A 2023 report grounded in women’s lived experiences of substance use in Ireland was launched by the then Minister for Justice Simon Harris TD on 30 March entitled, ‘You can’t fix this in six months’: Understanding the intersectionality of women’s substance use in the Irish context.1 The report highlights the complex nature of women’s substance use and the issues they face. It argues for female-only services that support motherhood and recognise the exploitation, trauma, and abuse many women who use substances experience (p. 19).1 The research, funded by the Irish Research Council New Foundations scheme, was carried out by a team from University College Dublin led by Dr Sarah Morton in partnership with Merchants Quay Ireland.

Context and study aim
The report argues that Irish drug policy and practice have often overlooked the gendered needs of women who use drugs. However, the authors recognise the gender dimension in Ireland’s national drugs strategy and the introduction of some gender-specific initiatives and services on the Irish service landscape.2,3 They explore the existing literature to illustrate how women have different substance-using patterns and trajectories when compared with men, and how the health-related and social consequences they experience may also differ, particularly in relation to physiological factors, experiences of trauma, mental health, and cultural considerations.

The authors argue that there continues to be a gap in our understanding of how women’s substance use intersects with other issues. They define intersectionality as ‘how one’s life experiences are constituted by reinforcing occurrences relative to different aspects of one’s identity, including gender and class’ (p. 3). Women’s substance use may intersect with issues such as poverty, migration status, trauma, domestic violence, sexual violence, prostitution, homelessness, motherhood, and involvement with the criminal justice system. The study aimed to explore the lived experience of women who were subject to such intersectionality to inform policy innovation and the treatment needs of women.

Methods
Qualitative interviews were carried out with 14 women aged between 25 and 60 years and with lived experience of substance use and other complex issues. Eleven were mothers, four were actively using substances, and 10 described themselves as abstinent. Transcripts of the interviews were analysed thematically and patterns and themes within the data were explored and reported on in the publication.

Findings
The women’s narratives illustrate the complex nature of their substance use and how it is interlinked with a wide range of issues, such as lifetime trauma and abuse, gender-based and domestic violence, transactional sex, homelessness, involvement in the criminal justice system, and motherhood. The authors identified five overarching themes in their analysis.

1   Substance use patterns and prevalence: Substances used by women in the study included alcohol, prescription medicines, and illicit substances. Two patterns were identified in relation to initiation of use. First were those who started when they were teenagers and were often ‘initiated or groomed into substance use and an intimate relationship by an older male’ (p. 18). These women often linked their use to difficulties, tensions or abuse in their home settings, with some reporting use among other family members. Second were those women whose use had started subsequent to an experience of violence or abuse within a relationship. Medication misuse was a common feature of these women’s initiation. Benzodiazepines and pregabalin were the two medications women reported as causing the most harm.

2   Relationships and family: While some women described having supportive parents or families, more often family relationships were characterised by abuse, neglect, and drug use. These experiences were perceived by the women to have left them vulnerable to grooming, exploitation, or an abusive relationship in their early teenage years. Across their relationship histories, domestic violence was a feature of every woman’s experience. Furthermore, coercive control, sexual violence, physical violence, and stalking also featured for some. For the majority of women, there was a deep interface between women’s substance use and their experiences of abuse and control.

3   Stigma and shame: Women spoke about stigma and shame, both in relation to their substance use and being a mother. This impacted on how they engaged with services. For example, some were reluctant to raise issues, such as experiences of domestic violence, with drug treatment services. They were concerned about how service providers would respond to these issues and whether it would raise child protection and welfare issues.

4   Implications and intersectionality: As mentioned above, domestic, sexual, and gender-based violence featured heavily in the women’s experiences. The authors found five subthemes that cut across their experiences to varying degrees: mothering; housing and homelessness; transactional sex and prostitution; criminal and civil justice involvement; and mental health and trauma. Each of these themes interacted with women’s substance in complex ways. For example, being a mother had been a source of great trauma for women due to the grief and devastation experienced from children’s deaths, miscarriages, and loss of contact with children. However, being a mother had also been a motivator for positive change among some women, as they were driven by a desire to meet their children’s needs. Another example is homelessness and a lack of security around housing, which was described as ‘normative’ (p. 13). Addressing substance use issues while experiencing homelessness and living in a hostel with other women who use, for example, was problematic.

5   Engagement with support and interventions: Three subthemes were identified in relation to this theme: turning points and initial contact with services; pathways through services; and policy and practice change. Involvement in the criminal justice system, the needs of children, and personal health issues were the three circumstances that led women to seek help. Factors impacting on women accessing services included the mixed-gender nature of most services, geographical location, childcare availability, and the treatment or intervention approach.

Policy and intervention implications
The report highlights the need for female-only services that recognise the specific needs of women as mothers as well as providing the support needed to address their experiences of exploitation, trauma, and abuse, among other issues. Given the prevalence of gender-based violence in these women’s narratives, the authors argue that ‘an effective response requires an integration of expertise and ongoing support to develop and maintain realistic and appropriate coping strategies’ (p. 19). They also highlight the need for women to be safe when seeking and accessing support: ‘This may include female-specific services and interventions, as well as safety planning, risk assessment, exploration with women about the current risks in their lives and clear policy and operational guidelines for mixed-gender interventions’ (p. 19). The authors call for attention to be paid to the prescribing and misuse of medications, highlighting in particular benzodiazepines and pregabalin and their associated risk of dependency and overdose. They also flag an initial interaction with the criminal justice system, or child protection, and welfare involvement as important opportunities to engage women in services.

1    Morton S, Gallagher B and McLoughlin E (2023) ‘You can’t fix this in six months’: Understanding the intersectionality of women’s substance use in the Irish context. Dublin: University College Dublin and Merchants Quay Ireland. Available from: https://www.drugsandalcohol.ie/38492/

2    Department of Health (2017) Reducing Harm, Supporting Recovery: a health-led response to drug and alcohol use in Ireland 2017–2025. Dublin: Department of Health. Available from: https://www.drugsandalcohol.ie/27603/

3    In particular, gender-specific initiatives and services such as Ashleigh House in Coolmine and Jane’s Place in Merchant’s Quay Ireland.