A long-time invisible issue in France, an increasing number of studies are investigating the use of licit and illicit drugs by women; moreover, care services are beginning to take this specific context into account. Over the last two decades, a new generation of researchers have made gender and drugs their chosen field of research [1,2,3,4,5,6,7,8,9]. This mobilization parallels that of professionals and activists in harm reduction for drug users and for the treatment of addictions. Despite the fact that research on gender in the field of addictions is still relatively scarce, and that gender-specific services are still far from adequately responding to the scale and diversity of women’s needs, these first steps are decisive: after years of polemic, the specific consideration of women has finally acquired legitimacy.

In 2013, as part of a framework created by the government to prioritize services for women suffering from addiction (2013–2017), the French addiction association network Fédération Addiction organized a working group on the issue of women with addiction [31]. The objective was to develop guidelines to improve care and support provided to women in various services (e.g., Addiction treatment clinics, called CSAPA) and HR services (e.g., CAARUD) [35]. An inventory taken at the time highlighted that approximately one in four persons provided care in CAARUD were women. The ratio was only slightly better for CSAPA. These figures are concerning given that an estimated one in three women consume drugs (depending on the drug used, these variations differ significantly) [11].

What can this underrepresentation of women be attributed to? For both CAARUD and CSAPA, this question arises in a context where specific services for women are infrequent and are mostly limited to a small number of tools such as female condoms, discussion groups and gynaecological consultations. Some CAARUD also offer women-only hours in mixed spaces; however, most male and female care providers question the need for this: does the use of gender-specific spaces not simply risk reinforcing the marginalization of women?

This was the context of a field-based research study conducted by Florent Schmitt between 2015 and 2018 in two CAARUD, in which he carried out an ethnographic immersion based on observations and semi-structured interviews with professionals and drug users [35]. One provided mixed-gender support, while the other offered support entirely reserved for women, something which was extremely unusual in the French context at that time. The study aimed to answer two questions: i) How can we understand inequality in access to CAARUD when the care and support offered by these services is based on a principle of unconditional access, without requiring a request for addiction treatment which is the case in CSAPAs ? To what extent can single-gender care services compensate for this structural inequality in access? One of the first answers to both questions was the non-use of the services by women. For Schmitt, this lack of use was linked to gender violence which weighs on women not only in places where drugs are sold and consumed, but also in their private lives. Interviews with women who went to the mixed-gender CAARUD demonstrated this; specifically, respondents reported that they avoided going to the CAARUD out of fear of meeting other drug users who frequented spaces for dealing and consumption (the CAARUD being located near such places) because they did not want to be robbed or solicited for sex. Furthermore, they declared that they might avoid going to the CAARUD if there was a risk that they would meet men whom they already knew and who had already been violent with them in their private lives.

However, the under-representation of women was not only due to their decision not to seek care; as Schmitt noted, “It is also the result of an undeclared gendered targeting which does not say its name” [19, p. 73]. Professionals are persuaded to offer universal services without distinction of gender, but this principle hides what actually happens in the centre which offers privileged access to men [6, 35]. More specifically, in convivial spaces, men tended to appropriate the furniture, chairs, tables and sofas, while women stood on the periphery and limited their use of services offered by the CAARUD to drinking the beverages offered. Social exchanges linked to drug use took place here among men inter se, with discussions about ‘good deals’ for supplying, reselling, donating or swapping drug products, or about recipes for preparing a rock of crack. Virility was asserted with sexist remarks, attitudes, and gestures; women were returned to naturalized functions associated with their gender. They were supposed to be sexually available and had to pay attention to their appearance.

Another gender norm highlighted in Schmitt’s research was that women must be providers of care; this justified an unequivocal moral condemnation of pregnant women or mothers who continued to consume. Consequently, the CAARUD providing women-only support was used by women to discuss the violence they experienced. This contributed to increase their awareness of the gender norms that weighed on them all and provided them with the means to develop strategies to resist these norms. Violence was therefore “the first gateway to women’s space” [19, p. 83], something observed by a woman educator in the CAARUD providing women-only support; it was only then that she became aware of the frequency of violence and rape, an issue left silent in mixed-gender spaces.

Moreover, women in the single-gender CAARUD – escaping male pressure – sat around a table, eating and chatting among themselves in the same way as men in the mixed-gender CAARUD did. They asked for and received harm reduction tools, including condoms, which in the mixed-gender CAARUD marked them as being sexually available. They also took advantage of the basic services offered; they took showers, washed their clothes, moved around the CAARUD – sometimes in their underwear – and, if they wished, they could also sleep on the floor, a behaviour also tolerated for men in the mixed-gender CAARUD, given the precariousness of this often-homeless population. Schmitt’s research comparing single-gender spaces to mixed-gender spaces therefore highlighted “a form of negative discrimination against women”, a gendered division of roles that was almost invisible, so much so that it seemed to be taken for granted, and something against which the mixed-gender CAARUD’s care providers could do very little to fight against, their mission being to welcome everyone without making any moral judgment on consumption practices or deviant behaviour. Indeed, the only limits in place were the prohibition of alcohol or drug consumption and physical violence within the centre.

Schmitt’s research did not focus on the professional practices of the team providing care in the women-only CAARUD, but it is clear that they were committed to this experiment; they were very attentive to users’ needs and provided adapted support services, something highlighted by the friendly atmosphere. The latter is far from being a general rule in France’s CAARUD and CSAPA; indeed, the relationships between drug users – who are most often very marginalized – and healthcare professionals are complex to say the least. The social exclusion associated with addiction arouses a range of emotions in professionals from compassion to rejection, from fear to anger in the face of violent or immoral behaviour, and from involvement to detachment when a care project appears doomed to failure.

Another study, conducted by Maïa Neff, focused on the emotions of care providers in a CSAPA dedicated to parenting [36]. Initially intended for pregnant women and mothers of children under 3 years old, the service was extended to include parenting, the aim being to offer to help better balance the responsibilities of each person in the couple, and therefore to reduce stigmatization of women. However, more than 70% of the patient^Footnote3 population in that CSAPA were women and monitoring focused on specificities identified as feminine: vulnerability, traumatic and violent experiences, the relationship to one’s body and self-representations. Neff found that drug consumption by a mother is very often sanctioned by losing custody over her child(ren), despite the fact that motherhood can be seen as an opportunity to change one’s social role and to break away from the confines of the ‘polluted’ identity of a drug addict as Laurence Simmat-Durand pointed out in a research published in 2007 [2]. Her work highlighted the four sets of standards that weigh on pregnant women or mothers who use drugs, namely (i) criminal norms punishing drug use, (ii) social norms of ‘good’ mothers, (iii) medical norms governing the monitoring of high-risk pregnancies, and finally (iv) gender norms. These norms do not consider the role of the father, who may be absent, violent, or even obstruct his partner’s access to care, particularly when he himself is a drug user.

In her study of the CSAPA, Neff found that care providers – who were mainly women – had a dual mission: to support women and to protect the child. However, while non-judgment is a requisite with regard to the mother, care providers must assess the quality of the bond between the mother and the child, and take the necessary measures to guarantee good living conditions for the latter. Indeed, the interests of the mother do not always converge with those of the child. There is no systematic training for qualified professionals, but voluntary training courses are offered which may relate either to the monitoring of pregnant women either on the management of personal emotions which is supposed to be sufficient to become aware of the weight of prejudices and constraints that weigh on pregnant women or mothers. Accordingly, care providers, particularly when they themselves are mothers, are encouraged to implement ‘emotional work’, which consists of trying to become aware of their own emotions and ensuring they do not interfere with the decisions they make.

In Neff’s work, the case of Sonia, a patient followed by two women – one a gynaecologist, and the other an educator – illustrates the tensions between representations of the ‘good’ mother and respect for this patient’s choices regarding at-risk behaviours. Sonia wanted to remove her contraceptive implant, which required the gynaecologist’s approval. However, according to the two care providers, Sonia’s support was “complicated”; she required an emotional investment from them that “went beyond the [established] framework”. She was followed during her pregnancy, with medical treatments, consultations to reduce her drug consumption, and her progress was initially judged “meteoric” by a nurse. But the hope of a happy motherhood suddenly collapsed after she gave birth; she was sent to mother-and-child accommodation in another city. Sonia abruptly left that structure, leaving her child alone there, returned to the city she had left, began squatting and started using drugs again.

The child was immediately placed in social care, as were her three previous children. Sonia’s request to remove the contraceptive implant aroused incomprehension and even indignation in the two professional care providers. They could not agree to a fifth pregnancy, which could only repeat previous mistakes. Sonia was described by “her fragility” and “her deficiencies”, something highlighted by “her strong emotional dependence” on her sexual partners, who followed one after another in rapid succession, and who often turned out to be violent. The lack of autonomy seemed obvious; according to the care providers, it reflected a psychiatric pathology.

Exacerbated by her fourth pregnancy, the salient features of Sonia’s personality exemplify the gender-related representations of drug users provided support in CAARUD and CSAPA: women “experiencing a great deal of suffering”, with “low self-esteem” as Carine Mutatayi also noted [37]. Professionals who use their own experience as a basis to define what a desirable motherhood is, are not aware that they are imposing a model which is specific to their own social environment, and which does not take into account the material conditions of existence. The emotions circulating in the CSAPA in question indicated to Sonia how unacceptable her request was, something which she perceived as a definitive disqualification from becoming a mother again in the future. This led her to flee the CSAPA where “emotional work is strongly intertwined with power relations such as those of gender, class and age” [36]. Neff also pointed out that the tension between what professionals perceived to be a desirable motherhood and the reality experienced by socially excluded female users, was so violent for care providers, that the CSAPA suffered from significant staff turnover, more than half the team changing their workplace over a one-year period.

In principle, relationships of support must be based on non-judgment, which implies a caring attitude. The ‘emotional work’ described by Neff calls on “the intimate experience of motherhood to be mobilized as professional knowledge”; this results in positive evaluations if care providers identify with the patient, or negative evaluations if the latter’s behaviour does not conform to the standards that define “acceptable maternity wards”. The patient’s behaviour is interpreted with regard to personality, without taking living conditions into account or indeed the burden of the stigma that weighs on drug users, a burden that is all the heavier in women who become mothers.

The clinical picture described by Neff confirms the stereotypical diagnosis made by men and women practitioners that weighs on women who use drugs, victims not only of violence by men, but also of their own deficiencies, their lack of autonomy, their emotional dependence, and the absence of self-esteem. This diagnosis neglects the particular moment when women using drugs request help. No wonder then that they report how difficult it is for them to talk to care providers about their problems linked to drug use. This is a time when women who use drugs tend to have low self-esteem. Does this mean that they have no autonomy, that they are irremediably condemned to a life of chaos? “Women? They’re worse than men”, clinicians sometimes said of their heroin-addicted patients before the arrival of OST at the end of the 1990s [38]. These clinicians were not aware that women who were better socially included and had sufficient control over their consumption avoided treatment services to protect themselves from value judgments. Published in recent years, guidelines dedicated to women using drugs now recommend fighting against stereotypes and stigmatizing representations, nevertheless, the emphasis placed on deficiencies, lack of self-esteem and associated mental disorders is often resented by women [27, 31, 37, 39].

The self-monitoring of drug consumption that women using drugs practice is invisible in healthcare institutions. As much as possible, they keep their consumption secret, which allows them to frequent non-specialized services, hospitals and general practitioners, but which implies a certain control over their drug use. Those who lose their ability to control this consumption find themselves on the street; they are then unanimously despised, described by their deficiencies, their traumas and are locked into chronicity. And yet no one – be it a man or woman – can live on the street without a survival strategy, something which “requires know-how, tactics and strategies, far from the image of people without autonomy, without control over their existence” [40].

Men, more than women, can resort to coping strategies, including illicit activities such as theft or drug resale. Given that women are a priori more marginalized than men in sociability networks, they find it more difficult to use coping strategies than men, so the last resource becomes their body. Whether or not they resort to sex work, women must protect themselves, which makes them true warriors, who can be proud of “their survival strategies in a hostile environment” to use Mathieu Lovera’s phrase [40, p. 89]. The experience they acquire on the street can become part of their resources. Breaking with their ‘imprisonment’ in chronicity means calling on their experience, their skills, their know-how. These empowerment strategies are now advocated in guides and training courses. It remains to be seen how professional practices evolve in the field of addiction, an under-explored research question.

To date, few scientific studies have addressed the intimate and marital experiences of women who use drugs. Most of the relatively small number of studies on couples who use drugs concern people in socially precarious situations, and highlight the frequent domestic violence and control-based marital relationships which women who use drugs are victims of [27, 31, 37]. There are very little data on the marital relationships of socially included women who consume and sell drugs. This population, with a double invisibility (because they are women and because they are socially included) constituted the study population that Sarah Perrin studied during her sociology doctorate thesis [30]. Specifically, she conducted a total of 65 interviews: 45 with socially included women who used and sold drugs (26 in Bordeaux, France and 12 in Montreal, Canada) and 20 with socially included men who used and sold drugs (12 in Bordeaux, 8 in Montreal), between 2018 and 2022. Most of the interviewees were heterosexual, and the mean age was 26 years. Most consumed cannabis daily, and used stimulants (cocaine, MDMA/ecstasy) and sometimes hallucinogens (LSD) in party contexts.

Her analyses corroborate the classic findings of the sociology of conjugal roles, in particular the idea that “like attracts like” [41] in terms of place of residence, social environment of origin, educational level, income, religion, and substance use. Specifically, participants reported that they preferred to date partners who also used illicit drugs, because otherwise it could create a feeling of mismatch [42]. Moreover, it was not enough that partners were also consumers; the uses within the couple also had to be similar. Participants therefore preferred to be in a relationship with someone who used the same drugs as them with similar frequencies and in similar contexts. Note that male and female partners can influence each other in their consumption (by increasing or decreasing it), and that in the sample studied, women were not introduced to drugs by their romantic partners. Both men and women started their drug use with friends.

Although individuals in general look for partners similar to themselves, men and women do not look for exactly the same thing in heterosexual relationships [41]. Expectations of partners are always shaped by gender norms. The drug users interviewed by Perrin were no exception to the rule. Men who used drugs were more likely to declare that they preferred to date a woman who consumed less than them, or who did not consume. This trend is not specific to the area studied; for example, in a study by Barrault, alcoholic men looked for partners without substance use disorders [42]. Men often look for female partners who consume less, in the hope that the latter will act as a barrier to the former’s consumption [43]. For these men, their partners must embody a maternal, reassuring, and even authoritarian role, which protects and restricts them in order to help them take care of themselves; this brings us back to the idea developed in Neff’s research of the ‘providing care’ role imposed on women.

During her research, Perrin only met one mother, called Louane. Her story is indicative of the gendered double standard that governs parenthood in men and women who use drugs, something revealed in the large number of public policies targeting mothers who use drugs, but which leave fathers unscathed. Examples of these policies are drug testing during pregnancy without the mother’s consent, and encouraging pregnant women who use drugs to have abortions [44]. Louane was 30 years old. She was an educational consultant in Montreal. Her doctor prescribed her with medical cannabis following health problems related to her anxiety. She had two children, aged 9 and 7. When they were born, she stopped using cannabis completely for several years because she wanted everything “to be very well supervised”. Her husband, who smoked cannabis recreationally every day, “reduced [his consumption] a lot” after the birth of the children, although Louane suspected he “smoked […] in secret when he went out with his friends”.

We can already see two very distinct behaviours here: Louane completely stopped smoking because she felt that it was the best thing to do at this time in her life, while her husband reduced but did not interrupt his smoking; moreover, he admitted to his wife that he had secretly smoked cannabis with friends. Louane reported that when she used cannabis in the family home, she was discreet about it: “I wait until the children are asleep or until they are really out of my sight before going outside to smoke my joint.” Instead, her husband, was “less careful”, which Louane justified by the fact that he smoked “a little more regularly”. Generally speaking, the father wanted cannabis consumption to be discussed in a very open manner with the children, for example by smoking their first joint with them, while Louane described herself as “more closed”.

This “closure” may be linked to Louane’s fear of being stigmatized if those around her learned that she was a mother who used cannabis. She feared that people would say that she was “not a good mother”, and sometimes felt guilty about the fact that she smoked joints despite having children: “I ask myself questions, […] I asked myself if I was doing the right thing.” Louane already felt judged by her own mother, whom she had confided in about her therapeutic use of cannabis, and who replied to her that she had to “be careful”, out of concern about Louane’s ability to perform her maternal role correctly. In contrast, Louane’s partner was not afraid of other people’s judgement, and was comfortable talking about his consumption in public. Louane directly correlated this contrast between her husband’s attitude and her own with the “patriarchal” context of our society:

A man has the right to drink, a man has the right to go out; a woman is judged more; and women, among us, we judge […] too. Society […] does not yet have, I find, the same openness in relation to what a man can do versus a woman.

Louane’s case reveals gender inequalities in parental roles. As in many couples, it is considered normal for the mother to abandon part of her individual identity for her children and for the father to maintain his autonomy and individuality without being judged.

In couples, the collective system of daily management is reflected through a distribution of household work that is often very gendered, automated and perceived as obvious by both partners [45]. The purchase and sale of drugs comes under the umbrella of the domestic tasks which the man performs. This gendered distribution in the work of buying and selling drugs within the couple is a direct consequence of the specific vulnerabilities of women, who are often the subject of various stereotypes, including that they lack credibility, that they have an incapacity for violence, and that they are lecherous [6, 7]. In Perrin’s work, participants explained that it was almost always the male partner who was responsible for purchasing the drugs used by the couple and that the reported reason for this was to spare women the task of buying substances from a potentially dangerous dealer who would try to defraud them or try to hit on them. Indeed, women are the subject of sexist stereotypes when they buy drugs [7, 28, 46, 47], which justifies in the couple’s eyes the fact that it is the man who is in charge of the purchases. Women, who are much more discreet in the face of police and security agents, transported drugs by hiding them in their underwear or handbags, whether in party spaces or in the street. Men, when carrying drugs, hide them in their socks or underwear, but they know that they are more at risk of being body searched than women, since most security agents and police officers are men, and that only a female agent can carry out a body search on a woman.

Again, this highlights the pervasiveness of gender norms, and how illegal practices were almost normalized in the domestic context. Negotiations, protection and risk-taking were for men, while women kept an eye on the spouse. This does not mean that women were incapable of selling without their partners. Most women interviewed who sold drugs had already done so alone, independently, without the support of a man; however, their sales practices did not fit into a marital management model. When the purchasing and selling tasks are divided between a heterosexual couple, it seems that a gendered distribution of tasks is put in place, for the sake of comfort and safety, with a view to having an element of routine in their daily life.

When partners stop having similar drug use patterns – because one increases, decreases or stops his/her use – tension can follow in the couple. In another study by Barrault, couples whose drug consumption patterns differed expressed less marital satisfaction, and drug use often lay at the heart of negative interactions between spouses [48]. In Perrin’s survey, conflicts were reported linked to the fact that the drug use patterns of the two partners were no longer similar. A form of romantic disenchantment could also occur when women tired of having to serve as a safeguard for their companions’ habits. Finally, the theme of violence – central in the literature on women and drugs – was also predominant in Perrin’s interviews of drug users about their marital experiences. Several women reported cases of violence within the couple, most often manifested through insults, controlling their private life (monitoring of social networks, bans on going out, etc.), threats, and more rarely physical violence.