1. Introduction

Over the past decade in the United States, women have accounted for an increasing proportion of individuals initiating drug use and those with substance use disorders (SUD) (Han et al., 2021; Jones et al., 2015). Research demonstrates that women experience disproportionate drug-related health harms and have greater unmet addiction treatment needs compared to men (Des Jarlais et al., 2012; Greenfield et al., 2007b; Harris et al., 2022). Rates of prescription opioid and heroin-related overdose deaths increased at a more than 2:1 rate in women compared to men between 1999 and 2017 (Jones et al., 2015; VanHouten, 2019). Given shifting epidemiologic trends and rising drug-related health harms among women, the field needs to understand how gender shapes drug use and addiction service experiences to inform effective addiction service and policy development (Keyes et al., 2008; Seedat et al., 2009).

Despite evidence demonstrating gender differences in access, experience, and effectiveness of SUD treatment, most substance use services (e.g. harm reduction programs, detoxification, residential treatment facilities, recovery support groups, and medication treatment services) have been designed and implemented using a gender-neutral approach (Iversen et al., 2015; Meyer et al., 2019; Meyers et al., 2020). Such approaches benefit men over women as they fail to consider the impact of gender-related marginalization and women’s specific needs (Choi et al., 2021; Collins et al., 2019). For example, women experience greater economic disparities, have a higher burden of mental health and trauma, have more childcare responsibilities, and have different physical, sexual, and reproductive health needs compared to men (Harris et al., 2022). Despite women accounting for approximately one-third of people with SUD, only one-fifth of people in addiction treatment are women, highlighting a persistent treatment gap (United Nations, 2020). Designing programs that address women’s needs could mitigate such disparities (Greenfield & Grella, 2009). Though some women-specific substance use services are available, they tend to be concentrated in urban settings and/or primarily designed for pregnant or newly parenting women (Boyd et al., 2020; Niv & Hser, 2007). Other key services for women’s well-being, such as interpersonal violence services, mental health care, sexual and reproductive health care, and child care services, remain siloed from substance use services. (Harris et al., 2022).

The fragmentation of services is problematic given that experiences of physical and sexual violence and related trauma may be key drivers of drug related risks and barriers to substance use prevention and treatment among women (Boyd et al., 2018a; El-Bassel et al., 2020; Harris et al., 2021). Intersectionality is a critical theoretical framework that draws attention to how systems of power and privilege impact those with multiple stigmatized identities (e.g., female gender) and practices (e.g., drug use, sex work) (Bowleg, 2008, 2012; Crenshaw, 2013). For example, related to the criminalization of and stigma associated with sex work, engaging in sex work exacerbates gender-based violence and drug related harms among women who use drugs (Beattie et al., 2015; El-Bassel et al., 2020; Goldenberg et al., 2020). Ethnographic studies on harm reduction services find that such settings can offer refuge from physical and sexual violence (Boyd et al., 2018a; Fairbairn et al., 2008). However, many harm reduction spaces remain male-dominated thereby reproducing societal gender-power imbalances (Bonny-Noach & Toys, 2018; Boyd et al., 2018b), and few studies have explored gendered experiences in other substance use service settings. Applying an intersectional lens is thus essential to understanding how multiple axes of discrimination related to social identities (e.g., female gender) and practices (e.g., drug use and sex work) intersect and influence what it means to be a woman who uses drugs in a particular social and cultural context (Kulesza et al., 2016; Logie et al., 2021; Shields, 2008).

Therefore, grounded in the theory of intersectionality, we conducted a secondary analysis of qualitative interviews among self-identified women using non-prescribed opioids to understand women’s needs around drug use and substance use treatment. We examined how the axes of gender identity and drug use and sex work practices intersected and related to: (1) drug use experiences, (2) experiences with substance use services, and (3) preferences for substances use services. Findings from this work may help inform the development of future gender-responsive substance use treatment services and drug policy.

2. Methods

2.1. Design and setting

We conducted a secondary analysis of a two-site, mixed-methods study of self-identified women. The primary study aimed to (1) assess the acceptability of research recruitment strategies and (2) describe experiences with and preferences for research and drug use service engagement among women actively using non-prescribed opioids. Interviews also explored drug use experiences. The University of California, San Francisco Institutional Review Board (19–29181) and the Boston Medical Center Institutional Review Board (H-39303) reviewed and approved the study.

2.2. Recruitment

Research staff in Boston and San Francisco recruited individuals who met the following criteria: identified as women, English-speaking, aged 18–65, and reported non-prescribed opioid use in the past 14 days. Previous research showed age as an important factor in women’s research participation and drug use experiences, thus we intended to recruit 15 individuals under age 30. The study included three planned recruitment strategies: collaboration with a community partners, social media, and respondent driven sampling (Gelinas et al., 2017; Heckathorn, 1997; M. Jones et al., 2022). Approximately two months after study recruitment began in January 2020, the emergence of COVID-19 restricted in-person recruitment approaches. In response, research staff at both sites implemented a 4^th recruitment strategy, “passive recruitment” defined below. Recruitment ended in October 2020.

In Boston, we identified a community-based partner that serves people who use drugs and the study supported 0.20 FTE of an outreach worker’s salary to support recruitment efforts. In San Francisco, a dedicated recruitment manager, with extensive community enrollment expertise, received part-time salary support to lead recruitment efforts at community-based organizations including syringe services programs, shelters, and health centers tailored for people who use drugs. Social media recruitment involved tailored ad campaigns on Facebook and Instagram featuring women of diverse racial identities and explicit reference to opioid use. As part of the respondent-driven sampling approach, the study invited participants to complete a training on study goals and peer recruitment strategies and were provided with coupons to distribute to potential participants. Women who completed the 30-minute recruitment training to implement respondent-driven sampling received an additional $50 of compensation. Passive recruitment involved posting flyers at organizations that work with people experiencing homelessness, youth, transgender individuals, and people who use drugs, including health care centers, syringe service programs, shelters, and social service programs.

2.3. Qualitative interviews and questionnaire

The study team, including two addiction medicine clinicians and a qualitative health services researcher, developed a flexible interview guide and brief demographic questionnaire. Interview guides were tested prior to study initiation by two research staff. Following informed consent, research staff invited participants to participate in individual 45–60 minute in-person or telephone interviews. Trained research staff (AML, VMM, CB, all identifying as women) completed interviews between January–November 2020. A brief questionnaire collected demographic characteristics, highest level of education, caregiving role, housing status, past 30-day drug use, preferred drugs and routes of administration, and past 30-day overdose data. Interviews explored: (1) experiences with drug use and social services and health care related to being a woman; (2) experiences of recruitment for the current study; and (3) experiences in other research studies. Study staff conducted seventeen interviews in person and 19 virtually or by phone. This analysis specifically focused on the first domain. Interviews were audio-recorded and transcribed verbatim. Participants were compensated $40 for their time.

2.4. Analysis

Research staff imported de-identified transcripts into NVivo qualitative data management software version 12.1 (NVivo, 2012) for analysis. The lead author (MTHH) developed a codebook (Appendix 1) comprised of concepts represented in an intersectionality framework that focused on the axes of gender identity and sex work, and their relationship to drug use and health and social service experiences (Crenshaw, 2013; Logie et al., 2011). The codebook was tested on two transcripts and amended to clarify concepts and incorporate emergent, inductive themes not represented in the conceptual model (Ando et al., 2014). Two coders (combination pairs of MTHH, JL, and EH) independently coded six transcripts and came together to assess agreement, with discrepancies resolved through a group consensus process (Burla et al., 2008). The remaining transcripts were independently coded, and the coding team met to review and resolve any coding uncertainties regularly. We used grounded content analysis to identify themes related to the intersectional framework and inductive emergent themes related to drug use and service experiences (Corbin & Strauss, 2014). Pseudonyms are used throughout the article to protect participant confidentiality.

3. Results

A total of 36 participants completed interviews, 16 in Boston and 20 in San Francisco. Seventeen participants were recruited prior to COVID-19 and related study activity changes and 19 were recruited after. Table 1 displays recruitment sources and participant characteristics. Most (31, 86%) participants were recruited through community partnership and passive community outreach strategies. The median age was 46 years; 58% were White, 14% were Hispanic, and 39% were unstably housed. Though we did not ask about sex work practices a priori, most women talked about sex work and 13 women reported engaging in sex work. Neither gender identity nor sexual orientation data were collected a priori and though none of the participants discussed experiences related to being trans- or queer-gender several participants identified as gay, lesbian, and/or bisexual. Multiple substance use was common among participants with more than half reporting heroin, fentanyl, benzodiazepines, and/or cocaine in the past 30 days. Methamphetamine use was also common and varied by region where 65% reported use in San Francisco and 31% reported use in Boston.

Table 1. Participant Demographics and Characteristics of Self-Identified Women with Opioid Use from San Francisco and Boston, 2020

_{a. Participants could respond yes vs no to multiple substances, thus drug use practices add up to more than 100%.}

_{B. Post secondary education included associate’s degree, bachelor’s degree, and master’s degree.}

_{c. Participants were asked where they slept most of the time in the past 30 days. Responses of car, bus, truck, or other vehicle, abandoned building, shelter, or on the streets were considered unstably housed; all other response e.g. living in an apartment or SRO were considered housed.}

Though the study predominantly recruited women from urban sites in Boston and San Francisco, women shared diverse life experiences spanning many years and locations. For example, women discussed drug use and service experiences from their youth and from other cities or states. From these diverse experiences and the content analysis, we distilled four themes related to the intersection of gender identity and drug use and sex work practices, and their impact on drug use and substance use care experiences.

3.1. The intersection of gender identity and drug use and sex work practices magnified experiences of oppression among women.

Women described how drug use practices intersected with gender-related oppression, compounding experiences of marginalization and exacerbating power imbalances between men and women. Women related such power imbalances to the fact that drug use environments, economies, and social relationships were controlled by men.

“It’s just hard, period. I mean, it’s like imagine a woman that doesn’t do drugs getting through the world, right? You take stuff like that, and you add a million on top of that, and that’s what it’s like [for women who use drugs]. I mean, most of the dope dealers are men…If you let them, [the men] will walk all over you.” (Darlene, <30-years-old, San Francisco)

A lack of safety while using drugs was a primary concern and was sometimes related to practical physical differences between men and women, as Deena (<30-years-old, Boston) described, “I mean, well obviously, we’re smaller, weaker, easier to get robbed, mugged, played, whatever from whoever...If you’re strung out and female, they will take advantage of you.” Participants described physical and sexual violence as ubiquitous in drug use environments, summarized by Sylvia (<30-years-old, San Francisco) “every single one out here, we have all been sexually assaulted”. Women attributed greater marginalization and violence to the intersection of female gender identity with drug use practices and assumed or intentional/coerced sex work practices.

“It’s almost like [the men] can smell the new females…And they get them and go take them somewhere, and start getting high, and the girl ends up passing out. And they wake up, and they don’t have nothing, and they’ve been raped, and all kinds of other things.” (Darlene, ≥ 30-years-old, San Francisco)

“As my addiction progressed, I turned to prostitution. I was on the street. I was actually held hostage by a drug dealer. You’re just an object that someone used to make a profit. feel like I’m a human statistic and stigmatized.” (Tamera, ≥30-year-old, Boston):

Women felt that the criminalization of drug use exacerbated gender-based violence. Criminalization and policing made women more, rather than less, vulnerable to violence because perpetrators knew women who used drugs would be less likely to seek help or report an assault.

“Anytime you’re high and you’re in a vulnerable state that makes it easy for someone to target you. The fact that you’re doing something that’s illegal and are less likely to want to go to the police, that makes you an ideal target.” (Sophia, <30-years-old, Boston)

Repeated experiences of intimate partner violence or street-based violence during drug use or sex work resulted in trauma that perpetuated a cycle of drug use and lack of empowerment for some women. Other women felt this cycle impacted their mental health and ability to cope with adverse experiences.

“They do whatever they want to you. It’s degrading and it’s so hard to get out of that. You remember what it’s like. And the drugs intensify it…You don’t want to stay sober because of that, you don’t want to remember.” (Sylvia, <30-yrs-old, San Francisco)

“It’s much deeper than just being hit. I meet a lot of these younger girls, and I can just see it. It’s plain as day. And the only reason I see it is because it’s in me, too... After [seeing a new woman] walk away, I’ll tell my girlfriend, “How long do you give her?” And she’ll be like, “I give that one two weeks.” [Two weeks] Until she’s totally broken down…When you first meet the girls, they’re clean. They look healthy…Broken down is when you see them again, they ain’t got no shoes on. They’re filthy. They weigh about two pounds, soaking wet. They’re either being ran around by some dude, or they’re talking to themselves, they’re lost...It’s an ugly dark thing...It gets your mind all twisted up.” (Rhonda, ≥30-years-old, San Francisco)

The intersection of gender, drug use, and sex work compounded experiences of oppression and physical and sexual violence against women. Criminal and legal structures exacerbated women’s vulnerability and diminished their ability to protect themselves.

3.2. Women perceived that substance use services favored men socially and structurally.

All women in our study accessed some form of substance use or health service supports, such as methadone treatment, detoxification facilities, residential treatment, office-based addiction treatment, harm reduction programs, and/or shelter or housing services (herein referred to as substance use services). Women shared experiences that spanned their life and from different cities and states. When trying to access services women felt less prioritized compared to men.

“I feel like I’m not looked at as serious as a man would be…It’s like, she’s a woman. We’ll give her help, but she’ll wait. She’s not a top priority. She’s second…that’s putting it in a nutshell, that’s just what I observe…from what I see on the streets and from what I hear on the streets, it’s not just me.” (Terry, ≥30-years-old, San Francisco)

Women reported that substance use services structurally favored men in terms of access and design. Table 2 summarizes some of the gender-specific barriers reported by women, which included unmet sexual and reproductive health needs, lack of childcare, and inadequate bed availability.

Table 2. Gender-specific barriers to substance use services: example quotes selected from thirty-six qualitative interviews among women with opioid use from San Francisco and Boston, 2020.

Overall, though all women engaged with substance use services, the experiences of gender-related structural barriers to care, such as a lack of bed availability and childcare services, made it harder to access and engage.

3.3. Gender-based violence occurred in substance use service settings and perpetuated cycles of trauma.

Women felt that substance use services were male-dominated spaces. Half of the women in our study also described experiences of assault within substance use services that were attributed to their gender identities and assumed or intentional/coerced sex work practices. For example, peer assault was permissive in peer-recovery settings.

“There was a high, very high risk, even in recovery, of sexual assault… [In recovery meetings] older men or women with a lot of time under their belt, who sort of present themselves as a mentor…and prey on the younger, less sober folks. Their intention was to simply ... to use you, to get you in a position where you trust them enough where they can try to make a move on you physically in a sexual manner.” (Lilianna, <30-years-old, Boston)

Women also witnessed and experienced sexual assaults in harm reduction programs, at times perpetrated by staff. While Sophia (<30-years-old, Boston) related an experience of assault from a physician at a harm reduction program, she emphasized “when I say that people are likely to target you, I’m not talking about drug dealers. I’m talking about doctors. People are who just like, ‘Oh, nobody’s going to believe her. She’s just some druggy.’ The people that I’ve had the most problems with are not other individuals who use drugs, it’s largely been medical professionals.” Such experiences of assault caused further traumatization and barriers to care.

“I know a lot of females that have doctors proposition them because they think that because you do dope, you’re automatically a prostitute…it’s still even hard for me to go to the doctor. I think my wife feels like this, my daughter does, too…I even know a couple of females that took them up on the offer because they thought, “Oh, doctor, okay. Lots of money” (Darlene, ≥30-years-old, San Francisco)

“I’ve talked to a few girls that think that kind of environment [a recovery high-school where abuse occurred] was good for them, and others who kind of had the same experience as me where they feel like it was just totally traumatizing and that they just came out worse as a result of it.” Abigail (<30-years-old, Boston)

In summary, women reported persistent gender-based violence and fear of violence in substance use service settings, and these experiences created more trauma and barriers to care.

3.4. Substance use services that were safe and responsive to women’s specific needs were valued and desired by women.

Women described resilience and empowerment related to identifying as a woman. Some women derived strength from parenting and other strong social connections or obligations. As Rhonda (≥30-years-old, San Francisco) explained, “as women, we’re already nurturers, we’re really the strong backbone of the family and the family inspired them to seek help and addiction treatment”. Similarly, women took care of each other in drug use environments.

“Everybody looked out for each other. If somebody was sick, we wouldn’t leave our friend sick. If we have money, we’re not making somebody go have sex or do something they don’t want to do to get high. We’re going to help them” (Alex, ≥30-years-old, Boston)

Women sought substance use services that facilitated female empowerment and addressed their specific needs. Table 3 summarizes some features of programs that women valued and/or desired. Women valued programs in which they felt safe, such as women-led or women’s only services or services tailored to LGTBQIA/queer individuals. Women also valued services that addressed their specific needs, including offering tampons, socks, underwear, and hygiene products. Programs that incorporated trauma-informed approaches were also key for women staying engaged with services. Women discussed the importance of staff having skills to support them during times of crisis, for example when they were feeling over intoxicated or having a manic episode. Some participants called for greater street outreach efforts to protect women engaged in sex work given their heightened risks of violence. Last, women appreciated programs that offered non-judgmental care and offered positive reinforcement throughout their substance use and treatment journeys.

Table 3. Features of substance use services preferred by women: example quotes selected from thirty-six in-depth interviews among women with opioid use from San Francisco and Boston, 2020.

Overall, women sought to engage with services that were safe, addressed their female-specific needs, facilitated connections between women, and were judgment-free. In general, women felt more outreach and gender responsive services were needed.

4. Discussion

This qualitative study among 36 women reporting recent non-prescribed opioid use in San Francisco and Boston identified several important findings. Interviews revealed that intersectional positions across multiple axes of discrimination including being a woman, engaging in drug use, and practicing sex work, exacerbated experiences of marginalization. Physical, sexual, and psychological violence were ubiquitous in drug use environments, and women attributed violence to the intersection of gender identity and drug use and sex work practices. Some women reported experiences of gender-based violence when engaging with substance use services, including violence committed by service providers. Such experiences perpetuated cycles of trauma and exacerbated barriers to care. Participants perceived substance use services that facilitated connections between women and addressed women’s specific needs as safe, valued, and sought after.

Our findings highlight the complex interaction of intersectional identities and practices resulting in experiences of marginalization among women who use drugs. Policies and systems exacerbated oppression, especially among women who practiced sex work. Women in this study noted that the criminalization of drug use and sex work intensified gender-based violence. The use of illegal drugs increased women’s vulnerability because assaulters knew that women would be less like to seek and/or receive help from the criminal-legal system. Our findings build on other studies that similarly show the deleterious consequences of drug use and sex work criminalization. Ethnographic data from cis-and transgender women sex workers in Vancouver, Canada showed that policing increased rather than decreased their vulnerability to violence (Krüsi et al., 2014). Among a cohort of sex workers also from Vancouver, most of whom used drugs, punitive policing practices were associated with increased odds of overdose and reduced odds of substance use treatment access (Goldenberg et al., 2020; Goldenberg et al., 2022). Our findings strengthen calls for decriminalization of drug use and sex work along with policies and interventions that strengthen trauma-informed substance use services. (Goldenberg, 2020; Shannon et al., 2008).

Our study highlights the need for more research that examines experiences of violence within substance use service settings. Half of participants reported experiences of sexual or physical assault when accessing substance use services. Assaults were perpetrated by other people using the services, but also by health and social service professionals delivering care. Such experiences of assaults caused further traumatization and exacerbated barriers to care for women in our study. Though evidence exists showing gender-based violence is common and a significant factor in increasing drug use harms and reducing access to substance use services for women who use drugs (Deering et al., 2021; El-Bassel et al., 2020; Lorvick et al., 2014), few studies have focused on violence occurring within these settings and the potential impact on treatment access and effectiveness. In addition to research, substance use services must examine policies, procedures, and cultures that may be contributing to violence against women and/or underreporting of assaults.

Women felt substance use services de-prioritized them and believed that services socially and structurally favored men in terms of access and design. Specifically, women noted that substance use services did not address women’s sexual and reproductive health and childcare needs. Such experiences are consistent with studies that show the persistent barriers to treatment among women and treatment service gaps between men and women (Aggarwal et al., 2021; Ayon et al., 2018; Choi et al., 2021). In keeping with past studies, women valued substance use services that facilitated empowerment and safety (Boyd et al., 2020; Meyer et al., 2019). Participants perceived women’s only and LGTBQIA spaces as safe and welcoming. Women appreciated programs that were trauma-responsive and offered sexual and reproductive health services. Research shows that gender-responsive SUD treatment, treatment that is tailored to address the specific needs of women, improves SUD outcomes such as treatment access and retention (Greenfield et al., 2007a; Niv & Hser, 2007). Previous work also shows that women-only and sex work specific service utilization increases linkage to other addiction and sexual and reproductive healthcare for women who use drugs (Ayon et al., 2019; Kim et al., 2015). Thus, our work strengthens calls for the development, implementation, and investment in gender-responsive substance use services. Such efforts should include the integration of women who use drugs within the substance use care-related work force based on the reported value of peer-support in our study and evidence that peer-delivered services increase engagement with care (Collins et al., 2019; Deering et al., 2011).

Our findings must be interpreted within the context of the study’s limitations. The study sample and approach mitigated exploring the impact of key racial and ethnic intersectional identities. Additionally, our study focused explicitly on female gender identity, and we did not collect nor explore diverse gender or sexual orientation identities and their intersectional impact on experiences. Thus, the value of women-only and sexual reproductive health services reported by our participants may be overstated and/or lacking nuance. More qualitative and quantitative research should seek to better understand the impact of multiple intersecting identities on drug use and substance use service experiences to inform establishing inclusive and responsive approaches. Young women were also under-represented in our study. Other studies suggest young women may experience more violence and greater barriers to care, therefore more research focused on youth experiences are needed (Chettiar et al., 2010; Hatzenbuehler & Pachankis, 2016). COVID-19 forced changes in recruitment and interview procedures during the study. Those recruited after the emergence of COVID-19 may have been different from the women recruited before and thus our findings may have been impacted by COVID-19, but this was not systematically assessed. Last, the study recruited participants from two geographic locations, and our data provides a snapshot of experiences that may be less generalizable to other settings.

5. Conclusion

Women described repeated experiences of marginalization when accessing substance use services that exacerbated a cycle of trauma and drug use. In addition to increasing gender-responsive services that integrate trauma-informed models of care, our study highlights the need for research that examines experiences of violence within substance use service settings. Participants spoke out about program cultures and policies that made it unsafe for them to seek needed care. The SUD treatment community should also investigate and address its own practices that may be contributing gender-based violence and the re-traumatization of women accessing care.

Introduction

In the United States over the last ten years, a growing number of women have started using drugs or developed substance use disorders. Studies show that women face more health problems related to drug use and have greater unmet needs for addiction treatment than men. For instance, between 1999 and 2017, deaths from prescription opioid and heroin overdoses increased at twice the rate for women compared to men. Given these changing patterns and the increasing harm from drug use among women, it is important to understand how gender influences drug use and experiences with addiction services. This understanding can help develop effective treatment services and policies.

Although research shows that men and women have different experiences with substance use disorder treatment, most services are designed without considering gender. This general approach often serves men better because it does not account for the unique challenges and needs of women. For example, women often face more economic hardship, a higher risk of mental health issues and trauma, greater childcare duties, and distinct physical, sexual, and reproductive health needs. Women make up about one-third of people with substance use disorders, yet only one-fifth of those in addiction treatment are women, showing a significant gap in care. Programs that address women's specific needs could help close this gap. While some services exist for women, they are often in cities or mainly for pregnant or new mothers. Additionally, other important services for women, like help for violence, mental health care, reproductive health, and childcare, are often separate from substance use services.

The separation of these services is an issue because physical and sexual violence, and related trauma, can drive drug-related risks and create barriers to prevention and treatment for women. Intersectionality is an important concept that highlights how systems of power affect individuals with multiple marginalized identities, such as being a woman who uses drugs or engages in sex work. For example, the criminalization and stigma of sex work worsen gender-based violence and drug-related harms for women who use drugs. While some harm reduction services can offer safety from violence, many remain male-dominated, reflecting existing power imbalances in society. Few studies have looked at women's specific experiences in other substance use service settings. Therefore, using an intersectional perspective is crucial to understand how different forms of discrimination, based on identities like gender and practices like drug use or sex work, shape the experiences of women who use drugs in different social and cultural settings.

This study, based on the theory of intersectionality, involved a secondary analysis of interviews with women who identified as using non-prescribed opioids. The purpose was to understand women's needs concerning drug use and treatment. Researchers examined how gender identity, drug use, and sex work practices combined to influence: (1) drug use experiences, (2) experiences with substance use services, and (3) preferences for these services. The results of this study aim to help develop future substance use treatment services and drug policies that are more responsive to gender.

Methods

This study involved a secondary analysis of a two-site, mixed-methods study that included self-identified women. The main study aimed to assess how acceptable research recruitment strategies were and to describe the experiences and preferences of women actively using non-prescribed opioids regarding research and drug use services. Interviews also covered drug use experiences. The study received approval from the Institutional Review Boards at the University of California, San Francisco, and Boston Medical Center.

Participants were recruited in Boston and San Francisco. Eligibility criteria included identifying as women, being English-speaking, aged 18–65, and reporting non-prescribed opioid use within the last 14 days. An effort was made to include younger women under 30. Initial recruitment strategies included working with community partners, social media campaigns, and respondent-driven sampling. Due to the COVID-19 pandemic starting in March 2020, a fourth strategy, "passive recruitment" via flyers in community organizations, was added. Recruitment concluded in October 2020.

A study team, which included addiction medicine clinicians and a health services researcher, created an interview guide and a short demographic questionnaire. These guides were tested before the study began. After obtaining informed consent, participants completed individual 45–60 minute interviews, either in person or by phone. Trained staff conducted these interviews from January to November 2020. The questionnaire gathered information on demographics, education, caregiving roles, housing, recent drug use, preferred substances, and overdose history. Interviews explored women's experiences with drug use, social services, and healthcare, particularly as they related to being a woman. Audio recordings of interviews were transcribed, and participants received $40 for their time.

Transcripts were imported into NVivo software for analysis. A codebook was developed by the lead author, focusing on how gender identity and sex work intersect with drug use and health service experiences. This codebook was tested and refined to include new themes. Multiple coders independently analyzed transcripts, meeting regularly to resolve any differences. Grounded content analysis was used to identify themes related to the intersectional framework and new themes about drug use and service experiences. Pseudonyms are used in reporting findings to protect participant privacy.

Results

Interviews were completed by 36 participants, with 16 in Boston and 20 in San Francisco. About half were recruited before the COVID-19 pandemic. Most participants (86%) were recruited through community partnerships or passive outreach. The average age was 46 years, and the group was diverse, with 58% identifying as White and 14% as Hispanic. Many (39%) were unstably housed. Although not specifically asked, 13 women reported engaging in sex work. Many participants reported using multiple substances, including heroin, fentanyl, benzodiazepines, and cocaine in the past month. Methamphetamine use was also common, particularly in San Francisco. The diverse experiences shared led to four main themes about the intersection of gender identity, drug use, and sex work, and their impact on drug use and substance use care.

The Intersection of Gender Identity, Drug Use, and Sex Work Practices

Women described how being a woman, using drugs, and engaging in sex work created amplified experiences of hardship. They noted that drug use environments, economics, and relationships were often controlled by men, leading to power imbalances and a lack of safety. Physical and sexual violence were reported as common in these settings, with perpetrators often taking advantage of women due to their perceived vulnerability. The criminalization of drug use and sex work worsened this violence, as women felt less likely to seek help or report assaults to authorities. These repeated experiences of violence and trauma often led to a cycle of continued drug use and decreased ability to cope. Overall, the combination of gender, drug use, and sex work increased women's exposure to harm and limited their self-protection.

Perceived Bias Towards Men in Substance Use Services

All participants had used some form of substance use or health support services. However, women felt they were often less prioritized than men when seeking these services. They believed that substance use services were structured in ways that favored men, limiting women's access and engagement. Key barriers for women included unmet sexual and reproductive health needs, a lack of childcare options, and insufficient bed availability in treatment facilities. These gender-related structural obstacles made it harder for women to access and stay engaged with necessary care.

Gender-Based Violence Within Substance Use Service Settings

Women reported that substance use service environments often felt male-dominated. Half of the participants described experiencing assault within these services, which they linked to their gender identity and perceptions of sex work involvement. These assaults occurred not only from peers but, concerningly, also from staff or professionals, including physicians. Such experiences of violence caused more trauma and created additional barriers to women seeking or continuing care. Ultimately, the fear and reality of gender-based violence in these settings worsened women's trauma and hindered their access to treatment.

Desired Qualities in Substance Use Services

Despite challenges, women expressed resilience and found strength in their female identity, often through parenting or strong social bonds. They also reported supporting one another within drug use environments. Participants wanted substance use services that promoted women's empowerment and met their unique needs. They valued safe environments, such as women-led or women-only programs, and services tailored for LGBTQIA individuals. Essential provisions like hygiene products were also important. Programs that were trauma-informed and offered non-judgmental care, along with positive reinforcement, were highly valued. Women also highlighted the need for staff trained to support them during crises and for increased outreach to protect women involved in sex work. Overall, women desired safe, gender-responsive services that fostered connections and offered compassionate care.

Discussion

This study of 36 women who recently used non-prescribed opioids in San Francisco and Boston uncovered several key findings. The interviews showed that having multiple marginalized identities, such as being a woman, using drugs, and engaging in sex work, worsened experiences of discrimination and exclusion. Physical, sexual, and psychological violence were common in drug use settings, and women linked this violence to the combination of their gender identity, drug use, and sex work practices. Some women also reported experiencing gender-based violence, even from service providers, while seeking substance use care. These experiences deepened cycles of trauma and made it harder for women to access treatment. Participants considered substance use services that fostered connections among women and addressed their specific needs to be safe, valuable, and desirable.

The study’s findings emphasize how different aspects of a woman's identity and life, like being a woman who uses drugs and engages in sex work, combine to create severe marginalization. Current policies and systems often worsen this hardship, particularly for women involved in sex work. Women in the study noted that making drug use and sex work illegal increased their exposure to gender-based violence. This is because attackers knew women would be less likely to seek help from the legal system. These findings support other research showing the harmful effects of criminalizing drug use and sex work. The study therefore reinforces arguments for decriminalization and for developing trauma-informed substance use services.

This study points to a need for more research on violence within substance use service settings. Half of the participants reported experiencing sexual or physical assault while trying to access these services. These assaults were sometimes committed by other clients, but also by health and social service professionals. Such incidents led to further trauma and created more barriers to care for women. While it is known that gender-based violence is common and significantly increases drug-related harms and reduces access to services for women who use drugs, there has been limited focus on violence occurring specifically within these treatment environments. Beyond more research, substance use services themselves must review their policies, procedures, and internal cultures to address factors that might contribute to violence against women or discourage reporting of assaults.

Women in the study felt that substance use services often put their needs last and were designed in ways that benefited men. They specifically pointed out that services did not address women's sexual and reproductive health or childcare needs. These observations align with existing studies that highlight ongoing barriers to treatment for women and a gap in services compared to men. Consistent with prior research, women valued services that promoted their empowerment and safety. They saw women-only and LGBTQIA-friendly spaces as secure and inviting. Participants also appreciated programs that used trauma-informed approaches and offered sexual and reproductive health services. Research indicates that substance use disorder treatment specifically designed for women's needs improves outcomes like access to and continued engagement with treatment. This study therefore supports calls for developing, implementing, and funding substance use services that are more responsive to gender. Such efforts should consider including women who use drugs in the workforce of these services, given the reported value of peer support.

The findings of this study should be understood within its limitations. The study design did not fully explore the impact of specific racial and ethnic identities. Additionally, the study focused on female gender identity and did not collect or examine diverse gender or sexual orientation identities, meaning the reported value of women-only or sexual reproductive health services might lack full nuance. Further research is needed to better understand how multiple intersecting identities affect drug use and service experiences, which can help create more inclusive approaches. Young women were also not fully represented in the study, and more research is needed on their experiences, as they may face more violence and barriers to care. Changes in recruitment due to the COVID-19 pandemic may have influenced the findings, though this was not systematically assessed. Finally, as participants were recruited from only two cities, the findings may not be broadly applicable to all other settings.

Conclusion

Women in the study consistently reported experiencing marginalization when trying to access substance use services, which worsened a cycle of trauma and drug use. Beyond increasing gender-responsive services that include trauma-informed care, this study emphasizes the need for research into violence within substance use service settings. Participants highlighted program cultures and policies that created unsafe environments, making it difficult for them to seek help. The substance use disorder treatment community should actively investigate and address its own practices that might contribute to gender-based violence or re-traumatize women seeking care.

Introduction

Over the past decade in the United States, a growing number of women have begun using drugs and developing substance use disorders. Research indicates that women often experience more severe health problems related to drug use and have greater difficulty accessing addiction treatment compared to men. For instance, the rate of deaths from prescription opioid and heroin overdoses increased significantly faster for women than for men between 1999 and 2017. Given these changing trends and the rise in drug-related harms among women, it is crucial for experts to understand how gender influences drug use and experiences with addiction services. This knowledge can help develop more effective treatment programs and policies.

Despite clear evidence of gender differences in accessing, experiencing, and benefiting from substance use disorder treatment, most services—such as harm reduction programs, detoxification, residential treatment, support groups, and medication-assisted treatment—have been designed without considering gender. These "gender-neutral" approaches often benefit men more than women, as they fail to account for issues like gender-related disadvantages and women's specific needs. For example, women often face greater financial challenges, a higher burden of mental health issues and trauma, more childcare responsibilities, and distinct physical, sexual, and reproductive health needs compared to men.

Even though women represent about one-third of people with substance use disorders, only one-fifth of those in addiction treatment are women. This highlights a significant gap in treatment access. Designing programs that specifically address women's needs could help close this gap. While some women-specific substance use services exist, they are often found mainly in cities or are primarily designed for pregnant or new mothers. Other vital services for women's well-being, such as support for interpersonal violence, mental health care, sexual and reproductive health care, and childcare services, often operate separately from substance use services.

This separation of services is problematic because experiences of physical and sexual violence and related trauma can be major factors driving drug-related risks and creating barriers to prevention and treatment for women. An "intersectionality" framework helps understand how various systems of power and privilege affect individuals with multiple marginalized identities (like being a woman) and practices (like drug use or sex work). For example, the criminalization and stigma linked to sex work can worsen gender-based violence and drug-related harms for women who use drugs. Understanding how different forms of discrimination related to social identities (such as being a woman) and practices (like drug use and sex work) interact is essential for understanding the experiences of women who use drugs in specific social and cultural settings. This study therefore uses an intersectional approach to explore women's needs related to drug use and treatment.

Methods

Design and setting

This study involved a secondary analysis of interviews with women who identified themselves as using non-prescribed opioids. The original study took place at two locations and used a mix of methods. Its main goals were to see how acceptable recruitment strategies were and to describe women's experiences with and preferences for research and drug use services. The interviews also explored their drug use experiences. The study received approval from the institutional review boards at the University of California, San Francisco and Boston Medical Center.

Recruitment

Researchers in Boston and San Francisco recruited women who met specific criteria: self-identifying as women, being English-speaking, aged 18–65, and reporting non-prescribed opioid use in the past 14 days. An aim was to recruit 15 individuals under age 30, as age has been shown to be an important factor in women’s research participation and drug use experiences. Three recruitment strategies were planned: working with community partners, using social media, and employing respondent-driven sampling. However, after the start of recruitment in January 2020, the COVID-19 pandemic limited in-person methods. As a result, research staff added a fourth strategy called "passive recruitment." Recruitment concluded in October 2020.

In Boston, a community organization that serves people who use drugs partnered with the study. In San Francisco, a dedicated recruitment manager, experienced in community enrollment, led efforts at various community-based organizations, including syringe services programs, shelters, and health centers for people who use drugs. Social media recruitment involved ads on Facebook and Instagram featuring diverse women and mentioning opioid use. For respondent-driven sampling, participants were invited to a training on study goals and peer recruitment, and given coupons to distribute to potential participants. Women who completed this training received additional compensation. Passive recruitment involved posting flyers at organizations assisting people experiencing homelessness, youth, transgender individuals, and people who use drugs.

Qualitative interviews and questionnaire

The study team, which included addiction medicine doctors and a researcher specializing in qualitative health services, created a flexible interview guide and a short demographic questionnaire. The interview guides were tested before the study began. After participants provided informed consent, research staff invited them to individual 45–60 minute interviews, conducted either in person or by telephone. Trained research staff, all identifying as women, conducted interviews between January and November 2020. A brief questionnaire gathered information on demographics, education level, caregiving roles, housing status, drug use in the past 30 days, preferred drugs and administration methods, and overdose data from the past 30 days. The interviews explored several areas, including: experiences with drug use, social services, and healthcare related to being a woman; experiences with recruitment for the current study; and experiences in other research studies. Seventeen interviews were conducted in person, and 19 were conducted virtually or by phone. This specific analysis focused on the first area of inquiry. Interviews were audio-recorded and transcribed word-for-word. Participants received $40 for their time.

Analysis

De-identified interview transcripts were uploaded into NVivo software for analysis. The lead author developed a codebook based on an intersectionality framework, focusing on how gender identity and sex work relate to drug use and experiences with health and social services. This codebook was tested on two transcripts and updated to clarify concepts and include new themes that emerged during the analysis. Two coders independently analyzed six transcripts and met to discuss and resolve any disagreements through group consensus. The remaining transcripts were coded independently, with regular meetings held by the coding team to review and address any uncertainties. A grounded content analysis approach was used to identify themes related to the intersectional framework and new themes about drug use and service experiences. Pseudonyms are used in this report to protect participant privacy.

Results

A total of 36 women completed interviews, with 16 in Boston and 20 in San Francisco. Seventeen participants were recruited before the COVID-19 pandemic impacted study activities, and 19 were recruited afterward. Most participants (86%) were recruited through community partnerships and passive community outreach. The average age was 46 years; 58% were White, 14% were Hispanic, and 39% experienced unstable housing. While sex work practices were not initially asked about, most women discussed it, with 13 reporting engaging in sex work. Neither gender identity nor sexual orientation data were collected at the outset, and though no participants discussed experiences related to being transgender or queer-gender, several identified as gay, lesbian, or bisexual. Using multiple substances was common, with more than half reporting heroin, fentanyl, benzodiazepines, and/or cocaine use in the past 30 days. Methamphetamine use was also frequent, varying by region, with 65% reporting use in San Francisco and 31% in Boston.

Even though the study primarily recruited women from urban areas, they shared diverse life experiences spanning many years and locations, including past drug use and service experiences from their youth or other cities. From these varied accounts, four main themes emerged concerning how gender identity intersected with drug use and sex work practices, and how these factors affected drug use and substance use care experiences.

The intersection of gender identity and drug use and sex work practices magnified experiences of oppression among women.

Women described how their drug use combined with gender-related oppression, intensifying their marginalization and worsening power imbalances between men and women. They linked these power imbalances to the fact that drug use environments, economies, and social relationships were often controlled by men. For example, one woman noted the difficulty for women who use drugs, saying, "It's just hard, period. I mean, it's like imagine a woman that doesn't do drugs getting through the world, right? You take stuff like that, and you add a million on top of that, and that's what it's like [for women who use drugs]. I mean, most of the dope dealers are men…If you let them, [the men] will walk all over you."

A major concern was the lack of safety while using drugs, sometimes related to physical differences. As one participant explained, women are "smaller, weaker, easier to get robbed, mugged, played, whatever from whoever...If you're strung out and female, they will take advantage of you." Participants frequently described physical and sexual violence in drug use settings. One woman stated, "every single one out here, we have all been sexually assaulted." Women believed that being female, using drugs, and engaging in sex work (whether intentional or coerced) led to greater marginalization and violence.

One woman described the predatory behavior of some men: "It’s almost like [the men] can smell the new females…And they get them and go take them somewhere, and start getting high, and the girl ends up passing out. And they wake up, and they don’t have nothing, and they’ve been raped, and all kinds of other things." Another shared how addiction led her to prostitution and being held hostage by a drug dealer, making her feel like "just an object that someone used to make a profit. I feel like I’m a human statistic and stigmatized.”

Women felt that the criminalization of drug use worsened gender-based violence. They believed that laws and policing made women more, not less, vulnerable to violence because perpetrators knew that women who used drugs would be less likely to seek help or report an assault. One participant explained, "Anytime you’re high and you’re in a vulnerable state that makes it easy for someone to target you. The fact that you’re doing something that’s illegal and are less likely to want to go to the police, that makes you an ideal target.”

Repeated experiences of violence, whether from intimate partners or on the street during drug use or sex work, often resulted in trauma. For some women, this trauma led to a cycle of continued drug use and a feeling of powerlessness. Others felt this cycle harmed their mental health and ability to cope with difficult experiences. One woman remarked, "They do whatever they want to you. It’s degrading and it’s so hard to get out of that. You remember what it’s like. And the drugs intensify it…You don’t want to stay sober because of that, you don’t want to remember.” Another described seeing younger women enter the same cycle, becoming "totally broken down" and losing their health and sense of self. The combination of gender, drug use, and sex work amplified oppression and violence against women, with legal systems further increasing their vulnerability and reducing their ability to protect themselves.

Women perceived that substance use services favored men socially and structurally.

All women in this study had accessed some form of substance use or health support, such as methadone treatment, detoxification, residential treatment, office-based addiction treatment, harm reduction programs, or shelter/housing services. These experiences spanned their lives and various locations. When attempting to access services, women felt less prioritized compared to men. One participant observed, "I feel like I’m not looked at as serious as a man would be…It’s like, she’s a woman. We’ll give her help, but she’ll wait. She’s not a top priority. She’s second…that’s putting it in a nutshell, that’s just what I observe…from what I see on the streets and from what I hear on the streets, it’s not just me.”

Women reported that substance use services were structured in ways that benefited men in terms of access and design. Common gender-specific barriers reported by women included unmet sexual and reproductive health needs, a lack of childcare services, and insufficient bed availability in facilities. For example, participants noted feeling their unique needs were overlooked: "I feel like women are forgotten about a lot of times unless you’re pregnant." Another highlighted the lack of safe housing options for women, stating, "They will put men in there with us. It’s supposed to be an all-female house, but they’ll put men in there, and that’s a dangerous situation.” The absence of childcare was a major hurdle for many: "You're trying to get clean, but you have no place to put your kid." Overall, despite engaging with services, women found it harder to access and commit to care due to gender-related structural obstacles like limited bed space and childcare.

Gender-based violence occurred in substance use service settings and perpetuated cycles of trauma.

Women felt that substance use services were often male-dominated spaces. Half of the women in the study also described experiencing assault within substance use services, which they attributed to their gender identities and perceived or actual engagement in sex work. For example, peer assault was often tolerated in peer-recovery settings. One young woman recounted, "There was a high, very high risk, even in recovery, of sexual assault… [In recovery meetings] older men or women with a lot of time under their belt, who sort of present themselves as a mentor…and prey on the younger, less sober folks. Their intention was to simply ... to use you, to get you in a position where you trust them enough where they can try to make a move on you physically in a sexual manner.”

Women also witnessed and experienced sexual assaults in harm reduction programs, sometimes perpetrated by staff. One participant described an assault from a physician at a harm reduction program, emphasizing, “when I say that people are likely to target you, I’m not talking about drug dealers. I’m talking about doctors. People are who just like, ‘Oh, nobody’s going to believe her. She’s just some druggy.’ The people that I’ve had the most problems with are not other individuals who use drugs, it’s largely been medical professionals.” Such experiences of assault led to further trauma and created more barriers to receiving care.

Participants spoke of doctors propositioning women, assuming that drug users were automatically prostitutes. This made it difficult for women to trust medical professionals. As one woman explained, "I know a lot of females that have doctors proposition them because they think that because you do dope, you’re automatically a prostitute…it’s still even hard for me to go to the doctor." Another shared how some women felt recovery high schools, where abuse occurred, were traumatizing and made them worse off. In summary, women reported ongoing gender-based violence and fear of violence within substance use service settings, and these experiences created more trauma and obstacles to care.

Substance use services that were safe and responsive to women’s specific needs were valued and desired by women.

Women described feelings of resilience and empowerment connected to their female identity. Some women found strength in their roles as parents and through other strong social connections or responsibilities. For instance, one participant noted that as women, they are "already nurturers, we’re really the strong backbone of the family," and their families inspired them to seek help and addiction treatment. Similarly, women often supported one another in drug use environments. As one woman described, "Everybody looked out for each other. If somebody was sick, we wouldn’t leave our friend sick. If we have money, we’re not making somebody go have sex or do something they don’t want to do to get high. We’re going to help them.”

Women sought substance use services that promoted female empowerment and addressed their specific needs. They valued programs where they felt safe, such as services led by women, services exclusively for women, or services tailored for LGBTQIA/queer individuals. They also appreciated services that provided essential items like tampons, socks, underwear, and hygiene products. Programs that adopted trauma-informed approaches were also crucial for women to remain engaged with services.

Participants emphasized the importance of staff being skilled in supporting them during crises, for example, when feeling overly intoxicated or having a manic episode. Some called for more street outreach efforts to protect women engaged in sex work, given their increased risk of violence. Lastly, women appreciated programs that offered non-judgmental care and provided positive reinforcement throughout their drug use and treatment journeys. Overall, women wished to engage with services that were safe, met their specific female needs, fostered connections among women, and were free of judgment. In general, they felt that more outreach and gender-responsive services were necessary.

Discussion

This qualitative study of 36 women who reported recent non-prescribed opioid use in San Francisco and Boston found several important results. The interviews showed that having multiple marginalized identities—being a woman, using drugs, and engaging in sex work—intensified experiences of oppression. Physical, sexual, and psychological violence were common in drug use environments, and women linked this violence to the combination of their gender identity and drug use or sex work practices. Some women reported experiencing gender-based violence even while accessing substance use services, with some acts committed by service providers. These experiences deepened trauma and created more barriers to care. Participants expressed that substance use services that fostered connections among women and addressed their specific needs were considered safe, valuable, and desirable.

The findings underscore the complex ways that intersecting identities and practices lead to marginalization among women who use drugs. Policies and systems exacerbated this oppression, especially for women involved in sex work. Women in this study noted that the criminalization of drug use and sex work increased gender-based violence. Using illegal drugs made women more vulnerable because attackers knew they would be less likely to seek or receive help from the criminal justice system. These findings support other studies that similarly demonstrate the harmful effects of criminalizing drug use and sex work. For example, research among sex workers, many of whom used drugs, found that punitive policing practices were linked to higher odds of overdose and lower access to substance use treatment. These findings reinforce calls for the decriminalization of drug use and sex work, along with policies and interventions that enhance trauma-informed substance use services.

This study highlights the need for more research examining experiences of violence within substance use service settings. Half of the participants reported experiencing sexual or physical assault when accessing these services. These assaults were perpetrated not only by other individuals using the services but also by healthcare and social service professionals providing care. Such experiences caused further trauma and created additional barriers to care for the women in this study. While evidence shows that gender-based violence is common and significantly increases drug use harms and reduces access to substance use services for women who use drugs, few studies have focused on violence occurring specifically within these settings and its potential impact on treatment access and effectiveness. In addition to further research, substance use services must review their policies, procedures, and organizational cultures that may contribute to violence against women or the underreporting of assaults.

Women felt that substance use services often de-prioritized them and were structured to favor men in terms of access and design. Specifically, women noted that substance use services did not address their sexual and reproductive health or childcare needs. These experiences are consistent with studies that highlight persistent barriers to treatment for women and ongoing treatment service gaps between men and women. In line with previous research, women valued substance use services that promoted empowerment and safety. Participants perceived women-only and LGBTQIA-affirming spaces as safe and welcoming. Women appreciated programs that were trauma-responsive and offered sexual and reproductive health services. Research indicates that gender-responsive substance use disorder treatment—care tailored to women's specific needs—improves outcomes such as treatment access and retention. Prior work also shows that women-only and sex work-specific service utilization increases connections to other addiction and sexual and reproductive healthcare for women who use drugs. Thus, this study strengthens calls for the development, implementation, and investment in gender-responsive substance use services. These efforts should include integrating women who use drugs into the substance use care workforce, given the reported value of peer support in this study and evidence that peer-delivered services increase engagement with care.

The findings of this study should be interpreted considering its limitations. The study sample and approach limited the exploration of the impact of important racial and ethnic intersectional identities. Additionally, the study focused specifically on female gender identity and did not collect or explore diverse gender or sexual orientation identities and their intersecting impacts on experiences. Therefore, the reported value of women-only and sexual and reproductive health services by participants may be overemphasized or lack full nuance. More qualitative and quantitative research is needed to better understand how multiple intersecting identities affect drug use and substance use service experiences, in order to inform the establishment of inclusive and responsive approaches. Young women were also underrepresented in this study. Other research suggests young women may experience more violence and greater barriers to care, indicating a need for more research focused on youth experiences. The COVID-19 pandemic led to changes in recruitment and interview procedures during the study. Participants recruited after the onset of COVID-19 might have differed from those recruited earlier, which could have impacted the findings, though this was not systematically assessed. Finally, the study recruited participants from two specific geographic locations, and the data provides a snapshot of experiences that may not be fully generalizable to other settings.

Conclusion

Women described repeated experiences of marginalization when accessing substance use services, which intensified a cycle of trauma and drug use. In addition to increasing gender-responsive services that incorporate trauma-informed care models, this study highlights the need for research that examines experiences of violence within substance use service settings. Participants spoke about program cultures and policies that made it unsafe for them to seek necessary care. The substance use disorder treatment community should also investigate and address its own practices that may contribute to gender-based violence and the re-traumatization of women seeking care.

Introduction

Over the last ten years in the United States, more women have started using drugs and have developed substance use disorders (SUD). Research shows that women experience more health problems from drug use and have greater needs for addiction treatment that are not met, especially compared to men. For example, between 1999 and 2017, deaths from prescription opioid and heroin overdoses increased much faster for women than for men. Given these changing patterns and the rising harm from drugs among women, it is important to understand how gender influences drug use and experiences with addiction services. This understanding can help create better addiction services and policies.

Even though there is clear evidence that gender affects access, experience, and effectiveness of SUD treatment, most drug services have been designed without considering gender differences. This approach often benefits men more because it does not account for specific challenges women face, such as financial difficulties, higher rates of mental health issues and trauma, more childcare duties, and different physical and reproductive health needs. Despite women making up about one-third of people with SUD, only one-fifth of those in addiction treatment are women, which highlights a major gap in services. Designing programs that address women's needs could help reduce these inequalities. While some services for women exist, they are often located in cities or are mainly for pregnant or new mothers. Other important services for women's well-being, like help for violence, mental health care, reproductive health, and childcare, are often separate from drug use services.

The fact that these services are separate is a problem. Experiences of physical and sexual violence and related trauma can be major reasons why women face drug-related risks and find it hard to get prevention and treatment. The idea of intersectionality helps explain how different forms of power and privilege affect people with multiple marginalized identities (like being a woman) and actions (like drug use or sex work). For instance, because sex work is often illegal and carries a lot of shame, engaging in it makes women who use drugs more likely to experience gender-based violence and drug-related harm. Studies have shown that harm reduction services can offer a safe place from such violence. However, many harm reduction spaces are mostly male-dominated, which can mirror power imbalances found in society. Few studies have looked at how gender influences experiences in other drug service settings. Therefore, using an intersectional approach is key to understanding how different types of discrimination related to social identities (like being a woman) and actions (like drug use and sex work) combine and affect what it means to be a woman who uses drugs in a specific social and cultural environment.

This study, using the theory of intersectionality, analyzed qualitative interviews from women who identified as using non-prescribed opioids. The goal was to understand their needs regarding drug use and treatment. The study looked at how gender identity, drug use, and sex work practices were connected to: (1) drug use experiences, (2) experiences with substance use services, and (3) preferences for these services. The findings from this research may help guide the development of future drug treatment services and policies that are more responsive to women's needs.

Methods

This study involved a closer look at information from a larger mixed-methods study conducted at two locations, one in San Francisco and one in Boston. The main goal of the original study was to see how well different ways of finding participants worked, and to describe the experiences and preferences of women who were actively using non-prescribed opioids regarding research and drug use services. The interviews also explored their drug use experiences. The study received approval from review boards at the University of California, San Francisco and Boston Medical Center.

Researchers in Boston and San Francisco recruited women aged 18-65 who spoke English and had reported using non-prescribed opioids in the past two weeks. The study aimed to include 15 participants under 30. Three recruitment methods were planned: working with community groups, using social media, and "respondent-driven sampling" (where participants refer others). After recruitment began, the COVID-19 pandemic limited in-person methods. As a result, staff added a fourth method: "passive recruitment" through flyers. Recruitment ended in October 2020. Recruitment efforts included partnering with community-based organizations, targeted social media campaigns, and encouraging participants to refer others.

The study team developed a flexible interview guide and a short questionnaire for demographics. Research staff tested the interview guides before the study began. After participants gave their informed consent, research staff invited them to individual 45-60 minute interviews, conducted either in person or by phone. Trained research staff completed interviews between January and November 2020. The questionnaire collected information on demographics, education level, caregiving role, housing status, drug use in the past 30 days, preferred drugs, and past 30-day overdose data. The interviews explored experiences with drug use, social services, and healthcare related to being a woman. This analysis specifically looked at these experiences. Interviews were audio-recorded and typed word-for-word. Participants received $40 for their time.

De-identified transcripts were put into a software program for analysis. The lead author developed a codebook, a list of concepts, based on an intersectionality framework that looked at gender identity and sex work, and how they related to drug use and experiences with health and social services. The codebook was tested and adjusted to clarify concepts and incorporate new themes that emerged during the interviews. Two coders independently reviewed transcripts and met to resolve any differences through discussion and agreement. A method called grounded content analysis was used to find themes related to the intersectional framework and new themes about drug use and service experiences. Fake names are used throughout the article to protect participant privacy.

Results

Interviews were completed with 36 women, 16 in Boston and 20 in San Francisco. Most participants were recruited through community outreach. The average age was 46 years. A majority were White, and over a third were unstably housed. Thirteen women reported engaging in sex work. Many participants used multiple substances, with common reports of heroin, fentanyl, benzodiazepines, or cocaine. Methamphetamine use varied by region, being more common in San Francisco.

Despite recruiting mainly from urban areas, women shared diverse life experiences from various times and places. Through analyzing these experiences, four main themes emerged. These themes highlighted how being a woman, using drugs, and engaging in sex work affected their drug use and experiences with care.

The intersection of gender identity and drug use and sex work practices magnified experiences of oppression among women.

Women explained that drug use combined with gender-related oppression made their struggles worse and increased power imbalances between men and women. They noted that drug environments, money-making activities, and social relationships were often controlled by men. For example, one woman stated, "It’s just hard, period. I mean, it’s like imagine a woman that doesn’t do drugs getting through the world, right? You take stuff like that, and you add a million on top of that, and that’s what it’s like [for women who use drugs]. I mean, most of the dope dealers are men…If you let them, [the men] will walk all over you.”

A major concern was the lack of safety while using drugs, sometimes linked to physical differences. As one participant noted, women are "smaller, weaker, easier to get robbed, mugged, played, whatever from whoever...If you’re strung out and female, they will take advantage of you." Participants described physical and sexual violence as widespread in drug use environments. One woman reported, "every single one out here, we have all been sexually assaulted.” Women connected greater marginalization and violence to the combination of being a woman with drug use and sex work. Another woman shared, “It’s almost like [the men] can smell the new females…And they get them and go take them somewhere, and start getting high, and the girl ends up passing out. And they wake up, and they don’t have nothing, and they’ve been raped, and all kinds of other things.”

Women felt that making drug use illegal worsened gender-based violence. Criminalization and policing made women more vulnerable because perpetrators knew women who used drugs would be less likely to seek help or report an assault. One woman explained, "Anytime you’re high and you’re in a vulnerable state that makes it easy for someone to target you. The fact that you’re doing something that’s illegal and are less likely to want to go to the police, that makes you an ideal target.”

Repeated experiences of violence, whether from intimate partners or on the street, during drug use or sex work, led to trauma that for some women continued a cycle of drug use and powerlessness. Others felt this cycle harmed their mental health and ability to cope. A participant noted, “They do whatever they want to you. It’s degrading and it’s so hard to get out of that. You remember what it’s like. And the drugs intensify it…You don’t want to stay sober because of that, you don’t want to remember.” Another participant described seeing young women become "totally broken down" by this cycle, becoming "filthy...lost...It’s an ugly dark thing...It gets your mind all twisted up.”

Overall, the combination of gender, drug use, and sex work intensified the oppression and physical and sexual violence women experienced. Legal structures made women more vulnerable and less able to protect themselves.

Women perceived that substance use services favored men socially and structurally.

All women in the study used some form of substance use or health services, such as methadone treatment, detoxification, residential treatment, or harm reduction programs. Women shared experiences from different times in their lives and from various cities and states. When trying to get services, women felt they were less prioritized than men. One woman described her experience: "I feel like I’m not looked at as serious as a man would be…It’s like, she’s a woman. We’ll give her help, but she’ll wait. She’s not a top priority. She’s second…that’s putting it in a nutshell, that’s just what I observe…from what I see on the streets and from what I hear on the streets, it’s not just me.”

Women reported that drug services were set up in ways that favored men in terms of access and design. They mentioned barriers specific to women, such as unmet sexual and reproductive health needs, lack of childcare, and not enough available beds. For example, some participants noted that services didn't always have female-only spaces, felt unsafe, lacked female staff, or didn't offer childcare. Others mentioned that detox beds for women were harder to find, or that female doctors weren't available for reproductive health needs. Overall, while all women engaged with substance use services, these gender-related structural barriers, like limited beds and childcare, made it harder for them to access and stay in care.

Gender-based violence occurred in substance use service settings and perpetuated cycles of trauma.

Women felt that substance use services were mostly male-dominated environments. Half of the women in the study also described experiencing assault within these services, which they linked to their gender identities and perceived or forced involvement in sex work. For example, peer assault was allowed in some peer-recovery settings. One participant noted a "very high risk, even in recovery, of sexual assault… [In recovery meetings] older men or women with a lot of time under their belt, who sort of present themselves as a mentor…and prey on the younger, less sober folks."

Women also saw and experienced sexual assaults in harm reduction programs, sometimes committed by staff. One woman shared an experience of assault by a doctor at a harm reduction program, emphasizing that "when I say that people are likely to target you, I’m not talking about drug dealers. I’m talking about doctors. People are who just like, ‘Oh, nobody’s going to believe her. She’s just some druggy.’ The people that I’ve had the most problems with are not other individuals who use drugs, it’s largely been medical professionals.” Such assaults caused further trauma and created barriers to getting care.

Another participant stated, “I know a lot of females that have doctors proposition them because they think that because you do dope, you’re automatically a prostitute…it’s still even hard for me to go to the doctor." These experiences often left women feeling worse off. One participant described it, saying some environments "just totally traumatizing and that they just came out worse as a result of it.”

In summary, women reported ongoing gender-based violence and fear of violence in drug service settings. These experiences led to more trauma and made it harder to access care.

Substance use services that were safe and responsive to women’s specific needs were valued and desired by women.

Women described strength and empowerment connected to their female identity. Some women found strength from being parents or from strong social connections. As one woman explained, "as women, we’re already nurturers, we’re really the strong backbone of the family and the family inspired them to seek help and addiction treatment.” Similarly, women looked out for each other in drug use environments. One participant said, "Everybody looked out for each other. If somebody was sick, we wouldn’t leave our friend sick. If we have money, we’re not making somebody go have sex or do something they don’t want to do to get high. We’re going to help them.”

Women sought drug services that promoted female empowerment and addressed their specific needs. They valued programs where they felt safe, such as services led by women or for women only, or those designed for LGBTQIA/queer individuals. They also valued services that provided essentials like tampons, socks, underwear, and hygiene products. Programs that understood and addressed trauma were also key for women to stay involved with services. Women emphasized the importance of staff being skilled at supporting them during crises, like when they felt overly intoxicated or were having a manic episode. Some participants called for more street outreach to protect women involved in sex work, given their high risk of violence. Finally, women appreciated programs that offered care without judgment and provided positive encouragement throughout their drug use and treatment journeys.

Overall, women wanted to engage with services that were safe, met their specific female needs, encouraged connections among women, and were free of judgment. In general, women felt there was a need for more outreach and services that are responsive to gender.

Discussion

This study among 36 women who reported recent non-prescribed opioid use in San Francisco and Boston found several important things. The interviews showed that having multiple marginalized identities—being a woman, using drugs, and engaging in sex work—worsened their experiences of being discriminated against. Physical, sexual, and psychological violence was common in drug use environments, and women linked this violence to the combination of their gender identity, drug use, and sex work. Some women even reported experiencing gender-based violence when using drug services, sometimes committed by the service providers themselves. These experiences led to more trauma and created barriers to care. Participants felt that drug services that helped women connect with each other and addressed women’s specific needs were seen as safe, valuable, and desirable.

The findings highlight the complex way that different identities and practices interact, leading to discrimination among women who use drugs. Policies and systems made their oppression worse, especially for women who engaged in sex work. Women in this study noted that making drug use and sex work illegal increased gender-based violence. The fact that illegal drugs were involved made women more vulnerable because attackers knew that women would be less likely to seek or receive help from the criminal justice system. These findings support other studies that show the harmful effects of criminalizing drug use and sex work. They also strengthen calls for decriminalizing drug use and sex work, along with policies and interventions that improve trauma-informed drug services.

This study also emphasizes the need for more research into experiences of violence within substance use service settings. Half of the participants reported experiencing sexual or physical assault when accessing these services. These assaults were committed by other people using the services, but also by health and social service professionals providing care. Such experiences caused further trauma and and created more barriers to care for the women in this study. While there is evidence that gender-based violence is common and significantly increases harm from drug use and reduces access to services for women, few studies have focused on violence occurring within these specific settings and its impact on treatment access and effectiveness. In addition to more research, drug services must examine their own policies, procedures, and culture that might be contributing to violence against women or making it hard to report assaults.

Women felt that drug services did not prioritize them and believed that these services favored men in terms of access and design. Specifically, women pointed out that drug services did not address their sexual and reproductive health or childcare needs. These experiences are consistent with studies that show ongoing barriers to treatment for women and gaps in services between men and women. In line with previous studies, women valued drug services that promoted empowerment and safety. Participants saw women-only and LGBTQIA spaces as safe and welcoming. Women appreciated programs that were sensitive to trauma and offered sexual and reproductive health services. Research shows that drug treatment tailored to women's specific needs improves outcomes like getting into and staying in treatment. This study, therefore, supports the call for developing, implementing, and investing in drug services that are responsive to gender. These efforts should also include women who use drugs in the drug care workforce, given the value of peer support reported in this study and evidence that peer-delivered services increase engagement in care.

Conclusion

Women in this study described repeated experiences of discrimination when accessing drug services, which made a cycle of trauma and drug use worse. Besides increasing gender-responsive services that use trauma-informed approaches, this study highlights the need for research that looks into experiences of violence within drug service settings. Participants spoke about program cultures and policies that made it unsafe for them to seek needed care. The addiction treatment community should also investigate and address its own practices that may be contributing to gender-based violence and re-traumatizing women who are seeking care.

Introduction

In the United States, more women have started using drugs and have drug problems over the last ten years. Studies show that women often get sicker from drug use than men. They also have a harder time getting the help they need for addiction. From 1999 to 2017, twice as many women died from opioid and heroin overdoses compared to men. Because of these rising problems, it is important to learn how being a woman affects drug use and experiences with help services. This will help create better services and rules for women.

Even though studies show women need different kinds of drug treatment, most services are made for everyone, not just women. This includes places like detox centers, rehabs, and support groups. These services often work better for men because they do not think about the special challenges women face. For example, women often have less money. They may have more mental health issues or have experienced more bad events. They also often take care of children, and their health needs are different from men's. About one out of three people with drug problems are women, but only one out of five people in drug treatment are women. This shows that many women are not getting the help they need. Making programs that think about women's needs could help fix this. Some drug services are only for women, but most are in cities or only for women who are pregnant or just had a baby. Other important services for women, like help with violence, mental health, or child care, are often separate from drug services.

It is a problem that services are not connected. This is because bad experiences like violence or past hurts can lead women to use drugs. These experiences also make it harder for women to get help. A key idea is "intersectionality," which means looking at how different parts of a person's life, like being a woman, using drugs, or doing sex work, can make problems worse. People with more than one of these things often face more hardship. For example, when sex work is against the law and looked down on, it makes women who use drugs and do sex work face more violence and harm. Some studies show that places offering "harm reduction" services can be safe havens from violence. But many of these places are mostly used by men, which can make things unfair for women. Not many studies have looked at how women experience other drug services. So, using the idea of intersectionality helps us understand how different parts of a woman's life, like being a woman, using drugs, or doing sex work, all come together. This shapes what it means to be a woman who uses drugs in different places and cultures.

So, using the idea of intersectionality, this study looked at talks with women who used opioids not prescribed by a doctor. The goal was to learn what women need when it comes to drug use and treatment. The study looked at how being a woman, using drugs, and doing sex work affected: how they used drugs, what happened when they used drug services, and what they wanted from drug services. What was learned from this study can help make better drug treatment and rules for women in the future.

Methods

This study looked at talks with women from San Francisco and Boston. The main goal was to learn about their experiences with drug use and what kind of help they wanted. The study also looked at how easy it was to find women for the study. People from 18 to 65 years old were asked to join if they were women, spoke English, and had used opioids not prescribed by a doctor in the last two weeks. The study tried to include younger women. They found people through helpers in the community, social media, and by asking people in the study to tell others. When COVID-19 started in 2020, they had to change how they found people. The study ended in October 2020. In Boston, a group that helps people who use drugs assisted with finding women. In San Francisco, a person with experience helped find women at places like homeless shelters and health centers. They also used ads on Facebook and Instagram. Some women were asked to tell their friends about the study. They could get paid extra for this. Flyers were also put up in places that help people who are homeless, young people, and people who use drugs.

The study team made a list of questions for the talks and a short survey. They tested the questions first. Women agreed to be in the study, and then they had private talks that lasted about 45 to 60 minutes. These talks were done in person or over the phone. These talks happened from January to November 2020. A survey asked about things like age, education, if they cared for others, where they lived, and drug use. The talks mostly focused on how being a woman affected their drug use and their experiences with health and social services. The talks were recorded and written down. Women were paid $40 for their time.

The recorded talks were put into a computer program. The lead researcher made a guide to help understand the talks. This guide looked at how being a woman, using drugs, and doing sex work were connected to their experiences. This guide was checked and changed as needed. Two people read some of the talks separately and then talked about what they found to make sure they agreed. Then, they read the rest of the talks. They looked for main ideas or "themes" about drug use and services. Fake names were used for the women to keep their information private.

Results

Thirty-six women took part in the study, 16 in Boston and 20 in San Francisco. Most were found through community groups. Their average age was 46. Most were White, and about 4 in 10 did not have a stable home. While not asked directly, many women spoke about doing sex work, with 13 reporting it. Many used different drugs like heroin, fentanyl, and cocaine. Even though the study was in cities, women talked about experiences from different times and places. Four main ideas came from these talks about how being a woman, using drugs, or doing sex work affected their lives and their use of services.

Women said that using drugs, along with being a woman, made their lives much harder. They felt that men often had more power in drug use settings. They often felt unsafe, knowing that women could be more easily harmed or robbed. Violence, including physical and sexual abuse, was very common where they used drugs. This was even worse for women who also did sex work. Women felt that because drug use was against the law, it made them more open to violence. People who hurt them knew they might not go to the police. Many had experienced repeated violence. This caused deep hurt and trauma, which made it harder to stop using drugs or feel strong. Some women felt this cycle hurt their mental health and their ability to deal with hard times.

All women in the study had used some type of drug or health service. But they often felt like men were given more importance. Women said these services were often set up in ways that helped men more. Women faced problems like not getting help for their health needs as women, not having child care, or not finding enough beds in treatment centers. These issues made it harder for women to get and stay in care.

Women often felt that drug service places were mostly for men. Half of the women in the study also said they had been hurt or attacked while getting help at these services. This included harm from other people also getting help. Some women even faced sexual attacks in harm reduction programs, sometimes by staff members. These bad experiences caused more hurt and made it harder for women to trust and get help. In short, women often faced violence or feared it in drug service places. This caused more trauma and made it harder to get the care they needed.

Women showed strength and felt strong because they were women. Some found power in being a parent or from close ties with others. Women also helped each other in places where drugs were used. Women wanted drug services that made them feel strong and met their special needs. They liked places that felt safe, like those just for women or for LGBTQIA+ people. They also wanted services that gave out items like hygiene products. Programs that understood past hurts were also important. Women wanted staff who could help during tough times and who offered kind, non-judgmental support. In general, women wanted services that were safe, met their needs as women, helped women connect with each other, and did not judge them. They felt more help was needed to reach out to women and offer services made just for them.

Discussion

This study talked to 36 women in San Francisco and Boston who used opioids not prescribed by a doctor. The talks showed that being a woman, using drugs, and sometimes doing sex work made life much harder for them. They often faced physical, sexual, and mental violence where they used drugs. Some even said they experienced violence from staff at drug treatment places. These experiences caused more hurt and made it harder to get help. Women felt that drug services that helped women connect and met their special needs were safe and good.

This study shows how unfair rules and systems made things worse for women who used drugs, especially those who also did sex work. When drug use and sex work are against the law, it made women more likely to face violence. Those who harmed them knew these women might not go to the police for help. This study supports the idea that making drug use and sex work legal could help women. It also shows a need for drug services that understand past hurts.

The study shows we need more research on violence happening inside drug service places. Half of the women said they were physically or sexually attacked while trying to get help. This violence came from other people getting help, and sometimes even from the staff. These attacks caused more pain and made it harder for women to get the care they needed. Drug services must look at their own rules and ways of working to stop violence against women and make it easier to report it.

Women felt drug services did not care about them as much as men and were set up to favor men. They said services often ignored women's health needs and did not offer child care. This matches other studies that show how hard it is for women to get and stay in treatment. Women in this study wanted services that made them feel strong and safe, like places just for women or for LGBTQIA+ people. They liked programs that understood past hurts and offered women's health care. Studies show that treatment made for women helps them get and stay in care. Our study adds to the call for more drug services made especially for women. This could include having women who have used drugs help others, as peer support was seen as very helpful.

It is important to know the study had some limits. It did not fully look at how race or other gender identities affected women's experiences. So, the ideas about women-only services might not fit everyone. More studies are needed to understand how different parts of a person's life affect drug use and services. Younger women were not well represented in this study. Also, the study changed how it found people because of COVID-19, which might have affected the results. Lastly, the study was only in two cities, so the findings might not be true for all places.

Conclusion

Women often felt ignored and unsafe when trying to get help for drug use. This made their past hurts worse and kept them in a cycle of drug use. This study shows that we need more services made for women that also understand past trauma. It also shows a need to study violence happening inside drug service places.

Women in the study said that the rules and ways of working in some programs made it unsafe for them to get the help they needed. Those who provide drug treatment should look into their own ways of working. They need to stop any practices that cause violence against women or make their past hurts worse.