It is the way you treat yourself, but also the way you allow other people to start treating you as well: perceptions of overdose risk among women who inject drug Open Access

In Australia, the rates of both fatal and non-fatal overdose are higher among men than women (Chrzanowska et al., 2023; Geddes et al., 2021). Yet prevalence data lacks in-depth analyses of risk factors and experiences specifically related to women (Lynn et al., 2020). The most commonly considered risk factors among women who inject drugs include psychiatric comorbidity, barriers to treatment, stigma and intimate partner violence (Gibson and Hutton, 2021; Lambdin et al., 2018; Spooner et al., 2015; McKenna, 2014; Meyers et al., 2021). Both epidemiological and qualitative research shows that intimate partners, especially male ones, can be sources of risk for women who inject drugs (Piatkowski et al., 2024a, 2024b, 2024c; Simmons et al., 2012; Wright et al., 2007; Sherman et al., 2001). Epidemiological literature demonstrates that women are more likely than males to rely on intimate partners for injection (Gibson and Hutton, 2021; Zahnow et al., 2018; Frajzyngier et al., 2007). Women are also more likely than men to be involved in behaviours, like sharing injecting equipment and practising unsafe sex, which place them at greater risk of contracting blood-borne viruses (Roxburgh et al., 2005; Weber et al., 2003; Des Jarlais et al., 2012; Lloyd-Smith et al., 2008). Intimate partners for heterosexual women are predominantly described as a context of harm and risk, enabling drug use and associated risky behaviours. Women then are implicitly and explicitly interpreted as enacting more passive and subordinate positions within relationships.

Alongside the epidemiological descriptions of gender and risk, a small body of sociological literature has focused on the gendered dimensions of drug use. Earlier works draw on feminist theories of gender and power emphasise the active roles women play in their initiation and use of drugs (Bryant and Treloar, 2006; Taylor, 1993; Maher, 1997; Du Rose, 2017; Ettorre, 2017; Ettorre, 2015; Ettorre, 2013). These authors effectively counteract the risk-based narratives of women that reproduce and reinforce hegemonic notions of femininity and victimisation, portraying women who inject drugs as “morally deviant” due to their drug use (Keane, 2017; Ettorre, 2015). This research suggests that focusing on harm alone reinforces hegemonic notions of femininity and victimisation (Keane, 2017; Ettorre, 2015) and that some intimate relationships can also provide safety and support for women (Rhodes et al., 2017; Rance et al., 2018; Rance et al., 2017; Fraser et al., 2016; Fraser, 2013; Seear et al., 2012; Dwyer et al., 2011). This movement away from perceiving women as simply vulnerable towards an examination of how social norms define and shape drug use allows for gender to “be used as a template for gathering important knowledge on drug use” (Ettorre, 2004). The conceptual turn brings into question the habit of characterising women in relation to weakness and opens up the prospect of analysing women’s drug use and the “governance of drug problems” in the social world (Duff, 2015). For example, by framing intimate partnerships as units of analysis within a broader social and economic milieu, researchers are increasingly advocating for a broader understanding of social strategies of care, interdependence and communal coping (Seear et al., 2012; Fraser et al., 2020).

Research on these practices of care within drug use practices and relations has emerged from a concern that the focus on the risks and harms associated with drug use reifies the “pathologising tendencies” of research on drug use (Duncan et al., 2017; Kolla and Strike, 2020; Race, 2008). It has been argued that via a focus on care, we can articulate with greater social sensibility the contexts that frame drug use (Austin et al., 2023; Duff, 2015). This concept of care is commonly drawn from Foucault’s ethics of care, where care is best understood within the relational context in which it is enacted (Duff, 2015). Understanding care in this way elucidates social norms as well as the power relations that mould practices of care. For people who use drugs, this means that social norms like gender and relationship dynamics intersect with social dynamics like drug laws and stigma (Austin et al., 2023; Lancaster et al., 2015; Kolla and Strike, 2020). This theoretical approach has offered insights into the relational practices and social contexts of people who use drugs including those living with hepatitis C (Fraser and Seear, 2016) and naloxone use (Farrugia et al., 2017).

In summary, available research on women’s drug use and experiences of risk and harm points to the importance of relationships, particularly intimate partnerships with men. Critical social science literature expands this focus on relationships, arguing for a consideration of social relations and the dynamics of power and care within. Our article contributes to this field in two ways: it challenges public health research to engage with women who use drugs as more than victims of men by analysing how interpersonal relations shape the experiences and meanings of overdose and it draws on theoretical sociological research to encourage the privileging of reciprocal relations of care between women and their colleagues, rather than focussing on harm alone. We argue that the ways that women who use drugs respond to overdose has the potential to highlight how the broader social networks and macrostructural forces, including policy environments and societal stigma, interact with relationships to shape overdose experiences.

This qualitative study draws on interview data from a larger project about overdose among people who use drugs (Piatkowski et al., 2024a, 2024b, 2024c, 2025) of which a substantial proportion injected opioids. Interviews were conducted between November 2023 and August 2024. A researcher specialising in qualitative research conducted all interviews for the study, introducing themselves and outlining the research objectives at the outset. There were no prior relationships between the interviewer and participants. Those who agreed underwent individually scheduled online interviews, providing recorded verbal consent at the outset. Participants were informed of their right to withdraw from the study at any point. As a token of appreciation for their time and expertise, participants received a $90 gift card. Identifying material has been removed from the data set and pseudonyms used in this article. Ethical clearance for the study was obtained from the Griffith University Human Research Ethics Committee (2023/782).

The recruitment strategy leveraged the research team’s personal and professional networks, including two peer-researchers (EK & TP). This approach involved consulting with peers, using social media platforms like Instagram and engaging in face-to-face discussions within peer networks at local needle and syringe programmes to invite people who use drugs to participate in an interview. Invited individuals received a plain language statement and had the option to decline participation. This study draws on a larger sample of 34 people who use drugs in Queensland, Australia. Of these, 21 participants identified as women with lived-living experience of overdose, and 19 of these women reported injecting drugs. This paper focuses on these 19 women, examining their perspectives on overdose risk, safety and stigma in the context of interpersonal relationships. Participants ranged in age from 42 to 63 years (M = 44.67, SD = 4.72).

Using a semi-structured interview guide, the interviews focused on participant’s lived-living experiences with drug use, overdose, harm reduction and community support. The guide was informed by both existing literature and the team’s lived-living experiences with substance use and overdose, ensuring that the questions were academically grounded while resonating with insights from affected communities. This approach fostered an empathetic dialogue that allowed for a nuanced exploration of participants’ narratives. The interview guide was piloted through two interviews with individuals who had relevant lived experience, ensuring the questions aligned with research objectives and enhanced researcher confidence. Interviews were conducted via the Microsoft Teams platform, with durations ranging from 50 min to 1 h and 49 min, averaging 1 h and 10 min (SD = 12 min). The interviews were transcribed automatically and manually reviewed for accuracy by the research team. Transcription data were then imported into NVivo (QSR, v12) for analysis.

Interview data from women participants were extracted from the larger data set and analysed for this study. An iterative categorisation approach was used to analyse the data (Neale, 2016). The lead author conducted a thorough review of the transcripts and notes, identifying and developing inductive codes, including “partnerships” “trust-building” and “informal care networks”. Further codes were developed through collaborative team discussions as new patterns and insights surfaced during the analysis. The team worked together to refine these categories, leading to the development of a comprehensive thematic coding framework (Neale, 2021). The analytical approach was grounded in understanding the structural vulnerabilities of people who use drugs as well as emphasising the co-productive relationships between people in co-creation of knowledge. The research team comprised diverse perspectives, including peer-researchers (TP and EK), whose lived-living experience offered critical insights into the challenges and practices of people who use drugs. Their contributions enriched the interpretative process by providing a nuanced understanding of the data. The team engaged in reflective discussions throughout the process, recognising how their diverse backgrounds and experiences shaped the interpretation of the data.

Exploring the narratives of women who use drugs about their experiences of overdose, we focus on accounts describing relations, both inter-personal and social. As has been identified elsewhere, women constructed overdose risk in the context of intimate relationships where, in addition to harm, many also described safety and care. Experiences of protection and risk extended from intimate relationships through to the community of people who inject drugs. Finally, there were also relational dangers in identifying as a woman who inject drugs and women’s narratives elucidated how social stigma about drug use is symbolically mobilised via shame, impacting on overdose-related safety. We present these ambiguous experiences of overdose in two themes, first looking at the ways women describe men and second their social experiences of being a woman who injects drugs.

Women’s experiences of overdose elucidate the dynamics of gender, power, care and neglect within intimate relationships. For some women, intimate relationships were characterised by vulnerability and power imbalances that heightened overdose risk. Harper’s account, for example, revealed how an abusive partner’s neglect during an overdose nearly had fatal consequences:

This account highlights that interpersonal connections can sometimes magnify overdose risk, and how these dynamics cannot be separated from the broader context of gendered patterns of abuse amplified by criminalised drug use. As reported elsewhere, the intersection of drug use and abusive relationships is a complex issue for women (Wright et al., 2007; Havnes et al., 2021). One such complexity is the criminalisation of drug use where fear of legal repercussions and internalised stigma can prevent women who inject drugs from seeking help. This structural context plays a critical role in shaping responses during moments of crisis, where decisions that may seem counterintuitive, such as hesitancy to call for help, are influenced by the wider social and legal environment. The relational nature of overdose risk is, thus, intertwined with these structural challenges, shaping actions in times of acute danger.

Understanding that women can be vulnerable to men in the context of injecting drug use, women also described how communal practices and peer assistance can serve as practical harm reduction measures. Assisting one another, sharing information and looking out for danger can act to counter the gendered dangers from men in drug-using communities of women:

However, relationships with men were not always sites of danger from women. Participants also described how the presence of a trusted male partner can provide a critical safety net in moments of crisis:

Aria’s narrative emphasises that safety, as well as risk, is constructed relationally, when mutual care and vigilance are present, interpersonal connections can become protective. The emotional and vulnerable elements of women’s intimate relationships highlight a dialectical tension, whereas interpersonal connections have the potential to compound risk when imbued with power imbalances or neglect, they can also provide safety and immediate life-saving support.

In addition to gendered power dynamics in relationships with male partners, women’s narratives expose the ways in which other relational practices contribute to their experiences of overdose. In particular, women described how the risk of overdose is acutely operationalised through social shame:

This illustrates how the affective dimensions of stigma are linked to relational dynamics, rather than emerging from isolated actions of a person or a couple. Overdose risk then emerges from the interplay of actions and pervasive social forces. As Rhonda’s quote below articulates, the social experience of stigma operates as a form of social control, where negative societal judgements are absorbed and reproduced in personal decision-making about health and help-seeking:

Women describe not only feeling stigmatised but “doing stigma”, where they hide practices and identities. For example, Mila and Scarlett’s accounts below illustrate how stigma becomes inscribed in relations as symbolic and actual oppression:

Women suggested that the stigma associated with drug use can lead to self-blame and silence, which, in turn, reduce access to crucial interventions. The interplay of internalised stigma and external punitive experiences create a feedback loop where silence becomes both a symptom and a cause of increased risk. Gianna encapsulates this phenomenon by linking silence with missed communal learning opportunities:

Maintaining secrecy, while protective against immediate social harm, could result in missed opportunities for life-saving interventions. Women consistently described overdose as an ever-present risk in their lives, shaped not only by individual behaviours but also by pervasive structural forces. Societal stigma emerged as a critical factor that both informs and constrains their actions, leading to secrecy and self-blame, which paradoxically increases their overdose risk. The shame women internalise, as well as the silence that follows, creates barriers to help-seeking and reduces access to life-saving interventions, reinforcing a cycle of increased risk.

The stigma associated with being a person who uses illicit drugs could, paradoxically, create safety for women. When discussing overdose participants referred to their community networks as critical sites of safety:

As Scarlett describes, drug use is enmeshed in a set of social practices involving participation in purposeful inter-relations with other people who use drugs. This extract highlights how drug use for this woman involves safety, other people who use drugs and a sense of belonging and, as such, the notion of overdose prevention and risk becomes social as well as individual. Safety was described as communal.

In embracing a relational framework, our findings demonstrate how overdose risk is co-constituted through social bonds. Gender-sensitive overdose measures that are solely preoccupied with women as vulnerable to men fail to encapsulate the social-relational process that generate safety as well as risk for women. Here women who inject drugs can be seen to be producing the conditions for their own safety practices and these dynamic and purposeful configurations can lay the ground for new and innovative overdose prevention activities.

This study examined how women who use drugs navigate overdose risk, with particular attention to how relational dynamics shape perceptions and experiences of harm and safety. Drawing on the social science theoretical turn towards care, in this analysis, we pay attention to the narratives of women who inject drugs as they navigate overdose in relationships and associated roles (e.g. partner or community member) as well as within the broader contextual factors of their lives. Public health and medical research often frame relationships between people who inject drugs as primarily centred around acquiring drugs and managing associated risks, such as blood-borne virus transmission (Rhodes et al., 2019; Rance et al., 2017; Fraser et al., 2014; Simmonds and Coomber, 2009; Simmons et al., 2012). In particular, these traditional narratives depict intimate relationships between people who use drugs solely as sites of risk and dysfunction. In this study, intimate partnerships for women could function as a significant arena for risk. As has been described elsewhere, however, intimate relationships were also sites of risk management and safety (Rhodes et al., 2017; Rance et al., 2018; Rance et al., 2017; Fraser et al., 2016; Fraser, 2013; Seear et al., 2012; Dwyer et al., 2011). In addition to experiences of abuse and harm in heterosexual partnerships, women reported care, support and stability fostered through these social bonds. We note that harm reduction-based acts of care can appear ambiguous, particularly within the relationship dynamics of women and their male partners. Without ignoring the real problems of gendered power dynamics for women who inject drugs, our analyses aimed to delve deeper into the links between drug use and overdose as a way of expanding our understandings of overdose harm reduction with and by women. In this way, we contribute to the research on the exploration of social “sites” of drug use by examining how these dynamics can serve as potential sites of safety and care as well as harm (Fraser et al., 2017).

Beyond intimate relationships with men, women also described safety constructed within their broader community networks, where shared knowledge and peer support serve as practical harm reduction measures. These social bonds emerge as essential resources for managing drug use and mitigating overdose risk, highlighting the broader relational sites that shape women’s experiences of harm and care (Austin et al., 2023). Yet connections to a stigmatised community are not without risk. Women’s descriptions of overdose demonstrate how societal views that drug use is morally deviant (Ettorre, 2015) are not only internalised by women, but are actively reproduced within social networks. Women described how the fear of judgement and societal condemnation compels people who inject drugs to hide overdose experiences, thereby reducing access to emergency help. As has been described elsewhere, negotiation of safety from drug-related harms balance multiple, sometimes conflicting, risks (Austin et al., 2023; Rance et al., 2018). Here, women’s silence about harm acted as both a protective mechanism and a barrier to life-saving interventions, highlighting the ambiguous nature of belonging to a stigmatised community.

Given the marginalisation of people who inject drugs, we argue that assemblages of care (as well as harm) and the relations in which they are enacted reflect social power relations (Farrugia et al., 2019). Thus, harm reduction care practised by people who use drugs can be understood as shared work within a drug-prohibitionist environment, navigating personal and community relationships within social and structural barriers. This sociological perspective allows for the reconceptualization of vulnerability and risk in public health and opens the possibility for gender-sensitive harm reduction in which women are not limited to victimhood. Gender-sensitive harm reduction recognises that women’s experiences of drug use, stigma and overdose are deeply shaped by gendered social norms and inequalities (Piatkowski and Dunn, 2024; Piatkowski et al., 2024a, 2024b, 2024c; Gibson and Hutton, 2021). Alongside the gendered barriers women face, such as fear of losing custody of children and intimate partner violence (Frazer et al., 2019; Goodman et al., 2019; El-Bassel et al., 2019; Thumath et al., 2021) services can also affirm women’s roles as active community members (Austin et al., 2023). Women-led peer harm reduction initiatives can play a pivotal role in advocating for women’s agency (Chang, 2020), providing safe, empowering environments where women support one another and the wider drug-using community.

In summary, we explore overdose as a case study to interrogate that ways in which people who inject drugs apply their own “ethos of care” throughout their practices of harm reduction (Fraser et al., 2016) and where women’s experiences of overdose offer different insights into living with overdose risk. Building on the perspective that overdose is a relational phenomenon, deeply embedded in social networks that can be mobilised to provide both care and support, we argue that harm reduction innovation needs to “filter through” these relations (Ettorre, 2004). Future directions for research and policy should build on these insights by investigating how harm reduction programs can more explicitly integrate relational and social dimensions of overdose risk management into service delivery. This includes exploring models that embed peer-led harm reduction within broader social support structures, such as housing programmes, childcare services and trauma-informed health care. Moreover, given the persistent role of stigma in limiting women’s access to harm reduction and health care, future research should examine how policy interventions, such as decriminalisation, non-punitive child protection policies and gender-sensitive health care training, can actively reduce the structural barriers that heighten overdose risk.

This study has several limitations that should be acknowledged. The study did not include the perspectives of male partners or connected social networks, which could have provided a more comprehensive understanding of the dynamics at play. The sample size was relatively small, and participants were drawn from specific community networks, which may not fully capture the diversity of experiences across different regions or social contexts. As this study draws on a subset of a larger mixed-gender sample, recruitment was not specifically designed to capture women with particular characteristics of interest, which may have influenced the range of perspectives included. In addition, while the interview guide was not explicitly tailored to women’s experiences, this limitation was mitigated by the expertise of the qualitative interviewers, who used organic prompting to explore gendered dimensions of overdose risk and harm reduction.

This study underscores the complex interplay between societal and interpersonal dynamics in shaping overdose experiences for women who inject drugs. Our findings demonstrate that overdose risk is a relational phenomenon, emerging from an at times conflicting dynamic of gendered power norms, intimate relationships, drug-using community membership and the pervasive effects of social stigma. Contrary to dominant narratives that often portray women as passive victims of their circumstances, the findings demonstrate the care and solidarity that can also define women’s experiences of drug use and overdose. Reorienting public health approaches to recognise and harness the protective potential inherent in both intimate and community-based relationships offers the opportunity to address the pervasive issue of overdose and related stigma.

The authors are immensely grateful to the participants of the study for sharing their experiences with them. The authors also thank the Peers who continually offer and provide a safe space for the community. The authors also thank the Queensland Injectors Health Network (QuIHN) for assisting with recruitment.

Funding: Queensland Mental Health Commission provided funding for this work to facilitate participant reimbursement and contribute to research personnel. The Commission did not provide any input on the execution of the project, including data collection, analysis, interpretation or write-up of results.

Declaration of interests: Emma Kill is the CEO of Queensland Injectors Voice for Advocacy and Action (QuIVAA), and Dr Piatkowski is a Director on the Board the organisation. QuIVAA is a non-government-owned and not-for-profit “Drug-User Organisation”.