“I’m not like others”: stigma navigation by people who inject drugs in Vietnam

Abstract

Background:

People who inject drugs are subjected to great stigmatization in many parts of the world. How they deal with stigma is closely linked to how stigma means to them. Understanding the strategies individuals employ to cope with these negative attitudes and what resources they mobilize in this process gives useful insights for clinical work and policy development.

Methods:

We conducted 12 months of field observation in 2017 and 2018 and 54 in-depth interviews with people who inject drugs in Haiphong, Vietnam. Grounded theory underpinned our sampling and data analysis.

Results:

The strategies participants used to manage stigma were both information and tension management. Many participants not only concealed their drug use but actively cultivated a pro-social image based on Vietnamese cultural virtues such as selflessness, hard work or harmonious living with others. Participants withdrew from social relationships to distance themselves from the stereotype of a money-begging drug user. They used techniques of neutralization to emphasize their good character and reframe their drug-related issues in a different light in order to negotiate their social status with their interlocutors.

Conclusion:

People who inject drugs endorse the same social values and aspirations as nonusers. A good support structure and resources could help them to cope more effectively with stigma.

Introduction

Stigma towards people who inject drugs is a global phenomenon that causes substantial detriment to individuals’ health and well-being (Room et al., 2001; van Boekel et al., 2013, 2015). People who inject drugs were blamed for their condition and perceived to be more dangerous than people with other ‘deviant’ conditions (Room et al., 2001). Public stigma was closely related to support for punitive drug policies (Kennedy-Hendricks et al., 2017)

Current literature has identified various strategies to manage drug-related stigma, including strategies to conceal their drug use and those to manage the interpersonal and intrapersonal tension that might emerge at the encounters between the person using drugs and her non-using audience. The strategies might serve to neutralize the negative emotions people experience (emotion-focused) or to alter the source of the stress (problem-focused) (Carver et al., 1989).

Emotion-focused strategies include hiding bodily evidence of drug use and striving to maintain normal functioning (Askew & Salinas, 2019; Whitaker et al., 2011). Investing in dental care to avoid having ‘meth mouth’, injecting drugs in areas like the groin or the neck that were less visible but more dangerous injecting sites than arms were reported as individuals’ efforts to manage drug-related stigma (Copes et al., 2016; Whitaker et al., 2011). Drug-using individuals might withdraw from social encounters or avoid getting into intimate relationships for fear of being disclosed (McKenna, 2013; Spooner et al., 2015). They can also employ neutralization techniques to reframe the situation in a more positive light and protect their sense of self-worth (Sykes & Matza, 1957). For example, women meth users in some studies constructed a symbolic ‘other’ with which to contrast themselves, then to claim that they were not ‘real’ meth addicts (Copes et al., 2016; McKenna, 2013).

Education and drug activism are examples of problem-focused strategies. American drug-using patients told their providers that addiction was a brain disease and that everyone could get it (Biancarelli et al., 2019). Some published their insider accounts on the compulsivity of addiction, hence painted a more complex picture of the condition, away from the stereotype (Fraser, 2015). Drug activist movements advocated for the rights of people who use drugs (Jauffret-Roustide, 2009; White, 2007). What strategies individuals employ to deal with stigma are closely linked to what stigma means to them (Fraser & Moore, 2008) and to the support available to them (Dageid & Duckert, 2008).

Recent studies argue that current drug-related stigma implied neoliberal social expectations of responsibility (Fraser & Moore, 2008; Trang et al., 2020). Stigma was employed as a political means to discipline human subjects into what was defined as legitimacy in contemporary societies (Fraser et al., 2017). Facing stigma, individuals might engage in two contradictory practices: on the one hand, they claimed the neoliberal status but, on the other hand, they rejected the neoliberal expectation of responsibility to refuse the blaming (Fraser & Moore, 2008).

Vietnam presents a unique context to investigate the question of how individuals manage drug-related stigma. Vietnam has recently witnessed significant changes in the status of drug users from a ‘social evil’ to ‘patients’ with the introduction of methadone maintenance treatment into the country in 2008 (Luong et al., 2019; Vuong et al., 2012). With the achievements of the methadone program, the Vietnamese Government has declared that addiction is a brain disease and acknowledged the rights of people with substance use disorders to get access to evidence-based treatment (Government of Vietnam, 2013). However, major barriers remain in the regulations of drug use and drug-related stigma continues to be significant, even among methadone patients (Luong et al., 2019; Nguyen et al., 2019). In another article, we argued that drug-related stigma in Vietnam centered on the social expectation of self-reliance but at the same time prevented individuals to achieve this (Trang et al., 2020). In this article, we describe the different strategies individuals put in place to manage drug-related stigma. We posit that people who inject drugs endorse the same social values as nonusers and that better support should be available to help them cope better with stigma.

Methods

The research on which this article is based was part of the DRIVE study – a longitudinal evaluation of a peer-delivered intervention package of harm reduction, referral to treatment and peer support designed to reduce HIV incidence among people who inject drugs in Haiphong, Vietnam (Des Jarlais et al., 2016). The Ethical Board of Haiphong University of Medicine and Pharmacy approved the DRIVE study. Participants provided written informed consent and received VND200,000 (~USD10) at each in-depth interview as reimbursement for the time, effort and costs involved in participation.

We collected data using ethnographic field observation and in-depth interviews in two rounds. The first round of interviews was done in the summers of 2016 and 2017 with participants who represented a variety of characteristics including age, gender, substances used, methadone treatment status, and HIV status. These interviews explored potential hardships of participants in their daily lives. Stigma and stigma management emerged as an important topic. For this reason, we decided to investigate this question more thoroughly with an additional sample of 17 participants in the second round of interviews in 2017 and 2018. The participants came from the same population of DRIVE and were of similar characteristics to those of the first interview. In this round, we explored participants’ experiences of stigma and their stigma management strategies in different social settings including family, extended family, community/neighborhood, workplace and among peers. Examples of the questions are ‘How do you perceive your relatives treat you?’ ‘What could be the reason of such treatment?’ ‘How does this treatment affect you?’ ‘How do you deal with it?’

The second round of interviews served as our main data source. As we analyzed data, we realized we needed more information from women and people living in downtown Haiphong to assess our emerging hypothesis concerning the intersection between addiction, HIV status, gender, and residency. Thus, we conducted theoretical sampling to retrieve the transcripts of participants with these specific characteristics from the first-round interviews. In total, the analysis was based on the accounts of 54 participants.

From June 2017 to January 2018 and from September throughout December 2018, the first author spent about 10 days a month in Haiphong observing the study population, peer workers and other research staff. Thanks to the introduction of peer workers, she also visited some participants’ homes as a member of the DRIVE team. Prior to each interview, the first author introduced herself as a PhD student of a well-known medical university. There was no difference in race and ethnicity between the interviewer and her informants.

Our field notes recorded observations outside the interviews and provided valuable context for the information we received from in-depth interviews. From our ethnographical work, we were able to observe how stigma management worked in interpersonal relationships. For example, we were able to see how the concealment of one’s drug using status might backfire if it failed.

We applied an iterative approach to data collection and analysis (Charmaz, 2014). We started with open coding until no new themes emerged (after 10 cases). We then grouped the codes into larger categories of strategies to manage the discreditable information and to manage tension to create a coding frame in NVivo 12. The subheadings in the Results section were formulated from these categories. For example, under ‘managing the discreditable information’, we included ‘concealment’ and ‘social avoidance’. Under ‘managing tension’, there were ‘social avoidance’ and the techniques of neutralization. Memo-writing, constant comparison and critical self-reflection were central to our analysis (Corbin & Strauss, 2015; Roulston, 2010).

All interviews were conducted in Vietnamese, tape recorded and integrally transcribed verbatim. All identifiable personal information was removed before the analysis. A summary of each interview and field notes (in English) were reviewed by LMG and LV. The first author analyzed data and discussed her insights with the other authors throughout the investigation.

Results

Table 1 presents the participants’ sociodemographic characteristics. Men made up two thirds of the sample. Most participants were between 30 and 50 years old and living in Haiphong downtown. 40.8% reported being married or living with a partner. Half of participant had intermittent jobs or were unemployed. About 60% were HIV-positive and a similar number of participants were currently receiving methadone treatment.

Table 1—

Characteristics of participants (N=54)

Characteristic	n
Age
<30	4
30–39	21
40–49	25
>=50	4
Sex
Male	35
Female	19
Highest level of education
Primary or middle school	20
High school	7
College	2
No information	25
Residency
Inner city	37
Outer suburbs of Haiphong	17
HIV status
Positive	33
Negative	21
Marital status
Married/Cohabiting	22
Single	20
Divorced/Separated/Widowed	12
Occupation
Unemployed	12
Insecure/intermittent employment	15
Stable jobs	27
Currently in methadone treatment
Yes	32
No	22

1. Managing discreditable information

Only a minority of our participants managed to conceal their drug use from people with whom they interacted in their everyday lives. Most had moved out from their family neighborhood or migrated from rural suburbs or smaller urban centers to downtown Haiphong.

Opiate withdrawal is often described as a horrible condition that participants seek to relieve at almost any cost. However, some participants were able to overcome withdrawal symptoms to maintain a socially desirable appearance in their daily encounters:

No matter how sick I am, I’m middle-aged now. […] Even though I was in withdrawal, I’d have to collect myself. I can’t let people see me like this. I keep myself in check. (Female, 45, sex worker)

This woman’s concern about keeping herself ‘in check’ is related to her social image as a respectable middle-aged woman. She paid attention to her facial expressions, posture and lifestyle to prevent these details from spoiling her performance.

Other concealment strategies included covering one’s face when going out to buy drugs or maintaining a low profile when consuming drugs. The same participant reported:

I use drugs at home. If I feel sleepy, I’d go to bed. Some people are ridiculous. When they get high, they cry, they sing, they laugh, they do all these things on the street. […] I’m not like that. (Female, 45, sex worker)

This participant tried her best not to draw attention to herself. When she relapsed and had to sell her electric bicycle to purchase heroin, she was tormented by fear that people would notice her vehicle was missing and ask questions that might lead them to suspect she was using drugs. This vigilant attention further reinforced the importance of respectability and stigma management.

Like many other participants, she not only attempted to erase details from their social image that were incompatible with a non-drug-using, respectable member of society, but actively cultivated the latter image, as the following quotation shows:

Sometimes I go out to pick some recyclable junk, pretending that I’m a hardworking person. […] Looking from the outside, I still have a job, not a stable one but enough for people to see me as someone who works. (Female, 45, sex worker)

This woman’s concern about her social image might also be complicated by the fact that she inhabited another stigmatized identity of a sex worker. The image of a hardworking woman that this participant created was similar to that of another participant who reported always wearing áo bà ba¹ when she left home. They hoped that this would project the image of a hardworking, modest woman, in contrast with the stereotype of a self-indulgent drug user.

Concealment might not always be a good strategy, as a home visit to another female participant one year after our first interview revealed. Although she had kept her drug use from her immediate family, her in-laws (with whom she had been living with her two young children since her husband had been incarcerated for dealing drugs) discovered it and accused her of deceiving them. Our visit was interrupted several times by her brother-in-law, who accused her of ruining the reputation of the family by going out at night to take drugs, and threatened to kick her out of home if she did not stop.

Purchasing and taking drugs covertly was not an option for all participants; in fact, only better-off users could afford to do so. These participants might hire peers to buy them drugs every day; often the price of this service was a dose for the purchaser. Many participants knew people in important social positions who had heroin delivered to their homes or who bought expensive street methadone instead of visiting methadone clinics.

2. Managing external and internal tension: social avoidance and techniques of neutralization

The drug use of most participants was known to others, so they applied tension management rather than information control to manage social stigmatization and internalized stigmatization. This section focuses on how individuals constructed a socially accepted self, using cultural cues, to resolve intrapersonal feelings of guilt and shame and negotiate status with their audience. The strategies they used were social avoidance and techniques of neutralization.

Social avoidance

In addition to managing stigmatizing information, the strategy of social avoidance serves to avoid judgment, often due to previous experiences of humiliation. Participants protected themselves by avoiding new relationships, restricting their social circles to drug-using peers and immediate family.

Another motivation for social avoidance was to self-affirm. Not all participants had encountered negativity in their social relationships. People of relatively high social positions reported that their extended family and other acquaintances treated them well despite their drug use. Still, some opted to withdraw from these relationships to spell out their difference and distance themselves from the stereotype:

Since I got addicted, I’ve hardly come to see my relatives. I don’t think they’ll avoid me. [but] I’m afraid that they’d think I come to borrow money from them. (Male, 40, welder)

This disengagement from relationships showed that even without actual experiences of discrimination and negativity, participants were aware of the drug user stereotypes and tried to stay away from them. By avoiding acquaintances, participants reduced the opportunity for these people to think negatively of them and strove to protect their sense of self-worth. Hence, fear of being misunderstood prevents or damages meaningful relationships and limits users’ ability to display other aspects of their identity.

Techniques of neutralization

Most participants provided examples of neutralization techniques, with which, they tried to distance themselves from more ‘problematic’ users and assert their adherence to mainstream social norms. The techniques of neutralization used included appeal to good character, denial of responsibility, denial of injury and condemnation of the condemners. While attempting to make sense of their accounts, we were mindful that the difference in social status between the interviewer (a PhD student) and interviewees was pronounced in some instances, and this may have affected the information participants selected to display (Roulston, 2010).

Appeal to good character

Participants’ efforts to make a good impression on the interviewer started with narration of childhood and the time before they turned to drugs. This period, which we termed ‘the glorious past’, was often talked about with great regret and contrasted with their gloomy present. The development of the glorious past served as a background upon which a pro-social self of the individual was established.

Participants often stressed that they had been good children from good families. This meant they were not spoiled ‘by nature’, and that what happened afterwards was not their true self:

My brother and I were the best-behaved children in our neighborhood. My parents were government officials. None of my relatives did drugs. Before I got married, I was very innocent. Only since my husband cheated on me that I became depressed and turned that way. (Female, 40, homemaker)

This participant used positive adjectives such as ‘best-behaved’ and ‘innocent’ to describe herself in the past. These words aligned with the description of her decent family. Against this backdrop, drug use was unexpected and could not be explained by anything other than external forces.

Other participants went on to portray a positive image of themselves as young adults who had ambitions, achieved greatly in school, had a prestigious job or made a lot of money. These virtues are embedded in Vietnamese culture, where education is valued highly and the ability to make money is admired (Trang et al., 2020). This selection of values to display is likely to have been intended to generate sympathy from the interviewer through comparison with her own status.

Stressing that one adheres to the highest social expectations despite one’s deviance is another aspect of the appeal to good character. Participants asserted that they lived faithfully by the ideals of womanhood and manhood. Most women described themselves as asexual:

Unlike my friends who want sex after meth, I can’t do it. (Female, 45, business owner)

This description might represent the desire to dismiss the assumption that women who use drugs were sexually loose.

Others emphasized their qualities of self-respect and trustworthiness by differentiating themselves from other ‘thick-skinned’ users who bore the shame of asking for favors:

I couldn’t afford my methadone then. […] I was so ashamed that I stopped coming to the clinic. Other addicts said I should come anyway and insist to get my dose. But I couldn’t. I’m not as thick-skinned as they are. (Female, 42, waste picker)

Manhood ideals centered on readiness to bear the consequences of their actions, fearlessness, strong will and ability to self-mock. A young participant stressed that he ‘dared to do, dared to take responsibility’ and that he could quit heroin if he really wanted to. Another one playfully admitted that although he made good money, his wife and children hardly saw it for he spent it all on drugs. Irony, in this case, served to display honesty and a good capacity for making money.

Denial of responsibility

Denial of responsibility is defined as negation of personal accountability, a claim that deviant acts are accidental; blame is then deflected to external forces beyond the control of the individual (Sykes & Matza, 1957). In denying responsibility, individuals admit the deviant acts while asserting their attachment to the normative system.

Denial of responsibility in our participants’ accounts takes two forms: blaming fate and blaming other external causes. These two forms are not always exclusive. Blaming fate means one believes that one’s situation is predestined, and for our participants was usually the overarching explanation of significant events that happened and diverted their lives. One man in his sixties considered his bankruptcy to be the key event that led him to drugs. However, he placed this event into a broader context of divine favor: ‘God pampers everyone, but for just some time in life.’ He used the fact that he had lived with one opium-addicted friend for a year without developing addiction to assert that his subsequent involvement with heroin was God’s plan.

Another participant held on to the concept that everyone had their own predefined function in society to explain how a successful person from a good family (like him) could end up taking drugs, being incarcerated and with HIV infection. To illustrate this idea, he contrasted one’s wishes with the reality:

No one wants to become addicted or sick. But it’s their fate that forces them into their current position. (Male, 31, unemployed)

By referring to fate as the script of all life events, participants gave up their responsibility and depicted themselves as powerless. However, some external factors did serve to explain why participants initiated drug use and why they continued. One woman reiterated her ignorance when she was first exposed to drugs:

I was young then, I didn’t know how harmful [heroin] was. I was proud of my capacity to make money. I thought that even if I got addicted, I’d never run out of money. (Female, 33, sex worker)

A typical situation of first drug use consisted of participants as the only nonusers among drug-using friends who persuaded them to ‘give in to’ drugs; only in retrospect did they recognize their error. Similarly, participants referred to external factors to explain their relapses; hence, controlling addiction was beyond their capacity. By evoking the image of an innocent and helpless person, they refuted the labels of ‘social evils’ and ‘self-indulgent’ that were attached to drug users and sought compassion from their audiences.

This denial of responsibility, however, is unlikely to be persuasive. There is a popular saying in Vietnam that instructs people not to listen to drug users, implying that they are liars. Both users and nonusers tend to agree with the saying and dismiss the justification, arguing ‘if you don’t take it, who would force you?’ Participants sometimes voiced this sentiment; one seemed to wrestle between an urge to bring in external forces to explain his drug use and the social demand for individual responsibility:

When my generation came of age, the media didn’t talk about drugs as widely as it’s doing now. It’s not to blame the society, it’s our charge. The society did its part, but it’s just a part. (Male, 35, unemployed)

Some participants went to the other extreme, bearing all the responsibility for their addiction. By adopting this attitude, they distanced themselves from the people they deemed irresponsible:

Some people blame the situation or their distress, it’s just an excuse. I’ve been irresponsible, I must accept that. (Male, 23, unemployed)

Denial of injury

This second major technique of neutralization focuses on the injury involved in the deviant act. By claiming that their acts do not hurt anyone, the individuals break the link between their acts and the consequences and redefine their behaviors as illegal but not immoral (Sykes & Matza, 1957). This parallels the debate about the need for criminalization of drug use and whether one is free to do anything if it does not hurt others (Sher, 2003). Participants denied the injuries their substance use may have caused by underlining their morality and self-reliance. Morality in this context is closely related to the Confucian notion that fulfilling one’s duties to others is the golden rule that keeps society in order. The accounts of our participants reflected this ideology. Parents in our sample claimed that although they used drugs, they took good care of their children:

I do drugs but I always care for my child. Once, she wanted a doll as we were going out. I only had enough money for the next dose [of heroin] then, but I bought her the doll immediately. (Female, 40, homemaker)

For this woman, prioritizing the desires of her children was important for her self-image as a good parent; even anticipation of painful withdrawal did not keep her from doing so. She also laid stress on parents’ ‘correct’ behaviors at home as criteria for good parenting. Being ‘correct’ meant she fulfilled the duties of parenthood and was able to command respect from her children.

I can be really filthy out on the street. But when I’m home, I’m correct. Mom is mom, dad is dad, and kids are kids. (Female, 40, homemaker)

The image of a parent contrasts with that of a ‘filthy’ drug user on the street. By adhering to the mother role in front of her children, she affirmed that her private habit did no harm to her children.

Of course, these definitions of good parenting were personalised to suit the lifestyles of drug-using parents. Outsiders can always criticize them for not spending more time at home with their children or accuse them of abandoning the children. Nonetheless, a realistic definition that fit their lifestyles might help them to deal with their guilt (Copes et al., 2016).

Participants’ denial of injury was often backed by the claim that their families were happy and that their children loved them. Parents proudly declared that their children achieved greatly at school. Some mothers asserted that they were best friends with their daughters, and many fathers reported that their children preferred them to their mothers. Since children are supposed to have a natural inclination towards good people, how can someone be immoral if children love him or her that much? By emphasizing this aspect, participants challenged the public stereotype of drug users and constructed their image as good people by nature.

Allegiance to the family is a key tenet of the Vietnamese value system; for single participants, loyalty to parents was considered to be the highest virtue. One participant said: ‘Addiction is acceptable, but disloyalty to parents is not,’ and that he would ‘spit in the face’ of those who were disloyal to their parents. Another participant differentiated himself from those who yelled at their parents to get money for drugs; just the thought of doing so to his parents terrified him.

Participants also emphasized their correctness in financial matters. Despite their drug use and consequent need for money, only two participants reported stealing. One woman’s first words when interviewed were: ‘I’m not like others. I can’t steal. I feel ashamed at just the thought of it.’ She was clearly aware of the drug user stereotype and wanted to affirm her difference from it.

While other participants admitted that their parents or friends sometimes gave them money for drugs, they stressed that they had never forced people to do so:

I’ve never cheated on my friends. If I’m too stuck, I’ll ask a good friend. If he’s willing to give me, he’d do it. I’ve never borrowed money and not returned it. This is why I’ve many friends, good friends. (Male, 40, shop assistant)

This participant emphasized the respectful manner in which he asked his friends for help. Because he did not put any pressure on them, if they gave him money, it was an act of love. Pointing to positive motives helped participants to reframe their requests for money in a positive way.

Our participants not only asserted that they hurt no one, they showed that they strove to protect others. An HIV-positive man proudly said he always wore condoms when going out with sex workers to protect them, although these women ‘at the bottom of society,’ with ‘nothing to lose,’ would accept unsafe sex for extra money. Participants reported a range of activities they undertook to minimise the impact of their drug use on their families, such as requesting a divorce to protect their spouses from their own financial difficulties, or insisting on keeping the family’s savings intact. This thoughtfulness and self-sacrifice went against the negative stereotype of the self-indulgent drug user.

Another instance of denial of injury was the juxtaposition of heroin with methamphetamine. By contrasting the ‘benign’, ‘therapeutic’ heroin with the ‘harmful’, ‘evil’ methamphetamine, participants claimed greater virtue for heroin users:

If you do meth, you might feel okay now but you’ll feel exhausted the next days. On opium, you’ll feel good all the time, not high but comfortable. Opium isn’t harmful. Meth is. (Male, 40, welder)

Comparing heroin and methamphetamine was popular among both people we interviewed and those we spoke with in the field. Vivid stories of paranoiac methamphetamine users who killed or injured family members and others were offered as proof that methamphetamine was much more dangerous than heroin. This discourse echoes the pejorative rhetoric of the media regarding methamphetamine, which has caused great anxiety and fear in Vietnamese society towards this drug (Ministry of Health, 2019).

Tapping on this societal fear of methamphetamine, heroin users offered evidence to deny the injury heroin might cause and divert the blame for drug-related harm onto methamphetamine users. Moreover, as one participant pointed out, heroin addiction could be controlled by methadone, while no medication could hold methamphetamine users back. This deployment of common knowledge helped them to be more persuasive in justifying their heroin use.

Condemnation of the condemners

The targets of condemnation by our participants were family members, neighbors, methadone providers and society. Participants living in the countryside often blamed the discrimination against them on the ignorance and low education of the stigmatizers:

Educated people, who read newspapers and watch television, see us in one way. Ignorant and uneducated people see us in another way. I heard that people abroad think of addiction as a disease that needs treatment, unlike people here, the rural ones who insist that addiction is a vice, a social vice. (Male, 31, unemployed)

This participant defined educated people not by educational attainment but by their up-to-date understanding of addiction as a disease. By criticizing rural people as ignorant, he distanced himself from them and sought to gain the interviewer’s sympathy.

Urban drug users condemned their stigmatizers from a different perspective. They criticized society for being hypocritical and unhelpful. While drug users were repeatedly told to reintegrate into society, it did not give them opportunities to do so:

I’ve knocked on so many doors, asking for a job, but they firmly refused. If they didn’t, things might have gone another way. (Male, 43, unemployed)

In mentioning his stereotyped appearance, his ‘addict’ label, this person accused society, with its stigmatizing attitudes, of causing his degradation.

Some participants cited a lack of sympathy from their families and the distrust of people around them to be the main reasons for their relapse. They stated that their families often expressed doubts about participants’ efforts to abstain and falsely accused them of taking drugs. They complained that rehabilitation centers that were supposed to help drug users instead provided an oppressive environment that pushed them to seek relief in drugs right after discharge.

Methadone patients reacted to what they saw as methadone providers’ disdainful attitude towards them by criticizing these providers for being corrupt, inconsiderate and inhumane:

We always have to wait. Normally three, four staffs should be there, but some days, there is only one person [who does all the work]. Isn’t it frustrating? It was in office hours but they are going out for coffee. How are they allowed to do that? (Female, 38, unemployed)

Another strategy of condemnation employed by stigmatized people is to selectively devalue the deviant dimension and highlight aspects in which they excel (Crocker & Major, 1989). Some of our participants felt superior to their stigmatizers regarding the ability to make money, which comforted them whenever they experienced negative attitudes from others. A former driver who used to make good money told himself:

They despise me but they don’t do it as well as I do. Let’s wait and see. (Male, 42, builder’s laborer)

From another perspective, participants explained their unjust treatment as the outcome of other injustices such as poverty or immigrant status, not of their deviant behavior:

Addiction leads to poverty, then it destroys affection. People who have money have a say. Without money, no one will listen to you. (Male, 38, unemployed)

Since they think I’m a tenant, they don’t try to get close to me. […] Tenants are different from owners. (Female, 45, sex worker)

By explaining addiction stigma in terms of other injustices, the individuals diverted the attention onto other social stigmatizations, portrayed themselves as victims, and hence were able to project a righteous anger towards the unjust treatment.

Appeal to higher loyalties

This technique explains the failure of participants to follow social norms (Sykes & Matza, 1957). They saw themselves as caught up in a role conflict. For example, our participants explained their continued use of drugs as necessary to fulfill their parental or work roles. As parents, they worked hard to feed their children; as workers, they were diligent. Using drugs was not a violation of norms but needed to fulfill their duties.

A single mother, who reported being physically abused by her parents as a child, swore that she would raise her son until her last breath. She differentiated herself from ‘irresponsible’ drug users who hung around with each other and took drugs constantly. The reason why she continued using heroin was that she could not afford detoxification:

Participant: If you want to detox, you need financial support that allows you to rest.

Interviewer: You mean if you get detoxed, you’ll have to stay at home?

Participant: Exactly. Without a cent, how can you do it? You can’t just lie down. You can’t. (Female, 42, waste picker)

Other participants needed to use heroin to keep working. A single father, infected with HIV and tuberculosis, used small doses of heroin when he felt really weak. He did it strategically, not exceeding two weeks of consecutive use to prevent development of addiction:

Since I first used heroin, I’ve never intoxicated myself. I take just enough so I can work. (Male, 44, employed intermittently)

One participant reported using heroin to maintain the quality of his output:

I can’t let myself go into withdrawal. That’s the only way for me to work well, to provide people a good service. (Male, 40, welder)

By describing themselves as people who worked hard, participants dismissed the negative association between addiction and self-indulgence or crime and asserted their observation of social norms.

Discussion

Individuals are not passive but resourceful in dealing with drug-related stigma (Goffman, 2009). Our study sheds new light on the motives of people who inject drugs in managing stigma and reveals the social norms that underlied this process. By drawing attention to the complexities of participants’ emotional lives, their beliefs and methods employed to combat stigma, we challenge the stereotype of an inhumane, irresponsible drug user and show the humanity of people who inject drugs.

Our participants employed many of the same tactics reported in previous studies, such as using drugs in private, concealing markers of drug use from nonusers, or withdrawing from social relationships to control information (Askew & Salinas, 2019; Spooner et al., 2015; Whitaker et al., 2011). However, they seemed more concerned about their social image than social rejection if their status was disclosed. Not only did participants try to conceal information, they actively constructed a pro-social image that directly contradicted the stereotype of drug users. This image was aligned with strong values in Vietnamese society, such as selflessness, hard work and harmonious living with others. Such effort put into curating one’s social image might relate to the importance of ‘saving face’ in collective societies (Fereidouni et al., 2015; Fotopoulou et al., 2015; Mak et al., 2015).

The various motives for social avoidance that we describe represent a novel finding. While previous studies mention social avoidance as a way to conceal information (McKenna, 2013) or avoid judgment (Gunn et al., 2018), our participants employed this tactic to prevent others from thinking negatively of them; thus, they affirmed their distinction from the stereotype.

The narration of a conventional past to emphasize participants’ true selves is comparable to the technique athletes use to explain how they came to use performance-enhancing drugs in competition (Yar, 2014). While athletes typically emphasize a problematic childhood, pure love of sports, honesty, and responsibility as their inherent qualities, our participants depicted their true selves to be consistent with Vietnamese values such as academic achievement, filial piety, ambition to work for the government and good family background. This backdrop serves to frame drug use behaviors as accidental rather than intentional. Thus, participants agreed with mainstream society that heroin use was bad, but distanced themselves from other heroin and methamphetamine users by arguing that the latter were inherently bad.

Participants’ consistent emphasis on adherence to gendered social expectations echoes the findings of previous studies (Couvrette et al., 2016; Gunn & Canada, 2015; Haritavorn, 2016; Hill & Stamey, 1990; McKenna, 2013). Women who use drugs worldwide embrace the ideals of motherhood and womanhood that dictate their devotion to children, modest sexuality and abhorrence of commercial sex (Couvrette et al., 2016; Gunn & Canada, 2015; Haritavorn, 2016; McKenna, 2013). Male drug users espouse manly ideals like fearlessness and ability to make money that represent a mix between traditional heroism and the goals of neoliberalism. The coexistence of blaming external factors and claiming the social ideal of responsibility demonstrates the struggle participants encountered in asserting their social position in the face of stigma (Fraser & Moore, 2008).

The fatalistic beliefs that our participants endorsed are novel, being much more common in studies of people living with HIV or cancer than of people who use drugs (Drew & Schoenberg, 2011; Hess & McKinney, 2007). Consistent with participants’ appeal to good character, drug addiction was framed as an accident that befell them. Hence, participants refused to see drug addiction, HIV infection or incarceration as the consequences of their behavior but as their misfortune.

Denial of injury by asserting one’s duty fulfillment was exemplified in a study of mothers who use methamphetamine (Couvrette et al., 2016). This study found that a deviant good mother model makes drug-using parents feel good about their parenting competency. Thus, beliefs about doing their best for their children might have helped our participants to feel confident in their parenting. This finding shows that parenthood is an important aspect in the lives of participants and goes against the stereotype of irresponsible drug users. Family has also been identified as a major factor in addiction treatment and in the general recovery process of patients (Filges et al., 2018; Li et al., 2013).

Distinctions between users of different drugs and related stigmatization are popular among drug users. Research has shown that cannabis users disapprove of the use of ‘harder’ drugs such as heroin or cocaine (Peretti-Watel, 2003), ‘hard’ users stigmatize ‘soft’ users (Gunn & Canada, 2015), and steroid users consider heroin users to be inferior (Simmonds & Coomber, 2009). Stigmatized people might feel the need to differentiate themselves from similar others to assert their position in the hierarchy (Copes et al., 2016). Pointing to ‘dangerous’ methamphetamine users, our Vietnamese heroin users reflected this phenomenon and claimed virtue for themselves.

The ‘condemnation of condemners’ was an active resistance to stigma as participants reframed, confronted and disrupted stigmatizing ideologies. Beside its function of diverting the transgression onto the stigmatizers, the use of the ‘condemnation of condemners’ technique reveals other issues in contemporary Vietnamese society, including stigmatization towards rural dwellers, migrants and poor people. These kinds of stigmatization could be considered more unjust than the stigmatization towards drug users. By reframing the negative treatment they received due to these unjust stigmatizations, participants’ anger became more righteous. This was the strategy of female sex workers in Sallmann’s (2010) study, who explained the stigmatization towards them as a gendered phenomenon and not as being caused by their sex work.

The stigmatization towards migrants in Vietnamese cities is historical. In the early 1990s, after the Đổi Mới (‘Renovation’ – economic reforms) of the mid-1980s, the government applied strict regulations to slow the rural-urban migration flow (Long et al., 2000). These regulations included denying household registration to migrants, thus preventing them to benefit from subsidized local public services and restricting their job opportunities to the lowest occupations (Long et al., 2000). This history describes the broader context in which the individual incidents of stigma that the participants described took place.

The evidence that participants put forth to justify their drug consumption goes against the stigma attached to people of low social status who indulge in drug use, in contrast to middle-class users who consume drugs to enhance their performance (McKenna, 2011). These testimonials echo findings among drug users in other contexts (Antunes Lima, 2017). This shows that Vietnamese people who inject drugs adhere to the same social expectations as nonusers and are more similar to nonusers than it is usually believed.

In investigating how participants resisted drug-related stigmatization, we did not find problem-focused coping strategies such as education or advocacy as has been the case in research into other marginalized groups (Basu & Dutta, 2008; Buseh & Stevens, 2006; Carricaburu & Pierret, 1995). Individuals tend to employ problem-focused coping if they perceive the situation to be changeable and emotion-focused coping if the situation has to be accepted (Carver et al., 1989; Folkman et al., 1986). Emotion-focused coping might reduce feelings of guilt and shame, but it might not improve the situation greatly (Dageid & Duckert, 2008). Material and social resources play an important role in how people feel about shaming and how they cope with it (Adler-Nissen, 2014). Hence, we infer that our participants might lack a support structure that can help them to protect themselves – against stigmatization.

Limitations

The homogeneous background of our participants constitutes a limitation. Most of the participants had little education and low income, and their drug user status was known to others in the community. Other groups of users who use new psychoactive drugs or whose status remains hidden might be different in their experiences of stigma and stigma management.

The methods we used for this study would have been stronger if we had been able to conduct more interviews to strengthen our findings instead of using previously conducted interviews, although the two samples had similar characteristics and came from the same population.

Conclusion

This study expanded the current understanding of the strategies that people who inject drugs employed to manage drug-related stigma. Participants mobilized different techniques to manage sensitive information, negative feelings, and to negotiate their social status while endorsing key values in Vietnamese society. Participants described themselves as conventional members of the society instead of transgressors of social norms. We contend that people who inject drugs have the same concerns and aspirations as nonusers, and advocate against the simplistic stereotype of the irresponsible drug user.