Developing a Women’s Health track within addiction medicine fellowship: reflections and inspirations

Assessing the needs of women who use drugs requires a comprehensive understanding of gender and intersectionality. Gender refers to socially constructed roles that vary based on time and place, and gender identity reflects one’s internal sense of being a woman, man, or anywhere along the gender spectrum, including transgender, non-binary, and genderqueer identities. In this article and in the fellowship track, we define ‘women’ as all individuals who identify as a woman, regardless of their sex (classification as male or female based on biological attributes). Intersectional perspectives recognize that women’s experiences with drug use are not homogeneous. Rather, other intersecting identities, such as gender identity, sexual orientation, race/ethnicity, and socioeconomic class shape individual experiences of oppression or empowerment [5]. In particular, structural racism, homophobia, and transphobia enhance discrimination and treatment barriers for Black, Indigenous, and other racialized individuals and for transgender and genderqueer individuals compared to White cis-gender women who use drugs.

Women who use drugs interact with individuals, communities, and social systems that reproduce structural sexism. Structural sexism is defined as “discriminatory beliefs or practices on the basis of sex and gender that are entrenched in societal frameworks and which result in fairly predictable disparities in social outcomes related to power, resources, and opportunities” [7]. For example, gender-based power dynamics in drug-using communities may restrict women’s autonomy to determine when, how, and why they use drugs. Such power imbalances are associated with greater adverse consequences in women compared to men including higher rates of injection drug use-associated infections, co-occurring mood and anxiety disorders, and experiences of intimate partner violence and sexual exploitation [8, 9].

Structural sexism is also apparent in the systems that affect pregnant and parenting people who use drugs. Pregnant individuals who use drugs face punitive consequences from legal and child welfare systems, hostility from the general public, and an addiction treatment system that is poorly suited to meet their needs. The child welfare system has traditionally viewed prenatal and parental substance use as synonymous with abuse or neglect, causing heightened shame, stigma, and fear of seeking treatment. Black and Indigenous women are disproportionately harmed by trauma related to child welfare service reporting and custody loss.

The reality of structural sexism means that some women’s addiction care needs differ from those of men. Care, as discussed here, refers to a wide breadth of harm reduction services, addiction and mental health treatment, and medical care for people who use drugs. For example, communication about drug use experiences should account for inequitable relationships that may reinforce women’s drug use and/or present barriers to recovery. Sexual and reproductive health needs often intersect with women’s drug use and therefore should be addressed within addiction care settings. Additionally, addiction providers must work to mitigate systemic racism that minoritized women face in medical settings by using trauma-informed and racially sensitive approaches to care.

Gender-responsive care attends to how being a woman affects women’s experiences with substance use through its setting, staff, and services [10]. Addiction care tailored to women has demonstrated benefits, including increased treatment completion and treatment satisfaction, decreased use of substances, and reduced mental health symptoms. Despite this evidence, availability and access remain limited in the United States.

Prior to developing the Women’s Health track, our fellowship curriculum featured training experiences in perinatal care for women with SUD, but generally lacked training in structural sexism and its effects on women’s drug use and care needs. Additionally, service gaps remained within our institution and local treatment environment, particularly for Black and Hispanic women, gender minority groups, and non-pregnant or postpartum women. Thus, we aimed to create a fellowship track that would integrate and expand upon existing services and train physician leaders who could transform addiction care to work better for women.

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