Category: Stigma

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When Society Gets in the Way of Health and Help

How stigma can prevent women from seeking treatment for addiction

Samantha Johnstone

Kathy sat on the floor of her bedroom, looking at the pile of gifts for her and her baby. Her friends and family had been so generous but seeing them stacked in the corner flooded her with an overwhelming sense of guilt. She poured another glass of wine. If anyone knew her secret, surely they would take back the gifts. She didn’t deserve them, she thought to herself.

Canva (March 2021). [Image cartoon girl sitting on floor, expressionless].Figure 1: Woman sitting on ground, slouched and expressionless. Graphic by Samantha Johnstone, template from CANVA is licensed under a Free Media License Agreement

Kathy knew that her drinking had gotten out of control before she found out she was pregnant. She tried really hard to stop once she found out because she knew the risks. But no matter how many promises she made to herself, she just couldn’t get it under control. She had thought about looking for a rehab clinic, but worried if people found out, no one would ever speak to her again. And even if it was possible to hide her therapy from the rest of the world, she would never be able to afford it alone. She would have to ask her parents, and what if they were disappointed in her? 

It was a never ending cycle of feeling guilty about drinking and then drinking to quell the guilt, again and again. If only she knew someone that could help, she thought.

Kathy faced numerous obstacles when trying to get treatment for her addiction. One of the recurrent issues was fear of negative judgement from her peers. She worried that the people around her would shame her for struggling to control her drinking. Kathy’s fear of negative judgement became a barrier in her way to accessing addiction treatment.1

What is a barrier to addiction treatment?


A treatment barrier refers to any element in a person’s life that makes it more difficult to access treatment.2. These are usually considered personal issues like not being able to take time off work, having to take care of children, or not feeling ready to seek help with your addiction.

Figure 2: Woman resting her head on her hand. Graphic by Samantha Johnstone, template from CANVA is licensed under a Free Media License Agreement

For example, if you need to access a treatment facility, but you don’t have anyone to look after your children, it would be helpful if the facility had funding to provide childcare. If the government did not allocate funding to this service because it wasn’t considered important, this would make it more difficult for you to seek treatment.

Are barriers to treatment different for women?


Women with addictions face unique barriers to treatment.2. Looking back at the previous example, we see that childcare is often a major obstacle. Women who need to access addiction treatment are more likely than men to be responsible for children.2. They are also less likely to have a stable partner that can take on the role of being the sole provider.2. As you can imagine, this makes it difficult for them to check into rehabilitative facilities when they need to.

Stigma as a treatment barrier: 

Figure 3: Speech bubble with the following text: “Quick Facts: People who experience high levels of stigma about substance use are less likely to seek treatment. Stigmas can also interact with each other. Negative attitudes about substance use interact with sexism and racism.”. Graphic by Samantha Johnstone, template from CANVA is licensed under a Free Media License Agreement

A key barrier to treatment that women with addictions face is stigma.2. Stigma refers to a set of unfair, negative beliefs about people based on certain characteristics.3 These beliefs are often about factors like sex or gender, sexual orientation, race, religion, or having an addiction. 

Addiction stigma may look like: thinking addiction is a choice, thinking people who use drugs are immoral, or that they deserve to be arrested.

Experiencing addiction stigma can result in people feeling judged, ashamed, or powerless, similar to how Kathy felt.3 They may feel like recovery is pointless. Let’s take a look at a couple of examples that help to illustrate the effects of stigma on women seeking treatment:

  • Stigma from the medical community: In the 20th century, doctors were prescribing stimulants and tranquilizers primarily to White women for weight management, general “housewife malaise”, a little “pick-me-up”, and other minor issues.4 On top of that, they weren’t warning women about the risks of developing an addiction to these drugs.4 At that time, a common negative belief in the medical community was that addictions were a “man’s issue” and doctors would often dismiss women when they asked for help.4 Some even went as far as to say that women were unable to develop an addiction.4

Imagine feeling that your use of a prescribed drug is out of control, but the doctor who gave it to you didn’t warn you that it was dangerous and didn’t take you seriously when you disclosed your concerns. You might convince yourself that nothing is really wrong and not feel motivated to seek out treatment. 

  • Stigma from the public: In the 1980s, the United States government declared a “war on drugs” and these policies were mostly being enforced in Black communities.4 This quickly became a way to reinforce racial power differences through unfair laws. The media contributed to this by promoting negative beliefs and shaming people from these communities. For example, Black women were continuously stereotyped as being sexually promiscuous in exchange for drugs.4 By targeting and shaming Black women specifically, the media was contributing to harmful attitudes about race, sex/gender, and addiction.

Widespread stigma about drug and alcohol use promoted by public entities like the media and government can be a barrier to treatment.4 Women who would otherwise want to seek treatment will see these messages, and may fear being judged if they ask for help. They may also worry about fulfilling racist or sexist stereotypes and being further discriminated against.4 

  • Stigma from friends and family: Similar to Kathy’s story, women can also face negative judgement from the people closest to them. Pregnant and parenting women report worrying about what will happen if people find out that they are using drugs or alcohol, which prevents them from seeking treatment.1 They worry others will perceive them as a “bad mother”.1 They may also be concerned about losing custody, or having child services get involved, and keep their addiction a secret rather than ask for help.2. 

Women are often judged more harshly than men by the people around them for using substances.4 People with negative beliefs about sex/gender and addiction may believe that pregnant women who use substances are undeserving of sympathy.4

The Motherisk Scandal: Taking a closer look at the intersection of sex/gender, race, and addiction stigma.

Figure 4: Six women holding hands in a circle. Graphic by Samantha Johnstone, template from CANVA is licensed under a Free Media License Agreement

We just discussed many examples of addiction stigma and how it may interact with sexism and racism in women. But often these forms of stigma are not distinct experiences.

The Motherisk scandal shows us how these stigmas can interact and act as barriers to treatment.

As recently as 2015, hospital policies in Toronto allowed doctors to administer faulty drug tests to pregnant women.5 The doctors would then involve child services. This punitive approach to addiction resulted in thousands of children being wrongfully removed from families.

  • The doctors involved ignored the fact that the tests were often wrong about the presence of drugs.5 Child services paid little attention to whether or not the mother took care of her children when deciding to remove the child. This shows a stigma against addictions.5
  • This practice was primarily aimed at pregnant and parenting women, although fathers were sometimes drug tested as well.7 This shows a stigma against women who use substances, specifically.
  • The majority of the women who lost custody of their children because of faulty drug tests in the Motherisk scandal were Black or Indigenous.5 This shows a stigma against Black and Indigenous women who use substances, specifically. 

The Motherisk scandal shows us how different forms of stigma can interact. The doctors and child service workers involved had negative beliefs about the women because of their race, the potential for drug use, and their sex/gender. The consequence? Thousands of wrongfully separated families, most of whom were Black and Indigenous.7  It also likely resulted many women avoiding medical care or treatment for addiction while pregnant or parenting out of fear of losing their children or being arrested.6 

Is there any good news?

The cool thing about being part of society is that we can help to influence other people’s negative attitudes and reduce stigma about addiction! 

  • Learn about language: The words we use matter. For example, terms like “junkie”, “addict” or “alcoholic” are considered rude, and diminish people to their illness. Instead, use person-first language like “people with addictions”. Other examples can be found here.
  • Educate others: Consider telling the people you know the facts about addictions, and how stigma and stereotypes can be harmful. You can start by sharing this article! Some other resources about addiction stigma that you can share can be found at the Recovery Village,  from the Government of Canada, and from the Stigma of Addiction Project.
Figure 5: Two women leaning on each other. Graphic by Samantha Johnstone, template from CANVA is licensed under a Free Media License Agreement
  • Break barriers: If you or someone you know is struggling with an addiction, consider looking into treatment options. Some reputable resources for addiction treatment can be found from the Government of Canada, as well as numerous online resources, and at Toronto’s Centre for Addiction and Mental Health (CAMH). There are also resources for family members at CAMH.

If you have questions or concerns about pregnancy and substance use, a fact sheet, along with a list of reputable resources can be found here. Additional resources for women and their families can be found at the Jean Tweed Centre in Etobicoke ON. 

References

1. Center for Substance Abuse Treatment. (2009). Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series 51. Retrieved from Rockville, MD: http://www.ncbi.nlm.nih.gov/books/NBK83252/

2. Greenfield, S. F., Brooks, A. J., Gordon, S. M., Green, C. A., Kropp, F., Mchugh, R. K., Lincoln, M., Hien, D., & Miele, G. M. (2007). Substance abuse treatment entry, retention, and outcome in women: A review of the literature. Drug and Alcohol Dependence, 86(1), 1-21. doi:10.1016/j.drugalcdep.2006.05.012

3. Kulesza, M., Matsuda, M., Ramirez, J. J., Werntz, A. J., Teachman, B. A., & Lindgren, K. P. (2016). Towards greater understanding of addiction stigma: Intersectionality with race/ethnicity and gender. Drug and Alcohol Dependence , 169, 85–91. https://doi.org/http://dx.doi.org/10.1016/j.drugalcdep.2016.10.020 0376-8716 

4. Becker, J. B., McClellan, M., & Reed, B. G. (2016). Sociocultural context for sex differences in addiction. Addiction Biology, 21, 1052–1059. https://doi.org/10.1111/adb.12383 

5.  Contenta, S., Rankin, J., & Mendleson, R. (2016, October 28). Motherisk tests played role in 10 families where children taken, first phase of review finds. Thestar.Com. https://www.thestar.com/news/insight/2016/10/27/motherisk-tests-played-role-in-10-families-where-children-taken-first-phase-of-review-finds.html

6. Illegal Drug Use While Pregnant is Not Child Abuse. (2019, April 4). American Bar Association. https://www.americanbar.org/groups/public_interest/child_law/resources/child_law_practiceonline/january—december-2019/illegal-drug-use-while-pregnant-is-not-child-abuse/

7.  “I haven’t seen her in almost six years”: Father on pain of losing daughter after Motherisk test. (2018, February 27). CTVNews. https://www.ctvnews.ca/health/i-haven-t-seen-her-in-almost-six-years-father-on-pain-of-losing-daughter-after-motherisk-test-1.3820345

Images

1. Canva (March 2021). [Image cartoon girl sitting on floor, expressionless]. 

2. Canva (March 2021). [Head of women resting her head on her hand]. 

3. Canva (March 2021). [Speech bubble with the following text “Quick Facts: People who experience high levels of stigma about substance use are less likely to seek treatment. Stigmas can also interact with each other. Negative attitudes about substance use interact with sexism and racism.”].

4. Canva (April 2021). [Six women holding hands in a circle].

5. Canva (March 2021). [Two women, leaning on each other]. 

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Why the words we choose matter

by Sarah S. Dermody, PhD @SarahSDermody

“Addict” or “junkie” are some of the words that are used to refer to people who have difficulties with their substance use. These are words used by people in the media (just one for example) and in our communities, and perhaps you have even used them as well. These words should be avoided, and here are some of the important reasons why.

An important place to start is to understand stigma.

Close your eyes and take a moment to imagine a recent media story or film that spoke about or portrayed someone who uses substances heavily. Perhaps they shared some negative beliefs and attitudes (or stereotypes) about how this person would behave, what they look and sound like, and what it would be like to spend time with them. The negative beliefs and attitudes towards people with addiction is called stigma.

“Day 003 – Shame” by marcandrelariviere 
is licensed under CC BY-NC-ND 2.0

Stigma is a problem with many health conditions, and we continue to see it with addiction. Stigma can truly hurt people coping with substance use related difficulties in many ways. Research has shown that fear of stigma is one of the top reasons that people choose not to get treatment for their substance use (Table 7.67B).1 When someone gets treatment, stigma can also get in the way of their successful treatment and recovery.2 Unfortunately, we also see that stigma can be an issue for treatment providers who are not properly trained to work with people who use substances.3

There is a ripple-effect of individual’s stigmatizing beliefs. The effects of stigma can go well-beyond the interactions between someone who uses substances and other individuals. People in positions of power may make decisions based on stigmatizing beliefs that can ultimately harm individuals who use substances.

Image: “Ripple Effect” by sea turtle is licensed under CC BY-NC-ND 2.0

A timely example of this is with the COVID-19 pandemic. Dr. Nora Volkow, the director of NIDA, recently wrote about this issue in her blog.

“the legitimate fear around contagion may mean that bystanders or even first responders will be reluctant to administer naloxone to people who have overdosed. And there is a danger that overtaxed hospitals will preferentially pass over those with obvious drug problems when making difficult decisions about where to direct lifesaving personnel and resources.”4

Dr. Nora Volkow

How the words we use promote stigma.

Remember the saying “sticks and stones may break my bones, but words can never hurt me”? Whoever coined this phrase did not consider the effects of stigmatizing language.

Research has shown that the language we use to refer to people who use or have difficulties with substance use can impact how we treat them. One example of this is a study by Goodyear, Haass-Koffler, and Chavanne (2018) where participants read descriptions of people referred to as a “drug addict” versus official terms like “opioid use disorder.”5  They found that there were more stigmatizing attitudes towards individuals labeled as a “drug addict” than those labeled as having an “opioid use disorder.”  

It is not hard to imagine how stigmatizing language can play out in a number of real-world settings to make a major impact.

Tips: Use words that describe – not stigmatize.

“Dictionary – succeed” by flazingo_photos is licensed under CC BY-SA 2.0

At this point, you may be wondering, what words could I use to describe these experiences? There are many helpful online resources that describe terms to avoid versus terms to use, and why, such as the primer on Overcoming Stigma through Language.6  Here is a summary of some of the important takeaways:

  1. Use “person-first” language: Put the words that refer to the individual before the words that describe their behaviours or conditions. For instance, instead of using terms like “alcoholic” or “addict”, a person would be described as “person with an alcohol use disorder.”
  2. Use official terms the reflect the condition: Using the medical language can help frame addiction as a health issue and a disease. Therefore, it is best to use official diagnostic language like “substance use disorder” instead of use words like “drug abuse” or “junkie.”
  3. Avoid slang and idiomatic expressions: Using slang to describe an individuals’ involvement with substance use often means that pejorative or biased language is being used (“pot head”, “strung out”, “getting clean”, as examples). Instead, it is best to describe behaviours and experiences with literal terms, like “someone who uses cannabis”, “someone who is intoxicated”, or “someone who is in treatment for their substance use.

This is just the start of the conversation.

Now that you know about the power of words and how to talk about substance use is a less stigmatizing way, it is time to put this knowledge into action! Together, we can make a real impact to reduce stigmatizing language by correctly the words that we use and educating the people around us to use less stigmatizing language.  

Sources

  1.  Substance Abuse and Mental Health Services Administration. (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001, NSDUH Series H-55). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved Sept 28, 2020, from https://www.samhsa.gov/data/
  2.  Crapanzano, K. A., Hammarlund, R., Ahmad, B., Hunsinger, N., & Kullar, R. (2018). The association between perceived stigma and substance use disorder treatment outcomes: A review. Substance Abuse and Rehabilitation, 10, 1–12. https://doi.org/10.2147/SAR.S183252
  3. Knaak, S., Mantler, E., & Szeto, A. (2017). Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthcare Management Forum, 30(2), 111-116. https://doi.org/10.1177/0840470416679413
  4. Volkow, N. (2020, April 22). Addressing the stigma that surrounds addiction. Nora’s Blog. https://www.drugabuse.gov/about-nida/noras-blog/2020/04/addressing-stigma-surrounds-addiction
  5. Goodyear, K., Haass-Koffler, C. L., & Chavanne, D. (2018). Opioid use and stigma: The role of gender, language and precipitating events. Drug and Alcohol Dependence, 185, 339-346. https://doi.org/10.1016/j.drugalcdep.2017.12.037
  6. Canadian Centre on Substance Use and Addiction. (2019). Overcoming stigma through language: A primer. (Guide.) Ottawa, Ontario. Retrieved Sept 28, 2020, from https://www.ccsa.ca/overcoming-stigma-through-language-primer