Gender and the overdose crisis in North America: moving past gender-neutral approaches in the public health response

North America’s overdose crisis is largely driven by the proliferation of fentanyl and fentanyl-related analogues in the illicit drug supply, with opioid-related overdoses now the leading cause of accidental death in North America (O’Donnell, Halpin, Mattson, Goldberger, & Gladden, 2017; Special Advisory Committee on the Epidemic of Opioid Overdoses, 2018). More recently, an increase in stimulant overdoses has occurred, suggesting a new phase of the epidemic (Ahmad, Rossen, Spencer, Warner, & Sutton, 2019). However, the ways in which the overdose crisis has been characterized in the media – with little attention to gender diversity – continues to obscure the diverse ways that women, transgender, two spirit¹, and non-binary persons are experiencing this epidemic. This is particularly important given that drug use is gendered, with research demonstrating that women – especially marginalized women and gender diverse persons – are differentially impacted by drug-related risks and harms in comparison to cisgender men who use drugs. This includes increased vulnerability to physical and sexual violence, HIV and hepatitis C transmission, and injection-related harms (El-Bassel & Strathdee, 2015; Poteat, Scheim, Xavier, Reisner, & Baral, 2016). Of note, drug policies stemming from the overdose crisis are often “gender-neutral” or reinforce gendered inequities by seeking to exert control over the bodies of cisgender women and gender diverse persons, as seen through punitive approaches to pregnant women who use drugs (Pinkham & Malinowska-Sempruch, 2008). Understanding the gendered dimensions of overdoses, including their social-structural contexts, will thus be imperative to the optimal and ethical implementation of the public health response to this crisis.

All too often, the overdose crisis has been framed as a men’s health crisis (Corday, 2017; Todd, 2017). While men have been more impacted by overdose deaths, women comprise approximately 30% of fatal overdoses in the United States (O’Donnell et al., 2017) and approximately 23% in Canada (Special Advisory Committee on the Epidemic of Opioid Overdoses, 2018). Moreover, fatal overdoses in the United States increased 260% among women aged 30–64 years and almost 500% among women aged 55–64 years between 1999–2017 (VanHouten, Rudd, Ballesteros, & Mack, 2019). The substantial increases of overdose experiences amongst women highlight the continued neglect of overlapping social and structural factors that increase women’s vulnerability of overdose. Further, these data underscore an urgent need to focus on the complex and intersecting factors shaping women’s gendered experiences of drug use amidst a public health emergency, so as to develop overdose-related supports responsive to the needs of women who use drugs.

Research has underscored how women, transgender, two spirit, and non-binary people who use drugs (PWUD) are disproportionately impacted by social (e.g. racializing practices, gender norms), structural (e.g. drug policy, criminalization), and interpersonal factors (e.g. gendered violence) operating within the broader environments in which drug use occurs (Pinkham & Malinowska-Sempruch, 2008). These factors reinforce the marginal status of women and gender diverse persons in ways that can render them more vulnerable to health- and drug-related harms. Such factors are exacerbated for racialized women and gender diverse persons affected by multiple marginalizing factors (e.g. racism, poverty, transphobia) (Hansen, 2017; Lyons et al., 2015). As such, there remains a need to further an overdose prevention and response agenda using an intersectional lens to better assess the needs of women, transgender, two spirit, and non-binary PWUD. Intersectionality highlights the heterogeneity of experiences and can better account for overlapping systems of oppression and discrimination (Collins, 1990). Additionally, stigma, gendered violence, and racism can create barriers to accessing mixed-gender health and drug treatment services for cisgender women and gender diverse persons, necessitating drug use practices that increase risk of overdose and other health and drug harms (e.g. using alone, using in public spaces) (Boyd et al., 2018; Lyons et al., 2015). Accounting for the influences of gender-specific challenges (e.g. sex work, loss of child custody, assisted injection) that contribute to overdose and other drug-related risks for women and gender diverse PWUD is critical to effectively intervening to reduce risk of overdose-related morbidity and mortality, and addressing the multiple impacts of this epidemic.

Moreover, racialized persons in North America face disproportionate rates of overdose (First Nations Health Authority, 2017; Schmitz Bechteler & Kane-Willis, 2017; Xu, 2018); however, overdose risks among racialized women and gender diverse persons remain poorly understood and warrant immediate attention to avoid reinforcing their exclusion in the overdose response. There is also a significant gap in public health reporting on the impacts of the overdose crisis on gender diverse persons, further obscuring their needs during this public health emergency.

While epidemiological data is important for guiding overdose intervention strategies, it cannot fully account for the multiple, intersecting factors that shape overdose risk for women and gender diverse PWUD. Current overdose surveillance data maintains the use of a gender binary, thereby failing to capture the various experiences of gender diverse persons. More nuanced data collection and reporting are thus required to ensure that the differential impacts of the overdose crisis on transgender, two spirit, and non-binary persons are understood and can be addressed with overdose prevention and response interventions. This can be further extended to substance use research in general, as the experiences of gender diverse people are underexplored, thereby reinforcing inequity.

Across North America, there remains a shortage of harm reduction and overdose prevention and response supports that consider the intersecting gendered dynamics of drug-related harms, despite recent calls from international organizations to incorporate gender-specific needs in to programs and interventions (United Nations Office on Drugs and Crime, 2016). Harm reduction interventions and services, such as supervised consumption sites, detox, and needle exchanges, have largely been designed and implemented using a gender neutral approach, which assumes equal impact and experiences of drug- and health-related harms between genders (Iversen, Page, Madden, & Maher, 2015). While these interventions provide needed services, the narrow approach taken in most overdose-related interventions and harm reduction services tends to overlook the variegated experiences of cisgender women and gender diverse PWUD (Boyd et al., 2018). As such, drawing on an intersectional lens can better inform tailored interventions and services that are more responsive to the intersecting factors (e.g. gendered violence, transphobia) shaping the lives of women, transgender, two spirit, and non-binary PWUD within the context of an overdose epidemic.

Expanding overdose-related interventions and services to better address the differential gendered needs of women and gender diverse PWUD should include initiatives such as establishing peer support workers with attention to racial, ethnic, and gender diversity at harm reduction and ancillary services, as these may mitigate barriers these populations face when trying to access harm reduction services. Moreover, establishing women-only and gender diverse-inclusive harm reduction interventions have the potential to create safer environments for these populations to use drugs and to access needed supplies. Further, creating and scaling up mobile harm reduction and ancillary support services may better serve marginalized women and gender diverse PWUD who may not feel safe accessing existing supports given previous experiences of violence and victimization. Importantly, additional funding is needed to support women and gender-focused harm reduction initiatives, including supervised consumption services and opioid agonist treatments that are tailored to these population. An intersectional lens also needs to be incorporated into drug policy to better address the health disparities of women and gender diverse PWUD.

As the overdose epidemic escalates, we must not forget to investigate and respond to the specific ways in which the overdose crisis impacts women and gender diverse persons, including differential impacts on those who are racialized, Indigenous, and are sexually diverse. Recognizing the variegated risks and experiences of women, transgender, two spirit, and non-binary PWUD is imperative to creating comprehensive harm reduction and overdose prevention and response strategies that can better address their needs within the context of a public health crisis.