Managing Stigma: Women Drug Users and Recovery Services

Abstract

Women who use drugs are stigmatized for their drug use behavior, which marginalizes them from mainstream society. Stigmatization can be viewed as an attempt by social services to exert control. Research shows that these strategies do not work well for discouraging drug use; whereas attempts to reduce the stigma related to drug use can encourage users to stop use. Using qualitative methods and grounded theory analysis, the goal of this study is to examine (1) the stigmatization of drug use through different stages; (2) how stigmatized women drug users perceive normality; and (3) barriers and challenges to recovery. Based on in-depth interviews from 20 women who used methamphetamine, the analysis focuses on stigmatization before the initiation of drug use, difficulties related to stigma as drug users, and challenges due to stigmatization as they recover from drug use. Findings show that women are stigmatized before they use drugs, face more stigma as they use, and even during recovery society still holds onto the label of former drug user, making it difficult to avoid stigma. The findings contribute to a better understanding of how stigmatization of women drug users impacts their recovery and provides suggestions for social service and treatment providers.

I. Introduction

Although many women initiate the use of drugs as a way to self-medicate and address social pressures, they are stigmatized by society for using drugs, and women who are mothers face even greater stigmatization (Lende, Leonard, Sterk, & Elifson, 2007; Radcliffe, 2011; Roberts, 1991). This study explores the initiation of drug use among women, as well as the difficulties women face as drug users and as they try to recover from drug use. The goal of this study is to examine (1) the stigmatization of drug use through different stages; (2) how stigmatized women drug users perceive normality; and (3) barriers and challenges to recovery. This qualitative analysis of the life histories of 20 women who used illegal drugs focuses on their social roles, the influences of initiating and using drugs, and the process of recovering from a stigmatized social identity. This study is significant in that stigmatization is examined at each stage of drug use with an in-depth focus on gendered social roles. The findings contribute to a better understanding of how stigmatization of women drug users impacts their recovery. The conclusions provide suggestions for social service and treatment providers.

The analytical framework for the study is informed by the concepts of stigma and normality (Goffman, 1963; Neale, Nettering, & Pickering, 2011; Radcliffe, 2011). The women who shared their stories were mostly poor or working-class white women living precariously on the edge of suburban middle-class society. The analysis distinguishes stages of drug use revealed in the women’s narratives. During the period called the before stage, various forms of stigmatization made the women feel insecure, which is one of the reasons to why they turn to drugs. However, to conceal their use and avoid stigma, the women try to become what they perceive as “normal” to meet gendered expectations set by society. The women face more stigmatization once they start using drugs (the during stage) due to society’s perceptions of drug users. The after stage consists of the period when women stop using drugs and their efforts towards becoming “normal” while the recovering from drug use. Findings show that although some women drug users make the effort to change, society still holds onto the label of “former drug user,” making it difficult to avoid stigma.

How do women in a stigmatized status maintain self-esteem? How do they fit in with mainstream society while using illegal drugs? After they are exposed as being drug users, how do they live with the identity of a former drug user? What types of treatment and resources are available for the women drug users to recover? Are these services effective? How does being a drug user or recovering drug user affect their mother roles for those who have children? How do perceptions of normality impact each stage of their drug use?

To answer these questions, the analysis focuses on the women’s perceptions of stigma and normality as they tried to “fit in” society and perform the gendered social roles at the standards they believed were expected of them. This study also examines the different types of social control that influenced the women, including treatment services, religion, and relationships, as well as the extent that gender played in women’s social lives.

II. Background

The conceptual framework of stigma and normality frames the analysis of the women’s lives. The literature on the impact of gender on drug use and access to services informs the analysis of their recovery efforts.

Stigmatization

Society has certain perceptions of what is normal and what is not. People who are considered different from “normal” are stigmatized, perceived as deviant, and often marginalized. White (2002) explains stigma as the process of labeling, stereotyping, social rejection, exclusion and extrusion, as well as the internalization of community attitudes in the form of shame by person and family. The literature on stigma draws primarily from the work of Erving Goffman (1959, 1963).

Goffman distinguished between those who are “discredited” when their stigma is known, from those who are “discreditable” when they are able to conceal their perceived stigma. Both discredited and discreditable stigma are negotiated through “impression management” (Goffman, 1959). Individuals with hidden stigma “may expend much energy to ensure that stigma-related ‘leakages’ do not occur” (Pachankis, 2007, 335). Yet, while they try to fit into “normal” or conventional society, they also struggle with feelings of insecurity, isolation and anxiety (Hetrick & Martin, 1987).

According to Goffman (1963), stigmatized individuals try to prove themselves by drawing attention to more positive aspects of their identity while attempting to conceal the aspect that is stigmatizing. Stigmatization can make individuals feel insecure, and they often turn to those similar to them (other stigmatized individuals) for social support (McKenna & Bargh, 1998). Goffman (1963) further explains the limitations and boundaries of what actually defines stigmatization as well as the underlying social functions of stigmatization, such as social control.

Studies consistently show that stigma negatively impacts health and contributes to health disparities found among marginalized populations (Chaudoir, Earnshaw, & Andel, 2013). Moreover, research shows that even hidden stigma can negatively impact psychological well-being and lead to social isolation and alienation (Pachankis, 2007; Quinn & Chaudoir, 2009).

Similarly, White (2002) discusses how social stigma toward alcohol and other drug addiction may be an obstacle to resolve problems or to even come up with a strategy to solve the issue of addiction. White (2002) further identifies several myths surrounding stigma and how it is important to understand the difference between stereotypes and facts. Moreover, stigma used by social services as a control mechanism limits attempts at recovery.

Social Control and Social Services

Social control theory proposes that delinquency and criminal behavior are a consequence of changes in the quality and strength of social ties (Laub & Sampson, 2003). Individuals are more likely to engage in deviant behaviors, such as drug use, when their bonds to society are weak or broken. Formal social control of behavior, such as laws and bureaucratic rules, are distinguished from informal social controls. Informal social control acts through the bonding that comes with attachment to others and ties to mainstream social institutions, such as school, work, and religious affiliation. Informal social control works through “strong bonds with family, friends, work, religion, and other aspects of traditional society motivating individuals to engage in responsible behavior or [acceptable] social norms” (Moos, 2007).

Being stigmatized marginalizes the discredited individual from mainstream society, and stigmatization by social services is often viewed as an attempt to exert social control (Palamar, Halkitis, & Kiang, 2013). Focusing on the stigmatization of drug users within society, Radcliffe and Stevens (2008) examine the categorization of “junkies,” which refers to long-term drug users. The authors find that “junkies” are stigmatized even within treatment services. While studies consistently show that treatment clients receive real or perceived stigma from the staff and professionals who work with them (Boyd, 1999; Campbell, 2000; Stengel, 2014), research in other healthcare contexts shows that stigma can be mitigated by acts of kindness (Walter et al., 2015).

Studies find that labeling, stereotyping, and discrimination are commonly used to stigmatize (Link & Phelan, 2001; Kyons et al., 2015; White, 2002), yet research shows that these strategies do not work well for discouraging drug use and are associated with adverse mental and social health outcomes (Bayer, 2008; Palamar, 2012; Radcliffe & Stevens, 2008). Jiménez et al. (2011) argue that stigmatizing actions are thought to uphold social order, but in fact they cause social divisions. Since drug users can lose family, friends, employment, housing, school loans and other social and economic benefits, many attempt to conceal their use even from those who can help them (Palamar, 2012). In contrast, attempts to reduce the stigma related to drug use and eliminate discriminatory attitudes toward drug users, particularly by health professionals and law enforcement, can encourage users to seek needed care (Rivera et al. 2015).

Normality

In order to understand stigmatization, it is important to define what is considered to be “normal.” Society has set perceptions of how individuals should act and standards of normality. However, it is difficult to define normality as there are varying opinions of what “being normal” actually means. For the purposes of this study, drug users are seen as deviant from mainstream society standards for normal, but even within the drug user community, definitions of normal vary.

Copes, Hochstetler and Williams (2008) explore the concept of identities within the drug user communities. According to these authors, social identity is referred to as a multivalent process where individuals identify themselves in terms of being similar to some people and different to others. Individuals construct boundaries and identities that separate them from others who they view as having lower status. Although society assigns negative labels for drug users, their identity is also influenced by other drug using individuals who define distinctions between drug users. For example, Copes and his colleagues explain that “hustlers” (i.e., minor criminals) within the drug community believe that they are above “junkies” (i.e. hardcore criminals). Although “hustlers” are still part of the same drug community as “junkies,” they see themselves as a step closer to being “normal” than “junkies,” who have fallen the lowest levels of drug user category.

Other research shows that even in the drug-using community, an occasional or weekend user is viewed in less negative terms than an addict or “junkie,” since they appear to control their use (Boeri 2004, Radcliffe & Stevens, 2008). People in drug treatment may attempt to navigate stigma renegotiating what normal means to them (Nettleton, Neale, & Pickering, 2012). Others try to reduce multiple stigmas by avoiding treatment itself, which is associated with the most stigmatized drug using stereotypes (Radcliffe & Stevens, 2008).

Perceptions of Women Drug Users

Gendered perceptions of drug users exist in both mainstream and drug-using worlds. Goffman (1963) explains how the stigma of group identity is related to the stigma of race, nation, and religion, affecting a whole group rather than an individual. Women as a gendered group face greater stigmatization than men for using drugs since they go against the character traits of perceived female identity. The stigma of drug use is also greater for mothers since they are expected to be the caregivers, raise children, and be more family oriented than fathers. Women are usually aware of these double standards and try to present a good image to society by hiding their drug use if they are mothers (Goffman, 1959).

Gendered differences in perceptions of substance use can be seen in the use of both legal and illegal drugs. Females are more negatively viewed when they smoke in public compared to males. While females who smoke are seen as “trash” and “sluts,” males who smoke are seen as “more masculine” and “attractive” (Nichter, 2006, 112). Therefore, females tend to smoke in groups in a more hidden environment to preserve their good reputation while males are able to freely smoke in public. This can be translated into the perception of how women are viewed when they use stronger drugs, such as cocaine or methamphetamine.

Substantial research shows that female drug users face stigmatization as “bad women” because they violate gender-role expectations (Boeri, 2013; Campbell, 2000; Ettore, 1992). Women who use drugs while pregnant are identified as having a moral ‘failings’ and ascribed a “spoiled identity” (Stengel, 2014; Stone, 2015). Beyond the stigma of being a drug-user, women can feel the burden of multiple stigmas, such as poverty, minority status, unemployment, transgender identification, and older age (Connera & Rosen, 2008; Lyons et al., 2015; Roberts, 1991).

Dluzen and Liu ((2008), exploring the differences between male and female users of methamphetamine, found that while violence and excessive use were more prevalent behaviors among female than male methamphetamine users, women responded to treatment better than males. Yet, women users have limited access to treatment resources and face more challenges during recovery than do men (Boeri, Gardner, Gerken, Ross & Wheeler, 2016; Maher & Hudson, 2007).

Barriers to Recovery

The greater stigmatization of female drug users presents several barriers for women when they try to get their lives back to “normal,” often without sufficient support, resources, or guidance. Luck, Elifson, and Sterk (2004) found that women who are drug users and are on the welfare system are perceived negatively by others. There are many people who believe that women who use drugs and receive the welfare system are “undeserving poor,” and some people in society may believe that the welfare system is funding the dependence on drugs. There are also speculations that the use of drugs leads individuals to welfare dependence, but the authors show that this is a more complex relationship than assumed. Although women in the welfare system are willing to take responsibility of their lives, the negative views from society make them feel disrespected and reinforces feelings of powerlessness.

The services needed are not as accessible as many think due to the stigmatization of those who apply for aid. Boeri, Tyndall, and Woodall (2011) show how the barriers to services that women need to help themselves improve their lives can be a reason why women use or continue to use drugs. Their study found that many of the women who are addicted to methamphetamine are willing to seek help, but barriers preventing the women from moving forward create a cycle of defeat. For example, the lack of identification (e.g., ID card) created barriers getting into shelters, being homeless created a barrier to obtaining an ID card, and without identification, these women were unable to apply for the programs that could help them. When social services turned them down because they did not meet all the eligibility criteria, the women found it more difficult to meet social expectations without access to the needed resources (Boeri, 2013).

Focusing on resources, Hall, Baldwin, and Prendergast (2001) propose that more treatment solutions are needed. They explain how community-based residential treatment programs are key elements in increasing the likelihood to avoid relapse. However, women often faced difficulties accessing these programs, ultimately leading them back to drugs or jail. These barriers exist on all levels. Many women are very limited in resources even though society claims that there are a multitude of services available to them. Some of these women have no means of obtaining the resources in their current social situations. For example, women who live in areas with no public transportation cannot get to needed services, and women who do not have a phone cannot make appointments or receive a call back when they leave messages (Boeri, 2013; Luck et al., 2004). Therefore, even though programs exist, it is also important to consider access to them for disadvantaged women (Sered, 2014; Woodall & Boeri, 2013). The negative perception of recovering or “former drug users” is another reason that these women do not go to these programs.

The literature on the social impact of stigmatization and perceptions of being normal discussed above suggests that there is greater stigmatization of female drug users compared to men who use drugs. It also shows that negative perceptions of drug use exist in mainstream as well as drug-using worlds, and these perceptions often create barriers for women attempting to recover. Informed by the literature, this study examined the lives of 20 women who used methamphetamine and other illegal drugs with the goal to understand every stage of their drug use, and with particular focus on barriers to recovery. Using a qualitative method known as “grounded theory” (Charmaz, 2006), the study examined how female drug users begin using drugs and how they strive to achieve a sense of normality while facing stigmatization as current or former drug users.

III. Methods

The data used for the analysis in this paper was drawn from a larger study on women who use methamphetamine conducted by Boeri (2013).¹ Female methamphetamine users were drawn from the suburban counties outside a large city in southeastern USA. Participants were recruited using a combination of snowball, targeted and theoretical sampling methods (Glaser & Strauss, 1967; Strauss & Corbin 1998; Watters & Biernacki 1989). Snowball sampling, also called chain referral, involved asking participants and interested inquirers to refer another potential participant to the study. Targeted sampling involved ethnographic fieldwork in communities where drug use was prevalent and establishing relationships with community members to reach potential participants. Fliers were used to publicize a “methamphetamine study” with a study number for interested individuals to call for more information. Once potential participants for the study were located or made contact through the study phone number, Boeri discussed the study time commitment, how the interview would be conducted, anonymity and confidentiality issues, and reimbursement for their time. Theoretical sampling, used in grounded theory, involved the collection of data based on theory that emerged from the data while it was collected, designed “to maximize opportunities to discover variations among concepts and to densify categories in terms of their properties and dimensions” (Strauss & Corbin, 1998, p. 201). Theoretical sampling was used to insure a diversity of participant experiences, as well as to focus on recruitment of specific kinds of users that emerged from ongoing analysis of the data.

While the study design seems straightforward, the reality of conducting research on illegal and stigmatized behaviors, especially in the suburbs, has aspects that can only be learned by doing it. People who used methamphetamine do not usually “hang-out” during work hours. Ethnographic fieldwork conducted by Boeri and her research team typically involved going out all day to find field sites, distribute fliers, and talk to anyone interested. In the evening and night, they frequented bars, clubs, and all night diners.²

A screening process helped to ensure that interested participants passed the eligibility criteria to participate in the study. Eligibility criteria included having used methamphetamine for at least six consecutive months, living in the suburbs, and being at least 18 years old. After a participant was screened and consented, the interview was conducted in a safe location agreed upon by the interviewer and participant. Places used included the interviewer’s car, the participant’s home, motel rooms, private university or library rooms, and cafes or bars during quiet hours. No identifying material, such as name and address, was collected. Data materials were identified with a study number. The interview consisted of three inter-related components: (a) a life history matrix; (b) a drug history matrix, and (c) an audio-recorded in-depth life history interview. The major themes in the interviews focused the context of drug use, time of use, interaction with others, social roles and health issues.

The study was approved by the university’s Institutional Review Board and received a “certificate of confidentiality” from a federal agency to protect the study data. The audio-recorded interviews were semi-structured and open-ended so that participants could also lead the conversation into new areas of interest. The recordings were then transcribed word-for-word.

For comparison purposes both women who had used in the last month (current users) and woman who had not used in the last month (former users) were included in the sample. Current users were defined as having used methamphetamine at least one time in the past month. Former users were defined as having used the drug for at least six consecutive months in the past but having been drug-free for the last month. Most women were polydrug users. None of the women were currently in drug treatment.³

Sample

The 20 participants used in the analysis for this paper were selected because they were mothers who had children in their care when they were using methamphetamine or they were of childbearing age. The mothers who currently had children in their care (custodial mothers) provided a comparison group for those who were not mothers or who no longer lived with their children. Most of the women in this sample were poor or lived in low-income communities. The life histories of these women provided rich data on life experiences and situations that could answer the key questions related to stigma, normality and challenges to recovery among female drug users.

As shown in the Table 1, ages ranged from 18 to 49, and all but one are white, which is representative of the suburban towns where the study was conducted. Six women were currently using methamphetamine at the time of the interview. All the women were using another legal or illegal substance, including eight who used a legal substance (alcohol (A) or tobacco (T)) and the remaining who were using both legal and illegal substances during the month before the interview. Among those who continued to use an illegal substance, the majority used marijuana (M) or prescription pills (P) obtained illicitly (cocaine = C). Significant to the analysis is that most of the women experienced violent abuse at some time, primarily rape and domestic violence. Seven of the women were custodial mothers at the time of the interview; among these, two were current users of methamphetamine and six had experienced violent abuse in their lifetime. All names used are pseudonyms.

Table 1.

Sample Demographics

Pseudonym	Age	Race/Ethnicity	Meth Use	Other Drugs*	Abuse	Custodial Mother
Abagail	20	White	Current	T, A, C, O	N	N
Audrey	18	White	Former	T, A, C	Y	N
Beth	23	White	Former	T	Y	Y
Chloe	18	White	Former	A	Y	N
Dolly	37	White	Former	T, A	Y	Y
Emma	26	White	Current	T, A, M,	Y	N
Grace	22	White	Former	T, A, M, P	Y	N
Harper	22	White	Former	A	N	N
Isabella	27	White	Former	T	Y	N
Katy	22	White	Current	T, A, P	N	N
Lily	21	White	Current	T, A, M, P	N	N
Linda	49	White	Former	T	N	Y
Lisa	30	White	Former	M	N	Y
Lydia	45	White	Current	T, A, M	Y	N
Madeline	22	White	Former	P	Y	N
Mercedes	34	Latina	Former	T	Y	Y
Rachel	19	White	Former	T	Y	Y
Sophia	23	White	Former	T, A, M	Y	Y
Tammy	35	White	Current	T, A, P, C	Y	Y
Tiffany	25	White	Former	A	Y	N

Analysis

The analysis involved coding over 400 pages of interview transcripts, which resulted in 70 pages of coding.⁴ The interviews were coded using modified grounded theory methods (Charmaz, 2006, Strauss and Corbin, 1998). Whereas grounded theory derives categories or themes that emerge from the data, a modified version makes use of different concepts derived from the literature as well as the data while focusing on relations between the categories (Malterud, 2001). The coding was conducted by reading each transcript and looking for insights related to the key objectives of this paper: (1) how female drug users manage stigmatization of their drug use; (2) how female drug users reclaim a sense of normality; and (3) barriers and challenges to controlling drug use and/or recovery. These were grouped by concepts found in the literature related to the stigmatization of women who used drugs, perceptions of normality, and barriers to services (Neale et al. 2001; Boeri et al. 2011). The coding involved a two-step process. As the analysis continued, the conceptual categories were expanded to include patterns found in the women’s perceptions of social life, drug use and recovery efforts (Radcliffe, 2011). For example, some women perceived the benefits of some drugs helped them to stop other drug use. This was coded as a “self-help” category and added to the concept of “services” to indicate “services/help.”

During the first step of coding five key concepts were developed: (1) mother/mom; (2) normal; (3) child/children/kid(s); (4) difficulty/hardship; and (5) services/help. The concept “mother/mom” was coded in the sense of women’s roles as a mother rather than discussing their own mothers. This allowed greater insight on the different aspects of being a mother as well as a drug user and how the two conflicting roles were maintained. The concept “normal” was used to understand what being normal meant to the participants. This showed how the women viewed society’s concept of “normal” and how they thought they measured up to that definition/standard. The categorical concept of “child/children/kid(s)” was used to determine if and when the women fulfilled their roles as mothers and how this impacted their drug use and recovery. This coding also showed the different perspectives of being a good mother as well as various methods the women used to provide for their family. The concept of “difficulty/hardship” related to the measures that the women had to take in order to survive or recover. There were difficulties that these women faced for being a drug user and a mother, so this term facilitated an examination of how they overcame the difficulties or not, and how it affected their lives. Lastly, the concept “services/help” encompassed the services provided by society as well as the women’s perceptions of self-help or receiving help from other than public services. Society’s help refers to the services provided by the government such as treatment programs; whereas the perception of self-help refers to perceived benefits that the women gained from doing drugs, such as weight loss, energy, and self-medication, as well as help they received from neighbors or strangers.

The second step in the coding process involved examining the coding under these main concepts to find relations between them, and developing conceptual themes for the analysis. Finding that some women used drugs to manage the stigma they felt as being poor or to cope with feelings of hopelessness before their drug use started, led to conceptualizing the stages of drug use. The theme of Stages includes before, during, and after drug use. The before stage covers the initiation of drug use and reveals why the women became dependent on the use of drugs. The during stage explores how drugs helped these women function in life as well as cope with stigma, enabling them to feel “normal” while using drugs. The after stage examines their lives after being exposed or discredited for using drugs, how the women handle the criticism and their path to normality without using drugs. These are further organized by sub-themes that were found to impact the women in each stage.

The second theme that emerged from the coding is Social Control, which is divided into sub-themes of treatment services, religion, and social environment. These sub-themes represent social control agents in the sense that they influence the women to control their drug use (in this case methamphetamine) or become drug-free. The social environment refers to the living situations of the women while trying to recover from drug use, which included jail and drug courts (formal social control), and their own neighborhoods and social networks (informal social control). The findings describe these themes in more detail, with examples from the transcripts. The women’s words are shown verbatim without editing for grammar.

IV. Findings

Stages of Drug Use: Before, During, and After

The use of drugs can be divided into several stages which do not necessarily correlate to the amount of drugs used throughout the drug-using period. Instead these stages refer to the concept of starting, using, and the aftermath of being exposed as a drug user by being caught or entering treatment. The Before stage in this paper explains the driving forces (initiation) that influence the women to turn to drugs. The During stage explains what the women perceive to gain from doing the drugs, even while hiding their use to appear “normal” to society. Lastly, the After stage explains the women’s situation after being exposed as a drug user and the challenges they face, especially mothers trying to regain custody of their children.

A. Before Stage

There may be many reasons why women turn to drugs, including the aspect of self-medication and social pressure to fit society’s high standards for “successful” women or “good” mothers. Many of the women went through emotional and psychological difficulties, such as depression and social stress, which they felt was addressed through the use of drugs. In both cases, the women began the use of drugs to avoid the stigma they faced in their current lives. The concept of “self-medication” examines coping with feelings of hopelessness and feeling different from those who seem happy in mainstream society. The social pressure to “fit in” was frequently mentioned. Specifically, idealized weight was a common reason that the women turned to methamphetamine when they felt that they were not meeting social expectations of the perfect female shape. Methamphetamine was an effective drug for losing weight.

Self-Medication

Many of the women started using drugs to help themselves recover from a break-up or separation from their significant others. For example, Linda, a 49-year-old mother, explained that drugs were what kept her sane through a divorce. She started to feel unworthy and unable to work, so she began selling and doing drugs.

“When I first started in the divorce, um, when we first separated, I was straight. I was tryin’ to do right. I had the kids in church. And it got so hard and somebody was always goin’ “well if you did this if you did that,” and I started feelin’ beneath. Uh, when I had the car wreck, I knew one way I could support my kids—I started sellin’ drugs.”

Methamphetamine gave Linda the energy she desired to keep up with her role as a mother, lifted her feelings of depression, and also provided a source of much needed income. Linda explained, “Yeah, you’d have to stay awake, so you used meth. With meth you feel like, uh, you’re more normal, you’re more equal to what you should be. You have energy.”

Chloe, 18 years old, had been raped a few years earlier and never reported it or received any counseling. She used drugs more often after this incident. Chloe stopped using drugs when she was in a relationship with a boyfriend who disapproved of drug use. After he left her, she felt the need to help herself emotionally and started using again.

“I think I started doing a wider variety after he left because it was like, he wasn’t around so I wasn’t afraid of getting caught. Like, he was the only person I was worried about, you know, looking down on me for doing it.”

Like Chloe and Linda, many of the women began to use drug as self-medication to make them feel better. Some had been separated from their significant others, but they revealed different reasons to use drugs to address their separation. Linda began her use of drugs as a means of financial aid to support herself as well as her children, while Chloe went back to her old habits of using the drugs she had used before meeting her boyfriend. Chloe was a previous drug user, but in this sense, the separation from her boyfriend triggered a greater variety of use.

In addition, many women faced hardships and/or difficulties in their lives that made them feel hopeless. For example, Audrey, 19 years old, explained:

“Like college is fucking hard now because I never had to study in high school and I did very well. And that was another reason why speed was such, was my drug of choice, because I would get geeked and my, like, tweak would be to do school work.”

“Speed” is a term used to mean methamphetamine. “Tweak,” to methamphetamine users, is what they like doing while high. Although Audrey was not trying to medicate herself from emotional stress, she was facing social stress in college. She used meth to try to “medicate” in the sense that it allowed her to complete her work for school. This concept of self-medication relates to the situations that the women faced that motivates them turn to drugs as a coping mechanism. Some are at a loss of what to do next with their lives after the change in social roles. Other women turn to drugs to try to improve or fix their situation and “cure” themselves—to feel normal.

Weight Loss

Many of the women also felt that there are societal pressures to being a woman that drives them to use drugs. These pressures made it stressful as well as hard for the women to meet the standards of what they perceived are perfect women. The most difficult aspect that was a common theme brought up by the women who used methamphetamine was their weight, which they perceived as not meeting the idealized or normal weight for women of their age. Dolly, a 37-year-old mother, described her reason to use drugs, “Cause it’s just hard to lose weight, you know. It’s so hard to lose weight. It’s not hard when you’re high.” Similarly, Katy, 22 years old, explained why she started using methamphetamine:

“You know, it used to be fun, hanging out with my friends, joking around, seeing idiots, but it’s… you know, it was hanging out, having fun, but at the same time maintaining a weight. For girls it’s a huge weight thing.”

Perceived societal pressure drove these women to drug use. Some society expectations, such as maintaining an ideal weight, may not be achievable for these women without the help of drugs. Therefore, they turned to drugs as aids, leading them onto the path of further drug use. Feeling they are bound to a standard that they are not able to achieve without “help” caused them more difficulties and hardships in the next stage of their use.

B. During Stage

Society has set norms of behavior for individuals, which translates into the standards of being “normal.” Some of the women, especially the poorer women, did not feel as if they “fit in” with mainstream lifestyles and felt stigmatized. Using drugs, they were able to find an identity for themselves and, ironically, feel part of society, as discussed in the before stage. However, the difficulty they now faced was that as a drug user, they would still be stigmatized. Therefore, the women hid their use to avoid stigma and still meet the expectations of society. In addition, many of the women using meth felt “normal” since they now were meeting society’s expectations of women’s roles. They found themselves with increased energy allowing them to be more productive, as well as having increased self-esteem.

The Dilemma of Avoiding Stigma and Feeling Normal

As discussed, some of these women did not feel normal before using drugs, but felt more normal while using. Other women used drugs as an attempt to prevent themselves from being stigmatized for what they felt were shortcomings. Yet by doing this, the women risked more stigma if they were caught. The sad irony of the women using drugs to feel normal was that it actually led them to behave contrary to the norms of mainstream society. It often led to associating with other drug users, considered outside conventional society as well.

Examples of feeling normal are shown in many of their justifications for using drugs. For example, Linda explained:

“With meth you feel, like, uh, you’re more normal. You’re more equal to what you should be…Uh, you feel like you fit in, um…you feel like you’re part of the human race instead of…something that’s been thrown aside. You feel like you fit in.”

In the case of Linda, she was stigmatized by the fact that she was poor and did not meet the general expectations of mainstream middle-class society. However, by using drugs and selling them, she met the expectations of making enough money to support her family as a single mother. This aspect allowed her to feel normal rather than being tossed to the side.

Likewise using drugs to avoid potential stigma and cope with difficulties, Madeline, a 22-year-old, had been kidnapped by an abusive boyfriend when she tried to leave him. She explained her drug use eventually became normalized behavior. “And then after I was doing it for a while, it was kind of like I was doing it just to be normal,” she said, “or what I thought was normal at the time.”

Other women felt they were normal when they use drugs, but at the same time needed to avoid being stigmatized as a drug user if discovered. For example, Audrey, a 19-year-old, experienced stigma from her own parents for doing the drugs. Describing an incident with her parents, she said, “I just remember her looking at me and shaking me and saying ‘what the hell did you take?’ And my dad’s in the background screaming at me.” Audrey’s parents were upset with her, but this only caused her to hide her use, like many women who take measures to hide that aspect of their lives. As Katy, 22 years old, explained, “don’t let your family find out what you’re doing because it will hurt them the most.”

When their drug use is exposed, they are more stigmatized, even if they felt they were acting “normal” while using drugs. For example, Katy felt normal using meth, but had to hide her use to prevent the stigma, as she explained:

“My family thought I was fine. And I pulled that off for four years and no one had a…I’m sure, I’m sure somewhere my mom knew in her head I was using, but nothing pointed to it you know. I was doing everything right.”

Although Katy was still using drugs, concealing it and acting “normal” helped her avoid the stigma that would come from being an exposed drug user. Like Katy, many women started drugs to avoid feeling stigmatized, but they were now forced to hide their drug use to avoid even greater stigma. Their stories reveal how drugs seemed to help them to not only feel better but also be more productive.

Increased Productivity

Using drugs like methamphetamine, the women felt an increase in energy, which led to more productivity and better functioning in their daily lives. Linda explained,

“Well look, when I snorted it I had energy. I could get all this stuff done that, let me tell you, I cleaned my house and somebody came by one day and they said “what are you doing?” I said well I’m cleaning. I was cleaning behind my dryer. I took the metal piece off and was cleaning it (laughs).”

The increased level of energy allowed Linda to complete strenuous household chores to the standard she felt was expected of her as a mother. Similarly, Abagail, a 20-year-old, explained the utility of using meth:

“It made me like more productive. I felt like I got done stuff on it. Like I could party and hang out with my friends, and then go to work the next day, and then go to school the next day.”

These women were able to accomplish multiple tasks due to the increased energy, which also linked to avoiding stigma. They felt that by using drugs they were functioning according to the norms of society. The adverse effects of drugs were not visible yet to others, allowing these women to conceal their use.

In addition to increase in energy, meth also provided the ability to focus in order to accomplish tasks in a more productive manner. Mercedes, 34 years old, explained:

“I feel like I can hold my composure better. The thinking is much clearer…normally you can focus so clearly. Like, I used to like to do my artwork and carve when, uh, especially by hand but even with a drill and what not. But by hand it’s like I would just have an exact…I could just make the most intricate carvings. And, um, keep my mind as to different tricks to use to get different textures and different techniques. I was very, uh, just on point. Very tactful, um, and I felt that was a result of the drug.”

Mercedes also provided an example of her friend using drugs to focus:

“You know, I had one friend that would love to study with it. She would use it to study. When she had finals, she would be up for like two weeks at a time. Like usually she would buy a half-ounce of speed, you know, a couple weeks before exams.”

The ability to focus and to work on the smallest details also helped them to conceal their use of drugs from others who may stigmatize them once they find out. These women are able to carry on with their lives and portray that themselves as “normal” and even productive to others, while feeling normal themselves only when using drugs.

Self-Esteem

Feeling normal for these women impacted their self-esteem, since their prior stigmatization from society made them feel outcast or different. Linda explained how smoking methamphetamine made her feel:

“Your self-esteem goes up with it. Um…when you start smoking it… anything, any pain anybody causes, you can kill it. You don’t have to…you can kill your emotions with it. And that’s what took over with me, with the [meth] pipe.”

The emotions that Linda referred to were the negative views the women perceived from others, but when they used meth, the emotions were subsided, ultimately increasing their self-esteem.

Isabella, a 27-year-old, had low self-esteem from having a boyfriend who physically abused her and verbally berated her for being overweight. Although her parents were upper-class and provided all her material needs, she felt ostracized by her peers. Using methamphetamine allowed her to feel better, as she explained:

“I really liked it. I just enjoyed the feeling that I got from it, is the only way I can really describe the feeling that I had. It was just I liked it. I almost felt normal, as sick as that sounds.”

The “feeling” that Isabella felt when doing drugs was reiterated by other women who said they felt they enjoyed their lives more and even felt empowered when using meth. Isabella used the phrase “as sick as that sounds,” knowing that she faced stigma within society for being a drug user. This supports the findings that many women used drugs to feel better on a personal level, despite the stigma associated with drug use.

Beyond, enjoying the feeling, there also are aspects of escape that relate to self-esteem. Mercedes, who experienced childhood rape, describes what drugs did for her. “I could escape from reality and the same time I could get high and still be on point and still be tactful,” she said. “And, in fact, it even increased that tactfulness and that energy.”

This analysis reveals that their perceived or actual social situation prevented some women from feeling valued. Beyond increasing self-esteem, when the women use drugs they enter their own social reality where things get done and they feel better. They are able to possess the abilities that they see in others that make them normal. They find value in themselves as they accomplish tasks and achieve goals that they believe society has set for them. Ironically, using drugs was a way for them to deal with feelings of being stigmatized, abused, or not valued, superficially raising their self-esteem for a time—until they are exposed as a drug user.

Being a Mother and Drug User

Being a mother and a drug user are conflicting roles. A mother is caring and supporting of the family, while a drug user is seen as an uncaring and selfish person that should be kept away from children. If a mother is a drug user, the children are believed to be exposed to a negative environment, and drug-using mothers are stigmatized in mainstream society. Several of these women expressed difficulty in maintaining their good reputation within society as a mother. This caused some to hide their drug use and only reveal what is accepted by society. Beth, a 23-year-old young mother, described how meth helped her maintain this image:

“Every bit of laundry would be done except for what they were wearing, and I couldn’t wait for them to hurry up and get undressed so I could grab those and throw them in the wash. Everybody’s socks had their initials on the bottom.”

When asked if people were suspicious, she answered:

“I don’t think so. I don’t think so. My kid’s homework was always done. Christmas time, all the school bus drivers got little baskets of cookies and homemade truffles, and I volunteered at every field trip.”

Similar to many other women, Beth was able to prevent people from suspecting she was using drugs because she maintained her reputation as being a good mother. For many, the image shattered once their drug use was discovered.

C. After Stage

This section explores the lives of the women after they were exposed as drug users and as they faced different types of criticism. Some were struggling with the difficulty losing their children. Many faced challenges of experiencing stigma again as they were given (or assumed) the label of “former drug user.” Although many of the women were trying to improve their lives and maintain their family relationships, society still stigmatizes them because they used to use drugs (a discredited status), or because they are not as productive as they were when they hid their drug use.

Facing Criticism

Many of the women faced hardships after stopping drug use due to the criticism they felt by not meeting expectations. Lily, a 21-year-old college student, explained her relationship with her mother after she stopped using meth:

“I actually stopped before I told her. I had been off for probably three months when I told her. Because she was giving me a hard time about my living situation and she knew about me not going to classes very much. She kept saying I was fucking up my life, and I got upset about it because I was like, you know what, I just got off of a really hard drug, and if you think that I’m such a fuck-up, well listen to this. I was on meth for a year and a half, or however long it was, and pretty much just to show her up, you know, that yeah, I have fucked up, but I’m working on it.”

Lily’s mother criticized her for not meeting her expectations as a daughter and a student. Others faced similar situations when they stopped using drugs to improve their lives.

Some women said they were expected to act as “normal” and productive as they were while using drugs but without the “help” that drugs gave them. For example, Katy described her interaction with her mother:

“I’m not using ice [meth] anymore. I said I’ve done it for four or five years, you didn’t know. I hid it from you I said and I’m clean. And she’s like but why have you gained so much weight. And I said, do you want me to be skinny and a crack-head, or fat and clean? Well of course I want you to be clean, but she never just dropped it at that. She would, every time I saw her I guess since April, this last April until now, just a month ago, every time I see her she won’t say anything without saying something about my weight first.”

Katy was criticized for not being thin as she had been when she was using methamphetamine regularly. It was difficult for Katy to stay drug-free when her mother kept bringing up the positive aspect of her drug use, in this case weight management. Their stories revealed the dilemma of using drugs to feel normal or cope with stigma, stigmatized for being a drug user, and criticized when they stopped using drugs for not meeting the standards set by society for women. It was a classic Catch-22.

Mother Roles

Many of the mothers were considered perfect role models of a mother while they were hiding their drug use. However, when the use of drugs was revealed, no matter how good of a mother they were, their children were taken away or threatened to be taken away by relatives or social services. For example, Tammy, 35-year-old mother whose children were taken from her three times, described the situation in which her drug use led to her losing her children:

“It hurt because I could remember all the good times that we used to have. I mean, you know, because basically I was, you know, I tried to be the stay-at-home mom, but, you know, I was working around the trailer park too, and all that. But just to wake up in the morning and get up and take care of my kids, and get them off to school, and then have to sit there and wait on them to come home, you know. Me and my kids, we was inseparable. But my sister, she told me, she says, ‘if you don’t stop what you’re doing,’ she says, ‘I’m going to take your kids.’”

Many of the women had expressed similar fear of losing their children or distress after losing them and having a difficult time regaining custody. Being a drug user prevents these women from fulfilling an acceptable mother role even though some effectively provided and cared for their children while using drugs. Society says they are not fit to be mothers, but it offers little help to meet the high standards set.

Although these women are drug users, they expressed care and love for their children. They tend to think of the future impact of their drug use on their children. Lisa, a 30-year-old mother, revealed that the care she felt for her unborn child while she was pregnant motivated her to stop drug use during pregnancy.

“I don’t know, that’s one thing I think about now, ‘cause I see all my friends and stuff that are pregnant and they can’t stop. But I just did, and I guess because I care more about my kid.”

Likewise, Beth revealed she was concerned about the home environment of her children. The people in Beth’s house, friends of her husband, were using drugs and influenced her to use drugs. After she stopped using, and in order to prevent her relapse, she encouraged her husband to ask them to leave.

“I told him, I said. Well, my thinking at that time was if they’re going to do it, what the fuck, I may as well do it too, because it’s going to be there. We’re going to get raided, we’re going to get arrested. We’re going to lose the kids. If they can’t pass drug tests, why the hell should I. And he went home and kicked them all out. And that was it.”

Many of the women whose children were taken away, worked hard to get them back because they wanted to be mothers. Beth explained her desire to have her children back when they were taken by a relative:

“My sister-in-law that’s got my middle daughter is saying, ‘well, when you get better you can have her back. When you get better you can have her back.’ I was going to get her back. I didn’t care if I had to go to rehab for ten years, I was going to get my children back, because they deserved it.”

Beth further expressed how she felt contrite for not being there for her children.

“My daughter had told me over the phone that she thought she was pregnant. Caroline was taken away from me. My youngest daughter started kindergarten. But there was a whole life that needed to be lived. (talking in very soft tearful voice). And my kids deserved the real me, not what I’d subjected them to.”

Some of the women were determined to be reunited their family, but they do not have the resources needed to be drug-free. Most of the mothers interviewed showed great compassion for their children and willingness to go to treatment to be with their family. Yet in society’s view, drug users are not “good mothers” and first they had to prove themselves. They were willing to change and attempted to get help, but many found help was not available. The formal social control agents—the police, social services and treatment providers—that coerced them to change did not provide the informal social control needed for them to remain drug-free in their own social environments.

Social Control

Not all women drug users have had the opportunity to receive treatment services. However, those who did found that they were not as effective as many assume them to be. Referring to the treatment services they experienced, the women explained the different aspects that could be improved. Others found religion to be helpful in remaining drug-free by living a godly life. Religion offered informal social control by providing a social group outside the drug using network, but religious belief was not for all women. The most important source of social control mentioned by the women was not treatment but instead the social environment where they lived and the social networks they had access to before, during and after using drugs. When their social environment provided positive relationships, they had enough help to stop drug use and recover over time.

A. Treatment Services

There are different services available for treating drug use, but many were shown to be ineffective. Even if the women were able to access drug treatment, some discovered it did not help solve the issue that they were struggling with before they started drugs or the issues they faced as a “former drug user.” Lisa explained her drug treatment experience:

“There was just, they give you, you go in Thursday, and talk about your problem, that’s all we had to do, one day a week (chuckles). So it was just inconvenience, and I guess ‘cause I had to go somewhere, but it didn’t help nothing.”

Harper, a 22-year-old, explained her experience with treatment classes in similar terms:

“I’ve been taking drug and alcohol classes for that. And I take them once a week for two and a half hours I guess…And it’s pretty good, but I still plan on smoking [marijuana] afterwards because I don’t think it’s wrong, and it helps my headaches.”

These two women considered the treatment services they attended were not very helpful, and they did not attain a drug-free life after they left the treatment services.

Many of the women found the treatment regime to be too difficult, especially drug-free programs where even prescription drugs were prohibited. On the other hand, Tammy described her experience with treatment services that provided medication in a more positive way:

“I recommend this rehab to anybody. Because when you go in, you don’t have to pay nothing. And they’ll take you and you can see, they help you with your medication. They don’t let you do no kind of, you know, hard narcotics or nothing in there, but they do help you with your, like, psychiatric drugs, you know, if you’ve got bipolar or anything. They will help you pay for them. They feed you. You go to drug classes every night. You go to, well the NA meetings. Then you go to drug classes five days a week from eight-thirty to one-thirty, and it’s a great place to be.”

Although Tammy described her program as more effective than others, she had the advantage of being offered an expensive residential treatment program with psychiatrists who treated her underlying causes of drug use. She also had substantial social support throughout her time in treatment and afterwards. Many of the other women could not access such resources, and some were told that as “former drug users” they could not use any psychotropic medication. Total abstinence was difficult to maintain.

B. Religion

Religion seemed to play a greater role than treatment services for many of the poorer women when trying to become drug-free, especially those who did not have access to expensive drug treatment. Dolly shared the spiritual help she felt while in drug court:

“I got the probation and all from the possession and the DUI charges. And I still got four years left on there [in drug court]. But I just moved down a level. They took me off intensive last week and I’ve got a new probation officer, and I’ve done all my community service and I’ve done everything I was supposed to do. All my programs and all my treatment and all my evaluations and therapy and everything. And it’s all helped, you know. But honestly the biggest thing is depending on God. If it wasn’t for God, I would have never made it. And I know that.”

Although Dolly thought that she has benefitted from the services that drug courts provided for her, she indicated that religion was what eventually helped her recover in her mind.

Similarly, Rachel said, “Yea, it’s about the strongest influence. My idea of God is there’s a God and He loves me a lot, and he wants what’s best for me. That’s it. And he helps me stay clean.” While her faith helped Rachel stay drug-free except for tobacco, Dolly used methamphetamine again soon after leaving drug court, but stopped using to be with her children. The act of believing in something was the motivation that allowed the women to stop using. They also believed that God was the factor that allowed them to “stay clean” and provided the help needed for them to move on with their lives.

Lisa, like many of the women, believed that the treatment centers she went to were not effective:

“I think if you found a treatment program that was like strict and some of the inpatient that you know you do get tested and stuff, and they really care, then I think that might help. But like [Generic Treatment Program] was just a joke ‘cause all you had to do was show up on Thursday, pay your ten dollars for your little meeting, talk about your problem and go home. They didn’t try to help you stop really. Cause half of our class went in high every week.”

In contrast, Tiffany, a 25-year-old, experienced the benefit of a more structured treatment environment.

“Honestly, right now it’s the fact that I’m in drug court. It’s the fact that I get random drug screens. I haven’t been tested this week but like last week I got tested three times. So it’s like very random. But going back to speed, like I graduate drug court March 3rd, Monday’s spring break. Like I’m finally going to be done with this. But I have no intention on ever using meth again. I mean I can’t tell you the future, like I can’t really, I’m not a psychic, but I saw what it did to me. Like when I was, when I used cocaine this last time I was in drug court and I had a positive screen and I had to go to jail for five days and I had to start over in that phase. Like, I mean I had consequences but they didn’t send me back to jail for good. And I asked them, you know the officer is part of the administration in drug court and so she agreed to pull up my original felony arrest picture and looking at that, it made me never ever use it again. I looked like death walking.”

The strict environment seemed to keep Tiffany on track as long as she was monitored, and it motivated her to start a new life. But it is still a coercive form of social control, which may not work for everyone, and without a structured social environment to go to when she leaves drug court, there is little hope that she will remain drug-free. As shown in her narrative, Tiffany became drug-free previously in drug court, but she relapsed after leaving because with nowhere to go, she returned to her old social environment.

C. Social Environment

The women’s accounts of ineffective services revealed that when they are not given the right resources that address the reasons they started using drugs, many turn back to the drugs that do help them cope with their personal issues. Based on their stories, a positive social environment was more important for their path to recovery than enrolling in treatment services or going to jail. After leaving treatment or jail, most of the women were back in the neighborhoods where they came from—sometimes with more drug use knowledge. “I’m not a criminal. I need help. I don’t need prison,” Beth explained. “Send me to prison and from what I’ve heard I can get more drugs in prison than anywhere else. There were drugs in the county jail.”

Although the women drug users were often separated from society until they recovered, this did not help address the reasons why they used drugs. As Beth mentioned, she actually increased her use in jail and after she left. The environment of the criminal justice system was not the right social situation for women to recover.

The most influential social environment to consider outside of a treatment service is the social network of the women. When going back to their communities, many women relapsed if their friends were still doing drugs. Isabella explained:

“I mean, you’ve got to change your mind. But I think the biggest problem that people have, because I tried to get clean several times just because other people wanted me to, and then I would see my old friends. I mean, you have to get away from those people, even if it means pushing them away and being mean if that’s what it takes. I mean, you really have to have your mind set to get away from meth.”

Social support for these women was critical after they left a structured treatment environment but many of the women were exposed to people who use drugs in the neighborhoods where they return.

Some women showed how distraction away from the drugs is a key aspect that is needed in the environment for the women drug users. Harper explained how she helped a friend remain drug-free after treatment by distracting her with drug-free social activities:

“I would, I would try to distract her. Because the only thing that will really help you, because once you want to use—you want to use. And if you can get a good distraction in there, it will last for a while.”

Similarly, Tiffany described her boyfriend’s positive influence keeping her involved in activities:

“He’s just a completely positive character. Uh, he would just calm me down a lot of times. I don’t know. And he had like more of a life. Instead of like waking up every day like how am I going to get high today, his was you know, ‘let’s go do this, let’s go do that,’ you know. It was more of like activity was a way of, you know, trying not to think about it. Like he was taking me everywhere. We’d go to the islands, we’d go, you know, to the lakes, like everywhere.”

The positive social environment that these women were exposed to helped them move on with their lives. They found social support and happiness through other means than using drugs. A positive social environment after stopping drug use played a greater role in remaining drug-free than the any other solutions mentioned by the women in the study.

V. Discussion and Conclusion

The findings in this study on women drug users show that there is not one reason for drug use and the women face several difficulties while using drugs as well as when trying to remain drug-free. Reasons for initiation included coping with the stigma of not meeting perceived social expectations, such as an idealized weight, and self-medicating to address stress or depression. The period during the drug use was the most difficult time in which the women tried to avoid stigma by concealing their drug use. Yet they said that they felt normal using drugs as they saw an increase in their productivity and self-esteem. The after stage revealed more difficulty for these women as they faced criticism on multiple levels. They were still criticized for having a “former user” label, and some women were not able to maintain the same level of productivity they showed when using meth. Another difficulty for those women who were drug users and mothers was trying to regain custody of their children. Some of the mothers stopped their drug use after being caught to be able to be with their children. However, as a “former drug user,” society still stigmatized them and formally controlled their status of motherhood with strict rules and requirements they often could not meet. A positive social environment after leaving treatment proved to be the most helpful, such as being surrounded by supporting people who wanted them to recover.

Although a few of the women believed that the treatment services were beneficial, others found that religion was a form of social control that worked for them. Religion also provided a social environment that offered access to a new social group and support for their new way of living, but not all women could embrace religious beliefs. Others found the treatment programs were not effective because some of the people in treatment were still using drugs, or it was easy to fall back into drug use when they left with insufficient social support. Treatment with a more structured environment helped some, but this kind of treatment was not available to most of the women.

While treatment and criminal justice programs such as drug court provided formal social control, the most effective form of social control was when the women were linked to a positive social environment that gave them motivation to stay drug-free. This typically included social activities or new networks outside drug using environments. This kind of informal social control focuses on the formation of bonds and relationships outside of drug using community that helps recovering individuals maintain a drug-free lifestyle within mainstream society. The findings support other research showing that new relationships in social environments are important factors to consider when trying to help former drug users maintain drug-free lives (Boeri, Gibson & Boshears, 2014; Moos, 2007; Zschau et al. 2015).

The findings presented here add to the literature by highlighting the impact of stigma on women and how continued stigmatization hinders recovery efforts. Typically, treatment services focus on changing the individual through formal social control, but there is much less focus on changing their social environment. The findings of this in-depth study, with its focus on all stages of drug use progression, show that women need a link to mainstream society and social bonds that help motivate them to believe they can “fit in” and be normal without drugs. Simply trying to change who they are will not allow them to integrate into new social networks that provide this sense of belonging and acceptance. Continuous emphasis on their “former drug user” status, such as requiring them to go to meetings with other former users, can increase feelings of inadequacy, marginalization and stigmatization. Women drug users faced stigma in all stages of their drug use, and reducing this stigma might be the clue to successful integration into society.

Limitations

This is a qualitative study using a small sample of women whose primary drug of choice was methamphetamine. More research is needed to discover if other drugs, such as crack or heroin, provide the same perception of productivity and self-esteem that these women felt while using methamphetamine. Since all women in this study continued using other substances (both legal and illegal) after stopping methamphetamine, more research is needed on the potential benefits of continued short-term or long-term use of some substances compared to total abstinence. Studies with a more racially diverse sample can provide further insights on how women drug users perceive stigma and normality. The findings of the impact of stigma on women drug users might be compared to men who use drugs in future studies. Finally, many of the women in this study had experienced violent abuse, which needs to be further analyzed to better understand its impact on their drug use and recovery.

Implications for Treatment and Social Services

This study suggests that for recovering drug users, treatment services must focus on the social environment of their clients after leaving treatment. It also suggests that social services can do more to prevent women from using drugs by providing greater access to needed resources in their social environment, and intervention services for women drug users can acknowledge the social context where the women live when developing their programs. The study findings show that women need resources as well as access to new social networks. While treatment programs are the most obvious space to facilitate access to new networks for recovery efforts, social institutions, such as religious organizations, schools, and workplaces, also can provide opportunities for social activities that link women to new networks outside their own communities. Social services might facilitate participation by providing free transportation. Religious organizations can provide space for social clubs and activities for people in the community other than their own congregations or members. Workplaces can offer treatment for all levels of employees, and incentivize social activities that encourage constructive relationships. Schools can provide subsidies and transportation for children to participate in social clubs and free equipment to participate in sports teams. Incorporating an understanding of the social environment in prevention, intervention and treatment shifts the focus from individuals to the relations between individuals and social networks.