By Pamela Woll, MA, CPS, Senior Consultant
African American Behavioral Health Center of Excellence
Editor’s note: To remain inclusive and patient-centered, we will refer to pregnant or birthing people to include the diverse populations that can conceive a child (eg, non-binary, gender non-conforming, etc.). Text that directly references women, pregnant women, or men refers to these terms as utilized by the research referenced.
For all our science and sophistication, we still live in a world where people are stigmatized, stereotyped, marginalized, deprived, and shamed for elements of their identities, their circumstances, and their health conditions.
This article is about behavioral healthcare at the intersection of four of these streams of stigma, stereotype, and discrimination: being Black, being female, being pregnant, and having a substance use disorder (SUD). Already in a state of heightened physical, psychological, social, and often financial vulnerability, these individuals are also targets of multiple myths and prejudices, blocking access to appropriate treatment and support.
How can behavioral health practitioners—from addiction medicine to recovery support—build safety, health, and stability for pregnant African Americans with SUDs—and for their children?
The stigma toward SUDs is a powerful set of myths, biases, judgments, terminology, attitudes, and emotions. It takes hold in cultures, communities, faith communities, families, and friendships—even in people who believe their attitudes and actions reflect only love and concern. Stigma also flourishes in policy venues and medical, social service, and criminal/legal systems and cultures, but its most vulnerable target is the mind of anyone who struggles with an SUD. According to Weber and colleagues, “Stigma acts on multiple levels by blaming people for having a problem and then making it difficult for them to get help” (Weber et al., 2021, p. 105).
In spite of public education efforts, stigma toward SUDs is still strong in the US, particularly in Black communities. Living for centuries under a dominant culture that might exploit and punish any perceived weakness, many African Americans learned to fear and disparage anything that looked like weakness in those they loved—or in themselves (Woll, 2021). In many Black families and communities, stigma still diminishes support for people with SUDs (Yu et al., 2022).
In America, just being Black can make an individual a target of multiple stereotypes, the roots of which extend back to the Middle Ages, when ambitious Europeans were spinning myths to justify colonization and enslavement (Kendi, 2017). However, it was during the quarter millennium of American slavery that the stereotypes took shape. These stereotypes helped the enslavers justify their actions, avoid seeing Black people as full human beings, win political support for slavery-friendly policies, and prevent alliances between enslaved people and their impoverished White counterparts (Kendi, 2017, McGhee, 2021).
True to the concept of “intersectionality,” each additional stereotyped element of identity—e.g., being Black, being female, being pregnant, having an SUD—further compounds the stigma and potential for contempt, discrimination, and misguided clinical or policy decisions (Rosenthal & Lobel, 2016). For each of these elements of identity, Table One notes stereotypes and their historical purposes.
The stigma toward SUD plays many destructive roles:
Pregnancy complicates stigma’s consequences: “Pregnant people report increased or even new judgment and shame from those previously participatory or tolerant of their substance use, leading to further isolation. Such stigma can manifest even in those otherwise educated on SUD and their treatability, such as health-care workers” (Weber et al., 2021, p. 106.).
Women and gender non-conforming individuals who use drugs may be more vulnerable to stigma than their cisgendered male counterparts (Rosenthal & Lobel, 2016). If they are also pregnant and struggling with SUDs, they are less likely to get a spot in treatment and more likely to be screened for substance use, referred to child welfare services, and/or lose their parental rights—outcomes that are even more likely if they are Black or Brown (Weber et al., 2021).
For pregnant individuals with opioid use disorders (OUD), the stigma may be more intense and the hazards even greater, given the powerful effects of chronic opioid use on the brain and the length of time people experience intense cravings. Effective opioid agonist treatment, blocking cravings without the “high,” is the safest and most humane option for people suffering from OUD (Kaltenbach, 2017).
When babies are born exposed to opioids, they may experience neonatal withdrawal syndrome (NWS) a few days (or up to 4 weeks) after birth. NWS is treatable, but the prospect of NWS may increase the level of stigma directed toward pregnant patients and deter clinicians from prescribing appropriate agonist treatment (Kaltenbach, 2017). Table 2 provides more details about the hazards of stigma to pregnant individuals with OUD, and the side-article included below provides an eloquent argument from Dr. Karol Kaltenbach on the importance of opioid agonist treatment.
So, how do we provide socially, psychologically, and physically safe and respectful services to vulnerable individuals who have been wounded by stigma, stereotypes, and discrimination? Table Three provides several suggestions, but first, a few central approaches from our sources:
Many historical and contemporary wounds cannot be repaired. However, myths can be exposed, systems can be changed, and human beings can find strength and healing. It requires initiative and courage from everyone—leaders, practitioners, and patients—but initiative and courage are contagious.
Whatever each one of us is willing to offer, it will be needed, it will make a difference, and it will contribute to a healing process that is long, long overdue.
Center for Substance Abuse Treatment (2018). Clinical guidance for treating pregnant and parenting women with opioid use disorder and their infants. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Kaltenbach, K. (2017). Historical evolution of family-centered care for pregnant and postpartum women. In Dallas, R.M., Icenhower, K., Kaltenbach, K., Kramer, D., McMahon, T., Ojeda-Rivera, I., and Spence, M. (2017). Perspectives on family-centered care for pregnant and postpartum women: Broadening the scope of addiction treatment and recovery. Kansas City, MO: ATTC Center of Excellence on Behavioral Health for Pregnant and Postpartum Women and Their Families.
Kendi, I.X. (2017). Stamped from the beginning: The definitive history of racist ideas in America. New York: Bold Type Books.
McGhee, H. (2021). The sum of us: What racism costs everyone and how we can prosper together. New York: One World.
Rosenthal, L. and Lobel, M. (2016). Stereotypes of Black American Women Related to Sexuality and Motherhood. Psychology of Women Quarterly, 40(3), 414-427.
Weber, A., Miskle, B., Lynch, A., Arndt, S., and Acion, L. (2021). Substance use in pregnancy: Identifying stigma and improving care. Substance Abuse and Rehabilitation, 12, 105-121.
Woll, P. (2021). Healing history: Where history meets behavioral health equity for African Americans. Atlanta, GA: African American Behavioral Health Center of Excellence.
Yu, Y., Matlin, S.L., Crusto, C.A., Hunter, B., and Tebes, J.K. (2022). Double stigma and help-seeking barriers among Blacks with a behavioral health disorder. Psychiatric Rehabilitation Journal, 45(2):183-191.