“Just an Unfair Score”: Perceptions of Gender Inequity in the Treatment of Substance Use Disorders among Women Involved in the Criminal Legal System

Abstract

Introduction:

Increasing overdose deaths and criminal legal involvement among women necessitate women-specific solutions to curb the adverse consequences of substance use disorders (SUDs). The current study is the pre-implementation phase of an implementation science study that works with various stakeholders—affected women, criminal legal professionals, and SUD treatment professionals—to identify and address high-priority needs for criminal-legal involved women with SUDs.

Methods:

This study uses semi-structured interviews (N=42) administered in 2022 to women with a history of SUD and criminal legal involvement (n=20), SUD treatment professionals (n=12), and criminal legal professionals (n=10). Interviews focused on participants’ history of substance use and criminal legal involvement, facilitators and barriers to initiating and completing treatment, and gender-specific issues encountered during treatment and criminal legal involvement. Drawing on the social ecological model of health, analyses identified gender-specific challenges impacting criminal-legal involved women’s treatment and recovery processes.

Results:

Participants identified five gender-specific challenges impacting women across social ecological levels. At the relational level, challenges stemmed from women’s roles as mothers and from victimization within healthcare and criminal legal settings; at the community level, from unequal resource allocation for treatment; and at the societal level, from stigma associated with certain intersectional identities and cultural norms that constrict job opportunities. Participants noted that providing women with effective care coordination and women-specific guidelines and spaces within the criminal-legal system could mitigate some of these challenges.

Discussion:

Findings highlight the need to consider gender-specific challenges faced across relational, community, and societal levels when implementing medical interventions and criminal legal proceedings for women. Given these findings and extant literature, the authors are developing an all-female, trauma-informed intervention that includes case management with female certified recovery specialists who are in recovery and have navigated the criminal legal system. By reducing some of the gender-specific barriers identified in this study, this future intervention aims to improve the substance use and criminal legal outcomes of participating women.

1. Introduction

Women are the fastest-growing population impacted by the criminal legal system in the United States (Kajstura, 2018). From 1980–2021, the incarceration rate for women increased by over 525% (Monazzam & Budd, 2023). Community supervision rates have also increased drastically among women, with women accounting for one-quarter of the probation population and one-eighth of the parole population by 2021 (Kaeble, 2023). Concurrently, the U.S. has been experiencing a drug overdose epidemic that has led to substantial increases in drug overdose deaths among all racial/ethnic groups of women (Jones et al., 2023a). Women in midlife, aged 35–44 (300% increase) and 45–54 (400% increase), saw the highest increases in overall drug overdose deaths from 1999–2021 of any gender-age demographic group (CDC, 2023). Increased criminal legal involvement and substance use harms are related: many women are arrested for committing drug-related crimes or other non-violent offenses under the influence of drugs or alcohol (Monazzam & Budd, 2023). Indeed, a report by Bronson et al. (2017) revealed that about 70% of incarcerated women met the criteria for substance dependence or abuse according to the DSM-IV.

While men are still more likely to be involved in the criminal legal system than women, women experience unique pathways to criminal legal involvement (Heimer et al., 2023; Wright & Cain, 2018). Feminist pathways research, in particular, has provided an important framework for researchers to identify the ways women come to offend that may differ from men (Daly, 1994; Wattanaporn and Holtfreter, 2014). This framework has been used to shed light on the ways that women uniquely come to use substances and face related criminal legal consequences. For example, Salisbury and Van Voorhis (2009) find that there are two common pathways to criminal legal involvement that involve substance use: experiencing childhood victimization or dysfunctional intimate relationships followed by substance use, which can then lead to related criminal legal consequences.

A considerable body of research has confirmed and underscored the importance of these gender-specific risk factors faced by women. Women who use drugs and are involved in the criminal legal system have high rates of experiencing violence in both childhood and adulthood; studies have found that as many as 80% of women who use drugs have experienced severe physical, sexual, and psychological abuse as children (Pettus, 2023; Jones et al., 2023b), and 57% of women in substance use treatment programs have experienced intimate partner violence (IPV) (Chermack et al., 2000). While criminal-legal involved men also experience such environmental risk factors at elevated rates, criminal-legal involved women have a higher prevalence and severity of trauma stemming from victimization and violence than criminal-legal involved men (Jewkes et al., 2019).

Research shows that this history of maltreatment and violence is a risk factor for later substance use and the development of substance use disorders (SUDs) (Cicchetti & Handley, 2019; Leza et al., 2021). However, there is also evidence that connections between violence, substance use, and criminal legal involvement are complex and multidirectional, intensifying the impacts of violence on women. For example, a study focused on women in methadone treatment found that the experience of IPV can motivate drug use, but that drug use can also then increase the likelihood of experiencing subsequent IPV (El-Bassel et al., 2005). A more recent study focused on criminal-legal involved women with opioid use disorder (OUD) found that criminal legal involvement itself can inflict additional trauma and victimization that further motivates substance use (Strong-Jones et al., 2024). Again, these experiences are especially pronounced among women: compared to men, women experience more physical (20.3% vs. 18.1%) and sexual victimization (15.3% vs. 9.7%) while incarcerated (Caravaca-Sánchez et al., 2022).

Outside of the gendered pathways framework, research has identified additional factors which can create feedback loops that intensify substance use and heighten the chance of criminal legal involvement for women. One notable factor is women’s social roles as mothers. Many criminal-legal involved women who use drugs have children, and research has shown that the trauma caused by losing custody of one’s children due to substance use can further motivate substance use (Thumath et al., 2021; Adams et al., 2021). Mothers also encounter unique challenges in initiating and completing treatment that may reduce the likelihood of entering and sustaining recovery. For example, while the use of both buprenorphine and methadone is safe and effective during pregnancy (Kinsella et al., 2022), providers may be hesitant to prescribe these MOUDs to pregnant women due to bias, stigma, or lack of education (Apsley et al., 2023; Frazer et al., 2019). Additionally, childcare responsibilities may make both inpatient and outpatient treatment difficult to consistently attend (Apsley et al., 2023).

Substance use treatment is limited in criminal legal settings in general, and, despite these gender-specific vulnerabilities, evidence suggests that substance use interventions for criminal-legal involved women are fewer than for criminal-legal involved men (Grella et al., 2020; Moore et al., 2020). Moreover, despite the high prevalence of trauma experienced by criminal-legal involved women with SUDs, there is a lack of drug treatment interventions that help participants navigate their extensive trauma histories (Lim et al., 2023; Moore et al., 2022). Additionally, while medications for opioid use disorder (MOUD) are the most effective treatment for those with opioid use disorder (OUD) (Malta et al., 2019; Moore et al., 2019), less than 5% of people with OUD who are referred to treatment by the criminal legal system are referred to a MOUD program (Krawczyk et al., 2017). These findings suggest that criminal-legal involved women with SUDs are likely to face considerable challenges initiating and completing treatment, especially treatment that is trauma-informed and, for those with OUD, treatment that involves MOUD.

In light of the increasing rate of criminal legal involvement and overdose deaths faced by women in the U.S., evidence-based, women-specific solutions are needed to curb these adverse consequences of SUDs. However, as women involved in the criminal legal system have unique needs, evidenced by the literature outlined above, insights derived directly from women with lived experience are needed to design these interventions effectively. To address this need, the current study triangulates the perspectives of women who have a history of OUD and criminal legal involvement with the perspectives of SUD treatment professionals and criminal legal professionals who work with women who use opioids. Through inductive data analysis and the application of the social ecological model of health (NIH, 2011), this study identifies gender-based inequities experienced by criminal-legal involved women with OUD at the relational, community, and societal levels that hinder their treatment and recovery success. While womenspecific barriers and challenges have been explored in a number of previous studies (Apsley et al., 2023), the analysis of these barriers and challenges through the social ecological lens constitutes a novel contribution of this study.

The current study is also the pre-implementation phase of a larger implementation science study that is working with the various stakeholders—affected women, criminal legal professionals, and SUD treatment professionals—to identify and address high-priority needs for criminal-legal involved women with SUDs (Goodrich et al., 2021). Data from this study will inform the development of a user-centered, evidence-based, gender-specific, and trauma-informed substance use treatment intervention. Thus, after outlining the gender-based inequities identified by participants across levels, this study draws on participants’ observations and experiences to design an intervention to meet the needs of this highly vulnerable population.

2. Methods

2.1. Study overview

This study draws on semi-structured interviews (N=42) that were conducted between May and July of 2022 of women with a lifetime history of OUD and criminal legal involvement, SUD treatment professionals (n=12), and criminal legal professionals who work with women who use opioids (n=10). This sub-sample size of 10–12 participants per group meets recent recommendations for reaching data saturation (Hennink and Kaiser, 2022).

The eligible women, SUD treatment professionals, and criminal legal professionals participated in semi-structured interviews conducted by trained study staff. These interviews lasted approximately one hour and were administered by phone. At the start of each call, trained study staff went through the informed consent process with participants and clarified that, should they find any questions uncomfortable, they could decline to answer. Interviews followed participant verbal consent. All participants received a $50 gift card as compensation for their time. The Penn State University Institutional Review Board approved this study.

2.2. Recruitment and eligibility criteria

To recruit participants across groups, the study team sent informational flyers to women’s prisons and MOUD treatment programs, contacted women’s prisons and MOUD treatment programs through direct phone calls, utilized chain referrals, and posted online advertisements. To be eligible for the study, affected women (n=20) were 18 years or older, lived in Pennsylvania, had a history of involvement in the criminal legal system, and had a history of OUD and related MOUD use.

SUD treatment professionals had to fulfill at least one of the following requirements: 1) prescribe methadone, buprenorphine, and/or extended-release naltrexone; and/or 2) provide behavioral modification counseling or other care as part of a MOUD treatment program. They also had to practice in Pennsylvania. The final sub-sample included SUD treatment directors (n=2), nurses (n=2), counselors (n=3), recovery coaches/case managers (n=3), a MOUD provider, and a case manager supervisor.

Eligibility criteria for criminal legal professionals held that they had to work in Pennsylvania with criminal-legal involved women who use opioids in either sentencing, drug court, corrections, or law enforcement. The final sub-sample included state prosecutors (n=2), law enforcement officers (n=3), treatment court professionals (n=4), and a corrections employee.

2.3. Data analysis

Trained study staff transcribed and de-identified audio recordings of interviews, and they stored these transcripts on secure servers. Through careful reading of transcripts, three study team members first generated a list of codes inductively. These team members continued reading transcripts until new transcripts required no new codes to be added to the codebook. Since each group of participants answered similar questions to identify points of convergence and divergence between the women and professionals, analyses across all sub-samples used a single codebook. A separate group of three study team members then coded the transcripts using this codebook. One study team member coded each transcript; the P.I. then double-checked all coded transcripts to ensure consistency across coders.

Perceived differences between men’s and women’s experiences in OUD treatment and in the criminal legal system arose frequently across sub-samples. One primary code captured these perceptions, “Perceptions of differential treatment due to gender.” This paper reports patterns found within this primary code, using the social-ecological model of health to organize the major themes identified by both impacted women and professionals. The social-ecological model is a widely used theoretical framework derived from Bronfenbrenner’s ecological systems theory (1981), which holds that individuals are affected by several interconnected social and environmental factors. According to the social-ecological model, alongside individual characteristics, a person’s health is also impacted by their friends, romantic partners, and family members at the relational level; their schools, workplaces, and other local institutions at the community level; and policies and cultural norms at the societal level (NIH, 2011). Analyses identify those gender-specific factors at the relational, community, and societal levels that impact the treatment and recovery processes of criminal-legal involved women with SUDs.

Additionally, in their interviews, both SUD treatment professionals and criminal legal professionals spoke to the ways that the healthcare and criminal legal systems could better serve criminal-legal involved women with SUDs. These insights were captured with the primary code, “Professionals’ experience working with women who use opioids.” After reporting the gender-specific factors that impact women across social-ecological levels, this paper reports the common suggestions posed by professionals to address these challenges.

3. Results

3.1. Participant characteristics

Among the 42 participants were 20 women with a history of criminal legal involvement and OUD. Their ages ranged from 24 to 54 years, with an average age of 37. Most of them, 70% (n=14), identified as white and non-Hispanic. The participant sample also included 12 SUD treatment professionals with diverse roles, as enumerated in section 2.2. Ten of these professionals were female, and two were male. Their ages ranged from 38 to 54, with an average age of 48, and 67% (n=8) identified as white and non-Hispanic. Finally, the sample included ten criminal legal professionals, whose roles are also enumerated in section 2.2. Among them, seven identified as female and three as male. The vast majority, 90% (n=9), identified as white and non-Hispanic. Their ages ranged from 34 to 56 years, with an average age of 44. Each group offered unique perspectives from their own lived experience navigating or working within the healthcare and/or criminal legal system.

3.2. Gender-specific factors impacting criminal-legal involved women with SUDs

Participating women spoke of five main forms of gender-based inequities across the relational, community, and societal levels, which they experienced while navigating treatment and recovery within the healthcare and criminal legal systems. SUD treatment and criminal legal professionals corroborated these stories with their observations from working within these systems. At the relational level, differential treatment stemmed from women’s roles as mothers and from victimization at the hands of staff members within healthcare and criminal legal settings; at the community level, from unequal resource allocation for treatment between men and women; and at the societal level, from the stigma associated with certain intersectional identities and cultural norms that constrict job opportunities upon completing treatment and/or a criminal legal sentence.

3.2.1. Gender-specific challenges at the relational level.

Women and professionals reported two types of challenges that arose at the relational level: challenges related to their roles as mothers and challenges stemming from victimization. Participants shared that parenting and childcare responsibilities often fall on mothers, impacting their willingness to engage in treatment and their likelihood of treatment success. One treatment court professional shared that childrearing typically “falls on the females in our program.” They recognized that this burden can make it difficult for female treatment court participants to meet the court’s expectations. Yet another criminal legal professional, a prosecutor, described that courts typically do not give special considerations to women who have these familial responsibilities:

I’ve never seen a court give a woman any sort of grace or leniency because she was unable to complete treatment because of some sort of childcare issue. I know not all women with an addiction have children, but I do think that’s something that affects women specifically and is not addressed by the court. [Participant 13, Criminal Legal Professional]

These participants recognized that motherhood can impact women’s abilities to follow court-mandated treatment plans; yet because courtroom actors do not consider these responsibilities when setting treatment plans, noncompliance may be more common and lead to higher chances of sanctions and punishments.

Yet, while having children posed a barrier, being pregnant could facilitate access to treatment opportunities and resources. Other participants described these pregnancy benefits within both the healthcare and criminal legal systems. For example, one woman recalled her experience receiving a lighter sentence than her partner when she was pregnant:

I was arrested with a person I was dating at the time and they ended up going upstate for three years for the same charges that I got seven or eight months for. I know that me being a woman definitely affected some of that. Me being pregnant definitely affected a lot of it. [Participant 28, Woman with History of Criminal Legal Involvement and OUD]

This participant had been to jail before, but she further explained that she was better cared for and received more connections to supportive services this time when she was pregnant. She started using MOUD while in jail and received accompanying counseling; these services were not an option for her non-pregnant peers:

The only time that I ever actually got any help was I ended up in jail one time when I was pregnant… That was the first time that I ever was on Methadone. I would say, honestly, that was the only time that a jail has ever given me any help where it was not just, “Here’s something to shut up.” No. It was, “We’re taking you a clinic. You’re going to get all the help you actually need. You’re not going to be sick. You’re going to get counseling…” I know for a fact that had I not been a woman who was pregnant, I wouldn’t have gotten into Methadone at all. [Participant 28, Woman with History of Criminal Legal Involvement and OUD]

Outside of the carceral setting, she had also received this additional care in treatment settings. She relayed that, on multiple occasions, MOUD treatment programs had given her take-home methadone doses while she was pregnant but would not do so for her partner.

I’ll go into treatment, me and my boyfriend will go into treatment together. They’ll give me bottles because I’m pregnant or something, but they won’t give him bottles. [Participant 28, Woman with History of Criminal Legal Involvement and OUD]

Participants spoke to a paradox, where pregnant women receive more robust opportunities for care and treatment, while mothers with children do not.

Women also spoke to the impacts of being victimized by others in both treatment and criminal legal settings. One woman shared that it was common for staff members to exhibit predatory behavior at the treatment facilities she had been to:

There was always a pervert, you know what I mean? At the one treatment place I was at, there was a tech, and he was older. He flirted with the girls and would take all of us to get sodas when we go on our walk every Wednesday. If we needed cigarettes, he would get them… I was like “Typical pig,” you know what I mean? He’s supposed to be there helping the girls, and he is obviously got an ulterior motive. [Participant 22, Woman with History of Criminal Legal Involvement and OUD]

Another participant shared a situation that had escalated into sexual assault:

I had a female counselor at this rehab that I was at. All of a sudden, this older male counselor started talking to me and encouraging me that if I had a problem to go see him and not my actual counselor. It just progressed to one day when he was having a talk with me in his office, he shut and locked the door and tried to make out with me and get me to do stuff with him. Here come to find out that he had also done that to a couple of other girls that were there at the same time that I was. That was an awful situation to put people like us into and have him there to be that monster. It was awful. [Participant 29, Woman with History of Criminal Legal Involvement and OUD]

The normalization of these behaviors created unsafe environments that the women made clear had inhibited their own recovery.

Women also reported harmful behaviors exhibited by correctional staff at the jails and prisons where they had been incarcerated. One woman shared:

I watched horrific things go on there with the women. There was only two blocks for us and the rest were men… Especially if you come in on drugs too, they take advantage of you. It’s even worse. [Participant 24, Woman with History of Criminal Legal Involvement and OUD]

These environments only compounded the trauma that women had already experienced, rather than helping them to navigate and heal from the trauma that often motivated their substance use.

3.2.2. Gender-specific factors at the community level.

Both the women and the professionals frequently identified a lack of treatment resources for women, both within community healthcare institutions and criminal legal institutions, as a barrier towards women’s treatment and recovery. One nurse practitioner working in a correctional setting asserted:

Women are absolutely minimized in terms of their needs and their issues. When you have a facility, and you only have a clinic for women one day a week, that could potentially be a problem. I think having dedicated resources and dedicated health professionals, mental health professionals, whatever the case may be to those women, even if you have a smaller population, could go a long way in terms of addressing what their needs are. [Participant 12, SUD Treatment Professional]

A common narrative expressed across participants was the lack of programming for women in jails and prisons compared to men. One woman (Participant 27) shared, “[The] warden would look at us and say, ‘It’s not a women’s prison.’ He hated having women there.” These women recognized that there were treatment opportunities available for men in their facilities—such as access to MOUD or greater opportunities for counseling—that were not available for themselves.

Criminal legal professionals’ experiences reflected the same observations as the women, corroborating the considerable lack of treatment programming available for women as compared to men. One treatment court professional stated:

It almost feels like for a woman, if they don’t go through a treatment court, they’re pretty limited on getting any help at all while they’re incarcerated. Whereas men, there’s so many different programs they can do… The females are more isolated, and then they get out of incarceration, and they don’t know any resources, they don’t know where they can get housing, what they can do. They go back to what they know. That’s just going to keep being a pattern because they didn’t get the help they need… They didn’t have enough population to start a program that was very involved, whereas on the male side, they did. [Participant 17, Criminal Legal Professional]

The criminal legal professionals held that this inequity resulted from the differences in the populations of men and women at these facilities. They explained that these programs were too expensive to create and sustain for a small number of women.

Yet despite the lack of resources for women in the criminal legal system, SUD treatment professionals felt that criminal-legal involved women with SUDs often have more serious and more entrenched issues to deal with, as compared to men. One SUD treatment professional reported seeing heightened levels of adversity among their female clients as compared to their male clients:

[Women are] really starting out with just an unfair score. It’s more difficult for women in, especially MAT [medication-assisted treatment], they’re stereotyped even more heavily than with men. They oftentimes are also carrying heavier mental health diagnoses, dual-diagnoses, and their comorbidity seem to be a lot more intense and severe. [Participant 11, SUD Treatment Professional]

Nonetheless, criminal legal professionals noted that women’s needs can be overlooked. One state prosecutor described how women’s issues are often not taken seriously:

I think a lot of times it’s discounted that a woman could have as serious of an issue as a man could…Law enforcement often looks for the guy who’s breaking into somebody’s house to support his addiction as opposed to obtaining help for the woman who’s arguably going through something more serious by prostituting herself or putting herself in that dangerous type of situation in order to get whatever substance she wants. [Participant 13, Criminal Legal Professional]

This prosecutor felt that focusing on men as more culpable led to women—often their partners—not being connected to the same level of resources and support in the case of a drug-related crime.

Echoing our findings from section 3.2.1, an exception to the dearth of resources allocated to women in the criminal legal system is when women are pregnant. One treatment court professional corroborated the lack of treatment services for women in jail, but specified that this looked different for pregnant women:

There are no services specific to women in the [local] jail. I think that’s very concerning both from a professional and lived experience standpoint. Like I said, they have a program for MAT for the men in the prison but not the women…unless they are pregnant, and then they can get assistance with MATs, and they get therapy and things like that. [Participant 11, Criminal Legal Professional]

Again, this paradox signals to women in correctional settings that while their fetuses are valued by the state, they themselves are not.

3.2.3. Gender-specific factors at the societal level.

Finally, women and professionals reported two types of challenges at the societal level: challenges arising from stigma faced by women with certain intersectional identities, and those created by social norms that limit job opportunities for women. Beyond the stigma faced by people with SUDs generally, participants explained that there are additional stigma barriers placed upon women who identify as members of the LGBTQ+ community and veterans. When women who identify as members of the LGBTQ+ community, especially those who identify as transgender, enter treatment, staff members at some treatment facilities said they try to act in supportive and empowering ways to combat stigma and create an environment conducive to recovery. A co-ed inpatient director shared:

[We are striving to be] more accepting…we have a designated area and we have to identify them by whatever they identify as. We don’t make a big deal of it, but we do. We can’t stop the stigma, but we do definitely redirect our patients, try to educate them. It’s difficult because it’s something that it’s ingrained in them, the other people, but we support wherever they’re coming from. There’s no issue there and our staff are educated in that. [Participant 1, SUD Treatment Professional]

Another participant spoke to the stigmatizing experiences commonly endured by women who served in the military and are seeking treatment. A SUD treatment professional (Participant 37) who worked in a Veteran’s Affairs facility discussed how other staff members often stereotyped women with a military background and assumed they “must be sleeping with” the men in the facility. She felt that these stereotypes and judgments created an environment that was not supportive of these patients’ recovery.

Participants also identified a lack of vocational training available for women within both the criminal legal system and healthcare systems. One prosecutor described these inequalities to us, saying:

I think a lot of times men are given the opportunity to learn to be an electrician or a construction worker or something, but there’s not the same options given to women such as maybe a cosmetology license or learning to be a counselor for the program that they’re currently in, where there’s some sort of end game where if you successfully complete it, you’re not just successfully completing it and starting at ground zero, you also have some sort of vocational training that you can utilize now in your sober life. [Participant 13, Criminal Legal Professional]

Beyond training opportunities, there were minimal job opportunities upon release from jail or a treatment program. Another state prosecutor shared:

I feel men have more options than women, especially upon release from a facility… I totally think that the work options after release are so much more available for men. Even the options of the type of work, they’ll be given more manual labor… I know that there’s more men that go through the criminal justice system. In some way, that makes sense. You have people who were released and they create a program and they hire other former people with records and stuff. Participant 15, [Criminal Legal Professional]

This participant pointed to similar population size explanations that others cited to account for the lack of treatment resources for women in jails. Regardless of the reason for this deficit, participants noted that a lack of vocational training and a lack of job opportunities post-release were crucial missing elements for women to sustain recovery.

Many of the women echoed that men had far greater opportunities for vocational training and employment in recovery, especially after criminal legal involvement. One woman shared the challenges she faced trying to find a job with a criminal record:

I definitely feel like it’s easier for men because they have that ability to be a laborer or something like that, and those jobs don’t often care about a background. As far as females, you’re going into anything with sales or anything that requires a licensure or anything like that, that all matters. [Participant 29, Woman with History of Criminal Legal Involvement and OUD]

Women can certainly work in manual labor jobs, but because men predominantly occupy these fields, women may not feel comfortable entering these careers. One woman who pursued forklift training and welding described how the male trainers “just didn’t show [her] much attention,” and she felt she was “not receiving the guidance that [she] needed” even after asking for assistance (Participant 37, Woman with History of Criminal Legal Involvement and OUD). Many of the women desired the chance to find meaningful careers that could aid their recovery journeys but felt that opportunities were few and far between.

3.3. Professionals’ recommendations for providing more effective care for criminal-legal involved women with SUDs

As the above examples demonstrate, there are many times when women with SUDs interact with healthcare providers and criminal legal professionals along their treatment and recovery journeys. The women spoke about various intervention points when healthcare providers could assist them across both acute (e.g., emergency department, inpatient) and longer-term (residential, outpatient, sober living) care settings. Criminal legal professionals also impact the treatment experiences of criminal-legal involved women in various ways, such as by choosing (or not choosing) treatment over incarceration, providing treatment programming in prisons and jails, and connecting women to ongoing recovery services while on probation or parole. Given the gender-specific factors identified in section 3.2, this section summarizes professionals’ suggestions for how to improve the care provided to criminal-legal involved women with SUDs. Professionals consistently cited a need to provide women with more individualized and compassionate care, improve care coordination across systems, and create more women-specific guidelines and spaces within criminal-legal settings.

3.3.1. Providing individualized and compassionate care.

Participants felt that many of the women-specific barriers identified in section 3.2 could be eroded by creating more individualized and compassionate systems of care in both healthcare and carceral settings. As one SUD treatment professional (Participant 7) shared, one of the hallmarks of compassionate care is being empathetic. She explained that, for her, this empathy comes from the realization that “A lot of people [who] are successful have also been unsuccessful at different stages.” Many professionals said they drew on their own lived experience with addiction to meet women where they are at.

Others shared that compassion could come from recognizing the profound trauma that the women they work with have experienced. One criminal legal professional illustrated how the women they have worked with endure ongoing trauma related to SUDs and how they acquire drugs:

I think it happens more often than is realized that women have to use their bodies in order to feed their habit, whereas I don’t see that as much with the male population. With the female population, they are taken advantage of greatly in order to feed their addiction… I think it’s just much more often than people realize, and I think that’s also more than partially why women need trauma treatment because trauma can be their whole life. It’s a repeating vicious cycle that until they get the treatment for that and know their worth, nothing’s going to change. [Participant 17, Criminal Legal Professional]

This professional also noted that compassion could be cultivated and actualized by better integrating trauma-informed services and frameworks into existing treatment modalities:

Although men have some trauma issues, I’d say 90% to 95% of the women that come through treatment court have trauma issues. Whether it be physical abuse, sexual abuse, that is something that women are dealing with differently than a man coming through the program. That’s something we try to focus on because even if we get them help with their addiction, if we don’t get them help with the trauma they won’t be successful. [Participant 17, Criminal Legal Professional]

These sentiments highlight the centrality of unresolved past and current trauma to the recovery of women with SUDs who are criminal-legal involved.

Beyond providing compassion and empathy that is informed by a recognition of traumatic backgrounds, professionals held that care should be responsive to each woman’s unique circumstances and needs; they felt that such tailoring of care would be crucial for treatment success. Another SUD treatment professional asserted:

Each woman has their own individual unique needs, so it’s up to what’s clinically going to be appropriate for them and what, as long as we can find a bed wherever they need to go, will get them there. [Participant 10, SUD Treatment Professional]

This participant emphasized that success can look different for each person. Ensuring that success required identifying that person’s goals and recognizing their unique strengths.

Many facilities already tout providing person-centered care, but some participants felt that greater steps could be taken to truly individualize care to each patient, not just in words but in actions. One SUD treatment professional told us:

[A] lot of places will say, ‘We have an individualized treatment program,’ and then you look at the treatment plan for every single person and they’re all the same. I really do mean individualized, and hearing what the patient wants, and so really being informed as a provider, regardless of your role, whether you’re the therapist, the case manager, the CRS [certified recovery specialist], the doctor, the team, being informed of what all the options are, presenting them to the person, let them decide what they want. Then, when they get there, help them, really support them into achieving that…It really has to be individualized and based on the person’s history and their substance use, and what are their hierarchy of needs, and what are the other social determinants of health. [Participant 6, SUD Treatment Professional]

As this participant suggests, individualized care requires not only tailoring services to a person’s unique history and situation, but also being able to connect women to other types of recovery services that meet their unique needs.

3.3.2. Improving care coordination.

In addition to engaging women to discern their specific needs and goals, participants also asserted that healthcare providers and criminal legal professionals should more effectively coordinate care. Healthcare services tend to be siloed, and women seeking recovery would benefit from an integrated care model. One SUD treatment professional outlined why such an approach is needed:

[T]he primary care provider is then consulting with a psychiatrist for support in that area because a lot of PCPs aren’t comfortable with prescribing psychiatric medications, but there’s such a shortage right now, so integrated care, especially right now, is needed more than ever. [Participant 6, SUD Treatment Professional]

Indeed, many women echoed the confusion and frustration they experienced when navigating so many different providers to meet their needs when pursuing recovery—they visited one provider to obtain MOUD, sought mental health medications at another, sought primary care at another, and sought pre-and post-natal care at yet another. Navigating the health care system was particularly challenging for those who cycled in and out of jail, as health insurance would be cut off and restarted with each entry and exit from the system.

Participants also suggested that extending the admission and retention criteria at treatment programs would better facilitate recovery for women. One outpatient neonatal abstinence syndrome (NAS) nurse shared:

Our programs specifically, it does not matter if you are currently using, you’re allowed to stay in our program. I find that a lot of places, if you are currently using, you have to drop out or get discharged. I think that not making that a requirement may keep them in therapy a little longer so that they can get to where they need to be… If they’re not honest in their treatment, they’re not going to receive the care that they need. [Participant 4, SUD Treatment Professional]

Women agreed that facing discharges for illicit substance use pushed them backward in their recovery goals, rather than helping them in a particular time of need. Meeting women where they are in their recovery journey—throughout their time in treatment—and providing them with the appropriate therapeutic support can help them achieve their goals and meet their healthcare needs effectively.

3.3.3. Creating women-specific guidelines and settings within the criminal legal system.

Finally, several of the criminal legal professionals shared their insights on ways to make the criminal legal system safer for women. One treatment court coordinator, for example, said that people are barred from participating in their treatment court when they have been charged with assault. But they had found that, for women, often assault charges stemmed from fighting back in cases of domestic violence. He worried that these women were unfairly denied an opportunity to seek recovery with the support of treatment court:

I think in some cases, there are some charges that should be allowed for females, even if they aren’t for males… Many times, what doesn’t come out during [a woman’s] case is that they may have these charges because of a domestic violence situation. If they have assault charges, they typically cannot come into a treatment court, and they’re not getting the help they need. They stay in that abusive situation, they stay in that addictive situation, and we’re just really doing them a disservice by not understanding that there are differences between women and men with addiction issues. [Participant 17, Criminal Legal Professional]

This participant also recommended that treatment courts hold separate sessions for men and women. He shared the perceived benefits of splitting treatment court by gender:

[In women-only spaces] the females are more likely to disclose information, they’re more likely to seek help and be comfortable speaking out. I’ve seen through trainings and personal experience, if you have both genders together in the treatment court, the women, they’re not as forthcoming with speaking and letting somebody know that they need help or that something’s happening. [Participant 17, Criminal Legal Professional]

He felt that women-only spaces would provide a safer environment, allowing women to open up and get more out of the treatment court process. Indeed, participants across samples said that providing safer opportunities for women within both the criminal legal system and healthcare system could enhance recovery success and shape women’s lives outside of treatment and carceral spaces.

4. Discussion

4.1. Key results

This study aimed to identify perceived gender inequities experienced by women with a history of criminal legal involvement and OUD as they navigate the criminal legal system and the traditional healthcare system. A novel contribution of this study is the use of the social ecological model of health to categorize these participant-identified inequities. Importantly, women and professionals alike noted inequities across relational, community, and societal levels. Thus, criminal-legal involved women with OUD face additional multi-layered and intersecting barriers in navigating treatment and recovery as compared to men. These findings highlight the need to consider gender-specific challenges faced across these levels when implementing medical interventions and criminal legal proceedings. These results are consistent with extant literature that calls for greater considerations of gender in treatment (Huhn et al., 2019; Koons et al., 2018), court proceedings and sentencings (Cerulli et al., 2022; Shaffer et al., 2019), and clinical research (Gunn et al., 2022; McKee & McRae-Clark, 2022). Decades of research have uncovered gender- and sex-based differences in the etiology and treatment of SUDs (McHugh et al., 2018). Considering gender-specific barriers and challenges at each level when creating and implementing SUD treatment programs is crucial to better serve women with SUDs, especially those with societally marginalized identities (such as a criminal legal background) and comorbid mental health diagnoses.

Women with SUDs often have higher rates of comorbid mental health diagnoses (Huhn et al., 2019; Huhn & Dunn, 2020; Rhee et al., 2020) and experience greater levels of psychosocial stress (Huhn et al., 2019) and intimate partner violence (Huhn & Dunn, 2020). Women also tend to face more stigma when beginning SUD treatment, especially those who are mothers and those who are involved in the criminal legal system (Huhn & Dunn, 2020; Joshi et al., 2021). Our data support these larger findings across scholarship on SUDs, with participants describing the prevalence and severity of co-occurring mental health disorders and the harmful effects of stigma on recovery outcomes. Provider attitudes toward using MOUD, specifically, can either reinforce stigma or help promote effective recovery (Pasman et al., 2022; Titus-Glover et al., 2021), and stigma reduction efforts across different care settings benefit affected women and providers alike.

The present study showcases the different treatment experiences of women compared to men and speaks to a broader need to conduct more women-specific social and clinical research. Participants consistently spoke about inadequate resources allocated to women in both healthcare and criminal legal settings. These trends are present across empirical scholarship, with women repeatedly underrepresented in study enrollment and reported findings. Sex and gender predict different clinical outcomes, and the lack of gender-specific research limits researchers’ ability to draw concrete inferences regarding treatment approaches and outcomes (McKee et al., 2022).

Women also face considerable barriers to accessing treatment. Participants in this study identified unstable housing, insufficient employment opportunities for those with a criminal record, and stigmatizing interactions as significant barriers to recovery. Extant literature supports the salience of these barriers, with accessibility (Shaffer et al., 2019; Titus-Glover et al., 2021), housing insecurity (Shaffer et al., 2019), unemployment (Shaffer et al., 2019), and stigma (Titus-Glover et al., 2021) all identified as obstacles in women’s recovery journeys.

Participants also shared their perspectives on how to improve recovery services for criminal-legal involved women, espousing individualized care models as paramount to treatment success. Empirical literature on SUD treatment for women has identified the use of gender-responsive care models that account for biological and social differences between men and women as vital for improving the outcomes of women (e.g., Shaffer et al., 2019). Programs tailored toward meeting women’s specific needs (e.g., mental health, trauma, childcare, family support) effectively enhance treatment retention and success across many domains (e.g., Huhn & Dunn, 2020; Shaffer et al., 2019). Maternal medical home models that combine prenatal care, mental healthcare, and social support have, for example, increased the likelihood of pregnant women entering and staying in MOUD treatment and receiving mental health counseling (Crane et al., 2019).

Finally, participants held that better care coordination could also facilitate women’s treatment success. Scholars elsewhere have argued that more comprehensive and effective approaches to treatment should better coordinate community-based care, thus providing affected women with high-quality and empowering treatment options (Joshi et al., 2021). Co-location of services helps reduce barriers to access and can promote care collaboration and integration, promoting successful recovery outcomes (Joshi et al., 2021; Titus-Glover et al., 2021). Women-specific criminal legal programs can also provide earlier opportunities for intervention (Cerulli et al., 2022) and address gender-specific concerns through specialty courts managing co-occurring substance use and mental health disorders, especially in underserved areas across the U.S. (Shaffer et al., 2019). This study and recent scholarship (e.g., Cerulli et al., 2022) emphasize the need for integrated approaches to SUD recovery across healthcare and criminal legal sectors.

4.2. Limitations

The contributions of this study should be contextualized with its limitations. The study sample reflects a specific sociodemographic and geopolitical context, which could limit the generalizability of the study’s findings. Racial disparities exist in the accessibility and utilization of treatment by women and in the likelihood of criminal legal involvement (Henkhaus et al., 2022; Schiff et al., 2020). It is likely that the experiences shared by participants in our study are generally reflective of women’s experiences, but they might not reflect the lived experiences of a more racially diverse population (Kovera, 2019). Lastly, the study sample consisted specifically of women with a history of criminal legal involvement and OUD who have also accessed MOUD for substance use treatment at some point. Thus, findings may not be generalizable to women with different SUDs or to women with OUD who have never accessed MOUD.

Alongside the limitations of this study are notable strengths. The study garnered rich insights into the differential experiences of criminal-legal involved women seeking treatment and recovery. The methodological choices guiding this study increase the generalizability of its findings by drawing upon the perspectives of affected women, healthcare providers, and criminal legal professionals. This study fills a gap in the literature by utilizing a nested approach to understanding the social-ecological contexts shaping women’s experiences with the healthcare and criminal legal systems. Much of the current gender-specific scholarship on treatment and criminal legal system involvement focuses on pregnant women (Crane et al., 2019; Henkhaus et al., 2022; Joshi et al., 2021; Schiff et al., 2020; Titus-Glover et al., 2021); by contrast, this study elevates the voices and experiences of women beyond the scope of motherhood alone.

4.3. Implications

Overall, there are greater calls for user-centered interventions, or interventions that are developed with information such as needs and constraints from the individuals and the settings in which such interventions will occur (Lyon & Koerner, 2016). The absence of user-centered designs can lead to implementation challenges and suboptimal outcomes even when scaling evidence-based interventions (Lyon & Koerner, 2016). Given these findings and current literature, the authors are developing an all-female intervention that includes case management with female certified recovery specialists (CRS)—individuals in long-term recovery who have navigated the criminal legal system and have completed a 72-hour state-certified training program. The CRS aims to provide emotional and social support and linkages to social services and drug treatment for women with SUDs reentering their communities. As participants in the present study identified gender-specific employment challenges as a barrier to recovery, the intervention incorporates consultations with a rehabilitation and employment counselor with extensive experience working with criminal-legal involved women. Also following the findings from this study, the intervention will offer childcare onsite at a community drug treatment program, along with transportation to and from the facility. In addition, half of the participants will partake in a trauma-informed support group, consisting of 12 group meetings that use evidence-based materials on trauma and substance use specifically designed for women with SUDs. Food, childcare, and transportation will be provided to limit barriers to attending these group meetings. By removing or reducing some of the gender-specific barriers outlined in this manuscript, the intervention aims to improve substance use, criminal legal, and well-being outcomes for criminal-legal involved women with SUDs.

Highlights

• We identify high-priority needs for an intervention for legal-involved women who use drugs

• We use data (n=42) from affected women and treatment and criminal legal professionals

• Comprehensive substance use treatment is vital for women in carceral settings

• Providing women with individualized, trauma-informed care improves treatment success

• Addressing childcare and transportation may increase women’s retention

Data Availability Statement:

Data can be requested.