Harm reduction for female drug users: what is at stake?

Due to a combination of biological, social and cultural reasons, women’s drug use is different from men’s.  Research has shown that women drug users, especially those who have been incarcerated, are faced with higher levels of abuse, discrimination and violence than men. Compared to male drug use, female drug use is associated with higher mortality rates, higher dependence rates, higher rates of HIV, risky injection and dangerous sexual behaviour.

Women are a sensitive and vulnerable population, and the way they experience drug use is wholly different than men’s. They are more likely to become dependent more easily after their first drug use, they are more likely to have an IDU sex partner and they are involved in sex work, which has been associated with inconsistent condom use and syringe sharing. Moreover, women risk to experience intimate partner violence (IPV).

Data on women and injecting drug use are limited, as women have been for a long time a hidden population involved in drug use as an illicit activity and due to the fact that data on injecting drug users are not usually disaggregated by gender.

Though precise data on women drug users is rarely available, according to the Open Society Institute data from 2007, women have been estimated to represent about 40 percent of drug users in the United States and some parts of Europe, 20 percent in Eastern Europe, Central Asia, and Latin America, between 17 and 40 percent in various provinces of China, and 10 percent in some other Asian countries. In some countries, including China, India, and Russia, which comprise 4.6 million of the world’s injecting drug users, drug use among women appears to be on the rise, and in many regions more women are seeking harm reduction services and drug treatment.

The estimated number of women as percentage of all people who inject drugs are: 33% in Canada, 30% in Russian Federation, 27% in South Africa, 26% in Ukraine, 20% in China, 18% in Vietnam, 11% in Indonesia and Kenya, 10% in Cambodia, Malaysia, Kyrgyzstan and Georgia and 9% in Estonia.  According to the available statistics, it has been clear that HIV is more prevalent among female IDU’s than among male IDU’S. Studies in 9 EU countries have found that the average HIV prevalence was more than 50% higher among female IDU’s than among male IDU’s.

According to the Global Coalition on Women and AIDS, incarceration affects women disproportionately compared to men; women in prison often experience harms and discrimination; they are more likely to share syringes unsafely, to experience higher rates of HIV and viral hepatitis, to be exposed to sexual violence advanced by the prison guards and to lose custody of their children.

Research has also shown that women drug users have difficulties to access effective harm reduction services. Some reasons can be the relationships dynamics which impede women from seeking treatment as easily as men, imprisonment of drug using women who do not have the chance to enter harm reduction programs and very often are punished for non-violent crimes and the social stigma that follows women’s drug use. The stigma can easily be seen in the lack of availability of opioid substitution treatment and antiretroviral treatment that are only available in men’s prisons. According to EMCDDA, in 2006 women represented 22% of new patients for opioid substitution therapy and 33% of new patients for amphetamine dependence treatment.

Despite the evident specific needs that drug using women have along with the vulnerabilities they experience, many of them still face insurmountable barriers in accessing harm reduction services. The social stigma, coupled with the male dominated policy design directed mainly towards male needs have reduced women’s access to health care and treatment.

Considered as a minority of people who use drugs, women in many instances are not included in harm reduction programs such as HIV treatment, drug treatment services and other medical services. In some cases, anti-retroviral treatment and opioid substitution treatment are only available in men’s prisons and not in women’s. Incarcerated women should have full access to NSP, OST and ARP interventions along with medical care, mental health care and psychological support.

Sexual and reproductive health, as well as pregnancy issues, are not taken seriously into account by current harm reduction programs. While the majority of them include condom distribution, HIV testing and sometimes treatment, female sexual and reproductive health are not addressed by many of them, making it difficult thereby for drug using women to seek parental care, drug treatment or a safe termination of their pregnancy. It is characteristic that the WHO, UNODC and UNAIDS comprehensive package for the prevention, treatment and care of HIV among drug users does not include contraceptive methods such as pregnancy tests, pre-natal and post-natal care.  It is crucial for those methods to be added to the comprehensive package so that female injecting drug users are able to have a degree of control over their reproductive health through the prevention of unplanned pregnancies and the control over pregnancy outcomes. Easy access to OST and flexible drug treatment programs should be an immediate necessity.

Many existing harm reduction programs do not respond to women’s specific needs. However, some efforts to introduce gender specific services have been done across the world. Some examples of gender oriented harm reduction provisions to date include women-specific items to basic harm reduction kits such as female condoms, additional material assistance form women at harm reduction sites –such as pregnancy tests, supplies for children, short-term babysitting while women receive medical help-, staff training on gender issues, active participation of women in harm reduction programs design, support groups exclusively consisted of women, links between services for drug users and sex workers, provision of specialists providing counselling on parenting skills, mobile harm reduction, job training, economic empowerment programs, open separate rehabilitation centres for women and many more.

According to the available statistics from the UNAIDS 2010 Global Report, governments in 80% of countries reported that ‘women are included as a specific component of a multisectoral HIV strategy, but the rate of inclusion of women differs by geographical regions’. The report highlighted that the number of countries having a specific budget for HIV activities related to women is significantly low : 46% (79 of the 171) reporting countries. ‘Among countries in sub-Saharan Africa, nearly all strategic plans include interventions benefiting women, and three quarters of countries allocate budget accordingly, indicating a greater awareness of the need for and benefits of women-centred AIDS responses’.

It is crucial for vulnerable and victimized women drug users to be able to have full access to harm reduction services tailored to their own, specific needs. In order for this goal to be achieved, support, education and encouragement of women rather than punitive or judgmental behaviours and approaches towards them are necessary.

You can read more at the Harm Reduction International Global State of Harm Reduction 2012 chapter on women injecting drug users here and from the Open Society Institute paper on Women, Harm Reduction and HIV here