"We Can Help One Another"—Drug Use, Survival Sex and Hope Among Afghanistan's Marginalized Women

Dec 15 2016

“We Can Help One Another”—Drug Use, Survival Sex and Hope Among Afghanistan’s Marginalized Women

December 15th, 2016

“What I see under the bridge is really hurting me,” said Leila, a petite homeless woman of around 30 from Iran. She lives by Pul-e Sukhta bridge in west Kabul, along with hundreds of homeless people who use drugs. “When kids, like 10 or 12 years old, they stand and see drug users, they come under the bridge and especially drug sellers give them drugs, people inject drugs and make them addicted … then they are addicted and sell sex to get more drugs.”  

As The Influence reported last week, Bridge Hope and Health Organization, an Afghan-led harm reduction initiative founded by Abdur Raheem Rejaey, a former injecting heroin user and death-row prisoner turned leader and advocate, delivers vital harm reduction services and support to people who use drugs in Kabul.

Rejaey leads a team of nine trained peer educators to conduct outreach, dressing wounds and mapping communities of their hard-to-reach peers to create awareness and facilitate help. The team members all use methadone or street drugs themselves. But it is significant that they are all men.

To achieve an inclusive harm reduction approach, Bridge thinks more gender-specific support of women is needed. It’s an issue that is also pertinent in the US and elsewhere. The current cohort of 55 patients remaining in Kabul’s pioneering methadone program is a case in point. “Now there are only men as the women left,” said Rejaey, referring to three couples that dropped out.  

For women, traveling to the site for treatment “can be a problem” due to cultural reasons and societal taboos, said Farhad Habib, who formerly worked as a psychologist with Médecins du Monde, which previously ran the methadone program. “They were coming in burkas and explaining to neighbors that they were coming into the city to look for work. Or, they must come by foot from the mountains, or by car. This can be expensive for them.”

Creating two or three treatment sites in Kabul, or having a mobile clinic, could help to address women’s concerns about privacy and access, Rejaey and Habib believe.


Threatened by Poverty, Stigma, Violence and Rape

But in a country where only 19 percent of women participate in the labor force in urban areas, women who are dependent on drugs face many additional problems.

Without incomes, they “might resort to sex work to pay for drug use, but there is stigma around this,” said Rejaey. Some women without an income, he explained, will instead make a short-term contract with a man for economic support, a type of temporary marriage called sigheh.  

During Bridge’s peer-educator training, I met a small-framed, quiet woman who appeared to be in her 30s. She fidgeted and asked permission to leave the training. Finally, after respectful and gentle questions from Rejaey, whom many of the women see as a brother of sorts, it emerged that she was unable to complete the first day of training because of a sigheh contract. She was homeless, used drugs and had a child to support. She said the man might beat her if she did not come to him immediately when summoned.  

No women ended up being trained that day, but Bridge hopes to be able to train three female peer educators in future. The organization, still seeking long-term funding for its male peer educators, has long recognized the need to meet women’s unique requirements.


[Rejaey, with a sign about Bridge Hope and Health Organization’s training program. Credit: Michelle Tolson.]

In August 2015, Bridge and CoAct (a UK-based group that provides technical support to grassroots organizations), ran four focus groups with different groups of Afghan women: women in prison, the wives of men who use drugs, sex workers and women who use drugs.

Judy Chang, a consultant with CoAct, facilitated the groups, using images and photos to ask the women about their needs and their knowledge of available services.  

“The women were asked to rank the problems in their lives,” she said. “They ranked violence, stigma and discrimination and no support networks as the key issues.” Chang believes that with the necessary funding, Bridge can address all of these issues, “and bring the women together.”

When I spoke with Leila through a translator after one such focus group, she confirmed that women at Pul-e Sukhta bridge sometimes sell sex to survive, and said they also face frequent violence and rapes. But she did not want to speak further on the record about this or give specific examples (and like the other women interviewed for this article, she did not consent to be photographed). In Afghanistan, rapes can bring blame on the victims rather than the perpetrators.  

Faced with this threat of sexual violence, homeless women have sometimes asked for shelter at Rejaey’s home during his outreach trips to the Pul-e Sukhta bridge, but it’s a request he can never grant.  

“If I did this, I would be killed,” he sadly explained, illustrating some of the cultural difficulties faced by Afghan women in need. Suspicious community members have even branded live-in treatment facilities for women as “brothels.”

Leila said she’s generally “treated well” and “considered a guest” in Afghanistan due to her foreign roots. She became dependent on opioids after initially using them for pain relief following an accident. They were given to her by her husband’s family, with whom she came to Afghanistan. Her daughter does not stay with her; it would not be safe.

Leila thinks media could change Afghan society’s perception of people with addictions as lost causes. “One reason that people go back to using drugs after leaving [it] use is the lack of trust society has of them, especially their families,” she said. “Most people cannot trust that they have left using drugs. NGOs should help media understand that.”

Most of the women in the Bridge’s focus groups reported initially using opioids either for pain relief or after being introduced to them by their husbands. And while homeless drug users may be the most visible, there are many more who are hidden.  


[Afghan women at a market (not those interviewed).]

A 2012 survey of over 2,000 households across 11 provincial capitals found that 11.4 percent of urban Afghan households hosted drug use (5.6 percent opiates). That represented 10 percent of men, 4 percent of women and 2.3 percent of children. Those numbers don’t seem huge for the world’s biggest opium-producer, but stigma increases both the likelihood of under-reporting and the risks involved for those who use.

“Drug use among women and children is extremely difficult to estimate in Afghan society as it is easier to conceal and most often occurs in the home,” noted a 2009 UNODC survey.

Samara, a woman who appeared to be in her 40s and lived with her four sisters and her fiancé, spoke to The Influence about using drugs to bring relief for pain. “When I use drugs it makes me feel good and it makes me forget about the pains that I have.”

The UNODC survey also stated: “As for children, informants reported that opium, tranquilizers and cannabis were most commonly used. This latter observation corresponds with the long‐established practice of using opium to placate children, especially in the North Eastern and Southern regions.”

The survey estimated that upwards of 30 percent of drug users shared drugs with children—a figure that emphasizes the potential dangers of problematic use among women, who are primary caregivers to the vast majority of children.

On the other hand, Bridge’s focus-group research indicated the potential of enlisting women in drug-using households, to train them, for example, in harm reduction practices to help injecting husbands. Training and education would also reduce the fatalism with which some women regard drug use.

“Females should have more information on this,” said Leila, who used to work at a hospital in Daikundi province before she became homeless. “There are women who get pregnant and they believe that because they use drugs, their kid will be a drug user too—so even if their kid is born, they do not take care of it.”

Another major challenge for many women is how to earn an income if their husbands or fathers can’t work, abandon them or die.

“[Before] I had a job and I looked better than this,” said Leila. “I escaped from situations that people want to rape me. I don’t have energy so I can’t escape from using drugs, but if I had a job then I would not be in this situation.”  

Another woman who was not homeless (and did not give her name), told me following a focus group discussion that she was “forced” to begin using tramadol, an opioid painkiller, by her abusive husband. Now with six children and the only one in their household working, the tall, slim woman in her 30s spoke openly about having transactional sex. “We have to do this, because we don’t have money to support our family.”

Read more from The Influence:

“Wet” Vs. “Dry” Feminists—And Why Society Can’t Handle Women’s Relationships With Alcohol

Cancer With No Pain Meds? The Tragedy of India’s Painkiller Shortage

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There are also non-drug using women—now heads of their households, many having been abandoned by their husbands due to their substance use disorders—who were identified by Bridge staff as supporting their families through transactional sex. Several women in this position came to Bridge’s office to share their problems as part of an informal needs assessment in October, with their greatest issues being violence (including from police), harassment and needing work.  

The women did not speak directly about sex work due to the stigma surrounding it, but more about the problems they faced in their daily lives. Rejaey explained that Afghan society tends to blame women who are forced into sex work for economic survival reasons.


“This is not a dream but an aim”—The Power of Education

After the discussion, two sisters in the group, who did not come from a drug-using household, spoke to The Influence about the problems faced by women with no working men in the homeand illustrated the hope human-rights education could bring for the next generation of Afghan women.

The younger, “Zahra,” who was 18, said she was put in an orphanage at the age of two with her two youngest sisters after the Taliban killed their father. Their mother was not able to support them. So their eldest sister, “Zohra,” took on the burden of supporting the entire family, partly through selling items at a market and sex work, and did not marry. Zohra and the mother visited the three younger sisters on weekends.  

After Zahra left the orphanage, she returned to her family and enrolled in university. She was supported in this by Zohra, who hopes Zahra can one day also be educated abroad.

The younger sister aims—“this is not a dream, but an aim”—to use her education to help other woman, as she knows Zohra has faced harassment and violence while supporting them.  

“I want all women to study, learn knowledge and have an independent life,” said Zahra. “It’s important because if we know our rights, we can help one another.” For instance, she said that sexual harassment is a problem for young single women looking for work, as employers ask them for sex rather than wanting them as employees. She said she herself had experienced this.

Leila believes that with support from imams (religious leaders), Afghan society might one day understand the social, economic and psychological problems men and women from drug-using households face. A representative of Madawa, the harm reduction organization that trained and funded Bridge’s nine male peer educators through a grant from the Czech Republic, explained during a training workshop in October that approaching the government’s Ministry of Hajj and Religious Affairs is a way to reach the imams, “as the Haj controls what the imams say.”

Madawa regularly works on advocacy to different ministries. But all this requires funding and fundraising, and this is where Afghans find themselves continually networking with the international community to bring support to these efforts in their country. Habib, Rejaey, Zahra and Zohra all noted that engaging in this kind of outreach can get Afghans branded by the Taliban as “working with the infidels.” 

For Zohra, seeking help in this way is not about “working with the infidels” but simply a matter of the international community giving back to a country from which she believes many foreign nations have benefited during decades of war: “Today you support me, and tomorrow I will help you.” 

She hopes that Afghanistan in the future “is relaxed and can be secure, and all women can work, like in another country.”

The photograph at the top of this article is of a mural painted by the Art Lords group in the Kart-I Char neighborhood of Kabul. Credit: Michelle Tolson.

Michelle Tolson has worked on media, research and communications projects in Afghanistan, Cambodia and Mongolia. Her work has appeared in publications such as Reuters Trust Law, Inter Press Service, The Diplomat and the GlobalPost. She has represented projects supported by the Asia Foundation Mongolia, Plan Cambodia, and UN Women, USAID and the US Embassy in Afghanistan.