Author’s note: Race is hard to write about; so is class; so is gender. I struggle with articulating — especially in a short essay — two truths. Broad social forces and inequalities impact life experiences. And, each individual has her own unique life experiences framed by the particular ways in which class, race, gender, sexual orientation, ethnicity, nationality, citizenship status and other social categories intersect for her. I thank Robin Yang and Lois Ahrens for helping me try to get it right here. I accept sole responsibility for bits where I’ve missed the mark.
Black men have been the face of incarceration in America for decades, and black men continue to be locked up at rates far exceeding those of other gender and racial demographic groups. But, over the past few years, just as the pace of incarceration finally began to decline for men and for black women, incarceration rates have risen by 47.1% for white women. Opiate use seems to be driving much of that increase.
CDC Director Tom Frieden, in a 2013 briefing, announced that rates of opiate use, abuse, overdose and death are rapidly increasing among women. Aside from age (those in the 45-54 year age group have the highest rate of opiate related death), Frieden did not offer demographic details beyond the rather meaningless “mothers, wives, sisters, and daughters.”
Research published last week by the Boston Globe found that the number of babies born in Massachusetts with opiates in their system is more than triple the national rate, and that the numbers in Maine and Vermont are even worse. This research did not track race, but we do know that Maine and Vermont are two of the whitest states in the county – 95% white, Massachusetts is 84% white, and that many of the opiate hot spots in these states are poor, white communities. In Fall River, for instance, approximately 72% of residents have received a prescription for opiates, a rate well above the state average of 40 percent.
While the media seems shocked to “discover” that white women make illicit use of drugs, we really should not be surprised. Indeed, over the same years in which black men were the face of incarceration, white women were the face of medicine. White women take more prescription and over-the-counter medication, are prescribed more pain medication, undergo more cosmetic surgery, and make more doctor visits than any other major demographic group. White women are the greatest users of commercial holistic healing (alternative and complementary medicine). And white women are over-represented on pharmaceutical commercials and in high profile “war on illness” campaigns such as the pink ribbon breast cancer extravaganzas.
Just as higher incarceration rates do not necessarily mean that black men are especially wicked, higher medication rates do not necessarily mean that white women are especially sick. They do mean that white women tend to be portrayed as particularly in need of — and deserving of — expert medical care, and that the health challenges of white women are treated with more attention than the health challenges of other groups. Think, for instance, of how the natural aging process becomes seen as a medical problem (medicalized) when millions of prescriptions are written for hormone replacement therapy (HRT) for women who do not have any disease other than not being young. And think of the racial implications of these findings from a large government study released in the 1990s: HRT use among white women was 89% higher than among black women and white women were 54% more likely than black women to receive HRT counseling from their doctors.
Women – and especially white women – are prescribed more psychiatric medication (especially for depression and anxiety) than men. Jonathan Metzl, in Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs, traced advertisements for psychiatric medication in the American Journal of Psychiatry over a period of decades. He found that marketing to doctors disproportionately addressed women’s problems. Advertisements for Milltown and then Valium featured women’s unhappiness with their husbands, family responsibilities and sex, and offered medication as a way to make them more compliant with expected gender roles. Overwhelmingly, the pictures in these advertisements were of white women benefiting from treatment provided by white male doctors.
What does all of this mean for white women’s experiences of opiates today? For most of the past decade I have been working on a project with Massachusetts women who have spent time behind bars. Reflecting the prison demographics in the state, three quarters of the forty-seven women who participated in the project are white and virtually all were drawn into the correctional system because of drugs. They also are poorer and have completed fewer years of formal education than the general population of white women of the same age cohort in Massachusetts.
All grew up in working or middle class families with parents who had steady jobs and housing. All came of age in an era in which economic policies kept wages low and employment unstable, making it nearly impossible for them to access the working and middle class lives enjoyed by their mothers. While several of their fathers had some history of incarceration, none of their mothers had ever been locked up. The deterioration in life experiences described by the white women in comparison with their mothers is consistent with national trends: Women with less than a high school education can expect to live five years less than similarly educated women of the previous generation.
Most of the white women I have come to know were introduced to psychotropic and pain relieving drugs by doctors. For example, Francesca was abused as a child and started on psychiatric medication to manage “my PTSD” in her early teens. She later became addicted to Percocet in the wake of pain medication routinely given her by doctors she saw at the ER after her husband would beat her up. Two women became addicted to medication prescribed for post caesarian section pain; when the doctors wouldn’t write more prescriptions they turned to the streets for pain-relieving substances. A few women are or have been crack users. But overwhelmingly the white women are hooked on pain medication.
None of the black women I met through this project were introduced to opiate use by doctors. This may be because black women are less likely to have health insurance and access to health care. It may be because black women are (incorrectly) more likely to be seen as potential addicts so doctors are less likely to prescribe pain medication. It may be because doctors (overwhelmingly white) are more likely to feel sorry for white women in pain or assume that black women are more able to “suck up” the pain. Or it may be because white women trust doctors more than black women do (several black women mentioned that doctors do “experiments” on black people; this concern is well-grounded.) It’s likely a combination of all of these reasons, but the fact remains that white women are more likely than black women to be turned onto opiates by doctors.
For Francesca, as for other white women with whom I work, a doctor’s prescription reinforces her sense that the root of and the solution to her problems are individual and internal. Illicit drug use is described by these women as “self-medicating.” All but two of the white women attribute their drug use and criminalization to their personal histories of trauma (in particular childhood sexual abuse) and to their individual inability to “get over” the effects of their traumatic experiences. Not a single white woman – at least in my hearing – has ever hinted that there are external factors such as the lack of good jobs that led her to drug use. Sexual violence is invoked by white women but always in an individual sense that, “I personally have a tendency to choose the wrong men.” Reflecting on comments I’ve heard in myriad contexts over many years, I am struck by the absence of any sort of collective consciousness that allows them interpret their pain in terms of anything other than their own bad luck and personal flaws. My intention is not to blame the women for being oblivious to institutionalized social inequality. Quite the contrary, the script of self-censure is repeatedly taught, drilled and rewarded in the therapeutic and rehab programs they voluntarily and involuntarily attend. And while Twelve Step culture has always focused on accepting personal responsibility for one’s problems and dismissed attention to outside causes as “denial,” the script of self-censure has taken on additional potency for women in the many “gender responsive” programs that (typically with benign intentions) attribute women’s use of drugs to female emotional and psychological weaknesses.
Most of the black women I have come to know in the Massachusetts project identify the outside world of lousy schools, discriminatory hiring practices and living in gang and drug-infested neighborhoods as leading to drug use. For instance, Tonya explains that she has gone for many job interviews but employers only see “an angry black woman with a doo-rag,” and come up with an array of reasons not to hire her. Anasia, a black woman in her late thirties, says that she became involved with drugs “because it was everywhere.” Other black women commented that “everyone was doing it and I wanted to fit in.” This does not mean that most or even many black women routinely offer protracted analyses of how race and gender intersect in their lives. This does, however, indicate recognition of race as a real social factor as well as some level of rejection of the therapy / rehab / Twelve Step self-blame script.
I hesitate to generalize from a small sample in a single American city. But I do think it legitimate to ask why white women, and especially poor white women, perceive themselves – and are perceived by their doctors – to be in so much emotional and physical pain.
At this particular moment in history social forces are coming together in ways that are increasingly and visibly deleterious for white women. The first of these is the unprecedented widening of income and wealth gaps in a society that has cultivated an absence of class consciousness and in which – despite all evidence to the contrary – we still like to say that most Americans are “middle-class.” Economic shifts of the past few decades (the decimation of the middle and working classes) coincide with increased medicalization of bodies and minds. Driven in part by the enormous profits to be made in the health care and pharmaceutical industries, medicalization continuously ups the ante for what can be “fixed.” Playing out in highly gendered and racialized ways, medicalization feeds into cultural ideals that, with enough expert help and personal dedication, white women should be able to be perfectly healthy, attractive, and pain free — ideals that dismiss the existential reality of the human condition as well as specific material conditions such as environmental toxins, low-wages and the relentless stresses of racism and poverty that cause pain and illness.
To be clear, these social forces affect everyone, not only white women. But I believe that we are seeing an acceleration of these forces vis-à-vis white women, and especially poor white women. This may simply be a matter of white women catching up with everyone else in terms of arrests and incarceration; it may be a market phenomenon in the sense that the illicit drug and the prison markets for men and for African Americans are saturated and white women represent one of the few arenas into which drug dealers and the highly profitable prison industry still have room to expand. Yet, I do think that that recent reports of rapidly rising rates of opiate related death and imprisonment among poor white women force us to think harder about how race and gender intersect with that great American unmentionable – class. Poor white women are medicated (and self-medicate) for the same socially construed gender weaknesses and pain as affluent white women, yet unlike their wealthier sisters they have to make do without the protections of good lawyers and platinum health insurance. Despite different racial narratives, increasing numbers of these white women are ending up in the same place – prison — as poor Americans across gender and racial divides.
Follow this link for more on the the medicalization / criminalization of misery: Incarceration by Any Other Name: A Return to the Cuckoo’s Nest? And follow this link for more on class in America: Orange is the New Black: What Pennsatucky’s Teeth Tell Us About Class in America