Sex and gender  are important determinants of health and influence the physiological and psychosocial aspects of many health conditions, including substance use disorders. Several clear trends regarding gender and opioid use have been identified, related to harms from opioid use, risk factors, and access to services. 

One is that opioid poisonings, both fatal and non-fatal, tend to be higher among men than women, with men representing 78% of drug-related deaths in 2022 in BC.390 While the reasons for this difference are unclear, several possible explanations have been offered. These include the higher likelihood of ingesting opioid medications through non-prescribed routes of administration (though these rates are high among both men and women),404 obtaining unprescribed prescription opioids,404,405 escalating opioid medication doses,406 and concurrent use of alcohol.407 Men are also more likely to have been arrested or under legal supervision407, which can lead to loss of tolerance and disruption of income, in turn resulting in greater harm when opioid use is resumed. 

Women, too, face their own set of risks and gender-specific factors related to opioid use, including significant psychiatric, economic, and infectious disease vulnerabilities compared to men.408 Psychiatric vulnerabilities include higher rates of bipolar disorder,408 major depression,404,408,409 anxiety/panic disorder,404,408,409 post-traumatic stress disorder,404 and history of suicidal behaviour.408 Economic vulnerabilities include significantly higher rates of sex work,408 higher likelihood of being financially dependent on someone else,408 and higher likelihood of being unemployed.404,407 Increased infectious disease vulnerabilities are due to a higher likelihood of sharing injection equipment.408 

Additional vulnerabilities and risk factors women face include higher rates of family and social functioning impairment,404 pain despite chronic opioid analgesia,410 prescription opioid use in response to negative or difficult emotions,404 opioid use to cope with physical symptoms,404 concurrent amphetamine use,407 and physical and sexual abuse histories,408 as well as a known association between chronic physical pain in women and experiences of trauma and violence, including in women on OAT.411 

It is noteworthy that, as a result of ongoing colonization, discrimination, and racism, Indigenous women are at substantially higher risk of drug toxicity death than non-Indigenous women. More than 32% of First Nations people who died as a result of drug toxicity in 2020 were women while women represented only 16.6 % of drug toxicity deaths in the general population.412 

In addition to the vulnerabilities identified above, a recent study of overdose prevention sites (OPS) in Vancouver, BC, found that many OPS are experienced as male-dominated or “masculine” spaces, despite the intention of being gender-neutral. Women reported routinely experiencing harassment from men at OPS, including from men accessing OPS who had previously victimized them.413 Thus, women may face barriers to accessing OPS, which may be alleviated by offering women-only services or hours.

The above-identified trends and relationships underscore the importance of sex/gender-informed and gender-inclusive care. The Centre of Excellence in Women’s Health has several resources available through their Trauma Gender Substance Use Project, including a Gender-Informed Approaches to Substance Use Resource List, the New Terrain Toolkit,71 and the Trauma-Informed Practice and the Opioid Crisis. Clinicians and care teams should also be familiar with and offer patients the option of sex/gender-specific substance use treatment and support services in their communities, if available and as appropriate.

4.2.i. 2S/LGBTQQIA+ Populations

Two-spirit , lesbian, gay, bisexual, trans, queer, questioning, intersex, asexual and other gender and sexually diverse people (2S/LGBTQQIA+) face unique challenges as a result of social prejudice and discrimination, internalized stigma, and lack of health care provider competencies specific to these groups.414,415 For example, due to the persisting heteronormative and often stigmatizing practices in the health system, trans individuals tend to feel unsafe in healthcare settings and may delay accessing care. As a result, gender-diverse and sexually diverse individuals tend to access care with more complex substance-related problems416,417 and greater physical and mental health care needs418,419 than individuals who do not identify as 2S/LGBTQQIA+. Some 2S/LGBTQQIA+ individuals report disproportionate rates of substance use,420-422 and enter treatment with greater severity of substance use problems.423 Suggested explanations for these disproportionate rates include the stress of being in a minority group, dealing with social prejudice and discrimination, internalized stigma, and lack of cultural competence in the health care system.423,424 Data on OUD specifically in 2S/LGBTQQIA+ individuals is lacking; however, given the high rates of substance use in some 2S/LGBTQQIA+ communities, OUD treatment should be culturally sensitive and include an awareness of the issues that 2S/LGBTQQIA+ individuals are likely to face. 

Strategies for working with 2S/LGBTQQIA+ individuals include actively communicating that services are available for 2S/LGBTQQIA+ patients, building relationships with organizations serving diverse marginalized communities, and using inclusive language in forms and clinical materials and during appointments.423 Although substance use disorder treatment for 2S/LGBTQQIA+ individuals is similar to that for other populations, additional factors must be considered, including acknowledging and affirming the patient’s feelings about their sexual and gender identities and the impacts of stigma and discrimination in their lives.425 Other strategies include respecting that identities are fluid and tailoring care accordingly; mirroring the language that your patients use (e.g., to refer to themselves, their relationships, and bodies); not assuming sexual activity levels or motives for substance use; and being affirmative—recognizing the ways that individuals successfully practice harm reduction in their lives. 2S/LGBTQQIA+ individuals may also have experienced discrimination in the health care system and thus require extra sensitivity from health care providers in order to build trust.425 Prescribers should make themselves aware of local support groups and resources for 2S/LGBTQQIA+ individuals. When feasible, gender-affirming and supportive bed-based, outpatient, or harm reduction services that are designated for 2S/LGBTQQIA+ clients can reduce barriers to accessing care. Additional information and guidance can be found in the Substance Abuse and Mental Health Services Administration’s publication, A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals. Health care providers may also benefit from taking the 2S/LGBTQQIA+ module in the BC Centre on Substance Use’s Addiction Care and Treatment Online Course.

A non-judgmental approach, active demonstration of awareness of and sensitivity toward trans issues, and a reinforcement of confidentiality can help trans people feel safe approaching care providers.426 Other ways to demonstrate trans awareness and sensitivity include placing trans inclusive brochures and posters in waiting rooms, asking about gender identity on intake forms (and avoiding conflating gender and sex ),426 and using open-ended questions about sexuality and gender.425 Additional strategies include being reflexive and acknowledging personal biases; recognizing an individual’s intersecting identities (e.g., race, disability, gender, sexuality) and how they may compound and impact patients’ experience of health care; and making gender neutral bathrooms available. More information on working with trans, two-spirit, and gender diverse patients can be found in Trans Care BC’s Gender-affirming Care for Trans, Two-Spirit, and Gender Diverse Patients in BC: A Primary Care Toolkit. Additional resources include the Trans Care Program, provides clinician education, medical forms, clinical resources, patient materials, and linkages to care; UBC CPD’s Gender-Affirming Primary Care course; Sherbourne Health Centre’s Guidelines and Protocols for Hormone Therapy and Primary Health Care for Trans Clients;427 and the Canadian Professional Association for Transgender Health. The RACE line and eCASE can also provide patient-specific guidance.