Research PaperRepresentations of women and drug use in policy: A critical policy analysis
Introduction
Contemporary clinical academic discourse on substance use endorses the idea that women who use drugs demonstrate unique characteristics and treatment needs, as evidenced by the push for ‘gender-sensitivity’ in treatment and policy (Grella, 2008; Martin & Aston, 2014; Tang, Claus, Orwin, Kissin, & Arieira, 2012). Research indicates that women who use drugs have high rates of mental health problems as well as histories of childhood victimisation and trauma, and have greater vulnerability to health and social harms from their drug use and dependence (Ashley, Marsden, & Brady, 2003; Copeland, 1997; Greenfield et al., 2007; Pelissier & Jones, 2017; Shand, Degenhardt, Slade, & Nelson, 2011). Women who use drugs are also less likely than men to enter treatment for their drug use, and they experience particular barriers to treatment entry, including childcare responsibilities, inappropriate treatment models, and gendered stigmatisation (Ashley et al., 2003; Copeland, 1997; Greenfield et al., 2007; Pelissier & Jones, 2017). Consequently, gender differences in drug use patterns, characteristics, and intervention needs represent an important policy issue.
At the international level, United Nations governing bodies have been concerned to ensure that gender issues and the specific needs of women and girls are considered in drug policy. The recent resolutions adopted by the United Nations General Assembly Special Session in 2016 provides an example of this by encouraging the adoption of ‘operational recommendations on cross-cutting issues: drugs and human rights, youth, children, women and communities’ (General Assembly resolution S30/1, 2016). Reflecting the broad push for ‘gender mainstreaming’ across a range of policy arenas, one of these operational recommendations is to:
[m]ainstream a gender perspective into and ensure the involvement of women in all stages of the development, implementation, monitoring and evaluation of drug policies and programmes, develop and disseminate gender-sensitive and age-appropriate measures that take into account the specific needs and circumstances faced by women and girls with regard to the world drug problem and, as States parties, implement the Convention on the Elimination of All Forms of Discrimination against Women (General Assembly resolution S30/1, 2016, p. 12).
From this, it is clear that the international community is committed to ensuring that gender is considered in drug policy and interventions, and as such domestic drug policies should reflect this commitment.
Despite this recognition that gender should be an important consideration in drug policy, there is still only a relatively small literature on whether and how gender issues are attended to in policy, including the ways that women are constructed as objects of government in official drug policy discourse (for exceptions, see Campbell, 2000; Du Rose, 2015; Harding, 2006; Malinowska-Sempruch & Rychkova, 2015; Moore, Fraser, Törrönen, & Tinghög, 2015). A recent special issue in the Howard Journal of Criminal Justice highlights the gendered nature of issues related to ‘drug mules’, and in particular draws attention to gendered discourses in international drug policy around women who use or traffic drugs, particularly in Latin American countries and South East Asian countries (Fleetwood & Seal, 2017; Giacomello, 2017). Furthermore, the journal of Contemporary Drug Problems has also recently released a special issue on gender in critical drug studies, inviting drug policy authors to incorporate gendered analysis into emerging scholarship on all aspects of drug use, markets, interventions and policy (Campbell & Herzberg, 2017). There is still relatively little research, however, that investigates domestic drug policies and whether they address gender issues (again, see for an exception Manton & Moore, 2016; Moore et al., 2015). Consequently, the purpose of this study was to investigate whether and how Australian governments have addressed women and gender issues in drug policy. Based on this broad purpose, data collection and analysis occurred in two main stages: 1. a policy audit of Australian drug and health policies federally and across all states and territories to investigate whether these policies attend to women and gender issues; and 2. a critical policy analysis of key domestic policy documents to examine how women and gender issues are represented in policy.
This article, which reports the outcomes of this work, begins by surveying what is known about the prevalence of drug use amongst women in Australia and briefly outlining a number of key issues in relation to this use. Second, we outline our methods of data collection and analysis including the policy audit and critical policy analysis. Following this, we summarise the results of our policy audit and review a number of relevant national and state/territory policies and programs. The policy audit provides a springboard for thinking about policy representations of women who use drugs. In this article we deploy a critical approach to draw attention to both the over-production of certain discourses around women and drug use, as well as areas of ‘policy silences’ — issues that are largely neglected in policy (Bacchi, 2000, Bacchi, 2009; Ball, 1993; Scheurich, 1994; Taylor, 2006). Overall, we argue that in Australia women have been represented in drug policy in two key overlapping ways, which focus on 1. reproductive and population health, and 2. vulnerability to harm.
There are significant gender differences in patterns of drug use, reasons for use, experiences, circumstances and characteristics of users, as well as treatment experiences and needs of people who use drugs. To provide context for the analysis and discussion presented in this article, this section reviews prevalence data on women’s drug use in Australia before discussing research on women’s experiences of drug use and interventions. The 2016 National Drug Strategy Household Survey (NDSHS) delivers the most recent population prevalence data on alcohol, tobacco and other drug use in Australia (Australian Institute of Health and Welfare, 2017b). Overall, women were less likely to report illicit drug use, alcohol consumption or tobacco use than males (Australian Institute of Health and Welfare, 2017b). This finding is consistent across all recent previous iterations of the NDSHS (Australian Institute of Health and Welfare, 2008, Australian Institute of Health and Welfare, 2011, Australian Institute of Health and Welfare, 2014b). In 2016, males aged 14 or older were almost twice as likely to report drinking daily compared with females (Australian Institute of Health and Welfare, 2017b). Similarly, more males reported any use of illicit drugs than females in 2016 (Australian Institute of Health and Welfare, 2017b). Recent use of an illicit drug was higher amongst males: 18.3% of males reported recent use of an illicit drug, compared with 13.0% of females (Australian Institute of Health and Welfare, 2017b). Rates of recent illicit drug use are highest amongst young women (ages 14–29) (Australian Institute of Health and Welfare, 2017a). The NDSHS 2016 report notes, however, that there was a statistically significant increase in females in their 30 s reporting recent use of illicit drugs — cannabis, ecstasy, and cocaine — between 2013 (12.1%) and 2016 (16.1%) (Australian Institute of Health and Welfare, 2017b).
Whilst fewer women report use of illicit drugs and alcohol than men, there appears to be less difference between men and women in the rate of occurrence of ‘problematic’ substance use and drug-related harm. In a review of the literature on gender differences in substance abuse, Pelissier and Jones (2017) note that there is inconsistent evidence around whether there are significant gender differences in substance abuse problem severity and co-morbid disorders (p. 353). These authors note, however, that there is more consistent evidence for ‘higher rates of sexual abuse, employment problems, and drug use problems among at least one family member experienced by women, as well as the greater percentage of women being responsible for a dependent child’ (p. 353). Research on drug trends suggests that women may be more likely to engage in risky practices and experience harm from drug use (Breen, Roxburgh, & Degenhardt, 2005; Swift, Copeland, & Hall, 1996). For example, whilst women comprise a smaller percentage of the population of people who inject drugs, an Australian study found that women who inject drugs may be more likely to engage in risky behaviours such as sharing needles or injecting equipment and performing sex work (Breen et al., 2005).
Women who use drugs demonstrate unique characteristics and treatment needs (Ashley et al., 2003). Women who use drugs have high rates of mental health problems, are more likely to experience adult victimisation in the context of an intimate relationship, and are more likely than males to have been introduced to substance use by a male partner (Ashley et al., 2003; Shand et al., 2011). Women also experience particular barriers to accessing treatment and interventions, including childcare responsibilities, problems accessing childcare, inappropriate treatment models based on male populations, and the perception and experience of gendered stigmatisation from friends, family or service providers (Ashley et al., 2003; Copeland, 1997). Whilst people who use drugs are highly stigmatised (Lloyd, 2013), gender is a key factor shaping how stigma impacts on people who use drugs. A number of authors have suggested that women face greater stigmatisation for their drug use than men, because of the breach of traditional gender and care-giving roles that their drug use signifies (Azim, Bontell, & Strathdee, 2015; Copeland, 1997; Greenfield & Grella, 2009; Simpson & McNulty, 2008). Research indicates that women who use drugs perceive greater stigma from their drug use: for example, an Australian study of pharmaceutical opioid dependent people found that being female was associated with higher levels of perceived stigma from drug use (Cooper, Campbell, Larance, Murnion, & Nielsen, 2018). For women who use drugs and are also primary care givers, there may also be the fear that health care providers will report them to child protection services (Azim et al., 2015; Taplin & Mattick, 2014). Factors such as race, class, sexual identity, criminal history, injecting drug use, HIV-status, contact with welfare and child protection systems, and involvement in sex work, can compound the experience of gendered stigma (Gunn, Sacks, & Jemal, 2016).
Gender appears to exert its major effect in terms of likelihood of treatment entry, but shows no real effect on treatment process or outcomes (Ashley et al., 2003; Greenfield et al., 2007) – although as Pelissier and Jones (2017) note there is limited data on outcomes for women. Research suggests that over the life-course women are less likely than men to enter treatment for problematic drug use, however once in treatment, gender does not predict treatment retention, rates of completion or outcomes (Greenfield et al., 2007). The limited research findings on gender-responsive treatment are less than equivocal. The majority of studies indicate that women-only treatment does not display greater efficacy than mixed-gender treatment (Greenfield et al., 2007), although it can assist with likelihood of treatment entry and retention for particular groups of women (for example, women with a history of trauma, women who have engaged in sex-work, and same-sex attracted women) (Ashley et al., 2003; Copeland, & Hall, 1992). A study by Prendergast, Messina, Hall, and Warda (2011) assessing the relative effectiveness of women-only (WO) outpatient programs compared with mixed gender programs found mixed results, with women in the WO group reporting less substance use and criminal activity than those in the mixed-group treatment. Of course, the provision of women-only treatment groups is not the only method of providing gender-responsive treatment. Gender-responsive treatment programming and interventions that address problems common to women who use drugs can enhance treatment entry, retention, and outcomes among certain subgroups of women who use drugs, for example for women with children or women who have experienced trauma (Greenfield et al., 2007). In general, whilst there is a lot of literature advocating the need to address gender issues in treatment and interventions, there are far fewer comprehensive outcomes studies of gender-specific programming (Pelissier & Jones, 2017).
This brief review of literature on women, drug use and treatment indicates that policies and interventions should be gender-responsive, and should be tailored to the needs of women who use drugs. As the clinical literature has been concerned to identify gender differences in treatment needs, critical and feminist scholars have been concerned to highlight the normative assumptions underlying clinical academic discourse in the drug field, suggesting that the production of this kind of knowledge actively contributes to and reproduces the stigmatisation and exclusion of women who use drugs (Campbell, 2000; Du Rose, 2015; Ettorre, 2004; Martin & Aston, 2014). So while the clinical addiction literature has seen a push towards ‘gender-sensitivity’ in treatment programming and policy, the critical and discursive literature has observed how these constructions of women as objects of government can serve to reproduce the same inequalities they seek to address (Martin & Aston, 2014). The critical drug policy literature has shown that the way problems are constructed in policy has consequences for the kinds of practices or ‘solutions’ that are advocated, and results in areas of relative policy silence or neglect (Bacchi, 2015; Fraser & Moore, 2011; Lancaster & Ritter, 2014; Manton & Moore, 2016; Moore et al., 2015). Consequently, in this study we were interested to investigate not just whether governments have attended to gender issues in drug policy, but how these documents construct the ‘problem’ of women’s drug use and contribute to areas of ‘policy silence’.
Section snippets
Method
Our investigation of whether and how Australian governments have addressed women and gender issues in drug policy involved a documentary analysis. To achieve our overall research purpose, the following two questions guided document collection and analysis: 1. Have federal and state and territory governments in Australia attended to women and gender issues in drug policy and are there any best practice guidelines around gender-responsive policy and treatment? 2. How have Australian governments
Women & drugs in Australian policy: results of the policy audit
Drug policy in Australia is a complex field, requiring partnerships and coordination across multiple agencies (e.g. health, law enforcement, education) and Commonwealth, state, territory and local levels of government, as well as the non-government sector, the community and people who use drugs (Ritter, Lancaster, Grech, & Reuter, 2011). Since the 1980’s, the Federal government has played an important role in coordinating, developing and implementing drug policy in Australia. In 1985, the
Conclusion
This article has identified a number of policy gaps in the response to women who use drugs in the Australian context. Whilst there are piecemeal acknowledgements of the need for gender responsivity across the drug policy documents analysed, there is a lack of coordination or guidelines on how to implement this in practice specifically in the context of substance use interventions. Very few of the drug strategy documents identify women as a priority population group for targeted drug and alcohol
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