Drug use among women is profoundly influenced by structural variables, most notably experiences of gendered violence. Among women, assault is associated with an increased
87Laura A. Siminoff, Gregory C. Graham, and Nahida H. Gordon. "Cancer communication patterns and the
influence of patient characteristics: disparities in information-giving and affective behaviors," Patient Education and Counseling 62, no. 3 (2006): 355-360; Gregory B. Diette, and Cynthia Rand. "The contributing role of health-care communication to health disparities for minority patients with asthma," CHEST Journal 132, no. 5 (2007): 802S- 809S.
88 Lisa Cooper et al., "The Associations of Clinician's Implicit Attitudes About Race with Medical Visit
likelihood of using drugs, even for those who have never used drugs.89 Research suggests a
majority of female drug users have experienced sexual assault, sexual/physical abuse, or other forms of violence.90 Female drug users are also more likely than males to present a range of psychological variables predicting relapse, including depression, anxiety, and suicidal thoughts.91 Research in public health and family violence suggests that childhood sexual abuse is present among 48 percent to 66 percent of women receiving treatment for substance abuse, and that between 47 percent and 90 percent of women receiving treatment have experienced intimate partner violence.92 Women in substance abuse programs also exhibit high rates of post-traumatic stress disorder, and substance abuse as self-medication for such conditions is common.93
89 Dean G Kilpatrick et al., "A 2-Year Longitudinal Analysis of the Relationships between Violent Assault and Substance Use in Women," Journal of Consulting and Clinical Psychology 65, no. 5 (1997).
90 Malitta Engstrom et al., "Childhood Sexual Abuse and Intimate Partner Violence among Women in Methadone Treatment: A Direct or Mediated Relationship?," Journal of Family Violence 23, no. 7 (2008); Jeffrey Fagan, "Women’s Careers in Drug Use and Drug Selling," Current Perspectives on Aging and the Life Cycle 4, no. 1 (1995); Virginia Gil-Rivas, Robert Fiorentine, and M Douglas Anglin, "Sexual Abuse, Physical Abuse, and Posttraumatic Stress Disorder among Women Participating in Outpatient Drug Abuse Treatment," Journal of Psychoactive Drugs 28, no. 1 (1996); Brenda A Miller, William R Downs, and Maria Testa, "Interrelationships between Victimization Experiences and Women's Alcohol Use," Journal of Studies on Alcohol and Drugs, no. 11 (1993).
91 Gil-Rivas, Fiorentine, and Anglin, "Sexual Abuse, Physical Abuse, and Posttraumatic Stress Disorder among Women Participating in Outpatient Drug Abuse Treatment."; Denise A Hien et al., "Do Treatment Improvements in PTSD Severity Affect Substance Use Outcomes? A Secondary Analysis from a Randomized Clinical Trial in NIDA's Clinical Trials Network," The American Journal of Psychiatry 167, no. 1 (2009).
92 Nabila El-Bassel et al., "Drug Abuse and Partner Violence among Women in Methadone Treatment," Journal of Family Violence 15, no. 3 (2000); Nabila El-Bassel et al., "Relationship between Drug Abuse and Intimate Partner Violence: A Longitudinal Study among Women Receiving Methadone," American Journal of Public Health 95, no. 3 (2005); Gil-Rivas, Fiorentine, and Anglin, "Sexual Abuse, Physical Abuse, and Posttraumatic Stress Disorder among Women Participating in Outpatient Drug Abuse Treatment."; Louisa Gilbert et al., "Childhood Abuse as a Risk for Partner Abuse among Women in Methadone Maintenance," The American journal of drug and alcohol abuse 23, no. 4 (1997); Miller, Downs, and Testa, "Interrelationships between Victimization Experiences and Women's Alcohol Use."; Renee Schneider et al., "Prevalence and Correlates of Intimate Partner Violence
Victimization among Men and Women Entering Substance Use Disorder Treatment," Violence and Victims 24, no. 6 (2009): 747.
93 Denise A Hien et al., "Promising Treatments for Women with Comorbid Ptsd and Substance Use Disorders," American journal of Psychiatry 161, no. 8 (2004); Hien et al., "Do Treatment Improvements in Ptsd Severity Affect Substance Use Outcomes? A Secondary Analysis from a Randomized Clinical Trial in NIDA's Clinical Trials Network."; Lisa M Najavits, Roger D Weiss, and Sarah R Shaw, "The Link between Substance Abuse and Posttraumatic Stress Disorder in Women," The American journal on addictions 6, no. 4 (1997). Between 26% and
Research has found that drug use also increases risk of assault and intimate partner violence, suggesting a cyclical relationship in which violence increases risk of substance abuse, which in turn increases likelihood of victimization.94 Studies focusing on violence during pregnancy confirm this finding, linking violence with significantly higher use of alcohol, tobacco, and illegal drugs during pregnancy.95 Notably, the same body of work links experiences of violence during pregnancy with fetal health problems, including low birth weight.
Attention to structural variables is equally important to understanding the health of drug exposed infants. In the case of the children of pregnant drug users, it is generally impossible to separate out structural variables from the effects of drug exposure. As a lawyer defending
mothers of “crack babies” argued, “[t]hese are poverty babies, and nobody wants to address that. So we call them crack babies.”96 Well after the crack baby scare, a twenty five-year study
confirmed that conditions associated with poverty are actually more harmful to children than gestational crack use.97 These conditions include insufficient maternal nutrition, which is associated with increased risk of pregnancy complications and health complications for infants,
59% of women receiving treatment for substance abuse suffer from PTSD, compared to 10%-12% in the general population
94 El-Bassel et al., "Relationship between Drug Abuse and Intimate Partner Violence: A Longitudinal Study among Women Receiving Methadone," 465-470; Kilpatrick et al., " 841-845."
95 Hortensia Amaro et al., "Violence During Pregnancy and Substance Use," American journal of public health 80, no. 5 (1990); Judith McFarlane, Barbara Parker, and Karen Soeken, "Physical Abuse, Smoking, and Substance Use During Pregnancy: Prevalence, Interrelationships, and Effects on Birth Weight," Journal of Obstetric, Gynecologic, & Neonatal Nursing 25, no. 4 (1996): 317.
96 Janine Jackson, “The Crack Baby Myth, Now They Tell Us,” Fairness & Accuracy in Reporting, January 30 2009, http://www.fair.org/blog/2009/01/30/the-crack-baby-myth-now-they-tell-us/.
97 Susan Fitzgerald, "'Crack Baby' Development Issue Not Side-Effect of Drug, but Poverty," The Philadelphia Inquirer, July 25, 2013, http://www.csmonitor.com/The-Culture/Family/2013/0725/Crack-baby-development- issues-not-side-effect-of-drug-but-poverty.
as well as neurological problems and sudden infant death syndrome.98 More recent research has
found that the stress associated with poverty in pregnant women can alter the structure of a child’s brain.99 In addition, a robust literature exists documenting the negative health impact of intimate partner violence on pregnant women and infants, violence to which young women, poor women, women of color, and drug users are more frequently exposed.100 The frequent
coexistence of drug use during pregnancy with contexts of stress, poverty, violence, and
inadequate nutrition make it extremely difficult to isolate the effect of exposure to drugs. Even if it were possible to isolate these effects, experts suggest that they would pale in comparison to the consequences of contextual variables.101
The denial of structural variables is a key element in the logic of criminalization, which places the blame for poor infant health on the “bad choices” of individual (predominantly poor, black) women in two key ways. 102 First, proponents of criminalization do not present drug use as a health problem shaped by context, but as poor individual choice. Under this view, the effects of
98 Tore Henriksen, "Foetal Nutrition, Foetal Growth Restriction and Health Later in Life," Acta Paediatrica 88, no. s429 (1999); Barbara A Laraia, Anna Maria Siega-Riz, and Craig Gundersen, "Household Food Insecurity Is Associated with Self-Reported Pregravid Weight Status, Gestational Weight Gain, and Pregnancy Complications," Journal of the American Dietetic Association 110, no. 5 (2010); Nina Øyen et al., "Fetal Growth Retardation in Sudden Infant Death Syndrome (Sids) Babies and Their Siblings," American journal of epidemiology 142, no. 1 (1995).
99 Kimberly G Noble et al., "Family Income, Parental Education and Brain Structure in Children and Adolescents," Nature neuroscience 18 (2015): 775-777.
100 Kathryn M Nowotny and Jennifer L Graves, "Substance Use and Intimate Partner Violence Victimization among White, African American, and Latina Women," Journal of interpersonal violence (2013); Phyllis W Sharps, Kathryn Laughon, and Sandra K Giangrande, "Intimate Partner Violence and the Childbearing Year Maternal and Infant Health Consequences," Trauma, Violence, & Abuse 8, no. 2 (2007).
101 Micah Lewis, professor of pediatrics and psychiatry at the Robert Wood Johnson Medical School has suggested that such contextual variables are “far more likely to damage a child’s intellectual and emotional development” than exposure to drugs before birth.
102 See Dorothy Dorothy Roberts, "Punishing Drug Addicts Who Have Babies: Women of Color, Equality, and the Right of Privacy," Harvard Law Review 104, no. 7 (1991): 1436. In which she argues, “[T]he prosecution of crack- addicted mothers diverts public attention from social ills such as poverty, racism, and a misguided national health policy and implies instead that shamefully high Black infant death rates are caused by the bad acts of individual mothers. Poor Black mothers thus become the scapegoats for the cause of the Black community’s ill health.”
drug use are purely the fault of individuals rather than the fault of biology or structural variables such as exposure to violence. Second, the logic of criminalization asserts that poor infant health is a direct result of drug exposure, disregarding the significant role of contextual variables. The consistent misrepresentation of the health consequences of perinatal drug exposure – as long- lasting, as addiction, as untreatable – enhances the gravity of this supposedly direct connection. Together, these assumptions allow proponents of criminalization to argue that individual women are responsible for poor infant health. This conclusion is made more palatable by the fact that the women in question are already marginalized and stigmatized in society; they are easy targets for blame.