Impossible Identities: The Double-Binds on Drug-Using Women in Rural Appalachia

On March 13, 2017 I settled into my chair in room 220 in the New Classroom Building at Virginia Tech. I was there to listen to a guest lecture by Lesly-Marie Buer, a doctoral candidate at the University of Kentucky. Two overhead screens on either side of the room displayed the title of the lecture: Paradoxical Treatment: Drug-Using Women’s Navigations of Impossible Identities in Rural Appalachia.

Addicted. Pregnant. Poor. book coverWomen in American society are often haunted, to different degrees, by the possibility of pregnancy. Kelly Ray Knight notes in Addicted. Pregnant. Poor. that, “The biological nature of pregnancy, specifically in reference to the potential for shared illicit substance use through shared blood between a fetus and mother, shifts the ontological status of the woman and initiates legal, technical, and political limits on her as an individual” (Knight 2007: p. 12). Due to the specter of pregnancy, women who suffer from addiction are maligned as child abusers or potential child abusers – as those who have failed to meet the ideal of the selfless mother.

Buer’s study looked at programs for women with SUDs in a 5-county area in rural Kentucky. Her aim was to determine what these programs are doing to help and also marginalize women, and their limitations. Buer interviewed 32 “gatekeepers,” or treatment providers and community leaders from different organizations. She also spoke with 40 women who went through the programs, many who did so several times.

The women in rural Kentucky have three treatment options: drug courts (which don’t believe in treatment with medications), buprenorphine clinics, and community mental health centers (such as Horizons). In Horizons, Buer reported that women are in contact with the state on a daily basis through law enforcement and Child Protective Services (CPS). Most of the women in Horizons have lost custody of their children after testing positive for illegal drugs once. Not all of the women in Horizons suffer from addiction. In fact, the women exhibit a wide range of drug use, from having smoked marijuana once or only on weekends to severe addiction to methamphetamine or opioids.

The dominant understanding of addiction at Horizons is that addiction is both a disease and a moral failing. Staff believe that the women made choices that caused a disease, that they will then pass on to their children through exposure to the drug and through genetics. Buer’s research revealed that some professionals selectively cite studies that appear to justify this concept.

Women in Horizons are thus doubly stigmatized by this “moral failure rooted in genetics and passed through generations.” They are categorized as “bad” mothers. This prevailing belief extends to all women as potential mothers, and asserts that women who use drugs “put all children in danger,” not only their own. Buer described a presentation she attended in which women using drugs were blamed as the cause of all disorders in the education system, without evidence.

As an example of the stigma women face, legislators and media have continually emphasized a notion of “babies born addicted,” where infants exhibit withdrawal symptoms at birth. The concept of “addicted babies” is a misunderstanding of addiction itself. The babies may be born dependent on an opioid, for example, but they do not persist using despite negative consequences so they are not addicted. Babies born dependent to substances are weaned off, and there is no evidence of adverse effects later in life. Yet, the myth of “babies born addicted” persists and stigmatizes mothers who do suffer from addiction.

Women who lose their children also lose human connection, and exchange their identities as “mothers” for “addicts.”

Women in rural Kentucky also suffer from another stereotype, that they are coping poorly with a “hyper-violent Appalachian culture that victimizes women.” The women are doubly dis-empowered as having no control over addiction, or over the presumed violent culture of which they are “victims.”

“The idea of these women as victims is used as a target for coercive state intervention,” Buer reported. Women must agree to urine tests for drugs, and if they do not agree, CPS will be called immediately. Buer, when hospitalized for an early delivery, underwent this urine test herself, and later her blood was tested for drugs without her consent.

Funding is a huge issue for Horizons. Administrators of Horizons recognize that stigma is a problem, but they do not have enough money to change the behavior of their clinicians. Sometimes they knowingly perpetuate stigmatizing practices in order to qualify for limited funding. More funding is clearly needed for these programs to combat the stigma that is causing so many problems for women in poverty. Unfortunately, funding is likely to be lost if the ACA is repealed.

The stigma isn’t limited to Horizons or to the medical system, however. Buer told the story of a program called CRACK that was started by a woman, a community member, who admitted to having race-related motivations. CRACK payed women $300 to get sterilized. An advertisement saying, “attention drug addicts & alcoholics,” targeted low-income neighborhoods, and especially those of people of color.

Women with addiction in poverty in rural Kentucky, beyond stigma, are subject to a practical double bind. They are forced to choose between childcare and self-care for addiction. Buer documented that men in NA groups criticized women for not doing more in the programs, though women needed to leave early to care for their children. The women were thus either “bad moms” for neglecting their children or “bad citizens” for neglecting to seek help for their “disease.”

Worse, Buer said that women in abusive situations feared calling the police, because CPS would intervene and take their children away. One woman was charged with neglect for not being with her children while her husband was beating her. The husband was not punished, which, Buer said, is often the case. The unequal treatment women receive from the state extends beyond domestic violence. Buer reported that police officers pull women over and check their arms for track marks, as a pseudo-drug-test.

Women in Horizons are stigmatized by law enforcement, medical practitioners, and the surrounding community. To regain agency and positive identity, Buer said that the women found ways to be good mothers while using by providing food and shelter and shielding their children from their drug use. They view themselves as strong in coping with adversity, and focus on proving people wrong, affirming things like, “I neglected myself, not my kids.” Some women choose to give up custody on their own terms, finding a friend or family member willing to assume custody and visiting their children whenever possible.

The paradoxical and stigmatizing identities of “bad mothers,” “bad citizens,” and “addicts,” combined with the extra stigma associated with poverty or race make for an impossible situation for these women in rural Appalachia. Many in American society have been passionate activists for “the rights of the fetus” and to safeguard children in unstable situations. Rarer are those who focus on the needs of women and mothers, and at some point the conflicting demands placed upon women in poverty are unrealistic and counterproductive.

In Addicted. Pregnant. Poor., Knight writes that, “Addicted, pregnant women are biopolitical projects on which social and legal interventions are attempted as pregnant, addicted women travel between environments of drugs and hustling and institutions of care and coercion. whether biological mechanisms or social-psychological histories are evoked to explain addiction, the path from pregnancy to mothering a child ultimately demands stability and abstinence” (Knight 2007: p. 31). To provide that stability, the addictions treatment and criminal justice systems need massive overhaul to combat stigma, and to increase access to treatment and vital resources for women in poverty.

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