Women: Research and Policy: Part I

What is known about women and drugs is influenced by scientific research, information dissemination, and the perspective of the scientist/ writer(s). Formal research is limited largely by what our government sanctions as "significant," or having the potential to contribute to the solution of an already defined problem. Whether protocols utilize quantitative methodologies, qualitative methodologies, surveys, clinical trials, or field studies, researchers with a conventional perspective generally collect and analyze data and ultimately produce information. Most have a covert investment in the status quo, the preservation of traditional values (including gender roles), and prevailing (prohibitionist) policy toward drugs.

The decision to publish research findings is political. Conventional scientific journals have ultimate decision-making power about which "findings" constitute serious scholarship, often defined as that which is government-sanctioned (and funded). The other major source of information, the popular media, is motivated to define drug use as problematic when it contains sensational stories. Historically, women's drug use has been defined as problematic when their traditional gender roles were violated or abandoned, therefore jeopardized. Details about women ingesting drugs during pregnancy and violating that most sacred role as caretaker and mother sells papers.

In sum, our knowledge of women and drugs is limited to that which is government-funded and published in scholarly journals and/or the popular media. This information does not represent the experience of the majority of women drug users. It does not even represent the majority of women who use illegal drugs, because most use drugs in controlled ways and without serious consequence. We know very little about how they manage and control their use because prohibitionist rhetoric dismisses such use as impossible, therefore research funding is difficult if not impossible to obtain.

Instead, most conventional research focuses on a relatively small group of women whose drug use becomes visible, therefore problematic. They use illegal means to earn enough money to buy (expensive) drugs. As a result of their illegal activities they come into contact with the criminal justice system. They are often poor, underskilled, undereducated, and supported by public assistance. They have difficulty taking care of their children and as part of the welfare system, come to the attention of social service agencies designed to protect children. Some have no real home and as a result much of their existence takes place "on the street." Most important, they incite fear because they deviate from sexual norms and in general violate traditional gender role expectations with regard to pregnancy and parenting.

Since women "emerged from the shadows" in the 1970s (2), patterns of drug use and problems associated with it have shifted. The focus of research on women and drugs mirrors societal concerns and has also changed. This chapter will examine some of the salient issues related to women and drugs, with primary attention given to research areas that have dominated the literature with special attention to research on pregnancy and drug treatment.

Societal responses to women who use (illegal) drugs has also shifted over the past 25 years. During the 1970s treatment expanded with the hope that rehabilitation would address the problem. By the late 1980s, with AIDS, the crack "epidemic" and a powerful war on drugs, a more punitive climate prevailed. Women drug users were being held responsible for many of society's ills and actively prosecuted for deviating from conventional gender roles.

This chapter will use research findings to examine shifting trends in and societal responses to women's (illegal, problematic) drug use during the 1970s and 1980s. It concludes with the 1990s and a discussion of feminist analyses of violence, treatment, and the implications of the War on Drugs. Finally policy recommendations are made for reducing drug-related harm.

THE 1970s

The early feminist movement of the late 1960s and early 1970s called attention to and encouraged women's participation in many activities in which they had been absent or invisible. It also opened a range of occupations that had been the exclusive or nearly exclusive domain of men. Among these occupations was illegal drug use, particularly heroin addiction. Research began with assessments of prevalence, in an effort to determine just how many women used illegal drugs (3-6). Epidemiological studies compared women with men, among themselves on the basis of race, with other drug users, and longitudinally (7-13). Several other studies focused on gender-specific aspects of women's participation in the drug world, including prostitution (14-17).

Another set of studies looked at the etiology of women's criminality (18-20, 27, 29). Women drug users had begun to participate in property (though not violent) crime such as burglary, larceny, and forgery. Their representation in large-scale money-making enterprises such as drug distribution was minimal, although many served as assistants to male dealers (17, 21, 30). Research on women heroin addicts revealed that a sizable proportion prostituted, at least occasionally, to earn money to support their heroin habits (8, 15, 16, 19, 20, 22-34).

By far, during the 1970s the bulk of research focused on a major concern regarding women's deviation from traditional gender roles, pregnancy, and motherhood. Drug treatment was another research area that dominated the 1970s.

Pregnancy and Heroin Use

Early studies of pregnancy and heroin use focused on physiological problems associated with addiction. During pregnancy, heroin addiction was thought to be connected with such problems as premature rupture of membranes, impaired fetal growth, diminished birth weight, preterm delivery, maternal infections, meconium staining, stillbirths, toxemia, and infant withdrawal (35-48).

At that time there was a dearth of information about pregnant women and heroin-addicted mothers. Rosenbaum and Murphy (17) first studied the career of the woman heroin addict addiction in 1977 by interviewing 100 women, 70% of whom were mothers. This sociological and ethnographic study produced findings that differed from, but often complemented, the more medically oriented publications appearing at about the same time (35-48). The discovery of pregnancy was problematic, as many women had stopped menstruating while they were addicted. By the time they were certain (often because they were "showing") they were in the fourth or fifth month and too far along for an abortion. It was also too late to stop using drugs, the rationale being that (a) most of heroin's most deleterious effects would have occurred during the first trimester, and (b) withdrawal in later stages of pregnancy was too dangerous to the fetus. Birth and delivery, according to the study participants, was often physiologically as well as psychologically difficult. Many of the women had suffered from such ailments as toxemia as a result of addiction as well as little prenatal care. As a result, birth could be a dangerous and fearful experience. In addition, hospital staff familiar with the women's addiction were less than supportive and often abusive. The last thing the women wanted to do was to return to such an unpleasant environment, and many never came back. To compound feelings of disdain they received at the hospital, women often went home with an irritable and difficult to placate infant. This combination had the potential to send them into motherhood with feelings of failure and a need to use heroin to relieve their suffering (17).

Drug Treatment

The establishment of National Institute of Drug Abuse's Program for Women's Concerns in 1974 opened treatment options for women heroin addicts. These included inpatient detoxification, outpatient detoxification, Narcotics Anonymous, methadone maintenance, and therapeutic communities. Despite these advances, women drug users had felt the stigma of being defined as socially as well as psychopathologically more deviant than their nonaddicted sisters or their male counterparts, and as a result, many hid their addiction, making it difficult to recruit them for treatment (49).

When women did decide to go to treatment, they found that many programs were incompatible with their needs and obligations as mothers (50, 51 104). As a result most women were limited to outpatient detoxitication and methadone maintenance.

The increasing recognition of women as a "special" population of addicts due to their childbearing and childrearing roles occurred simultaneous to the expansion of methadone maintenance treatment (MMT). At that time, research on MMT and pregnancy focused on medical issues pertaining to the fetus and newborn and the management of the pregnant addict (40, 48, 52-69, 112). Research findings, while in general supportive of methadone as a tool to reduce drug-related harm, were inconsistent in terms of fetal health and severity of withdrawal symptoms. Still, for a pregnant addict who found it impossible to quit the use of heroin, maintenance was one of few viable options, and, by the end of the 1970s, women occupied nearly one third of new MMT slots (70).

The rehabilitative orientation of 1970s resulted in the proliferation of treatment, with methadone maintenance the single largest modality available (71). A subsequent study by Rosenbaum (72) focused on the methadone experience for women, which found MMT to be a "presence" in the heroin world for the 100 women on MMT interviewed for the study. Women had to confront the possibility of getting on methadone, whether or not they chose to enroll in a program. A major impetus for women to enlist in a methadone program was pregnancy (72). Many women who became pregnant opted for the control methadone provided. Their lives were necessarily stabilized due to (a) the highly structured clinic routine, and (b) the elimination of the need to participate in criminal activities for the purpose of buying heroin. Women's lives became as routinized as possible, enabling them to work around their addiction, provide a home for their baby, eat well, and learn skills in preparation for motherhood.

Despite enlisting in drug treatment and stabilizing their lives, women reported that when they went to the hospital to give birth, they were faced with the stigma of being "just a junkie." The guilt which may have been suppressed during pregnancy surfaced very quickly - often brought back by the attitude of the hospital staff, which was most often neither knowledgeable nor sympathetic.

The guilt experienced by women on methadone extended from birth and continued throughout the baby's childhood. It began in the hospital, but did not end there. They felt responsible for the baby's withdrawal, although there was no way to predict severity of withdrawal, or even whether it would happen at all (47, 62, 73-76).

Motherhood often began badly for women on methadone, and there were more problems when the baby came home from the hospital. Just as with heroin, babies in withdrawal could be extremely irritable (74, 75), with "postpartum depression" accentuated and extended for addicted mothers. The guilt experienced by mothers on methadone haunted them, and never seemed to end. First they looked for signs their babies were addicted. Later women wondered if their children's problems might be attributable to their own use of heroin or methadone. The guilt and fear could extend through life, and every ailment was suspect.

Despite an increase in treatment options for women in the 1970s, there were not enough programs, and the quality of treatment was questionable at best. Women often found the structure of treatment, including long waiting lists, difficult to negotiate. Some women expressed little respect for counselors, especially those who were ex-addicts. Women on methadone often experienced physiological problems. Many women were dissatisfied due to the male orientation and their own lesser position within the treatment world, regardless of the particular modality. In the early years it was not uncommon for programs to limit their acceptance of women to the wives or girlfriends of male clients as an incentive for men to enroll. Women heroin addicts in treatment were defined as "sicker" and more deviant than their male counterparts (7, 23, 77-78). When they enlisted in drug treatment, they discovered they were treated as more pathological than male addicts, and experienced discrimination and sexism as a result (79-81). The major obstacles women faced in accessing and utilizing treatment effectively were (a) the lack of facilities for children and (b) the failure of institutions to acknowledge the difficulties they faced in attempting to fulfill their mothering obligations while following a treatment regimen.

The 1980s

The study of women and drugs was altered radically in the 1980s. The AIDS epidemic and its relation to drug use, the introduction of "crack" to the drug scene, and an unprecedented escalation in the war on drugs changed the drug experience for women.

AIDS

Intravenous drug use accounts for half of all AIDS in women (82). Epidemiological and etiological studies have found that women injection drug users (IDUs) were vulnerable to the disease through both needle sharing and unsafe sexual contact (83-93). Women's risk through unsafe needle sharing had much to do with their inequitable power relationship to men (94-98). Researchers found that women were much more likely than men to obtain drugs through their (male sexual) partners; that men often controlled the level of intake of drugs for their women partners; and women tended to be "fixed" by someone else more often than men, increasing their chances of being "hit" by a previously used needle (17, 97-99).

Prostitution, or "sex work," as it was called by the 1980s, contributed greatly to women's HIV risk and sexually transmitted diseases. Still, women had fewer economic resources and conventional job skills than their male counterparts (100-103), and as result of a reduction in programs for the poor, fewer resources than they had in the 1970s. This wanting economic situation rendered them desperate, forcing them to engage in sex work to earn enough money to support their basic needs as well as their drug habits. Women's need to support themselves through sex work created an insidious cycle. Women remained in sex work because they had few, if any, other ways to make a living. But in order to cope with the distasteful nature of prostitution, they used drugs to block their feelings. They were therefore unable to separate themselves from the drug world, which was in turn tied to prostitution (16, 105-107).

Drugs and prostitution added up to a tangled package creating increased HIV risk for women through both needle-sharing and sexual contact (108-110). Drug-dependent women in withdrawal and in desperate need of money were vulnerable to the demands of a "trick" who did not want to use a condom (117). Furthermore, incest, economic hardship, physical abuse, and cultural influences such as perception of control over one's own life shaped women's use of contraceptive technologies, including condoms (111). Numerous studies were completed documenting cultural and racial factors that contributed to risky sexual behaviors (85, 113-124).

Crack

By the mid 1980s, cocaine had replaced heroin as the most dangerous drug. A number of cross-sectional surveys had documented the dramatic rise in incidence and prevalence of cocaine use and related problems (125-128). Drug use among women in general seemed to be increasing (129), with use among women of childbearing age in particular increasing as well (130). Researchers compared women and men (103, 131); looked at sexuality (133-134); "sex for crack" exchanges and implications for the spread of HIV and other sexually transmitted diseases (132, 135-141, 185); women's participation in the cocaine-selling economy (142-146); and pregnancy, fetal development, and neonatal behavior (147-148).

In a qualitative study of 100 women who used crack cocaine (151), Murphy found that women crack users' impoverished early lives set the stage for what would occur later:

Early in life, many were trapped by childhoods in violent, fragmented, or drug-involved households; teenage pregnancies; truncated educations and lack of skills; poverty that was worsened by diversion of resources to drugs; oppressive relationships with men; and eventually by the demeaning social world surrounding crack cocaine (149).

Murphy also found that victimization characterized these women's perspectives; they had little hope for a better future. Parenting concerns were central in women's lives.

Motherhood, Pregnancy, and Crack

The majority of Murphy's (151) study participants (68%) were mothers, and parenting and pregnancy issues were of paramount concern to them. Women's viewpoints on pregnancy had much to do with their (non) use of birth control, believing themselves to be controlled by sex rather than sex being controllable by them. Many believed babies, rather than a chosen responsibility, came "from God." Fertility was a "distant issue" rather than a present reality and distinct possibility. Unforeseen sexual experiences were attributed to youth, lack of knowledge, powerlessness, carelessness, or ambivalence. As a consequence of women's beliefs and unforeseen experiences, most became pregnant unexpectedly (149). Most women in the study population wanted to be mothers at some point in their lives, even if they did not themselves determine when this would occur. Lacking the opportunity to assume other viable social roles involving occupational success, motherhood remained as one of few conventional, respectable life options.

Crack-using women in this study population were not at all like the "monsters" portrayed in the popular media at that time (150-152). On the contrary, they felt a strong responsibility for their children, as well as deep pride. As mothers, they expressed their goals as nurturing and modeling. The use of crack cocaine presented mothering problems: a drain on attention to children's needs, finances, and role modeling. Women found themselves in a downward spiral, as the use of crack served to alleviate mothering concerns and ultimately worsened the situation. Nonetheless, women attempted to carve out various strategies involving "defensive compensation" and the effort to maintain mothering standards while using crack. They separated drug use and parental roles, budgeted money, tried to get away from the crack scene. As a very last resort they reluctantly but voluntarily relinquished their children "for their own good" to a more responsible party. When custody was lost, the downward slide escalated and women often used even more crack, claiming, "they took my self" (150-151).

Paradoxically, along with well-meaning action, an insidious force was working with regard to pregnancy, motherhood, and drug use: the Reagan-Bush version of the War on Drugs. It was fueled by the crack cocaine "epidemic" and the American need for swift, punitive action. Ira Chasnoff, in his 1989 article citing 375,000 "crack babies," set off an hysterical panic about the out-of-control epidemic of pregnancy and cocaine use (153). The popular press seized this story, claiming the needs of babies who were exposed to drugs in utero "will present an overwhelming challenge to schools, future employers and society" (154); "crack cocaine can overwhelm one of the strongest forces in nature, the parental instinct" (155-156); and drug use during pregnancy was "interfering with the central core of what it is to be human" (154). Negative media attention on drugs peaked with the phenomenon of the "crack baby." When preliminary research findings indicated crack use during pregnancy might be associated with fetal morbidity, the popular press quickly ran a series of alarmist stories. Journalists reported that mothers addicted to crack cocaine lost basic parenting instincts (154) and had utter disregard for their children (155-156); maternal crack cocaine use robbed children of "the central core of what it is to be human" (154), and crack made a mother "indifferent to her child or abusive when its cries irritate her" (157). The use of drugs and even more specifically the use of crack during pregnancy was the equivalent of abusive parenting, and crack severed "that deepest and most sacred of bond: that between a mother and child" (158).

According to media representations, the problems of maternal drug use extended beyond the mother-child unit. News stories linked this phenomenon to a collection of social problems by asserting that pregnancy and drug use was draining public drug treatment funds and medical resources (155, 156, 159-162) and threatening the nation's school and criminal justice systems (154, 163-168).

The Criminalization of Pregnancy

By the late 1980s the fetal rights movement had combined with the War on Drugs (169). As a result of the scientific "crack baby" literature and subsequent media attention, pregnant drug users were increasingly stigmatized and further marginalized. At this point the United States government stepped in to take action, with prosecutors in nearly half the states in the United States hoping to solve the problem by punishing pregnant drug users through prosecution (170-175). As a consequence, a drug-using pregnant woman could be arrested and incarcerated for "delivering drugs to a minor" (176). A woman who tested positive for drugs during delivery could immediately lose custody of her newborn. Although by 1991 the association between fetal harm and cocaine use had been seriously questioned by medical research (177-182), hundreds of infants and children continued to be removed from their mother's custody, overloading the child welfare system, and jeopardizing women's control of their own bodies. As Boyd (183) notes:

Feminists conclude that the criminalization of pregnancy, and emerging fetal rights (171, 184), have culminated in a situation where the well-being and security of women's bodies is legally and physically challenged (186-187).

Class and racial bias in these prosecutions were obvious (188). Although the use of illegal substances was distributed fairly evenly throughout the population in terms of class and race, all of the women who were prosecuted were not only poor but non-white (189-191), with Jennifer Johnson's case perhaps the most famous (2).

The social conditions characterizing crack-users' lives were far more deleterious to the health, well-being, and safety of mother and child than drugs. The media and political focus on drugs was not only oversimplified but purposeful. Crack mothers were being scapegoated, diverting attention from (a) the realities of the failed, post-Reagan social experiment with cutbacks of needed social programs and (b) complex social conditions that would require major political change (152, 174, 192, 193). As Lisa Maher wrote:

The criminalization of "crack pregnancies" facilitates the punishment of those who blatantly violate established social mores. It provides a way of striking out simultaneously at minorities, druggies, and women who fail to conform to engendered cultural expectations. At the same time, Middle America can vent its moral indignation by using the rhetoric of compassion for those "poor little [black] babies. .. ." [W]omen who use crack cocaine provide an attractive place for Middle America to circle its wagons, and crack pregnancies provide an ideal opportunity for projecting deep-seated cultural anxieties about the urban minority poor and about drugging, crime, and female sexuality. (194, pp. 123-124)

The increase in prosecutions suggested that more information was needed to intervene in the misdirected, unjust, and downright harmful direction of persecution, prosecution, and punishment of pregnant drug users. The prevalence of drug use during pregnancy was not subsiding (195) and low birth weight, small head circumference, irritability, SIDS, and malformation among babies born to addicted mothers continued to be commonly reported (196). Others had discovered that the pregnant addict was less likely to attend prenatal care appointments, more likely to live in poor conditions, more likely to have a host of confounding problems such as sexually transmitted infections, more likely to experience higher rates of violence than non-drug users, but no more "pathological" than women in the general population (197-199). With all the research that had been conducted, the perspective of pregnant women themselves was rarely the focus. There was a need to present a "human" view of the pregnant drug user while attempting to humanize her treatment.

The author and Sheila Murphy learned that the crack-using pregnant women studied were stigmatized and consumed by guilt. They expressed great concern about the levels of drug-related harm that occurred during their pregnancies, their evaluations varying according to the particular drug(s) they were using, and often based on what they had heard or read through the media. Contrary to popular myth, study participants cared very much about the outcomes of their pregnancies and used a variety of strategies to reduce drug-related harm. They tried to lower their intake, switched from "harder" to "softer" drugs such as marihuana which would help them eat and sleep, and ingested health-promoting substances such as vitamins (200). Perhaps most problematic in this potpourri of methods was prenatal care (201). The crack-using women in the author's study population, 82% of whom were African-American, were well aware that because they were black, as soon as they entered a clinical setting they would automatically be suspect of illegal drug use. They would be targeted for drug testing, which could lead to punitive social service and criminal justice interventions such as incarceration and removal of their children (175, 189, 202). Quite simply, despite their intent to reduce drug-related harm through contact with medical institutions, if they believed custody would be jeopardized, they made the difficult decision to stay away. Chavkin summarized the problem:

Attempts to criminalize drug use during pregnancy may further deter (pregnant women) from seeking care or from giving accurate information to health care providers. Anecdotal reports suggest that efforts to detect maternal drug use by means of urine toxicology testing of the newborn may even frighten some women away from delivering in hospital (203).

THE 1990s

By the 1990s feminist scholars questioned basic assumptions about gender roles and the way women and drugs had been viewed (151, 204-206). The ways in which abuse, violence, drug treatment, and the War on Drugs have shaped women's experience have become central concerns in this last decade of the twentieth century.

Abuse and Violence

Researchers have consistently found high levels of past and present abuse in the lives of women drug users (144, 197, 207, 209, 210). Many have suggested that there is a relationship, if not absolutely causal, between violence experienced by women and drug use (211-228).

In one study of pregnancy and drug use (208), 70% (n = 120) of the study participants reported they had been in one or more relationships in which they had been physically battered by a male partner. Of the 84 women who had been assaulted by their partners, nearly half (45%) reported being battered during their current or most recent pregnancy. Twenty-five of the 84 women (30%) who had been victims of partner violence were in a battering relationship at the time of the interview. In addition to the violence they endured within their homes, the neighborhoods these women grew up in were, in many instances, veritable "combat zones." Between gang warfare, police raids, random shootings, and drug dealing, fear became a way of life for the overwhelming majority of the women who participated in this study. These findings concur with other studies that indicate a link between childhood experiences of violence, sexual abuse, physical abuse, and the increased likelihood that a woman will develop drug and alcohol problems later in life (224). For many of the study participants, drug use was a way of numbing themselves to the violence that engulfed them.

In a recent study of methadone maintenance (117), 51% of the 108 women (n = 55) reported some form of past or present violence in their lives. Forty percent (n = 22) of the women who experienced abuse reported surviving multiple abuse patterns, such as a combination of child abuse, rape, and domestic violence. Some violent partners prohibited women from seeking or continuing treatment. In addition, women's limited economic resources meant they had few options for ending violent relationships. The implications of such violence, although difficult to determine in a tangible way, did affect women's perceptions of their treatment progress. The study found that violence provided a catalyst to self-medicate (230, 231). In addition, women's sense of self-worth, importance, competence, and control was eroded with the accumulation of violent and abusive experiences (214, 232). As such, each of these experiences formed a link with women's problems in treatment and acted as a barrier to successful MMT in the following ways. First, psychological turmoil from violent episodes drove women to initiate or continue to use heroin for self-medication and escape. Secondly, the effects of past violence, if not sufficiently addressed in counseling and therapy, could continue to haunt the women and propel them towards using heroin for escape and, ironically, control (205).

Drug Treatment

Recent studies of drug treatment have focused on themes of violence, male dominance, dependence, motherhood issues and depression (233, 234), pregnancy (235); retention and relapse (236-239), ethnic and gender differences (240), treatment in a criminal justice setting (210, 241, 243), and treatment of women with HIV (244).

In Rosenbaum et al.'s recent study of MMT (117), the women's primary reason for entering a program was to reduce drug-related harm to themselves and their children. They experienced barriers to treatment also faced by men (such as prohibitive clinic fees and waiting lists), but also had to contend with women-specific barriers that discouraged and sometimes prevented some from entering and others from fully engaging in treatment.

Although both men and women shared many similar motivations for treatment, such as avoiding the criminal justice system, burning out on "the life," and desire to change their lives, women spoke specifically of their relationships and family responsibilities as reasons for entering treatment programs. They sought MMT when their partners influenced them to use heroin and/or other drugs and to share injection equipment in an unsafe way, and when they were in abusive relationships. Occasionally these women could not initiate the treatment process until they had ended these relationships,

As has been the case for decades, many of the women in the study population (117) viewed pregnancy as a motivation for entering treatment. They wanted to "clean up for the baby," and saw the pregnancy as an opportunity to make other positive changes in their lives. In addition, women's desire to improve their capacity for parenting was a motivation for treatment. Both pregnant women and women with children experienced tremendous feelings of guilt over drug use and its potential detrimental effects on their children. This guilt often translated into efforts to seek treatment.

The data revealed at least three substantial barriers to treatment for women: (a) family responsibilities, (b) interpersonal and sexual violence, and (c) sex work. Either alone or in interaction with other factors, these barriers often effectively deterred and possibly prevented women from seeking treatment. Ironically, for those women in treatment, occasionally clinic policies converted motivations into barriers that may have prevented them from maximizing the therapeutic benefits that MMT had to offer (117).

The familial barriers fell into two categories: sexual partners and children. It was not uncommon for women to experience resistance from their partners in seeking treatment. Sometimes this resistance was subtle, such as in cases when they received no help with child care from their partners while they were trying to meet clinic demands. At other times resistance was more overt, such as when a partner's violence was meant to prevent a woman from seeking treatment. These women wanted MMT and all the benefits of stabilization, but they often faced resistance from those closest to them, their partners.

Although pregnancy and children were motivations for treatment, both also served as barriers to treatment. Some programs were hesitant to take pregnant women because of the extra resources they required. Even when they did present for treatment during pregnancy, many experienced discrimination at the hands of health care and social service workers within the clinic setting. So although pregnancy was a primary motivation for women to seek MMT, it also deterred them from getting help for their drug dependency. This effect had negative health consequences for both the women and their children, since adequate health care was not received.

A final barrier to treatment specific to women was their working situations. Sex work, in particular, made it difficult for women to fully engage in treatment, since the social worlds of sex work and drug use are closely intertwined. Many of the women found it economically necessary to continue with sex work, as they had few job skills and little social or economic support. In addition, many of the women in the Rosenbaum et al. study had criminal records. They reported that it was next to impossible to find conventional work after serving time. Although men, too, frequently struggled to find legal work after a jail or prison term, the women we interviewed believed it was especially difficult for them because of what they saw as greater social stigma attached to jail terms for women. With few or no legitimate work possibilities, women continued to find economic support in occupations such as sex work, which as noted earlier, increased their risk of HIV infection (117).

Implications of the War on Drugs for Women

The Reagan-Bush drug war was overt in its emphasis on interdiction and enforcement. The rhetoric of the Clinton war initially suggested a public health orientation, with proposed funding reversing to 70% for prevention, education, and treatment and 30% for enforcement. Ultimately, however, Clinton's drug control strategy allocated 64% of the budget to enforcement (245). The result has been that more drug users than ever before have been arrested and incarcerated.

For women. the war on drugs has been devastating, and for African-American women it has been a catastrophe. Drug arrests for women have escalated, and according to Wellisch, Anglin, and Prendergast, "From 1982 to 1991 the number of women arrested for drug offenses, including possession, manufacturing and sale, increased 89%, a rate almost twice that for men during the same period," (210). Incarceration rates have also soared. From 1980, the beginning of the escalation of the War on Drugs, to 1992, when Clinton took office, the female prison population increased by 276%, compared with "just" 163% for men (242, 247). Mandatory minimums had a tremendous impact on sentencing for women. In 1986, when the "mandatories" were instituted, one woman in eight was incarcerated in prison for a drugrelated crime, and by 1991 that figure had increased to one in three, an increase of 433% (compared with a 283% increase for men). Drug offenders accounted for over half (55%) of the national increase during this period (248).

Women have been arrested and incarcerated at escalating rates, not because their criminality has increased or that they are more violent and threatening. Owen and Bloom found quite the opposite:

Whereas the increasing population of imprisoned women implies an increased criminality among women, we disagree. Both our data and the research literature on imprisoned women stress the prominent role played by substance abuse, physical and sexual abuse, and poverty and underemployment in the role of female offenders. Our survey data also support the contention that a significant proportion of female offenders are not dangerous, are not career criminals, and thus do not represent a serious threat to the community. The impact of the huge increase in drug-related offenses is seen in the state and federal surveys as well as in the California data. We suggest that the criminality of women has not increased; instead, the legal response to drugrelated behavior has become increasingly punitive, resulting in a flood of less serious offenders into the state and federal prison. (249)

African-American women have experienced even more dramatic increases in arrest and incarceration rates. Between 1986 and 1991 there was an 828% increase in the number of black women incarcerated for drug-related offenses, which was nearly double that of black men (242). This increase is due to conservative fiscal policies that reduced not only economic options but government support for the poor, as well as an escalation in criminal justice sanctions as part of the War on Drugs. The crack economy provided those without economic options the opportunity to earn money at the cost of the incarceration of nearly one in four young black Americans.

The punishment of women extends far beyond themselves and into their families and communities. When women go to prison, their absence is felt by the 125,000 children under 18 they leave behind, whose lives are disrupted emotionally, psychologically, and physically. One wonders who is actually being punished:

Children of incarcerated mothers suffer disproportionate disruption in their lives. In 1992 about 90% of fathers in state prisons reported that their children were living with the children's mothers. Only a quarter of female inmates had similar support from a father. Ten percent of mothers said their children were living in foster homes, children's agencies or institutions. For children of women who are imprisoned more than once, the situation is even worse. Children are shuttled from home to home, relative to relative, institution to institution, returning to their mothers only to be separated. (250)

Alternatives to prison, such as treatment, for drug-related, nonviolent crimes, have not been realized. Despite a "treatment on demand" rhetoric emanating from Clinton's first drug czar, Lee Brown, Americans seem to be much more willing to spend shrinking funds on prisons than options such as drug treatment, which cost a fraction. Despite evidence that women are overwhelmingly arrested and incarcerated on (nonviolent) drug charges, the vast majority have not, for a variety of reasons, been exposed to drug treatment (242,249,251,252).

Finally, the War on Drugs has contributed directly to increased AIDS risk for women, their sexual partners, and their children. The government has gone beyond refusing to support and endorse needle exchange. Recently the Clinton administration actively suppressed important evidence demonstrating the HIV-reducing efficacy (without increased drug use) of syringe exchange programs.