The Impact of Global Drug Policy on Women: Shifting the Needle

This edited collection brings together contributors from around the world in an exploration of women, drugs and the impact of drug policy enforcement on women. The dramatic expansion in the availability and use of psychoactive substances over recent decades has transformed the way women interact with illicit drug markets. Either directly as cultivators, manufacturers, distributors and users of mind and mood-altering substances or indirectly as the partner, par-ent or carer of people involved in drug markets, an ever-expanding number of women are engaging with plant-based, chemical and diverted pharmaceutical substances. In turn, this means that more women are being caught up in drug policy enforcement.

while prevention and treatment are neglected. As discussed in the first chapter, whatever the financial outlays, prohibition is unachievable. Not only is it an unrealistic policy goal, the strategy of criminalising all forms of engagement with controlled drugs as set out in the 1961 United Nations Single Convention on Narcotic Drugs is counterproductive. It has generated a massive and lucrative illicit economy, one in which seizures of illegal drugs drive up prices, incentivising participation in the illicit trade. Eradication and interception dissipate drug market activities, extending manufacture, trafficking and use into new territories and geographical spaces. Enforcement of criminalisation leads to violations of human rights, corrupts state actors, corrodes state institutions and generates new forms of social and political violence. In criminalising personal and private behaviours, drug policy perpetuates stigma and generates multiple risks to individual and public health. In sum, criminalisation causes infinitely more harm than good.
The negative impacts and outcomes of drug policy implementation are neglected and inadequately captured by drug control institutions. Remarkably, and unlike any other area of public policy, the persistence of current drug policy approaches is justified through reference to unmeasured protection of 'health and wellbeing' and the promotion of higher moral purpose. The reality is that a greater variety of cheaper and purer drugs are available to an ever-expanding global market of consumers (UNODC, 2019a). From local to international level, we are not protected from the assumed dangers of drugs. Rather, drug policy galvanises drug market innovation and adaptation, while criminalisation exposes all of us to new and multiple forms of risk and vulnerability.
This collection is a catalogue of the routine and multiple injustices that women experience as a result of a policy that is not fit for purpose. The costs and impacts of drug policy enforcement are widely recognised as unequally distributed. Drug policy policing and criminal justice processes have been extensively documented as racist (Alexander, 2012;Hart, 2014;Koram, 2019) and targeted towards a variety of 'deviant' groups (Musto, 1999). Enforcement practices reinforce marginalisation, vulnerability and structural inequalities, with the most exploited countries and communities carrying the heaviest financial and social costs of a flawed policy. Until very recently, little attention was paid to the impacts of drug policy and enforcement on women. Men are the main actors in both the illicit trade and in its prevention and policing, as well as treatment services. In emerging into this heavily masculinised space, women are experiencing new forms of misogyny, exclusion, violence and sexual violence perpetrated by both non-state and state actors, informal and formal institutions. This layers onto other existing practices of gender discrimination and exclusion.
This book aims to advance new ground. Firstly, it explicitly focusses on women, breaking with a long tradition of scholarship, policy and policy analysis that has been gender blind (Campbell & Herzberg, 2017;Maher & Hudson, 2007). Secondly, in working internationally, it seeks to expand the small corpus of existing analysis of women and the drug trade, which has been overwhelmingly dominated by North American, and to a lesser extent, West European scholarship. Prohibition and the criminalisation of drugs is international and structured through a series of United Nations conventions. Chapters in this collection expand the geographical boundaries of engagement with the issue of women, drugs and drug policy, reflecting universalised and wholly negative commonalities of experience. The book also seeks to be innovative in bringing together contributors who are not only from different parts of the world but also a diversity of backgrounds and experiences related to drugs and drug policy. Practitioners, professionals, academics and those with lived experience are brought together in this collection with the aim of overcoming traditional silos, to decolonise approaches and to provide an opportunity to hear from those who are usually neglected or distilled into codes and numbers in scholarship. Alongside chapters presented in a traditional academic format, we integrate policy-based commentaries and 'voices'the verbatim accounts of women with direct experience of the many failures of drug policies. In a rare contribution to drug policy debates, this book also welcomed auto-ethnographic chapters. As outlined by Walker in Chapter 3, this situates 'the individual epistemologically in the political and cultural through the personal'. Following Ettorre (2017a), auto-ethnography is intended to transform personal experience into 'narrative representations of political responsibility' (p. 359). It serves here as an active demonstration of the personal as political.
This approach was hugely valuable. It enabled us as a collective to identify major gaps in research and policy, to engage with a breadth of experiences, to better understand the international dimensions of women's exposure to militarised drug 'wars' and policing, and to learn from each other. The most salient takeaway for the editorial team was the emotions, vulnerabilities and tragedies opened up and exposed by this endeavour, the value of mutual support whatever our backgrounds and nationalities, and the enormous resilience and strength of women demanding defence and promotion of their fundamental rights and campaigning for change to a policy that routinely violates and erodes their human rights.

A Note on Terminology
Gender-based discrimination permeates society and the policy-making process. As discussed by Macaulay in Chapter 2, we understand gender relations as a socially constructed set of expectations around men and women's roles, behaviours, practices and symbols in any given society. Gender norms are also relational: femininities and masculinities are constructed in relation to their own variants ('good women' and 'bad women') as well as in relation to one another (men who are seen as 'feminine' are seen as failed). Gender norms are also the product of patriarchal and unequal societies, which regard women as essentially inferior. As outlined by Schleifer and Pol (2017, p. 254), gendered identities 'affirm and reestablish a higher level of privilege for those categorized as male with respect to access to resources, employment and personal autonomy'.
Our approach in this book is to understand biological sex as more complex than assumed in the binary delineation of female and male, and we acknowledge that for some individuals, birth-assigned and self-identified gender are in conflict. Delineating who is, and who is not, a 'woman' is not our preoccupation. Our concern is the experience of intersecting patterns of exclusion and discrimination on the basis of assigned or assumed femaleness and how these are reinforced by the disciplining tool of drug policy. We draw attention to the inadequacy of monitoring, reporting and evaluation systems and the failure of nation states to fulfil their obligations to women, defined inclusively, as set out in international human rights treaties including the UN Charter, International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights. The 1979 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) defines the right of women to be free from discrimination. It establishes core principles to protect this right and provides an agenda for states to achieve equality between men and women. This includes by ensuring women's equal access to and equal opportunities in public life, education, health and employment. This book demonstrates that in the enforcement of drug policy and through the persistence of criminalisation-based drug policy strategies, states are reneging on these obligations, including in relation to the reproductive rights of women as set out in CEDAW (see also Schleifer & Pol, 2017).
At the same time, we acknowledge that the experience of women cannot be homogenised. Discrimination on the basis of race, class, age, religion, sexual preference, gender identity and ethnicity create intersecting vulnerabilities, disadvantage and denial of human rights. We did not want to pursue an approach that can be conceived as tokenistic. Many of us have experience of the divisions and debates within each of these individual streams of exclusion, and it is not for us to determine who does and who does not speak for particular communities. We are of the view that this particular historical moment, a period of resurgent rightwing nativism and pushback against women's freedom and rights, requires a common platform. In particular, this is a call for feminist research and advocacy to grasp the salience of drug policy as a women's issue and for feminist and women's movements to engage with the urgency of drug policy reform.
Stepping from the disputes within feminism and around womanhood, we are aware that some readers may object to our use of the term 'drugs'. For some within the drug policy reform and drug policy abolition movement, perpetuating the terminology of 'drugs' distracts from the social and political construction of the risks associated with a range of naturally occurring plant-based substances and synthetics (see e.g. Nutt, King, & Phillips, 2010). Furthermore, these risks are overwhelmingly linked to criminalisation. As discussed in Chapter 1, criminalising the manufacture, cultivation, distribution, possession and use of drugs and enforcing this with punitive policing and legal processes prevents individuals from knowing the contents of substances they are consuming, it encourages cutting and diluting for profit, and it leads to dangerous consumption practices. In our use of the term 'drugs' in this collection, we refer to those substances that are scheduled in the system of controls and restrictions established in the UN international drug treaty conventions (see Jelsma & Hallam, 2014).

Structure of this Collection
For those unfamiliar with drug policy, Chapter 1 by Julia Buxton and Lona Burger provides an overview of history and approaches. It discusses the norms and assumptions that have framed international strategy and national level policies by default. It is acknowledged that international drug policy may be at a turning point. The traditional consensus around criminalisation is fracturing, with over 30 countries and a significant number of individual states in the United States introducing some form of decriminalisation initiative over the last decade. While this is a positive step for drug policy reform, the changes to date relate largely to cannabis, have been subject to reversal by incoming governments, and they are implemented at the edges of a prevailing prohibition consensus. As such, we write about a prevailing drug policy paradigm, one that has failed to make any progress in the availability of controlled drugs, which continues to cause grave harm in enforcement impacts and which remains unacceptably gender blind in its evaluation and assessment of outcomes.
In Chapter 2, Fiona Macaulay steers discussion of drug policy towards consideration of how analysis can and should be gendered. Her contribution discusses existing structures of gendered inequalities and vulnerabilities of women, including in relation to health and security, and how these are exacerbated and reproduced by drug policy and criminalisation approaches. This frames subsequent contributions on the impact of drug policy policing and criminal justice processes and issues around health, ill health and women's access to treatment and services. While this collection is overwhelmingly focussed on the searing and disproportionate negativities of drug policy enforcement and criminalisation on women, Chapter 3 by Ingrid Walker addresses the issue of pleasure in research about women and drug use. Through the lens of critical drug studies, Walker explores women's drug use as a mechanism of rebellion, activism and self-exploration, which are emphasised as mechanisms for change in the concluding section of this book. Chapter 4 introduces Fiona's Story, an interview with Fiona Gilbertson of Recovering Justice. Following from Walker, this is a narrative of empowerment and mobilisation from the lived experience of exclusion. In what emerges as a common theme in the collection, Fiona's Story illustrates how gendered hierarchies are reproduced across social and organisational spheres, including within the recovery and drug policy reform community.
The section 'Health Care and Treatment: Stigma, Gaps and Vulnerabilities' drills down on the particular vulnerabilities of women, both as users of drugs and as experienced relationally as the partners of men who use drugs. The contributions in this section highlight unacceptable weaknesses in research, epidemiology and services for and in relation to women and the barriers women face in accessing appropriate care and treatment. Claudia Stoicescu, Ariel Richer and Louisa Gilbert address a 'nexus of risk' configured around gender-based violence, HIV and drug use; April Shaw analyses risk behaviour among older women who use drugs and Zsuzsa Kaló explores issues of pre-existing mental health conditions, trauma and post-traumatic stress disorder. Underscoring the universalised nature of the obstacles that women face, Daria Matyushina-Ocheret examines the barriers to health services faced by women in Eastern Europe and Central Asia. In the second of our 'Voices' contributions, Suzanne Sharkey relates a personal experience of struggle: to access appropriate and female centred provision in treatment, care and recovery. It is a compelling narrative, a journey that starts with her former career in the police service and which recounts the stigma, guilt and shame of dependent use. These themes are echoed in the contribution by Anastacia Ryan. Using the case study of sex work, Ryan reminds us that legal change without an agenda of social justice is an inadequate mechanism for addressing structural inequalities and social marginalisation.
The section 'Criminal Justice, Injustice and "Criminality"' turns attention to women's experience of enforcement and exposure to criminal justice system processes. To contextualise these trends, Julia Buxton provides an analysis of existing research on women's changing roles in drug supply activities. Corina Giacomello and Coletta A. Youngers explore the staggering rise in the incarceration of women for drug-related offences in Latin America. Their research draws attention to women's lack of access to justice in the region, the pressures that women face from male relatives and partners to engage in drug-related activities, and the circumstances of chronic vulnerability and poverty that renders the illegal drug trade a viable means for women to support vulnerable livelihoods. This latter aspect is further developed by Isabel Pereira and Lucía Ramírez in their discussion of women coca growers in Colombia. They highlight conditions of rural marginality and insecurity that renders engagement in coca cultivation a crucial livelihoods strategy. Ingrid Marcela Muñoz Quesada provides a profile of these women, trapped in a cycle of poverty, insecurity, insurgency and drug 'war' violence.
Discussions around disproportionate and punitive sentencing in penal processes relate back to earlier themes of patriarchy and cultural expectations of women, and the draconian nature of punishment for transgression. This is echoed by Giavana Margo in her analysis of policing and sentencing practices in Russia, and by Chontit Chuenurah and Ukrit Sornprohm in relation to drug policy and women prisoners in South East Asia. Drawing on diverse geographical experiences, all three chapters emphasise the failure of states to provide appropriate support, rehabilitation and services for female prisoners, the vulnerability of incarcerated women to institutionalised violence and the impacts of punitive sentencing on families and children.
Mary C. K. Chepkonga served as Deputy Commissioner for Kenya's Prisons Service. From a national perspective, she comments on the failure of states to adopt best practice recommendations for the protection and care of female prisoners, and the gap between declaratory statements and national commitments on prison standards and the institutionalised hostility to actual implementation. Wilson Box presents a snapshot of the rise in the numbers of women who use drugs in Zimbabwe. As with earlier chapters in this section, the contribution from this non-governmental organisation focusses our attention on police and border guards as complicit in women's drug-related activities and as perpetrators of violence and sexual violence against women who use or distribute controlled drugs. As discussed in Chapter 1, this abuse of institutional power and office underlines a core myth of drug policy: that there is a neat binary between the 'evil' drug trade and the 'good' state. Criminalisation corrupts state actors and corrodes state institutions. Rather than a black and white Manichean drug 'war' struggle, the reality in all of our countries is a dirty grey area where formal and informal blur. This links to our third Voices contribution from Kristine Mendoza. Working in the front line as a street lawyer in the Philippines, her narrative presents a damning indictment of the violence and rights abuses of President Rodrigo Duterte's drug 'war'.
While the collection focusses on women's exposure to crude and violent enforcement impacts and state neglect, we felt it necessary to include other considerations of women and the drug trade. Just as Walker provides a discussion on drug use and pleasure, Cecilia Farfán Méndez provides a fascinating analysis of women's involvement in organised crime and drug trafficking through a comparative analysis of Mexican and Japanese organisations.
The final section 'Best Practice, Mobilisation and Reform Agendas: Towards Narco Feminism' brings together academics and activists from diverse geographical contexts, all relating strategies of survival and politicisation. Two contrasting 'Voices' reflect the diversity of drug policy enforcement experiences that inform our demand for radical policy change. Happy narrates her experience of drug use, service denial and emergence as a drug policy reform activist in the narrow and dangerous space of advocacy work in Tanzania. Rose is British and retired and writes from her experience of grief. She narrates the tragedy of losing two sons in a protracted and unsuccessful struggle to get treatment and support for their drug dependence. In a theme that weaves across our collection, Rose talks of the stigma that prohibition has built around the use of drugs and the impacts that this has on families. In her story, Rose narrates the isolation created by cultures of silence and shame and discusses how the organisation Anyone's Child provided -for the first time -a community of shared experience: families grieving the unnecessary and tragic death of loved ones.
Bethany Medley, Fatma Jeneby and Iga Kender-Jeziorska pull us across the globe, with insights on harm reduction, self-organisation and strategies for reaching women made vulnerable by the criminalisation of drugs in the United States, Central Europe and East Africa. Medley's chapter examines overdose prevention strategies among pregnant women in New York City, while Jeneby and colleagues discuss best practice in outreach and medical services for female drug users in Kenya. Kender-Jeziorska analyses recreational drug use among women at music festivals in Hungary and Poland, with her chapter presenting strategies for reducing associated harm. Ailish Brennan draws from her experience as a transgender woman who uses drugs to discuss the differential and compounding impacts of drug policy enforcement on sexual and gender minority groups. Using the term 'womxn' as explicitly inclusive of non-cisgender women, Brennan highlights the overlapping exclusions which further complicate queer women's access to drug-related services.
As discussed in Chapter 1, it is only very recently that international drug control institutions have acknowledged the importance of a gender perspective and gender sensitivity in drug policy. It was only in 2016 that the UN General Assembly Special Session on Drugs (UNGASS) saw Drugs saw member states commit to mainstream: 'a gender perspective into and ensure the involvement of women in all stages of the development, implementation, monitoring and evaluation of drug policies and programmes' and to recognise the specific needs, vulnerabilities and circumstances of women and girls (Schleifer & Pol, 2017). But as with so many aspects of high-level commitments and the reality of actual implementation, little has been achieved in practice. Marie Nougier addresses a key gap: information. Her contribution provides a valuable analysis of how drug policy metrics can be gendered so that the performance indicators of national and international drug policy institutions can better engage with the impacts of implementation on women. Through the lens of national-level experience, Anna L. Ross outlines the challenges that women and women who use drugs face in being recognised and accepted as stakeholders in drug policy. Anna brings auto-ethnography into her account, recounting with welcome frankness how self-identification as a woman who uses drugs can close many policy doors. Silencing and excluding those who engage with illegal drug markets precludes the uptake of evidence from people with lived experience, pushing them to the margins of drug debates. Imani Robinson and Judy Chang present two powerful calls for action, rebellion and mobilisation. Like Anna, both integrate personal experience with scholarship and evidence-based research to present compelling argumentation -not only for drug policy change, but for social justice, respect and personal autonomy.

A Few Words of Thanks
We present a diverse and eclectic mix of chapters, stories and insights, in turn reflecting the diversity of women's experiences and interactions with drugs and drug policy across the globe. Contributors were initially brought together through a series of workshops and organisational platforms unified by the common themes of providing necessary visibility to the experience of women and of the urgency of change to international and our own national-level drug policies.
We would like to take the opportunity to thank colleagues who supported and participated in these events and to acknowledge the importance of their research, advocacy and activism in driving increased attention to the gross injustices and vulnerabilities resulting from the criminalisation of drugs and from drug policy enforcement activities. We thank the Global Drug Policy Programme of the Open Society Foundations and our grant manager Matt Wilson for the financial support that enabled us to develop this project and Mama Diene who assisted us in convening our regional workshop in Ghana. The organisational and administrative assistance of the Global Policy Academy led by Bernhard Knoll-Tudor at Central European University in Budapest was invaluable in keeping our activities and events on track with thanks to Livia, Nora and Tanja. We express our immense gratitude to OSF for allowing us to redirect funds that were planned for (pre-COVID) conference activities to Open Access of this publication, and to the International Network of People Who Use Drugs (INPUD) and the Center for US-Mexican Studies, University of California San Diego for the additional financial support that got us over the line for full Open Access publication. Our sincere gratitude to Judy Chang at INPUD and Professor Rafael Fernández de Castro at UCSD. The editors met while variously working and studying at Central European University in Budapest, where in his capacity as founding Dean of the School of Public Policy, Professor Wolfgang Reinicke offered unending encouragement and support for drug policy research.
In particular, we thank Kasia Malinowska, Director of the Global Drug Policy Programme at Open Society Foundations, without whom this would not have been possible. We dedicate this book to Kasia, and acknowledge the immense contribution that she has made in supporting voices, perspectives and ideas North and South of the globe that would have otherwise struggled to overcome prejudice, hostility and lack of funding opportunities available for this vitally important but marginalised issue area. Dziȩkujemy Ci. Z wyrazami miłości.