“You don’t belong here”

This is an English summary of the report “Du har ikke noe her å gjøre” (“You don’t belong here”), from the Norwegian Human Rights Institution (NIM).

The full report is available in Norwegian here.

This report examines experiences of discrimination and stigmatisation among people with substance use disorders (SUD) when interacting with public services. We examine whether perceived discrimination and stigmatisation shape this group’s encounters with public services, how such processes might manifest, and why they occur. The report is based on a qualitative study conducted by NIM, where we have interviewed people with SUD, representatives from civil society organisations for people using drugs, healthcare professionals and law enforcement officers. The findings are assessed in light of Norway’s human rights obligations.

In this report, a distinction is made between discrimination in a legal sense and subjective experiences of stigma and discrimination. The term “discrimination” is used when referring to legal protection from discrimination, while “perceived discrimination” is used when referring to the informants’ subjective or self-reported experiences of discrimination. Similarly, “perceived stigma” is used to describe the informants’ subjective experiences of stigmatisation. An individual experience of discrimination may exist even if the experience does not legally constitute a violation of anti-discrimination laws. It is beyond the scope of this report to assess whether each informant’s experiences are “objectively true” or constitute discrimination in a legal sense.

Protection from discrimination for people with substance use disorders

Discrimination is prohibited under international human rights conventions, the Norwegian Constitution, and other national legislation. Discrimination can be defined as unreasonable and disproportionate differential treatment based on one or more protected characteristics. Substance dependence is not specifically mentioned as a protected characteristic in international conventions, but people with SUD may be protected from discrimination through the protected grounds “other status” and “disability”. Under Norwegian law, substance dependence is not directly mentioned as a protected characteristic, but the Equality and Anti-Discrimination Act provides people with SUD protection from discrimination when dependence has been caused by or resulted in a disability. However, the state of the law is unclear regarding which groups and situations are protected and how to assess the kinds of differential treatment that may be permissible. This requires consideration of the principle of minimal interference and the individual facts and circumstances of a given case.

Which experiences do people with SUD have with stigma and discrimination?

NIM has conducted in-depth interviews with 17 people with current or former SUD. The purpose of the interviews was to collect personal stories about the informants’ encounters with public services and any experiences they have had with perceived discrimination and stigma.

Most of the informants describe experiences of perceived stigmatisation and discrimination in their interactions with public services. Many say that they are generally met with negative attitudes, suspicion and unfair judgement when accessing public services. This includes being seen as dangerous, manipulative, responsible for their own substance dependence, or having poor self-control. Several informants claim that prejudices have negatively impacted how they have been treated and the types of services they have received. However, these experiences do not apply to everyone, and some report having experienced little or no stigmatisation and discrimination from public services.

Experiences of perceived stigmatisation and discrimination are particularly prominent in interactions with healthcare services and law enforcement.

Experiences from interactions with healthcare services

• Prejudices: Several informants report being met with suspicion, prejudices, and offensive comments when interacting with healthcare services.
• Rejection: Some informants report being rejected from health care services because of their SUD. This includes experiences of rejection from hospitals, emergency rooms, and general practitioners.
• Medical records: Several informants report that healthcare professionals’ attitudes change negatively when they discover their SUD mentioned in the medical records. Some report that their medical records have triggered negative comments, while others have experienced rejection or threats to call the police.
• Medication: Several informants report that they experience stigmatisation when accessing medication and claim they have been denied necessary medication because of their SUD. Several of the informants report not receiving adequate pain relief after medical procedures. Others have found it difficult to obtain medication for ADHD because of their SUD. Several have also experienced stigma in opioid-substitution therapy (OST).

Experiences from interactions with law enforcement

• Prejudices: Many informants report experiencing stigmatisation and prejudice in their interactions with the police.
• Use of force: Several informants believe that the police have used unnecessary force against them on various occasions because of their SUD, in the form of checks, body searches, house searches, and the use of physical force.
• Rule of law: Many feel that they as a person with SUD lack legal protection and equality before the law when interacting with the police. Several report that their criminal record is used against them by the police long after they have committed crimes.

Experiences from other areas

The informants also report experiencing perceived stigmatisation and discrimination in other areas, although these experiences are more sporadic.

• Other areas: Some informants report experiencing stigmatisation when interacting with the Norwegian Labour and Welfare Administration (Nav), the Child Welfare Service (Barnevernet) and the Correctional Service (Kriminalomsorgen). There are also some reports of stigmatisation when accessing housing and being rejected from shelters.
• Other contributing factors: The informants attribute some of these experiences to their own SUD. In other cases, these experiences reflect a more general critique of services that are not linked to stigmatisation or discrimination.

Consequences of the informants’ experiences

The informants report that perceived stigmatisation and discrimination have had several negative consequences for them. Three consequences are particularly common:

• Health status: Several informants report that perceived stigmatisation and discrimination have negatively affected their mental and physical health, either directly or through exacerbation of existing conditions.
• Help-seeking behaviour: Several informants say they have become more sceptical about seeking help when needed due to fear of encountering prejudices and rejection.
• Social exclusion: Several informants say that being met with stigmatisation and discrimination has led to increased substance use, crime, and social exclusion.

What do public services and civil society organisations say about stigma and discrimination?

Following the in-depth interviews with people with SUD, focus group interviews were conducted with representatives from civil society organisations for people using drugs, law enforcement personnel and healthcare professionals. The purpose of the focus group interviews was to complement and contextualise the personal stories and collect perspectives about what might explain some of the experiences.

Civil society organisations

The conversations with four representatives from civil society organisations for people using drugs largely reflect the findings of the in-depth interviews. The participants connect perceived stigmatisation and discrimination to punitive and prohibitionist drug policies, lack of knowledge about substance dependence, cultural roots of stigmatising attitudes, and media portrayals of people with SUD. The participants highlight several examples of what they perceive as stigmatisation and discrimination:

• Requirement of sobriety: According to the focus group, there is often a requirement or expectation that one must be sober in order to receive healthcare. The participants highlight this as a cause of people with SUD being rejected from mental health services and other parts of the healthcare system.
• Driver’s license: Several of the participants claim that people with SUD often automatically lose their driver’s license when seeking residential treatment, without a specific individual assessment.
• System design: According to the participants, public services are designed for resourceful individuals, indirectly leading to differential treatment of people with SUD and other vulnerable groups.
• Police: The focus group believes that the way law enforcement deals with open drug scenes often contributes to stigmatisation, and that the police’s protection of people with SUD from crime is often insufficient.
• Housing: Several of the participants consider many housing services for people with SUD as stigmatising.

Healthcare professionals

The focus group with healthcare professionals consisted of four individuals working at different levels of the healthcare system. The participants have several reflections on what they believe may explain perceived stigmatisation and discrimination among people with SUD:

• Medical ethics: Several of the focus group participants describe what they perceive as challenging ethical dilemmas in the treatment of patients with SUD. According to the participants, such dilemmas may lead to treatment being restricted in certain cases. Medication is mentioned as a particularly challenging area.
• Lack of knowledge: Several of the participants feel there is a general lack of knowledge about substance dependence in the healthcare system, which may lead to poor patient encounters.
• Communication challenges: Several participants have experienced that healthcare professionals and patients with SUD often struggle to understand each other’s needs, perspectives and approaches in a treatment process, which may lead to conflicts and communication challenges.
• Resources: The participants also highlight that time constraints and lack of resources often hinder good patient encounters. This may lead healthcare professionals to say or do something that may be perceived as offensive to the patient.

Law enforcement personnel

The focus group for law enforcement personnel consisted of six individuals with different roles in the police force. The participants provided several reflections on what they believe may explain perceived stigmatisation and discrimination among people with SUD:

• Resources: According to the participants, time constraints and lack of resources may lead to negative encounters between the police and people with SUD.
• The police’s mandate: The focus group particularly highlights the police’s mandate to combat crime and maintain law and order. Several have experienced that people with SUD are more involved in crime and disorderly conduct than the general population.
• Communication challenges: Several of the participants experience communication with people in open drug scenes as challenging. The focus group attributes this to a lack of understanding among people with SUD of the police’s mandate and perspectives, as well as to difficulties explaining complex police assessments.

NIM’s assessments and recommendations

This study shows that several of the informants feel stigmatised and discriminated against by healthcare services, law enforcement, and other public services. Informants describe incidents where they have encountered negative attitudes, offensive comments, poor treatment, and rejection by public services because of their SUD. For some, such experiences have had significant negative consequences in various areas of life.

This study is not based on representative samples and documents individuals’ subjective experiences. It is therefore neither possible to generalise the findings nor to conclude whether the described experiences constitute discrimination in a legal sense. Some of the informants’ experiences likely lack important context and have reasonable explanations. Other experiences may more accurately reflect the informants’ actual encounters with public services. The experiences likely stem from both structural, interpersonal and individual factors.

Several findings in this study give reason for concern from a human rights perspective. Although many of the findings describe situations that may not necessarily meet the threshold for human rights violations, the study highlights two human rights challenges that should be addressed:

Need for improved legal protection from discrimination

The findings illustrate that people with SUD in various contexts may have a factual need for legal protection from discrimination. Some of the informants’ experiences do not sufficiently reflect the principle of minimal interference. The authorities should consider how this group’s legal protection from discrimination can be made more effective.

People with SUD have some degree of legal protection from discrimination under international human rights conventions. However, it is unclear how far this protection is implemented in the Norwegian Equality and Anti-Discrimination Act, which seems to require that substance dependence has been caused by or resulted in a disability to be covered. As a result, there is reason to question how effective this legal protection is. It is unclear which groups and situations are covered and how to draw the line between legal and prohibited differential treatment based on this group affiliation. NIM therefore believes there is a need to clarify the legal protection from discrimination for people with SUD. This could, for example, be done by adding “other status” as a protected characteristic in the Equality and Anti-Discrimination Act. There may also be a need to assess whether this group’s protection from discrimination is adequately safeguarded in other legislation, regulations and public sector guidelines in various areas.

Such work will involve challenging delineations and be based on complex dilemmas. However, in NIM’s view, these challenges should not stand in the way of clarifying people with SUD’s need for clearer legal protection from discrimination. Having these legal boundaries defined more closely at the normative level, will also provide valuable clarification for frontline workers.

Need for measures against harmful prejudices and stereotypes

The authorities also have a positive obligation under human rights law to combat underlying stereotypes and prejudices that may lead to discrimination. This study describes examples of offensive comments and actions that the informants have experienced as insulting and stigmatising. In order for people with SUD to have an effective legal protection from discrimination in practice, authorities should implement measures to improve attitudes and raise knowledge about this group in public services. Such measures should be based on people with SUD’s human dignity and right to freedom from discrimination.

This translation has been made using artificial intelligence (AI) and subsequently quality controlled by NIM’s staff.