Gendering the Scene: We need to listen to women and gender-diverse people who use drugs

Over the past several years, Canada has been in the grip of an overdose crisis. We have seen the devastating effects both of a contaminated drug supply and of punitive laws that restrict access of people who use drugs to effective treatment and support. Now we are facing the twin crisis of the novel coronavirus disease (COVID-19) pandemic, which has radically altered the way we interact with one another and affected the drug supply chain.

Access to supervised consumption services in many areas has been curtailed and those that remain open are seeing fewer clients in order to facilitate physical distancing and comply with other public health guidelines. The combination means that people who use drugs are doing so with more dangerous substances and are more likely to be isolated when they do.

There is little doubt that the current situation urges a rethink. Unless our approach to drug policy changes, people will continue to overdose and experience other drug-related harms. And if this reimagining is going to benefit everyone, attention must be paid to women and gender-diverse people. Applying a “one-size-fits-all” approach fails to account for the specific needs and realities of women and gender-diverse people who use drugs.

There is scant research in Canada on women and gender-diverse people who use drugs. This is why the Canadian HIV/AIDS Legal Network sought to compile what research does exist into one report: Gendering the Scene: Women, Gender-Diverse People, and Harm Reduction in Canada, (also available in French here). In it, we make specific recommendations for harm reduction services and law and policy reform that we hope will help increase the visibility of women and gender-diverse people who use drugs and their access to gender-sensitive harm reduction services.

HIV, hepatitis C and overdose

Among people who inject drugs, HIV and hepatitis C disproportionally affect women. Women are more likely to rely on a partner to obtain their drugs and to also inject them. Often second on the needle, they are at increased risk of HIV and hepatitis C infection. They also have less control over how they use, which puts them at greater risk of overdose. This underscores the need to develop harm reduction programs specifically designed for women and gender-diverse people that enable them to assert agency over their drug use, including through assisted injection programs at supervised consumption services.

Gender-based violence

At the same time, gender-based violence is a major determinant of health for women and gender-diverse people who use drugs, particularly for those who sell sex, are Indigenous, trans, or have sex with other women. Power imbalances and violence in intimate relationships can make it difficult for women to access harm reduction services or drug dependence treatment, or to practise safer drug use and safer sex.

State violence, including that perpetuated by law enforcement, also hinders their access to services. Not only can harm reduction interventions reduce the risk of overdose and infections, they can also reduce the risk of violence for marginalized women and gender-diverse people who use drugs. In particular, supervised consumption services can provide a refuge from various forms of violence that women and gender-diverse people may experience on the street.

Domestic violence for women and gender-diverse people who use drugs is undoubtedly exacerbated during the COVID-19 pandemic as isolation efforts continue, intensifying the need for violence against women (VAW) shelters to better accommodate women and gender-diverse people who use drugs.

But many VAW shelters continue to make abstinence from drug use a requirement for those seeking shelter, which means many women and gender-diverse people who use drugs have far fewer options for safe shelter. They will therefore be more likely to stay in violent or otherwise dangerous intimate relationships. As the National Inquiry into Missing and Murdered Indigenous Women and Girls concluded, strict policies against substance use in shelters “further marginalize the already marginalized.”

Recommendations for action

Encouragingly, Ontario developed standards in 2015 for VAW shelters stipulating that all women (including those who use substances) must be provided with access to shelter services, meaning abstinence-based policies of refusing access to shelter for those who use drugs is no longer permitted.

Sadly, Ontario’s standards are an exception. Now, more than ever, VAW shelters should ensure women and gender-diverse people are not turned away because of their drug use. Just as it is essential that links between violence and drug use be taken into account when planning and implementing harm reduction services, it is equally imperative that VAW services account for the specific needs of women and gender-diverse people who use drugs.

These are crucial steps to address the needs of women and gender-diverse people who use drugs. But bolder steps must also be taken, including the decriminalization of simple drug possession. This would dull the stigma of drug use, remove a major legal barrier to the scale-up of supervised consumption services, and curb police surveillance of people who use drugs, which leads to riskier drug use practices. It would also mean fewer women in jail.

In recent decades, there has been a substantial increase in the proportion of women, particularly those who are Indigenous and Black, serving a prison sentence for a drug offence. The majority of them are mothers and the primary caregivers to their young children prior to incarceration.

The imprisonment of women for drug offences creates lasting damage to families. It also increases women’s risk of HIV and hepatitis C infection because of inadequate access to harm reduction measures in prison. Decriminalizing drug possession would not only lessen familial damage, but spare some women who use drugs from the heightened risk of HIV and hepatitis C, as well as the combustible spread of COVID-19 behind bars.

Their bodies, their choice

All of these issues – and more – are laid out in the Gendering the Scene report. Women and gender-diverse people who use drugs have long been ignored in conversations about drug policy and the design of harm reduction strategies. But as a group of women who use drugs declared in a statement on International Women’s Day 2019, there must be a “complete reform and transformation of the current system of prohibition”. In their words:

We work to reclaim our bodily sovereignty, including rights to the full range of sexual and reproductive health, gender-sensitive health services and rights to use drugs. We do not ask for charity but for solidarity. We demand to live in safety and freedom. …Our bodies – our choice, our rights, our voice.

It is time for the world to start listening.

Sandra Ka Hon Chu and Cécile Kazatchkine are lawyers with the Canadian HIV/AIDS Legal Network and co-authors of Gendering the Scene: Women, Gender-Diverse People, and Harm Reduction in Canada.