By Anonymous

In the early morning hours of August 17, 2017, Michigan State police busted into a quaint, corner walk-in pharmacy on the corner of Warren and Yinger in Dearborn, Michigan, a suburb south-west of Detroit, interrupting the daily deluge of transactions regularly accruing round-the-clock lines out the door at the infamous local “pill mill.”

Dr. Mohammad Derani was arraigned and had his medical licence suspended from the Department of Regulatory Affairs. Derani, who had written over 500,000 prescriptions since January 2017, averaging 43 every work day between 2015 and 2017, ranked among the most prolific distributors of controlled substances in 2015 and 2016, according to sources.

The national epidemic abuse of opioids, which include heroin or prescription pills, is often considered a white rural or suburban issue. Though Arabs and Muslims have not be spared from the epidemic, their ability to surmount the challenges of diaspora and tackle a nationwide drug epidemic shows a success, rather than deficiency, at the intersections of culture and community.

Like millions of Americans, Dearborn’s residents battle a nationwide drug epidemic that claims the lives of an estimated 100 Americans a day. In the city, drug-related arrests have jumped from 500 in 2011 to 1,000 in 2016. Opioid deaths more than doubled across the country as drugs of choice among users transitioned from prescription opioids to hard street drugs like fentanyl and heroin — a transition that coincided with the skyrocketing price of drugs following a period of overprescription.

My Family Members Struggle With Addiction — Why Don’t I?
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Dr. Derani was one high profile case, but many doctors have been involved in fraud, overprescription, or other opioid scams. In June 2017, six southeast Michigan doctors were found guilty of pocketing illegal kickbacks amounting to $132 million in a nationwide insurance fraud scheme.

“Easily 8 out of 10 of our calls and cases were due to overdoses,” Ed, a 22 year-old emergency medical technician and second generation Arab-American, estimates. “Heroin, opioid, drug overdoses are an overwhelming problem, regardless of age, background, or nationality.”

Arab American communities face the tribulations of war at home compounded with the complications of adjusting to what is regarded within the community as a uniquely American problem of addiction. Both professionals and community members note the relative silence their issues are met with in mainstream America, and how that silence is internalized by Arab Americans, discouraging them further from seeking help.

Numerous community professionals and leaders, for years, noted the stigma surrounding mental health and substance abuse in the Arab American community. Silence and denial hamper any discussion around addiction. At funerals for the victims of a disease that claimed no one demographic, at times, deaths became reported by family and community members as heart attacks or as other natural causes. No one wanted to admit the actual cause.

At funerals for the victims of a disease that claimed no one demographic, at times, deaths became reported by family and community members as heart attacks or as other natural causes.
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“People wanted to say these youth had heart attacks, at 18, 19 years old,” said Mona Hijazi, public health lead at ACCESS. “Back in 2016 [when we started these programs] we couldn’t find anyone to talk to regarding these experiences.” Now, the program ACCESS pioneered, the ACCESS Substance Abuse Program (ASAP), boasts frequent community conversations, addiction counseling coaches, and informational resources that have been translated into Arabic.

Hijazi, also ASAP coordinator, is no stranger to the effects of addiction. Having grown up alongside a family member who spent two decades battling prescription drug abuse and addiction, she understands the challenges that many of her clients face. But she also draws upon her experiences in her role as part of the community coalition. “I never talked about [addiction] until I started my work because I felt that I was holding back from people that I was talking to. I actually had to go and talk to my mom and asked her if she would be okay if I said something — and not say who or even go into details — and she said, if you save one mom a heartache, why not.”

Since 2016, Hijazi recognizes that there had been tremendous change. ACCESS and the ICA began to partner up on ASAP, holding frequent talks and informational sessions and seeking community based help. The community outreach has been effective in raising awareness and breaking stigma. “The good thing about this partnership [with the mosque] is the Imam talks about how he can’t save somebody’s child with religion; that this is a medical issue and addiction should be treated as a disease.”

Dr. Hoda Amine is a Dearborn-based psychotherapist and social worker treating those suffering from addiction in the city’s east neighborhood. She pinpoints self-esteem issues as the factors predisposing her patients towards addiction. These factors, she identifies, are the result of the liminal status second generation Arab Americans find themselves in as “not quite” one or the other. “They don’t know how to be Arab and don’t know how to be American,” she says. “There’s a lot of pressure from the family and the society. They want to fit in — but they also want to disassociate.”

Want To Reduce Drug Use? Listen To Women Drug Users
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The opioid epidemic saw its transition from its prescription drug phase in the 1990s to a heroin and street drug crisis as the influence from the legacy of over-prescription manifested itself in the production and proliferation of street drugs. As drugs became more expensive, many that had become addicted to pain medication, finding their supply running out, turned to street drugs or more potent — and more dangerous — opiates.

While the grassroots efforts in the Arab American community have helped discussion and dialogue proliferate, institutions such as mosques and even law enforcement are also highly involved in community education and emergency treatment around addiction.

Local police nationwide are known for their participation in some of the most invasive, anti-black and Islamophobic policies and practices, including military and intelligence trainings with Israel, widespread surveillance of Muslim and Arab communities, and impunity for police murders of black people. Dearborn PD is the only police department in the state accepting Countering Violent Extremism (CVE) funds, supported by a highly controversial DHS grant issued to sponsor surveillance of mainly Muslim American communities, resulting in more names on the watch list than any city in the U.S. behind New York. However, they are also lauded for their perceived contribution in local addiction recovery efforts. Police partner with groups like the Dearborn-based SAFE substance abuse coalition group, mosques, and local schools to promote substance abuse awareness, and to provide resources such as naloxone, an anti-opioid agent.

This also highlights a complicated relationship between local law enforcement and minority communities, especially considering the deeply embedded role law enforcement has in opioid recovery. Yet despite the police’s public image as the front line in the war on opioids, it is women and progressive youth that have, as those most acutely impacted, made true efforts in changing the culture and breaking the stigma.

Safaa is one example of many who suffered in silence due to the stigma of coming out with an addiction. Like many others, her use started with doctor’s prescriptions, worsening once her tolerance level matched her prescribed supply. In recovery, Safaa realized that there was a need for a confidential support group for women in her community facing addiction. “It’s embarrassing for women to talk about these issues [around men] because there’s a stigma, there’s shame,” she says.

Thankfully, according to studies, women are more likely to seek treatment — however, counselors who work with Arab and Muslim American clients note that these women will seek care only outside of the community gaze.

It’s embarrassing for women to talk about these issues (around men) because there’s a stigma, there’s shame.
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Assembling the first Arab women’s addiction recovery support group, Safaa opened up a space where local women not only have access to confidentiality and support, but where, two years in, informational resources translated into Arabic have been made accessible, and honest dialogue on the issue in private spaces is facilitated. “[We are] the first Arab women’s (addiction’s anonymous) coalition,” she adds. “We do outreach, get together, talk about [drug] abuse.”

Zeinab, a freelancer who wrote for a local paper during the summer of 2016, recalls the response local outlets faced to publishing news on the sudden deaths of young community members, mostly young men, that had overdosed. These platforms received backlash that at times amounted to threats.

However, Zeinab says things are changing. “Yes, there was a backlash after the reported deaths in 2016, but I think our generation kind of shushed the angry voices,” she says. “They paved a way for discussion through organizations like SAFE and even youth programs at religious and academic institutions.” She credits new mediums and voices, as well as existing grassroots spaces, for helping move the conversation forward.

An Arab Trans Woman, Struggling To Find Myself In Language
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As these initiatives show, Arabs and Muslims have leveraged social and cultural dynamics to help combat a nationwide epidemic. It is because of — rather than in spite of — cultural tenants in religion, community, and service that they have been so effective at finding and creating solutions for recovery.

And for many of them, the very women, who, while less likely to die of painkiller abuse, are still more at risk, their bearance of the greater share of emotional and social burden in the home and in the community also render them the leaders in this effort.

“As women, we take on so much and we don’t say anything…we approach that especially when it came to substance abuse,” adds Hijazi. “Yet it’s possible to get through this [together], that you’re not alone as a mom, as a sister, as a friend.”

Content warning: descriptions of child abuse

The clinic I took my sister to is housed in a new building; it has abstract paintings on its very white walls and overly quirky sodas in the waiting room. Pain management clinics that pedal opiates strive to look respectable.

If all goes as planned, this clinic will prescribe the opiates that she will become addicted to—again. They will dull her constant physical pain. They will dull her psychological torment—the particular trait that makes them so attractive to so many. The doctors involved in prescribing them largely overlook the psychological torment, however; a narrow view of a very complicated problem makes for convenient medical treatment. It makes for compelling media narratives.

It makes for more addicts.

I could start the story of my sister’s addiction by talking about the first pain management clinic she went to, 10 years ago. The one where the doctor was eventually arrested for trading prescriptions for cash. She was prescribed an ever-increasing dose of oxycontin, oxycodone, and eventually a fentanyl patch along with oral narcotics. She became a slow-motion zombie who nodded off while standing, lost her balance, and broke bones from falling. In the time it took her to enunciate a simple sentence, she would forget what she was trying to say. She lost her job, then her health insurance, and, finally, access to her prescription opiates. She spent a week dope sick, without any medical care, and emerged sober.

But that’s only part of The Opiate Story.

My sister’s story of addiction began when she was 4, when the sexual abuse began. A relative would creep into her bedroom at night; so much abuse at such a young age affected the way her pelvic muscles developed. Children lack the words to describe such violations of body, mind, and soul, and like most victims of sexual abuse, she never told anyone as a child. When she finally grew up and told our mother, she didn’t believe her. And because she was abused in New York, the state’s statute of limitations on the crime kept her from pressing charges as an adult.

Her angry, depressed childhood and angry, depressed teenaged years culminated in some pretty severe bouts of anorexia and a suicide attempt at college. But with the help of campus mental health services and continued distance from her home, she gained psychological distance from the abuse, got a decent job, and tasted a semblance of healthy adulthood.

Depending On Painkillers Doesn’t Make Me An Addict
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In her mid twenties, she developed severe pelvic pain, which baffled experts for years. It started out as debilitating menstrual pain, something doctors minimize. Pretty soon it started before her period, lasted beyond it, and then would happen a few random times throughout the month. Within the course of a year she was experiencing severe pain every day, absolutely confounding a growing list of doctors and specialists.

She finally went to one of the best medical centers in the nation for a diagnosis and treatment plan. She saw five specialists the first day there, and at least two of them asked her, point-blank, if she was sexually abused as a child. One of them explained exactly how penetration at such a young age—as well as the struggles against it—can warp the development of pelvic muscles. They explained that an office job which required sitting for hours caused a change in muscle tone that had snowballed into her chronic, debilitating pain.

Children lack the words to describe violations of body, mind, and soul.
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After my sister was diagnosed, the doctors at the medical center said she would need treatment with opiates. They discussed a nerve block, but she was too young and otherwise healthy. They suggested physical therapy and acupuncture too, which didn’t work. Debilitating pain was managed with debilitating doses of opiates. Two bad options, but the opiates made her less miserable.

After she lost her job, she moved back to the same house she was sexually abused in, with emotionally brutal parents who weren’t sympathetic to her plight. She applied for Social Security Disability, a process that takes years in New York.

There isn’t much academic research about the adult life of child sexual abuse survivors, but existing research and anecdotes imply her life is fairly typical. The Adverse Childhood Experiences study of the 1990s proved that child sexual abuse—along with nine other childhood traumas—have lifelong, significant, and surprising impacts on the health and futures of those grown children. Earlier research documented the increased risk of mental illness and drug abuse. But the increased risk of cancer, diabetes, heart disease, and COPD that the ACE study documented were surprising, especially when other risk factors were corrected for. Absenteeism from work and serious financial hardship were even more surprising.

And one of the more obscure metrics? The study linked childhood trauma to chronic physical pain.

At every pain clinic my sister has visited, she talks about the abuse in as few well-rehearsed, stilted words as possible, trying not to cry. And always the doctor says, “It’s OK, we see this all the time here.”

In the 1990s the “war on drugs”—when crack cocaine was framed as Public Enemy #1—was blamed, in part, on youth culture. The “just say no” campaigns targeted kids, while the DARE program, and the phrase “peer pressure,” ingrained itself into our vocabulary. Fast forward a decade, when methamphetamine threatened to gobble up Appalachia and inner cities that had just survived crack.

This time poverty shouldered the blame, and pop culture gave us Breaking Bad.

Now, America is in the midst of an opiate epidemic that is drastically thinning our ranks. America’s mean lifespan is declining, largely due to opiate overdoses and suicide. People are willingly casting off their mortal coil, or only persisting in it if they can numb the hell out of it.

We love blaming the evil pharmaceutical companies that flooded America’s streets with very dangerous, very addictive painkillers under the false pretenses of safety. They deserve it; but it’s also crucial to note that only 25% of America’s current opiate addicts got started using legally prescribed medications—progressive addiction to alcohol, street drugs, or illegally distributed prescription medication are responsible for the rest. Addiction, something a leading addiction researcher wants to rename “ritualized compulsive comfort-seeking,” is often a direct, logical consequence of childhood trauma.

Pharmaceutical companies aren’t the only villains; adults who sexually abuse children only get convicted about 20% of the time. Our national disinterest in preventing other forms of child abuse and childhood trauma is reckless and immoral.

Maternal home visiting programs—which provide the parents most likely to abuse their children with emotional support, life skills, parenting skills, and case management—actually prevent abuse from starting, and prevent most Adverse Childhood Experiences (ACEs). They dramatically improve the lives of children and their families. But at least 90% of eligible families are not served by the Maternal, Infant and Early Childhood Home Visiting program (MIECHV). Even the Titanic had enough lifeboat seats to save half its passengers. After the Titanic sank we made changes; why don’t we have a national discourse or hear a peep from our elected leaders when thousands of children die directly from abuse, and millions are cursed with ACEs every year?

Meanwhile I’m left struggling to decide if opiate addiction is my sister’s best, or worst, option.

I remember her addicted. Her skin was nearly numb, all the time, but her scalp itched constantly. She would scratch it until she gouged out chunks of flesh, leaving open sores and streaks of pink in her blond hair, and dried blood and skin shards under her chipped nails. She would fall over. She could barely speak in sentences. And I was always worried about her overdosing.

When my sister lost her job, she lost her health insurance. Eventually she got Medicaid, but for a few months she had no coverage. No coverage meant no legal opiates. She went through withdrawal (no clinic in a two-hour radius was willing to take her), and started life without any heavy-duty opiates. Her pain stabilized, and between alcohol and some low-level narcotics she was able to get through the day.

But for reasons unknown to me or her doctors, her pain suddenly became worse, and her anorexia is relapsing. She went from a size 12 to a size two in a matter of weeks. The last time my sister was anorexic she was so weak I couldn’t hear her voice unless she was sitting next to me. She’d pass out from low blood sugar. It’s a familiar refrain; her entire life has been, essentially, slipping from one self-destructive coping mechanism to another and hoping no one will notice.

Our national disinterest in preventing child abuse is reckless and immoral.
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While addiction is always a source of shame, anorexia is a source of pride. It is the execution of something most women want to accomplish, a prize most women covet. I know from personal experience that anorexia is a sort of mind game that can only be played by a very active, very discontent mind. Anorexia—not depression or substance-abuse disorder—is considered the deadliest mental illness.

The option I want for my sister is a genuinely healthy life. But she has no clear path to that. For her, a healthy life requires income allowing her to live on her own. It requires trauma specific therapy, psychotherapy, psychiatry, and pain management. It requires a community where child abuse victims are believed. Where their wrecked lives are considered evidence as readily as a burglary victim’s shattered window. A community where abuse victims have access to justice and compensation whenever they’re ready for it.

Under her scars and scabs and tattoos and snark, my sister is still there. My other half, my best friend, the only person I’ve ever trusted, the only healthy, long-term relationship I’ve ever had. The person who can make me laugh by reciting a joke I heard when I was 14. The person who will ask me how I am and can tell if I’m lying when I say “fine.”

Like millions of others my sister needs to figure out how to play the hand she was dealt. I don’t know a better way for her to play it.

For now I’ll help her get opiates.

A woman’s treatment for addiction shouldn’t require her silence about sexual abuse.

frankieleon/flickr

Last month, Noah Levine, author of Dharma Punx and creator of the recovery group Refuge Recovery, was accused of sexual misconduct. Levine denies that he hurt anyone, and in an email to followers, he said the encounters between him and his accuser were “mutual with clear and open communication.”Against the Stream Buddhist Meditation Society, which Levine founded, has suspended him from their organization after receiving the complaint. Has #MeToo finally come to recovery?

Levine’s accusation reveals how rape culture pervades and influences recovery — a culture where silence, discretion, and anonymity are the rule. Recovery programs rely on anonymity to make participants feel safe — that they can reveal the darkest parts of themselves and still be supported. While those rules allow some participants to build trust, they often are a gag order for rape survivors, putting women with substance use disorder at risk when they seek help for addiction.

Levine is a powerful, influential figure who has built a spiritual empire within the world of recovery. His books, which include Refuge Recovery and Against the Stream, are used to teach Buddhist principles to people seeking relief from addiction. Refuge Recovery is additionally the name of a Buddhist treatment center, also founded by Levine, and the recovery program he started. It is described as an alternative to 12-Step programs such as Alcoholics Anonymous. As a guru who has preached a message of spirituality for over a decade to millions of followers, Levine is a potent figure: Accusing him of sexual misconduct is akin to admitting you were raped by Saint Peter.

Want To Reduce Drug Use? Listen To Women Drug Users

Many women who have made an attempt to get sober have learned the hard way that recovery meetings are not the safe, sacred spaces that they’re intended to be. Every recovery group, from Narcotics Anonymous to SMART, preaches a message of inclusiveness. All are welcome. Yet, that inclusiveness — which keeps the door open to rapists and predators — isn’t truly inclusive. It is the inclusion of all, at a high cost to some.

One woman described a harrowing rape that resulted in not only victim-blaming, but also exclusion from her 12-Step community. Other women say that creepy guys, stalking, and pressure to distrust their instincts have caused them to leave meetings and try to recover on their own. Some have given up on recovery completely, and gone back to drinking and using, feeling that there’s no safe alternative. There are women-only meetings, and women-only programs, but once someone’s initial trust is broken, how many women are willing to take another risk? A woman’s sense of unease doesn’t mean the meeting will change, or the program. Victims are likely to be pushed out or punished for complaining, or told that raising concerns may alienate their attacker, who “needs recovery too.”

The culture of silence and “anonymity” that surrounds recovery is harmful to women, and allows leaders, elders, and trusted community members to prey on women with little fear of repercussions. There’s a commonly held myth that the wrongs committed before getting sober don’t count. Victims of harassment or assault are told to pray for their attackers, rather than report them. Some are encouraged to “see their part” in the attack, or try to reframe sexual assault as a spiritual gift, a gateway to growth. Levine said, “We all sort of have a different doorway to dharma or spiritual practice. Suffering is a doorway.”

For women, that doorway is often sexual assault.

Women are more likely to be raped, harassed, and abused. Women are also at higher risk of developing substance use disorder: Physiologically, addiction advances quickly in women. Also, there’s a strong, well documented connection between surviving sexual assault and substance use disorder. However, although there are some female powerhouses in the recovery world, the vast majority of recovery programs were created by men. There are fewer recovery resources designed for women, especially women from marginalized groups. (Trans women, in particular, have almost zero options for help designed specifically for them.)

Put those numbers together, and it’s unsurprising that women are less likely to recover than men. Women often describe feeling unwelcome in recovery meetings, even those like Refuge Recovery. On its website, Refuge Recovery indicates some of the measures it’s taken to create safe space for women: “Our aspiration is to provide a safe place for women that is free of stalking, lurking, geographical information, or any other technology, that could place our members in a vulnerable and/or dangerous position. Also, it is true that women thrive who have a safe place to tell their truths, to speak aloud in their creatively defined ways and to hear others do the same.” But there’s nothing about how to handle or report sexual harassment by other members — or the program’s founder.

Is Alcoholics Anonymous Really A Harmful Religious Cult?

Asking women to take a vow of silence in order to access potentially life-saving recovery is part of rape culture. The message: Keep your mouth shut, and you’ll stay sober. Speak up, and you risk relapsing. Gossip, which can help women share information about dangerous men, is discouraged. The stigma of addiction works with sexism and the stigma of sexual assault to silence the people who need help most. And it creates the ideal environment for predators: a ready-made community of vulnerable, frightened, silent women.

Allegations against Levine or any other recovery leader are not shocking, to people who have longevity in recovery. Although it’s often billed as a “safe, inclusive space,” recovery meetings do not leave rape culture at the door. Human nature and human problems, including male entitlement, toxic masculinity, and power structures that silence and punish women, are not only present, but reinforced by “group tradition” — traditions that were created by men, and largely for men. What’s surprising is that, in this case, the problem is being treated with transparency.

Whatever the implications for Levine’s personal life, this accusation should open the door for women to share their stories, demand safe spaces in recovery, and hold attackers accountable. Silence should never be the price women pay for access to recovery support. Those who perpetuate rape culture within the rooms, no matter how powerful they are, must be shown the door.

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]]> https://theestablishment.co/what-metoo-looks-like-when-youre-in-recovery-64c0ade43411/ Tue, 10 Apr 2018 15:30:47 +0000 https://theestablishment.co/?p=1658 Read more]]> A woman’s treatment for addiction shouldn’t require her silence about sexual abuse.

Last month, Noah Levine, author of Dharma Punx and creator of the recovery group Refuge Recovery, was accused of sexual misconduct. Levine denies that he hurt anyone, and in an email to followers, he said the encounters between him and his accuser were “mutual with clear and open communication.”Against the Stream Buddhist Meditation Society, which Levine founded, has suspended him from their organization after receiving the complaint. Has #MeToo finally come to recovery?

Levine’s accusation reveals how rape culture pervades and influences recovery — a culture where silence, discretion, and anonymity are the rule. Recovery programs rely on anonymity to make participants feel safe — that they can reveal the darkest parts of themselves and still be supported. While those rules allow some participants to build trust, they often are a gag order for rape survivors, putting women with substance use disorder at risk when they seek help for addiction.

Levine is a powerful, influential figure who has built a spiritual empire within the world of recovery. His books, which include Refuge Recovery and Against the Stream, are used to teach Buddhist principles to people seeking relief from addiction. Refuge Recovery is additionally the name of a Buddhist treatment center, also founded by Levine, and the recovery program he started. It is described as an alternative to 12-Step programs such as Alcoholics Anonymous. As a guru who has preached a message of spirituality for over a decade to millions of followers, Levine is a potent figure: Accusing him of sexual misconduct is akin to admitting you were raped by Saint Peter.

Want To Reduce Drug Use? Listen To Women Drug Users
theestablishment.co

Many women who have made an attempt to get sober have learned the hard way that recovery meetings are not the safe, sacred spaces that they’re intended to be. Every recovery group, from Narcotics Anonymous to SMART, preaches a message of inclusiveness. All are welcome. Yet, that inclusiveness — which keeps the door open to rapists and predators — isn’t truly inclusive. It is the inclusion of all, at a high cost to some.

One woman described a harrowing rape that resulted in not only victim-blaming, but also exclusion from her 12-Step community. Other women say that creepy guys, stalking, and pressure to distrust their instincts have caused them to leave meetings and try to recover on their own. Some have given up on recovery completely, and gone back to drinking and using, feeling that there’s no safe alternative. There are women-only meetings, and women-only programs, but once someone’s initial trust is broken, how many women are willing to take another risk? A woman’s sense of unease doesn’t mean the meeting will change, or the program. Victims are likely to be pushed out or punished for complaining, or told that raising concerns may alienate their attacker, who “needs recovery too.”

The culture of silence and “anonymity” that surrounds recovery is harmful to women, and allows leaders, elders, and trusted community members to prey on women with little fear of repercussions. There’s a commonly held myth that the wrongs committed before getting sober don’t count. Victims of harassment or assault are told to pray for their attackers, rather than report them. Some are encouraged to “see their part” in the attack, or try to reframe sexual assault as a spiritual gift, a gateway to growth. Levine said, “We all sort of have a different doorway to dharma or spiritual practice. Suffering is a doorway.”

For women, that doorway is often sexual assault.

Women are more likely to be raped, harassed, and abused. Women are also at higher risk of developing substance use disorder: Physiologically, addiction advances quickly in women. Also, there’s a strong, well documented connection between surviving sexual assault and substance use disorder. However, although there are some female powerhouses in the recovery world, the vast majority of recovery programs were created by men. There are fewer recovery resources designed for women, especially women from marginalized groups. (Trans women, in particular, have almost zero options for help designed specifically for them.)

Put those numbers together, and it’s unsurprising that women are less likely to recover than men. Women often describe feeling unwelcome in recovery meetings, even those like Refuge Recovery. On its website, Refuge Recovery indicates some of the measures it’s taken to create safe space for women: “Our aspiration is to provide a safe place for women that is free of stalking, lurking, geographical information, or any other technology, that could place our members in a vulnerable and/or dangerous position. Also, it is true that women thrive who have a safe place to tell their truths, to speak aloud in their creatively defined ways and to hear others do the same.” But there’s nothing about how to handle or report sexual harassment by other members — or the program’s founder.

Is Alcoholics Anonymous Really A Harmful Religious Cult?
theestablishment.co

Asking women to take a vow of silence in order to access potentially life-saving recovery is part of rape culture. The message: Keep your mouth shut, and you’ll stay sober. Speak up, and you risk relapsing. Gossip, which can help women share information about dangerous men, is discouraged. The stigma of addiction works with sexism and the stigma of sexual assault to silence the people who need help most. And it creates the ideal environment for predators: a ready-made community of vulnerable, frightened, silent women.

Allegations against Levine or any other recovery leader are not shocking, to people who have longevity in recovery. Although it’s often billed as a “safe, inclusive space,” recovery meetings do not leave rape culture at the door. Human nature and human problems, including male entitlement, toxic masculinity, and power structures that silence and punish women, are not only present, but reinforced by “group tradition” — traditions that were created by men, and largely for men. What’s surprising is that, in this case, the problem is being treated with transparency.

Whatever the implications for Levine’s personal life, this accusation should open the door for women to share their stories, demand safe spaces in recovery, and hold attackers accountable. Silence should never be the price women pay for access to recovery support. Those who perpetuate rape culture within the rooms, no matter how powerful they are, must be shown the door.

In some ways, AA helped me. But as an afrolatin trans woman, it also hurt me.

“My name is Princess and I’m an alcoholic!”

“Hi, Princess!”

This ritualistic greeting used to be welcome. Now, it’s little more than a reminder of the worlds I became imprisoned in — the dual worlds of addiction and recovery.

When I joined Alcoholics Anonymous and its spin-off, Narcotics Anonymous, I was seeking escape from my dependence on opiates and alcohol. Three and a half years later, I am free of heroin and alcohol in part because of the 12-step program, and I continue to apply some of its principles to my life.

But the program’s ideology was in many ways irrelevant to me. The literature of AA and NA preaches a heteronormative approach to sexuality — unavoidable, perhaps, as both programs were founded by heterosexual men at a time when queer people were repressed. Politically, the adherents of the programs, and the text themselves, also promote an anti-liberation, “bootstraps” approach that I’ve never been comfortable with.

But the bigger issue is that, as an afrolatin trans woman, I often found the 80-plus-year-old program and its strict adherents to be psychologically abusive.

I was first introduced to AA when I was at a mental hospital that included programs for drug-addicted people. I didn’t check myself in for addiction specifically, but because I had heroin, marijuana, and other drugs of abuse in my system, I was funneled there. Though I technically could’ve said no to attending an AA meeting, doing so could’ve led to me being labeled uncooperative, which in turn could’ve ensured a longer stay.

At the first AA meeting I attended at the hospital, I was pulled aside by one of the speakers, who told me I should get off my hormones and pray for God to “remove my problem.” It was clear he wasn’t talking about my drinking or my using, but my gender “problem.”

And so it was that my rocky relationship with 12-step programs began. I enjoyed, and would still enjoy, the AA and NA meetings I felt comfortable attending. But as I was typically the only trans person in the room — and in some cases, one of the only people of color — I also often experienced harassment and humiliation.

I was typically the only trans person in the room.
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Members at subsequent meetings told me to pray my gender dysphoria away, or declared that the dysphoria remaining was a sign that I failed to move through the steps thoroughly. Complicating this was the fact that that my drug abuse did start off as a way to cope with gender dysphoria (and my being trans in a Latinx household) — but because of the judgemental environment, I never felt comfortable expressing that.

Other times, members would attempt to use meetings as their conversion therapy camp. In one instance, a group of religious men gave me their phone numbers because they felt that I needed men to set me on a religious path and make me masculine again. They seemed to believe that trans women who used and abused drugs and alcohol became trans as a “symptom” of addiction or alcoholism.

Other times, I faced sexual harassment or physical intimidation (usually if I rejected advances). One incident resulted in me having to change my phone number because I was getting threats and insults daily for refusing a man.

Misgendering was also startlingly common at meetings. Sometimes, members would be handed a list of other members to call if they feared a relapse; these were supposed to be gender segregated, with men given lists of other men, and women of other women. Once, a man tried to fight me for putting my name and number on a woman addict’s phone number list. Another time, I was given a list of phone numbers entirely composed of men.

It’s not hard to discern why AA and NA meetings often felt so hostile to someone like me. Membership surveys report that 62% of AA members are male, and 89% are white. NA membership, meanwhile, is 59% male and 74% white. Like many such organizations, there is virtually no accounting for trans or gender nonbinary members. Because both organizations have roots in religious principles — the ultimate goal of sobriety is a “spiritual awakening,” and seven of the 12 steps refer either to a deity or religious practices — they also perpetuate conservative beliefs, and often attract conservative Christians as adherents.

62% of AA members are male, and 89% are white.
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There are also underlying issues with the 12-step ideology itself, with fundamental program principles effectively encouraging abuse against the marginalized.

Gaslighting, the psychological abuse tactic of twisting information about something in order to make someone doubt or take guilt upon themselves, is touted as part — an important part — of AA and NA.

From the book Twelve Steps and Twelve Traditions, the founder of AA writes, “It is a spiritual axiom that every time we are disturbed, no matter what the cause, there is something wrong with us.” He goes on to say that if someone else hurts us, we’re still in the wrong. The book Alcoholics Anonymous, meanwhile, includes such passages as, “Sometimes they hurt us, seemingly without provocation, but we invariably find that at some time in the past we have made decisions based on self which later placed us in a position to be hurt” and “Putting out of our minds the wrongs others had done, we resolutely looked for our own mistakes.”

Gaslighting is touted as part — an important part — of AA and NA.
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Sometimes, this line of thinking manifested as members subtly challenging my “victimhood,” a painful charge that was not only debilitating — I couldn’t respond without “proving” the taunt — but loaded. The subtext was clear: If you don’t get over your oppression, you’ll drink and die. Other times, cishet white men essentially demanded that I take responsibility for being sexually harassed, publicly humiliated, and physically intimidated — not only in my life outside the program, but during the meetings themselves. If I suffered, I was told, it had to be my fault.

The idea of fear, too, was exploited in dangerous ways. As the AA book puts it, “Fear is an evil, corroding thread; the fabric of our lives is shot through with it.” It is fear, we are told, which can kill alcoholics. Anything that might be fear, or anything that one can reduce to being fear, is interpreted as a sign that we’re still in the same place we were in when we were drinking.

But while combatting fear in some ways make sense, this becomes problematic when applied to the marginalized. The fear I expressed wasn’t unreasonable; it was rooted in a necessary sense of self-preservation.

Is Alcoholics Anonymous Really A Harmful Religious Cult?

Trans women of color face excessive levels of violence, violence that has unfortunately touched all the places I call home. When I refused to go to meetings in areas that I know are notorious for queer bashing or racist harassment — or to meetings at night because of street harassment, or to those near ones where I had been mistreated — I did so to ensure I didn’t face violence or even death. But because of the ideology and literature of AA and NA, these decisions were interpreted as me not committing to my recovery, as one member once explicitly accused me of.

I am grateful that I was able to get help from AA and NA, and I do intend to live my life according to the 12 steps to the best of my ability without the meetings. But considering the harm caused by the organizations, I can also say confidently that walking away was the best decision I could’ve made.

The fear I expressed wasn’t unreasonable; it was rooted in a necessary sense of self-preservation.
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Considering that transgender people are at a high risk for substance abuse, and often need the kind of support that AA and NA can provide, my experience should cause alarm.

That said, there are other options for feminists, queer people, and others who share my feelings and who need to recover from alcoholism or drug addiction. My advice? Seek out community. Seek out alternative methods of recovery. There are many available to us: SMART Recovery, Women for Sobriety, LifeRing Secular Sobriety, Moderation Management, the Sinclair Method, and drug replacement therapies are all viable options. Hell, seek someone like me out, someone who lives by the 12 steps but doesn’t attend AA.

Most importantly, know this: You don’t have to expose yourself to abuse to recover.

“I’ve always been interested in cannabis as a social justice issue and a matter of public policy, but I was never able to embrace it as medicine until these veterans really taught me how,” Sisley told me.

Sisley was “highly dismissive and judgmental” of marijuana at first but, over time, as more and more veterans shared their experiences, she started to accept its therapeutic potential.

Now, not only does she regularly treat multiple conditions by prescribing legal medical cannabis as an Arizona-based family physician, she’s part of a team involved in the first government-funded study to examine the effectiveness of cannabis in treating post-traumatic stress disorder (PTSD) in vets.

The growing awareness of this plant’s therapeutic potential — as well as the spread of legal recreational and medicinal cannabis across the United States — has eased issues of access, but some significant barriers remain. One such obstruction is a Veterans Affairs administration that remains resistant to the drug, asserting that “marijuana use for medical conditions is an issue of growing concern” and that “there is no evidence at this time that marijuana is an effective treatment for PTSD.”

This decade, however, has seen some movement on the issue: The administration today usually allows vets to use cannabis without penalty in states where its access is legal.

Still, the government writ large remains resistant to cannabis law reform, even though numerous studies already show that cannabis can hold promising benefits for treating PTSD and many other conditions, including chronic pain.

While Sisley and her colleagues are eager to begin studying cannabis’ potential benefits as scientists, veterans like Joshua Apollo are already helping fellow vets access cannabis and teaching them how to use it more effectively.

Apollo’s service as a U.S. Army infantryman left him with lingering physical injuries and struggling with post-traumatic stress disorder, all culminating in a suicide attempt before he began treating himself with cannabis in 2010.

“Cannabis was the ultimate treatment for me. It saved my life. I haven’t had suicidal thoughts or tendencies since starting marijuana,” Apollo told me.

According to a recent study conducted by the Department of Veterans Affairs, there are 20 veteran suicides per day in the U.S., many of them older vets — a shockingly high figure that some veterans I’ve spoken to speculate may actually be too low.

As a vice president of the Sacramento, California, chapter of Weed for Warriors, Apollo’s helping to raise awareness on the medical benefits of cannabis and the need for legal reform. Founded in San Francisco in 2014, the national nonprofit shares donated medical cannabis with veterans, ensuring they can afford their medicine and use it in the most effective ways possible.

And while medical professionals continue to debate the benefits of cannabis for PTSD, the plant is bringing veterans closer together — and giving them an opportunity to bond over their shared suffering.

“Our meetings aren’t just about passing out meds, they’re about bringing like-minded individuals, veterans, together so they’re not locked in their house, so they don’t feel so alone,” Apollo said.

Soon, in addition to this solidarity, Sisley’s research may allow more vets to access key — sometimes even life-saving — treatment options related to the plant.

‘Without Cannabis I Would Be Dead’

Apollo enlisted in the U.S. Army in 2001 at 17 years old. “Within a week of signing my paperwork, September 11 happened and that changed a lot of my view of the service and the world and everything that was going on.”

Apollo was shuttled around the U.S. before being deployed to Afghanistan, where he faced frequent firefights. Within a week of deploying, an IED (homemade bomb) put his life at risk. “I lost friends and comrades in war and outside of war,” Apollo said, recalling a team leader and squad leader who died in a “horrific” car accident in Hawaii, and the suicide of one of his first roommates and friends in the military.

“I was not prepared for that at 18 or 19 years old,” he said. “Physically, mentally, my mind was warped by the things I was told to do, the things I witnessed. By the things I had to do.”

Apollo continued, “Coming back from that, what was the main issue was seeing my family and not being able to tell them [what I’d experienced] . . . and the nightmares, that was the worst part.”

Once he’d been released from the military, he struggled not only with chronic pain from a broken leg and several other injuries, but also with PTSD, which can cause depression, social anxiety, unexplained anger and other difficult emotions, insomnia, and unpleasant feelings of hyper-alertness, among other symptoms. Veterans Affairs’ prescribed three different pharmaceuticals for Apollo, which he said left him feeling mentally foggy. Typical VA treatment for PTSD focuses on SSRI antidepressants, but many are also prescribed sleep aids or anti-anxiety drugs.

Like Sisley, Apollo was resistant to the idea of cannabis at first. Desperate for him to experience cannabis’ benefits after his 2010 suicide attempt, Apollo said his little brother “forced marijuana on me. He put me in the truck and hotboxed the truck.”

As he inhaled thick clouds of second-hand cannabis smoke, the effects were almost instantaneous. “I felt clear, I felt normal. I could grasp what was going on around me.”

Within six months, he told me he had quit using illegal street drugs and weaned himself off the prescription medications prescribed by the VA.

He still struggles with nightmares and insomnia, but said, “the only thing that allows me to sleep is cannabis.”

It also eases his social anxiety. Without cannabis, he said, “I would lock myself in my house and not go anywhere. I’m very much a recluse and a hermit without cannabis.”

He continued, “I don’t like the world, I don’t like how it treats veterans, I don’t like how we’re just left to die. Without cannabis I would be dead.”

Cannabis Has ‘Transformative’ Effect On PTSD

I asked Sisley about how she came to accept the potential therapeutic benefits of cannabis.

“There were a bunch of specific cases where patients had transformative responses where they went from being almost lifeless and nonfunctional on the conventional meds that I was giving them.”

Without Sisley’s endorsement, her patients would begin to treat themselves with cannabis after hearing about the plant’s potential by word-of-mouth from other veterans. She continued:

“Then these vets would come back to me. That’s what’s really impressive to me, when vets find that path with cannabis, they always are determined to share that with the world . . . They would always have their spouse or their kid in tow to corroborate their stories. Over time it was really compelling.”

Many veterans seem to have become self-taught experts on the plant and the ways it can be ingested. “I use different strains, different types of concentrates for different things that are bothering me, for different ailments — if I need to sleep, if I’m in pain, if I can’t focus,” Apollo told me.

“It’s amazing how sophisticated these vets are. They attack it like a science,” Sisley remarked.

“I actually prefer tea,” said Victoria, another Weed for Warriors veteran I interviewed, when I asked how she treats her PTSD.

Victoria is a private pre-school teacher in California now, and cannabis helps her control symptoms that include depression and anxiety.

“I put medicated honey in my tea, and consume that. A warm cup of tea before bed helps me sleep through the night.”

She also uses cannabis edibles and even bath bombs. Of the latter, she said, “It’s not like a high, it literally calms you, it just relaxes you.”

She never uses cannabis at school, but Victoria told me she’ll sometimes wake up early, so she can medicate herself and wait for the high to pass before work. “So by the time my day starts I’m fine, and I’m calm,” she told me, ready to deal with her students whom she described as “loud, loud, loud!”

Like the other vets I interviewed for this story, Victoria lives in California, where medical cannabis is widely available. “I haven’t been on any medication since I’ve been diagnosed with PTSD in 2013. In three years, I’ve been just using cannabis without meds,” she said.

When she doesn’t have access to cannabis, Victoria said she struggles with her mood and feeling hyper-alert to stimuli. “My depression kind of takes over. I’m way more irritated and easily startled.”

Before moving to California, she experimented with prescription antidepressants, but found them ineffective with unpleasant side effects. “I had really bad headaches and I felt like I couldn’t feel. I was just here. I was a gray blob. Just an outline of myself.”

‘They Don’t Want To Be In The System’

Until the Veterans Affairs issued an important 2011 directive on the use of medical cannabis, vets could lose access to other pain medications if they tested positive for marijuana. Thanks in part to veterans’ activism, the VA is no longer supposed to penalize vets for using cannabis in legal states. But even now, Sisley told me, the directive is “inconsistently” applied.

“There’s no consistent approach for how VAs will deal with this,” she continued. “Not to mention the other 20-plus states that have no legal market — those vets are out of luck. They have to stay on the black market.”

In July 2014, Kristoffer Lewandowski, a U.S. Marine Corps veteran, faced life in prison for drug possession after a flare-up in his PTSD symptoms led to a domestic violence report, and police discovered the cannabis plants he was using to treat himself. Freed on bail, Lewandowski and his family moved from Oklahoma to California, where he easily obtained a medical permit for his treatment. But law enforcement surprised him in May 2015 with a raid at his children’s preschool, and extradited him back to Oklahoma to stand trial as a fugitive. Federal marshals said he was wanted for missing a pre-trial hearing, but Lewandowski told OC Weekly’s Nick Shou on September 7 that he’d never been informed about the hearing.

Fortunately, after Lewandowski’s story went viral last year, the state dropped felony charges against him, although he could still be sentenced to up to five years in prison at an upcoming sentencing hearing. His story remains an example of what can happen to vets seeking medical cannabis during the war on drugs.

In states without medical marijuana programs, Sisley told me, vets often avoid treatment at VA hospitals and doctors altogether, out of fear of that they could be drug-tested and lose their health benefits or violate a pain treatment contract. “Most of these guys will not seek treatment for any other medical conditions because they realize that cannabis will be a deal-breaker for their care at the VA.”

Many of them believe their disability benefits could also be put at risk. “I haven’t seen evidence of that happening ever but it’s a concern on every vet’s mind who receives disability payments,” Sisley noted.

“Vets in general are appropriately distrustful of the government. They don’t want to be in the system and be monitored by the government, to be tracked,” Sisley added.

‘I’m A Strong-Ass Person’

Sisley told me she’s seen “tons of patients who have opioid abuse or dependence and most of them are on methadone or suboxone and they can’t get off of it.” But here, too, cannabis offers promise as a “substitution therapy.” Sisley explained: “Cannabis has been a really successful intervention for a lot of guys who have been stuck on opioids for years. They micro-dose cannabis throughout the day to help manage the opioid withdrawal syndrome.”

As PTSD tends to provoke or worsen substance abuse issues, thousands of veterans are also struggling with addiction to prescription painkillers.

Michiko, another vet I interviewed, is self-treating her dependence on fentanyl, a potent and dangerous pharmaceutical opiate, with cannabis. After a total of six years of service in Afghanistan, she has PTSD, a herniated disk, and nerve damage in her spine.

“I joined the military basically in a man’s world,” Michiko said. “They never thought that I could do what they do. I was always looked at like basically I’m a weak link.”

Michiko’s using cannabis, in part, because her PTSD is triggered by hospital settings and authority figures, making it difficult or even impossible for her to receive conventional treatment. That’s because, when she was in basic training, Michiko’s commander raped her while she was in a military hospital suffering from a fever.

“I left with the same fever because I was so scared to be in there,” she recalled. “Then I come back and there’s [military police] at my basic training, and they’re hounding me for information.”

Although her commanding officer was eventually punished as a serial rapist, she told me she was left with little emotional support as her military career continued. In Afghanistan, Michiko was sexually assaulted again by another superior officer.

“Every time I go into a doctor’s appointment I get triggers,” Michiko said. “Even at dentist appointments they have to heavily sedate me.”

And managing her addiction is still a struggle — she told me sometimes she feels like she wants to tear off her own skin — but for her it’s far preferable to treatment in a clinical setting, and in general, cannabis helps her sleep at night and eases her pain.

“[The VA wants] to put me in a rehab program or a detox program in a hospital. Well what’s that going to do for a person like me? Trigger!”

Further, Michiko fears that if she sought treatment through Veterans Affairs, officials would “punish” her for her addiction by limiting her access to future pain treatment. And like Apollo, Michiko feels like the VA relies too much on pharmaceuticals.

“I feel like it’s a catch-22: medicate to medicate to medicate more — and they don’t hear me screaming for help.”

Sisley agreed that conventional medicine has few reliable solutions for addiction, and said cannabis “desperately needs more testing, and hopefully you’re going to see a lot more scientists focusing on this.”

She continued:

“We’re the opioid overdose capital of the planet here, and we don’t have any good solutions. We’re forcing doctors to go to seminars on how to cut back on their opioid prescribing, but honestly that’s not going to fix this. We have to find other good treatments to help the existing addicted population to stop, and we don’t have any good treatments now.”

For her part, Michiko told me she doesn’t regret her military service, despite all she suffered. “It made me into the person I am today. And I’m a strong-ass person, and I wouldn’t give that up for the world.”

‘Relentless Amounts Of Government Red Tape’

“I believe these veterans when they claim that they are better, but those are their subjective reports, and now it’s time to put the plant through the rigors of a randomized control trial and see what data we generate by that,” Sisley said.

Most studies of cannabis, especially studies with government funding, focus on the safety of cannabis, rather than attempting to quantify its potential benefits as a medicine. That’s beginning to change, in part thanks to a study — “Placebo-Controlled, Triple-Blind, Randomized Crossover Pilot Study of the Safety and Efficacy of Four Different Potencies of Smoked Marijuana in 76 Veterans with Chronic, Treatment-Resistant Posttraumatic Stress Disorder (PTSD)” — led by the Multidisciplinary Association for Psychedelic Studies (MAPS), which received final government approval to proceed in April.

The study has been years in the making, first originating in a 2009 conversation between Sisley and Rick Doblin, the founder and executive director of MAPS. The goal is to demonstrate whether smoking marijuana can reduce symptoms in veterans whose PTSD is resistant to conventional treatment.

Sisley continued:

“I never expected seven years ago when we started down this path that it would take us this long to implement a study that was FDA approved so quickly, and had full funding. I had no way to anticipate the relentless amounts of government red tape that would be involved in trying to implement this thing.”

Controversy over the study even led to Sisley being fired from the University of Arizona in 2014, adding yet another hurdle. She told me her “personal opinion” is that “super wealthy, powerful groups” like the pharmaceutical industry, police, and the prison-industrial complex “have an abiding interest in keeping cannabis illegal, and thus any data that might legitimize marijuana as medicine is very threatening to them and to their business model.”

Through MAPS’ advocacy, the study not only moved closer toward its launch date through the years, but helped pave the way for future research as well. In June 2015, President Obama ended Public Health Service review of cannabis research, an extra review process that would frequently last months and which duplicated existing FDA standards for research.

Another stumbling block for MAPS is that researchers must use strains of cannabis grown by the National Institute on Drug Abuse, a government-funded addiction research institute, which the government claims is a safeguard against research cannabis being leaked onto the black market. As a result, one of the four strains in the study is less potent than the team would like, and may not reflect the strength of cannabis that veterans are using in the real world. But, in August, the DEA agreed to let new growers provide cannabis for future studies. Though Sisley expressed grave concerns about the bureaucracy surrounding the process of accrediting growers, it’s still an important step toward opening the field to more research into how cannabis can heal.

This historic study is the first-ever randomized-control trial of the efficacy of whole-plant cannabis (as opposed to extracts or synthetic concoctions) in PTSD in veterans. Seventy-six veterans will be selected, each with chronic PTSD that is resistant to other forms of treatment. The research is funded by a grant of over $2 million from the Colorado Department of Public Health and Environment (CDPHE).

MAPS has assembled an impressive team of medical experts to take on the research. Sisley will study one cohort of veterans in Phoenix, while Dr. Ryan Vandrey will oversee the other at Johns Hopkins University in Baltimore. Dr. Paula Riggs from the University of Colorado School of Medicine is overseeing the scientific integrity of the study as a whole, with Marcel Bonn-Miller, PhD, from the University of Pennsylvania acting as the study’s coordinating principal investigator.

“I have been forced to become an activist just out of sheer determination to get this study implemented, and to make sure our veterans get answers to the legitimate questions that they have,” Sisley said. “I think the public has this impression that I’m pro-cannabis when I’m not at all.”

She continued: “I’ve never used cannabis personally; I’m not part of the industry, I don’t own dispensaries, I’m a completely independent thinker on this, and I really have no idea what the results are going to show here. I hope that our hypothesis will prove correct, but there’s also a lot of variables here.”

Still, Sisley remains cautiously optimistic that the study will at least open the way to future research. “We just want to get objective data from any starting point.”

At the end of our conversation, Sisley praised the work of MAPS, but told me she thinks veterans are really the ones leading the way to nationwide legalization of medical cannabis.

“The political activism of the veterans groups are really astounding. It’s truly the tip of the spear here in persuading even the most conservative Republicans that this is medicine.”

Susan was found in a city park one chilly October morning, her beloved cattle dog guarding her body. Her death was unexpected. Everybody thought she’d been doing so well. In my office, my phone began buzzing with texts from long-term research participants and mutual friends wondering whether I’d heard the news. I curled my grief inward, a bundle of anger and confusion, scientific objectivity suspended, replaced by indignation. In a country that touts itself as the wealthiest and greatest in the world, how is it that so many live in the streets? How is it that people die there?

Susan was the first person to join my study on methamphetamine use in northern Colorado. She was the first of my research participants-turned-friends to die during its course. We first met in a borrowed office at the local resource center on a surprisingly sweltering spring day. Susan fussed over her dog, Rick, who was always at her side. She wouldn’t settle until he had water and a comfortable place to nap in the cool of the air conditioning.

She wasn’t naturally talkative, but she was candid and kind as she shared her history, her story. She cried as she explained how her husband’s illness was the beginning of their financial downturn. He couldn’t work, and eventually, neither could she. She left her job to care for him and for a while the two made do on social security.

But when Susan’s husband died, just a couple of years before we met, she was faced with more than grief. She lost both his social security income and hers as a caretaker. In her late forties at the time, she struggled to find work. Taking the time to mourn wasn’t an option as she struggled to navigate insufficient safety nets she’d never before needed to use. They had always been fine financially. They’d had dogs and motorcycles, a house, jobs and friends and money to splurge and go out on occasion. They’d had a “normal” life.

Soon, she found herself homeless. Having lost her own house and exhausted friends’ couch-surfing generosity, she was on the streets. Since Rick wasn’t a service dog, shelters weren’t an option, but neither was abandoning her one friend and connection to her old life. As a homeless woman on her own, Susan depended upon Rick’s loyalty, not just as a faithful companion but as a dauntless guardian.

Each night she managed threats that came from all sources, all directions. She was the first to tell me that sometimes she had to walk all night to stay alert and avoid the police or the risk for harm. She was the first to explain the importance and challenge of finding a safe place to rest.

Susan’s story provided my first window into the complex and harrowing realities of homelessness and housing insecurity in the United States. And while her story is individual, it isn’t unique.

On a single night in 2014, the U.S. Department of Housing & Urban Development’s (HUD) Point-in-Time survey counted nearly 600,000 Americans without shelter. As people struggle with unemployment, the battle for a living wage, and a shortage of affordable housing, the risk continues to grow. Increasingly, too many of us teeter on the brink, just one illness, car repair, or short work-week away from the streets.

Yet most places lack the resources to combat the underlying causes or immediate consequences of homelessness and housing insecurity. The same HUD study shows that 62% of reporting jurisdictions nationwide cannot meet the demand for shelter beds in their communities. In 2014, over 153,000 people had to sleep in the streets or actively seek alternate shelter each night.

Nearly two hundred years ago, America formally abolished its debtors’ prisons, institutions where the poor were incarcerated for failing to make payments. Following this, the notion of some people’s poverty as a social ill slipped into the background until the mid-20th century. Not until the early 1960s did we renew dialogue suggesting that hardship and vast wealth disparities represent a national problem.

Although many scholars and politicians agree that poverty in the U.S. tends to be intergenerational, there remains dissent as to the underlying causes. And while we, as a nation, struggle to get on the same page about the sources of these economic gaps, our communities are once again criminalizing poverty, especially homelessness. According to the National Law Center on Homelessness & Poverty, 34% of U.S. cities ban public camping, 57% prohibit it in certain areas, and 43% disallow sleeping in vehicles. Others have policies against sleeping in public, begging, and sharing food with homeless people.

Charles, a tall man with a booming baritone, first found himself on the streets in his early fifties. Previously an entrepreneur, a husband, and a father; he’d never imagined himself homeless. He’d always seen himself as a community member, a leader, never a criminal. But as we settled in on the porch of a local coffee shop, his eyes were bloodshot and squinty from lack of sleep. Clumsy with fatigue, he fiddled with his bag, pulling out his phone to charge at our table’s electrical outlet. He was waiting for a call from two young girls he had met the night before, who he had talked into attending an NA meeting with him later in the day.

“You ended up in jail because of all those camping tickets?” I asked. Charles looked at me solemnly. He was exhausted. He’d been up all night. Since we first met, when he had just lost his home, I had watched him become rundown, emotionally and physically. His girlfriend, Jackie, had been in jail all this time, but he never failed to keep money on her books.

Whatever he brought in panhandling or hustling or working odd jobs went to Jackie. She was his girl, his ol’ lady. And Charles had a traditional view of relationships. No matter what else he did, he had to continue to provide. So he typically spent his days working, earning, and to ensure there was money for her, his nights passed without shelter. This in a city with a camping ban and not enough beds.

“Yeah, I failed to appear,” he explained. “They caught me surviving, literally. The first ticket, the very first ticket, was our very first night outdoors. Less than eight hours from them giving us the sleeping bag. They’re gonna charge me $100 plus for each one of those. A $100 ticket and then there’s court costs and all this other stuff. It turns out to be $275, or sixteen hours of community service or six days in jail.”

“So you took the six days in jail?”

“Yeah, I took the six days in jail,” Charles said. “By default.”

For countless individuals like Charles, it is the crime of being poor that ultimately results in jail time when they are unable to pay their escalating fines. But the criminalization of homelessness has consequences that extend beyond spending a few days in jail. Some scholars and activists suggest that the underlying social intent of so-called “crimes of homelessness” may be to render these individuals invisible rather than reduce the problem itself.

University of Colorado Denver’s Dr. Stephen Koester has spent decades studying drug use and homelessness in Colorado. He observes, based on recent research on Denver’s camping ban, that the city’s police “don’t seem to want to give them [the homeless] tickets. They want to keep them moving, or out of sight.”

In the northern Colorado town of Fort Collins, recent plans to bulldoze a park where many homeless gather throughout the day support Koester’s theory. Los Angeles has tried on five separate occasions since 1997 to remove the “visual blight” of the homeless by removing and destroying their belongings. Though the city has repeatedly lost these cases, officials drafted a new ordinance for 2015 permitting law enforcement officers to promptly confiscate homeless individuals’ unattended property. Under the guise of gentrification, appealing to many for the ensuing influx of hipster-friendly, edgy watering holes, cities push their poor and homeless further toward the margins.

If the aim of criminalization is, in fact, to make the homeless disappear, we must consider its range of consequences. Surely, an abundance of these repercussions are intangible, even philosophical in nature. The haves wield their social power over the bodies of the have nots to avoid feeling uncomfortable over their craft cocktails or upon leaving their lunchtime yoga classes. But scattering the homeless doesn’t just damage disenfranchised bodies in the abstract. It directly and deeply damages social ties and disrupts access to social resources. Several researchers have highlighted the fact that when the homeless are relocated, they often lose access to safety net organizations and resources.

From a human interest perspective, the criminalization of homelessness is clearly bad politics. It dehumanizes people and perpetuates both poverty and suffering. But more specifically, notes Dr. Lee Hoffer of Case Western Reserve University, the promise of punishment forces geographic and social dispersion, and the results of these policies are “detrimental to public health.”

Initiating And Encouraging Drug Use

Fort Collins, Colorado is a medium-sized college town that has been voted one of America’s “most livable” cities several years running. Between college students, growing tech and start-up companies, and booming gentrification projects, affordable housing in the city is increasingly difficult to find. Vacancy rates continue to fall (1.8% in 2015) while housing prices and rental costs rise.

Like other cities along Colorado’s Front Range, Fort Collins has had a camping ban for years. In August 2014 alone, police targeted 54 illegal campsites and issued 32 citations. Those unable to find an approved place to sleep must remain invisible or risk incarceration. Thus, the town’s homeless stay on the move, camp solo and in small groups, and creatively bargain for couch space. These processes can have a peculiar but logical consequence of their own, encouraging and perpetuating drug use, even among people who would like to quit.

Before moving to Fort Collins in the mid-aughts, Dorothy had spent over a decade of her life on the streets. In her early thirties, she lost her children to policies that deemed her an unfit mother due to mental illness and her constant struggle to keep a roof over her family’s head. Though she had dabbled with methamphetamine to work strange hours driving a truck, she used regularly only after becoming homeless. At first, meth was merely a means of networking and negotiating for a place to sleep. By the time we met, nearly two decades later, she described herself as a full-blown addict.

“A lot of my meth use when I first started was, ‘gee, I suddenly became homeless and the way to find a bed to crash on is to get high with people,’” she explained during one of our early meetings. “ ‘Here, I’ll go buy a bag for you. I’ll do the running. I’ll take the chances.’ I’ll come back, I’ll get high. ‘Oh, I’m sorry, I fell asleep.’ You know, they gave you a bed and a hot meal. When you’re homeless, it’s how you put your feelers out. It’s how you couch surf.”

For homeless individuals who are already drug-dependent, quitting may be especially difficult. Eddie, a former health professional in his thirties, struggled to quit abusing meth. After losing his job he faced eviction and, eventually, landed on the streets with Boris, his best friend and dog of several years. Like Susan, Charles, and others who find themselves without shelter in cities with camping bans, Eddie sometimes walked all night. But hours of shuffling over concrete and asphalt, icy sidewalks or parched fields tore Boris’ feet apart, a consequence Eddie couldn’t accept. When he was denied entry or long-term stay in treatment and sober living facilities due to their “no dog” policies, Eddie turned to the only people who seemed willing to accept him — former drug using partners.

Like Dorothy, Eddie established credibility with his hosts by his willingness to use, undermining his intentions to quit. But there was also something simpler at play — temptation. By staying with fellow addicts and, specifically, people with whom he had previously used, old patterns quickly reared their heads, and thirty days sober became zero.

For others still, it’s the specific nature of methamphetamine that holds the key for survival. The central nervous system stimulant enables users to stay awake and alert, sometimes for days at a time. By some accounts, it even enhances vigilance. Policies that keep people on the move perpetuate the need to stay on the lookout for law enforcement, to remain ever-ready to get up and go.

Thus, many homeless meth addicts, including several participants in my own research, report using specifically to avoid problems with the police. Charles often camped on his own or with only one or two acquaintances. Not wanting to make the long trek out of city limits to avoid the authorities, he and a partner would sleep in shifts along river banks or under bridges. But he always felt vulnerable: “Some folks, they enjoy the mental torture of being up for days and days and days,” he explains. “And I don’t understand that part. I really don’t. I use the excuse, and generally it’s not an excuse because being out here living in the forest, to me, I’m vulnerable. If I go to sleep, I don’t hear nothing. That means somebody can slip on me, you know?”

The especially cold nights make even alert camping unrealistic and dangerous. And when left with no other options, Susan, Eddie, and others found that meth made the endless walking more bearable.

Aggravating Pre-Existing Mental Health Conditions

In the U.S. today, there are only about fourteen inpatient psychiatric beds for every 100,000 individuals in need. This is less than 5% of the resources available in 1955 and about the same coverage we saw in 1850. Official estimates suggest that between 20 and 50% of homeless individuals in the United States suffer from mental illness.

Given these severely restricted resources, they may represent one of the most drastically underserved segments of the homeless population. Conditions and particular experiences run the gamut but, in my work, I saw a lot of bipolar disorder, depression, schizophrenia, and PTSD.

For many, the consequences of mental health issues are greatly intensified by the circumstances of the street. Similar to addiction, mental illness can render sufferers ineligible for generalized safety nets, including some shelters unequipped to deal with related complications. Outbursts associated with schizophrenia resulted in Charles being temporarily banned from one Fort Collins shelter.

Paradoxically, homeless status can be cause for ineligibility to in-patient psychiatric services. When Dorothy sought in-patient psychiatric and drug abuse treatment, she was ruefully informed that no beds were available for people lacking a permanent address.

Furthermore, it is difficult to maintain a treatment schedule and adhere to prescribed medications when routines change daily and belongings must be carted around in a backpack. Many psychiatric medications not only demand ingestion on a strict schedule but some must be taken with food while others without.

For individuals rushing to make meal times at charities or hustling all day for cash or a place to crash, meeting these requirements is a challenge. And if that backpack is lost or stolen, as Charles’ was, people who can’t afford a place to sleep can rarely afford to replace expensive psychiatric medications.

But it’s not just the specifics of homelessness that present a problem. Policies that disproportionately target the poor and those without homes cause damages of their own. Having a history of arrest and incarceration limits access to safety net resources, including mental health services.

Not only can time spent in jail prevent individuals from meeting important appointments with mental health professionals, convictions can preclude them from access to supportive services, even outpatient services.

The very real and constant threat of getting caught is a source of stress that can directly damage psychological well-being. Of 441 homeless individuals surveyed, 36% had been arrested, 70% ticketed, and 90% harassed. Even the promise of such encounters with law enforcement presents a risk, especially for people with histories of trauma.

As Nancy Peters of Denver Homeless Out Loud (DHOL) explains, “There is all this emphasis right now on trauma-informed care.” And that’s fine; it’s important. “But,” she continues, “before we ever get to that, there is this potential for re-traumatization that is inherent in our policies.”

And while policies such as camping bans do nothing to prevent homelessness, they do ensure people stay hidden and on the move, devastating chances for social support. The streets thus become more dangerous, and those camping alone or in small groups become more vulnerable to violence. Homeless women are especially affected by the damage to social safety nets.

While Charles felt vulnerable when camping alone, as a large man, he knew most people, besides law enforcement, would leave him alone. Staying awake and alert all night was generally a sufficient, if still undesirable, precaution. But Susan, a petite woman on her own, was rightfully wary of any encounters. To avoid both law enforcement and intoxicated men, she and Rick often slipped into the auto-locking bathrooms in Old Town just before they closed. The small space provided a safe spot to overnight. But it wasn’t always an option.

Policies that scatter the homeless also undermine a very basic human need: sleep. In No Right to Rest, researchers observed that lack of sleep results in reduced quality of life, negative mental states, and an increase in visits to emergency departments. Bolstered by an abundance of supporting research, Peters will address sleep deprivation as a mental health priority in Denver Homeless Out Loud’s future campaigns.

Public Health In The Community At Large

As the bodies of homeless people are increasingly restricted by criminal legislation, policy undermines public health in the broader community as well. In an effort to keep people from using public bathrooms for personal hygiene, several communities place restrictions on their use. For example, a Denver Homeless Out Loud survey showed that, despite being inhabited by thousands of homeless, Denver has only 25 public restrooms that are accessible to the homeless. None of these are open around the clock, and many lack running water. Grand Junction, a smaller city on Colorado’s Western Slope, locks public bathrooms and shuts off water fountains in certain parks. And day shelters that offer showers often have long lines and lottery systems that interfere with the rest of the day’s survival tasks.

While limiting public restroom access may seem appealing to retailers and even customers, it directly curbs people’s ability to survive in public spaces and negatively impacts community health. Hindering access to basic hygiene services, and even all-important hydration, drives hygiene activities into far less appropriate, unsanitary places. Forcing homeless people to wash, urinate, and defecate in the open not only violates the United Nations Declaration of Human Rights, but is also detrimental to community sanitation and public health.

What Now?

Several organizations and communities nationwide are fighting for the reevaluation and dismantling of such troubling policies and pushing for the development of protective legislation. Thirteen cities and states have passed or are considering a “Homeless Bill of Rights.” The Western Regional Advocacy Project continues to advocate for a “Right to Rest Act” in California, Colorado, and Oregon. And some communities have begun to implement innovative programs that not only address the consequences of homelessness but also offer alternatives to its criminalization.

Initiatives such as Housing First have dramatically reduced homelessness; Utah was the first state to adopt the policy and their success has been astonishing. The Houston Police Department’s Homeless Outreach Team works to obtain housing for the chronically homeless. And Philadelphia’s Medical Respite Center assists in the transition of homeless people from hospitals back into their communities. Thanks to these and other programs, we now have a working laboratory from which to learn.

Still, challenging the criminalization of homelessness itself remains essential, not only in improving public health, but as a social responsibility. In recent years, many Americans have openly pushed for the reevaluation of policies and programs that disproportionately harm (or benefit) segments of our population. Yet as a society, we continue to be comfortable blaming and punishing the poor for “their” circumstances and “our” problems, ignoring any hint at social accountability.

As we support efforts to reenergize and “clean up” our urban downtowns, countless communities continue to adopt policies that directly and indirectly punish the homeless. With each camping ban and panhandling prohibition, we recreate the debtors’ prisons banned nearly two centuries ago. And in so doing, we further institutionalize the systematic oppression of the poor.

This article was originally published on STIR Journal. Reprinted with permission.