9.4 A gender approach to harm reduction

Women who use substances have unique needs when it comes to health services and support.  Women who use substances are often discriminated against from healthcare to employment to parenting. For example, some women who use substances and are pregnant have been targeted with Birth alerts in Nova Scotia.^[1]

Harm reduction programs that do not take into account gender fail to address the systemic and everyday racialized and gendered discrimination, stigma, and violence that can be experienced by women in an all-gender harm reduction service, which limits some women’s access.^[2] While all genders who use substances can experience the socioeconomic, physical and mental health impacts of substance abuse, women are at a greater disadvantage because of systemic inequity.^[3]

This means women have less employment opportunities and earn less, have more health risks, and have barriers to education.^[4]  Using intersectionality we can examine the different risks, including pregnancy, sexualized violence, violence, sex work and human trafficking, recognizing not all women have the same experiences.

Women and Violence

In Canada, rates of police-reported domestic violence have decreased due to increased social equality and financial freedom for women; there is improved public awareness, more treatment programs for violent men, improved training for police officers and Crown attorneys, more coordination of community services, and the creation of domestic violence legislation in some areas of Canada.^[5]

There are also trends that are disturbing, including an increase in intimate partner violence among those who are not married, as well as an increase in gendered violence during natural disasters.^[6] Girls are 1.5 times more likely to experience violence at home and we know approximately every six days, a woman in Canada is killed by her intimate partner.^[7] This results from a complex interplay of social, political, and economic factors.^[8] When we examine harm reduction from a gender perspective, however, violence must be one of the areas we are willing and able to address.

Women and Pregnancy

I’ve never seen a pregnant woman in there [SisterSpace], first of all, and I never seen anyone I know who has their kids. I think they would be discouraged because they don’t want people to see them and call the Ministry [of Children and Family Development] on them. So I don’t think… like I wouldn’t go there if I had my…[kids].^[9]

For women who use substances, reproduction is a complicated issue.  Pregnant women and mothers who use substances have been judged harshly, as substance use has not been seen as conducive to having children or even being engaged in family life.^[10]  For decades mothers who use substances have had children removed from their care.  “Whether their babies are taken from them after birth or they are told to have an abortion, be sterilized, etc., these bodies are viewed as not fit to reproduce”.^[11] Women, whether they use substances or not, have a basic human right to reproduce (Ettore, 2004), therefore, this group of women need programs which address their needs, not seeking to demonize them.

Women and Sex Work

Sex work is being paid (this may include cash, clothing, tuition, housing, or other currencies) through work in strip clubs, ‘sugaring’ [explain], selling nudes, escorting or agency work, massage parlours or freelancing, drift sex or survival sex.^[12]  The work may take place indoors (with an agency) or outdoors (drift sex). On an occupational level, women who engage in drift or survival sex work are confronted with many risks including sexually transmitted or blood borne illnesses, sexualized and physical violence and overdose; “sex workers are more likely to experience violence and poor health than the general population”.^[13]  Does this mean that engaging in sex work will result in substance use and violence?  No, “the violence and poor health currently experienced by some sex workers are not inherent to the work — they are the products of punitive laws and inadequate social conditions”.^[14]  There are risks associated with sex work, and it is important to be aware of the risks from a gender perspective when working with women who engage in sex work.

In offering harm reduction services to those doing sex work, it is imperative that trauma-informed services must be embedded in every level of service provision.  Programming in a harm reduction program for women who engage in sex work must include an understanding of the sex industry. There is one program in Nova Scotia which supports sex workers and provides education harm reduction workers, Stepping Stone Nova Scotia.  If we look beyond Nova Scotia, an example of one of the organizations in Canada that supports harm reduction and women is STELLA, located in Montreal.  STELLA is an organization supporting female identified sex workers.

When we use an intersectional lens in harm reduction programming for women, addressing some of the topics above, we recognize women’s unique needs.  Women who inject substances engage in practices like injecting in less visible areas on their body, to conceal their use from peers and partners.^[15] Women who use opiates, in particular fentanyl, have an increased vulnerability to violence due to the nature of the substance on the body and using in public places (i.e. passing out).^[16]  If women are using substances alone, due to the stigma associated with injection use, they are at an increased risk of death due to overdose.^[17]  Knowing these factors Social Service workers can develop programs that are supportive to women’s needs.  Sister Space, located in Vancouver BC, the world’s first and only safe consumption site for women, trans-women, non-gender binary and femme-identified individuals.^[18]

Sister Space addresses basic fundamental needs such as food (amidst entrenched poverty), temporary shelter (amidst housing insecurity), and overdose reversal (amidst an overdose crisis), as well as a reprieve from gendered and racialized violence, misogyny and punitive policing practices.^[19]  It is important to note that the stigma and fear of repercussion, particularly for those pregnant and/or parenting and/or Indigenous, remains a substantial barrier to accessing services.^[20]

When a program comes from a place of nonjudgmental service and caring, this can help build relationships. For many women, a positive relationship with a health care provider is one in which a woman feels she can be honest about herself, her substance use, and her health care issues.^[21]