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An Opportunity to Live in Health
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Women in Need Klinic (WINK) in Toronto, Ontario has developed a low-barrier model for providing health care and social support services to street-involved women engaged in sex work. Bernadette Lettner, RN, describes WINK’s approach to outreach, engagement, and low-barrier service delivery.
An Opportunity to Live in Health

Janet’s* process of recovery originally started because she needed bananas. And the Women In Need Klinic (WINK) at the Sherbourne Health Centre in downtown Toronto—which prides itself on helping women find what they need—had a steady supply of them.

Janet was living on the street and using crack cocaine regularly when she discovered that she had low potassium during a visit to the emergency room. She first started coming to WINK—which holds early morning clinic hours aimed at street-involved women—for their healthy breakfast options. But, over time, Janet started opening up to the staff and her peers there about her addiction and long-time estrangement from her family. In her words, the only thing that made her feel better was crack; yet the main thing that she felt was making her life worse was crack.

Out of a desire to be sober when she attended WINK, Janet started using crack less and less. Eventually, she reduced her use to just one time each month. And her story is a powerful one, says Bernadette Lettner, RN, Infirmary Admissions Referrals and Clinical Case Management at Sherbourne Health Centre. She explains that women who hear stories like Janet’s are more inclined to come to WINK because it reframes their idea of success.

Bernadette started working at Sherbourne Health Centre because of her fundamental belief in health care as a basic human right. “We are working with the women who are the least served, have the least access, and have the greatest barriers to health care,” she says. She describes WINK’s model as one that recognizes that health care goes beyond just seeing a doctor or a nurse; it also includes things like helping people develop a sense of community, decreasing social isolation, and eating a healthy diet.

“For us, it was really important to look at health care in a holistic sense and create an environment in which people live health instead of just consume health,” she says.

WINK’s model of care supports this in every way it can. Outreach staff drive around Toronto in dedicated health buses from 4:00 a.m. until 9:00 a.m. on Wednesday mornings to conduct outreach with street-involved women engaged in sex work, with other stops throughout the week. Because women expressed a preference for accessing services at the end of their nightly shift, WINK holds early morning clinic hours once a week for them, where they are treated by a multidisciplinary team of specialists. The clinic offers women a broad range of services that includes primary care, STI and rapid HIV testing, short-term counseling, and chiropractic and naturopathic care.

But the services don’t stop at medical care, says Bernadette. The staff see the waiting room as an opportunity for both planned and unstructured activities to engage the women. Staff members give health education presentations, peer workers are always on hand to talk to the women, and the program’s facilitator takes the opportunity to check in with each woman individually. This becomes a series of mini counseling sessions, says Bernadette, relying heavily on the principles of Motivational Interviewing.

While waiting for medical appointments, women can also choose to play or listen to music, write in journals, engage in mindfulness meditation, connect with the Safer Strolls program, and chat with each other. Others head out to the garden together or participate in art projects—although no one is forced to participate in any of the activities. “We ask women what they want to hear, see, and be involved in as they enter the building,” says Bernadette, “and this sets the tone for the entire program.”

Bernadette explains that staff are also careful to avoid the term ‘recovery’ unless women bring it up themselves. “Part of the reason for this is that women who are active in sex work often run into the mentality of We need to save you, and there’s a lot of moralizing that happens,” says Bernadette. “If we had a center based on a recovery model, a lot of the women would end up resisting that. They would ask, ‘Why are you telling me that I need to be different?’ and would not want to be in our space.” Many women at WINK do end up identifying recovery as being important to them, but Bernadette says it is important that the women choose and define that for themselves.

Bernadette describes a conscious effort on the part of the staff to make WINK a welcoming place for all who attend. “A lot of it is being proactive in identifying and de-escalating any client’s behavior that would make the space uncomfortable or hostile for the other women,” she says. The other critical piece, she adds, is letting every woman know before they walk through the doors what their responsibilities are in making WINK an open and accepting space, and giving them the choice about whether they want to participate before they enter.

WINK’s responsive approach has kept more complex individuals—such as Janet—engaged in care for longer, says Bernadette. The fact that the program happens every Wednesday provides a routine, and it also motivates the women to come in regularly for the social aspects of the program. This consistency, as well as the mutual respect among the women and staff, creates a community so strong that the women tend to moderate their own behavior while at WINK.

Bernadette says that many of the women at WINK fear that the more they build themselves up, the farther they will fall. But seeing someone who has built and built and hasn’t fallen—such as Janet—gives them hope that they can do it, too. “At WINK, women learn that you can have amazing successes even though, all around you, things aren’t perfect,” says Bernadette. And it is that reframing of success that gives women the space to explore their own unique paths to achieving it.

*Not her real name. Her name has been changed to protect her identity.

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