Stigma is a major barrier to women with substance use disorder (SUD) receiving reproductive healthcare and contraceptives.
“Women may not feel like they can talk to their substance use providers about their healthcare needs, or they don’t feel they can tell providers about their substance use,” says Lauren MacAfee, MD, MSc, FACOG, assistant professor at the University of Vermont Medical Center. “They also believe their babies will be taken away from them. That’s a huge fear for them if they already have children or are pregnant and planning to parent,” she says.
The stigma is felt bi-directionally. “They feel stigmatized by substance use disorder providers when they want to talk about reproductive health, and they feel stigmatized by health providers when they talk about substance use disorder,” MacAfee says. “To some extent, yes, this stigma happens; we see a lot of stigma for women who report a substance use disorder during pregnancy, even when they’re in treatment.”
There is a natural inclination for clinicians to be concerned about a woman using substances that could harm her baby. “It brings us against everything we know about motherhood, so there is a lot of stigma and shame,” MacAfee says.
This viewpoint was reinforced in the 1980s when governments arrested women who used cocaine, and the stigmatized image of the “crack baby” was reinforced in the media. Words were used to reinforce stereotypes and increase stigma during the 1980s war on drugs. Now, this viewpoint has shifted, and there is a better understanding that addiction is not a moral issue, but a healthcare issue, MacAfee says.
“We’ve shifted. We thought it was a moral failing for someone to use drugs, and if they made bad decisions it was because they were bad people, and we needed to approach that from a police services perspective,” she explains. “Now, we recognize that substance use is a mental health and public health issue. It shouldn’t be criminalized, and it needs to wrap around medical and mental health services.”
Stigma also could play a role in contraceptive counseling and recommendations. Family planning providers should be aware of any bias that might result in their recommending long-acting, reversible contraceptives (LARC) more often to women with SUDs or suspected of having SUDs.
“I think if LARC is targeted at a particular population, like women who are low income, have a large number of children, or who are actively still using drugs, that’s just unethical,” says Sarah H. Heil, PhD, professor of psychiatry and psychological science at the University of Vermont. “If we believe LARC is effective and a good option, we should talk about it with everybody. There’s a lot of emphasis now about talking with patients and doing shared decision-making.”
Clinicians should ask women, including those with SUD, about their goals, values, and what they find most important in contraception, Heil says. “Then, offer recommendations that would fit with what they talked about.”
If clinicians want to use the right words, they could follow suggestions by the National Institute on Drug Abuse (NIDA). NIDA published a guide, titled “Words Matter: Terms to Use and Avoid When Talking About Addiction.” (The guide is available at: https://www.drugabuse.gov/sites/default/files/nidamed_words_matter.pdf.)
For example, NIDA says that stigma about people with SUD could include inaccurate thoughts that they are dangerous, cannot manage treatment, or are at fault for their condition. NIDA also lists words to avoid, such as the word “addict,” which can be replaced with “person with substance use disorder.” Other words to avoid are “junkie,” “substance- or drug-abuser,” “alcoholic,” “drunk,” “former or reformed addict,” and “habit.”
Research shows that stigma is reduced when people believe a person did not cause their problem. For example, if the language used to describe someone’s substance use included the words “junkie” or “abuser,” clinicians might react more negatively to the patient than if the words used were “substance use disorder.” One study revealed that health professionals held greater negative associations with the term “substance abuser” than they did with the term “substance use disorder.”1,2
“The responses are very different, depending on the words used,” MacAfee says.
Robert A. Hatcher, MD, MPH, chairman of the Contraceptive Technology Update editorial board, shares his personal experience.
“Thirty-four years ago, I went to my first Alcoholics Anonymous meeting. I never had another drink. The success of the Alcoholics Anonymous message immediately struck home, but the word ‘alcoholic’ and the name of the organization were quite difficult for me to deal with. ‘Alcoholic’ is a word which definitely carries a stigma. Almost immediately, I felt great about Alcoholics Anonymous because I wasn’t drinking. It was, for me, very straightforward. However, I can remember a woman at a meeting in the first few months who said, ‘I am a grateful recovering alcoholic.’ I listened to her say that repeatedly, and I said to myself ‘How could she use the words ‘alcoholic’ and ‘grateful’ in the same sentence? I hated the word ‘alcoholic’ for a long time. But I no longer think that, and there are a lot of people who have difficulty around it. The take-home message: Don’t be afraid to refer peopole having problems with alcohol to AA. It costs no money, and it works for some people. When it works, it provides so much more support around issues other than alcohol.”
- Zwick J, Appleseth H, Arndt S. Stigma: How it affects the substance use disorder patient. Subst Abuse Treat Prev Policy 2020;15:50.
- Ashford RD, Brown AM, McDaniel J, et al. Biased labels: An experimental study of language and stigma among individuals in recovery and health professionals. Subst Use Misuse 2019;43:1376-1384.