People who use drugs (PWUD) across diverse global contexts are facing an unprecedented overdose crisis, with rates of overdose-related morbidity and mortality continuing to increase in many settings. Although opioid-related overdoses represent an urgent public health and social emergency that affect men, women, and gender-diverse individuals, our current understanding of gendered experiences and needs in the context of the overdose crisis remains limited.1 To inform robust responses to the overdose crisis, research, policy, and interventions must carefully consider gender-based experiences, including the unique harm reduction and addiction service needs of women who use drugs.2,3 For example, harm reduction services tend to be male-oriented spaces, and women often report highly gendered barriers to accessing harm reduction, including the unique and overlapping stigmas faced by women who use drugs, concerns regarding safety, and the threat of violence in and beyond service delivery settings.4

Sex workers are overrepresented among PWUD2,3,5 and face disproportionate health and social inequities, including a high burden of HIV and sexually transmitted infections,2,3 as well as workplace violence, criminalization, and stigma.3,6 The current study by El-Bassel and colleagues7 provides a novel contribution by examining the association of various forms of violence—including intimate partner violence and other forms of gender-based violence—with nonfatal overdose among female sex workers who use drugs in Kazakhstan. Given that little is known regarding the overdose experiences of women who use drugs, sex workers in low-income and middle-income countries, or the associations of these with gender-based violence, this work has important implications for the design of harm reduction and other health and social services for women who use drugs and sex workers.

Using baseline data from a cluster randomized clinical trial of a combination HIV risk reduction and microfinance intervention with 400 sex workers who use drugs, this cross-sectional study7 reported a high burden of overdose among this population, with 37.5% of women reporting lifetime overdose and 18% of them reporting an overdose in the past 3 months, with most overdoses linked to heroin or nonmedical use of prescription opioids. Both incarceration and multiple forms of violence experienced by women sex workers were associated with an increased burden of nonfatal overdose.

The data highlight the severe structural violence faced by women sex workers who use drugs—89.7% reported lifetime exposure to violence, 51.5% experienced recent intimate partner violence, and 40% experienced gender-based violence by other perpetrators (eg, clients, police, and drug dealers or suppliers).7 One-third reported lifetime incarceration, which was the factor most strongly associated with nonfatal overdose, conferring a substantial 4.34-fold increased risk of nonfatal overdose after adjustment for other factors. Although scale-up of evidence-based addiction and harm reduction services are well documented as being essential for reducing overdose-related morbidity and mortality, this evidence also suggests that structural interventions that address the severe burden of violence and criminalization faced by women who use drugs, including sex workers, remains a crucial and often missing element of public health responses. For example, multilevel interventions that include harm reduction and addiction services, sex worker–specific support, and structural policy reforms, such as the decriminalization of possession of illicit drugs as well as sex work, are recommended. Criminalization of drug use and sex work create dual, intersecting vulnerabilities for sex workers who use drugs; this provides police with broad leverage to arrest, surveil, and violate their rights, considering that sex workers and PWUD are often perceived as undeserving of protection and rights under such legal regimes. In the absence of structural changes, we are likely to see the harms associated with the current overdose crisis persist or worsen.8

El-Bassel and colleagues7 accurately note that addiction services have rarely incorporated a gendered perspective on intersecting issues of violence, drug use, and sex work. Indeed, there remains a critical need for gender-based approaches to public health interventions for women who use drugs and sex workers, including through trauma-informed harm reduction, addiction services, and other health and social services. As others have argued,8 enabling legal environments are necessary to support marginalized and criminalized communities’ engagement with services. States’ continued reliance on criminal law and repressive policies across both the war on drugs and within sex work policy has been consistently linked to human rights violations and poorer health outcomes (eg, HIV or hepatitis C virus infection). Decriminalization of sex work and of the personal use and possession of drugs are recommendations aligned with the positions of key global policy bodies, including various United Nations agencies (eg, the United Nations Special Rapporteur on the right to health, Office of the United Nations High Commissioner for Human Rights, and the Joint United Nations Programme on HIV/AIDS) and Amnesty International. Alongside efforts to shift toward decriminalized models of sex work and drug policy, interventions to reduce police harassment and violence should be considered through meaningful leadership and engagement with affected communities of women and other PWUD.

Although multilevel, gender-sensitive overdose response interventions for women who use drugs remains a crucial priority globally, this is particularly urgent in low-income and middle-income settings, where coverage of such interventions has been especially low. In the study by El-Bassel et al,7 only 10.3% of women who use drugs had ever heard of naloxone, and of those who experienced a recent nonfatal overdose, only 7.4% reported receiving naloxone, in addition to 22.2% for whom an ambulance was called. Previous research has suggested that women may be more likely than men to witness and respond to overdoses. El-Bassel et al7 found that participants reported witnessing an mean of 2.8 nonfatal and 2.9 fatal overdoses only in the last 3 months, which reminds us of the important role that women who use drugs can play in intervening in overdoses when given appropriate resources to do so (eg, naloxone access and training). Although grim, these data are unfortunately not unique to Kazakhstan; highly criminalized and marginalized communities around the world continue to report high levels of unmet need for evidence-based harm reduction, overdose prevention, and overdose response services as the result of criminalization and stigma.8

The current overdose crisis and coronavirus disease 2023 (COVID-19) pandemic indicate that changes remain needed now more than ever. Far from being the great equalizer, the COVID-19 pandemic has worsened inequities faced by marginalized communities, including those related to gender-based violence and overdose. Public health attention and resources have shifted away from other areas, including harm reduction, sex work outreach, and violence services. Border closures affecting drug supply chains and the potential for increased isolation while using drugs have been implicated as key factors shaping the escalating overdose crisis in recent months. Reports have also highlighted how the risk of gender-based violence may be elevated by increased social and physical isolation, socioeconomic stressors, and reduced access to frontline support services. Sex workers have been particularly affected by the pandemic, facing near-complete loss of income, ineligibility for public benefits, loss of access to outreach services, and punitive and stigmatizing treatment by governments—including increased police crackdowns, harassment, and the demolition of homes and sex work venues during the pandemic.

Policy and programmatic shifts to support the health, agency, and human rights of women who use drugs—including sex workers—are urgently needed. Current evidence suggests that interventions to address intersecting realities of violence, criminalization, and overdose among women who use drugs should optimally include a multipronged approach, including shifts away from criminalization toward policies that uphold health and human rights, in tandem with trauma-informed, gender-sensitive, and integrated harm reduction and addiction services.

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Published: October 12, 2023. doi:10.1001/jamanetworkopen.2023.21066

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Goldenberg SM. JAMA Network Open.

Corresponding Author: Shira M. Goldenberg, PhD, Faculty of Health Sciences, Simon Fraser University, 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada (dr.goldenberg@cgshe.ubc.ca).

Conflict of Interest Disclosures: Dr Goldenberg reported receiving grants from the National Institutes of Health and the Canadian Institutes of Health.

Additional Contributions: I wish to express my deep gratitude to all of the women, staff, and community partners who have contributed their valuable expertise, time, and effort to the research program over the years. Megan Bobetsis, BA, Arveen Kaur, BA (Hons), and Peter Vann, BA (Hons), provided research and administrative support; they are staff members at the Centre for Gender and Sexual Health Equity and were not compensated for this work beyond their regular salaries.

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