Free fall: Alcohol and drugs fuel the HIV infection rate, particularly among young, defenceless women who are not supported by their families and various organisations and institutions.(David Harrison)

They suffer the cruelty of our care

Bronwyn Myers
SA society continues to betray traumatised young women who spiral into a life of drugs and abuse.

COMMENT

Preventing all forms of violence against women aged 18 to 25 is critical not only for their wellbeing but also as part of a broader strategy for curbing the very high rate of new HIV infections, particularly in this age group.

Young women in violent partnerships are at risk for HIV because they are unlikely to discuss condom use for fear of reprisals from their partners. And, despite this prevention imperative, poor, young women who use alcohol and drugs do not feature on violence prevention agendas, even though they are vulnerable to all forms of abuse and violence.

A 2009 study in the Journal of Consulting and Clinical Psychology reported that close to 80% of women with substance problems have been exposed to abuse and violence, with the vast majority of these women reporting that this abuse first occurred during early childhood. Early abuse changes the brain’s reward circuitry and increases young women’s propensity to use substances as a way of numbing out unpleasant emotions and to cope with traumatic experiences.

Yet poor, young women who use drugs and who have been victimised remain neglected and unsupported by the very institutions that should intervene to protect them. Many leave school early because of their untreated mental health problems that emerged from early trauma and their subsequent use of substances as a coping mechanism.

Age disparate relationships
With limited education, few job skills and little opportunity for employment or to change their circumstances, they seek out relationships with older men who provide them with financial support to survive. Because of this financial dependency, they are often unable to negotiate condom use or leave these relationships when they turn violent.

In the townships in the Western Cape, many of these older men are gang-affiliated, increasing young women’s risk of continued exposure to drugs, violence and sexual abuse. Across nine studies with more than 2?000 drug-using women, it has been deeply disturbing to hear narratives of beatings, broken bones, forced sex and the inevitability of becoming infected with HIV. They feel trapped in a cycle of violence and substance use that is likely to continue unless the context of their lives changes.

These young women lack a social and economic safety net. This is largely because people stigmatise and discriminate against women who use substances, eroding any social support that might be available. Young women who use drugs are not seen as "proper women" and are consequently treated as though they are expendable. Whereas family and neighbours would normally intervene when a young woman was being beaten by a man, they turn a blind eye when this happens to a woman who uses drugs.

The social institutions, for instance the police, that are meant to protect women against violence also do not intervene. Both young women and service providers have told us how the police do not respond to requests for assistance or refuse to lay charge when a drug-using woman is being beaten by a partner or is raped.

Families also seem to offer little support. Some parents put pressure on young women to stay in violent relationships, especially where the partner provided for the family financially. Even where this did not occur, punitive parenting seems the norm, with little warmth being evident in young women’s descriptions of their family relationships. For the most part, they did not feel that they could turn to their parents for support in their efforts to change.

Although opportunities to complete their education or for vocational skills training could help them gain independence from their families and partners, there are few skills development programmes targeting young women and none to help them complete their education. Young women who use substances are often denied access to the few training and income-generation projects that do exist, because of their substance use. This discrimination entrenches their feelings of powerlessness to change their circumstances and the trajectory of their lives.

Breaking the cycle
To break the cycle of substance use and violence, they need treatment for both their drug and alcohol problems and the trauma they have been numbing with substances. Yet there are no services that treat these problems in an integrated manner. Many services for gender-based violence refuse to assist women with substance use problems until they stop using (which they cannot easily do because this is their coping mechanism). Substance-using women are described as "difficult" and "challenging". It is almost impossible to find emergency shelter for a woman who uses substances, even though her life may be in danger.

Similarly, little is done in substance abuse treatment services to address underlying trauma and continued exposure to violence. Traumatised women have poorer drug use outcomes than those who have not been exposed to violence. Consequently, young substance-using women who have been victimised slip through the cracks of these silos of care.

In response, the South African Medical Research Council, in partnership with the Research Triangle Institute, is piloting a brief trauma-informed substance abuse intervention programme focused on reducing alcohol and drug use, addressing trauma and empowering young women with self-care skills.

But to be truly effective the social context of young women’s lives also needs to change. Doing so will require partnerships with their communities, nongovernmental organisations and government so that a viable safety net for young women is created. Securing a better future for them, and by extension their children, is critical for building a healthy society and enabling everyone to participate in the economy.

For this to happen we need to ensure that young women who use drugs and alcohol are on the agenda for the 16 days of Activism for No Violence Against Women and Children. 

Professor Bronwyn Myers is a chief specialist scientist in the alcohol, tobacco and other drugs research unit at the Medical Research Council, and works in the department of psychiatry and mental health at the University of Cape Town

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substance abuse16 Days of Activism for No Violence Against Women and ChildrenMedical Research Council of South Africa