In this briefing on the Icelandic national alcohol and drug policy, the focus will be on the visibility of gender in policy documents, how the policy relates to international policy trends, and what implications this has for the situation of women with alcohol and drug problems in Iceland. There is also a discussion of the treatment system in Iceland and the unfortunate power structure characterizing the treatment system in a country with few inhabitants and a monopolized NGO run treatment offer.
In many respects Iceland differs from other European and Scandinavian countries both in the history of alcohol and drug patterns, and in policy and treatment; trends and differences will be described in broad outline. The paper ends with some considerations that are necessary if Iceland is going to take gender issues seriously at this point of change in the history of drug and alcohol policy and treatment.
Policy and treatment in Iceland has been characterized by abstinence based policy and a focus on the reduction of supply, since the beginning of the 20th century. The International Good Templars Organization (IOGT) was very influential in Iceland, founded in 1894, and as a result of their efforts a prohibition went into effect in 1915, prohibiting all alcohol in Iceland until 1922, when wine was legalized, and in 1935 all alcohol beverages were legalized, except beer, which was prohibited until 1989 (Ólafsdóttir, 2012; Government Offices of Iceland, n.b.). The history of drug and alcohol consumption in Iceland has been marked by this long-lasting ban on beer drinking, making Icelanders a “spirits-drinking society par excellence” (Ólafsdóttir, 2012:26) and also making Icelanders’ alcohol consumption the lowest in Europe for most of the twentieth century. After the lifting of the beer ban in 1989, drinking habits have changed but Iceland is still one of the European countries where people drink less frequently, according to the European Health Interview Survey statistics (Statistics Iceland, 2017).
According to Helgi Gunnlaugsson, Professor in Criminology at the University of Iceland, there is a great opposition, both by the public and government against drug use in Iceland, and drug use is insignificant compared to other European countries. Only certain groups (mainly young people) use illegal drugs on a regular basis, and Gunnlaugsson draws the conclusion that the small size of the nation, the distance from other countries and the homogeneousness of Icelanders are factors that contribute to this negative attitude towards drug use. There is only a small group with serious and excessive use of drugs in Iceland (Gunnlaugsson, 2013).
One other factor, in the status of alcohol and drug consumption in Iceland, that is worth mentioning, is that there still is a state monopoly on the sale of alcohol and a ban on advertising it. In recent years there have been attempts to end the state monopoly, and the fifth bill towards that end has now been submitted to the Parliament (Fontaine, 2018, 25 September). The public is very opposed to this bill but a growing alcohol production and industry is pushing for the bill to pass.
In Iceland the treatment for drug and alcohol abuse has been characterized by the 12 step approach for the last four decades, or since a group of Icelanders went to the Freeport Hospital in New York for treatment of alcohol abuse. After a few years of Icelanders travelling to Freeport for treatment, those who had sought treatment there, mostly men, founded SÁÁ-National Center of Addiction Medicine-in 1977 (SÁÁ, n.d.). Many of the founders were well-known upper-class men, who launched a crusade against alcoholism, this time, with the Minnesota model of ideology as their weapon. The status of these entrepreneurs ensured their success and secured SÁÁ as an unrivalled leader in the sector.
Most of the treatment for alcohol and drug abuse in Iceland is paid for by the state but run by NGO’s. The National Hospital services people with dual diagnoses, that is, severe mental health symptoms and addiction. Apart from SÁÁ and the National Hospital, there are a few organisations offering treatment, founded either on Lutheran belief or the 12 step model, or on both. This is only a small part of the treatment that is offered in Iceland, with SÁÁ being the dominant treatment provider.
The Minnesota model, or what has been called the Icelandic model, has dominated treatment for alcohol and drug abuse in Iceland since the foundation of SÁÁ. This means that everybody goes, more or less, through the same treatment, since addiction is defined as a brain disease but not a result of social or psychological factors, or the fact that “fiddling, curiosity and social peer pressure are the most likely cause of why individual try drugs or alcohol for the first time” (Sigurðsson, 2018).
Although SÁÁ has offered some form of gender specific treatment since 1995 it can be argued that the treatment system in Iceland has been characterized by gender blindness and paternalistic epistemologies or “epistemologies of ignorance” as defined by Ettorre and Campell:
Multiple ‘epistemologies of ignorance’ work along gendered, sexualized, classed, and racialized lines to make knowing ‘what women need’ difficult to discern in this domain. These epistemologies define ‘what women need’ in popular women’s culture as divorced from feminist political thought, which is typically viewed as a destabilizing force (Campell & Ettorre, 2011:2).
One of the problems with the Icelandic treatment system is that there has been very little research in the field of addiction and treatment focusing on other aspects than research into biology and/or genetics of addiction. As a result, very little evidence exists about women with addiction problems in Iceland. The brain disease model of addiction is the dominant model in the addiction field, and until recent years, little attention has been given to social or gendered aspects of addiction in Iceland, in policy, treatment, or research.
One exception is research done at The National Hospital’s then treatment facility in the nineties. Ása Guðmundsdóttir, a specialist in clinical psychology, is the researcher. Seventy-one women participated in the research, which argues for a specialized treatment for women as well as a different approach than treatment dealing with men. She points out the necessity of looking at the reasons why women drink, and that such knowledge is vital because of the importance of women’s gender roles and the accompanying psychosocial factors. She also notes that there is a great lack of data about women with alcohol problems (Guðmundsdóttir, 1997a). The main results are as follows:
The women suffer from a lack of self-esteem, guilt, shame and powerlessness. Broken relationships, a tendency to confirm with drinking partners, sexual problems and sexual abuse were all found to be important reasons for female abusers’ drinking. Drinking to reduce stress, to relax, or for the intoxicating effect were also significant factors in the women’s drinking patterns. Emotional problems relating to the women themselves were stronger incentives for change than social problems. The results suggest that therapeutic intervention for women must focus on raising self-esteem, solving emotional problems and managing stress (Guðmundsdóttir, 1997b).
The research shows that 50% of the women had been sexually abused as children, a factor also shown by recent research by RIKK – Institute for Gender, Equality and Difference and The Root – Association on Women, Addiction and Mental Health, in Iceland, on women’s experiences of treatment, presented by Kristín I. Pálsdóttir at the DAFW in Manchester in May 2018.
There is also a mention of women in the treatment system in a big, government funded, research project on violence against women in Iceland, done for the Ministry of Welfare. It states that violence is a collective experience of the women who seek help at SÁÁ’s detox hospital, Vogur, that most of them (70 – 80%) have a history of sexual abuse; interviewees, many of them professionals, agreed that violence was seen as a ‘normal’ factor in the lives of women who abuse substances, and that they don’t perceive this as their biggest problem (Gíslason, 2010).
The recent Alcohol and drug policy in Iceland was adopted at the end of 2013. The name of the policy document is “Stefna í áfengis- og vímuvörnum til ársins 2020” (Eng. Drug and Alcohol Prevention until 2020) (Icelandic Ministry of Welfare, 2013). The main goals of the policy are:
- To restrict access to alcohol and other drugs
- To protect sensitive groups against harmful effects of alcohol and other drugs
- To prevent young adolescents from initiating the use of alcohol and other drugs
- To reduce the number of those who develop harmful use of alcohol and other drugs
- To secure the access of those affected by misuse and addiction to continuous and integrated services, built on best knowledge/practices and high of quality
- To reduce harm and prevent deaths caused by one’s own, or others’, use of alcohol or other drugs
The goal was to implement the policy the following year, in 2014, but little has happened in that direction. Already, in January 2014, a month after the publication of the new policy, the Parliament, with the initiative of the Pirate Party, has started discussions on changing the policy towards a more harm-reductionist document. As a result, a working group was founded in May 2014 to revise the new policy on the “grounds of a solution focused and humanitarian resources, on the terms of the health and social systems, to assist and protect the users of the substances and their social rights”.
The working group delivered a report in August 2016, proposing a policy more in the direction of harm-reduction. In the policy from 2013, the first signs of harm-reduction are seen in the Icelandic drug and alcohol policy, where it is stated that one of its main goals are “To protect sensitive groups against harmful effects of alcohol and other drugs” (Icelandic Ministry of Welfare, 2013, 3).
Under the goal to protect sensitive groups against harmful effects of alcohol and other drugs, there is the single mention of women in the policy document:
Some social groups are more sensitive than others, for example the children of parents with alcohol and drug problems, pregnant women and adolescents. All children and adolescents have the right to grow up in an environment that they are protected against the negative effects of alcohol and substance abuse. In addition, Women are in far more danger of experience violence than others. Screening, public health care services, and the services of municipalities, such as welfare services, are examples of measures to protect individuals (Icelandic Ministry of Welfare, 2013, 7). (Emphasis added)
The classical approach to women’s use of drugs focuses on substance use and misuse as a disease, with individualistic explanations, and an invisibility of gender, as opposed to the postmodern approach that deals “more effectively with persistent systems of social inequalities” and “social differences based on class, gender, ethnicity, ability” (Ettorre, 2004:328). The postmodern approach also presents possibilities for harm reduction, but Ettorre emphasises the importance of these measures being gender-sensitive.
The first mention of women in the document is in relation to pregnancy. That is typical of the way women are referenced in policy documents, where “the focus is on the role of women in producing children and the potential negative effects of drug use on the; women matter by virtue of their capacity to reproduce” (Thomas & Bull, 2017). The second and last mention of women, relates to the violent experiences of women with substance use problems. This latter mention is actually in the policy due to my involvement in the making of the new policy. The word ‘gender’ (Ice. kyn) is not mentioned in the document at all.
It can be seen that the policy is not very detailed, that these are the main goals, and that implementation strategy has not been produced as planned, except for the report of the working group, (which was called the “harm reduction committee” (SÁÁ, 2015)), which produced a more detailed document which was, however, as void of gender reflections as the policy from 2013. The results of the working group were somewhat of a disappointment for those in favour of harm reduction, such as the Pirate Party, which initiated the work on the revision of the policy, since the policy didn’t go as far in the direction of harm reduction as they would have liked (Alþingi, 2016). This is not a surprise since there were representatives on the working group that have very varied views and interests.
Most of the services in the treatment system in Iceland are offered by NGO’s, with SÁÁ being by far the largest one. SÁÁ has promoted the abstinence based classical model. It has been criticised as having almost a monopoly of addiction treatment services in Iceland. This situation has made it complicated for the state to enter into agreement with SÁÁ, and gives the organisation an unhealthy power status in negotiations with the state and municipalities. It also prevents a broader offer of treatment options (Pálsdóttir, 2017).
It is clear that such an imbalance in the treatment sector characterizes the situation in Iceland. SÁÁ is also a very influential participant in policy making within the sector, and the organization had a representative in the working group. On the other hand, there were no representatives from other organisations representing service users, except for the biggest service provider (Pálsdóttir, 2017). This means that organizations promoting harm reduction and gender mainstreaming, Snarrótin – Association on civil rights, and Frú Ragnheiður, the Icelandic Red Cross harm reduction project, and The Root – Association of Women, Addiction and Mental Health, or Olnbogbörn – Association of relatives of young people at risk, were not a part of the working group, although the group met their representatives. Consequently, that there were no strong voices promoting gendered approaches or users’ views in the working group, and this absence leaves its mark on the report.
Looking at the report with regard to gender, there are very few mentions of women. Apart from the two mentions repeated from the policy document, women are mentioned only a few times, mostly in relation to statistics. There is also a discussion on the outcome of the special session of the United Nations General Assembly on the World Drug Problem, UNGASS 2016, which was a great disappointment to those in favour of harm-reduction strategies, and which missed the opportunity of “embedding the drugs issue comprehensively within the UN’s three pillars: development, human rights, and peace and security (Bewley-Taylor & Jelsma, 2016).
In the Icelandic report, referencing UNGASS, it is stated that it is necessary to look especially into women’s equal access to health care, but there is no mention of other operational recommendations in the outcome document of UNGASS 2016, such as on the treatment of drug use disorders, rehabilitation, recovery, and social reintegration, prevention, treatment and care of HIV/AIDS, viral hepatitis and other blood-borne infectious diseases. The report states:
We recognize the importance of appropriately mainstreaming gender and age perspectives in drug-related policies and programmes;
We reaffirm that targeted interventions that are based on the collection and analysis of data, including age- and gender-related data, can be particularly effective in meeting the specific needs of drug-affected populations and communities (UNODC, 2016, 3).
In the operational recommendations of the UNGASS 2016 outcome report on cross-cutting issues, drugs and human rights, youth, children, and women and communities, the focus is on gender mainstreaming:
Mainstream a gender perspective into and ensure the involvement of women in all stages of the development, implementation, monitoring and evaluation of drug policies and programmes, develop and disseminate gender-sensitive and age-appropriate measures that take into account the specific needs and circumstances faced by women and girls with regard to the world drug problem and, as States parties, implement the Convention on the Elimination of All Forms of Discrimination against Women (UNODC, 2016, 15).
The Icelandic report supports the outcome of UNGASS 2016 in its adherence to the classical approach to drug policy, keeping the focus on the supply site of drugs distribution, but also mentioning human rights issues, as does UNGASS 2016. But the Icelandic report presses the view to “keep the balance in threading the way between preventing the use of drugs and servicing those who are dealing with substance abuse, as far as possible, with regard to age, gender and public health. No discussion took place about a holistic change in the direction of “decriminalisation” of the use of drugs” (Icelandic Ministry of Welfare, 11).
The report tries thus to go both ways without a clear direction or decision to decriminalize the use of drugs and it also fails to take a firm stand on the importance of informed gender policy.
In reality, the Icelandic system is moving towards a more harm-reductive system, and last month this became clear when the Minister of Health, answering questions in Parliament on the opium epidemic, said that funds have been set aside for the opening of the first injection room in Iceland (RÚV, 2018). It is clear that changes are under way, although it seems difficult to change policy documents.
The Icelandic policy and treatment system has been characterized by classical, brain disease, Minnesota, and 12 Step, approach up until now. This approach has dominated all discussion, policy, and treatment for the last forty years. In recent years, new voices have entered the stage claiming changes in the direction of a more post-modern approach to addiction, with emphasis harm reduction, decriminalisation, gender-sensitivity and more varied treatment offers, recognising that people with drug and alcohol problems are not a homogenous group with the same needs.
Icelandic policy is moving very slowly in these new directions and there is a reluctance to let go of the old ways. The good thing about such a small homogenous society as Iceland, is that things can move fast when they start moving; we saw this when SÁÁ was founded and everybody suddenly got the opportunity to avail of treatment services. There is an opening, as can be seen by the opening of an injection room. Iceland has a good reputation for being one of the most gender equal country in the world (OECD, 2018) and should ensure that this status includes the most marginalized groups of women in the country, women with substance use problems. Both in policy and practice.
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