Queering Recovery: Harm Reduction and Nuanced Care

Beyond Abstinence

Does the traditional recovery model as you know it feel inapplicable or inaccessible to your version of substance use? Does abstinence feel restrictive and like it disregards your needs as a person?

It did for me, as both a recovery specialist and as a person in recovery.  Fortunately, that discomfort eventually invited the opportunity to delve into a more open and freeing version of recovery and treating addiction. This non-traditional model even affirmed my queerness.

Being at odds with the traditional model is a very queer experience, according to the definition of “queer” by bell hooks:

'Queer' not as being about who you're having sex with (that can be a dimension of it); but 'queer' as being about the self that is at odds with everything around it and that has to invent and create and find a place to speak and to thrive and to live.”

Creating and finding a “place to speak and to thrive and to live” can be done within the world of harm reduction and its inherently political history; harm reduction’s queerness is in that it is inventing your own way of thriving.   

Let’s first discuss what harm reduction is, practically speaking.

Harm reduction can be an umbrella term to refer to using substances in a way that is safer and decreases negative consequences without giving up a substance entirely. This can range from someone who wants to drink less alcohol to someone who needs to use a safer method of drug use to survive. Harm reduction also encompasses mitigating the harm caused by drug policies and laws. This article will discuss the former definition and how harm reduction applies to substances specifically.

Most treatment methods maintain that complete abstinence from substances is the only way to end problematic use. For many people, this rings true and is lifesaving. For others, though, total sobriety doesn’t fit for a variety of reasons.

In this article, I discuss the complexities of harm reduction and delve into the scary question: When is it actually safer to use a substance than not to? I also discuss harm reduction and how it relates to queerness, historically and today. 

Measuring Harm with Nuance

What do you do when using a substance causes harm, but there will be more harm if you don’t use? That isn’t the framework under which harm reduction always operates, but oftentimes it is, and this question is posed in the middle of a therapy session, with seemingly no right answer. What do you do when you know using is harmful, but you’re liable to be at greater risk if you don’t use?

Some of you may be asking: what are scenarios in which it’d be less harmful to use? This can include scenarios such as self-medicating suicidal ideation, or as a deterrent to other, more serious forms of physical (or emotional) self-harm. Sometimes we use so we don’t hurt ourselves worse.

I pose this scenario because it can be a scary one, both for a client and for their therapist. This is when harm reduction becomes very true to its name–the goal is literally to reduce harm, to reduce proximity to serious injury or death. When the all-or-nothing model of abstinence doesn’t work, it’s because too often the person in question is opting for the “all”--i.e., harmful substance use. It can be helpful, in these instances, to look at the spectrum of potential harm and figure out how to opt for the lower end.  

Person-First Care

It is risky to advocate for “less harmful” use, given the stigma around substance use of any kind. That’s a risk I’m willing to take because of how important I think harm reduction is to the field of recovery. This includes intentional, thoughtful substance use as an alternative to what would otherwise be chaotic use, other forms of self-harm, or worst case scenario, death. 

Harm reduction literally saves lives because it accounts for most approaches to staying alive, including safely using substances. Harm reduction, as it’s defined, isn’t about conforming to society or being “palatable”; in fact, its definition is “person-first” and prioritizes the dignity of the people it is being applied to. The National Harm Reduction Coalition defines “Harm Reduction” as follows: “Incorporating a spectrum of strategies including safer techniques, managed use, and abstinence to promote the dignity and well-being of people who use drugs.” 

With the definition in mind, we return to our previous question: What is less harmful? Is it less harmful to use the substance but test it first, and call a hotline that helps individuals avoid using alone? Is it less harmful to find a clean needle injection site? Is it less harmful to smoke weed instead of using opiates for pain management? Or is it less harmful to use opiates instead of smoking weed because you have asthma?

One can only define harm reduction for themselves; trying to apply a one-size-fits-all model to it inevitably fails.

Harm Reduction History

With this kind of subjectivity and uniqueness so inextricably linked to the nature of harm reduction, I believe harm reduction is inherently very queer. It works outside of binaries, establishing itself as definitively political.  

There is a history linking queerness to harm reduction, rooted in the HIV/AIDS

movement in the 80s. With HIV transmission increasing among people who inject drugs, community members responded by creating an underground needle exchange to prevent exposure. These exchanges were illegal at the time.  

Harm reduction is also inherently queer in that it doesn’t necessarily abide by laws and rules. This is where the substance use as a means of harm reduction comes in—you might still be doing something "illicit" when you’re practicing harm reduction. Does this mean you’re not reducing harm? My take is: no, of course not.

Unfortunately, we live in a carceral society, one that doesn’t necessarily hold space for the nuances of harm reduction. Abstinence being enforced punitively is all too common for many recovery programs. This kind of violence is not unrelated to the violence enacted by the entities that wanted to sweep HIV/AIDS under the rug. Safe Injection Sites (SIS) were started in direct opposition to this violence, and to this day, SIS are associated with a lower rate of overdose mortality according to the National Library of Medicine.

In this way, harm reduction is not unrelated to all forms of protest or anti-carceral work.  It is rooted in human rights, whether that be pertaining to recovery or other forms of social justice.

Unlearning Guilt

I think there is a guilt that can come with some forms of harm reduction. I am in recovery and have been since 2018. I have tried multiple paths for recovery and certain kinds of harm reduction did make me feel guilty, like I was cheating the system or betraying my recovery.  Most of us internalize that recovery means abstinence and anything else is “wrong” or “bad.” You’re either in or you’re out, you’re either sober or you’re not, you’re either doing well or doing poorly. It’s very black and white. It’s very rigid. It doesn’t allow for those of us who need something else. Even when we find the method of harm reduction that works for us, we might feel guilty because it doesn’t look like the pretty package of sobriety we were promised.

Similar to practicing harm reduction, practicing queerness might initially bring up

guilt for some of us. Compulsive heterosexuality aside, we are told that we are meant to fit in one category or another, completing the binary we were all raised with. Freedom from those categories can be liberating, joyful – and can also bring up some guilt because we’re being told by society that it is “wrong.”  

I write this article in the hopes that it will contribute to the conversation destigmatizing harm reduction. I also wanted to reflect on the very political nature of harm reduction, because it is rooted in social justice and human rights. It is inextricably linked to issues such as housing rights, to the multiple genocides occurring in places like Sudan and Palestine, to an individual’s right to bodily autonomy. It is also queer–it is dedicated to existing outside of binaries and societal norm; dedicated to, as bell hooks put it, “being at odds.” If nothing else, I want to see harm reduction embraced for what it is–a more forgiving way of valuing human life. 

If you are interested in exploring harm reduction in a queer-affirming space, our new harm reduction group is open for enrollment! Our eight-week virtual harm-reduction group will support you in your journey to achieve a recovery that works for you, informed by queer history and guided by a queer/trans recovery and harm reduction specialist. Join today, or inquire about our sliding scale spots!