How survivors of exploitation who use drugs navigate systems of care: an analysis of survivor insights using the intersectional risk environment

Abstract

Background

Drug-related risks such as adverse health outcomes, overdose, and violent victimization vary across populations due to the marginalization of identities, structural inequities, and differing environments. Discrimination and criminalization exacerbate drug-related risks specifically for survivors of sexual exploitation who use drugs. This study aims to understand how survivors who are not currently utilizing intensive treatment services perceive their risk environment, including available resources, and identify possible mechanisms to address health equity. Emphasizing the role of harm reduction and the expertise of lived experience, this paper encourages innovative approaches to supporting survivors.

Methods

A research team conducted seventeen semi-structured interviews with survivors of exploitation who currently or formerly used drugs in a midwestern US state. This project emerged from a larger study exploring how survivors of exploitation navigated substance use treatment services. The team used Deterding and Waters’ twenty-first century flexible coding approach to generate both inductive and deductive codes for data analysis and met weekly to discuss codebook development and code application. The intersectional risk environment framework was used to interpret the findings.

Results

Survivors identified characteristics of the physical, social, policy, and economic risk environments that contributed to increased barriers to obtaining long term health and safety. While most participants had previously accessed intensive services for substance use disorder (SUD), restrictions on geographic mobility, poor medical care, and disproportionate criminal-legal involvement were noted as persistent issues faced by survivors upon leaving SUD services, that contributed to ongoing substance use and health inequities. Barriers across risk environments were compounded by the dual stigmatization of drug use and exploitation and further escalated for those with multiple marginalized identities.

Conclusion

Increasing access to harm reduction for survivors who use drugs requires a multipronged approach that tackles structural drivers of inequities as well as community and individual level stigma and discrimination. Critical, actionable research that accounts for this complexity is needed to advance health equity for this group.

Background

Drug-related risks and harms are experienced differently across populations, shaped by intersecting forces such as the marginalization of individual identities (e.g. racism, sexism, homophobia and transphobia), structural inequities (poverty, public policies), and physical environments (neighborhoods, service access) [1]. These interconnected factors are often magnified among individuals with lived experience of sexual exploitation [2–4]. Although the strength of the correlation between exploitation and substance use is unknown, studies have shown that both cisgender and transgender women who use drugs report a high lifetime prevalence of gender-based violence of all types [5, 6], while a recent study using data from emergency departments found that individuals identified as having experienced sex trafficking had higher rates of substance use disorder (SUD) than labor trafficking survivors and those who have not been trafficked [7]. The co-occurrence of being a survivor of exploitation and having a SUD can complicate service provision to survivors [8], making it necessary to understand how this population experiences broader service systems.

Individuals who have experienced exploitation and use drugs often have unique mental and physical health needs stemming from complex trauma. Addressing these needs requires rigorous evaluation of integrated treatments for survivors as well as the development of innovative treatment approaches and complementary programs, including peer support and harm reduction-oriented services [9, 10]. Indeed, the intersectional marginalization and complex barriers faced by this group necessitates an anti-carceral and anti-oppressive orientation to service provision to counter pervasive stigma and systemic discrimination. In recognizing the value of the perspectives of those with lived experience, it is important to consider survivors’ perceptions of how to enhance such services.

This study aims to examine multi-level barriers to services for survivors of exploitation who use drugs and interrogate sources of power and oppression through the intersectional risk environment framework. We used qualitative interviews with 17 individuals who had experienced exploitation and self-defined problematic substance use in a Midwestern US state, to answer the following questions:

1. How do survivors who use drugs experience their intersectional risk environment?

2. What intersecting barriers hinder survivors in cultivating long-term well-being?

3. How do survivors perceive the role of harm reduction services in promoting health equity?

We begin by defining and explaining the use and application of the terms exploitation, substance use, and drug use. We then examine the intersection of exploitation and substance use, followed by the role of harm reduction services in supporting survivors. We then introduce the intersectional risk environment framework, which integrates insights from intersectionality and Black feminism. We proceed to outline our qualitative methods, including our use of Deterding and Waters’ twenty-first century flexible coding approach [11]. Our findings explore participants’ perceptions of their risk environments and their views on solutions to health inequities, such as their experiences with harm reduction services. We conclude with a discussion on the importance on applying intersectional feminist perspectives to inform interventions and services for survivors who use drugs.

Use of terms

The terms “sex work”, “survival sex”, “sex trade” and “sex trafficking” are often used interchangeably despite representing different constructs [12, 13]. While force and/or coercion is not a factor in voluntary sex work, the criminalization and stigmatization of any form of commercial sex increases the risk of harm for those involved and interferes with service access and basic needs [14]. These barriers are further amplified for those who use drugs and those who hold historically marginalized identities [3, 15, 16]. For this project, participants were asked to define exploitation in their experience, even if it did not fit the definition of “human trafficking” used by the US federal government. While many of our participants described their experience as trafficking, others perceived themselves to be exploited within the commercial sex trade. The authors wanted to give room to participants to be able to define their experience for themselves, noting that sex trade experience may be perceived divergently by different individuals. For instance, it has been noted that for Black sex workers in turn-of-the-century Chicago, sex work was an arena ripe for exploitation, but also for challenging middle-class norms of acceptability, and building wealth, providing nuance to the sex work discourse [17]. The authors also assert that some involved in the sex trade may consider their involvement to be necessary for survival and may consider it to be exploitative due to their lack of other employment options. For this project, those involved in commercial sex work who did not consider their experience to be exploitative were ineligible.

The terms “substance use” and “drug use” are broadly used interchangeably in the literature to describe a range of behaviors, including the overlapping constructs of substance misuse, symptoms of SUD, and nonproblematic substance use, among others. For this study, we used participants’ subjective assessment of how substance use impacted their psychological well-being, and occupational functioning. We use both “substance use” and “drug use” to capture what participants described as problematic substance use.

Existing services for survivors of exploitation

There are many challenges associated with providing effective services to survivors of exploitation [18, 19]. Survivors are met with stigma within human service settings and face the threat of punitive legal approaches to substance use, sex work, and HIV transmission, rendering them skeptical of health and human service providers as a whole [20]. Many programs geared toward those in the commercial sex trade consider exiting the sex trade to be the primary goal of participants. However, certain approaches may contribute to ongoing exploitation by drawing on “rescue and redemption” narratives that can reinforce punitive, carceral responses to trafficking and sexual exploitation [21–27]. Relying explicitly on the carceral system to intervene in trafficking and/or the sex trade may further exacerbate health risks for people who trade sex and use substances [14, 22–24]. For example, some services are designed based on the belief that survivors’ freedom and autonomy should be restricted to ensure their safety, which can perpetuate harm in certain circumstances [16, 28–30]. Some argue that the pathologization and stigmatization of sex work and related behaviors (such as drug use) by service providers disenfranchises survivors [31]. If the goal is to help individuals exit sexual exploitation, as is the case in abstinence-based programs targeting this population, such programs have shown limited effectiveness; clients often end up back in the sex trade that they exited, and survivors who use drugs may find it difficult to maintain sobriety outside of a clinical setting [31–35].

Finally, it should be mentioned that survivors of exploitation who use drugs often receive services from other types of service programs, including SUD treatment programs, housing services, domestic violence organizations, and immigrant-serving organizations, among others. These organizations may not have expertise in service provision to survivors of exploitation considering they primarily focus on overlapping populations and frequently lack education in working with survivors [36, 37]. The significant intersection between having experienced exploitation and post-traumatic stress disorder (PTSD), as well as the overlap between substance use and PTSD, necessitates a trauma-informed approach to providing effective treatment to survivors of exploitation who use drugs [38–40]. This is where harm reduction programming can emerge as an alternative for individuals who may not be interested or able to take part in abstinence-oriented services.

Harm reduction, mental health, & peer support alternatives

Survivors who use drugs who seek out SUD treatment face several access barriers, including lack of detox services, rigid sobriety requirements, and vulnerability to re-exploitation [3]. There is a notable dearth of empirically studied SUD interventions for survivors of exploitation, which is striking considering the well-documented overlap between SUD and exploitation [7]. Recent work has focused on the possibility of harm reduction programming to provide services to trafficking survivors and others involved in street-based economies who have experienced exploitation [16, 41]. Specifically, grassroots peer-support and harm reduction models have been shown to mitigate the harm that results from carceral involvement of those in the sex trade [22, 42].

Trust has been identified as a critical component of any kind of service delivery for those who have experienced exploitation [16, 43]. While not overtly geared toward trafficking survivors, US researchers found that a brief trauma-informed harm reduction-oriented intervention increased safety and reduced HIV risk for drug-involved women who trade sex, in addition to being found to be feasible and acceptable by community members [44]. However, recent work from Canada (where sex work is legal for sellers) finds that there are policing barriers associated with harm reduction interventions for drug-using sex workers, which may make effective implementation more difficult [45]. This dynamic may be particularly true in the US context, where full service sex work is criminalized (outside of brothel-based rural counties in Nevada), and states vary on the legality of harm reduction interventions as well as the political will to implement harm reduction.

Intersectionality

A critical intersectional perspective on exploitation emphasizes the role of multiple compounding systems of oppression in creating inequities for survivors [1]. For example, survivors with disabilities face unique barriers to service access [46], and despite sexual and gender minorities being at disproportionate risk of exploitation due to structural and institutional discrimination [47], service providers were found to have inaccurate and outdated understandings of the intersection of homophobia, transphobia, and exploitation risk [18]. Studies have described the role of various systems in increasing risk for those with multiple marginalized identities through their exploration of survival sex engagement among unhoused sexual and gender minority young adults [48]. Sexual minority female sex workers were found to have increased odds of injection drug use, binge drinking, homelessness, physical IPV, and being a minor at sex work entry compared to other groups, emphasizing the critical importance of an intersectional perspective when considering interventions for survivors [15, 49].

Intersectional risk environment

Given the intersectional marginalization influencing the health outcomes of this population, we apply the intersectional risk environment framework [1] to understand the factors that influence drug-related harm among individuals who have experienced exploitation. The intersectional risk environment is the “convergence of social and structural dimensions and individuals’ intersecting social locations in ways that interact with and impact individual behaviors to produce health outcomes” [1] (p. 6). This framework combines elements of intersectionality theory, rooted in Black feminist scholarship and activism [1, 50, 51] and the risk environment framework [52] which focuses on environmental determinants of harm. Together, these frameworks counter the predominant public health focus on individual-level methods of changing behavior, through examining how interactions between social locations, socio-structural processes, and geographical and historical contexts contribute to differential risk outcomes [1, 53, 54]. Intersectionality theory broadly relies upon critical feminist epistemology to advance knowledge through lived experiences [50, 51] the approach we take in this study. Importantly, the intersectional risk environment sheds light on systemic and environmental sources of marginalization that challenge neoliberal understandings which place the responsibility of risk solely on the individual [1, 55]. In doing so, it aligns with the growing need to explore anti-carceral approaches to substance use and trafficking services.

Methods

Data for this study are a subset of interviews from a larger project designed to understand how survivors of exploitation and trafficking navigate SUD treatment services. The authors come to this research from a pro-harm reduction stance and with many collective years working in harm reduction environments. The research team’s positive regard for harm reduction philosophy, grassroots initiatives, sex workers, survivors, and people who use drugs, along with a critical feminist epistemological orientation, informs the analysis and findings of this study. The interviews for this subset were conducted by one of the co-first authors, a white, cisgender woman with advanced degrees in social work who has over 20 years of involvement with harm reduction and sex worker rights work. It is important to consider how her identity and experiences shaped the nature of the data, and the dynamics of the interview processes.

Design and sampling

Between June 2024 and May 2025, the research team conducted 37 interviews with individuals who had experienced exploitation with co-occurring problematic substance use. The data from this project comes from a subset of 17 individuals who had experienced exploitation and were not currently receiving inpatient or outpatient SUD or trafficking treatment services. All interviews were done in urban metro areas in a Midwestern US state, where certain forms of harm reduction services are not sanctioned statewide. For participant recruitment, the research team collaborated with an anti-trafficking advocacy and service organization and a harm reduction program to disseminate information about the study. Flyers were distributed through an anti-trafficking advocacy group to other agencies across the state, as well as placed in organizations that were likely to provide services to individuals who have experienced exploitation and SUDs. The authors’ provided a link to a REDCap survey, as well as one of the co-first authors’ email address and phone number to contact if the individual expressed interest.

To participate in the project, respondents must have been 1) 18 years old or older 2) have experienced labor or sexual exploitation in the past, in whatever way they defined exploitation, and 3) consider themselves to have or have had problematic substance use. Participants were provided the flexibility to define both what they considered to be exploitation and what they deemed to be problematic substance use. For example, while the authors do not view the commercial sex trade as inherently exploitative, respondents who engaged in commercial sex work and identified it as exploitative were eligible for the project. Similarly, we allowed respondents to define what they felt was problematic substance use without requiring a formal professional diagnosis of SUD (indeed, most respondents had been professionally diagnosed with an SUD). Consent to participate in the study was obtained when respondents agreed to schedule an interview during the screening process. We received a waiver of signed consent, and received verbal consent from our respondents. Before the interview began, respondents were reminded of their rights, including the right to stop the interview at any time, to refuse or stop audio recording, and to decline to answer any question they did not wish to answer. Each person was given a $50 debit gift card as a thank you for their time. We also provided respondents with a list of resources if requested.

The project was approved by The Washington University in St. Louis Institutional Review Board, #202405008.

Data collection

Semi-structured qualitative interviews were used to understand how participants navigated substance use services as well as human services generally and were conducted in a setting of the respondent’s choosing: by phone, in a password-protected Zoom room, or in a private office, with only the interviewer and respondent present. If the interview was conducted over the phone or over Zoom, the interviewer confirmed with the participant that they were in a safe and private location. The interviewer wanted to establish an environment where the respondent felt safe in disclosing information and accepted the respondent’s assurance in this regard. Interviews lasted from 27 to 120 min, averaging around one hour. Interviews were audio-recorded with respondent permission, professionally transcribed using Trint software, and then manually checked for fidelity.

Data analysis

Transcribed interview data was analyzed using Dedoose qualitative software. The research team iteratively developed a codebook, incorporating inductive and deductive coding techniques designed to accommodate emerging themes while maintaining alignment with preexisting theoretical frameworks. To ensure consistency and reliability in the coding process, the team held weekly meetings to collaboratively discuss and refine the application of codes to maintain rigor and transparency. Each interview was coded separately by two researchers who met weekly to discuss and negotiate the application of the codes.

To guide the analysis, we utilized Deterding and Waters’ twenty-first century flexible coding approach [11], which is particularly effective for managing large-scale textual data. This approach allowed for the chunking of extensive interview transcripts into manageable sections, facilitating a more focused analysis that promoted engagement with broad sections of the data. This iterative process ultimately led to the development of key themes that reflected the experiences and insights of survivors, contributing to a nuanced understanding of their experiences through the intersectional risk environment framework. Here, the risk environment was operationalized into four structural domains—the policy, social, economic, and physical [52] and individual risk of harm within the environments was understood to be compounded by the marginalization of experiencing intersecting forces of oppression [1]. We introduced the theoretical framework after the first round of flexible coding to identify themes in the data.

Results

Survivors ranged from 19 to 63 years old; nearly half (47%) identified as Black, Indigenous, or people of color (BIPOC), approximately three-quarters (76%) identified as cisgender female, and approximately one-quarter (24%) identified as being a member of the LGBTQ + community. Nearly three-quarters of the participants (71%) had children with varied parenting relationships with their children, ranging from no contact to full custody. Thirteen out of the 17 participants (76%) included in the sample identified as having current problematic substance use, with the rest identifying as having had problematic substance use in the past. Many participants were unhoused, either living on the street or otherwise precariously housed with a friend or family member, at the time of the interviews. Table 1 includes demographic information as well as participants’ pseudonyms.

Table 1.

Demographic information & pseudonyms

Pseudonym	Race / Ethnicity	Gender	LGBTQ +	Age	Parent	Marital Status	Services	Housing	Intersectional Identity
Liz	white	Female	Yes	26	Yes	Partnered	SSP	Unstably housed	white, queer female, young adult
Jabari	Black	Male	No	27	Yes	Single	None	Stably housed	Black male young adult
Amara	Black	Female	No	25	No	Single	None	Stably housed	Black female, young adult
Elena	Latine	Female	No	25	No	Single	None	Unstably housed	Hispanic female, young adult
Alyssa	white	Female	No	38	Yes	Separated	SSP	Stably housed	white female adult
Stephanie	white	Female	No	44	Yes	Separated	SSP	Unstably housed	white female adult
Sierra	Multi-racial	Female	No	35	Yes	Separated	SSP	Unstably housed	Black/multiracial female adult
Ava	Black	Female	No	34	Yes	Single	SSP	Unstably housed	Black female adult
Linda	Black	Female	Yes	63	Yes	Single	SSP	Stably housed	Black queer female older adult
Brooke	white	Female	Yes	19	No	Single	None	Stably housed	white, queer, female, young adult
Donna	white	Female	No	59	Yes	Divorced	SSP	Stably housed	white female older adult
Lisa	white	Female	No	55	Yes	Separated	SSP	Stably housed	white female older adult
Matt	white	Male	No	34	No	Single	SSP	Stably housed	white male adult
John	Black	Male	No	51	Yes	Single	SSP	Unstably housed	Black male older adult
Darrell	Black	Male	Yes	63	No	Single	None	Stably housed	Black queer male older adult
Gwen	white	Female	No	52	Yes	Single	SSP	Unstably housed	white female older adult
Tiffany	white	female	No	39	Yes	Single	SSP	Unstably housed	white female adult

^* “Queer” is used in this table to indicate when a participant said “yes” to being a part of the LGBTQ + community

Survivors’ experiences within risk environments

Participants demonstrated an understanding of the structural and individual barriers that prevented them from exiting exploitation or ending substance use. Notably, all participants currently using drugs (13/17) expressed a desire to cease substance use yet also articulated the systemic and individual causes that complicate cessation or contribute to returning to use. Those who had successfully ceased substance use reflected on the factors that facilitated that transition, while acknowledging the aspects of their circumstances that heightened their vulnerability.

As John, an unstably housed Black man, described, his experience with shelters increased his risk for substance use, and with that, exploitation in the sex trade:

So that's where I was at, because when I started [using drugs], I stayed in a shelter. You know, I was homeless, and I was in a shelter, so coming out seeing people, and I thought that that [drugs] was the pastime thing to do. So I went with the crowd, and wish I wouldn't have done that, because it's a burden on my back now....Right now I'm basically, a friend is letting me stay with them for a short time. I told them that I was trying to get myself together and coming through [organization] so [they’re] trying to get me into the methadone clinic....And yeah, I'm just tired, you know, you get tired of it [drugs] after a while....And as far as supporting my habit, some I used to, excuse me, steal, and some females and guys...would, I mean, pay me to have sex.

John noted that drugs were around him in homeless shelters and acknowledged that they were not a safe place for him to stay. He was cognizant that his drug use led to his experience in what he considered to be exploitation within the commercial sex trade. This description also dovetails with his experience in homeless shelters, which prior work has demonstrated are not always safe spaces for those with a history of being in the commercial sex trade and/or with other minoritized identities [56–58].

For many individuals who experienced exploitation and substance use, having completed SUD treatment did not lead to what they viewed as lasting recovery. While many of the participants in this study had at some point accessed 30-day treatments (or treatments with a similar rehabilitation structure), returning to their immediate environments without the presence of programmatic structure often facilitated a return to substance use, perceived by participants as being somewhat involuntary and serving as a coping mechanism for unaddressed trauma.

As Tiffany, a white, unstably housed participant in a syringe services program (SSP) recounted, she had been doing everything she was “supposed” to do after leaving treatment, including going to AA/NA meetings and parenting classes. Here, she described her return to substance use as being connected to a lack of transportation and a chance encounter with an unsupportive social network that led her to miss her programmatic obligations:

I was coming home from a NA meeting and I was going to go home and change and then get ready to go to my parenting graduation class and then I ran into, like, an old, actually, an ex -boyfriend of mine and it was, like, pouring down raining so he gave me a ride. And he was supposed to take me to the parenting class, but he stopped at someone's house on the way there, and they were all using, and I was waiting on the car for like an hour, and I went in because I was getting impatient, I was gonna be late, and then everyone was using, I got stuck over there, and he actually left me over there, and I ended up relapsing there.

Tiffany’s experience illustrates how overlapping dimensions of the risk environment, including mandated programming, lack of transportation, and unsupportive social networks, can intersect to create conditions that undermine an individual's recovery efforts. Another participant, Lisa, a stably housed white woman accessing SSP services, described the multiple times she became sober: the first time after her experience in prison and the second time after her experience at a rehabilitation center. During her second experience in sobriety, she experienced a significant loss, which, combined with her return to her home environment, likely contributed to continued use after six years of sobriety:

I went to prison for my first time. I got clean. I got back out. I started using, which I knew I would. My second time I actually went to a treatment center, and I got clean. I had almost six years clean before I moved back to [city] and the house I'm in now, I had some family there and I screwed up. I lost my sobriety. Prior to that, I did a heroin awareness walk cause I lost my oldest son to it. It truly mentally did something to me...And just, um, I couldn't get high enough... not realizing that I have another son that needed me. I was so caught up and it's horrible. And, uh, his sickness is worse than mine. If we could handle the sickness, we would quit.

Lisa acknowledged the intense difficulty in maintaining sobriety without supportive aftercare services through the grief of losing a child. John, who had negative experiences in homeless shelters as recounted previously, noted that he relapsed as soon as he returned to his home city after a period of stability elsewhere:

There was a church program, trying to think of the church, but a guy funded my ticket to catch a Greyhound there [another city]. But the first phase was being there for 30 days, not being able to leave out of the building. And the next phase was, it was like sober living...We could leave at our leisure and come back, but I had to pay $250 per month. The church paid for two months for me to be there. And I got the job there and everything.... I was working in a meat factory place and I found another sober living house that cost $750 a month, but I was making the money where I could pay for that. It felt good being sober and everything, but the temp job, it ended and the house [didn’t allow] enough time to find another job. I was asked to leave, so they paid for me a ticket to come back [to home city].

When asked about what he thought would happen if he had stayed outside of his home city, he said “I feel like I would have been doing great… I was at 170 [from 130 pounds] and face was full, everybody seen the glow around me and I even liked looking at myself in the mirror, you know”. Others noted that they could have been helped had they “been transferred somewhere”, or “given an option to relocate”. Given John’s experiences with the shelter system, as described previously, his story highlighted the significant role of housing support and services for those who are working towards recovery.

Gwen, an unstably housed white woman who did not use drugs prior to being unhoused, mentioned that she started using drugs to stay awake in order to prioritize security and safety on the streets, which contributed to the development of an addiction:

I didn't do drugs, so I came out on the street and I did, I was doing, um, I started doing speed so I could stay awake and be aware.

Respondents who were not involved in services described having insufficient access to SUD support along with an inability to meet their basic needs such as food and housing. As Amara, a stably housed Black migrant who came to the US during COVID described, her vulnerable position was exploited in multiple ways, including through sexual exploitation and forced drug distribution:

Selling drugs is not easy. Like, some people just want to use you like they know you have no option. The only option you have is just to sell the drugs so that you can sustain your life. I didn't have any clothes, so I sold drugs for, like, a month. I got enough money. Then I went and rented my house, a small house. So I was able to maybe I had somewhere for shelter and maybe some money, maybe for my needs, food. So it was hard to say how it [substance use] started because at some point I was so sad that using the drugs to cool off my stress and maybe forget some of my problems... Because at that time, it was it was coronavirus period. So getting a job was kind of difficult... Selling drugs was the option I had.

Amara detailed her awareness that she was being taken advantage of because of her vulnerable circumstances and economic precarity. As a migrant to the US, she had limited options for meeting her basic needs, leading her to sell and eventually use drugs. She perceived herself as being vulnerable to exploitation, while using substances as a mode of coping and escape—a rational response to trauma and isolation.

Jabari, a stably housed Black male migrant, had a similar experience with exploitation and substance use:

It was because I was being exploited, because I was introduced into selling drugs and using drugs without knowing. I just thought they were my friends and they're giving me a lie. But later on, like I came to realize that this is just exploitation when you are being forced, being able to move the job...being forced to do it and being put in that setting, [without] selling the drugs they might get rid of me, maybe attack me or they're going to kill me.

For participants, constraints on choice, autonomy, and options for meeting basic needs were described as key barriers to both sustaining abstinence from substances and accessing needed services. A return to unsupportive home environments and a lack of access to stable housing often precipitated substance use, demonstrating the critical role of housing and community networks. Additionally, the interplay of trauma, grief, and systemic neglect drove individuals toward substances as a coping mechanism, which underscores the important role of ongoing social support. As Lisa, a white woman in her 50s who regularly used a syringe service program, described:

At first [during exploitation], I was very young. And when it finally started affecting me, I would come home and sit in a hot shower and scrub my body until it bled. After a while I just would get high first. Or drink, get numb. And I would just try to block it out, to get that money, and then I could buy drugs, and I could buy clothes, and I could eat with that money, and I could live, and I could do whatever the hell I wanted because I had that money.

For individuals such as Lisa, whose poignant description of substance use illustrates the way she coped with the trauma that she had experienced in exploitation, substance use was a critical means for survival. For others with similar experiences, being able to access supportive non-judgmental services is critical to cultivating experiences that work towards fostering healing and safety. However, survivors who use drugs often experience significant structural barriers in accessing such services, with implications for their ability to receive support and achieve well-being.

Systemic barriers to well-being and health equity

Health inequities can be distilled to group-level differences in health and service access that hinder the achievement of positive health outcomes for specific groups [59]. For respondents, experiences with varied service providers were noted as both barriers and facilitators toward achieving positive health outcomes. While most of the participants had sought health or human services at some point, they described a mix of feelings towards the individual providers they had encountered; some providers were explicitly described as discriminatory and judgmental; and others were described as kind and supportive actors operating within a harmful system outside of their control. For instance, participants noted that some providers “did everything they could.” In recounting her experience working with a housing service provider, one participant noted that “they helped me but I missed the meeting so it was my fault I lost housing”, highlighting a process of self-blame in response to punitive service approaches. Others were more critical of providers, noting that “a lot of times the counselors were late…they just have us sitting around sometimes doing nothing,” with the participant expressing frustration at providers’ lack of support.

During the interviews, respondents were asked to reflect upon suitable ways for providers to work with individuals who have experienced exploitation and substance use. Respondents spoke specifically about the treatment of “addicts,” a term that some used to refer to themselves. Often, they perceived that support and non-judgment within human service systems helped them counteract the trauma and violence that they have experienced in their lives, as Liz, an unstably housed white woman who accesses SSP services describes:

I think they need to treat addicts more like addicts and give them more help...I feel like, I don't know. It's rough, you know, like, I feel like they need to pay more attention to people and people that are in the system and stuff. Yeah, because I have like, you know, mental disorders and stuff like that and take it seriously.

Others discussed the discrimination that they faced from individual providers. Elana, an unstably housed Latine woman who was not connected to services described the stigmatization and victim-blaming that she experienced from a therapist in the past, and that this was partially the reason for her exit from services:

It was from the way she spoke to me, I could feel that she saw me as someone that's, that is bad. Because she was asking me, like why would a young girl like me involve myself into this sort of situation. She was just saying a lot of things that I was not happy with.

Respondents described their concerns about disclosing their substance use to medical professionals due to fear of stigma, which can contribute to health inequities by fostering mistrust, and discouraging engagement with the medical system, as Tiffany and Donna (white woman, stably housed, SSP user who previously used methadone) recounted:

Tiffany: Well just before, like, they would prescribe me, like, pain medicine and stuff like that. And now like, you know, like I've been to the hospital before and, um, because I'm in there for overdosing, I guess in the system, like they don't want to give me pain medicine.

Donna: ...I went to the emergency room before, and I can't remember why, but it had to do for serious pain, and um, they wouldn't give me a narcotic, and you know being an addict especially, and having a high tolerance, ibuprofen doesn't do shit. So I wasn't treated like I would be, if they didn't know that I was an addict. Which I do understand, but a lot of doctors, don't understand addiction, and absolutely don't know about treating people on methadone.

Participants also talked about their lack of access to primary care doctors, which is particularly challenging for those who are economically precarious. Ava, an unstably housed Black woman who uses SSPs, recounts her experience seeing a doctor for a standard health care need:

I need to find me a primary care doctor. Like, I got bitten by a spider [laughs]. I'm sorry! It is not funny because when I did go to the hospital, I went to [HOSPITAL] And they sent me home with some medicine. But the next day it had gotten worse, and I went to [HOSPITAL] and they told me that it didn't need to be bust. I got home, and it bust. And I was like, it didn't need to be bust. Besides, I don't know, and they told me straight, what I asked them, they told me it didn't need to be bust, but I got home and it did.

For someone who holds multiple historically marginalized identities (Black, female, unstably housed, person who uses drugs), there is a higher likelihood of medical stigma, which may lead to inconsistent medical treatment [60, 61]. While some participants, particularly older participants, did have access to regular medical care, others mentioned lacking access to primary care providers, which can offer continuity of care and provide support for moderately urgent health care needs, such as a spider bite. Donna, who did see medical doctors regularly, mentioned that she did not think her doctors needed to be aware of her substance use, noting: “Oh no, that has nothing to do with my knees. If I felt that was important, I would definitely say something,” mentioning that she had been treated poorly by physicians in the past due to her drug use, affecting her disclosure.

Regarding experiences with the carceral system—a system with which respondents frequently interacted—views were mixed. Some acknowledged that they were able to achieve sobriety while incarcerated (although the sobriety was often short-lived), with others acknowledging that law enforcement actively caused harm. For those with existing records, law enforcement was seen as a significant impediment to accessing health and social support and resources, as Sierra, a multiracial woman, and Gwen, a white woman, both unstably housed SSP users, recount:

Sierra: But I know for me and a lot of my friends, male or female don't call law enforcement because you don't trust them... Because a lot of times when we call them or when they are called, you know, they're, they're distracted by the situation...what we call them for isn't taken care of because they're too busy worried about other things, like four year old warrants or, you know, I didn't call you for four year old warrants. I called you because I'm being beaten up.

Gwen: [I need] services where I don't need to worry about having a warrant. Let you be able to get on your feet and be able to stand strong to be able to go in and show, hey, look, this is what I've done. Yeah. You know, because going in with a warrant, I can't do nothing, I'm still a loser.

Interviewer: So they tell you that they can't help you because you have a warrant?

No, I've been told that if you have a warrant, that they will call it in. I just want to wait and not be standing on some kind of ledge when I do, you know, so that um, I'm not just a drug addict out on the street. I'm doing something in my life. I want to do something in my life.

Even if it is the case that having a warrant may not preclude this person from receiving services, her concern speaks to the intertwined experiences of poverty and criminalization, leading her to avoid services. As Alyssa, a stably housed white SSP user noted, law enforcement should only be involved if there was actual harm being done, with law enforcement exacerbating existing inequities through their treatment of “drug addicts”.

I think, like if you're out here running around, like committing crimes...then yeah, they should be involved. But like, if you're just out here minding your business. Then like, I don't feel like they should even be involved in any of that. You know what I mean? Like because my drug case like I was at a house where the house got raided. It wasn't in my house. But they found drugs on me.... I really like, I feel like they treat drug addicts like way worse than anything. It's crazy I don't know how to explain it. And like a drug addict, there's no hope for you or whatever. Yeah, that's what it seems like in there.

Survivors face the compounding stigma of substance use and exploitation in human service and healthcare settings, which is often further exacerbated by stigma associated with criminal legal involvement and homelessness. Due to longstanding racist and discriminatory practices embedded within health care and criminal justice systems, these interconnected factors may be exacerbated for those with historically minoritized identities, as well as those who have experienced exploitation.

Harm reduction and health equity

Thirteen out of seventeen participants had experience receiving harm reduction services, specifically SSPs. Involvement ranged from minimal (occasionally picking up syringes) to extensive engagement (attending events, regularly visiting the drop-in center). Although all participants explicitly acknowledged their desire for sobriety, they perceived that the harm reduction program was crucial to their well-being and contrasted its environment with abstinence-oriented rehabilitation centers.

Participants mentioned the role of peer support, which they considered important for creating a sense of connection. While peer support is often present and promoted at abstinence-oriented treatment centers, participants reported that interacting with peer harm reduction staff was a way to care for themselves, by surrounding themselves with individuals who respected and cared about them. While our respondents did not directly use the term “trust” to define their relationships with harm reduction employees (who were made up largely of peers), their relational and embodied experiences with the employees fostered experiences that differed from those with other service providers. Indeed, they noted that such employees were supportive of their well-being, regardless of their choices. As Sierra describes:

They [harm reduction employees] really care enough about us and our day, our week or whatever, and how we're doing mentally in general. They have amazing support here. Yeah like I can talk to, I can talk to the peers here, or the people that work here better than I could talk to anybody in my life. And that's saying a lot for me because I don't like to talk to anybody [laughs].

Sierra mentioned that staff at other organizations, including other peers working in abstinence treatment centers, did not appear to care as much—she felt judged by them, and perceived that they were simply there “for a paycheck”. As someone who acknowledged that her trauma contributed to her not liking “to talk to anybody”, she found reassurance in her experience with peer harm reduction employees, whom she felt holistically cared for her well-being. For Sierra, this was not an experience she had had in previous settings, and it contributed to her being a frequent participant of the organization—when there was an event the organization held, she said that she would be there, because of what the organization had meant to her.

The concept of “care” was prominent in the data, as participants appreciated having a place where drug use was regarded as normal, and their wellbeing was of primary importance. As Ava recounts:

Yes, we know that someone does care. Actually, when I first came here, I was like, so they’re [okay] with us using, they're providing us things to use with. They want us to be safe in how we use it. Yeah. I love it.

Amidst a conversation about her experience with other service providers, Stephanie described her perception of harm reduction staff, indicating that they were the only people who consistently showed that they cared. As an unstably housed white woman accessing SSPs, she narrated:

They're the only people that really care about us. They do a lot for us. They feed us. They supply us with clean needles and clean tools to do whatever we do. Stay safe, you know, I mean, they do everything but give us the drugs [laughs] for real....They just want to make sure everything's safe.

Even as most respondents expressed a desire to quit using substances, they simultaneously felt that the services provided through harm reduction programming were necessary for maintaining their safety. Several participants proposed the idea that harm reduction options could go further than syringe services and drop-in centers, such as overdose injection sites which are currently only legal in New York City and Rhode Island in the US. As Alyssa noted:

Like, I think they should decriminalize drugs...And I think like. I know like other places have like where you can go in there and get high like the little room things or whatever...I think I seen that one in Germany like on that, like I might've been like on my phone or something...See, that would be such a good thing to have up here. Like, yeah, I feel like people would really use it.

Discussion

Discrimination at the intersection of exploitation and drug use, compounded with other sources of social oppression such as racism, sexism, and classism, leads to multi-level obstacles for survivors of exploitation who use drugs. Notably, they are often further stigmatized by the providers and systems that are regarded as sites of service entry for vulnerable clients, and the fear of encountering these multiple stigmas exacerbates the risk of drug-related harm for survivors of color [62]. The continued presence of these issues despite the increase of public information campaigns and media attention generated on the topic of human trafficking over the past couple of decades [63] speaks to the pervasiveness of racism, stigma, and sexism embedded within health and human service systems.

These narratives underscore the critical role that harm reduction services play in addressing participant needs and fostering health equity among multiply marginalized populations in the absence of systemic change. Although these harm reduction services operate in a challenging sociopolitical environment, they were considered to be essential to respondents’ emotional and social well-being. Participants recounted incidences of stigma and discrimination by some service providers who may have supported initial sobriety, but the lack of aftercare and ongoing support from these providers made it difficult to sustain long-term wellbeing. Being respected, seen, and cared for despite the stigmatization they have experienced from other providers can be crucial for participants working to maintain a certain level of stability.

For participants, harm reduction services offered low-barrier and nonjudgmental support for those whom an abstinence-only framework was untenable despite a desire to reduce drug use and/or exit exploitation. Although most survivors in this study had had prior access to intensive SUD treatment, these services had not resulted in long-term sobriety, nor had they supported sustained health and well-being. Unconditional positive regard, perceived care, and understanding from harm reduction staff, along with seemingly minor interventions such as providing lunch or internet access, made a meaningful difference in some respondents’ sense of belonging and access to healthcare. This finding aligns with previous research that indicates abstinence-based programs targeting this population have shown limited effectiveness in both reducing substance use and supporting survivors to exit exploitative circumstances[31–34, 64] and underscores the need to augment abstinence-oriented services to provide more comprehensive, supportive interventions to facilitate positive rapport and engagement.

Structural barriers were found to be important components of survivors’ risk environments, such as limited housing and geographic mobility. When participants left intensive substance use services they often returned to the exact location and conditions they had been in prior, leading them to engage with the same social networks and structural dynamics that contributed to their problematic drug use and exploitation [65]. Further, despite some participants having access to homeless services such as shelters, these environments were not always safe or conducive to recovery, and in fact often contributed to ongoing exploitation [57]. Although some survivors had had various experiences of gaining access to housing through housing service providers, they had also experienced losing access due to “missing meetings” or otherwise not adhering to rigid programmatic requirements. Being forcibly displaced frequently prompted problematic substance use and exploitation for participants, as has been found in previous research around evictions and substance use [66]. Strengthening neighborhood and community assets to protect against risk of exploitation, along with broadening the reach of services to make geographic relocation feasible through transportation and stable housing are critical considerations for future program development.

Participants described a range of experiences and feelings about the role of law enforcement and the criminal justice system in supporting their service needs. Survivors of sexual exploitation face the dual criminalization of drugs and sex work that exponentially increases their exposure to the legal system and results in periods of incarceration, which is known to substantially accelerate drug related risks, including overdose [67]. This risk is compounded among minoritized groups who must also navigate social and political structures while experiencing systemic discrimination, thus interfering with engaging in substance use treatment. While mitigating this policy landscape is often considered to be outside of the scope of programmatic harm reduction at the service level, these findings highlight the need for harm reduction activists to support drug and sex work decriminalization to improve health equity for survivors of exploitation who use drugs. These findings also revealed the role of the criminal legal system in creating barriers to sustainable housing, illustrating the complex relationship between the criminal legal and housing service systems.

For survivors who have experienced multiple levels of stigmatization and trauma, cultivating trust in service organizations can be particularly challenging [3, 43, 68]. Survivors experience various forms of distrust, whether resulting from experiences in the medical system, the criminal-legal system, or other social services, and thus it is crucial that harm reduction services remain a space where survivors who use drugs can experience consistent and supportive services from individuals who demonstrate holistic non-judgment in their behaviors and attitudes. Indeed, trust, according to Essex (2022) is a relational process that needs to be continually addressed in each service encounter to prevent retraumatization and cultivate a sense of safety [69, 70]. While our respondents reported multiple positive experiences with staff at their harm reduction organization, this may not reflect the experiences of individuals at other harm reduction organizations, particularly women, non-binary, BIPOC or LGBTQ + individuals who may experience additional forms of stigmatization. Even though the strategies of harm reduction are meant to reduce power imbalances between service user and provider, these imbalances can still persist in practice [71]. In our interviews, we note that one of the indicators of trust was the presence of peers, which aligns with prior literature [72]. While respondents did not necessarily define or use the term trust, they situated it in an experience that they considered to be embodied and relational, characterized by feeling understood and respected as survivors and drug users. For them, indicators of trust focused on the presence of an emotional bond grounded in non-judgment. Specifically, respondents reported having a person with lived experience, who supported them and kept them safe while using substances, fostered trust that they may not have experienced in other service settings.

In considering the important role of harm reduction for survivors who use drugs, it is not just a service model, but also a strategy for structural reform. This being said, no single harm reduction intervention is a panacea, as they do not address structural gaps in service provision. As Lisa described:

I've begged, borrowed, weeded, scrounged, done without, been hungry, turned off lights. Um, in fact, when I first made the appointment with you, my lights are off. They came yesterday to turn off my heat. I, I can't hold a job anymore because I have physical ailments that prevent me from working 40 to 60 hours a week. And I lost my transportation.

Despite being in regular contact with harm reduction services, Lisa still faced multiple structural barriers to achieving well-being. It is important to center survivors’ experiences in program design and policy advocacy to understand what can be improved in services, and what programmatic and policy changes are needed to attend to the intersecting realities that shape survivors’ experiences and to ensure that the full spectrum of needs is met.

Given the range of intersecting experiences and intersecting identities that our respondents inhabit, it is critical to recognize that harm reduction services do not operate in a neutral or depoliticized environment. Women are more likely than men to experience poverty and stigma related to using drugs, and this is compounded for LGBTQ + women, racialized women, and women with criminal-legal involvement [73, 74]. Indeed, women who use drugs may frequently face more severe social consequences than men, which may include loss of child custody, stigmatization from health care providers, and social exclusion from their networks [74]. A growing body of research shows that there are gendered barriers to accessing harm reduction services, particularly for racialized women and non-binary individuals [71, 74–76]. These barriers may include anticipated or experienced stigma, physical or geographical accessibility, providers’ lack of training in gender responsive care, considerations for gender-based violence, and stereotypes around caregivers who use drugs [71, 77]. Having such perceptions of harm reduction services may be a significant barrier for women and non-binary individuals in accessing such services, particularly those with a history of sex work or sex trafficking, criminal legal involvement, or caregiving responsibilities.

While our respondents were largely supportive of the harm reduction services available to them, we believe co-locating harm reduction with other basic needs services may improve access to those who may not be aware of such services. Gender-responsive services, which may include having child-care available at the location, having special times for women and non-binary individuals to visit a center, and/or having designated peers that can support them in trauma recovery, are pragmatic suggestions for low-barrier harm reduction services that can better meet the needs of women, non-binary, and LGBTQ + individuals that may also be seeking basic needs services [71]. Other scholars have suggested the possibility of including increased flexibility in services, such as telehealth and mobile health services [78], although our respondents appreciated having the ability to build trust with providers in a designated, face-to-face context. We also suggest the possibility of harm reduction organizations partnering with sex worker rights organizations, which may create referral pathways, and build and foster autonomy among individuals who have experienced stigma because of their experience in exploitation.

This study demonstrated that the intersectional risk environment provides a useful framework for mapping complex relationships between individual and structural barriers to services, especially regarding how these factors influence participant engagement in safer use behaviors. The value and function of this conceptualization should be explored in future work. In its sole application, the risk environment framework has been criticized for underemphasizing the role of power within service delivery systems, and depoliticizing the role of harm reduction in the lives of drug users [79]. Further, there is ongoing discourse surrounding the role of intersectionality theory in health equity research and how it may or may not complement other prominent theories commonly applied in research aiming to understand disparities and social determinants of health [80, 81]. Indeed, our analysis highlighted the importance and utility of applying a critical feminist perspective when considering systems-level and individual-level intervention development, along with the need to interrogate neoliberal ideologies that often drive counterproductive service provision for survivors.

Limitations

First, we used the intersectional risk environment to interpret the findings, however we did not ask questions about identity-based discrimination or the risk environment as we ultimately operationalized it explicitly during the analysis of semi structured interviews. Any direct commentary about marginalization based on race, gender, sexual orientation, and class emerged organically and findings were interpreted through the assumption that systems of oppression compound for those with multiple historically marginalized identities. The choice to interpret findings through a structural framework aligns with the research team’s feminist epistemological orientation to disrupt health inequities that stem from systemic sources of power and oppression.

Second, although the exact prevalence and demographic breakdown of the population of people who use drugs who have also experienced exploitation are largely unknown and likely underestimated, prior findings suggest sexual and gender minorities and people of color are inequitably represented within this group [82, 83]. Hence, we suspect our study population underrepresents LGBTQ + and BIPOC survivors. No respondent identified as transgender, which is important considering a rise in transphobia nationally, and suggests the need for human services and research to more fully address the experiences of those who are transgender and/or gender non-conforming [84]. Finally, interviews were limited to English-speakers, narrowing our ability to reach foreign-born survivors.

Future research should explicitly capture the experiences of survivors who identify as gender non-conforming to better understand their barriers to health equity. Mainstream social services are generally not curated to those who hold these identities, and most participants were recruited through formal harm reduction and trafficking services that may be accessible by only some groups of survivors. Additionally, this research was conducted during the 2024 presidential election in the US, during which the rights and healthcare needs of sexual and gender minorities and drug use in general were explicitly negatively targeted by political campaigns. This larger political climate and the pervasiveness of discriminatory rhetoric may have limited survivors’ comfort in participating in research or fully disclosing all aspects of their identity within the research context, particularly for those who may be undocumented and/or transgender or gender non-conforming.

Conclusion

An intersectional perspective is essential to meaningfully examining and disrupting barriers to services for survivors of exploitation who use drugs given the marginalization of the multiple identities and complex needs held by this group. Expanding services beyond abstinence-only SUD treatment and rescue-based human service frameworks to tackle structural barriers related to stigma is critical to advancing health equity for survivors. Low barrier, nonjudgmental harm reduction services can provide accessible and supportive healthcare access points for those who are vulnerable to exploitation and drug related harm.

Author contributions

TA is the principal investigator for the study, responsible for securing funding and overseeing the project's overall progress. In addition, she conducted the interviews and contributed to data management, analysis, and interpretation, as well as manuscript writing and editing. She is co-first author with HT. HT contributed to data management, data analysis and interpretation, study conceptualization, and manuscript writing and editing. She is co-first author with TA. NAD contributed to data analysis and interpretation, grant writing, study conceptualization and manuscript writing and editing. KP contributed to data analysis and interpretation, study conceptualization, and manuscript writing and editing. LMG contributed to data analysis and interpretation and manuscript writing and editing. LBG contributed to manuscript writing and editing. All authors reviewed the manuscript.

Funding

Washington University in St. Louis, National Institutes of Health, T32DA015035; Washington University in St. Louis, Here and Next Grant; Washington University in St. Louis, Institute for Clinical and Translational Sciences, National Institutes of Health CTSA Grant Number UL1TR002345.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to the sensitive nature of what our participants disclosed throughout the interview process. However, they are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.