Mishka Terplan, MD, MPH
Women with drug and alcohol addictions have unmet reproductive health needs. They are more likely to acquire sexually transmitted infections (STIs), less likely to use contraception, and consequentially more likely to have unplanned pregnancies. Therefore reproductive health services should be prioritized for women with drug and alcohol addictions regardless of where they enter a system of care. For example SBIRT should be standard of care for all primary care visits, including reproductive health care; and reproductive health services (either onsite or with a warm handoff referral) should be available for women in substance use disorder (SUD) treatment.
Although reproductive health services focused on risk reduction interventions for STIs and unplanned pregnancies are important, they are insufficient. Reproductive health services should not be “fear-based.” Many women with drug and alcohol addictions have histories of sexual abuse. Many have used substances to self-medicate the sequelae of the abuse as well as to hide their fears associated with sex. However SUD treatment providers can be reluctant to discuss sex and sexuality. Furthermore programs often have “abstinence” policies towards sex (both during the initial residential period and often for a period of time beyond). The neglect of sexual health coupled with program “abstinence” policies communicates to women arguably places women at greater risk of relapse.
Reproductive health services for women with drug and alcohol addictions need to be part of a larger sexuality and sexual health curriculum. One of the goals of SUD treatment must be a healthy sexual self – which is everyone’s human right. A life-course approach to addictions requires emphasizing recovery support and relapse prevention. As we learn more about sexuality (especially sober sex) as a trigger for relapse, we need to consider including sexual health into the content of treatment.
We know that women with drug and alcohol addictions experience discrimination both from society in general and within their healthcare experiences. Neglecting the sexual domain of human experience can compound such discrimination by forcing women to further hide their shame and guilt, and puts them at greater risk of relapse.