Gender aspects of health and social risk of female partners of Injecting Drug Users

Gender aspects of health and
social risk of female partners of
Injection Drug Users

Belgrade, 2012

Main goals of the study
• To provide an empirical basis for formulating gender
sensitive recommendations that should be included
in the Action Plan for the National Strategy on HIV in
Serbia.
• To develop recommendations for gender sensitive
services for governmental and non-governmental
actors for people infected by and at risk of HIV.
• To get insight into gender aspects of HIV risk among
female partners of IDUs within the broader context
of their living conditions and exposure to social and
health risks.

Specific goals of the study
• To identify specific patterns of social and health risk
that female partners of IDUs are exposed to.
• To deepen the understanding of various aspects of
partner relationships and the impact IDUs have on
risky behavior - sexual work, initiation into drug
injecting practices, use of sterile equipment etc.,
• To identify and assess accessibility and the role of
governmental and non-governmental services
available for women who are at risk of HIV.

Implementing organization - SeConS in
brief
• Independent think-tank, founded in 2005 in
Belgrade by a group of sociologists and social
researchers.
• SeConS’ mission is to contribute to integrated
and sustainable development of Serbia and the
Region.
• Organization’s good practices have spread in
neighboring countries, Montenegro and BiH.
• Areas of SeConS’ support are: social inclusion of
vulnerable groups, such as women, Roma,
refugees and IDPs, people experiencing poverty;
regional and local sustainable development;
institutional and organizational reform and
development of the public sector; HR
development; evaluation of development
programs and projects and assessment of public
policies at the national, regional and local levels.

SeConS in brief (cont.)
Expertise of SeConS:
• Designing methodologies and conducting empirical research from
different fields in Serbia and the region
• Drafting comparative studies, analyzing policies, legislation and
providing recommendations for further improvement in Serbia and
the region
• Designing and conducting training and education programs for
individuals, institutions and organizations, to support their work in
social inclusion
• Empowering marginalized groups and individuals through trainings,
to improve information sharing and help them to become more
proactively involved in decision-making processes
• Advocating for social development, through representation of
interests of vulnerable groups and networking with relevant
stakeholders.

Method of data collection:
Qualitative research method - in-depth semi-structured interviews with focus
on:
• Personal characteristics and features of the respondents family context
during childhood and in the present - history of gender relations and risk
behaviors,
• initiation into into the world of drug use,
• characteristics of current and former relationships with partners who are
IDUs,
• personal history of vulnerabilities - patterns of health and social risks,
• experience with health and social service providers,
• coping strategies and/or exit strategies,
• and, subjective perceptions of risk and the need for social protection.

Quantitative research method: short survey focusing on the socio-
demographic profile of respondents

Sensitive topics research - challenges
The research could have negative effects on
respondents:
(1) questions can intrude into the most intimate sphere
of their lives and problems, issues that can provoke
pain, stress or shame and therefore can cause
secondary victimization of respondents;
(2) questions can be related to activities that are illegal;
(3) respondents can be afraid that revealing
information can put them in danger, lead to
punishment or revenge of other persons in their
surrounding that might be in power positions.

Sample

• 99 in-depth interviews in Belgrade and
Nis
• Snowball sampling in two Drop-In
centers where IDUs can obtain sterile
equipment
• Respondents selected according to
following criteria’s:
a) women that are in a relationship with an
IDU (regardless of whether they are IDU
themselves or not),
b) or, women that are themselves IDUs who
have previously been in a relationships
with IDUs.

Analysis and fieldwork
• Duration of fieldwork: 22nd of November - 9th of
December.
• 23 interviews completed in Nis and 76 interviews in
Belgrade – all interviews were audio-taped and
transcribed ‘word to word’
• Qualitative content analysis conducted
• Quantitative data processed in SPSS and
subsequently analyzed

SOCIO-DEMOGRAPHIC
CHARACTERISTICS

Socio-demographic characteristics
Respondents’ socio-economic position is extremely
unfavorable and they belong to the most vulnerable social
groups.
• Education levels are low – 37% without qualifications
• Household conditions are unfavorable – 28.1% of
households do not meet minimum standards in housing,
5% are homeless or live in e.g. containers, barrack etc.
• Material deprivation is high – 60% struggle to make ends
meet, 30% can barely cover basic costs.
• A vast majority unemployed - only 15.5% are employed

Genesis of risk – social and family context
Research shows a few key factors (push factors) that impact
later drug use and life of risk among respondents:
• lack of parental care and supervision;
• experience with/exposure to different forms of violence
(psychological, physical, and sexual);
• substance abuse problems within the family;
• life on the streets and exposure to sexual work,
delinquency, and peer pressure;
• curiosity or submissiveness in relation to the impact of
people from family and peer networks;
• and, lack of awareness about the risks and consequences
of drug use.

• Identified risk factors during childhood and adolescent
years are interlinked and contextually bound – they
continually reinforce one another.
• All risk factors are saturated with powerful gender
specific roles:
– Respondents are often subordinate in relation to a male figure
from early childhood.
– Internalization of gender roles (in which women are in a
submissive position, with less or no power) influences the
reproduction of gender inequality in the future life of the
respondents - it leads to greater exposure of women to the risk
of initiation into drug use, relationships with partners who are
IDU, and social and health risks.

Partner relationships and life with drugs
Several key gender patterns (gender inequalities) put women in
relationships with IDUs in a specifically risky position:
1. Partners play an important role in initiating drug use of their
partners: IDUs often conceal their addiction at the start of
the relationship and they are often actively trying to force
their partners to start using drugs (directly through mental
and physical coercion, pressure, and persuasion), as well as
by different forms of allurement.
2. Household priorities are dependent and centered around
the need for drugs - all other needs in the household are
subordinated to the priority of procuring drugs and means
for drugs. When the partner is not IDU herself, her and her
children's needs are subordinated to that of the partner and
they often live in constant deprivation of basic needs.


3. Strategies for providing funds for drug use:

– Women often internalize and accept the responsibility of providing for the
livelihood of the household – they are most often the main household providers.

– Sexual work is a very common strategy whereby respondents use their 'women's
resources‘ as means to obtain drugs. This is not simply the choice of respondents,
rather, in many cases this is a direct result of coercion and pressure from their
partners. Furthermore, women often practice sexual work in order to protect their
partners from risks related to other criminal acts, which can result in stronger
sentences than sexual work. This type of responsibility whereby women are
sacrificing their own resources and putting themselves in a vulnerable positions in
order to protect their partners, has deep roots in patriarchal patterns of gender
roles that are largely present in the social environment of women.

– Women who are not users themselves are also often the main providers of
financial means for their partners drug use: borrowing money from friends and
relatives, using their welfare checks, and stealing. This is often due to fear of
possible outbreaks and aggressiveness of their partners.


4. Gender inequalities of household life
that expose women to numerous health
and social risks:
– respondents are almost exclusively
responsible for care of the household and
children
– women are systematically exposed to
domestic violence and violence against
women - physical, sexual, economic and
psychological violence are dominating
partner relationship


– male domination in the drug market puts women who are
IDUs themselves in a position where they are dependent
on their partners for the procurement of drugs
– practices of injection drug use produces a range of
additional risks:
• women who are not IDUs help with preparation of equipment and
injection itself due to fear of ‘crisis’
• when both partners are users, these risks are closely related to
practices of sharing equipment whereby partner authority should
not be questioned


5. Exit strategies from a life with drugs and a life with
IDUs are very difficult to follow through. There are
two main strategies, both mostly unsuccessful:
– Treatment of addiction: failure of treatment
– Ending the relationship: physical and psychological
violence and socio-economic dependency

Inability to exit an abusive relationships or a relationship
where the woman is continuously exposed to health and
social risks, leads to the acceptance of and adaptation to
adverse circumstances.

PATTERNS OF HEALTH RISK AND
ACCESS TO HEATH SERVICES

Patterns of health risk
1. Infectious and sexually transmittable disease
(especially, HIV, HCV and HBV).
Prevalence of HIV among respondents and their partners
Respondents Partners of respondents
total % total %
HIV postive 5 5,1 4 4,1
HIV negative 79 79,8 71 71,7
Unknown 13 13,1 13 13,1
Missing 2 2,0 11 11,1
Total 99 100 99 100

Prevalence of HCV among respondents and their partners
Respondents Partners of respondents
total % total %
HCV positive 40 40,4 40 40,4
HCV negative 36 36,3 36 36,3
Unknown 17 17,2 17 17,2
Missing 6 6,1 6 6,1
Total 99 100 99 100

Main cause of infection:
– unprotected sexual relations,
– sharing of drug injecting equipment (in cases where
respondents are IDU),
– and injury related to drug injection practices (in cases when
women are not IDU).
Mechanisms that increase exposure include:
– limited knowledge of infectious and sexually transmitted
diseases,
– exposure to violence,
– accidental injuries,
– and lastly, conscious exposure to disease as a ‘pathological’
desire to share experiences and problems of partners.

2. Reproductive health is often at risk as a result of:
– high-risk pregnancies,
– unwanted pregnancies,
– and frequent abortions and miscarriages.
These problems are closely associated with:
– addiction problems,
– lack of information of risks and disregard of risk,
– trust in partners,
– no use of protection - because they find it less satisfactory, and
because the partner rejects use of such forms of prevention.
3. Physical injuries as a result of violence (in their relationships
or by other male figures in the family or environment) and
injuries related to long-term injection drug use.
4. Psychological problems associated with addiction problems
and/or adverse living conditions.

Health care services
Access to health services is limited due to:
– lack of proper documentation (id cards, health insurance),
– lack of trust in health services providers and medical personnel
(unpleasant and antagonistic communication with health
personnel),
– discrimination and refusal of health care professionals during
provision of services (inadequate provision of health services is
rooted in the dismissal and stigma related to the lifestyles of the
respondents and prejudices of possible attaining an infectious
disease) manifested through a lack of attention, superficial and
inaccurate diagnosis, and inadequate therapy,
– lack of psycho-social support,
– and finally, fear that the police and/or the Center for Social
Work might be contacted.

PATTERNS OF SOCIAL RISKS AND
SOCIAL SERVICES

Patterns of social risks
Main social risks female partners of IDUs are exposed to:
1. poverty and material deprivation,
2. exclusion from the labor market and therefore high
prevalence of engagement in informal sectors of the
labor market,
3. delinquency and problems with the law enforcement,
4. family dysfunction and instability,
5. exposure to domestic violence and violence in the
environment,
6. and social discrimination, social exclusion and isolation.

Social service
Access to social services limited due to:
• Lack of information about different types of support
and procedures necessary to be able to access these
forms of social protection,
• discrimination and stigmatization when trying to
access such services,
• avoidance of contact with governmental institutions
due to the fear of loosing custody over children,
• and, experiences of violence or threat of violence,
especially in regard to law enforcement personnel.

Prevention of health and social risk
1. Enable and adapt various forms of protection against
domestic abuse and neglect:
– Identify dysfunctional families and different types of problems
in family relations
– Support to parents who experience communication or other
forms of problems with their children
– Provide adequate protection from and systematic monitoring of
children in families with substance abuse problems
– Systematic support against domestic violence
2. Encourage integration of girls from vulnerable
groups/socially excluded groups (Roma, poor, homeless
girls, and so on) to be educated and involved in extra-
curricular activities.

Prevention of health and social risk
3. Strengthen channels of information on health and
social risks that are a result in risky behavior:
– Inform boys and girls about risks and preventive measures
related to infectious and sexually transmitted diseases and the
reproductive health of women.
– Inform young people about different forms of violence and
support systems for victims of gender-based violence.
– Empower girls through normative education on gender
equality in school.
– Educate teachers in this field and how they can recognize risky
behavior and family problems.
– Educate health care providers to recognize violence against
children, as well as other forms of risky behavior.
– Educate parents about the effects their risk-behavior has on
children and how identify risky behavior in children.

Support measures
1. Sensitize the social care system on the specific
needs of women who are at risk.
– Improve availability of information on the right to financial
social support, child support, one-time municipal aid, Red
Cross assistance, soup kitchens etc.
– Ensure rights to material assistance for women and
children victims of violence throughout Serbia
– Provide material assistance to IDUs that have finished
treatment against addiction
– Educate social care professionals on the specific needs of
women with IDU partners, women who are IDUs, sex
workers etc.

Support measures
2. Improve measures for women victims of violence
(especially for female partners of IDUs and women that
have more children).
– Inform about support systems in the event of violence in an
accessible way through 'close‘ institutions (especially non-
governmental org.)
– Provide shelters for women who are victims of violence and IDU
– Improve support systems in cases of psychological, sexual and
economic violence
– Sensitize employees in the judiciary and police against
discrimination of female IDUs and sex workers.
3. Improve provision of legal aid to female partners of
IDUs and female IDUs:
– Provide free legal aid throughout Serbia
– Provide free representation in court when it comes to lawsuits

Support measures
4. Improve health provision to women who are exposed to many health problems
because they are IDUs, female partners of IDUs and sex workers:

– Educate health personnel at health centers (and other health care facilities) about
working with IDUs and other vulnerable groups in order to reduce discrimination and
improve health services for people with and at risk of HIV.
– Systematize trainings of health workers on infectious diseases (HIV, HCV, HBV),
substance abuse problems, and pregnant women in this vulnerable group.
– Inform vulnerable groups on infectious and sexually transmittable diseases,
– Increase availability of psychological help,
– Develop gender sensitive programs for treatment of addiction,
– Increase access to and information about free testing for HIV , HCV, and HBV,
– Provide free sterile injection equipment ,
– Complement sterile equipment services with psychological support, work with the
NSP, work with children from IDU partnerships, etc,
– Link sexual and reproductive health with measures related to HIV / AIDS strategies and
programs,
– Provide free contraception and information about various types of protection,
– Improve the accessibility of health insurance to women who do not have id
documents or support for attainment of personal documents.

THANK YOU FOR YOUR ATTENTION

For more information:
www.secons.net
seconsoff@hotmail.com
office@secons.net

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