Contraceptive risk-taking among substance-using women

Abstract

Substance-using women use contraception less frequently than do women in the general population, and as a result have higher numbers of unplanned pregnancies. In addition, substance-using women regularly utilize abortion as a means for controlling their number of births. A number of factors complicate this phenomenon, including sex-for-drugs exchanges. This study analyzed data from interviews with women receiving substance abuse treatment in San Francisco, CA. Interviews explored behaviors associated with contraception and abortion as well as complicating factors surrounding prostitution. The existing literature in this area lacks theoretical insight into these behaviors. In this article, the Theory of Contraceptive Risk Taking (TCRT) is used to explore the behaviors of this sample. The TCRT predicts that contraceptive risk-taking (i.e. not using contraception) will occur after a woman navigates a series of steps in a decision-making process, including weighing costs and benefits of contraception and pregnancy, estimating her probability of becoming pregnant, and measuring her ability to obtain an abortion should her risk be unsuccessful. The participants identified many costs of contraception. The theory largely explained the behavior of this sample, except that pregnancy costs and benefits were overlooked. Implications for social work include eliminating logistical barriers to contraception and increasing benefits to contraception by offering financial incentives to use.

Keywords

Abortion drugs HIV/AIDS prostitution substance abuse theory of contraceptive risk

Introduction

Prevalence rates of contraception use among illegal substance users are difficult to obtain. Researchers have, however, attempted small-scale studies, most often with treatment seekers. Existing research finds that substance-using women are inconsistent in their contraception use and use unreliable methods (Armstrong et al., 1991; Gutierres and Barr, 2003; Ralph and Spigner, 1986; Shah et al., 1998; Weber et al., 2003). In the general population, only 7 percent of women for whom contraception would be necessary (e.g. those not sterile or pregnant) do not use contraception (Mosher et al., 2004). Nonetheless, many who use contraception do so irregularly, and they account for 53 percent of the nation’s unplanned pregnancies (Guttmacher Institute, 2004).

Substance users are more likely than those who do not use substances to obtain an abortion (Coleman et al., 2002; Martino et al., 2006; Reardon and Ney, 2000). Substance use also appears to be related to multiple abortions (Prager et al., 2007). Exhibiting high levels of unconventional behaviors (e.g. being a risk taker) may explain the relationship (Martino et al., 2006; Reardon and Ney, 2000). Furthermore, lower rates of contraception use are logically related to higher levels of unplanned pregnancies among substance users, so higher abortion rates make sense.

Abortions are not equally available to all women in the US. In 2008, for example, the rate of abortion in the US was 19.6 per 1000 women of reproductive age. In California (where all participants in the current study lived), the figure was higher: 27.6 per 1000 women of reproductive age. In the same year, a reported one-third of all American women lived in the 87 percent of counties in the US that had no abortion provider. This is much different than in California, where 22 percent of its counties did not have an abortion provider, but only 1 percent of the female population lived in those areas. Further, California does not impose restrictions common in other jurisdictions, such as waiting times and mandatory parental involvement (Guttmacher Institute, 2011).

High rates of unintended pregnancy are the predictable result of low rates of contraception use. In a nationally representative sample of young women, Martino et al. (2006) found that women with a history of illegal substance use were more likely than their peers to have had an unplanned pregnancy. Other studies estimate the range of unplanned pregnancy in this population to be from two-thirds to three-fourths of all pregnancies (Armstrong et al., 1991; Black et al., 2012; Shah et al., 1998). In comparison, in the US overall, less than half of pregnancies are unintended, a figure that has remained constant since the mid-1990s (Finer and Henshaw, 2006; Henshaw, 1998).

Special at-risk population: Women who trade sex for drugs

Women who trade sex for drugs are of special concern because of the frequency of intercourse and the circumstances surrounding such exchanges (Incidardi, 1993). In the literature, sex-for-drugs exchanges have most often been associated with crack cocaine use. Most of the research was done in the 1990s and is silent on how this practice differs by drug type. It could, however, be predicted that such exchanges are more frequent among crack cocaine users because of the short-lived high experienced with crack cocaine, resulting in the likelihood users would be driven to alternative ways of obtaining drugs. Some female users become so anxious about the depressant effects that occur after a crack cocaine high, they resort to behaviors they would not otherwise believe themselves capable, such as performing sexual acts for male dealers (Bourgois and Dunlap, 1993; Inciardi, 1993; Kearney et al., 1994; Ouellet et al., 1993). Avoiding these depressant effects, coupled with the desire to get high, mitigate any anxieties over consequences of not using contraception (Sharpe, 2001).

The connection between substance use and prostitution is not straightforward. Some women began prostituting, only later turning to drugs as a way to cope with the realities of prostitution. Over the last two to three decades, with the increased use of crack cocaine, others began using drugs and later turned to prostitution to support their habits. Both activities seem to reinforce each other, and a cycle develops of exchanging sex for drugs more frequently as an addiction worsens, while additionally requiring more of the drug to cope with prostitution and perform sexual activities (Erickson et al., 2000; Potterat et al., 1998; Sallmann, 2007; Young et al., 2000).

One study of females who traded sex for crack cocaine found that over half of the participants (19 of 34) never used any birth control, and many others used it inconsistently. Eighteen reported they had become pregnant because of an exchange; 11 became pregnant more than once (Sharpe, 2001). Some prostitutes will refuse to have sex unless customers wear a condom, but will not require primary partners (i.e. non-paying or boyfriend) to wear one (Boyle and Anglin, 1993; McCoy and Wasserman, 2001; Muller and Boyle, 1996). Women who trade sex to support drug use may also command higher prices (both money and drugs) if they do not use a condom (Nadeau et al., 2000).

Theory of contraceptive risk taking

Much of the existing research lacks theoretical guidance to explain birth control practices of substance-using women. In this article, I apply the Theory of Contraceptive Risk Taking (TCRT; Luker, 1975) to the birth control behaviors of substance-using women and use it to suggest social work intervention strategies. The TCRT suggests that contraceptive risk-taking, which sometimes results in pregnancy, occurs after a multi-stage individual cost-benefit analysis results in a determination that contraception is relatively too expensive (Luker, 1975). Women do not consciously consider each of the steps sequentially. Rather, it is a useful framework for explaining behavior, and it accounts for the women’s beliefs, as Luker demonstrates. Further, it can be used to guide interventions.

The first piece of the TCRT is navigating what Luker calls the ‘utility’ of both pregnancy and contraception, and the utility includes the costs and benefits simultaneously. High utility toward contraception implies benefits outweigh costs. Alternatively, low utility means costs outweigh benefits. Similarly, low utility for pregnancy suggests costs outweigh benefits of pregnancy; a high utility for pregnancy means benefits outweigh costs. When a woman has both low utility for contraception and high utility for pregnancy, in TCRT she is more likely to take a contraceptive risk. If either of these conditions is missing, she will be less likely to take the risk. That is, she will be more likely to use contraception.

The next element is considering her likelihood of becoming pregnant. Unsurprisingly, if a woman believes she has a low probability of becoming pregnant, she will more likely take a contraceptive risk. If, on the other hand, she thinks she is likely to become pregnant, she will be less likely to take a risk and more likely to use contraception. Finally, she considers her ability to undo any consequences of her risk-taking. That is, if she believes she cannot escape the consequences of the contraceptive risk, she will not take the risk. If she can easily terminate a pregnancy, she is more likely to take the contraceptive risk.

Luker developed her theory with abortion-seekers who were not necessarily substance users. Its applicability to a substance-using population will be explored in this study. I use the theory to suggest social work interventions to better meet the needs of female substance users. This study seeks to fill existing gaps in both the substantive and theoretical literatures.

Methods

In this study, I examine the research question, ‘How does the Theory of Contraceptive Risk Taking explain the behaviors of substance-using women?’ In-depth face-to-face interviews were conducted that explored issues surrounding birth control, sexual behavior, pregnancy, partner issues, and experiences with trading sex for drugs.

Recruitment

Three distinct agencies served as recruitment sites. Each provided services to substance users, and all were located in San Francisco, CA. One agency was a transitional housing program for women with a history of incarceration. Another provided a range of substance abuse services including detoxification, services for pregnant and HIV-positive women, and residential and outpatient treatment. It served low-income, uninsured, and under-insured residents of San Francisco. The third recruitment site served sex workers and their partners. It provided free physical health care and social services, including contraception, needle exchange, and substance use treatment.

All women receiving services from these agencies were invited to participate. The researcher hung flyers and attended staff meetings to discuss the study and invited staff to make clients aware of it. A purposive sample was necessary for obtaining members of this hard-to-reach population. All clients who contacted the researcher, volunteered for participation, and met inclusion criteria were included, for a total sample of 26. Inclusion criteria included active and former drug- and alcohol-using adult women, who regularly used illegal substances within 12 months prior to participation in the study, or at least once per week within 12 months of entry to a program, and who recently regularly engaged in vaginal intercourse with a male partner. Interviews were conducted between July 2007 and January 2008.

UC Berkeley Office for Protection of Human Subjects (OPHS) gave approval for the study (protocol #2007-3-80). Upon suggestion by the OPHS, because of the sensitive nature of the research, participants were not required to sign a consent form.

Data collection

The author conducted face-to-face interviews with all participants, and each interview lasted approximately 75 minutes. Interviews were audio recorded and transcribed. All participants were given a $25 gift card to a local grocery store. After each interview, extensive notes were written, including themes that had arisen during the interview; subsequent interviews explored emergent themes.

Analysis

Each step in the TCRT decision-making process, as outlined above, will be considered, and its applicability to the behaviors of this substance-using sample of women will be discussed. Transcriptions were coded for themes developed a priori from the TCRT and organically from the interviews; positive and negative cases were coded. Direct quotes were used as supporting evidence.

Sample composition

Participants ranged in age from 20 to 54 years (mean = 36.3). Four participants identified as White, 14 as African American, two as Hispanic, and six as mixed ethnicity. Two women were born outside of the country, and 15 were born in the state of California. Of the 26 participants, 11 had not graduated from high school, and 12 had yearly incomes of less than $8000. Nine participants were HIV-positive or had AIDS, and four had Hepatitis C.

Results

Participants in this study had a high level of knowledge about contraception, as demonstrated by the rate at which reliable forms of contraception had been used (See Table 1). Though many reliable forms of contraception had been used at some point by the women, all reported limited use and many did not request or retrieve refills of prescriptions, including contraceptive injection (which requires a new shot every three months). Other researchers (e.g. Harding and Ritchie, 2003; Kendall et al., 2005; Vidal-Trecan et al., 2003) have reached similar conclusions: the lack of follow-up is more problematic than either initial access or lack of contraceptive knowledge.

Table 1.

Types of birth control used.

Type of contraception	Users
Male condom	n = 26 (100%)
Contraceptive pill	n = 22 (85%)
Abortion	n = 20/24 ever pregnant (83%)
Contraceptive injection	n = 10 (38%)
Female condom	n = 8 (31%)
IUD	n = 5 (19%)
Tubal ligation^a	n = 4 (15%)

Either four or five participants had received a tubal ligation; it was unclear with one participant. In closed-ended questions, she reported receiving a tubal ligation, but her interview suggested this was not actually the case. It is possible she did not understand what it meant. A number of other times throughout the interview she asked for clarification about questions that did not require clarification from other participants. For example, she asked for clarification of the word ‘contraception’ at two different points during the interview, to which the author explained ‘birth control.’

Utility of contraception

TCRT (Luker, 1975) predicts women will be more inclined to take a contraceptive risk if she has a low utility toward contraception (i.e. when costs of contraception outweigh benefits of contraception). Indeed, women in this study identified no benefits to contraception; therefore only costs of contraception are discussed. Recall, however, that a positive utility toward pregnancy (i.e. benefits of pregnancy outweigh costs) must also be present in order for contraceptive risk-taking to be more likely. This will be discussed in the next section. There were four costs associated with utility of contraception. They included relationship costs, obtaining contraception costs, method-particular costs, and sex-for-drugs exchanges costs.

Relationship costs

This emerged as a theme with nine participants. Relationship costs refers only to men with whom participants otherwise had a personal relationship, not to clients. Condoms were the only type of contraception used regularly so they are the only contraception discussed.

Participants expressed relationship costs as different levels of threat to the relationship: from their partner’s simple dislike of condoms, to a fear that their partner would leave if he were forced to wear a condom.

Respondent 7: He used to be like if I gotta use a condom, I’m gone.

Respondent 9: I’ve asked them to use condoms. They don’t like it. Like, my youngest daughter’s father, when I started having sex with him, I asked him to use a condom, he was like, he don’t use condoms. I was like, why is that? He always said,’cause I don’t use condoms. Ain’t nothing wrong with my meat. You know what I’m saying? I’m like, okay, whatever, but with me you gonna use a condom.

So we used condoms for a minute, and then we stopped using condoms.

Interviewer: How would he feel if you asked him to use a condom?

Respondent 11: Who am I fucking, and what for? It’d be an issue.

Obtaining contraception costs

The fact that so many of the participants in the sample had used or been prescribed hormonal forms of contraception suggests that access to effective contraception is not a problem. This is not surprising because all participants were recruited from social service agencies which, at least minimally, assisted clients with medical concerns. Only five participants did not have insurance. Three of these five were recruited from the health clinic for sex workers, where they received free medical care. Contraception was frequently offered or administered directly after a birth or abortion, but participants reported not returning for subsequent shots, or refusing contraception altogether. Most participants explained that when they were actively using substances, they almost never went to the doctor (except for a birth or abortion), describing their overwhelming feeling of apathy toward anything other than obtaining more drugs.

Respondent 4: Because of the drug use, you’ll be saying I have a doctor’s appointment, and before you know it, you’re out using and you forget all about your business.

Respondent 13: It didn’t matter. That’s where all my kids came from … was my drug addiction, shit, all my kids. You out there using drugs … you ain’t trying to care about nothing but where the next high comes from.

Respondent 20: But when you in your addiction you don’t think about condoms. You think about getting your money and your drugs.

Respondent 22: Just because it requires you seeing somebody … there’s easier access to condoms when you’re out there on the streets than it is to go like to a doctor and get a contraceptive, pill or whatever, yeah.

Condoms were widely available to all participants. Most reported getting free condoms at health care clinics, at drug treatment facilities, at welfare offices, and from outreach workers on the street. Because of their ready availability and STD-prevention properties, condoms were the most commonly used form of contraception, even though many of the women indicated they were more concerned about condoms’ ability to prevent HIV than to prevent pregnancy. However, all participants reported very sporadic condom use; no one reported using condoms all the time.

Method-particular costs

Among participants who used contraception more than sporadically, many reported adverse side effects, both physical and emotional, as well as logistical problems associated with contraception use. Most (n = 22) had used birth control pills, but use was extremely limited. Nine participants reported they had trouble remembering to take the pill every day. Not all participants were asked directly why they stopped taking the pill, so the actual number may be higher.

Respondent 4: I would forget when to take it, and the three-day-after pill whatever they called it, to catch up or whatever, it just got confusing after a while. I got off schedule, so I was like forget it.

Respondent 11: I forget to so I don’t even need to fuck with … the pill, I just can’t, I think I may have used them once, but I never remember to take the motherfuckers, and by the time I think about it, I fucked up a whole month worth of pills’cause I didn’t take’em.

Eleven participants reported they did not use a contraceptive shot or pill because they had experienced side effects, usually depression and weight gain, or they had heard from others that they would experience such side effects.

Respondent 2: I never took it long enough. But I have friends that, like, gained weight, and they, um, didn’t like how it kind of messed up their hormones and the way they acted and stuff, but like I said I never took it long enough to experience it.

Respondent 6: I took birth control when I was 16 … [and] my attitude changed. I gained weight … my first baby daddy told me get off that shit.’Cause you don’t need nothing to mess with your attitude,’cause you already got a fucked up disposition. You know, it just make me act cranky.

Respondent 12: Some people get fat on it … and then I’ve seen TV shows where you know people die …

Respondent 21: I don’t want to be on birth control, you know? Um, it also fucks with your mood, and I have a tendency toward depression so I’m like, no thanks.

It is interesting that eight participants reported they did not want to put chemicals in their bodies or risk their physical health by using hormonal forms of contraception, even though they were participating in other harmful activities, such as smoking cigarettes and using illicit substances.

Respondent 4: [Interviewer] Why did you stop using the pills?

Because for one I was a cigarette smoker, and I heard how high risk it is.

Respondent 6: Most of the time, with birth control, they got so many, just medicines and chemicals and shit up in there.

Respondent 12: I don’t really like taking any kind of like medication … it’s funny I say that because I didn’t mind taking street drugs [laughs], but you know, any kind of like medication stuff like that, I really just don’t like taking it, and I think it irregulates your period, you know.

Respondent 21: I’ve never wanted to be on the pill, probably because of my weight and because I used to be a smoker and um, and for those reasons, the health complications seem like, fuck it.

Sex-for-drugs exchange costs

Because use of contraception other than condoms was very limited, this section discusses only condom use. Twenty-three participants traded sex for drugs or money to pay for drugs. For most participants, prostitution was the primary means for acquiring drugs. At least nine participants became pregnant at least once from these exchanges.

Previous research has documented costs of using condoms to women who trade sex for drugs, including the fact that condoms prolong the time it takes a client to ejaculate and thus the time until the reward (i.e. either drugs or money for drugs) is received (Nadeau et al., 2000). Similarly, negotiating with a client to use a condom takes time, thereby delaying payment (Sharpe, 2001). In addition, a customer may pay less if forced to wear a condom, thus generating a financial cost as well. This study found similar costs in terms of time and money.

Out of the 23 participants who had traded sex to support drug use, six reported they always used a condom with clients, and 14 reported they did not always use a condom. For three participants, this information was missing. A few participants who initially reported always using condoms, changed their answer as the interview progressed, reporting not always using condoms with ‘regulars.’

Respondent 9: [Says always uses a condom] [Interviewer] Did you use any birth control?

Birth control? I used condoms.

[Interviewer] Every time you had sex?

Every time I had, yes. That was one thing, I was like, scared of, is the condom breaking, you know,’cause you dating all kinds of people out there, you don’t know if they’re gay. You don’t know if they’re straight. You don’t know … it was kind of like scary.

Respondent 9: [Later, amends to not always use a condom] [Interviewer] So if they say they don’t want to use a condom, what do you usually do?

Huh? We just don’t have sex.

[Interviewer] You just don’t have sex?

No, we just don’t have sex. Unless I want to or something like that. But it’s like, half of the time I don’t, you know, unless I feel like it, you know, especially if I’m really, really drunk, and I’m tipsy, and I’m off other drugs, you know, but I really have to learn, like, to be cautious about myself, about what I’m doing sometimes, unless I really, really know the person.

[Interviewer] So if it’s somebody you know, you’re more inclined to have sex anyway?

Yeah

Respondent 11: [Implies always uses a condom] I’m not the type to just, I would wake you up even if you was my neighbor … I’d be on your door, like can I get some condoms? You got some condoms for me today? Or I’d catch your ass coming from work … So, hey, you got some condoms?

Respondent 11: [Later says did not always use condoms] [Interviewer]: You always used condoms when you were trading sex for drugs?

Not all the time … If the dick was good, no I didn’t. Not gonna sit up here and lie and say that I did,’cause I didn’t … There’s men who perform poorly, and there’s men who have good sex, so if the dick was some good dick, and good dick came around, you let good dick raw dick you … So when good dick was coming around, you know, I wouldn’t use my rubbers.

Another factor reducing the likelihood of condom use was the higher price that could be commanded by not using one.

Respondent 15: I’m like, well, you gotta have a condom. That’s where that gift for gab come in at. They say, well, I pay you this … and if I seen that if I kept saying no, and they would go higher, and higher, and higher, and my mind’s calculating how much dope I can get, and, and everything, all at the same time they’re going higher, and then I go okay, I’ll go ahead, just this one time.

Respondent 20: One john, after he found out I had HIV, one john I told that we need to use a condom,’cause I’m HIV, he said, I pay you more money if we don’t use condoms. I’s like, I’m telling you I’m HIV positive. He said, ‘so?’ I’m telling you I’ll give you more money if we don’t have to use condoms.

[Interviewer] Did you take more money?

Mm mm.’Cause I didn’t want, even though it was tempting, but I didn’t know what he had, you know?

[Interviewer] He might have AIDS?

He might have AIDS or some kind of infection, and I coulda caught it, you know, I just said, no that’s okay. ‘Cause most the people, there’s most the johns out there who will tell you I’ll pay you more money if we don’t use condoms, and that’s a red flag right there. You know, I’ll give you an extra hundred dollars if we don’t use condoms. You have to think, why’s he giving you extra money when you, when I, when you used to deal with this john over a period of time, and all of a sudden he said I give you extra hundred, we been using condoms, but all of a sudden he tell you I give you an extra hundred not to use condom. I said no, there’s something wrong with this picture. You know.

Respondent 25: [Interviewer] What was the difference between when you used a condom and when you wouldn’t?

Um, I think it was only like once or twice, once was when I really needed the money, and he was offering extra. And I did what I never, you know, told myself to ever do, but I really needed the money, so, so I said okay …

Still other participants simply did not seem to care about condoms. Others indicated they found sex more enjoyable without a condom so did not always use one.

Utility of pregnancy

As with contraception, both the costs and benefits of pregnancy are considered before a woman takes a contraceptive risk. If the benefits of pregnancy outweigh the costs, she is more likely to take a contraceptive risk. It may be more accurate with this group, however, to say that as long as costs do not outweigh benefits, contraceptive risk-taking is likely. While participants did not identify any benefits to pregnancy, they also did not see any substantial costs. In fact, no benefits of pregnancy were found in the evidence, and many actually specifically reported that they did not desire a pregnancy. Evidence of their desire not to become pregnant includes the following:

Respondent 3: You know because when you a user, that’s when I should have been using the birth control, yeah. And when you a user, you know, why bring something in the world, if you’re not able to afford it, why have it, on the drug thing, I don’t think that’s you know, I think it’s punishment.

Respondent 6: … when I was using and getting pregnant … shit, is the baby drugged up? Oh my God. Is that baby still living,’cause I didn’t, ooh, I done drank, like how many beers last night? Oh my god, I was drinking all that liquor … Stuff like that. That baby gonna be Down’s Syndrome, or I gonna have a retarded ass child, you know what I’m saying.

Respondent 15: All I knew was how to get high, and I didn’t want to be a parent, you know, and I had to accept that term, too, that I really did not want to take care of my kids. You know, um, that was one of the reasons why I got my tubes tied’cause I wasn’t gonna have no more babies.

Probability of becoming pregnant

The TCRT predicts contraceptive risk-taking if it is believed there is a low probability of becoming pregnant. Fourteen participants in the sample discussed their beliefs around fertility. Four believed they had a high chance of becoming pregnant, and 10 believed they had a low likelihood of becoming pregnant. Those who thought they were not likely to become pregnant generally believed that their drug use had made them infertile:

Respondent 10: I thought that, you know, because of my drug use and my irregular habits of not eating and sleeping and stuff I felt like as long as I was dirty, I wasn’t going to end up pregnant a lot of times.

Respondent 11: Shit, I thought I had smoked and numbed all of the inside, where I couldn’t get pregnant.

Respondent 12: We wouldn’t use’em (condoms). And I never got pregnant, so I just thought I couldn’t get pregnant. Maybe it was the drugs.

Nonetheless, the women who believed they had high fertility still took contraceptive risks.

Ability to reverse decision

The final component of the TCRT involves one’s self-efficacy in terms of obtaining an abortion. Of the 24 participants who had ever been pregnant, 20 had received at least one abortion. This demonstrates the accessibility of abortions for these women, many who were recipients of Medi-Cal, which covers the cost of abortions, and who all resided in the San Francisco Bay Area, where abortions were geographically available. This suggests a high level of confidence that, should a contraceptive risk not pay off and a pregnancy occur, an abortion provided a plausible alternative.

Summary

The TCRT predicts that when utility of contraception is low, it will not be used. The participants’ strong negative feelings about contraception indicate they associate high costs with the practice: hormonal contraception was unpleasant to use, their partners did not like condoms, and the practice of trading sex for drugs presented its own complicating costs. The utility of pregnancy, on the other hand, is not as clear. Its utility is not positive, but it is not clearly negative, either, because most often, participants simply did not consider pregnancy. That is, they did not identify any costs to pregnancy, even as they did not identify any benefits. In light of the TCRT, the utility of pregnancy seems to simply be removed from the decision-making process. This could be because the women simply did not care about the consequences of their actions, or they did not think that a particular incidence of sexual activity would result in pregnancy. It is not inconsistent to realize that there is a good chance of eventually becoming pregnant, while believing that a single sexual act will likely not result in pregnancy. Participants were also more likely than not to believe they had a low probability of becoming pregnant. Finally, should a contraceptive risk fail (i.e. a pregnancy occurs), an abortion was both geographically available and financially accessible.

Luker (1975) developed the TCRT with women who were not substance users; she considered the theory useful for intervention because her subjects were rational and capable of making appropriate decisions. The women in this sample, on the other hand, are clearly influenced by their drug use, as exemplified by their responses, and their ability to make rational decisions is compromised, in particular with regards to the long-term consequences of not using a condom. The theory arguably fits these data, however, because the TCRT indicates that if a woman is not sufficiently motivated to prevent pregnancy, she will be less likely to use contraception. Here, results indicate the ease with which an abortion could be obtained, if a participant found herself pregnant. That is, there was insufficient motivation to avoid pregnancy.

Discussion and implications

Limitations

The study has a number of limitations. First, each participant was interviewed only once and therefore topics could not always be fully explored. This was partly attributable to the inability to cover many complex issues in one sitting. Follow-up interviews with clients were not possible both because of resource constraints and because of the transient nature of the population. Second, respondents sometimes gave conflicting responses to questions. This was particularly notable when asked about the consistency of their condom use. This was possibly due to social desirability. In addition, at least one respondent was unclear about terminology associated with contraception.

Meeting needs of substance-using women

Programs must meet the needs of substance-using women, including continuing to make contraception widely available and easily accessible. However, requiring a visit to a clinician, and filling a prescription, are difficult for this population. San Francisco has many programs where condoms are freely distributed, but more reliable forms of contraception require a prescription and visit to a medical facility. Prager et al. (2007) suggest that one harm reduction strategy to reduce unwanted pregnancies that end in abortion would be to recommend long-term birth control options for substance users. Based on my findings, it appears that participants were already being offered such services by their providers both after abortions and after giving birth, but by their own admission, they did not follow up or return for services. A better approach may be to offer mobile contraceptive services, perhaps in cooperation with a mobile needle exchange, in areas of need. Many participants got a contraceptive shot after having an abortion or giving birth, but they did not return for subsequent treatment. If a mobile clinic brought injections to the community, substance users may be more willing to continue this form of birth control. Many participants reported they did not want to take hormonal forms of contraception, but 10 had received a contraceptive shot and many others had used contraceptive pills. It is possible that participants were providing socially desirable reasons for not using contraception, but in reality their lifestyles precluded utilizing effective methods of contraception, as discussed above. Social workers who serve active drug users in, for example, criminal justice, child welfare, or public health settings, could educate their clients about resources for obtaining contraception, including mobile clinics, where appointments would be unnecessary. The New York Times recently reported on the success of a campaign to vaccinate gay and bisexual men at risk of meningitis in New York City. Vaccinations are distributed free of charge at after-hours clubs, and men are choosing to receive the vaccination while socializing, demonstrating the efficacy of bringing the intervention to where the target client is (Hartocollis, 2013).

Black et al. (2012) found that many women in substance abuse treatment programs would prefer contraceptive services be available within drug treatment facilities, indicating a potential willingness to use contraception if it were logistically accessible. Elko and Jansson (2011) report success of a family planning clinic located within a pediatric clinic, which was in turn part of a drug treatment facility. Such novel approaches to contraception distribution show promise in increasing contraception use, at least among women seeking treatment services. Social workers are critical in the process of drug treatment and are therefore in an ideal position to advocate for the integration of contraception services as part of a holistic approach to recovery.

The TCRT suggests that the key to increasing contraception among substance-using women may be to increase costs of pregnancy and simultaneously increase benefits of contraception. Because participants did not want to become pregnant, increasing benefits to contraception should be the focus. At least three participants in this study learned they had HIV because they were paid to be tested and return for results (not discussed in this article). Paying substance users to use permanent contraception has faced much controversy because it is considered coercive (Lucke and Hall, 2012; National Advocates for Pregnant Women, n.d.; Roth, 2002), but a similar system of paying substance-using women to get a contraceptive shot, which is short-term but effective, has the potential to increase use of contraception among substance-using women. Lucke and Hall (2012) provide an extensive overview of alternatives to providing a large lump sum of cash to encourage long-term or permanent contraception. Most notably, they suggest offering small cash payments for maintaining use of reversible forms of contraception or offering cash only after a woman has participated in contraception counseling. They argue that incentives are simply a public health intervention and can be ethically done. Such incentives may be one of the few interventions that substantially reduce the number of unplanned pregnancies among substance-using women, and dialogue among policymakers and service providers should be encouraged, in particular with regards to effective, but not permanent, forms of contraception.

Keeping abortion accessible

Because almost all participants in this study utilized abortion as a method of birth control, and it will likely continue to be utilized by substance-using women, it should be kept legal and accessible, while simultaneously increasing access to contraception. There is a danger that some will argue that if abortion were not as accessible, women would be more likely to use contraception. Indeed, the TCRT may seem to point in that direction, but not if the whole picture is considered. It is clear that the decision-making ability of the women in this sample was compromised, and abortion was used as a means to control births. As utility of contraception is made more favorable – that is, the benefits are increased – abortion rates will go down. However, accidents still happen, and the women in this sample are clearly not reliable users of contraception; unplanned and undesired pregnancies will still occur, even if at a lower rate. Luker (1975) also addresses this: she asserts that for some women, there is simply no alternative to contraceptive risk-taking, and abortion should be kept accessible. For the substance users in this sample, there are a number of factors that would certainly continue to make risk-taking a likely behavior. However, increasing the utility of contraception as outlined above should reduce the demand for abortion.

Previous research has identified a definite relationship between abortion and substance use (Coleman et al., 2002; Martino et al., 2006; Reardon and Ney, 2000), but it has been unable to disentangle the relationship. The research presented here suggests that substance users engage in a lifestyle that does not include regular use of contraception. It also suggests that female substance users do have the capacity to take action in regards to childbearing, at least after they become pregnant. That is, if they do not desire a child, or another child, or they believe themselves incapable of raising a child, they often act definitively once they have made the decision not to carry a pregnancy to term. Some participants reported a desire for an abortion, but did not get one because they never took the time to actually obtain the procedure. Most of these women, however, had received an abortion with another pregnancy, demonstrating the importance of abortion in controlling births among this population. Future research should further explore whether substance-using women consider abortion to be an acceptable form of birth control. This issue was not explored in great detail in this study, but at least some of the participants seemed to consider abortion to be a form of birth control at the time of intercourse. This suggests that substance-using women are thinking about the possibility of pregnancy, at least some of the times they have sex. As discussed, abortions are particularly accessible to women in California so the findings of this study are unlikely to reflect the abortion history of women elsewhere in the US or in the rest of the world.

Unplanned births are one of a number of problems associated with substance abuse. Helping substance-using women to reduce unplanned births will not solve their substance use problems, but it will address at least one particularly difficult one. The TCRT should be utilized to guide interventions that will increase the use of contraception and decrease unwanted pregnancies among substance-using women.

Footnotes

Funding

This research was supported through funding from National Institutes of Health, National Institute of Alcohol Abuse and Alcoholism, Graduate Research Training on Alcohol Problems, T32 AA007240. It was administered by The Alcohol Research Group in Emeryville, CA.

References

Armstrong

Kenen

Samost

(1991) Barriers to family planning services among patients in drug treatment programs. Family Planning Perspectives 23(6): 264–268.

Black

Stephens

Haber

Lintzeris

(2012) Unplanned pregnancy and contraceptive use in women attending drug treatment services. Australian and New Zealand Journal of Obstetrics and Gynaecology 52(2): 146–150.

Bourgois

Dunlap

(1993) Exorcising sex-for-crack: An ethnographic perspective from Harlem. In: Ratner

(ed.) Crack Pipe as Pimp: An Ethnographic Investigation of Sex-for-Crack Exchanges, New York, NY: Lexington Books, pp. 97–132.

Boyle

Anglin

(1993) ‘To the curb’: Sex bartering and drug use among homeless crack users in Los Angeles. In: Ratner

(ed.) Crack Pipe as Pimp: An Ethnographic Investigation of Sex-for-Crack Exchanges, New York, NY: Lexington Books, pp. 159–186.

Coleman

Reardon

Rue

Cougle

(2002) A history of induced abortion in relation to substance use during subsequent pregnancies carried to term. American Journal of Obstetrics and Gynecology 187(6): 1673–1678.

Elko

Jansson

(2011) Contraception in drug-dependent women: A novel approach. Social Work in Mental Health 9(6): 445–455.

Erickson PG, Butters J, McGillicuddy P and Hallgren A (2000) Crack and prostitution: Gender, myths, and experiences. Journal of Drug Issues 30(4): 767–788.

Finer

Henshaw

(2006) Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health 38(2): 90–96.

Gutierres

Barr

(2003) The relationship between attitudes toward pregnancy and contraception use among drug users. Journal of Substance Abuse Treatment 24: 19–29.

10.

Guttmacher Institute (2004) Facts in Brief: Contraceptive Use. Available at: www.agi-usa.org/pubs/fb_cont_use.pdf (accessed 7 April 2004).

11.

Guttmacher Institute (2011) State facts about abortion: California. Available at: http://www.guttmacher.org/pubs/sfaa/pdf/california.pdf (accessed 14 January 2013).

12.

Harding

Ritchie

(2003) Contraceptive practice of women with opiate addiction in a rural center. Australian Journal of Rural Health 11: 2–6.

13.

Hartocollis A (2013, May 17) For gay men, a fear that feels familiar. New York Times. Retrieved 17 June 2013 from nytimes.com.

14.

Henshaw

(1998) Unintended pregnancy in the United States. Family Planning Perspectives 30(1): 24–29, 46.

15.

Inciardi

(1993) Kingrats, chicken heads, slow necks, freaks, and blood suckers: A glimpse in the Miami sex-for-crack market. In: Ratner

(ed.) Crack Pipe as Pimp: An Ethnographic Investigation of Sex-for-Crack Exchanges, New York, NY: Lexington Books, pp. 37–67.

16.

Kearney

Murphy

Rosenbaum

(1994) Learning by losing: Sex and fertility on crack cocaine. Qualitative Health Research 4(2): 142–162.

17.

Kendall

Afable-Munsuz

Speizer

Avery

Schmidt

Santelli

(2005) Understanding pregnancy in a population of inner-city women in New Orleans: Results of qualitative research. Social Science and Medicine 60(2): 297–311.

18.

Luker K (1975) Taking chances: Abortion and the decision not to contracept. Berkeley: University of California Press.

19.

Lucke

Hall

(2012) Under what conditions is it ethical to offer incentives to encourage drug-using women to use long-acting forms of contraception? Addiction 107(6): 1036–1041.

20.

McCoy

Wasserman

(2001) Gender differences in condom usage among rural crack-using men and women. Women and Health 33(1/2): 143–162.

21.

Martino

Collins

Ellickson

Klein

(2006) Exploring the link between substance use and abortion: The roles of unconventionality and unplanned pregnancy. Perspectives on Sexual and Reproductive Health 38(2): 66–75.

22.

Mosher WD, Martinez GM, Chandra A, Abma JC and Wilson SJ (2004, December 10) Use of contraception and use of family planning services in the United States: 1982–2002. Advance Data from Vital and Health Statistics, No. 350. Available at: http://www.cdc.gov/nchs/data/ad/ad350.pdf.

23.

Muller

Boyle

(1996) ‘You don’t ask for trouble’: Women who do sex and drugs (attitudes toward HIV infection risk). Family and Community Health 19(3): 35–48.

24.

Nadeau

Truchon

Biron

(2000) High-risk sexual behaviors in a context of substance abuse: A focus group approach. Journal of Substance Abuse Treatment 19: 319–328.

25.

National Advocates for Pregnant Women (n.d.) C.R.A.C.K. Available at: http://www.advocatesforpregnantwomen.org/issues/crack/ (accessed 28 October 2008).

26.

Ouellet

Wiebel

Jimenez

Johnson

(1993) Crack cocaine and the transformation of prostitution in three Chicago neighborhoods. In: Ratner

(ed.) Crack Pipe as Pimp: An Ethnographic Investigation of Sex-for-Crack Exchanges, New York, NY: Lexington Books, pp. 69–96.

27.

Potterat JJ, Rothenberg RB, Muth SQ, Darrow WW and Phillips-Plummer L (1998) Pathways to prostitution: The chronology of sexual and drug abuse milestones. The Journal of Sex Research 35(4): 333–340.

28.

Prager

Steinauer

Foster

Darney

Drey

(2007) Risk factors for repeat elective abortion. American Journal of Obstetrics and Gynecology 197(6): 575.e1–575.e6.

29.

Ralph

Spigner

(1986) Contraceptive practices among female heroin addicts. American Journal of Public Health 76(8): 1016–1017.

30.

Reardon

Ney

(2000) Abortion and subsequent substance abuse. The American Journal of Drug and Alcohol Abuse 26(1): 61–75.

31.

Roth

(2002) The perils of pregnancy: Ferguson v. city of Charleston. Feminist Legal Studies 10: 149–158.

32.

Sallmann J (2007) Using substances and exchanging sex as “going hand-in-hand”: An exploration of the connections between substance use and prostitution for a sample of prostitution-involved women. In: The annual conference of the Society of Social Work and Research, San Francisco, CA, USA, January 2007.

33.

Shah

Hoffman

Shinault

LaPoint

(1998) Screening for pregnancy and contraceptive use among women admitted to a Denver detoxification center. Public Health Reports 113(4): 336–340.

34.

Sharpe

(2001) Sex-for-crack-cocaine exchange, poor black women, and pregnancy. Qualitative Health Research 11(5): 612–630.

35.

Vidal-Trecan

Warszawski

Coste

Bajos

Delamare

Grenier-Sennelier

(2003) Contraceptive practices of non-HIV-seropositive injecting drug users. European Journal of Epidemiology 18: 863–869.

36.

Weber

Tyndall

Spittal

Coulter

O’Shaughnessy

(2003) High pregnancy rates and reproductive health indicators among female injection-drug users in Vancouver, Canada. European Journal of Contraception and Reproductive Health Care 8(l): 52–58.

37.

Young AM, Boyd C and Hubbell A (2000) Prostitution, drug use, and coping with psychological distress. Journal of Drug Issues 30(4): 789–800.