Public and patient involvement (PPI) in health care may refer to many different processes, ranging from participating in decision-making about one's own care to participating in health services research, health policy development, or organizational reforms. Across these many forms of public and patient involvement, the conceptual and theoretical underpinnings remain poorly articulated. Instead, most public and patient involvement programs rely on policy initiatives as their conceptual frameworks. This lack of conceptual clarity participates in dilemmas of program design, implementation, and evaluation. This study contributes to the development of theoretical understandings of public and patient involvement. In particular, we focus on the deployment of patient engagement programs within health service organizations. To develop a deeper understanding of the conceptual underpinnings of these programs, we examined the concept of "the patient perspective" as used by patient engagement practitioners and participants. Specifically, we focused on the way this phrase was used in the singular: "the" patient perspective or "the" patient voice. From qualitative analysis of interviews with 20 patient advisers and 6 staff members within a large urban health network in Canada, we argue that "the patient perspective" is referred to as a particular kind of situated knowledge, specifically an embodied knowledge of vulnerability. We draw parallels between this logic of patient perspective and the logic of early feminist theory, including the concepts of standpoint theory and strong objectivity. We suggest that champions of patient engagement may learn much from the way feminist theorists have constructed their arguments and addressed critique.

This paper presents the results from in-depth interviews with 30 crack-using women also working in the sex trade to support their drug use. The gender roles perspective highlights traditional beliefs from past decades about the appeal of cocaine to women, its effects on their sexuality, and the reasons they become prostitutes. These are contrasted with the harsh realities of the dangers and marginalization faced by female crack users who work the streets in the contemporary sex trade. These women operate at the lowest levels of street drug use and prostitution, experience a considerable amount of violence and sexual exploitation, and are subject to riskier practices in their sex work. Their crack addiction fuels this extreme vulnerability and contributes to their highly deviant and stigmatIzed social Image. We conclude that, similar to findings in other studies, the increase in crack consumption and availability has had serious negative repercussions for poor women who were, or became, involved in the sex trade. Moreover, the powerful appeal of crack to these women poses a challenge for harm reduction alternatives and other services that might improve their health and safety.

Although exploratory, the findings merit attention both for what they tell us about women's experiences, and because they suggest disparities in access to treatment and psychosocial support.

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