One of the most important things
we can do to improve public health
is to restore trust, in patients,
for their providers.
So often, the great divide
between patient and provider is trust.
You know, people who use drugs are often
refused the same access to HIV services
and care offered to others.
Stigma and discrimination in healthcare
has been a crisis all its own,
and that crisis has created a barrier to care
for people who use meth,
including gay and bisexual men.
How do providers provide
compassionate care for men
who are all too often stigmatized
and discriminated against?
That is what I needed to know.
So, I think it's really important to meet people
where they are at and to not judge them
for anything that they're doing,
whether it's not using condoms,
whether it's using methamphetamine.
There is this tension,
and I think that there is
this very real need to help people, right?
And one very common strategy
is what I refer to as the “don’t you know” strategy.
The “don’t you know that meth use
can harm you?”
“Don't you know that unprotected sex
can lead to X and Y,” right? “Don’t you know?”
And we feel this incredibly, profoundly,
this need, because – and I think
it’s motivated from love, right?
It's motivated often
from love for the community.
“I love you. I need you to stop doing this.”
But the problem is – there's two problems.
One is, “I already know.”
I would challenge you
to find a smoker who does not know
that smoking causes cancer, right?
And so, if I already know it,
then, what I perceive you to be saying to me,
when you say to me — “Don't you know?” —
is you're trying to make me scared,
and you're trying to shame me.
And people know when they’re being listened to,
and it brings out trust.
And for many of us, I don't know,
people from marginalized groups,
there's already
so many layers of distrust.
And fear and shame, this is the second piece,
are the most alienating of experiences.
And, so, any time we root these messages
in fear or shame,
we are, by definition, alienating individuals
from the acceptance of that message
and from hearing us at all.
And what they hear is;
“You don't care about me.”
And that, to me, is the most damaging thing
about this type of messaging.
There’s a better way for us
to treat people who use drugs
without judgment.
When you get to something
that is highly stigmatized,
like substance use,
you want to create a space
where somebody can be
honest with their provider
about what they're doing
so that their provider can give them
the best treatment possible.
And that's the important elements
of why it's important to meet your clients
where they are at,
because then they will be honest with you
about what's going on in their lives.
I have enough shame already
that I'm bringing to myself.
I don't need to look at somebody else’s face
and see them judging me or
imagine that they're judging me.
A lot of this is really thought to stem from
the experiences of social stigma and rejection
that sexual minority men experience.
That can often be multilayered, right?
We think about intersecting identities,
like being a drug user,
being an ethnic minority man.
There are lots of ways that guys
experience stigma in their communities.
So, for me, the best definition of stigma
is the linking of social judgments
about a particular characteristic –
in this case a behavior – to a person
who is engaging in that behavior.
And that linking is profoundly
a form of social control.
What are some of the ways health care providers
can start the process of restoring the trust
of people who use drugs?
They’re humans. Their need is healthcare.
Their need is to be understood.
Their need is to be taken care of — judgement-free.
Their need is to be safe.
Their need is to have a place to be
where they can just come
and express themselves and be themselves.
Ask your patients, “What's going on?”
“Are you using?”
“Tell me about it,” in a non-judgmental way.
Because I think, many times, in PrEP clinics,
STI clinics, or general medical doctor visits,
people are uncomfortable disclosing, right?
They're uncomfortable initiating that discussion
about their substance use.
And so, just asking can really open that dialogue.
“Tell me your biggest concern
about substance use right now.”
That type of question might enable a person
to actually have a conversation about their life,
as opposed to a litany of...
“Do you do this, do you do this?”
“How often do you do this,
how often do you do this?”
And might really focus
on the piece that the provider
actually needs to help them with most.
My psychiatrist really asks me questions
and makes me think about things.
He's earned my trust by asking questions
that really mean something.
One of the things that I feel
very strongly about
is that we need to only ask questions
that we're going to do something
with the answers.
You ask people about themselves,
not in a way of getting in their business
just to know, but, “What can I do for you?”
“What are the services you're looking for?”
“What can I provide for you?”
Because that's what we're here for, right?
And even though I have used,
I've always not wanted to use.
And I think that that's been
a part of my seeking out
people that are going to help me
and point me in the right direction.
Working in healthcare settings
and in medical units, it's widely accepted
that drug users can be stigmatized and mistreated.
And that is really one of the major
things that drove me to do this work,
is to try and find ways that we can reshape
the experience of health care
for people who use drugs
like methamphetamine and deliver,
I think, more compassionate and integrated care.
I hope that the work
that we're putting out there not only speaks
to the scientific community,
but it also speaks to,
you know, health professionals
that are working with people
who are using substances -
to see their clients
where they're at, to meet their clients
where they're at,
to recognize that this is going on
within these communities
and asking the best questions
to get the best treatment
for these individuals.
There's so much, shame
about queerness.
There’s shame about my addiction
that I had to deal with.
There’s definitely shame about the HIV
that I had to deal with.
And once I addressed
the fact that there was shame
and I start talking about it
and started being real
and being vulnerable,
that's when I start to connect.
You allow them to speak to you freely.
You allow them
to express
what they are comfortable expressing
without digging too deep.
Of course, first visit
they may not give you all of that
because they don't know you yet,
but that's why you allow them
to just speak freely,
allow them to know that
you're there for them,
and you welcome them back.
And isn't that just it?
Despite the stigma and discrimination
being allowed, the autonomy
to own your vulnerability
and allowing that vulnerability
to lead you to a healthier you.
You know, lack of trust
might be the great divide –
but building that trust back
can be the game changer.
People living at the intersection
of substance, use, HIV,
queerness and race deserve more –
so let's keep listening.
If you or someone you care about wants help,
you can learn more
by calling the National helpline
at 1-800-662-HELP (4357)
or by visiting findtreatment.gov.
To learn more about substance use
and addiction research,
log on to nida.nih.gov.