Exploring gender in harm reduction: Toward more inclusive and responsive services

Gender is a multifaceted aspect of our identities that influences all facets of our lives. In this article, the complexities of gender will be discussed with the goal of helping us become more self-reflective and sensitive to the diverse experiences that shapes individuals’ access to, usage of and benefits from harm reduction services. Concrete examples will be provided of gender-responsive harm reduction and different strategies will be highlighted that can be incorporated to foster a more inclusive and equitable approach to harm reduction for women and gender-diverse people.

What is gender?

Gender is a complex and multifaceted concept that encompasses socially constructed roles including behaviours, expressions and identities of women, men, girls, boys and gender-diverse people.¹ Gender affects how individuals perceive themselves and each other, their interactions with other people and the distribution of power and resources in society.² Gender is not just a binary concept of girl/woman and boy/man. There is a great deal of diversity in how individuals and groups understand, experience and express their gender.

Transgender and gender-diverse individuals are those whose gender identity and/or expression differs from the sex and gender they were assigned at birth. Transgender individuals may identify as man or woman, masculine or feminine, or neither. This identity can be fluid and may change over time. Gender-diverse, gender-fluid and non-binary individuals may identify as both male and female or as neither male nor female, or they may not identify themselves as having a fixed gender. Some people may also identify as another gender, such as those recognized by Indigenous or other cultural groups, like Two-Spirit.

Gender and sex are related concepts. Sex is also socially constructed but is used to refer to biological attributes including physical and physiological features like chromosomes, hormones and anatomy.² Typically, sex is classified as male or female, but there are variations in biological attributes and how they're expressed. For instance, while on average men are taller than women, not all men are taller than all women. Some people are born with a combination of male and female biological characteristics, which is known as intersex.

It’s important to note that this article in not intended to consolidate all women into a single homogenous group. Instead, by discussing gender, the intent is to draw attention to the oppressive dynamics that shape many, if not all, people’s lives and leave women and gender-diverse individuals at a disadvantage.³ Author bell hooks coined the term “imperialist white supremacist capitalist patriarchy” to capture the interconnectedness of various systems that grant privilege to some while disadvantaging others.⁴ The focus on the impacts of patriarchy in this article does not diminish the importance of considering the other systems of oppression and their outcomes (e.g., racism, classism) when developing and operating harm reduction services.

Why is it important to consider gender in harm reduction?

It is crucial to take gender into account in harm reduction. Gender-related factors have a significant impact on how people navigate the world, including their experiences with substance use and their ability to access suitable care.

Gender is a social identity that is influenced by our social systems and interactions with others. In our society, patriarchy is a social system that privileges men. For women and gender-diverse individuals who use drugs, patriarchy manifests as power dynamics and gender norms that create structural vulnerabilities, increased levels of violence, harsh judgment and stigma.^3,5 Moreover, the intersection of social factors like sexism and racism with structural issues such as poverty and drug criminalization produce disproportionate social suffering for those who are not cisgender men.⁶

It’s important to consider gender because without this attention, existing systems of oppression, like patriarchy, can become embedded in the delivery of harm reduction services. While most harm reduction programs are considered “gender neutral" these services tend to cater better to the needs of white cisgender men if the prevailing power relations in our society are not explicitly considered.¹

Delivering services without considering gender, also known as gender-blind services, can unintentionally perpetuate harmful power dynamics and gender norms that translate into negative experiences in harm reduction services for women and gender-diverse individuals.^7,8 For instance, in a study of overdose prevention sites in Vancouver, researchers found that women and gender-diverse individuals viewed these services as “masculine” spaces.⁹ Within these spaces, participants felt pressure from male peers and staff to conform to gendered roles such as taking care of men who used the service or helping with cleaning.⁹

For all people, there are barriers to accessing harm reduction services (e.g., supervised consumption sites, needle and syringe programs). These barriers include stigma, discrimination, lack of appropriate services and the criminalization of substance use.^10,11 However, women and gender-diverse individuals face amplified versions of these barriers when engaging with gender-blind harm reduction programs.¹²

Women, trans and non-binary individuals are often subjected to discrimination, misogyny, harassment, physical violence, sexual exploitation and victimization when accessing in-person harm reduction services.^9,13 Additionally, for many women, the fear of being reported to child welfare agencies and having their children apprehended is a major obstacle to accessing services.¹² Consequently, they may avoid such services to protect themselves. While avoiding services may provide people with more control over their environment, it increases their risk of overdose and other drug-related harm.

By considering gender-related factors in the development and delivery of programs and services, harm reduction providers can better address the unique needs of all individuals and enhance their access to appropriate care.

What is gender-responsive harm reduction?

The approaches to gender in harm reduction services can be viewed as a spectrum, ranging from gender unequal and gender blind to gender specific and finally gender transformative.¹⁴ Gender-specific services recognize gender norms, roles and relationships, such as women’s roles as mothers. A gender-specific harm reduction service would include accommodations for mothers such as offering childcare. Gender-transformative services work to challenge the patriarchal structures that perpetuate gender-based inequalities, such as unequal power and resource distribution.⁹ Together, gender-specific and gender-transformative services are sometimes called gender-responsive services.¹⁴

The following two examples highlight important issues related to gender-responsive services including cultivating violence-free spaces, accommodating childcare and family responsibilities, including trans and non-binary people, challenging gender norms and focusing on trauma-informed practice.

Example: Women-specific overdose prevention sites

SisterSpace in Vancouver’s Downtown Eastside provides the world’s first community-accessible women-only safe consumption service where women can use their own drugs under the supervision of trained staff. The space is inclusive of trans women, genderqueer women and non-binary people. Women have access to sterile injection equipment and can receive counselling, support and referrals to other health and social services.^15,16

SisterSpace acknowledges the unique challenges faced by women and gender-diverse people related to substance use, such as stigma, violence, trauma and childcare responsibilities, and provides services tailored to these needs. At SisterSpace women can use wherever they feel comfortable, not just in injection booths, and women often come in together and use as a group. The site has mobile furniture including single chairs and screens for privacy as well as couches and a large table for socializing. Additionally, SisterSpace is open early in the morning and late at night so that it’s accessible to women who do street-level sex work.

SisterSpace uses a peer support model that helps clients feel comfortable and safe.¹⁶ Women with lived experience of substance use and other challenges commonly faced by women in the Downtown Eastside (i.e., peers) work in pairs to operate SisterSpace. Workers are trained in overdose response and non-violent crisis intervention. The trusting relationships peer workers build with women who use SisterSpace are crucial for the program’s success. Clients describe how empowering it is to have a space where they can speak without fear of judgment as people who often face stigma and dehumanization.¹⁵

Evaluations of SisterSpace have found that clients describe it as a safe and accessible program for highly marginalized and underserved women.^15,16 Women who access SisterSpace describe valuing the opportunity to socialize and connect with other women while using substances together or simply hanging out in a comfortable space. By being gender responsive, SisterSpace provides clients with physical and mental safety.

Example: Virtual overdose prevention planning

The practice of ”spotting” is an approach to reducing the risk of overdose where a substance user connects with a spotter either informally (e.g., friend or family member) or through a telephone service or a mobile app.¹⁰ A spotter then monitors the person’s drug use and will intervene (e.g., in person or by calling emergency services) if the person overdoses. While spotting is not a new approach, during the COVID-19 pandemic formalized spotting services across Canada were implemented in the form of call centres and mobile apps.¹⁰ Examples of such services include the National Overdose Response Service (www.nors.ca) and the Lifeguard app (lifeguarddh.com).

Spotting provides an opportunity to deliver gender-responsive overdose prevention services.¹⁰ Accessing overdose prevention services remotely, in a private location, can increase people’s privacy and confidentiality. This can help address issues such as gendered violence and stigmatization that act as barriers to accessing in-person harm reduction services.¹⁰ Spotting can also overcome some of the challenges related to attending in-person overdose prevention services among people with childcare responsibilities. Additionally, by offering alternative ways for pregnant and parenting people to access services, online and other virtual services can help reduce the risk that their clients will be exposed to child welfare agencies by peers or service providers.¹⁷

By empowering women and gender-diverse individuals to use drugs safely, virtual services can help them further assert their agency in potentially coercive or negative relationships.¹ This may be especially important for women and gender-diverse people living in small or remote communities with strict abstinence-based policies or ideologies. Additionally, virtual services can facilitate more accessible and safe options for trans and gender-diverse individuals who may have concerns or fears about accessing in-person services (e.g., needing to “pass” as cis-gender to feel safe).^18,19

While virtual services are promising for incorporating gender-responsive approaches into harm reduction, it’s important to be aware that moving services online could provide additional avenues for surveillance by law enforcement and child welfare agencies (e.g., recordings of Zoom meetings, posts to discussion boards or apps). For example, social media platforms like Facebook have been increasingly incorporated into surveillance practices related to criminal justice,²⁰ which can harm women and gender-diverse people who use drugs.²¹ It is important for service providers and services users to be aware of this reality and understand the potential limitations to virtual services.

Implications for service providers

Gender is a crucial determinant of health and needs to be considered when designing and delivering harm reduction services. Recognizing the diversity and complexity of gender identity and expression is critical to ensure people can access services that provide appropriate care and support for all individuals. By including women and gender-diverse people who use drugs in the design, delivery and evaluation of programs, we can create services that are more accessible and effective for everyone.

Women and gender-diverse people who use drugs often experience high rates of violence and trauma, and the importance of trauma-informed practices needs to be emphasized when discussing gender-responsive harm reduction.^1,22 Trauma-informed practice is an approach to service delivery that aims to avoid replicating experiences of control and oppression that can lead to further trauma.

Women who use drugs are often viewed through a lens of “pathology and powerlessness.”⁵ If the focus is only on aspects of exploitation, victimization, powerlessness and dysfunction in women’s experiences, they are denied agency in navigating their world. However, if the focus is on abilities, skills and actions that benefit themselves and others, the dichotomy of victim or villain is minimized because agency is foregrounded. As illustrated in the examples above, instead of focusing on the specific experiences of trauma, by keeping the trauma-informed principles of choice, collaboration, safety, trustworthiness, strengths-based approaches and skill building foregrounded, we can design and deliver services that better meet the needs of women and gender-diverse people.^1,23

The inclusion of women and gender-diverse people who use drugs in service planning, delivery and evaluation is also of critical importance. For many reasons, research data often exclude the experiences of women and gender-diverse people, which has significant implications for service planning and policy responses. For instance, as harm reduction services tend to see a lower proportion of women, when research is conducted among clients of a harm reduction program without an equity approach, fewer women are involved, which diminishes their impact on policy and planning decisions. It is essential to recognize and address these gaps to ensure inclusive and effective service planning and policy development.

It’s important to recognize that gender-specific spaces and online services are not sufficient to fix oppressive policies and issues related to structural violence that can negatively impact women and gender-diverse people who use drugs. For example, child welfare policies that can lead to people’s children being taken need to change so that women and gender-diverse people who use drugs and have children can access services safely.

Harm reduction service providers and those working to develop harm reduction services and/or policies about substance use need to understand how gender affects how people use substances and the unique needs of women and gender-diverse individuals when accessing services. Without a conscious effort to be gender responsive, we run the risk of replicating hostile, unsupportive, stigmatizing and gender-blind environments that are not trauma informed. To best meet the diverse needs of women and gender-diverse people who use drugs, both virtual and in-person services must mobilize resources to consider and further integrate gender into their harm reduction services.

References

1. Schmidt R, Poole N, Greaves L et al. New Terrain: Tools to Integrate Trauma and Gender Informed Responses into Substance Use Practice and Policy. Vancouver (BC): Centre of Excellence for Women’s Health; 2018.
2. Institute of Gender and Health. Science is Better With Sex and Gender. Ottawa (ON): Canadian Institutes of Health Research; 2018.
3. Ettorre E. Revisioning Women and Drug Use: Gender, Power and the Body. New York (NY): Palgrave Macmillan; 2007.
4. hooks b. Feminism Is For Everybody: Passionate Politics. Second ed. New York (NY): Routledge; 2015.
5. Anderson TA. Neither Villain nor Victim: Empowerment and Agency among Women Substance Abusers. New Brunswick (NJ): Rutgers University Press; 2008.
6. Collins AB, Boyd J, Cooper HLF et al. The intersectional risk environment of people who use drugs. Social Science and Medicine. 2019;234(112384):1-24.
7. Jackson M, Klee H, Lewis S, editors. Drug Misuse and Motherhood. London (UK): Routledge; 2002.
8. Ettore E. Women and Substance Use. New Brunswick (NJ): ‎Rutgers University Press; 1992.
9. Boyd J, Collins AB, Mayer S et al. Gendered violence and overdose prevention sites: a rapid ethnographic study during an overdose epidemic in Vancouver, Canada. Addiction (Abingdon, England). 2018;113(12):2261-70.
10. Perri M, Kaminski N, Bonn M et al. A qualitative study on overdose response in the era of COVID-19 and beyond: how to spot someone so they never have to use alone. Harm Reduction Journal. 2021;18(85):1-9.
11. Kerr T, Mitra S, Kennedy MC et al. Supervised injection facilities in Canada: past, present, and future. Harm Reduction Journal. 2017;14(28):1-9.
12. Wolfson L, Schmidt RA, Stinson J et al. Examining barriers to harm reduction and child welfare services for pregnant women and mothers who use substances using a stigma action framework. Health and Social Care in the Community. 2021;29(3):589-601.
13. Boyd J, Lavalley J, Czechaczek S et al. “Bed bugs and beyond”: an ethnographic analysis of North America's first women-only supervised drug consumption site. International Journal of Drug Policy. 2020;78(102733):1-10.
14. Pederson A, Greaves L, Poole N. Gender-transformative health promotion for women: a framework for action. Health Promotion International. 2015;30(1):140-50.
15. Thulien M, Nathoo T, Worrall J. Sisterspace: Shared Using Rooms Women-Only Overdose Prevention Site. Vancouver (BC): Atira Women’s Resource Society; 2017.
16. Atira Women’s Resource Society. Sisterspace Women-Only Overdose Prevention Site: Utilization-focused Evaluation. Vancouver (BC): Atira Women’s Resource Society; 2021.
17. Perri M, Schmidt RA, Guta A et al. COVID-19 and the opportunity for gender-responsive virtual and remote substance use treatment and harm reduction services. International Journal of Drug Policy. 2022;108:103815.
18. Collins AB, Bardwell G, McNeil R et al. Gender and the overdose crisis in North America: moving past gender-neutral approaches in the public health response. International Journal of Drug Policy. 2019;69:43-5.
19. Lyons T, Krusi A, Pierre L et al. Experiences of trans women and two-spirit persons accessing women-specific health and housing services in a downtown neighborhood of Vancouver, Canada. LGBT Health. 2016;3(5):373-8.
20. Collier K, Burke M. Facebook turned over chat messages between mother and daughter now charged over abortion. NBC News. 2022 Aug 9.
21. Mason C, Magnet S. Surveillance studies and violence against women. Surveillance and Society. 2012;10(2):105-18.
22. The Jean Tweed Centre. Trauma Matters: Guidelines for Trauma-Informed Practices in Women's Substance Use Services. Toronto (ON): The Jean Tweed Centre; 2013.
23. Nathoo T, Poole N, Schmidt R. Trauma-informed Practice and the Opioid Crisis: A Discussion Guide for Health Care and Social Service Providers. Vancouver (BC): Centre of Excellence for Women’s Health; 2018.

 

About the author(s)

Rose Schmidt is a researcher and PhD candidate at the Dalla Lana School of Public Health, University of Toronto. Rose’s community-engaged mixed methods research focuses on gender-based determinants of health inequity and the application to harm-reduction oriented approaches to substance use.