The Impact of Global Drug Policy on Women: Shifting the Needle

This chapter presents a broad introduction to women’s varied interactions with drugs and drug markets. It provides a brief overview of the international framework of drug control and the ways in which drug policy enforcement differently impacts women and men. It highlights the negative and disproportionate impacts on women of criminalisation-based approaches and how drug policy serves to reinforce existing problems of structural discrimination. This provides context for the contributions to this edited collection, which are summarised in the introduction. The book situates drug policy reform as a crucial and underlooked feminist issue.

This chapter explores the norms and assumptions that frame and sustain international drug policy and the international drug control regime. Drug policy is conceptualised as a ‘policy fiasco’ that persists despite extensive evidence of goal failure. The absence of effective monitoring and evaluation, impact assessment, stakeholder participation and mainstreaming of rights-based approaches, conflict sensitivity and gender sensitivity is emphasised, substantiating the argument that drug policy is a case study of ‘institutional path dependence’. Drug policy has repeatedly missed targets for achievement of a ‘drug free world’. This is explained through reference to the counterproductive and ‘unintended consequences’ of a drug policy approach of criminalisation. The impacts of drug policy enforcement are shown to be negative, pernicious and disproportionately born by the poor, by vulnerable communities and those subject to discrimination on account of race, gender and class.

This chapter addresses the differential impact of drug policy enforcement on women and the interactions of these processes with other sources of social marginalisation. It explores how broader processes of stigmatisation and exclusion play out in the context of global drug policy enforcement, limiting women’s access to effective voice and representation. The author illustrates the increasing salience of this issue through an exploration of global rightwing pushbacks and the intersectional impacts on those whose voices and identities are increasingly criminalised. The framing of women who interact with drugs or drug markets as deviant and anomalous by policy actors is constrictive of their rights, and it is crucial that reform agendas be advanced.

Critical drug studies have developed a significant body of work that illuminates understanding of gender and drug use as well as drug pleasures. However, framing the study of women and their drug pleasures through critical drug studies presents potential limitations. The posthuman turn de-emphasises the primary goal of drug use: a particular subjective experience. Both the language and theoretical frameworks of new materialism potentially distance researchers, as interlocutors, from engaging the human experience of drug pleasures, rendering drug use abstract and unknowable.

In a historical context in which women’s intoxication has invoked shaming and criminalisation, control of their bodies, and silencing of dissent, scholarly activism by and inclusion of women who use drugs should be foundational to critical drug studies. Autoethnography offers a modality by which personal narrative becomes a convention of academic writing. It also presents a way of performing the self critically and authentically within conceptual frameworks that explore the complex, intersectional politics of women’s drug use, ways that are representationally missing in the scholarship. An ethics of care as part of one’s practice of the self proposes a radically different way of framing drug use. The recognition and normalisation of drug pleasures as the complicated, emergent, expressions of ethical self-care that they are for women (and all people who use drugs) promises fertile ground for future scholarly exploration. Research based in the lived experience of women who use drugs will help establish languages that resituate drug use in the phenomenology of their experience.

Global evidence indicates that multiple structural, biological, and behavioural mechanisms link gender-based violence (GBV), HIV/HCV, and substance misuse among women and adolescent girls. The aim of this chapter is to briefly summarise and synthesise recent literature that examines the complex and bi-directional relationships among these epidemics in different populations of adolescent girls and women around the world. To inform this chapter, a selective search strategy was conducted, prioritising use of meta-analytic epidemiological studies and research on interventions and policies that address different aspects of the syndemic among women and girls who use drugs worldwide. The search targeted publications from 2015 to 2019 using PubMed, MEDLINE, and Google Scholar. The chapter highlights methodological and geographic gaps in existing policy, intervention, and implementation research and makes recommendations for strategies to tackle these gaps. It also identifies a continuum of multilevel evidence-based interventions that target the risk environments and key syndemic mechanisms linking these intersecting epidemics that have been found to be effective in reducing intimate partner violence and other forms of GBV, substance use, and HIV/HCV risks. This chapter also assesses inclusiveness of existing research and interventions for underserved and disproportionately affected populations, affecting adolescent girls, sexual minority women, and racial/ethnic minority women and identifies strategies to target gaps or disparities for these key affected populations. Finally, this chapter describes the gaps and opportunities that harm reduction programmes, medical settings, and other community organisations experience in implementing gender-responsive programmes and policies to redress these intersecting epidemics.

The prevalence of older people who use drugs is increasing in many countries, with evidence that some women continue or begin illicit substance use in midlife and older age. While research on older people who use drugs is limited, evidence of risk behaviours among older women who use drugs is particularly inadequate. Unsafe drug use and sexual practices that are prolonged and sustained over many years increase the possibilities for poorer health, leading to potentially greater morbidity and early mortality among older drug users. This chapter is a timely contribution to the extant literature and explores our current knowledge of the risk behaviours of older women who use drugs.

Although midlife is viewed as a transition period in the life course, the normative role expectations of midlife and older women run parallel to the stereotypes of women who use drugs. Furthermore, drug-using bodies are politically and culturally shaped through control and containment practices centred around notions of difference and risk. Acknowledging the intersection of age, race and gender, this chapter frames its position around the concepts of ‘risk’ and ‘edgework’. Utilising these theoretical concepts, this chapter argues that a shift towards a support-focussed model, rather than control of, older women who use drugs is required. The absence of a focussed, gendered analysis of the lives and experiences of older drug users, and older women who use drugs in particular, limits our understanding. Consequently, the chapter concludes with a call for well-designed studies of this increasing and largely hidden cohort of drug users.

Sex and gender are regarded as critical structural determinants of mental health and mental illness. Mental illness is a complex phenomenon, and risky behaviour and substance use commonly occur simultaneously or subsequent to one another. A gendered vulnerability in biological, environmental, and behavioural risk factors has been registered in the development and escalation of mental illness. Studies have found that women who use drugs experience greater physical and mental health repercussions than men. Women who use drugs present higher rates of depression and anxiety, suicidal tendencies, isolation and general psychological distress. This chapter addresses the most common mental illnesses associated with women who use drugs: depression, anxiety, trauma-related disorders, and eating disorders.

Eastern Europe and Central Asia (EECA) is home to 21% of the world’s population of people who inject drugs and it is the region with the fastest-growing HIV epidemic. HIV prevalence among women who inject drugs is significantly higher than among men in EECA. Even in places with high coverage of needle syringe programmes and HIV testing and treatment, women’s access to opioid substitution treatment is lower than men, and women’s sexual and reproductive health needs remain unaddressed. EECA has a unique system of drug registries that store the personal data of people who use drugs. Registration lowers the chances of employment and access to education and for women and increases the risk of losing custody of their children. The system of drug registries contributes to drug-related stigma. Breaches of confidentiality of drug registry data lead to the further marginalisation of women who use drugs. Criminalisation, past experience of police violence and poverty contribute to healthcare access barriers for women. There is a need for legislative changes to improve personal data protection, decriminalise drug use and reduce police violence. The positive effects of these changes would only be seen in the long term. In the interim, women need special access programmes that are designed specifically to address their needs, that provide free-of-charge services and that ensure the safety and confidentiality of personal data.

This chapter explores sex work and compares legal regimes in two case study contexts of Scotland and New Zealand. It highlights parallels in policy norms and approaches towards women in sex work and women who use drugs, including stigmatisation and punishment of ‘deviant’ women or alternatively, approaches that seek to ‘rescue’ women and which frames them as victims. Different policy approaches and regulatory regimes are discussed but the chapter argues that without attention to social justice issues, the structural drivers of women’s engagement in sex work will continue to be overlooked. Participation in policy processes by those with lived experience is emphasised, both to ensure better understanding of sex work by policymakers, and also in recognition of the citizenship, voice and agency of sex workers.

Women across the world are being incarcerated at an alarming rate. Between 2000 and 2017, the female incarceration rate worldwide increased by 53.3%, whereas the male incarceration rate increased by only 19.6%. In Latin America, drug offences are the first or second cause of female incarceration. The excessive use of pre-trial detention, mandatory minimum sentences, and disproportionate penalties characterise the region’s drug policies. Recent data compiled by the Washington Office on Latin America show that between 35% and 70% of incarcerated women, depending on the country, are behind bars due to a drug offence, while for men the rate is much lower. In other words, harsh drug laws disproportionately impact women.

Qualitative research on female prisoners accused of drug-related offences shows how gender roles, gender-based violence and social exclusion are often triggering factors for women’s participation in the drug trade. Agency and victimisation co-exist in these women’s stories, and while drug trafficking becomes a means to cope with adversity, it also further enhances previous vulnerabilities, and incarceration can have a devastating impact on their families. These women are engaged in high-risk activities but represent a low risk to society. Drug law reforms and the use of alternatives to incarceration could reduce the number of women behind bars for low-level drug offences.

The Russian Federation has taken a harsh, punitive approach towards drug policy. There are limited health and social services available to people who use drugs and widespread, documented discrimination within the criminal justice system. Amongst those who use drugs, the proportion of women who use injection drugs is estimated to be approximately 30 per cent. While a minority, women who use drugs are often disproportionately impacted by drug policy enforcement and remain underrepresented within research. Moreover, women who use drugs experience specific gender-based forms of discrimination within social, health and criminal justice systems, which result in particular vulnerabilities. This chapter examines policing and sentencing practices within the Russian criminal justice system and their gendered impacts, especially concerning women who use drugs. Human rights reports and court cases as well as interviews from civil society organisation (CSO) workers are analysed in order to understand how gender roles, gender-based discrimination and gender-based violence shape these interactions and result in disproportionate negative impacts on the lives of women who use drugs. This analysis also highlights key areas that need greater involvement and attention from researchers, policymakers and advocates.

Parallel with trends in the wider East Africa region, there has been an increase in the number of women involved in drug use, trafficking and drug-related crime in Kenya (Beckerleg, Telfer, & Hundt, 2005 ). Vulnerable populations, such as domestic labourers, ethnic minorities, those living in slums, bar attendants, sex workers and refugees, are recruited into criminal organisations and assigned roles that expose them to negative health outcomes, human rights violations and incarceration (NACADA, 2016 ). In cases where women do not directly participate in drug use or the drug trade, they often are responsible for mitigating the risks arising from drug use by family members and the community. This reflects their triple burden of care and support when family and social life deteriorates (Mburu, Limmer, & Holland 2019).

The Kenya Narcotic Drugs and Psychotropic Substances Control Act of 1994, criminalises possession and trafficking of illicit drugs. The enforcement of this legislation has led to an increase in the number of women incarcerated in Kenya for drug, but also (and mainly) alcohol offences. This goes against the recommendation of the UN Commission on Narcotic Drugs in 2005 that States should adopt innovative measures and policies that prioritise treatment and rehabilitation as opposed to incarceration. In Kenya, prisons have adopted the Mandela and Bangkok Rules, enabling a paradigm shift in the provision of correctional services for women offenders, including remote parenting, family open days and linkages to aftercare services. However, these policies need to be anchored in the legal framework, with adequate resources to hasten the realisation of goals for the care and treatment of female drug and criminal offenders.

Over the past decade, an increase in the numbers of women prosecuted, sentenced and imprisoned for drug-related offences has prompted concern and debate amongst criminal justice practitioners and policymakers. The female prison population in Southeast Asian countries is high compared to other regions. The direction of national drug policies and law enforcement are critical determinants of this situation. This chapter discusses the trends in the illicit drug market, the different types of policy responses, and the impacts on correctional services in the region. It provides an overview of women prisoners’ profiles, their backgrounds and their involvement in drug-related crimes. Key issues relating to the treatment of women in Southeast Asian prisons are analysed and addressed through the lens of the relevant provisions of the United Nations Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders.

Illicit drug use amongst women in Zimbabwe is increasing. The most common drugs of choice are marijuana and new psychoactive substances like ecstasy, cough syrups with a high content of codeine, and other small intoxicating pills like mangemba (diazepam). The most affected population group are women between the ages of 20 to 40.

In a community engagement undertaken by Zimbabwe Civil Liberties and Drug Network in five of Zimbabwe’s provinces, socio, cultural and economic factors were identified as the drivers of increased engagement with the drug trade. The urge to be independent and the inter-related aspect of sex work were also identified as push factors accounting for the increase in illicit drug usage in the country. The community engagement showed most women use illicit drugs as a way of liberating themselves within a heavily patriarchal society and due to the traumas associated with sex work. Sex work in turn exposes women to opportunistic infections, rape, violence and sexual violence. Women perform different roles in the illicit drug economy. In their role as sellers of controlled drugs, women aimed to support their families, maximising the opportunities presented by life in illicit economies. Whilst advocacy groups are pressing for drug policy reform in Zimbabwe, interventions can be designed to help women extricate themselves from this quagmire through empowering them and having a drug policy that among other facets, strengthens communities.

Women are increasingly involved in a range of drug supply activities, but their role is overlooked in scholarship and policy processes. Women are key actors in plant cultivation (opium poppy, coca and cannabis), trafficking and distribution, but roles in the illegal drug economy are highly gendered stratified. Women most usually occupy low levels in supply and distribution chains, with their access to markets mediated by men. Nevertheless, participation by women in drug supply enables them to support precarious household incomes and/or cover the costs of dependent or casual drug use. More women are coming into drug supply and use at a time when a number of countries are adopting more repressive and punitive drug policies. The impact of enforcement is a sharp increase in numbers of incarcerated women, with implications for care of families and children.

Organised crime, including drug trafficking groups, are often thought of as male-dominated industries. However, even when leveraging romantic or kinship ties, women can be active participants and exert influence in the business operations of these groups. Based on interviews with Mexican and Japanese government officials, indictments, and investigative journalism, this chapter compares the notorious and long-lived Mexico-based Sinaloa drug trafficking group and the Japanese Yakuza Yamaguchi-gumi organisations. It shows that despite substantial differences in their criminal activities as well as the illicit markets in which they operate, women perform active roles along the supply chains. Furthermore, it shows that despite constructions of gender roles that see women as intruders in organised crime, women attain positions of authority even when their membership is not always formally recognised.

Colombia has been one of the main cocaine producing countries. The state’s response has been a repressive approach against the primary levels of the coca economy, such as cultivators and consumers. Although recent literature has documented the gendered impacts of drug policy, that is not the case for women who grow illicit crops. This chapter examines the ways drug policy has impacted women coca growers, cocaleras, in Putumayo, Colombia. Cocalero or cocalera is the term referred to rural workers dedicated to the cultivation and harvest of coca leaf. The term is a vindication from these communities, dignifying the rural activities they perform. In this chapter, we will use the term cocalera to refer to women coca growers.

From an intersectional gender perspective, the chapter explores the implications of rural life, gender, armed conflict and illegality over the trajectories of cocaleras in Putumayo, southern Colombia, a region where non-state armed actors, poverty and a precarious state presence converge. In this context, cultivating coca has become the main livelihood for rural families. It has transformed women’s roles within their communities, providing them with economic autonomy they previously did not have, but also located them in vulnerable positions. This chapter – which is an adaption from some chapters of the book ‘Voices from the coca fields: Women Building Rural Communities’ (Dejusticia, 2018 ) – is the outcome of research undertaken through in-depth interviews and social mapping exercises.

This case study examines unique overdose risks and prevention strategies for women who have used heroin during pregnancy in New York City. The overdose crisis has resulted in increased efforts to implement drug user health services; yet, pregnant and parenting women who use drugs continue to be left behind. Three women who currently use heroin and had experienced at least one pregnancy during their heroin use history were interviewed using semi-structured qualitative interviews. Their experiences documented in this case study illustrate several gender-specific considerations when responding to the overdose crisis in New York City. Overwhelmingly, barriers to healthcare and overdose prevention were correlated with perceived stigma and the fear of or actual loss of child custody. Compassionate, gender-responsive interventions remain largely absent in policy and practice, especially for pregnant women. The shared experiences highlighted in this case study should be used to develop improved drug user health policies and practices as well as increase overall advocacy efforts for women of reproductive age who use drugs.

Recreational drug use is widespread. It is argued that it has reached a phase of ‘normalisation’ among youth and has become a part of mainstream culture. While there is a substantive body of literature addressing substance use in club settings, the world of music festivals is underexplored. The research aims to fill this gap by analysing patterns of drug use and implementation of harm reduction measures among Polish and Hungarian women at music festivals. This explorative inquiry used an online questionnaire, which was shared via social media channels. The data collection lasted for one month during the summer of 2017.

The study found that over 95% (N=510) of women use psychoactive substances at festivals. The most popular drugs are alcohol and cannabis, and the least popular cocaine and psilocybin. The majority of women declare moderate use of alcohol and light to moderate use of cannabis. One-fifth of the respondents report a moderately heavy use of 3,4-methylenedioxymethamphetamine and 8% heavy use of amphetamine. There are numerous positive weak relationships between the intensity of use of various substances. Increased use of drugs is also related to increased frequency of combining them. Low prevalence of illicit drugs testing is observed. There seems to be a negative correlation between the intensity of substance use and the adoption of harm reduction measures. The results have high practical relevance primarily for harm reduction and medical services. Especially cases of moderately heavy and heavy use should be of interest, even more so given that combining substances seems to be prevalent. The data suggest that we can distinguish between two groups: one aware and implementing various measures of harm reduction and second not adopting any of them. There is a need for more widespread drug education and harm reduction promotion, which should be implemented in a favourable legal and policy environment.

This chapter discusses how ‘hidden’ populations of women who use drugs (WWUD) in coastal Kenya became ‘visible’ through accessing health, harm reduction and rights services. This effort was facilitated by the Muslim Education and Welfare Association (MEWA) and their work with community leaders. Mapping undertaken by MEWA outreach workers identified women who use opioids and other substances in isolated drug use settings. MEWA introduced daily meals in identified sites, needle and syringe services and residential rehabilitation services for opioid withdrawal. The introduction of residential adherence services for HIV and tuberculosis and the provision of methadone enabled compliance with the 90-90-90 UN HIV cascade. These services achieved sustained HIV viral load suppression at 83% and a 100% cure rate for tuberculosis among WWUD. In addition, disclosure and partner risk tracing was established in the ‘drug dens’ for women who test positive for STIs. The introduction of women-only hours once per week at the drop-in centre contributed to a better understanding of drug dependency among outreach workers and clinicians. Policies on gender-based violence were also refined, leading to an increase in reported cases. Programmes targeting families were introduced to promote effective communication and improve parenting skills. Access barriers to social security programmes were tackled by a network of paralegal officers in partnership with Kenyan authorities. Finally, entrepreneurship training and mentorship programmes were implemented to build resilience among WWUD.

Through the lens of critical drugs theory, which sees drug policy as an oppressive framework that seeks to de-legitimise and stigmatise behaviour that threatens dominant social, cultural and gender norms, this contribution focusses on drug policy participation and governance. It focusses on the different ways women and drug-using women engage with drug policy debates and policy development in the case study of Scotland, and the activism that has enabled their recognition as legitimate participants in the policy process. The contribution calls attention to the generic challenges of civil society engagement in drug policy design, monitoring and evaluation; the particular silencing and marginalisation of drug user’s voices in national and international drug policy processes; and the multiple impediments but also opportunities for women to create stakeholder spaces.

Global drug policy has undergone significant change over the past decade, especially with the advent of the 2016 UN General Assembly Special Session (UNGASS) on drugs. This was a catalyst moment both in highlighting the need for a gender perspective in drug policy, and in initiating a review of the indicators used to evaluate progress in drug policy.

To date, the UN has not adequately tracked gender-specific data in drug policy. This is symptomatic of the lack of focus granted to the specific vulnerabilities and needs of women in the illicit drug trade. This has resulted in a knowledge and understanding gap in relation to the issues faced by women worldwide.

The importance of quantitative and qualitative data and analysis of how and why women are involved in the illicit drug trade, and how this relates to their age, ethnicity, socio-economic status, family situation and history of trauma, violence and mental illness cannot be understated. Without adequate indicators on the underlying factors of their engagement in the trade, the differentiated impacts that both drugs and drug policies have on their lives, and the vulnerabilities they may face, policy makers will be unable to design and implement drug policies that are truly effective.

This chapter provides a historic overview of how data on women has so far been tracked by the UN. The chapter will then look to the future, focussing on opportunities to identify more meaningful indicators within a revised Annual Reports Questionnaire, and also by leveraging the Sustainable Development Goals, UN human rights mechanisms and civil society research.

This chapter paints a picture of the war on drugs, and the structures of prohibition and punishment that drive it, as extensions of broader systems of state and interpersonal violence. I outline the failures of prohibition through the criminalisation of drug-related activities and put forward a framework for harm reduction that has as its foundation a radical critique of punishment in all spheres of our lives. This chapter urges those who advocate for drug policy reform to build broader alliances with the many communities around the world that organise against the continuation of the prison industrial complex (PIC) as a whole, including: people in prison, gendered, racialised and LGBTQI+ communities, sex workers and prison abolitionists. I conclude by offering a vision for abolitionist drug policy, whose ultimate goal is to resist the expansion of the PIC globally and in doing so, to foster greater community resilience both across difference and beyond our increasingly siloed fields of expertise. As drug policy experts, the author can choose to situate the millions of people who use drugs worldwide within global contexts of ongoing state violence and control, so that the reforms the author advocate for match the fullness and complexity of the people and worlds the author are fighting for and tackle the root causes of the many harms our communities face.

Women who use drugs are one of the most maligned, misunderstood and maltreated groups in contemporary culture and society. Despite this, little public outcry nor empathy is given. As a woman who uses drugs, the author examines what lies behind this neglect. A post-structuralist approach is taken in order to examine the categories of meaning assigned to bodies under the twin ruling structures of prohibition and patriarchy. This is done with the intent to better understand and challenge the process of (masculinist) knowledge-making and practices surrounding women who use drugs that treats us as mere objects of knowledge. Furthermore, this chapter draws from feminist auto-ethnography, as the author uses own personal experiences as a woman who uses drugs, a feminist and a drug user advocate as a lens through which to give form to this analysis. Ultimately, the author argue that it is time to let go of outdated, unjust and prejudicial images by challenging established norms and practices, test and apply new theories and negotiate different identities outside of those currently available to women who use drugs. In undertaking this piece, the author hopes that the critical reflections contained within this chapter can ‘cause some trouble’, by being politically useful for the growing movement surrounding women who use drugs.