Addressing gender, diversity, and precarity: participatory research to transform addiction services in Canada

Background

Addiction services are generally not well adapted to the needs of women, people with diverse sexual and gender identities and people in situations of social precarity, in particular those with a long-term trajectory of substance use disorder (SUD). This lack of adaptation can prevent people from seeking help or lead to discontinuation of service use, contributing to and even accentuating health inequities and stigmatization. These factors are compounded when interventions fail to build upon the strengths and capacities of people who use psychoactive substances (PS). This study aims to improve addiction-related interventions by expanding research and applying knowledge to guide the development of integrated services that take sex, gender, and socio-economic circumstances into account.

Methods

Semi-structured interviews on PS use and recovery trajectories were conducted in Quebec (Canada) with 75 participants who report problematic PS use and two or more associated difficulties (e.g. legal, housing, mental health problems). Among participants, 39 (52.0%) self-identified as a man, 25 (33.3%) as a woman and 11 (14.7%) as having another gender identity. For sexual orientation, 30 (40%) self-identified as heterosexual and 45 (60%) as non-heterosexual. Transcriptions were analyzed thematically, guided by an intersectional approach and a gender-based health promotion framework (Pederson et al.) to improve services. A participatory, consensus development process fostered the active involvement of people with lived experience and other stakeholders in co-producing the research and identifying key findings and recommendations.

Results

Barriers to treatment and recovery were related to experiences of violence and trauma, feeling unsafe in the context of care, and the perception that addiction service providers are insufficiently informed and trained with respect to issues faced by women and people with diverse gender and sexual identities. Stigma and economic precarity exacerbate these barriers. Lack of safety in locations where services are offered (shelters, residential addiction treatment settings) was reported. Obstacles to care were compounded for women, people experiencing homelessness, and people with diverse gender identities. While PS users living with SUD face multiple vulnerabilities and forms of stigma, they have a capacity to take action, individually and collectively, and can identify many strengths and sources of recovery capital that come into play along their trajectories.

Conclusion

Adapting services to promote gender equality, empowerment, and the social inclusion of marginalized groups has the potential to significantly improve recovery pathways. Barriers to access can be addressed by strengthening the participation of women, people with diverse sexual and gender identities and people in situations of socio-economic precarity in decision-making with regard to harm reduction and treatment services that better address their needs.