The interference of the care context with the visibility of the drug consumption by women

Abstracts

Considerando a crescente demanda por assistência à drogadição feminina e sua internacionalmente reconhecida especificidade, este estudo qualitativo, realizado em Salvador-Ba, no período de outubro/2003 a setembro/2004, com profissionais de saúde, propõe investigar se o contexto assistencial em que eles se encontram interfere na visibilidade do consumo feminino de drogas. Através da observação participante e da análise de conteúdo de entrevistas com dezenove profissionais, revelaram-se situações específicas quanto à visibilidade de mulheres usuárias de acordo com o local de atendimento ("instituição" versus "rua"). Diferenças na percepção da demanda, tipo de droga utilizado, idade, papéis sociais desempenhados e influência do parceiro para início e manutenção do consumo de drogas demonstraram que o contexto assistencial influencia na representação daqueles profissionais sobre as usuárias de drogas, o que pode interferir nas estratégias assistenciais implementadas. Recomenda-se a articulação entre os dois contextos assistenciais na unidade estudada e desta com outros serviços de saúde.

transtornos relacionados ao uso de substâncias; mulheres; assistência à saúde; identidade de gênero

Considerando la creciente demanda por la asistencia a la drogadicción femenina y su internacionalmente reconocida especificidad, este estudio cualitativo, realizado en Salvador-Ba, en el período de octubre/2003 a septiembre/2004, con profesionales de salud, se propone investigar si el contexto asistencial en el cual se encuentran influye en la visibilidad del consumo de drogas en mujeres. A través de la observación participante y del análisis de contenido fueron entrevistadas diecinueve profesionales, quienes expresaron situaciones específicas en relación a la visibilidad de mujeres consumidoras de acuerdo con el lugar de atención ("las instituciones" versus "la calle"). Diferencias en la percepción de demanda, tipo de droga utilizada, edad, roles sociales desempeñados e influencia del compañero para inicio y continuidad en el consumo de drogas muestran que, el contexto asistencial influye en la representación de aquellos profesionales sobre las consumidoras, lo que puede interferir en las estrategias asistenciales utilizadas. Se recomienda la articulación entre los dos contextos asistenciales en la unidad estudiada y de esta con los otros servicios de salud.

trastornos relacionados al uso de sustancias; mujeres; asistencia a la salud; identidad de género

ORIGINAL ARTICLE

The interference of the care context with the visibility of the drug consumption by women

Jeane Freitas de Oliveira^I; Mirian Santos Paiva^II; Camila Motta Leal Valente^III

^IDoctoral student at the Public Health Institute, Professor College of Nursing, email: [e-mail]

^IIPostgraduate, Professor

^IIINursing undergraduate student, email: [e-mail]. Federal University of Bahia

ABSTRACT

In light of the increasing demand for female drug addiction care and its internationally acknowledged specificity, this qualitative study was carried out in Salvador, BA, Brazil, from October 2003 to September 2004. It aimed to investigate whether the context of care in which participants are inserted interferes with the visibility of female drug addiction. Participant observation and content analysis of 19 interviews performed with health care practitioners revealed that some aspects of female drug addiction were perceived differently according to the context of care (institution versus outdoors): demand, kind of drug used, age, social roles and partner's influence in the initiation and maintenance of drug use. Since the context of care impacts the health care practitioners' representation of female drug users which in turn can affect the strategies devised for their care, we recommend that not only the contexts of care within the studied unit should be articulate, but these contexts with those from other health services as well.

Descriptors: substance related disorders; women; delivery of health care; gender identity

INTRODUCTION

The complexity and diversity of problems created by the drugs phenomenon, considered as production, trade and consumption, have generated distinct impacts in societies. In terms of health, the different problems deriving from drugs consumption (use and abuse) have demanded greater involvement and attention from professionals, with a view to the implantation and implementation of public policies and actions to solve and/or minimize them⁽¹⁾.

Around the world, the consumption of psychoactive substances PAS, is still greater among men, according to data presented in the 2005 World Drugs Report⁽²⁾. However, many countries have recorded a decreased proportion between men and women for drugs in general and the predominance of medication usage among women, more specifically benzodiazepines, stimulants and appetite stimulants⁽³⁾. The tendency towards "gender equality"⁽⁴⁾ in drugs consumption is justified by changes in the women's lifestyle, mainly in the last century^(5).

In Brazil, data from the 1^st Home Survey on Psychotropic Drugs Use, held in 2001, confirm this panorama. This survey was elaborated with a sample of 41.3% of the country's total population, 57% of which is female. Alcohol and tobacco were indicated as the country's most prominent public health problem, with higher usage percentages across the lifecycle among men. The use of hemp (6.9%), solvent (5.8%) and appetite stimulants (4.3%) was predominant among men, while the use of benzodiazepines and amphetamines was three times higher among women^(6).

Although information about female drugs users is scarce, recently published Brazilian and international studies highlight that women face structural, systemic, social, cultural and personal barriers in the search and continuation of treatment for PAS consumption⁽⁷⁾. Prejudices and discrimination, mainly by health professionals, are indicated as one of the main barriers⁽¹⁾. The little visibility of female drugs users in specialized services is a recent source of concern on the agenda of policy makers and funding bodies.

A study carried out in Salvador-BA confirms female users' tendency to exchange sex for drugs, to maintain sexual relations with male drugs users without a condom and to avoid seeking health care in institutionalized spaces⁽⁸⁾. Women using alcohol and other substances become more vulnerable to HIV infection, whether due to physiological reasons or sociocultural constructions directed at women and female drugs users^(8-10).

The acknowledgement that addicted women constitute a different subgroup from men, with their own specific characteristics and treatment needs, has gained increasing relevance. Situations specific of the female condition should be taken into account in care actions, such as pregnancy, responsibility in child care, traumas deriving from physical and sexual abuse in childhood and/or adolescence, higher levels of mental health problems in comparison with men and, also, sex work^(11). Particularities of manhood and womanhood, as well as the influence of gender relations on individual and group drugs use should also be considered^(12).

This article aims to examine if health professionals' care context interferes in the visibility of female drugs use. The presented data refer to care activities aimed at drugs users, developed by a health unit in the institutional and street contexts. Discussions are based on the conception that social representations SR are related with values, notions and individual practices that guide conducts in the daily reality of social relations and are manifested through stereotypes, feelings, attitudes, words, phrases and expressions⁽¹³⁾. SR guide us in the way we choose and jointly define the different aspects of daily reality, in the way we interpret these aspects, make decisions and assume a position towards them, sometimes defensively⁽¹⁴⁾.

METHODS

The data presented here are part of a larger research that analyzed how the gender perspective permeates health professionals' representations of drugs consumption. The project was approved by the Ethics Committee of the Collective Health Institute at Bahia Federal University. Ethical criteria established in Resolution No 196/96⁽¹⁵⁾ were respected in all research phases.

A qualitative and exploratory study was carried out between October/2003 and September/2004. The field research was developed at a public health unit that delivers care to drugs users and their relatives in Salvador (BA), through actions performed in the institutional and street contexts. Actions mainly rest on psychoanalysis and on the Damage Reduction policy⁽¹⁶⁾. Health professionals active at the unit served as the study subjects.

Data were collected through participant observation and semistructured interviews, which were considered adequate for the study design. During participant observation, we tried to approach the research subjects and register data about the client flow and demands, client characteristics, routines and types of care delivered by the unit. During the interviews, we emphasized questions related to the professionals' training and activities, characteristics of the care population, aspects related to the clients' drugs consumption and perceptions about care delivery to drugs users.

After two months of observation, the interviews were scheduled and held at the unit, at the nineteen interviewees' convenience, who were active in internal and external activities. The number of professionals was defined by the reoccurrence of information. On the average, each interview took 45 minutes, and interview contents were transcribed in full. Data analysis was based on thematic content analysis⁽¹⁷⁾. After having read the interview contents several times, data were organized in two thematic categories: female drugs users in the institutional context and female drugs users in the street context.

RESULTS

Nineteen professionals were interviewed, ten of whom worked in the institutional context, that is: three physicians (men), one social assistant (woman) and six psychologists (woman), between 36 and 50 years old, who had worked at the unit between two and 14 years. All of them affirmed they had other paid work in public and/or private services and possessed a graduate degree (specialization and master's) in themes related to psychoactive substances. They highlighted that little reference had been made to drugs issues during their undergraduate courses.

The other nine interviewees were damage reducers (four women and five men), between 23 and 51 years old, who lived in one of the communities where they were active. All of them declared that damage reduction work was their only paid activity and highlighted this work as a significant factor to improve their own self-esteem and citizenship. Their activity time at the unit ranged from 18 months to eight years.

Differences were identified in the interviewees' reports, related to demand perception, to the type of drugs used, age, social roles performed and the partner's influence to start and maintain drugs consumption, connected with distinct care contexts. During the analysis process, we did not identify perception differences related to the interviewees' gender.

Female drugs users in the institutional context

Activities in the institutional context showed greater demands by male drugs users, mainly with respect to illegal drugs, in comparison with women. Professionals active in institutionalized activities affirm that even without statistical data, I'd say that 90% of the population that comes to us is male. Women addicted to cocaine, women using hemp, we see very little of that here at the Center, although women appear with significant demands as companions and/or relatives. Data reflecting this reality were recorded during observations at the waiting room and in therapeutic groups for the care clientele.

In the waiting room, we noticed a large demand by women who sought care for family, friends and neighbors, and a reduced demand by women as drugs users. In this specific situation, the woman generally arrived very near the time of her appointment and, while in the waiting room, she remained silent and kept her head down. As companions and/or relatives, the women tended to be talkative and expansive.

In group activities, the number of male participants in comparison with women was remarkable. In the group for consumers of alcohol and other drugs, which consisted of about 20 participants, the presence of only one woman was registered in several sections, who mentioned alcohol abuse. In smoking and family member groups, female participants predominated.

According to the professionals responsible for the smoking group, this situation reveals the increased tobacco consumption by the female population. The professionals responsible for leading the family group, on the other hand, justify the significant number of women by the incorporation of the social and culturally constructed role of "caregivers". They also emphasize the female participants' difficulty to accept men's presence in the group, although they generally complain of men's lack of participation in education and care for their children. It is something historical and cultural says one of the interviewed professionals.

Moreover, the interviewed professionals highlight that the cultural role, this social function the woman has always assumed and, more recently, with the woman's insertion in the labor market, women deal with a very large overload, so they often have a double or triple work journey has favored drugs consumption by women. And, in the institutional context, the interviewees underline the abuse of drugs for medication purposes (antidepressants, tranquilizers and amphetamines), tobacco and alcohol by women and the reduced demand by illicit drugs users, mainly of crack and cocaine. They consider that women in a world like ours, in the way the world is functioning, are suffering much more. So they are taking benzodiazepines in a very abusive way, except that this has often been prescribed by the doctors. As health professionals, they highlight that medication is used as a way of mitigating anxiety and stress situations resulting from the burden of responsibility attributed to women, deriving from the different pre-established social and cultural roles and female beauty standards.

Professionals in the institutional context reveal that the attended population is mostly very young, between 15 and 30 to 40 years old. In this group, most female drugs users are between 24 and 40 years old, are married and/or have a fixed partner, belong to the middle class and are black. Education levels range from secondary to higher education.

As to the start of drugs use and the subject's relation with the drug, this group of health professionals affirms that although these women present damage caused by drugs use, I observe that they use less than men. And they are more concerned about family functioning than their partner, who most times is a drugs user. In general, women start to use illicit drugs through their partner, but it seems that the responsibilities and relations they maintain with the family and with society make them more resistant against the development of dependence.

Hence, they consider that the social and cultural responsibilities attributed to women in their different roles as mothers, housewives and wives at the same time predispose to drugs use and protect them against situations of dependence. They highlight that women's growing insertion in the labor market, many times assuming the condition of family heads, has increased the overload of activities and responsibilities they face in daily reality, often placing them in situations of vulnerability to different health problems, including drugs consumption.

Female drugs users in the street context

In the activities developed in the street context, it was emphasized that ninety percent of the women we attend, all of them are either drugs users or partners of drugs user, or both at the same time, with increasing involvement in marginality.

The interviewees highlight that the number of female drugs users, mainly of alcohol, has always been high, but what happened is that they used more hiddenly, today they want to equal men and go to bars. So, consumption among women is very high, not only of alcohol but also illicit drugs. They evidence the perception that, in some communities they worked in, there are more female than male drugs users. According to their observations, besides the increase in the number of female drugs users, women are using more drugs than men.

Moreover, they highlight that the women took drugs with their boyfriend, with their husband more discretely and in more hidden places while today, they are taking drugs anywhere, with anyone.

Crack stood out among the drugs women use in the street context. The interviewed damage reducers inform that in some of the communities where we deliver care, a very large group of women uses crack, very, really very large, some of them do not assume it, highlighting the perception that more women than men are consuming crack and that men, in turn, have preferred using cocaine because they consider that it is less damaging than crack. They appoint easy access to crack in the local drugs market, the purchase value and the large acceptance of sex in exchange for drugs, which is indicated as a very frequently used mode among female users, as factors that facilitate crack consumption by the female group.

In the street context, three distinct groups of female drugs users were identified: housewives, sex professionals and the so-called "periguetes". For each group, the interviewees appoint characteristics, mainly related to the type of drugs that is used and to the way of purchasing. They highlight the existence of distinct stigmas and prejudices for the identified group, based on social, cultural and gender constructions.

Housewives preferably use hemp and alcohol, which they consider light drugs. Their consumption tends to be hidden, that is, within the private sphere of their home, and their usage network is limited to their partner, who tends to supply the drugs they use, especially those that are socially considered as illegal. In view of these behaviors, and also because they are housewives, which involves care for their children and husband, this group of female drugs users are still respected by the community they live in.

With respect to sex professionals, the damage reducers indicate the fact that their drugs addiction is strongly related to their activity. They preferably tend to use hemp, crack and cocaine, substance which they purchase directly from the "smoke houses" or through an intermediary, with money they obtain through their work. Besides these substances, they mentioned alcohol abuse in this group of women. Considering their role as responsible for family maintenance, the damage reducers say that female sex professionals who use drugs are, in a way, respected in the communities under study.

The same is not true for the group of female drugs users called "periguetes". This group, according to the interviewees, characteristically consists of girls who are prostituting themselves simply because of the drug, it's not even because of the money anymore but because of the drug itself. They normally live in other communities and come to where they know the drug is more present, just to use drugs. And they subject themselves to anything for the drugs, especially to exchange sex for drugs, with one or various partners at the same time. Many of them are pretty, young. They consider the "periguetes" as a disease transmission vehicle and as a threat to the community, as they end up reducing sex professionals' clients and maintain sexual relations with male drugs users or not, who are partners of women in the community. In this conjuncture, the damage reducers highlight that the "periguetes" are not respected and are also harder to approach for prevention work, because they are more interested in the drug.

DISCUSSIONS

The differences shown in the care context in terms of demand perception, type of drug used, age, social roles performed and the partner's influence for women to start and maintain drugs addiction demonstrate the influence of the institutional and street contexts on the visibility of female drugs users.

The participant observation and interviews revealed that, although meetings are held between the two groups, these are merely administrative, without any discussions about the realities each of them experiences. Thus, it can be affirmed that the lack of integration between the activities and the health professionals is a factor that contributes to the invisibility of the study situation. The reality of each care context points towards the expansion of drugs consumption among women, highlighting social and cultural issues that mark inequalities.

Therefore, it is evidenced that social representations are elaborated on the basis of each subject's reality in his/her environment⁽¹⁴⁾. However, the SR are not a copy of reality, but a translation, a recovery. They are established to give meaning to what is strange and new, turning the conversion of the non familiar into familiar into their main function^(18).

The identification of specific groups of female drugs users in the street context (housewives, sex professionals and "periguetes"), distinct representations directed at each of them and the tendency to use crack reveal situations of vulnerability for drugs users and gaps that health services need to address. This evidences the need to incorporate the gender perspective into health actions as a possibility to acknowledge the sociocultural impact in constructions of manhood/womanhood and the revelation of heterogeneities among drugs users, moving towards a more equalized care⁽¹¹⁾.

Literature emphasizes the identification of drugs users' specificities⁽¹⁰⁾. It is recommended that treatment and care of drugs users should consider individual and group particularities^(7-11). Field work is highlighted as a powerful way of identifying peculiarities and giving visibility to users and/or groups of users who are still hidden.

FINAL CONSIDERATIONS

The presented data alert to an important social and public health problem which health professionals and services have to deal with drugs consumption by women. At the same time, they highlight the importance of multiple actions to face the drugs phenomenon and underline the need to carry out integral activities, mainly in distinct care contexts within the same service.

Considered as a socially constructed and shared knowledge, the interviewees' social representations revealed to be linked with their realities and reflect sociocultural constructions that mark inequalities, including gender relations. These constructions seem to interfere in the elaboration and implantation of health care strategies aimed at drugs users and also constitute a barrier for female drugs users' search for and involvement in specialized services. Hence, they influence the visibility of female drugs consumption. In view of these data, we recommend new studies, in order to examine other aspects related to the visibility of drugs consumption by women.

ACKNOWLEDGEMENTS

To the entire team of the Interinstitutional Training Program in Gender, Sexuality and Reproductive Health Research Methodology and of the GEM/EEUFBA for their cooperation in the elaboration and development of this project; to Prof. Antonio Nery Filho, PhD, and his entire team for the support and availability that permitted the realization of this study. To the Ford Foundation for the funding received. To my master and friend, Henrique Santos, for his teachings and guidelines in the elaboration of this article.

Recebido em: 2.1.2006

Aprovado em: 25.9.2006

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Publication Dates

• Publication in this collection
  29 May 2007
• Date of issue
  Apr 2007

History

• Received
  02 Jan 2006
• Accepted
  25 Sept 2006