Applying Intersectionality to Understand the Harm Reduction Service Needs of Trafficking Survivors Who Use Drugs: Insights from Survivors

Interconnected factors at the individual, community, and policy levels often reinforce persistent health inequities for trafficking survivors who also use drugs. These factors include racial and gender discrimination in healthcare, limited access to safe and affordable housing, and legal consequences due to the criminalization of both illicit drugs and sex work. Given this complexity, strategies to promote access to harm reduction services for survivors who use drugs are underexplored.

This study applied the Intersectional Risk Environment – a novel conceptual framework derived from Risk Environment and Black feminist Intersectionality theories – to examine multi-level barriers and interrogate sources of power and oppression. In this study we ask: 1) What intersecting factors uniquely impact survivors who use drugs in accessing harm reduction services? and 2) What insights can be gained from survivors who use drugs surrounding strategies to promote health equity considering these intersecting factors?

Methods:

We conducted 18 semi-structured interviews with survivors of human trafficking and/or sexual exploitation who currently or have formerly used drugs in a Midwestern US state. None of the participants were engaged in outpatient or inpatient treatment services during the time of the interviews. The research team created an iterative codebook of inductive and deductive codes and met weekly to discuss and negotiate the application of codes to the interview data. We used Deterding & Waters’ flexible coding approach (2018), which chunks large-scale text into specific sections to facilitate focused and transparent analysis.

Results:

Survivors ranged from 19 to 63 years old; 43% identified as BIPOC, 78% identified as female, and 22% identified as being part of the LGBTQ+ community. Participants highlighted the dual stigma associated with drug use and sexual exploitation as a primary source of interpersonal and institutional mistreatment in the healthcare setting. Reproductive services were often entangled with carceral systems including child protective services and the criminal-legal system. Systemic involvement was described as having a cascading negative impact on well-being, including limiting access to housing, disrupting relationships with children, and limiting the ability to relocate to a safer environment after exiting trafficking/exploitation. While many participants described having had access to intensive substance use treatment at various points, these services were generally unable to meet their complex needs.

Conclusions and Implications:

Discrimination at the intersection of exploitation and drug use – compounded with marginalization of other identities - leads to multi-level obstacles for survivors who use drugs. Notably, they are often further stigmatized by the providers and systems that are generally regarded as sites of service entry for vulnerable clients. Addressing this paradox could improve health equity for survivors who use drugs.

This study also demonstrated that the Intersectional Risk Environment is a useful framework for mapping complex relationships between individual and structural barriers to services. With this complexity in mind, our analysis highlighted the importance of applying an intersectional feminist perspective when considering intervention development along with the need to interrogate neoliberal ideologies that often drive oppressive and counterproductive service provision for survivors who use drugs.