Moral Economies of Care and Women Who Use Drugs in Ukraine

Abstract

This article analyzes interviews with women who use drugs in Ukraine to understand the care conundrum they face as members of a stigmatized group. In the interviews, the women sought to position themselves as deserving and needing care as members of a vulnerable category—sometimes as women who use drugs or people living with HIV, but also as mothers—yet also themselves capable of providing care for others. We examine how women who use drugs in Ukraine navigate a moral economy of care involving judgments about deservedness and social worth, the obligatory nature of care, and expectations for reciprocity. For programs for women who use drugs to be successful, they must acknowledge and engage with the moral economies of care in which these women operate. We offer recommendations for how health and social service providers can better meet the unique needs of women who use drugs.

Keywords

addiction drug use HIV moral economy care women who use drugs Ukraine

Introduction

Globally, women who use drugs are a vulnerable population that faces unique challenges of gender inequality, interpersonal violence, poverty, stigma, and discrimination (Beckham et al., 2015). Women who use drugs worldwide are at an increased risk of HIV compared to their male counterparts (Des Jarlais et al., 2012). This is true in Ukraine, where women who inject drugs are disproportionately affected by HIV: women account for 27% of all people who inject drugs in Ukraine, but they represent 44% of HIV cases ( HIV Infection in Ukraine. Newsletter No. 50, 2019; Springer et al., 2015). Women who use drugs in Ukraine are more likely than men who use drugs to be HIV positive, engage in risky injecting behavior (Corsi et al., 2014), engage in high risk sexual behavior (Booth et al., 2007), and exchange sex for drugs (Iversen et al., 2015). Women who use drugs are also at increased risk for intimate partner and other forms of violence and mental health issues (Azim et al., 2015; Booth et al., 2013; Corsi et al., 2014; El-Bassel et al., 2011; Strathdee et al., 2015). One study found that in Ukraine, women who use drugs were over 10-times more likely to have experienced sexual violence by police than men who used drugs (Kutsa et al., 2016).

The risk of women who use drugs for HIV and other negative health and social outcomes are embedded in and shaped by gender norms, attitudes, and expectations. These gender norms affect how women interact with their drug use and sexual partners, their family members and children, and service providers. They also shape the policy and programmatic responses to women’s needs, including medical services, non-profit HIV service, and government social services. Ukrainian women who use drugs face significant challenges to secure needed services, including family planning and reproductive health services, interpersonal violence support, legal aid, and drug treatment (Gaventa, 2013; Owczarzak et al., 2021). Women in Ukraine who use drugs or are HIV positive have been pressured or coerced to have abortions or to put their children in state care (Meksin & Meksin, 2011; Pinkham & Malinowska-Sempruch, 2008). Drug treatment and related services (e.g., harm reduction programs) in Ukraine historically have excluded women and women-specific issues (Carroll, 2011; Pinkham & Shapoval, 2010). Research shows that gender-related factors negatively affect women who use drugs in Ukraine’s access to harm reduction, drug treatment and reproductive and sexual health services (Pinkham & Malinowska-Sempruch, 2008). Moreover, service providers may view women’s vulnerability to HIV and other harms as a product of lack of personal agency and motivation for self-care (Owczarzak et al., 2018)

The experiences of Ukrainian women who use drugs occur against a backdrop of strong gender norms informed by Soviet ideologies, Ukraine’s movement for national independence, and global and local feminist movements (Barth, 2021; Kis, 2005). Soviet gender policy guaranteed important socioeconomic and political rights for women, including opportunities for education and near universal literacy. However, the formal equality Soviet legislation declared for women had many gaps in practice: the system perpetuated the idea that childbirth and family caregiving should be women’s primary concern, leaving working women with a “second shift” of caregiving and housework, the notorious “double burden.” The Ukrainian independence movement in the late 1980s and early 1990s ushered in “neotraditional gender” ideals (Johnson & Robinson, 2007), as a resurgence of nationalism promoted traditional patriarchal gender images of distinct roles for men and women in society (Hankivksy & Salynykova, 2012). In Ukraine, the female ideal is tied to the figure of Berehynia, a figure from pre-Christian mythology revived in the post-Soviet period of Ukrainian nation-building, that aligns women with home, hearth, and nation (Phillips, 2008). In this schema, a woman’s primary role is to be a mother, including raising children and managing the household, while also working outside the home (Channell-Justice, 2020). The berehynia image circulates in contemporary Ukraine through the public symbols such as atop a column in Kyiv’s Independent Square (Channell-Justice, 2020), in political speech such as during the 2013–2014 Maidan protests (Phillips, 2014), and in public education (Haydenko, 2011).

While some Ukrainain scholars argue that this image has limited effect on women’s actual lives (Kis, 2005) and feminist scholars and activists promote gender equality and challenge neotraditional gender stereotypes (Barth, 2021; Channell-Justice, 2020), studies have shown that many men and women in Ukraine agree that a woman’s primary goal and responsibility should be childbirth, motherhood, and caring for the “traditional” family (UNFPA Ukraine, 2018). Income gaps between men and women in Ukraine are high: a woman’s average individual income is about 65% that of a man’s. The highest income gap occurs at younger ages, corresponding to childbearing age (women age 18–29 have income 50% that of men’s, women age 30–34 have income 47% of men’s) (Livbanova et al., 2012). Women are more likely than men in Ukraine to live in poverty, and women continue to dominate in the “caring professions” which include some of the lowest paid jobs: teaching, social work, and psychology, for example (Strelnyk, 2018). The “second shift” continues to be a reality for many women, too: Over 75% of women responding to one survey indicated that they were mainly responsible for cleaning the house and making meals, while only 7%–27% said both partners were responsible for certain household responsibilities (Livbanova et al., 2012). Therefore, despite some strides—including adoption of gender policy legislation, high educational achievements for women, and women’s increased visibility in public life during and since the 2013–2014 Revolution of Dignity—gender role stereotypes still privilege women’s roles as mothers, and assign the bulk of caring and housework to women, who continue to experience precarity in the Ukrainian labor market.

The concept of the “moral economy of care” is a framework for understanding the discursive judgments about deservedness, obligation, and reciprocity that structure expectations of women who use drugs to take care of others, and to receive care themselves and how gender norms and expectations of ideal womanhood articulate with negative stereotypes and stigma surrounding people who use drugs. The idea of a moral economy posits that “the economy is ‘moral’ in that it operates within a circumscribed context of societies’ wider institutions and values” (Watters, 2007). At its root, the moral economy is about relationships, the “shared mores and values with which people evaluate their relations with others” (Prince, 2012, p. 536). Fassin (2009, p. 1255) expanded the concept of moral economy beyond a specific economic meaning to encompass “the production, distribution, circulation, and utilization of moral sentiments, emotions and values, norms and obligations in the social space.” The moral economy reflects wider societal values regarding who has the duty of care toward whom and how claims for care are made, including “legitimate” or “illegitimate” claims for care (e.g., welfare support, shelter, mental health services) (Thompson, 1971).

The moral economy highlights tensions, conflicts, and contradictions, and crystallizes the debates constructed around social issues such as immigration, poverty, and violence (Fassin, 2013). More recently, scholars have attended to the ways in which gender role stereotypes and expectations shape moral economies of care in contexts of drug use services for women (Meksin & Meksin, 2011). Buer et al. (2016), in their study of women’s navigations of social networks and prescription drug misuse in Central Appalachia, explored how women who use drugs navigated social networks, caregiving responsibilities and violence in efforts to decrease their drug use (Buer et al., 2016). Women’s “demonstrations of care” in their networks created a moral economy wherein people who use drugs offered mutual support and established bonds of fictive kinship. The researchers found this moral economy to have a negative side, however: it was a site of both solidarity and betrayal “where care and intimidation are intertwined” and the obligations of the moral economy compelled women to endure threats and violence to stay in their drug networks (Buer et al., 2016). As Lopez (2014) found in her study of impoverished and unstably housed women with histories of illicit drug use in San Francisco, institutional interventions for such women operate in a gendered moral economy of care that reinforces the women’s hypermarginality and exacerbates their suffering. Studies that theorize the gendered moral economy of care in contexts of women’s drug use reveal the discursive representations that women must navigate, the strategies they use and relationships they create in this process, and how state and other institutions buttress or mobilize these representations in policies and practices around access to services.

In post-Soviet contexts, intimate supportive networks are essential to everyday survival, as documented in Russia (Caldwell, 2004; Hojdestrand, 2009; Ledeneva, 2008), Poland (Dunn, 2015; Pawlik, 1992) and Ukraine (Fedirko, 2013). Separate from “blat,” or the use of personal networks and informal contacts to obtain goods and services in short supply and to skirt formal procedures (Ledeneva, 2008, p. 120), these “close ties” or “regimes of affection” are relations in which participants share a “mutual concern for the other’s well-being” and demonstrate the importance of being useful to others—to care (Rivkin-Fish, 2005, p. 154). These close ties can be especially important and problematic for marginalized and socially excluded groups. In her ethnography of social welfare and international aid in Moscow, Caldwell (2004), for example, illustrated that people without social channels to access resources are the most vulnerable to poverty and deprivation. Similarly, in her exploration of homelessness in St. Petersburg, Russia, Höjdestrand (2009) detailed how close social ties “constitute the only functioning social safety net for the penniless” (pp. 112–113). People with “no close ones” (“whoever could have helped—if there was anyone in the first place—was not there any longer, whether dead or disappeared or simply unwilling to help”) were left to make do on their own. Moreover, she argued, people who could not participate in reciprocity and mutual care were often blamed for failing to “fulfill the expectations that the mutual neededness of near and dear ones implies” (pp. 113–114), which in turn contributed to one’s sense of shame for being a burden to others.

In this context of reliance of close ties for survival and gendered norms that prioritize women’s roles as mothers and caretakers, our study asks how women who use drugs negotiate gendered societal expectations of themselves as women and as members of a marginalized, stigmatized population. We use the lens of moral economies of care to explore how highly marginalized women (women who use drugs specifically) engage with gender norms and institutional and social support systems to secure care for themselves in Ukraine. We attend to the narratives of women who use drugs in Ukraine—marginalized women who are not often considered in discussions of gender and care—to try to understand the moral economy of care in which they operate as gendered subjects (e.g., mothers, partners, friends, clients).

Method

Data Collection

This article emerged from a broader study that sought to understand how women who use drugs in Ukraine access and use various HIV prevention and treatment, drug treatment, and health care services and to identify gaps, challenges, and successes in gender-responsive service delivery for this population. While Ukraine has recently increased availability and accessibility of medication for opioid use disorder (MOUD), enrollment in MOUD programs remains low (only between 3 and 12% of opioid users in Ukraine are currently enrolled in MOUD programs, depending on region) (Bojko et al., 2015; Kuzin et al., 2020; Makarenko et al., 2016) due to beliefs about the effectiveness of MOUD, concerns with registering as a person who uses drugs in order to receive treatment, inconveniences of retrieving medication, and fears of mistreatment by clinic staff. Other treatment options include faith-based rehabilitation centers, self-help groups such as Alcoholics Anonymous, private addiction treatment centers, and detoxification (Dmitrieva et al., 2022; Zaporozhets et al., 2015). However, access to these services is low (e.g., unavailable in rural areas) or lacking evidence of effectiveness. Moreover, women under utilized these services due to potential punitive measures that could result in having their children removed from custody and stigma in the service provision setting (Makarenko et al., 2016).

This study was conducted from December 2017 to October 2018 in Poltava and Sloviansk, Ukraine. These study sites were chosen as part of a larger project that explored how contextual factors such as economic stability and range of service-providing organizations affected women’s access to drug treatment programs and services. Poltava is a medium-sized city (population 289,000) located in central Ukraine. Sloviansk is a small city (population 111,486) located in the Donetsk oblast in the Donbas region of eastern Ukraine. The Donbas was the site of significant military conflict when Russia invaded Ukraine in 2014 and is a key battleground in Russia’s 2022 invasion of Ukraine. Despite a ceasefire agreement signed in 2014, low-intensity fighting has continued in the region causing significant population displacement. During the study period, neither study site experienced active military conflict, although Sloviansk was the site of active military conflict in 2014 that disrupted services for people who use drugs and access to medical care, among other consequences. In 2019, an estimated 12% of people who use drugs in the Poltava region and 4% in the Donetsk region were enrolled in an MOUD program (Kuzin et al., 2020). HIV prevalence among pregnant women under aged 25 years old was highest in the Donetsk region (0.78) and above the national average in Poltava (0.37) (Kuzin et al., 2020).

We used a combination of direct recruitment and snowball sampling. Inclusion criteria were identifying as female, living in one of the two study cities, and injected drugs of any kind during the prior 30 days. Participants were recruited through direct contact with service providers who worked with women who use drugs. Recruiters also used direct contacts to identify women who met inclusion criteria. Women who completed the interview also referred acquaintances to the study team for potential participation. We used the concept of “information power” to guide participant recruitment strategies and final sample size (Malterud et al., 2016). During the data collection process, we continually reviewed the demographic characteristics, personal experiences, and initial analytic insights from each participant. We recruited participants until our sample represented a wide variety of demographic characteristics, service utilization trajectories, and socioeconomic and parenting statuses; no new codes or themes were identified in the data; and we had a comprehensive understanding of the issues raised in the data (Hennink et al., 2017). In total, we interviewed 37 women who used drugs.

Interviews focused on a variety of topics including employment, economic status, motherhood, partner and family relationships, and use of government and nongovernmental organization provided social or medical services. All interviews were conducted in Russian or Ukrainian by bilingual, native Russian and Ukrainian speakers based on the participant’s preference. Interviews were semi-structured and followed an interview guide; interviewers used probing and follow-up questions to clarify and expand issues raised by respondents. Interviews were audio recorded. Women who use drugs who completed the interview were compensated 300 Ukrainian hryvnia (approximately 10 USD). Participants also completed a short demographic questionnaire that included information about socioeconomic status, relationship status, housing situation, HIV and HCV status, and drug use, among other characteristics. All participants provided oral informed consent. This study was reviewed and approved by the Institutional Review Board at Johns Hopkins Bloomberg School of Public Health.

Analysis

This study was informed by an ethnographic perspective and followed a modified grounded theory approach, reflected in the iterative approach to data collection and analysis and the attention to the ways in which social context shapes people’s experiences and how they make meaning of their experiences (LeCompte & Schensul, 2010; Strauss & Corbin, 1990). Interviews were transcribed in the original language and then translated from Russian or Ukrainian to English. Transcripts were uploaded into MAXQDA, a qualitative data management and analysis software program that facilitates the coding, analysis, and retrieval of qualitative data. Analysis used principles of grounded theory analysis (Strauss & Corbin, 1990) in that analysis took place deductively and inductively by exploring major domains related to the study’s overall aims but remained open to unanticipated themes, patterns, and relationships. The coding tree was developed collaboratively by all authors using an open coding and iterative and collaborative process to ensure reliability and consistency (Carey et al., 1996; Ryan, 1999). In open coding, members of the research team independently read the same transcript and identified preliminary coding categories. During this open-coding process, both a priori and inductive codes were generated and applied. A priori codes included codes that reflected key topics and content areas in the interview guide, including types of services accessed, clients’ relationships with family and health care providers, substance use, HIV and drug use disclosure, parenting and motherhood, and financial status (income, economic security). Inductive codes, or themes that emerged from the data but not explicitly asked in the interview, included financial status and partner relationships, trust, stigma, and isolation and loneliness. We then formed an initial coding scheme and members of the research team each individually coded a second transcript using this initial coding scheme. The process was repeated until team members were satisfied with the finalized coding tree. The remaining transcripts were then divided and coded individually by team members, periodically checking for consistent code use.

After text codes based on the coding tree described above were applied to all transcripts, we conducted axial coding to understand how codes and underlying data related to each other. Axial coding involved examination of codes relating to client relationships (including motherhood, partner relationships, relationships with friends/family, and relationships with healthcare workers), experiences within these relationships (including trust, stigma, isolation and loneliness, and shame), and service utilization (nongovernmental organization vs government services). Participant responses were summarized by both relationship type and common key features (economic precarity, stigma and discrimination, social isolation) within each relationship type identified. These summaries were used to identify care dynamics through discussion with team members and form the basis of our arguments about the moral economy of care. Due to small sample sizes, participants’ experiences were analyzed as a group and not delineated by study city. However, in the Results, we include each participant’s city for reference.

Results

Participant Characteristics

The average age of participants across both sites was 35 years old. Among participants, 27% were single at the time of interview, 51.4% were married or living with a partner, and 13.5% were widowed or divorced. Half of participants reported having one to two children, 27% reported no children and 18.9% had three or more. Participants reported struggling financially, with 43% describing their financial situation as “below living wage,” 40.5% as “can afford only essential needs,” and only 13.5% as “enough resources to meet most needs.” Approximately 45% of participants reported a history of homelessness and incarceration. HIV and Hepatitis C virus were common among participants, with 40.5% reporting a history of HIV and 70.3% reporting a history of hepatitis C. Over half of participants (51.4%) indicated opiates as their “drug of choice,” followed by stimulants (27.0%). Demographic information for participants by site is summarized in Table 1.

Table 1.

Participant Demographics.

Participant Demographics
	Slavyansk (n = 18)	Slavyansk Percent (%)	Poltava (n = 19)	Poltava Percent (%)	Total (n = 37)	Total Percent (%)
Average age	35	N/A	33	N/A	35	N/A
Financial situation
“Below living wage”	10	55.6	6	31.6	16	43.2
“Can afford only essential needs”	5	27.8	10	52.6	15	40.5
“Enough resources to meet most needs”	2	11.1	3	15.8	5	13.5
No answer	1	5.6	0	0.0	1	2.7
Relationships
Single	4	22.2	6	31.6	10	27.0
Live with partner, not married	5	27.8	6	31.6	11	29.7
Married	1	5.6	7	36.8	8	21.6
Divorced	1	5.6	0	0.0	1	2.7
Widowed	4	22.2	0	0.0	4	10.8
Other	1	5.6	0	0.0	1	2.7
Don’t want to answer	2	11.1	0	0.0	2	5.4
Ever been homeless
Yes	9	50.0	8	42.1	17	45.9
No	6	33.3	10	52.6	16	43.2
Don’t want to answer	3	16.7	1	5.3	4	10.8
HIV
Yes	7	38.9	8	42.1	15	40.5
No	10	55.6	11	57.9	21	56.8
No answer	1	5.6	0	0.0	1	2.7
HCV
Yes	12	66.7	14	73.7	26	70.3
No	5	27.8	5	26.3	10	27.0
No answer	1	5.6	0	0.0	1	2.7
Ever incarcerated
Yes	7	38.9	10	52.6	17	45.9
No	8	44.4	9	47.4	17	45.9
No answer	3	16.7	0	0.0	3	8.1
Number of children
0	4	22.2	6	31.6	10	27.0
1 or 2	7	38.9	12	63.2	19	51.4
3+	6	33.3	1	5.3	7	18.9
No answer	1	5.6	0	0.0	1	2.7
Primary drug
Homemade opiates	8	44.4	11	58.0	19	51.4
Stimulants	5	27.8	5	26.3	10	27.0
Street methadone	2	11.1	1	5.2	3	8.1
Other	3	16.7	2	10.5	5	13.5

Overview of Results

Our analysis found that participants were caught in a “care conundrum”: challenged to perform the care work expected of women (especially mothers) yet excluded from receiving care themselves. They navigated a moral economy of care in which they were expected, as women, to care for others, yet for various reasons—including drug use, poverty, and lack of support (social, economic, psychological)—most often the women struggled to provide others with basic necessities (housing, food). They were unable to access the care they themselves needed, including from family, partners, friends, and institutions. We identified three major overlapping dimensions of the moral economy of care across all care domains for women who use drugs: women’s obligation to care for others; calculations of deservedness and social worth; and expectations for reciprocity in care relations. We examine these three dimensions separately, though we recognize them as intersecting and overlapping phenomena.

Women’s Obligation to Care for Others

Interviewees often expressed the neotraditional view (Johnson & Robinson, 2007) that “women are supposed to have a family, to raise children, [to be] the keeper of the hearth,” as a mother of two from Poltava stated. Most of the women we interviewed had children, and they viewed themselves as primarily responsible for kids and often emphasized how well they could take care of them. For example, a mother in her late 20s whose daughter was in kindergarten said that although her daughter currently lived with relatives, “When I look after [her], she is always well-dressed and even if I use drugs, she doesn’t suffer because I’m the main person who is supposed to look after her.” Likewise, they emphasized that they would put their children’s needs before their own, for example, forgoing surgeries and other medical procedures to spend limited funds on their children. As another mother of three from Poltava, summarized: “I worry about my daughter…. Only about her. I do not worry about myself anymore.”

Despite this strong desire to provide a stable and comfortable life for their children, many struggled to provide basic necessities and balance their drug use with providing for their children. A mother in her mid-40s from Sloviansk lamented that she was unable to give her child basic necessities that she herself had enjoyed when growing up. She longed for a stable job and steady income but also recognized that she would need to spend money on drugs:

I want to work, have a job, not to wake up every morning, and think: ‘Oh, my God, what shall I give my child? Where can I get money for his everyday needs? Where shall I get money? You’re thinking hard. Well, seriously, you cannot sleep at night.…You think: “Damn, I need just 300–500 hryvnias.” And I really cannot find it. This is what happens. It would seem that it’s not a problem but it’s really a big problem for me. It kills me. And for me the biggest problem is finance[s]. And, when the children do not have that.…I find something to eat. But I can’t afford anything else. Besides, I want to get a dose—also such a terrible need. Something like this. I want the child to have everything. And I cannot give it.

This obligation to care for others extended to partners (e.g., boyfriends and husbands) and other family members. Some interviewees welcomed these obligations and tried to meet them. The women frequently indicated that in addition to carrying out major domestic tasks, including cooking and cleaning, they were the primary decision-makers in their households, in charge of making financial decisions and dealing with paperwork and bureaucracies (e.g., school matters, legal issues). Women living with male partners reported that men’s domestic duties were limited to doing “handyman chores,” gardening, and the like. A woman in her early 20s from Poltava bemoaned that she could not better care for her boyfriend. It bothered her that her boyfriend still lived with his mother; she felt like a “traitor” because she “still had responsibility for him…because as a girl, I should be there to correct and instruct him.” One of her goals was to have stable finances and housing so that she and her boyfriend could live together and she could be the one to “mother” him. Other participants, however, bristled at the expectation that they care for partners. The same woman from above who worried about not providing for her children, described her boyfriend as a “third child” and a “mother’s darling” who she “needs to take care of, like a son.” She said that she does not view him as a “real man” because he does not “earn money for himself.” She was angry that her boyfriend did not live up to social expectations as a (male) breadwinner and lamented that she had to “take care” of him physically, economically, and emotionally.

Although women who use drugs’ obligations to their partners were often framed in terms of caring for them, in fact our interviewees often described themselves as being dependent on their male partners. A woman from Poltava in her early 30s who took care of her chronically ill husband lamented that she “completely disappeared” into her husband and no longer had any friends. Moreover, many women in our study reported interpersonal violence in their current or previous relationships. A mother of three from Sloviansk said that “everyone around” (his parents, neighbors) was aware that her first husband beat her, but no one offered to help. She described him as extremely jealous and said he sometimes beat her when he was drunk. She said that she “lived with him just because of my children, and I have no parents—no one—I had nowhere to go.” At the time of interview, she was living with her third husband, who she said “saved” her from the streets (commercial sex work), helped her stop using drugs, and provided for her “completely.” He also isolated her from her family:

Respondent:

I do not communicate with anyone. My husband doesn’t allow me. He blocks it immediately. I talked with my son when I was in the [rehab] center. And then somehow my husband found out about it and blocked the website. My elder daughter doesn’t deal with me categorically. She cannot forgive me.…My husband does everything. He took me off the street. He helped me quit using drugs. I do not use drugs. I stay at home…. He dresses me, buys footwear for me, he completely provides for me.

Interviewer:

Well, you perceive this as care, I understand that you don’t think he limits you, do you?

Respondent:

No, he loves me very much. He is very jealous for me. I am very grateful to him. I love him.

This narrative of caring and being cared for by partners reveals complicated gender dynamics of domination and abuse of women who use drugs by male partners and how relationships can be simultaneously caring and compassionate (Simmons & Singer, 2006) and shaped by jealousy, control, and dependency (Gilbert et al., 2001; Radcliffe et al., 2021).

The women we interviewed expressed both an expectation and desire to care for others, including their children, kin, and partners. Frequently, the expressions of care for others invoked neotraditional gender roles and expectations, including the expectation that they care for both children and partners. The mothers in our study longed for the resources to take care of their children in a way they envisioned as good mothering (Kearney et al., 1994). Our interviewees were sometimes consumed by shame when they were not able to perform the care expected of them as mothers and partners.

Deservedness and Social Worth—Women Who Use Drugs as Problematic Objects of Care

In the context of their drug use, interviewees reported varying levels of support and care received from their families, including parents and siblings. Some participants said that their parents helped them financially and materially, for example, to receive legal assistance, undergo medical procedures, or secure housing (often living with them). More commonly, participants reported strained or broken relationships with family that they attributed to their drug use. Family members sometimes no longer wanted to communicate with them after learning of their drug use. This was true for a woman in her early 30s from Poltava who said that drugs had “crippled” her life and “messed up” her relationships. She regretted that her relationships had changed and felt that her family members were unable to see past her addiction or believe that she was a “normal person.”

That women who use drugs were not seen as deserving care or support themselves was made most apparent by participants who described that while their parents helped their grandchildren, they were unwilling to provide material support to their daughters. One mother of two in her mid-20s from Poltava insisted that her parents did not care about her and were only supporting her to indirectly help their grandchildren. Similarly, a woman in her late 30s from Poltava who lived in a shelter with her two children, felt that her godmother only helped her only to benefit her children:

She feels sorry for my children.…She believes that these children, well, not only that my life is all messed up but that they have no future. And now, while I have not been deprived of maternal rights [note: from a legal perspective], she sends me this money, so that I bring them some musical toys there, at least. That, anyway, some of this money will still be for children. Maybe she treats me humanely, but…the motivation is more for the children.

The support women who use drugs received from their families reinforced the women’s “duty” to provide care for children while diminishing the participants’ own needs outside of those related to their children. Some of our interviewees expressed the view that Ukrainian society—including their own parents—judged women who used drugs much more harshly than men who used drugs. One participant from Poltava thought it was expectations about women’s biological capacity for pregnancy and motherhood that led to harsher social judgment for women who use drugs than for men. She said, “[People say] I’m a goner, a bitch who hasn’t protected her health in the proper way.…It seems to me that women who use drugs are treated worse, even [worse] than those who drink. The men are like, ‘Why do you drink? Why do you smoke?’ You should have children!” In other words, family members and compatriots (including other people who use drugs) saw women who use drugs as inherently irresponsible—unwilling or unable to fulfil their biological and social “obligation” of healthy pregnancy and childbirth.

Often, tensions around whether a participant’s family deemed her worthy of care revolved around continued drug use and addiction. One woman in her early 20s who lived in Poltava explained that she had no one she could rely on for financial support:

My parents refused me, I’m alone now, yes, there is a situation like that.…They do not even say hello to me. And I have asked for financial help recently, but they refused me.…They helped me when I was in the rehab center, I mean, they paid for it. So they sent money then. But they are offended because of my addiction. They say that I betrayed them. It was my fault.…They’re already burying me. They say that I won’t live much longer, because I am rotten, it’s over. So they decided to push me away.

This experience was echoed by other participants whose parents similarly provide support only under specific conditions. Another woman from Poltava recounted that her parents gave her money while she was in a drug treatment center because “they knew that I was there under supervision.” But, once she left the facility, her parents stopped providing her with financial support, telling her, “It’s your life. It’s up to you to choose.” In many cases, the women seemed to be operating in a moral economy of care relative to their families of origin in which they, as women who use drugs, were rewarded with support only to the extent to which they were seen as demonstrating “good behavior.” These experiences exposed the care conundrum that women who use drugs found themselves in: they could be in desperate need for support but could not receive this support from their families unless they were able to demonstrate that they deserved the care, for example, by quitting drug use.

One consequence of an inability to demonstrate that they deserved care was a profound sense of isolation and abandonment. When asked, “Who can you rely on? When you have a problem, who can you turn to?” many of the women said, “No one,” or, as a woman from Sloviansk put it, “I do everything on my own. No one helps me.” An unmarried mother of two in her early 40s from Poltava, offered: “I’ve learned that you can only depend on yourself in this life. It seems like every time I think I can rely on somebody, it doesn’t work out.” Another single mother of two in her early 30s from Sloviansk similarly said that while she had a male friend that she could confide in, for the most part, she said, she dealt with things on her own: “If I’m sad, I usually sit and cry on my own, and then I feel better. That’s better. It’s better on my own. Because right now you can’t trust anybody.”

This sense among participants that they realized that others do not see them as deserving care due to their drug use extended to the health and service sectors. Interviewees told many stories of being mistreated and disrespected because of their drug use and HIV positive status by professionals who should be providing them care, especially health care workers (nurses, doctors, dentists). Participants recounted that providers had expressions of disgust on their faces, put on “body armor” (multiple pairs of gloves, masks), and appeared hesitant to touch them. A woman in her mid-30s from Sloviansk believed that because she used drugs she received substandard state-provided medical care, which impeded her ability to provide adequate care for her three children. One participant who was living with HIV thought she should receive better medical care and more regular check-ups. She recalled the attitudes of the healthcare professionals when she gave birth to an underweight baby. She remembered the doctors saying, “‘How can people like you give birth?'…. Instead of supporting me, people reproached me, and said that people like me shouldn’t be having babies.” Another participant from Sloviansk recalled that when she went to the hospital to treat an abscess on her leg, the surgeon yelled at her, “You’re a drug addict! A goner! Why should I help you?” She had to enlist the help of a social worker from a local nongovernmental organization to advocate for her and get her the care she needed.

As a result of similar negative experiences with medical services, interviewees reported that they sought medical care only when necessary and rejected prenatal care, ART treatment, surgeries, dental work, and much more because of past care-seeking or medical trauma and the expectation of stigma and abuse. When they absolutely needed care, they would try to “hide” their drug use or HIV status (“I try not to show who I really am,” a woman in her early 30s from Sloviansk stated) to avoid the stigmatizing behaviors and negative attitudes they encountered in the clinic.

At the same time, the women were quick to praise medical personnel who treated them with respect. Positive interactions and nonjudgmental provision of care typically occurred in HIV-specific hospitals and pharmacies or clinics that also treated substance use. In Sloviansk, the doctors and nurses at the AIDS Clinics earned high marks, as did a pharmacist located across from the city’s main HIV service agency. Women in Poltava likewise had positive experiences with health care providers at the AIDS clinics and specialty gynecology/obstetrics clinics that treated women living with HIV, as one participant from Poltava recounted:

Well, I mean, those who have HIV are treated there.…I had a problem with my ears two years ago–I’m losing my hearing.…I stayed in Hospital No. 2. The head is a great woman.…She treated me ideally, and although I am HIV-positive, she says, “What difference does it make?” Well, I mean, she understood.…They say that society is ready for this—it is not ready at all! They fear us as if we are lepers. Say what you like, but I assure you, this is my experience.

She went on to explain that she received all her care at this hospital because they had the expertise and compassion to treat patients with similar backgrounds.

Overall, women in our study operated in a moral economy of care where their deservedness and their social worth were continually being evaluated and questioned. They frequently gave examples of how other people, including their own friends and family members, had denigrated them as not deserving of care and as lacking in social worth. Assessments of women’s deservedness were highly gendered and eroded the women’s possibilities to receive care and in turn, to provide care to others.

Reciprocity, Interdependency, and Mutuality of Care

The care obligations described above were often imagined or assumed by women who use drugs to, ideally, involve some sort of reciprocity or mutuality of care, however indirect. Our interviewees expressed a desire to enter relationships involving care as reciprocal and interdependent—as a two-way street or a chain of care. With children, this reciprocity was reflected in routines and images that conveyed a sense of domestic tranquility and support, despite limited economic means. A mother of two from Poltava explained that she no longer communicated with her sister and could only sometimes ask her mother for help. In contrast, she cultivated a close relationship between herself and her children:

So we do household chores together. We cook, do the washing, walk, read, and count a little. And we have dances, and music.…My child loves to sing.…Then my elder son comes from school, we do homework together, we eat, we are also busy in the evening. Then some watch cartoons, the others watch a movie, some draw, some do other things. This is what the whole day is like. We also have a small kitchen garden. We work in the garden and water plants. But we do everything together.

In this example, the participant emphasized a sense of togetherness and cultivating a sense of home and family through these shared activities.

As discussed above, narratives of caring for and being cared for by partners could reveal underlying dynamics of domination and abuse of women who use drugs by male partners. At the same time, in the absence of other supportive relationships, participants often characterized their relationships with their husbands and partners in terms of interdependence and mutual support when they had been cut off from friends and family. One mother of three from Sloviansk, who had been with her boyfriend for about a year, said that they tried to make decisions together and help each other, and although not legally married, they try to create a sense of family through mutual aid. She would help him take care of his ailing mother and he helped her with her children from a previous relationship:

We try to help each other. He has a sick mother—stage four cancer.…He can’t take care of her like a woman can. I come to his house, cook for him, take care of his mother, I help him bathe her. And he, of course, helps me to go for a walk with my children, for example, when it’s hard for me. He comes, takes the children, goes with them to the playground, plays football with them. They walk, eat ice cream. He sometimes stays at my place for the night.

She and her boyfriend built a sense of family through reciprocal caregiving. She assumed traditional gender roles by cooking and cleaning for her boyfriend’s mother. She concluded, “Either we are a family or not. Either I can rely on you in life, or I should rely on myself.”

In the absence of reciprocally supportive relationships with kin, some of our interviewees turned to their informal social networks with other people who inject drugs (Bourgois, 1998; Simmons & Singer, 2006). One woman from Poltava identified a person she had provided drugs to in the past as someone she could rely on to loan her money. A fellow woman who used drugs, she said, had helped her find a job. In such networks, women who use drugs were often able to offer drugs in exchange for favors or services rendered. She, as well as several other women who use drugs, described relying on this kind of informal exchange of drugs for childcare. Some participants even advocated for formalizing these relationships through the establishment of various kinds of “community” and “mutual support” groups that would benefit them and other women who use drugs. When asked “What do you, as a woman, think—what other services should this agency offer?” one mother of two adult sons from Sloviansk, answered:

[Opportunities for] communication, probably, for women’s communication. To give women the opportunity to gather and talk about their problems. Maybe I could help solve someone’s problem. Yes. Maybe somebody needs something to be sewn for free, to alter some clothing for their child. I would help. And maybe she could help me with something. Even just, for example, hanging wallpaper together. I mean something like that.

However, participants also characterized their relationships with other people who use drugs as lacking trust and transactional, rather than reciprocal, as one participant in her early 50s from Sloviansk observed:

Basically, drug users are all dishonest. They’re always jerking me around. They take advantage of my kindness. I try somehow.…And, if I turned to them somehow then I would be fooled in some way. So I try not to ask. Like I gave money for the drug, and she went away with the money, that’s it. No money, no drugs. Well, is this a friend? Can she be trusted? No.

She went on to distinguish herself from other people who use drugs by emphasizing that she can be trusted and does not engage in unscrupulous transactions.

The women in our study also turned to state-run services and nongovernmental organizations to address their needs. Significantly, very few participants were currently enrolled in drug treatment programs, had enrolled and dropped out of MOUD programs in the past, or tried private or church-based programs if they had the financial resources to pay for them. As a result, they did not have meaningful relationships with drug treatment specialists. Rather, they turned to social workers affiliated with nongovernmental organizations for advice or support. Women who use drugs spoke of the reciprocity at the foundation of these relationships and minimized their client-provider dimensions. A participant from Sloviansk said that she had been going to the same nongovernmental organization for over 10 years and formed a close relationship with several of the social workers there. In addition to them listening to her, giving her material resources, and providing a safe space (“I like coming here. I just like it. I even relax here morally somehow.”), she also offered that she was able to help one of the social workers when her daughter was sick. Similarly, another participant said that she appreciated the help she got from social workers at a local nongovernmental organization and that she always tries to express her gratitude: “As a token of gratitude, if I have money, I can buy a chocolate bar for her…I’m such a person that I love to thank.” Being able to help the social worker bolstered her sense of self-worth (cf. Caldwell, 2004). However, when this friendship aspect was missing from relationships with social workers, participants found them unsatisfactory. One participant from Sloviansk noted how the social workers at the HIV service organization she frequented were too young to understand her “grown up woman” problems: “I’m 46. Am I going to go complain to a 20-year-old girl [social worker]? How can she help with my problems…they all have to do with children, relatives, and finances.”

In the interviews, the women sought to position themselves as deserving and needing care and assistance as members of a vulnerable category—sometimes as women who use drugs or people living with HIV, but also as mothers (e.g., single mothers, see Haney, 2002)—yet also themselves capable of providing care for others. When articulating their need for care, women who use drugs sometimes asserted that receiving care would help them get on their feet so they could get a job, make more money, get more rest, or better care for their children. This was a “paying it forward” approach to thinking about obligations of care that bolstered the women’s sense of social worth and deservedness.

Discussion

The women we interviewed operated in a moral economy that expected them, as women, partners, and mothers, to care for others. However, almost all our interviewees were unable to provide enough—or good enough—care for others, especially their children. Many participants were unemployed or unstably employed and could not rely on financial assistance or other forms of support from significant others in their lives or from the state. They often reported having no one to rely on for emotional, material, or other types of support. The participants in our study were prevented from entering the reciprocal relationships that constitute a moral economy. Their exclusion from reciprocal relations of care, and their failure to carry out their own perceived obligatory care functions, produced feelings of inadequacy and shame, which often contributed to their social isolation. To varying degrees the women had experienced disappointment when placing confidence and trust in relationships—with their partners, parents, friends, and fellow women who use drugs. Their inability to provide care often stemmed from addiction, economic precarity, and other life circumstances. They reported being constantly disappointed by the institutions (social services, health clinics, AIDS centers, and nongovernmental organizations) that were supposed to provide care for vulnerable populations. In the absence of these care supports, the women lamented, they were unable to effectively carry out their own caring duties, as women, partners, and mothers.

For women in general and women who use drugs in particular, the concepts of care and care work are mired in long histories of gender stereotypes, role expectations, and feminist critiques (Knight, 2015). Buer (2020) illustrated that, in a context of economic deprivation, women who use drugs relied on family members for financial survival while also demonstrating care for others through unpaid care work (caring for children, elderly family members, extended family), distribution of limited resources to others (e.g., produce from a home garden), and sharing drugs with people who were experiencing withdrawal. Jaye et al. (2018) argued that within a moral economy, participants use the currency of “moral capital” to compel others to engage in reciprocal relationships and fulfill obligations. Moral capital is the “ways in which moral and ethical values become embodied in individuals, communities, organizations, and the State” (Jaye et al., 2018, p. 524). Women who use drugs operate in the moral economy with diminished moral capital that stems from the stigma associated with drug use. They have a need to actively demonstrate their moral “correctness” by invoking the tropes of good womanhood/motherhood to build their moral capital. On the one hand, women who use drugs may actively cultivate a sense of gendered identity that demonstrates they are “good” mothers, deserving of care and able to care for others (Kearney et al., 1994; Radcliffe, 2009, 2011a, 2011b; Sufrin, 2017). On the other hand, such active demonstrations may perpetuate rather than challenge gender norms that continue to be used to deny women services and support that they desperately need (Buer, 2020). While feminist scholars and activists have opened spaces for reconceptualizing gender roles and challenging neotraditional gender stereotypes in Ukraine (Hrycak, 2006; Kis, 2005, 2012; Martsenyuk, 2012; Phillips, 2014; Tarkhanova, 2021; Zychowicz, 2020) women who use drugs have yet to see benefits from these changes.

Understanding the nature and qualities of women’s social relationships and reciprocal care obligations is especially critical given the importance of close ties and personal relationships for everyday survival and access to services in post-Soviet contexts and the economic precarity at the root of many of the women’s struggles to navigate the moral economy of care. The need for marginalized women to constantly prove their social worth may delay seeking care (Bungay, 2013), suggesting that providers need to be better educated and equipped to treat marginalized women in a way that respects their personhood, lived experiences, and social context. In addition, prior work has explored the complicated dynamics of caregiving, dependency, and violence among women who use drugs and their male partners (El-Bassel et al., 2011; Radcliffe et al., 2021; Simmons & Singer, 2006), and how gender norms and role expectations can underpin violence. Radcliffe et al. (2021) suggest that these complicated dynamics are often rooted in gender norms, and violence reduction interventions should work to reframe gender role expectations around dominance and control, even for populations that do not meet idealized gender norms such as women who use drugs. In addition, building community among and mobilizing women who use drugs to advocate for programs and policies that meet their needs, change community norms, and challenge stigma have been effective strategies to reduce health risks among women who use drugs (e.g., HIV risk), build economic independence, and reduce intimate partner violence (Blankenship et al., 2015; El-Bassel & Strathdee, 2015; Kerrigan et al., 2014; McCrimmon et al., 2018; Richardson et al., 2012). Microenterprise interventions aimed at female sex workers and women who use drugs have also been shown to reduce risk taking behavior (Basu et al., 2004; McCrimmon et al., 2018). A desire to maintain a positive parenting role could encourage women to enter recovery and treatment providers need to address the complexity of women’s social networks and create opportunities for women to foster positive and reciprocal relationships to support recovery that acknowledge caregiving and care receiving (Brown & Stewart, 2021; Ciambrone, 2002; de Guzman et al., 2006).

Our study had several limitations. First, due to our recruitment methods, we likely interviewed a subset of the target population. Because our study partners in each community were primarily nongovernmental organization that worked with people who use drugs in general, it is possible that women who either do not need services from such organizations or who were extremely isolated were not reached. Second, we conducted one-time interviews with participants, rather than longitudinal interviews, which could reveal how care relationships and obligations change over time, for example, as children age and partnerships dissolve. Finally, our study only included the perspective of women who use drugs. Further research that includes men who use drugs could shed light on the relevance of care, reciprocity, and obligation to people who use drugs in general as they navigate their family and other relationships.

Conclusion

A moral economy of care that deems women who use drugs as undeserving and harshly judges them for their “failure” to perform their expected caring roles, often places those women who need services beyond the parameters of care. A moral economy lens can enrich our understanding of care and care work. The moral economy of care framework reveals expectations of care and deservedness in a social group—who is expected to care for others, and who is seen as deserving of care (Buch, 2015). A critical interrogation of care can reveal the “antagonisms, exclusions…and terrors of many sorts in the historical shaping of care, its objects, and its practices” (Duclos & Criado, 2020). As Kleinman (2009) writes, caregiving is a “moral practice” that makes caregivers “fully human” because it demands empathic imagination, responsibility, witnessing, and solidarity with those in great need. By demonstrating how they care for others, despite their economic circumstances and drug use, women who use drugs demand that they also are “fully human” and deserving of the practical and emotional support that caregivers need (Kleinman, 2009).

Studies focusing on care provision have used the notion of moral economy to examine “how morals come into play during the provision of services, transactions, and within the context of relationships” (Logan, 2019, p. 9). Buer (2020) argues that all people who use drugs, regardless of their gender identity, should have access to services in a justice-informed approach. The women in this study felt excluded from care by health care and social service entities for a range of reasons, including stigma, poverty, lack of official documents and medical records, and lack of time (King & Maman, 2013; Owczarzak et al., 2021). Our interviewees longed to be active parties in the moral economy of care as both recipients of care and active “doers” of care—for children, family members, and other women who use drugs. In their relationships with social workers, for example, women who use drugs wanted to both receive care and demonstrate that they could provide care, even through small gifts of gratitude, and thus be active participants in the moral economy of care. The disconnect between the gendered expectation for these marginalized women to care for their families (and take “better care” of themselves), and the lack of support (economic, social, and emotional) they received to do so, was striking. As women, and especially as mothers, women who use drugs’ obligation to care for others was taken for granted. What was not taken for granted, however, was that these women—whose deservedness and social worth was questioned at every turn—had a right to be cared for themselves.

Footnotes

Acknowledgments

We thank Sergiy Sedykh and Mikhail Karelin for their continued support and collaboration, and whose input in data collection was vital. We are grateful to our study participants for sharing their stories.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a grant from the National Institute on Drug Abuse (grant number R21DA040969).

ORCID iDs

Jill Owczarzak

Alyona Mazhnaya

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