For the first time in this country’s history, a US president has made harm reduction services a central element of federal drug policy.1 To move this initiative forward, the US Substance Abuse and Mental Health Services Administration (SAMHSA) has announced a new grant program that would provide nearly $30 million to harm reduction programs.2 Despite backlash from those who oppose harm reduction services,3 research indicates that these programs are effective in yielding positive health outcomes, such as reducing infectious disease transmissionReference Aspinall4 and connecting people to treatment.Reference Hagan5 Effective harm reduction, however, is not one-size-fits-all.
Historically, harm reduction strategies, and addiction policy in general, have centered on the experiences of men who use drugs, excluding women who may benefit from these services.Reference Pinkham and Malinowska-Sempruch6 Now, policymakers and community-based programs have the opportunity to implement harm reduction strategies that are sensitive to the particular needs of women. Currently, programs aimed toward addressing substance use disorders in women are often limited to prenatal health initiatives and programs supporting sex workers; some experts have argued that this scope reflects the fact that research and substance use disorder programming related to women’s drug use tends not to focus on the health and welfare of women themselves, but on “the dangers that drug-using women pose to their children and families, and to civil society more generally.”Reference Boyd7
Women are a unique population of people who use drugs. A 2019 study on women and addiction revealed that women are the fastest-growing population of substance users in the United States.Reference Ait-Daoud8 This may be due, in part, to the fact that women tend to experience a more rapid progression of addiction than men after using smaller amounts of a substance over a shorter period.9 Women also tend to be more vulnerable than men to negative medical and psychosocial consequences of alcohol and other drugs.Reference Moran-Santa Maria10 Importantly, women who use drugs face unique external challenges when compared with men: the social and structural oppression of women virtually everywhere exposes them to abuse, coercion, and stigma.11 While reproductive and sexual health is a critical issue that should certainly be addressed by harm reduction programs, a more holistic, whole-person approach for women who use drugs would create the opportunity to address other factors that facilitate harm for women who use drugs, such as punitive policies, discrimination and stigma by police and health care providers, and inaccessible health services.12
While it is clear that drug policy priorities in the United States have progressed significantly beyond the Nixon-era “War on Drugs,”13 there remains a dearth of successful efforts to reach women who use drugs in a holistic and gender-sensitive way.Reference Terplan14 Harm reduction, a public health strategy and social justice movement “aimed at reducing negative consequences associated with drug use”15 provides a useful framework for addressing the overdose crisis as it affects all aspects of women’s lives, including, but not limited to, sex work and reproduction. A gender-sensitive harm reduction program would entail an environment reflective of the realities of women’s and girls’ lives, one that addresses and responds to their challenges and strengths.Reference Covington16 In adopting such a framework, the Biden Administration, as well as any other organization or political body seeking to utilize harm reduction as part of its strategy to combat the overdose crisis, should take care to highlight and address the unique barriers to wellness for women who use drugs.
While it is clear that drug policy priorities in the United States have progressed significantly beyond the Nixon-era “War on Drugs,” there remains a dearth of successful efforts to reach women who use drugs in a holistic and gender-sensitive way.
In this article, I provide a short overview of three key social and structural factors that facilitate negative health outcomes for women who use drugs. I then discuss potential solutions to these barriers in the form of harm reduction strategies.
Women Who Use Drugs: An Overview
In the United States, services for those in need of addiction treatment and harm reduction are, generally, inaccessible.Reference Staff17 People with substance use disorders often face numerous barriers to care, such as geographic location, poverty, and stigma; members of marginalized communities, such as people of color, the unhoused, and the incarcerated, face even more barriers.18 Disenfranchisement of these populations also takes many forms. The low social status of women who use drugs causes negative outcomes extended from unequal distribution of sexual, social, and economic power between men and women.Reference Auerbach and Smith19 Women who use drugs need care that acknowledges the consequences of women’s societal status. In particular, three themes emerge that significantly limit opportunities for wellness and stability: stigma, poverty, and mental health.
Stigma
One particularly powerful factor affecting the health of women who use drugs is stigma. Cultural stereotypes that hold women to certain expectations and roles in society are amplified and weaponized against women who use drugs.Reference El-Bassel20 When women admit to drug use, they are exposed to harsh judgment from health care providers, law enforcement agents, child welfare agencies, and their own social networks, among others.21 After enough exposure to discrimination, many women are justifiably skeptical of any positive outcome when they seek help.Reference El-Bassel and Strathdee22
Medical sexism affects many women, broadly,Reference Cleghorn23 but women who use drugs are particularly vulnerable to stigma by health care professionals. In fact, cisgender women who use drugs may be treated differently based on their fertility status, for fear that they may become pregnant and give birth to children with long-term disabilities.Reference Broussard24 Medical health professionals may also be untrained in addiction care, which can even lead to stigmatization of patients who are in recovery. One anecdote by a pregnant patient thrown out of her OB/GYN’s office when he learned of her methadone treatment illuminates the damage that ignorance and stigma can do to women seeking medical care.25 In her words, “[h]e kicked me out of the office and said I should have stayed on heroin.”26
Women are vilified and criminalized for their drug use, often in the context of how their drug use impacts others, such as their children or the people they have sex with.27 Harsh drug policies and criminalization of drug use have a disproportionate impact on women: according to the United Nations Office on Drugs and Crime, the proportion of drug users among women who are incarcerated is higher than among men who are incarcerated.28 Women with children are particularly vulnerable to punishment, as drug use is often used as grounds for incarceration or child removal, and women are often powerless against the child welfare system, where workers may test mothers for drug use without their consent, subject them to ruthless investigations, and remove their children on the grounds of drug use.29 Stigmatization in the child welfare system is so prevalent that the most common allegation in child maltreatment investigations is drug use, with mothers of color disproportionately affected.30 Even mothers who are not incarcerated for drug use while pregnant, parenting, or both are at risk of losing custody of their children, a punitive measure that negatively impacts women and their children.Reference Trivedi31
Finally, women who use drugs may lack social support such as childcare due to stigma held by their families and friends.32 They may also be subject to less sympathy when they become victims of violence. Hostile attitudes toward women who use drugs promote sexual and physical abuse against those women, suggesting that those who use drugs do not deserve respect or autonomy.33 Women also may internalize the stigma they face, making them less likely to report violence committed against them.34
Poverty
Poverty impacts millions more women and girls than it does men,35 and, for women drug users, it is a destabilizing and detrimental determinant of health. Poverty increases stress and feelings of hopelessness and decreases self-esteem, social support, and access to health care.36 Poverty impacts decision making, forcing women to make difficult choices that harm their health and safety. Moreover, women who are involved with the justice system are at an even greater disadvantage: incarceration and its consequences post-release creates even more barriers for women’s economic and social mobility.
Often, for women who use drugs, “poverty lies at the heart of risk.”37 In general, poverty can lead women to trade sex for drugs, food, shelter, or other necessities; in such situations, concerns about infectious diseases such as HIV can be less urgent than immediate survival.Reference Pinkham38 Transactional sex, unlike sex work, is less likely to take the form of an explicit exchange of goods for services, and is “more likely to be framed in terms of gratitude, indebtedness, trust, and dependence.”39 The ambiguity in this type of transaction can leave little space for women to negotiate, including insisting on safe sex measures such as condoms.40 The choice between necessities like food or shelter and safer sex is not a free one, since daily survival often takes precedence over more abstract or long-term risks, such as sexually transmitted infections.41
As discussed above, women who use drugs are incarcerated at higher rates than men, often because they are more economically disadvantaged to begin with. The United Nations Entity for Gender Equality and the Empowerment of Women, also known as UN Women, has emphasized that “women’s involvement in drug use and the drug trade reflects the decreased economic opportunities and lower political status that women face in everyday life.”42 UN Women has reported that women who participate in the drug trade are usually in low-level positions, and they often do so because they “lack education [and] economic opportunity or have been victims of abuse.”43 The UN Special Rapporteur on violence against women reported in 2013 that drug laws and policies “are a leading cause of rising rates of incarceration of women around the world” and expressed concern that in some countries “women who commit relatively low-level drug crimes” are more likely to be handed long prison sentences than men who commit major trafficking offenses.44
After release, the status of women with criminal records may further limit their opportunities for employment and access to social or economic support programs. For example, numerous states in the US require a negative drug test as a condition of receiving housing or welfare benefits, a policy that exacerbates the already low status of women in need of economic support.45 Poverty, then, seems inescapable. Without support, women who use drugs are often forced to make risky choices to protect and support themselves — whether in the form of transactional sex, involvement with drug trafficking, or in other ways.
Mental Health
Women who use drugs also suffer worse mental health impacts than men, sometimes as consequences of their drug use, and sometimes as its cause.Reference Ait-Daoud46 They tend to have higher rates of co-occurring mental health disorders, including depression, anxiety, eating disorders, and post-traumatic stress.47 These co-occurring mental health issues often stand in the way of wellness and stability, particularly for women; as one review found, comorbid depression has a more detrimental impact on health outcomes for women as compared to men.Reference Weinberger48
Women who use drugs are also at a heightened risk of exposure to gender-based violence and resulting trauma.49 One multi-site clinical trial of the Job Seekers’ Workshop found women reported higher rates of physical and sexual abuse as well as suicidality than men.Reference Keyser-Marcus50 The prevalence of sexual and physical abuse is three to five times higher among drug using women than among their non-using counterparts.51
Exposure to violence influences not only drug use, which is often a way of coping with trauma, but also risk of HIV, since women in abusive relationships and women experiencing sexual violence often do not have the option of insisting on condoms, and because the trauma, disempowerment, and loss of self-esteem associated with such violence can make it more difficult for women to avoid high risk sex.52 Experts assert that this violence may create a context of fear and submission that makes it difficult for women to negotiate safer sex, access HIV treatment, and seek harm reduction services.53 In women with co-occurring disorders, 55% to 99% have experienced trauma from abuse and tend to engage in self-destructive behaviors.Reference Covington54
Women’s vulnerability to violence tends to influence them to partner with a man, so that they are less at risk of violence from multiple sources; though violence from partners is commonplace, “it is a single, familiar threat that replaces attacks from many sides.”55 In exchange for a measure of protection, men receive financial support through women’s sex work, shoplifting, or drug dealing.56 In these situations, men also exert control of women’s drug use: men purchase the drugs, prepare them, and then inject them.57 In instances of intravenous drug use, men sometimes inject first and then inject their partner with the used needle, or they prepare the drugs out of sight so that their partners cannot tell whether they are using a clean syringe.58 These partnerships also tend to influence women’s access to health care services: Research shows that, “[w]hile physical assault by a husband, boyfriend[,] or former partner is generally associated with increased access to health services … the same is not true for women who use drugs.”Reference Shirley-Beavan59 Rather, abusive partners use violence and other cruel behaviors to prevent women from seeking harm reduction services and encourage continued drug use.60
Despite the critical need, trauma-informed anti-violence services remain largely unavailable to women who use drugs. Providers responding to the needs of people who use drugs or sex workers often lack necessary knowledge and skills to address gender-based violence, while anti-violence shelters often explicitly ban criminalized women, resulting in a service gap.Reference Malinowska-Sempruch and Rychkov61 In her 2011 report, the UN Special Rapporteur on violence against women asserted that the unpreparedness of domestic violence shelters to serve women who use drugs constituted a human rights violation.Reference Manjoo62 Women need services that will address the mental health issues that cause and arise from their drug use, including services for their co-occurring disorders and trauma-informed care.
Harm Reduction: How It Helps, and How it Can Do More
The purpose of harm reduction as a framework for addressing substance misuse and substance use disorder is to meet people “where they’re at.”63 There is no requirement that a person will stop using drugs immediately in order to have access to lifesaving services. Instead, there is the reasonable expectation that removing certain obstacles will beget greater health outcomes and, eventually, stability and wellness. In recognizing the context of people’s drug use, the harm reduction model removes barriers to addiction management and critical health services. As a strategy, harm reduction has been shown to work for drug users both in the United States and abroad.Reference e.g and Marlatt64
Harm reduction services include syringe services programs, overdose prevention sites, and testing strips for substances such as fentanyl and xylazine. Some programs respond to the specific needs of certain subpopulations, such as those in detentionReference Sander65 and sex workers.66 Yet, there is a dearth of programs that tailor care to women, who make up a large proportion of the drug-using population and often intersect with other marginalized groups. Addiction services, designed originally for men,Reference Ettorre67 still reflect the outdated but persistent belief in medicine that men are the standard to which women must adapt.Reference Nowogrodzki68
A successful harm reduction program for women is one that would help, at minimum, address the three factors of women’s health discussed above: stigma, poverty, and mental health. By creating more opportunities for women who use drugs in spaces such as safe injection sites, and by connecting women with health care providers and peer support services, harm reduction programs can give women the opportunity to access critical resources without fear of stigma and shame. Additionally, programs that fulfill basic needs by providing food, shelter, transitional housing, clothing, and showers allow women in poverty to have more autonomy, thus providing alternatives to transactional sex, selling drugs, and other dangerous choices. Finally, programs that can connect women with critical mental health services can enhance women’s experiences and give them the best chance at recovery and stability.
Specialized resources for women who use drugs can take a variety of forms, depending on the funding available to programs seeking to provide gender-sensitive services. On one end of the spectrum are basic additions to standard harm reduction care, such as hygiene supplies, contraceptives,69 and information materials specific to women’s needs. Research shows that these additions are feasible and sustainable.70 Programs may also designate special times for women to visit a center, have a staff member available to watch children while their mothers receive counseling or other services, or open women-only support groups. Harm reduction programs may also work to become more welcoming for women by ensuring a gender balance in their staff, training staff on gender issues, and addressing gender-specific needs. Programs may also incorporate counseling to respond to gender-based violence and other trauma. Many programs have found it useful to establish relationships with “trusted” gynecologists and other specialists who are familiar with drug use issues and who provide women with supportive, informed, nonjudgmental care.71 A more ambitious model may also involve parenting classes and counseling for families, mobile medical services for women unable to visit fixed service sites, legal aid, economic empowerment resources, and sexual and reproductive health services, including gender-affirming care. These added services can make real differences in addressing the range of barriers to recovery and stability.72
Studies of these programs show that these services are working. One review analyzed studies of alcohol and drug treatment programs for women that included child-care, prenatal care, women-only programs, supplemental services, and workshops addressing women-focused topics, mental health programming, and comprehensive programming.73 These components were positively associated with better recovery outcomes, reduced mental health symptoms, improved birth outcomes, employment, improved self-reported health status, and HIV risk reduction.74
Programs that combined medical and social support increased women’s sense of self and personal agency, engagement with the program staff and sense of giving and receiving support, and reported openness about their feelings.75 These programs also improved women’s ability to recognize patterns of destructive behaviors and helped women set goals.76 These psychosocial processes were reported to play a role in women’s recovery and contribute to favorable health outcomes.77
Conclusion
President Biden’s turn toward harm reduction as a strategy for addressing overdose deaths in the United States provides a perfect opportunity to expand these services nationwide. Yet, harm reduction services overwhelmingly center the needs of men who use drugs or promote the facade of gender neutrality,78 which wrongly assumes equal impact and lived experiences between genders.Reference Collins79 As the implementation of harm reduction strategies increases, those providing funding should consider the pressing need to include women. It would behoove the Biden Administration, SAMHSA, and other government bodies seeking to expand access to harm reduction services to focus their efforts and their funding on providing more gender-sensitive care.
Note
This article was prepared by Somer Brown in her personal capacity. The opinions expressed in this article are the author’s own and do not reflect the official views of the Substance Abuse and Mental Health Services Administration, the Department of Health and Human Services, or the United States government.
