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Sexual and reproductive health care for people living with substance use disorders

Unique challenges to accessing and opportunities for improved integration of sexual and reproductive health care.

by Rebekah Rollston, MD, MPH

published 11/09/23

Substance use disorders (SUDs) are medical conditions characterized by the problematic use of substances, such as alcohol, illicit drugs, or prescription medications. SUDs involve a pattern of behaviors where an individual’s use of substances leads to significant impairment or distress. Symptoms can include social and occupational impairment, risky use despite negative consequences, and physiological changes resulting in tolerance and/or withdrawal. The National Survey on Drug Use and Health found that in 2021, 46.3 million people aged 12 years and older—that is, 16.5% of the U.S. population—met the DSM-5 criteria for having a substance use disorder. This survey also found that 94% of the population living with SUDs did not receive any medical treatment. Importantly, SUDs often co-occur with other mental health conditions, like depression, anxiety, or post-traumatic stress disorder.

Individuals living with SUDs use highly effective contraceptives at rates lower than the general population and, ultimately, have disproportionately high rates of unintended pregnancy. There are a multitude of barriers for these individuals when attempting to access sexual and reproductive health care, including high prevalence of sexual trauma and transactional sex, as well as intimate partner violence and coercive relationships; experienced and/or anticipated stigma from health care providers; distrust of the health care system and fear of criminalization; lack of knowledge and misinformation about contraceptive methods and fertility. Additional barriers include competing social and general health needs, including homelessness; cost and/or lack of insurance; transportation challenges; and weak support networks.

Additionally, the health care system’s division between substance use counseling and the availability of sexual and reproductive health services presents notable logistical obstacles.

Best Practices for Providing Sexual and Reproductive Health Services to People Living with SUDs

Many individuals living with SUDs have experienced various forms of trauma, including stigmatization and trauma imposed by the health care system. Trauma-informed care acknowledges and responds to the widespread prevalence of trauma in individuals’ lives and its potential impact on their physical and emotional well-being. This approach seeks to create a safe, supportive, and empowering environment for individuals who have experienced trauma by integrating the understanding of trauma’s effects into all aspects of care delivery. This includes during all three phases (before, during, and after) a clinical visit, getting consent in the exam room, and centering the principles of reproductive justice, as individuals living with SUDs have oftentimes experienced high rates of reproductive coercion by sex partners and are at risk of reproductive coercion by health care providers (particularly in regards to use of long-acting reversible contraceptives).

When taking a sexual history, ask patients living with SUDs the same questions that you would ask all your patients, like gender identity, sexual orientation, sexual practices (e.g., oral, vaginal, rectal sex), partner history, history of sexual violence, history of sexually transmitted infections (STIs), contraceptive use, sexual pleasure, and reproductive history.

One Key Question is a simple and effective approach that can also be used to initiate discussions about pregnancy desires and contraception during clinical visits. The goal of this approach is to routinely ask all patients about their pregnancy desires and offer appropriate contraceptive options and counseling based on their preferences. This approach helps to integrate reproductive health conversations into routine health care visits, making it easier for individuals to make informed decisions about their reproductive health based on their unique circumstances and goals.

Additionally, all patients should be offered STI testing, treatment, and counseling based on their risk. It’s important to discuss the use of condoms for STI prevention, ensuring patients understand that this is the only form of contraception (other than abstinence) that can prevent transmission of STIs. As many individuals living with SUDs may be involved in transactional sex or intravenous drug use, it’s critical to also counsel on pre- and post-exposure prophylaxis (PrEP/nPEP) to reduce the risk of HIV acquisition.

Patient-Supported Interventions

SexHealth Mobile is an innovative initiative developed in partnership with a federally qualified health center in Kansas that delivers comprehensive sexual and reproductive health services to individuals who inject drugs. The mobile unit travels to various locations frequented by people who inject drugs, and it provides a range of services, including contraception, STI testing and treatment, pregnancy testing and counseling, harm reduction supplies, and referrals to additional health care and social services. The unit is staffed by trained providers who offer non-judgmental, culturally competent, and trauma-informed care to create a safe and supportive environment for patients. By meeting individuals where they are, the unit reduces stigma, increases access, and improves the overall health and well-being of its target population. Evaluation of the SexHealth Mobile unit demonstrated increased STI testing rates, uptake of contraceptives, and positive feedback from service recipients.

Additional models have been implemented where sexual and reproductive health services are provided at needle syringe exchange programs, as was done by Public Health Seattle and King County. In order to optimize service acceptability and sustainability, it’s important to involve clients in the planning and evaluation stages.

Bottom Line

Individuals living with SUDs face various barriers in accessing high quality, non-judgmental, and trauma-informed care for sexual and reproductive health. Patient-supported interventions include meeting individuals where they (physically) are through outreach like the SexHealth Mobile unit or within needle syringe exchange programs.

Rebekah Rollston is a Family Medicine Physician at Cambridge Health Alliance, Instructor at Harvard Medical School, and Faculty of the Massachusetts General Hospital Rural Medicine Program. She completed her residency at Tufts University Family Medicine Residency at Cambridge Health Alliance, with specialized training in family planning and addiction medicine. Her professional interests focus on social determinants of health & health equity, gender-based violence, sexual & reproductive health, addiction medicine, rural health, homelessness & supportive housing, and immigrant health.
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