increased dramatically over the past decade with persistent and notable racial inequities in these investigations.

'I don't chase drugs as much anymore, and I'm not dead': Client reported outcomes associated with safer opioid supply programs in Ontario, Canada.

INTRODUCTION: The ongoing opioid overdose crisis, which has killed over 30,000 people in Canada since 2016, is driven by the volatility of an unregulated opioid drug supply comprised primarily of fentanyl. The Canadian government has recently funded safer opioid supply (SOS) programs, which include off-label prescriptions of pharmaceutical-grade opioids to high risk individuals with the goal of reducing overdose deaths. METHODS: In 2021, we examined the implementation and adaption of four SOS programs in Ontario. These programs use a primary care model and serve communities experiencing marginalisation. We conducted semi-structured interviews with program clients. We present the results of a thematic analysis with the aim of describing clients' self-reported impact of these programs on their health and well-being. RESULTS: We interviewed 52 clients between June and October 2021 (mean age 47 years, 56% men, 17% self-identified Indigenous, 14% living with HIV). Our results indicate multifaceted pathways to improved self-reported health and well-being among clients including changes to drug use practices, fewer overdoses, reduced criminalised activity, improved trust and engagement in health care, and increased social stability (e.g., housing). DISCUSSION AND CONCLUSION: Most clients reported that the intervention saved their life because of the reduced frequency of overdoses. Findings suggest that SOS programs improved clients' health outcomes and increase opportunities for engagement in health services. Our results provide insight into the mechanisms behind some of the emergent evidence on the impact of safer supply prescribing.

Association of Illicit Fentanyl Use with Injection Risk Practices Among People who Inject Drugs.

We investigated the association between fentanyl injection frequency and sharing of injection equipment among people who inject drugs. We surveyed 249 people who inject drugs in Toronto in 2019. We estimated predicted probabilities of associations between fentanyl injection frequency and injection risk practices. In prior 6 months, 117 (47.0%) of participants injected fentanyl daily, 49 (19.7%) less than daily, and 78 (31.3%) did not inject fentanyl. Participants who injected fentanyl daily shared syringes more often than those not injecting fentanyl (25.0% vs. 4.9%; χ2 = 11.54, p = 0.0007). Participants who injected fentanyl daily (42.4% vs. 11.3%; χ2 = 18.05, p < 0.0001) and less than daily (37.2% vs. 11.3%; χ2 = 5.88 p = 0.02) shared cookers more often than those not injecting fentanyl. Participants who injected fentanyl daily (30.2% vs. 9.7%; χ2 = 9.05, p = 0.003) and less than daily (30.3% vs. 9.7%; χ2 = 4.11, p = 0.04) shared filters more often than those not injecting fentanyl. No differences in probabilities of sharing equipment were detected between participants who injected fentanyl daily and less than daily. People using fentanyl reported injection practices that increased risk for infectious disease transmission.

Frequency of fatal and non-fatal overdoses and response to grief and loss among people who inject drugs: An unexplored dimension of the opioid overdose crisis.

BACKGROUND: We investigated the relationship between overdose events and grief and loss responses among people who inject drugs. METHODS: We conducted a cross-sectional, tablet-based survey with a convenience sample of people who inject drugs (n = 249) from four community-based harm reduction programs in Toronto in 2019. We examined the association between frequency and types of overdose events (own, witnessed, death of significant person) in the last 6 months with grief and loss responses, identified using latent class analysis. RESULTS: Among respondents, 70 (48.6 %) reported 2 or more personal overdoses, 173 (79.5 %) witnessed 2 or more overdoses, and 69 (41.4 %) experienced overdose deaths of 2 or more significant persons in the last 6 months. We identified 2 latent classes with probability of membership of 38.6 % (95 % confidence interval [CI]=31.0, 46.7) for medium/low intensity of responses to grief/loss and 61.4 % (95 % CI= 53.3, 69.0) for severe responses to grief/loss. In adjusted Poisson regression models with robust standard error estimators, severe responses to grief/loss were associated with exposure to two or more own overdoses (prevalence ratio [PR] = 1.44; 95 % CI=1.12, 1.84, p-value=0.004), and having witnessed one (PR=2.09; 95 % CI=1.05, 4.15, p-value=0.04) or witnessed two or more overdoses (PR=2.25; 95 % CI=1.24, 4.09, p-value=0.008). Severe grief/loss responses were also more common in individuals exposed to all three types of overdose events (PR=2.42; 95 % CI=1.08, 5.41, p-value=0.03). CONCLUSIONS: Cumulative overdose events were associated with severe responses to grief and loss. Bereavement interventions should consider the complex nature of grief and loss following overdoses.

Health consequences of child removal among Indigenous and non-Indigenous sex workers: Examining trajectories, mechanisms and resiliencies.

The child protection system can be a highly consequential institution for mothers who are sex workers, yet scant attention has been paid to the health consequences of its policies on this population. Drawing on 31 in-depth, semi-structured interviews with 19 Indigenous and 12 non-Indigenous sex workers in Vancouver, Canada, and using the stress process model and the concept of slow violence, this study proposes a typology of four trajectories through which child removal by this system shaped sex workers' health. Results suggest that child removal has health consequences beyond the conventionally thought of mechanism of mental distress and related health sequelae, to additionally alter women's social conditions, which also carried risks for health. Notably, while trajectories of Indigenous and non-Indigenous sex workers were similar, Indigenous participants, whose families are disproportionately impacted by long-standing colonial policies of child removal, were more severely jeopardized. Findings highlight how child removal can enact violence in the form of reverberating harms to sex workers' health, further reinforcing their marginalized statuses. This study calls for greater attention to how the child protection system (CPS) may influence the health of marginalized mothers, including how health inequities may be both causes and consequences of interventions by this system.

Do socioeconomic and birth order gradients in child maltreatment differ by immigrant status?

BACKGROUND: While literature has documented strong gradients in child maltreatment (CM) by socioeconomic status and family composition in the general population, how these patterns extend to immigrants remain inconclusive. Using population-based administrative data, we examined, for the first time, whether gradients in CM by neighbourhood income and childbirth order vary by immigrant status. METHODS: We used linked hospitalisation, emergency department visits, small-area income, birth and death records with an official Canadian immigration database to create a retrospective cohort of all 1 240 874 children born from 2002 to 2012 in Ontario, Canada, followed from 0 to 5 years. We estimated rate ratios of CM among immigrants and non-immigrants using modified Poisson regression. RESULTS: CM rates were 1.6 per 100 children among non-immigrants and 1.0 among immigrants. CM was positively associated with neighbourhood deprivation. The adjusted rate ratio (ARR) of CM in the lowest neighbourhood income quintile versus the highest quintile was 1.57 (95% CI 1.49 to 1.66) for non-immigrants and 1.33 (95% CI 1.15 to 1.54) for immigrants. The socioeconomic gradient disappeared when restricted to children of immigrant mothers arrived at 25+ years and in analyses excluding emergency department visits. Compared to a first child, the ARR of CM for a fourth or higher-order child was 1.75 (95% CI 1.63 to 1.89) among non-immigrants and 0.57 (95% CI 0.44 to 0.74) among immigrants. CONCLUSIONS: Immigrants exhibited lower CM rates than non-immigrants across neighbourhood income quintiles and differences were greatest in more deprived neighbourhoods. The contrasting birth order gradients between immigrants and non-immigrants require further investigation.

Factors associated with cyber-victimization among immigrants and non-immigrants in Canada: a cross-sectional nationally-representative study.

OBJECTIVES: There is a paucity of research on patterns of cyber-victimization in minority groups, including immigrants. This study aimed to identify individual, interpersonal and contextual characteristics associated with cyber-victimization among immigrants and non-immigrants. METHODS: We drew on nationally representative data from adolescents and adults in the Canadian General Social Survey on victimization (2014). We used multivariable logistic regression to identify potential factors associated with cyber-victimization in the last 12 months, stratified by immigrant status and sex. RESULTS: Among 27,425 survey respondents, the weighted prevalence of cyber-victimization in the last 12 months was 2.1% among immigrants and 2.3% among non-immigrants. Cyber-victimization rates differed significantly by sex among immigrants (2.8% for males vs. 1.4% for females), but not among non-immigrants (2.1% for males vs. 2.4% for females). While most other factors associated with cyber-victimization were similar for immigrants and non-immigrants, there were pronounced associations of past child maltreatment (adjusted prevalence odds ratio [aPOR] 4.85, 95% confidence interval [CI] 2.76, 8.52) and residence in an unwelcoming neighbourhood (aPOR 5.08, 95% CI 2.44, 10.55) with cyber-victimization among immigrants that were diminished or absent among non-immigrants. Additionally, sex-stratified analyses among immigrants showed cyber-victimization to be strongly associated with having a mental health condition (aPOR 3.50, 95% CI 1.36, 8.97) among immigrant males only, and with perceived discrimination (aPOR 4.08, 95% CI 1.65, 10.08), as well as being under 24 years old (aPOR 3.24, 95% CI 1.09, 9.60) among immigrant females. CONCLUSIONS: Immigration status and sex were differentially associated with cyber-victimization. Findings support the salience of a social-ecological perspective and gender-stratified analyses to better elucidate complex pathways linking cyber-victimization to potential gender-based health inequities among immigrants.

Help me fix: The provision of injection assistance at an unsanctioned overdose prevention site in Toronto, Canada.

BACKGROUND: There is an acute public health crisis from opioid-related poisoning and overdose in Canada. The Moss Park Overdose Prevention Site (MP-OPS) - an unsanctioned overdose prevention site - opened in a downtown park in Toronto in August 2017, when no other supervised consumption services existed in the province. As an unsanctioned site, MP-OPS was not constrained by federal rules prohibiting assisted injection, and provided a unique opportunity to examine assisted injection within a supervised setting. Our objective was to examine the association between assisted injection and overdose, and whether any association between assisted injection and overdose differs according to gender. METHODS: Drawing on data from 5657 visits to MP-OPS from October 2017 to March 2018, we used multivariable logistic regression to investigate the relationship between assisted injection and overdose. To examine the influence of gender on this relationship, we further conducted stratified analyses by gender. RESULTS: Among 5657 visits to MP-OPS, 471 (8.3%) received assisted injection, of which 242 (51.4%) were received by women and 226 (48.0%) by men. Using multivariable logistic regression, assisted injection was not associated with overdose in the overall sample (adjusted odds ratio [aOR]1.58, 95% confidence interval [CI]: 0.94, 2.67). In gender-stratified models, women receiving assisted injection were more than twice as likely (aOR 2.23, 95% CI: 1.17, 4.27) to experience overdose than women who did not receive assisted injection, and no association between assisted injection and overdose was found among men. CONCLUSION: Findings that women receiving assisted injecting are at higher odds of overdose within the supervised setting of the MP-OPS are consistent with previous literature on assisted injection in community settings. Rules banning assisted injection in supervised consumption services may be putting a group of people, particularly women and those injecting fentanyl, at higher risk of health harms by denying them access to a supervised space where prompt overdose response is available.

Family Separation and Maternal Self-rated Health: Evidence from a Prospective Cohort of Marginalized Mothers in a Canadian Setting.

OBJECTIVES: Involuntary child removal via the child protection system disproportionately affects marginalized women, yet the impacts on maternal health are under-investigated. This study prospectively examined the association of child removal with self-rated health of mothers who are sex workers. Given high levels of intergenerational family separation in this population, particularly among Indigenous sex workers, we also estimated joint effects of child removal spanning two generations. METHODS: Analyses drew on 2010-2015 data from AESHA (An Evaluation of Sex Workers' Health Access), a prospective cohort of sex workers (n = 950) in Vancouver, Canada. Using logistic regression with generalized estimating equations, we modeled the association of past child removal and current self-rated health in a sample of 466 sex workers who ever had a live birth. Joint effects of child removal and history of removal from own parents were also investigated. RESULTS: Of 466 sex workers, 180 (38.6%) reported child removal at baseline and 147 (31.6%) had a history of removal from own parents. In main effects model, child removal was associated with increased odds of poorer self-rated health [odds ratio (OR) 1.50, 95% confidence interval (CI) 1.04, 2.16]. Joint effects model showed higher odds of poorer self-rated health (OR 2.04, 95% CI 1.27, 3.27) among women with intergenerational family separation. CONCLUSION FOR PRACTICE: Child removal was negatively associated with sex workers' health that was worsened when family separation spanned two generations. Findings underscore need to develop sex worker and Indigenous-led family support services, along with tailored interventions to address health needs of those separated from their children.

Prenatal care among mothers involved with child protection services in Manitoba: a retrospective cohort study.

BACKGROUND: Prenatal care is one of the most widely used preventive health services; however, use varies substantially. Our objective was to examine prenatal care among women with a history of having a child placed in out-of-home care, and whether their care differed from care among women who did not. METHODS: We used linkable administrative data to create a population-based cohort of women whose first 2 children were born in Manitoba, Canada, between Apr. 1, 1998, and Mar. 1, 2015. We measured the level of prenatal care using the Revised Graduated Prenatal Care Utilization Index, which categorizes care into 5 groups: intensive, adequate, intermediate, inadequate and no care. We compared level of prenatal care for women whose first child was placed in care with level of prenatal care for women who had no contact with care services, using 2 multinomial logistic regression models to calculate odds ratios (ORs). RESULTS: In a cohort of 52 438 mothers, 1284 (2.4%) had their first child placed in out-of-home care before conception of their second child. Mothers whose first child was placed in care had much higher rates of inadequate prenatal care during the pregnancy with their second child than mothers whose first child was not placed in care (33.0% v. 13.4%). The odds of having inadequate rather than adequate prenatal care were more than 4 times higher (OR 4.29, 95% CI 3.68 to 5.01) for women who had their first child placed in care than for women who did not have their first child placed in care. INTERPRETATION: Mothers with a history of having a child taken into care by the child protection services system are at higher risk of having inadequate or no prenatal care in a subsequent pregnancy compared with mothers with no history of involvement with child protection services.

Factors associated with sexually transmissible infection testing practices among men who have sex with men in Jamaica: results from a cross-sectional, tablet-based survey.

Background Men who have sex with men (MSM) are at elevated risk for sexually transmissible infection (STI) acquisition globally. Yet, limited research has explored STI testing practices among MSM in contexts where same-sex practices are criminalised, such as in Jamaica. METHODS: A cross-sectional, tablet-based survey with MSM in Kingston, Ocho Rios and Montego Bay, Jamaica, was conducted. Multivariable logistic regression analyses were conducted to determine the adjusted risk ratio for lifetime STI testing and lifetime STI diagnosis. Multinomial logistic regression analyses were conducted to determine the relative odds of having had an STI test 3-5 months ago and 6-12 months ago in comparison with <3 months ago. RESULTS: Three-quarters (74.8%) of the 556 participants reported receiving an STI test (44% <3 months ago; 32% 3-5 months ago; 13% 6-12 months ago; 10% >12 months ago); 12.1% reported ever receiving an STI diagnosis. In adjusted multivariable analyses, STI testing was associated with sociodemographic (education, location), individual (depression, perceived risk), social (relationship status, sexual stigma) and structural (healthcare provider access) factors. In multinomial analysis, reporting a less recent STI test (>3 months ago) versus <3 months ago was associated with increased likelihood of sexual stigma and food insecurity. Lifetime STI diagnosis was associated with sociodemographic (location), individual (HIV infection) and social (lower social support) factors. CONCLUSIONS: Findings document associations between structural factors and delayed timing of STI testing. Further research is necessary to explore how to address social ecological factors in sexual health interventions with MSM in Jamaica.

Social-ecological factors associated with selling sex among men who have sex with men in Jamaica: results from a cross-sectional tablet-based survey.

BACKGROUND: Globally, men who have sex with men (MSM) experience social marginalization and criminalization that increase HIV vulnerability by constraining access to HIV prevention and care. People who sell sex also experience criminalization, rights violations, and violence, which elevate HIV exposure. MSM who sell sex may experience intersectional stigma and intensified social marginalization, yet have largely been overlooked in epidemiological and social HIV research. In Jamaica, where same sex practices and sex work are criminalized, scant research has investigated sex selling among MSM, including associations with HIV vulnerability. OBJECTIVE: We aimed to examine social ecological factors associated with selling sex among MSM in Jamaica, including exchanging sex for money, shelter, food, transportation, or drugs/alcohol (past 12 months). METHODS: We conducted a cross-sectional survey with a peer-driven sample of MSM in Kingston, Ocho Rios, and Montego Bay. Multivariable logistic regression analyses were conducted to estimate intrapersonal/individual, interpersonal/social, and structural factors associated with selling sex. RESULTS: Among 556 MSM, one-third (n = 182; 32.7%) reported selling sex. In the final multivariable model, correlates of selling sex included: individual/intrapersonal (lower safer sex self-efficacy [AOR: 0.85, 95% CI: 0.77, 0.94]), interpersonal/social (concurrent partnerships [AOR: 5.52, 95% CI: 1.56, 19.53], a higher need for social support [AOR: 1.08, 95% CI: 1.03, 1.12], lifetime forced sex [AOR: 2.74, 95% 1.65, 4.55]) and structural-level factors (sexual stigma [AOR: 1.09, 95% CI: 1.04, 1.15], food insecurity [AOR: 2.38, 95% CI: 1.41, 4.02], housing insecurity [AOR: 1.94, 95% CI: 1.16, 3.26], no regular healthcare provider [AOR: 2.72, 95% CI: 1.60, 4.64]). CONCLUSIONS: This study highlights social ecological correlates of selling sex among MSM in Jamaica, in particular elevated stigma and economic insecurity. Findings suggest that MSM in Jamaica who sell sex experience intensified social and structural HIV vulnerabilities that should be addressed in multi-level interventions to promote health and human rights.

Social-ecological factors associated with HIV infection among men who have sex with men in Jamaica.

In Jamaica, where homosexuality is criminalized, scant research has examined associations between sexual stigma and HIV infection. The study objective was to examine correlates of HIV infection among men who have sex with men (MSM) in Jamaica. We conducted a cross-sectional tablet-based survey with MSM in Jamaica using chain referral sampling. We assessed socio-demographic, individual, social, and structural factors associated with HIV infection. A logit-link model, fit using backwards-stepwise regression, was used to estimate a final multivariable model. Among 498 participants (median age: 24, interquartile range: 22-28), 67 (13.5%) were HIV-positive. In the multivariable model, HIV infection was associated with increased odds of socio-demographic (older age, odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.00-1.10]; residing in Kingston versus Ocho Rios [OR: 6.99, 95% CI 2.54-19.26]), individual (poor/fair versus excellent/good self-rated health [OR: 4.55, 95% CI: 1.81-11.42], sexually transmitted infection [STI] history [OR: 3.67, 95% CI: 1.61-8.38]), and structural (enacted sexual stigma [OR: 1.08, 95% CI: 1.01-1.15], having a health care provider [OR: 2.23, 95% CI: 1.06-4.66]) factors. This is among the first studies to demonstrate associations between sexual stigma and HIV infection in Jamaica. Findings underscore the need to integrate STI testing in the HIV care continuum and to address stigma and regional differences among MSM in Jamaica.

"I felt for a long time like everything beautiful in me had been taken out": Women's suffering, remembering, and survival following the loss of child custody.

BACKGROUND: Child Protective Services' (CPS) placements of children in out-of-home care disproportionately impact families marginalized by poverty, racism and criminalization. CPS' mandate to protect children from neglect and abuse is frequently criticized as failing to address the multiple social and structural domains shaping parents' lives, especially mothers. METHODS: We conducted a thematic narrative analysis of in-depth interviews to explore the impact of child custody loss on 19 women who use drugs residing in Toronto, Canada. We also assessed the potential roles of intersectional forms of violence and inequities in power that can both give rise to child custody loss and mediate its consequences. RESULTS: Trauma was identified as a key impact of separation, further exacerbated by women's cumulative trauma histories and ongoing mother-child apartness. Women described this trauma as unbearable and reported persistent symptoms of post-traumatic stress disorder and other mental health conditions. Practices of dissociation through increased use of drugs and alcohol were central in tending to the pain of separation, and were often synergistically reinforced by heightened structural vulnerability observed in increased exposure to housing instability, intimate partner violence, and initiation of injection drug use and sex work. Women's survival hinged largely on hopefulness of reuniting with children, a goal pivotal to their sense of future and day-to-day intentions toward ameliorated life circumstances. CONCLUSION: Findings highlight needs for strategies addressing women's health and structural vulnerability following custody loss and also direct attention to altering institutional processes to support community-based alternatives to parent-child separation.