Belgrade, 2012

Gender aspects of health and social risk of female partners

of Injection Drug Users

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.

METHODOLOGY

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

RESEARCH FINDINGS

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

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.

Genesis of risk – social and family context

Genesis of risk – social and family context

• 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

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.

Partner relationships and life with drugs

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.

Partner relationships and life with drugs

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

Partner relationships and life with drugs

– 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

Partner relationships and life with drugs

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

Prevalence of HCV among respondents and their partners

Respondents Partners of respondentstotal % total %

HIV postive 5 5,1 4 4,1HIV negative 79 79,8 71 71,7Unknown 13 13,1 13 13,1Missing 2 2,0 11 11,1Total 99 100 99 100

Respondents Partners of respondentstotal % total %

HCV positive 40 40,4 40 40,4HCV negative 36 36,3 36 36,3Unknown 17 17,2 17 17,2Missing 6 6,1 6 6,1Total 99 100 99 100

Patterns of health risk

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.

Patterns of health risk

Patterns of health risk

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 services

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.

RECOMMENDATIONS

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

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