Module 5: Population-specific Considerations
This module covers population specific considerations among:
- People who Engage in Sex Work
- Transgender and Nonbinary People
The following will outline some population-specific considerations for SAPs. Many of the issues and needs that people have are the same regardless of identity. However, certain communities and sub-cultures are particularly underserved and will have specific needs or may respond better to a particular or tailored approach.
When working with specific populations, the difference is often in the details. For example, prevention and education materials need to be tailored to speak to the population you want to reach. This could be as simple as people “seeing themselves” in the images included in the materials, or it could mean adjusting language to ensure that it will resonate with the target population. In some cases, significant differences will exist in the kinds of injecting messages that will be meaningful to people, based on the drugs that are being injected. For example, for street drugs such as heroin and cocaine, drugs will be mixed and pulled into the syringe from a cooker, while hormones, Botox, silicone or ketamine and other pharmaceutical drugs may be pulled from a vial. It is the SAP’s responsibility to ensure that people identify with the messages and are able to understand them.
Youth may be one of the most severely underserved populations among IDUs. Mainstream social norms make people especially reluctant to acknowledge that young people inject drugs at all. When drug use is recognized among youth, it is most often approached in a manner that is patronizing and fails to validate young people’s experiences, pain, circumstances and choices. Traditionally, access to real information about drugs and drug use is limited and guarded from youth. Instead, “scared straight” campaigns rooted in fear and shame encourage abstinence over practical education, despite the fact that young people always have and always will experiment with and use drugs.
Youth are also at an increased risk for transmission of HCV. Research suggests that 64-75% of injection drug users will become HCV positive within 6 years of initiating injection. While staggering, this figure also suggests a window of opportunity for engaging with young or new injectors to educate them about HCV prevention early. Younger drug users may approach injection with a feeling of invincibility. Further, it is not uncommon for young people who have faced repeated hardships to develop a cynical fatalism early on, and to adopt a perspective that they may not live long enough to worry about the impact of an HCV infection. This fatalism is compounded by the fact that so many young injectors are already infected with HCV, potentially making infection seem inevitable and in some cases, almost like a rite of passage. Without proper education, young people may also learn and adopt unsafe injection habits that may be hard to change later.
Certain approaches to working with youth will be especially meaningful for building strong, trusting relationships. Young people may be struggling to understand their place in the world around them, to develop independence and to define their identity. Respect and honor the autonomy of young people, and engage with authenticity and honesty, especially when talking about drug use. Whether they are experimenting or struggling with more serious addiction, young people are likely to respond best to frank and honest information that supports, but does not impose rigid bottom lines. Active listening is critical; sometimes the most significant thing for a young person is to have a place to talk about their struggles and feelings without judgment. It is important for youth to be cared for, heard, understood and valued. Young people can appreciate when people “keep it real”, which includes pointing out the negative consequences of drug use and the impact of their behaviors on others when done in a sensitive way that does not feel punitive or coercive.
Many young people may be struggling to define or redefine family. They may have had struggles or conflicts with their family of origin, grown up in foster care, or never experienced strong family bonds. Definitions of family subsequently become more fluid, with young people forming strong networks among their peers and other people that they feel are loyal, trustworthy, and willing to accept them. In some cases, young people may “test” SAP workers in ways that challenge these values. Transparency, honesty and respect can go a long way.
Developing youth-specific services may pose certain legal challenges and require a level of sensitivity even beyond regular SAP services. Child protection laws, mandatory reporting and parental rights issues can come into play with younger users and it is important for SAPs to understand any potential legal restrictions while maintaining the highest level of confidentiality and professionalism. Investigate age-specific guidelines about working with youth, such as intake or counseling requirements.
The SAP will also have to decide who is considered “youth”. Programs and services that specifically target youth can face challenges when people age out of eligibility for the program (get too old) or when young peoples’ primary social networks are older and therefore would not be eligible for the same youth-specific services. Finding ways to transition young people to other services provides continuity of care, maintaining and supporting the stability of participants. Unfortunately, younger adults may not yet feel comfortable in programs that serve older adults with different lifestyles or at different stages in their use. Collaborations between youth and adult/multi-age programs can encourage cooperative education and age-appropriate programming.
Other strategies for SAPs working with youth:
- Develop referral networks for youth-sensitive/specific housing assistance.
- Connect youth with health care services that are appropriate for and sensitive to their needs.
- Design culturally appropriate outreach and education materials accessible to youth.
- Choose hours of operation that are manageable and realistic for youth.
- Conduct support groups specific to youth on topics chosen by youth
- Emphasize early and consistent HCV and HIV testing to support prevention and identify new infections early.
- Make showers and laundry services available.
- Consider special services such as access to sterile tattoo and piercing needles.
- Emphasize safer sex messages and education, including birth control.
- Be creative!
- Prioritize confidentiality and safety.
- Acknowledge and validate the diversity and individuality of youth.
PEOPLE WHO ENGAGE IN SEX WORK
Drug use and sex work have a complex relationship. Sex workers face stigma, discrimination, criminalization and violence on many levels and are often among the most marginalized and underserved populations. Engaging in multiple levels of illegal activity, sex workers may be less likely to access services for fear of judgment (from SAP staff or other participants), yet may have an even higher level of need than non-sex working clients. Sex work often entails negotiating relationships with complicated power dynamics that can influence an individual’s level of drug- related risks while drug use may shape how and to what degree sex workers manage their safety and relationships. SAPs have a responsibility to understand the unique needs of sex workers and take steps to meet these needs with compassion and sensitivity.
SAPs should provide training to their staff to help them understand the needs of sex workers, and confront any personal stigma or judgment they may bring with them to the job. Staff should understand that sex work encompasses a range of activities including but not limited to dancing, escort services, stripping and modeling as well as full- and limited-service sex trade.
It is not uncommon for drug users to trade sex for drugs. Given the persistent need for money in order to maintain a drug habit and difficulties in maintaining traditional jobs (either because of discrimination when their use becomes known or because of difficulty in meeting employer expectations while using drugs), sex work may become one of few perceived economic options. In some cases, “managers” (or pimps) may encourage drug use as a means of control. In still other cases, sex workers may use drugs as a coping mechanism to deal with trauma related to their engagement in sex work or may be encouraged to use drugs by their clients or peers. It is, of course, also important to acknowledge that some people choose sex work and drug use.
Drug users who turn to sex work as a means of supporting their drug use may deal with shame and self-judgment and may not be willing to disclose their actions to others. In addition, the act of engaging in sex work may raise trauma issues from both present experience and past trauma or sexual abuse. Participants may not always be ready or interested in addressing these issues; however having resources and appropriate referrals for mental health and violence will be valuable should they be needed.
Extra discretion and sensitivity is important when providing services to sex workers. SAP participants engaging in sex work may be willing to discuss their needs if they can trust SAP workers to keep this information private. When outreach is being conducted with sex workers, be mindful that participants may be working while conducting syringe transactions; be discreet about any syringe access activities in front of other sex workers, potential clients and managers who may be nearby.
SAPs may need to make special accommodations with regard to hours of operation and outreach schedules in order to best meet the needs of sex workers. Evening, late night and/or early morning hours may be best. IDUs engaging in sex work may also need to conduct more frequent syringe transactions since it may be difficult for them to carry equipment on them. Practically speaking, sex workers may be on their feet or working the streets and not want to carry more than a few condoms and a few personal items with them. In addition, they may be at increased risk for interactions with the police and not want to risk revealing their use to clients or managers. It may be helpful to create small “one-hit kits” for sex workers that include supplies for a single injection (syringe, cooker, cotton, a water vial, a tourniquet and an alcohol swab) and condoms.
In addition to syringe access services, SAPs targeting sex workers should also prioritize safer sex resources and related harm reduction education and materials, such as:
- External condoms (commonly reffered to as “male” condoms for the penis or sex toys that will come in contact with fluids) and Internal condoms (commonly referred to as “female” condoms or FC2s, can be inserted into the anus or vagina)
- Lubricant packets
- Dental dams
- Hemorrhoid cream (both for treatment of hemorrhoids and for healing track marks)
- Hygiene wipes
- Hard candy (to stimulate saliva production, in addition to palate cleansing)
- HIV and STD information and testing referrals
- Cosmetics, hygiene supplies, cotton underwear, and stockings
- Referrals to nonjudgmental legal resources
- Information on negotiating safer sex
- “Bad date” or “ugly mug” sheets that provide information about clients that may be dangerous or should be avoided for other reasons
Other considerations for SAPs working with sex workers include:
- Educate participants about rotating and minimizing track marks and/or safer injection in hidden injection areas.
- Engage with participants around managing their drug use while they are working in order to prioritize alertness, control and safety.
- Utilize sex working peers in outreach activities, support groups, “ladies nights” and/or other SAP activities. Encourage sex workers to talk with, learn from and support one another.
- Discuss the negative impact of sex workers undercutting each others’ prices as a means of discouraging this behavior and promoting supportive relationships.
- When possible, offer the use of a mirror, toilet, shower, phone and washer and dryer.
- Support participants to report rapes, assaults and other violence, providing escorts to medical services and police when possible and appropriate.
- Understand local laws pertaining to sex work and prostitution.
- Support participants in reporting abusive law enforcement.
- Collect street sex work-appropriate clothing donations as well as umbrellas.
- When possible, provide foods that are rich in vitamin C (such as tomato soup, citrus and cranberry juices) to prevent bladder infections, bleeding gums and easy bruising.
- If possible, provide workshops and training to help sex workers develop good street skills and self-defense as well as relaxation, meditation and creative visualization.
- Support sex workers interested in leaving the sex industry, as well as those who wish to continue to work in it.
TRANSGENDER AND NONBINARY PEOPLE
Transgender and nonbinary people– including all individuals who in one way or another do not conform to traditional gender norms associated with their biological sex – are especially vulnerable to harassment, stigma and discrimination at all levels of social engagement. Transgender people are commonly rejected by their families and are routinely denied employment and other opportunities for social resources. This marginalization, along with high incidence of violence toward transgender persons, has serious impacts on mental health, self-esteem and stability, often leading to increased rates of poverty, drug use, illicit hormone injection, sex work and HIV.
Discrimination against transgender people extends to traditional social and healthcare services. As a result of repeated insensitivity, transgender people may be reluctant to access these services. SAPs must work to ensure that transgender participants feel safe to access services without fear and with the knowledge that they will be respected and that their needs will be understood by all staff. Training is required to ensure that staff are educated about the diverse experiences of the transgender communities, including the complex intersection of issues on the biological, psychological and social levels. Staff must respect the personal choices of all participants; however privacy and sensitivity may be especially important when working with transgender participants.
Transgender people are often at higher risk for HIV and HCV transmission on multiple levels. Hormone replacement therapy (HRT) requires routine injections of estrogen or testosterone administered intramuscularly, and can be very costly and is rarely covered by public insurance. This has led to an underground market and the common practice of self-administered hormone injection, which can be risky. In addition to complications related to the unknown quality and purity of hormones not directly obtained from a pharmacy, there can also be significant and serious side effects related to HRT that are best managed under professional supervision.
SAPs should consider the following measures to assist transgender participants engaging in prescribed or underground self-administered HRT:
- Stock 3 cc syringes for intramuscular injection.
- Educate participants about safer muscle injection, HCV and HIV prevention and other risks associated with improper injection.
- Provide comprehensive information about side effects and potential drug interactions with estrogen-based and testosterone-based HRT. Health effects should be addressed at the physiologic and psychological level.
- Work with participants to manage side effects of HRT.
- If possible, develop relationships with doctors, physicians’ assistants and nurses willing to assist with Shot Clinics – a dedicated time for people of transgender experience who are receiving prescribed HRT to come and have their shots administered or supervised by medical professionals. Shot clinics can also be used to teach people how to administer their own injections, as well as teach family and friends to assist with injections and provide a space for people to discuss any concerns relating to HRT.
- Offer support groups for participants of transgender experience undergoing HRT.
Given the heightened challenges that transgender IDUs may have in accessing traditional sources of employment, sex work presents as a common alternative – especially for trans women. In addition to having multiple sex partners, trans women rmay be more likely to engage in receptive anal sex, placing them at higher risk for transmission of HIV. Also, some research suggests that issues related to self-esteem can lead transgender sex workers to engage in unprotected sex as a means of validating their chosen gender identity. SAPs should prioritize safer sex education and condom distribution. The section above on Sex Workers in this module offers additional suggestions.
Other considerations for SAPs working with transgender participants include:
- Provide gender-neutral bathrooms.
- Be sensitive to name and pronoun changes, as these may be in flux over a period of time.
- Include transgender-specific categories on all forms (enrollment, data collection, etc.).
- Prioritize hiring transgender staff.
- Employ transgender peers to engage in outreach in clubs, on the streets and at other social service agencies.
- Provide training for all staff, volunteers and peers on transgender issues. If possible, organize additional training for law enforcement and collaborating organizations.
- Offer training and workshops on self-care, life skills and job training for transgender participants as needed.
- Create trans-friendly provider directories, including lists of transgender/queer NA and AA meetings and other drug treatment providers.
- Put affirming signs/symbols/pictures in your office or van, to signal that your program is transgender friendly.
- Organize transgender-specific legal workshops for issues related to things like name changes and gender- related bias crimes and discrimination.
- Advocate for changes in policy to protect the rights of people of transgender experience.