1. Background
Addiction to illicit drug is a serious public health concern with a global prevalence of 3.3% to 6.6% among the adult population (1). Although, men are more likely to use drugs compared to women, this does not necessarily reflect a lower risk for women (2-4). However, drug treatment centers are often focused on men and less women are enrolled in and receive services through these centres. While several socio-cultural factors could be at play, a part of this disproportionate enrollment can be explained by the higher prevalence of drug use, involvement in drug-related activities, and therefore higher referral rates of men to these centres (4).
Social role theory highlights that men and women act based on different stereotypes that determine their social roles and expectations. Dominant notions of femininity (e.g., responsibility of taking care of the family) and masculinity (e.g., macho attitudes) often influence men’s and women’s risk taking behaviors (5). Gender-based differences cannot be overlooked when it comes to the pathways to substance use and misuse. Dissimilarities in men’s and women’s drug addiction patterns could be due to a number of socio-cultural, biological, and mental factors (4, 6). For example, risk aversion behaviors vary across the genders due to the effect of nature versus nurture; men are more likely to take risks while women are often promoted to lead a cautious lifestyle due to their personal preferences or socio-cultural norms and expectations (7).
The motives and underlying reasons that drive women to illicit drug use and addiction may be different from those in men. While men are mainly introduced to drug abuse through their peer and friendship networks, women may start using drugs due to familial matters and the influence of their intimate relationships (3, 6). Men and women are also attracted to different types of drugs; for example, men are more likely to smoke marijuana, while women are more likely to abuse alcohol and prescription drugs, such as benzodiazepines and sedatives (3, 6). Moreover, men and women may abuse drugs to fulfill different desires (4).
In the Middle East and North Africa (MENA) region which faces a large drug use problem, our understanding of gendered experiences of exposure to illicit drug use remains limited (8). Among MENA countries, Iran has one of the largest drug using population, partly due to its long borders with Afghanistan and Pakistan, two major producers of illicit drugs. Although drug use is common in Iran, some provinces seem to have a significantly higher rate of drug abuse in comparison with the rest of the country. For example, the Kerman province, located in southeast Iran, has the highest rate of opium use in the county. Drug related problems, in Iran’s largest province, are usually explained by its proximity to the Afghanistan and Pakistan borders, as well as the cultural acceptability of opium smoking. Based on a recent study, residents of Kerman have been ranked as those with the highest acceptance rate of opium use, both subjectively and objectively (9).
2. Objectives
Given the paucity of evidence on the gendered-experiences of exposure to drug use in this region, and a possible unique pattern due to the different socio-economic and cultural situation, a qualitative study was carried out on male and female people who use drugs (PWUD) in a drop-in center (DIC) and HIV triangulation clinic in Kerman.
3. Patients and Methods
3.1. Study Setting
Due to the hard-to-reach nature of PWUD, particularly women, the stigma attached to addiction, and the criminalization of drug possession in Iran, we chose our samples from an HIV triangulation center and a DIC for women. The triangular HIV center was established in Kerman in 2004 to provide specific services exclusively to people living with HIV. These services include counseling, treatment, and methadone maintenance therapy. As the sample of women at the HIV triangulation center who had a history of drug use was limited, we recruited more study participants from a DIC for women. This center is the only one to provide services to vulnerable women who are either drug-addicted, sex workers or both; it provides specific harm reduction services such as methadone therapy, distributing free condoms, serving free meals, and counseling. Due to participants' reluctance to disclose their demographic characteristics, we were not able to collect precise information in this regard. However we know that they were all young or middle aged and had limited years of education.
3.2. Data Collection
In this qualitative study, a convenience sample of participants (men and women) were recruited between September and November 2011. We prepared an interview guide on the main areas of the study, exploring the high risk behaviours associated with HIV infection, (e.g., risky drug use and sexual practices). Regarding drug use, we asked the participants to share their history of using drugs. In particular, we explored their drug use initiation and continuation experiences. We probed the experiences of the participants, their route of drug use and the influential people who encouraged them to use drugs for the first time. Interviews were conducted in Persian and all participants received a non-monetary incentive of food worth US$ 8. No personal information or any traceable information were obtained. Data were collected through in-depth interviews that took approximately 45 to 60 minutes to complete. The interviews went on until we reached the theoretical saturation.
3.3. Data Analysis
Interviews were transcribed on the day of the interview and and data were analyzed using thematic analysis (10). To analyses the data, initial codes were extracted and categorized to form the main categories and themes of the study. Themes and categories were finalized through a group discussion with co-authors.
3.4. Ethical Considerations
The proposal of this study was reviewed and approved by the ethics committee of Kerman University of Medical Sciences. The participants were given information about the aim of our study and how our results would be disseminated. They were also reassured about the confidentiality of their identities. Participants’ responses were not shared with other clients and the centers’ staff members. All interviews were conducted in a private room in the HIV center, where no one else could hear the conversations
All participants consented verbally to participate and were reassured that they could skip any question they felt uncomfortable with or stop the interview whenever they desired. All interviewees consented to the recording of their interview. Data were coded and kept on a password-secured desktop computer, and all audio files were destroyed two weeks after the final analysis.
4. Results
4.1. Study Participants
We interviewed 29 participants (14 men and 15 women). Participants preferred to mention their approximate age only; however, they aged from their mid-20s to their early 50s. Most of them were single or divorced and unemployed or in unstable jobs with low incomes. At the time of the interviews, the majority of the participants were living on their own or staying with friends. Most had been born into low- or middle-income families and had not completed high school.
Most participants were introduced to illicit drugs through their family members. Opium, crystal meth, and heroin were the most frequently reported drugs and most participants had started drugs when they were young. Many men had a history of prison and drug injection.
4.2. Main Themes of the Study
Most men (13 out of 15) in the study were single and had started smoking cigarettes before using drugs. Conversely, most women were married (13 out of 14) when they started using drugs, and had started drug use with opium. Only one single woman had begun drug use with heroin. Also, except a small proportion of women who had later shifted to crystal meth and heroin, others continued to use opium. On the other hand, men reported a different pattern; they had started with a light substance (i.e., smoking cigarettes), and ended up using chemical (e.g., crystal meth) and heavy substances (e.g., heroin).
4.2.1. Motivations to Use Drug
A majority of men were encouraged to smoke and use drugs by their friends, and only a few of them had commenced drug use on their own. Men’s reasons for drug use initiation ranged from curiosity to peer pressure. For example, male interviewee 2 stated: My parents were drug users, and I had frequently seen them smoke. I was curious to experience it. Moreover, male interviewee 3 reported: When my friend offered me to smoke a cigarette, I did. I wanted to know how it feels. Male interviewee 1 who had first experienced smoking with his friend, mentioned starting smoking to look manly and strong. We [him and his friend] were in a park and he [his friend] lit a cigarette and gave it to me, “Come on! Smoke,” he said. I was surprised; He said "Do not be scared", he sounded okay and comfortable with smoking. His brother and my brother were also in the park, so I did not want to wimp out. He said "Don't be a sissy", and teased me, so I tried it.
Some interviewees reported a lack of power to say no as a major reason of commencing their drug use. For example, male interviewee 5 declared: My friend offered me drugs. I was scared, but I just could not say no to him!
A number of participants used drugs or smoked to cope with their painful emotions. For example, male interviewee 2 whose wife had concealed her genetic disease before marriage and passed it on to their son, stated: When I realized my son has a genetic disease, it was so upsetting. My wife had not told me about that before. My friend suggested that I use drugs to kill my emotional pain.
The results of our study show that women were encouraged to use drugs through different mechanisms than men. Women’s friends did not have a considerable role in encouraging them to initiate drug use; however, they had often been introduced to drug use through their husbands, in-laws, or own families.
Women’s reasons for drug use were diverse. Some had initiated drug use to relieve their physical pains and ‘refresh’ themselves. For example, female interviewee 4 reported physical pain as a reason for her first exposure to drugs: I fell over and hurt myself. My leg was painful, and my husband told me that opium is good for leg pain and back pain. Female interviewee 5 who had a drug using mother also stated: I was working hard and my mother [who was addicted as well] told me it was good for me to use opium and refresh myself and improve my general health.
Moreover, female interviewee 1 talked about how she had started drug use because of her difficult delivery: When my first baby was born, they [her relatives] said that doctors are useless and would cause you trouble. My mother-in-law and my sister-in-law called a traditional midwife, and I had a very difficult delivery. I almost died, and I did not know anything. They told me to use opium, because it was good for my sutures and pain.
Some participants however, reported higher work performance as a motive to start drug use. For instance, female interviewee 3 stated: My aunt told me that opium is good for you, it numbs your pain, it is good for leg pain, it will refresh you and you can work harder. Furthermore, similar to a subgroup of men, some women used drugs because they did not have the power to say no to a friend or an intimate partner who had offered them drugs.
Female interviewee 7 declared: I was with my boyfriend, whom I married later on. He prepared the stuff and asked me to use heroin. I was scared, so he helped me and taught me how to use drugs. I could not say no to him. I wanted him to be happy with me because we were friends.
In addition, emotional pain was another reason for starting drug use among men and women.
Female interviewee 2 said: My husband was in prison and I was upset. They [relatives] told me that opium is good for me and would calm me down.
For some women, drawing attention from others was the main cause for drug use initiation.
Female interviewee 6, a former prisoner outlined: when I was in prison, I asked my husband to forgive me and stay with me; however, he refused to do so. I told him that if he would not come back to me I would use drugs but he did not seem to care. Therefore, I started using drugs when I was released from prison.
Interestingly, two women who were introduced to drugs by their husband or in-laws reported that they were encouraged to use drugs by their husband to avoid bothering them about their job and financial instabilities.
For example, female interviewee 8 stated: It was at my wedding night when my father in-law offered me drugs. I wanted to please them and could not say no. Later in life, whenever my husband would not look for a job or work, I would give him a hard time about our financial struggles. Once I heard my father in-law told my husband: “if she becomes a drug addict, she would neither bug you anymore nor leave you.”
Lastly, female interviewee 9 had gone through a similar situation: My husband encouraged me to use drugs, as I would always fight with him over his unemployment. He made me an addict to stop bugging him about work.
5. Discussion
The results of our study suggest that social roles and stereotypes which define the expected gendered behaviours, could create different drug use patterns and practices across men and women. Gender differences are not only observed in drug types amongst men and women, but are also present in their motivations or reasons of drug use initiation. Such differences could originate from socio-cultural factors or physiological differences across genders.
In the current study, men were mainly single when they started smoking cigarettes or using drugs, however, most women were married. In the conservative and patriarchal context of Iran, compared to men, single young women are often subject to more restrictions and supervisions; reducing their chances of accessing drugs. On the other hand, once they get married, they may be encouraged by their partners or their families, to start using drugs. Previous studies support the idea that women’s decisions to start drug use are mainly influenced by their relationships with men (11). The impact of a man as a husband on a woman’s decision regarding drug use could be explained through a complex combination of love, power, and women’s status (12). Nonetheless, family influence can be both negative and positive for women. While some women might start using drugs under pressure from their husbands, others might cease drug use for the sake of their family (11).
Furthermore, different popularity and social acceptance patterns could impact substance abuse practices across genders. The ways in which boys and girls behave to win popularity and social acceptance often vary. For girls, parental socio-economic status and their own physical appearance matter the most, whereas boys mostly care about ‘coolness’ and social skills (13). Socialization can affect people’s behaviors through different mechanisms, including learning from observation and self-concepts, (i.e, adopting behaviors consistent with a group identity). However, whether people start smoking due to peer pressure is the subject of controversy. Some studies acknowledge the importance of peer pressure on smoking initiation (14), but others argue that it is not a strong predictor for commencing smoking. They suggest identity statements and coolness as important determinants of smoking debut (14). In our study, women did not report showing off as a motive for drug use debut; however, other studies have observed showing off to play a role in smoking initiation among young women (15).
Smoking is often regarded as a ‘gateway’ to drug use across several settings (16). This could also be the case in Iran where about 93.5% of PWUD had smoked cigarettes before they started illicit drug use (17). However, consistent with our findings, the evidence suggest a different gateway to drug use debut among women where most Iranian women who use drugs have often begun with opium (17). In Iran, several studies have shown boys to be more likely to smoke cigarettes than girls (13, 18). This could stem from different gendered expecatations and socio-cultural norms around smoking cigarettes that disapprove women’s cigarette smoking but show a tolerance for men who smoke (19).
The degree of acceptance of drug use in Iran could also be rooted in the belief in the usefulness and benefits of drugs. In our study in particular, women started opium use mainly to alleviate physical pain and refresh themselves; a finding that could be attributed to the popularity and acceptability of opium in our study setting (i.e., Kerman). Based on a study conducted in Iran, among Iranian people, residents of Kerman had a high acceptance of opium use, both subjectively and objectively (9).
Lastly, curiosity was mentioned as a motive for drug use initiation among men. This could point to the difference between men’s and women’s perceptions of risk. Men often evaluate the outcome of a risky behavior less critically and enjoy engaging in risky behaviors more than women (20).
Overall, the pathology of drug abuse in Iran is a multifaceted problem and requires a multi-dimensional policy across different public health and law enforcement sectors. Different experiences of men and women in entry into illicit drug use calls for gender-specific harm reduction approaches and polices. Educating families on the adverse health-related effects of drug use could be a starting point in initiating a socio-cultural shift. Youth should also be empowered and educated with a set of skills to say no to drugs. As men have been at the centre of attention in most drug-related policies, scaling up specific interventions catered towards women who use drugs is necessary. Lastly, we would like to acknowledge the limitations of our study. Our participants belonged to low- or middle-income families and often had a history of incarceration and drug injection. Therefore, the results of this study in two single centres in Kerman have limited generalizability to other demographics of PWUD across the country. However, given the hard-to-reach nature of this population, female PWUD in particular, the current study does contribute to our understanding of different experiences of entry into drug use across men and women in the context of Iran.
