Article By Haley brown, Graphics By Han Hamel
CW: Discussion around transphobia, ableism, mental health, suicidal ideation, and various forms of violent oppression including conversion therapy, physical violence, and incarceration.
Substance use is as complicated as the people who are using.
As a harm reduction worker who is nonbinary, autistic, and ADHD (attention deficit/ hyperactive disorder), I am very aware of this. I believe it is critical that the harm reduction community uplift diverse perspectives, not as an obligation, but as a source of celebration and insight. Neurodivergences and gender diversity are a common intersection among people who use drugs. Understanding this community is one way to ensure everyone in harm reduction spaces is seen, loved, understood, and supported.
Substance use exists on a spectrum from abstinent (no use) to chaotic use (unregulated use that harms other areas of your health and wellbeing). Marginalized communities are more likely to experience chaotic use because it meets many needs (safety, belonging, relief) that are structurally denied. Intersecting marginalizations further complicate this picture. Transphobia, ableism, and stigma around drug use directly deny safety, belonging, and comfort. The risks associated with chaotic substance use are a direct harm created by intersecting systemic oppression. Effective harm reduction lives in these intersections, providing individuals and communities with empathy, information, and empowerment.
Gender diversity and neurodiversity regularly overlap far beyond statistical coincidence. Both gender diverse people and neurodiverse people are also much more likely to experience active substance use. Holding these stigmatized identities can increase stress and negative health outcomes, decrease access to social and financial resources, and fuel chaotic use. Often, the needs stemming from one identity are denied on the basis of the others, leaving open spaces for chaotic use to fill.
Many autistic people experience delays to and denial of gender affirming care. Doctors frequently dismiss autistic people’s self-knowledge and free will regarding their gender identity. Some doctors assume patients experience gender dysphoria due to fixation on gender as a special interest. Others invalidate trans identity by ascribing it to a form of Obsessive Compulsive Disorder (OCD) that they attribute to Autism Spectrum Disorder (ASD). Other trans people are not believed about their gender identity due to a disregard for societal norms of transness. Since autistic people are often less likely to follow societal norms to begin with, many autistic trans people are less concerned with adjusting their gender presentation, physically transitioning, or changing their name, as compared to neurotypical trans people. This leads to doctors dismissing their identity and blocks access to gender affirming care because gender dysphoria diagnoses are based on the ways neurotypical trans people present. Many neurodivergences can make gender transition uniquely challenging due to sensory issues around hair, clothing, binders, hormones, and surgery. Difficulties with memory and planning can increase the challenge of remembering appointments and sticking to a medication schedule.
Vice versa, being gender diverse heightens many common difficulties of being neurodiverse. ASD is already underdiagnosed in every population that isn’t cis-men. Many people’s social issues are attributed to their gender divergence, leading to a delay in diagnosis for ASD. Many neurodivergent people experience strong isolation. Many neurotypical Trans and Gender Noncomforming (TGNC) people and cisgender neurodivergent people are able to cope with this isolation as communities. This is frequently unavailable to TGNC neurodiverse people. Transphobia in neurodivergent spaces and social difficulties as a result of neurodivergence lead to rejection even in neurodivergent or trans spaces.
Many issues are faced by both neurotypical and TGNC communities independently, but are compounded by the intersecting experiences. Neurodiverse people frequently struggle with employment, and adding gender identity discrimination further lowers the chances of independence and stability. TGNC people frequently turn to sex work as a result of this gender identity discrimination, a valid occupation deserving of protections. Neurodiverse people are already more vulnerable in the workplace. In the absence of legal protections, the dangers of sex work signifcantly increase when the person is also neurodivergent. Many sex workers turn to substances to cope with this intense vulnerability.
Difficulties in romantic relationships are compounded by both identities. Where they are already complicated for TGNC people, neurodivergences can complicate navigating disclosure before or transition during relationships. More complex romantic situations and the experience of prejudice in romantic rejections can further the pain of social isolation. This social isolation, combined with the experience of transphobia, less access to coping skills, and rigid thinking increases the risk of suicidal ideation in this community. Isolation and emotional pain both can contribute to chaotic use patterns.
Violent abuse is all too common in neurodivergent and trans communities, bringing to mind the torturous practices of ABA, the Judge Rotenburg Center, transmisogynistic violence, and conversion therapy. In a combination of transphobic and ableist violence, many autistic trans people describe being subject to “normalizing treatments” in a report by the Autistic Self Advocacy Network. People who experience violence and trauma are much more likely to turn to chaotic use patterns as a coping strategy.
We know less about some types of neurodivergence and their intersections with gender and use, possibly because we lack research on some conditions or the people experiencing them lack social resources to empower gender self-advocacy. Also, when marginalized people exhibit trauma behaviors, doctors may overdiagnose personality disorders because they are uneducated about systemic trauma. As such, this post mostly discusses ASD and ADHD. This does not mean the neurodivergent community is limited to these identities. I specifically acknowledge the stigma and lack of resources associated with cluster B neurodivergences (a group of personality disorders considered dramatic, overly emotional, or erratic). I firmly uphold your place in the neurodivergent community. It is clear these diagnoses experience additional challenges beyond what is discussed here.
Stigma surrounding substance use worsens these experiences. A history of use makes it harder to access treatment for some mental health disorders. Trans and neurodivergent people are more likely to experience physical disabilities, likely the physical toll of trauma and stigma. And yet, substance use is often a barrier to receiving proper care for this pain. All three identities can lead to medical providers dismissing health concerns.
In addition to this, nonwhite people in the United States are also contending with systemic racism. White supremacy manifests in transphobia, ableism, and drug stigma, each much more likely to result in violence and incarceration against Black and Brown people. White creators frequently encourage people to stop hiding their neurodivergent behaviors, without taking into account the risk this creates for Black autistic people. What is perceived as eccentric behavior in white people is perceived as threatening behavior in Black people. This racism is deadly, as we’ve seen in the violence against Elijah McClain and countless others. Beyond neurodivergence, Black trans women are among the most marginalized people in the United States, facing a heightened risk of violence, discrimination, and trauma. All too often, white spaces ignore these overlapping crises.
It’s obvious that people would seek comfort, belonging, and safety through substance use in the wake of this incredible violence. It is a normal human response to oppression. Racism then further manifests in our response to substance use. Substances more likely to be used by black people are punished much more harshly in courts, and Black people systemically experience much harsher sentencing for the same convictions compared to white counterparts. Where white people might find empathy and treatment, Black people are met with punishment.
Having so many unmet needs is exhausting and disorienting. We must respond to this with tenderness and care. Be compassionate. Celebrate your identities. Work to unpack your internalized stigma. Join the vibrant tradition of queer harm reduction. Find your community, in person or online. Marginalization is intersectional. Affirmation must be as well. Black and Brown people deserve spaces of racial solidarity and affirmation. You are not responsible for the stigma you experience or the context you inhabit. It is the responsibility of harm reduction advocates to facilitate intersectional spaces of healing. Oppression is a harm reduction problem and we must unite in advocating for community care and systemic solutions. Individual solutions are insufficient in the face of systemic problems.
Ultimately, this post is a love letter to the neurodiverse, gender diverse community of users. You deserve access to everything you need to use safely. You deserve care providers who do not stigmatize you for your use, your gender, or your presentations of neurodivergence. You deserve accessible communication. You deserve care strategies oriented to your unique needs and challenges in life. You deserve empathy, community, safety, and love. I want you to feel seen, to feel valued, and to feel an abundance of self-compassion. This world is structured against us. You are not alone in your struggles, your feelings, your identity, or your use. You are worth taking care of and worth every new chance, You are worth harm reduction.