Drugs, Alcohol and Medicine in Sweden

Abstract

This background chapter sets the scene for the ethnographic study of Swedish women who use drugs (Part II of this book). It reviews historical and contemporary research on, and cultural representations of, drugs, paying specific attention to class and gender. How drugs first came into use in the Western world is examined under the heading Drug Laws and Drug Culture, and from there how they spread and how different substances and preparations came to be regarded from a legal and moral perspective. Why is alcohol not obviously perceived as a drug, and what roles do class and gender play in the laws and moral positions related to intoxication? Drugs and Women focuses on the legal market for controlled medicines and its connection to women. Why do women use more medicines but fewer illicit drugs than men? This is related to how women’s drug use has been constructed historically, and how the effects of different substances can be related to gender and class. In 1968, the Narcotics Penalty Act came into force in Sweden, and from then onwards, certain drugs became more strictly regulated. The fourth section, Sweden’s Drug Problem from the 1960s Onwards, examines how this happened and explains that illness and social deviation have been two influential perspectives on how drug use is viewed, with roots extending far back in history. This is reflected in the remarkable gap between drug policy and drug research in Sweden since the 1980s, during which period repressive policies have been fiercely debated. The last section, Qualitative Research on People who Use Drugs, looks into studies based on fieldwork and interviews with people who use drugs, especially women. The majority of such studies, and drug research in general, focus on men and on socially marginalised people who use drugs. In this book, I argue that such a focus helps to shape the understanding of drugs and drug use in Sweden. When linked to marginalised people only, moral condemnation of drugs and drug use that builds on that research will be directed towards a specific group of people, rather than particular substances and their use.

Nicotine pouches and cigarettes, tea and wine and Absolut vodka. People crave temporary alterations of their starting point, the body’s experience of the present. A quick look around reveals just how widespread such desires are. The modern world offers almost endless opportunities to alter one’s state of mind.

In his book on the history of psychoactive substances in the West, Forces of Habit (2002), historian David T. Courtwright describes how he had a sudden realisation while in an airport:

I found myself wondering why I was surrounded by drugs. Marlboro cartons loomed to my left, Drambuie bottles to my right, Belgian chocolates behind me, Kenyan coffee straight ahead – everywhere I looked, I saw imported psychoactive products. How did these things get here? And why could “here” be anywhere – why did duty free shops all seem to be stocked with the same merchandise? (p. vii)

This quote highlights just how well known and widely available these products are. More than anything, however, it illustrates the everyday nature of psychoactive products—commonplace to the point of invisibility. Courtwright can write “Marlboro” instead of “cigarettes”, safe in the knowledge that the reader will know what he is talking about. Duty-free shops almost exclusively sell psychoactive products, and the goods on offer are the same irrespective of where in the world the airport is located. Courtwright, a drug researcher for decades, conveys a surprising sense of not really having noticed this before. He writes that he has come to understand the trade in psychoactive drugs as one of the defining features of the modern world. Indeed, he goes so far as to call the last 500 years the psychoactive revolution (2002), and points out how people’s ability to use psychoactive stimulants during this time has escalated from a single local preparation to the range available today.

It is thus within a context full of different possibilities for changing the mind that people in the twenty-first century move, which means a constant orientation either towards or away from these possibilities. Saying “no” or “yes” are, above all, everyday decisions that are part of the “obscure flows of habits and attitudes” that ethnologists Orvar Löfgren and Billy Ehn describe as characteristic of what ethnologists find when they take a closer look at people’s everyday lives (2012, p. 15). However, the fact that actions are everyday does not make them less significant, quite the contrary. Such actions both create and challenge social life (ibid., p. 5). Drug use, in Courtwright’s broad sense of including chocolate as well as heroin, is part of a culture of consumption that accentuates differences. Proximity to and distance from psychoactive substances are linked to the creation of identity (cf. Löfgren and Ehn 2001, pp. 64ff.). Attitudes to various psychoactive substances are thus performative acts (Butler 1990), i.e. a subjectivity that comes into being through its expression.

Alcohol consumption in Sweden is a good example of this. For most of her career, well-known etiquette expert Magdalena Ribbing advised Swedes on how to behave, in her characteristically proper way. In an interview, she looks back on her youth and describes how red wine was drunk while sitting on the floor in mahjong clothes during the 1960s (Hellqvist 2008). Criminologist and TV celebrity Leif G. W. Persson regularly speaks out about crime, but has also made a name for himself as a proponent of traditional masculinity. In his Big Macho Book¹ (1990), he describes joining a hunting party; one of the men treated the others to white wine and even added some to the food he was cooking. The entire party consequently assumed that the man was gay, according to Persson (pp. 202f.). Beer, brandy and slightly sweet dark-rye bread with falukorv sausage and butter, on the other hand, are what “real” (heterosexual) men consume, Persson claims, before adding racist remarks to the homophobic, cautioning against drinking rosé Champagne:

Rosé Champagne isn’t a beverage, it is a symbol for slickness. Only shady southerners drink it; upstanding northerners steer clear of it. You know what I mean. (ibid., p. 200)²

These examples show how alcohol (as well as the colours pink, white and red, just like food, clothes, sitting on the floor, etc.) can become tools with which to perform gender, race, age, class, sexuality and other aspects of one’s identity (cf. Measham 2002; Moore and Measham 2013). Such cultural keys also affect the way in which the effect of alcohol—drunkenness—is interpreted.

Most women in the West are expected to drink alcohol nowadays. In spite of this, women are still held to different standards than men when they are intoxicated (cf. Sigfridsson 2005). The examples are many, but one serious consequence of gendered beliefs concerns sexual abuse. Numerous studies have shown that when a man has raped a woman and the case is brought to court, the verdict is often to the detriment of the woman if she happened to be drunk—but in the man’s favour if he had been drinking (Nilsson and Lövkrona 2015; Wiklund and Damberg 2015, pp. 187ff.). A related problem is how women’s visible intoxication is condemned. Freelance journalist Lisbeth Borger-Bendegard writes in her 1975 book Open Letter on Women and Alcohol³:

It is considered ugly for women to drink. […] Male alcoholics at Karolinska Hospital’s group therapy often despise their female peers, even though they are being treated for the same thing. Even girls who drink themselves find it “scarier to see a drunk girl than a drunk guy”. […] There is no equality within alcoholism. (p. 12)

Ethnologist Lisa Wiklund and journalist Jenny Damberg quote an interview with “football wife” Malin Wollin by Malou von Sivers on the latter’s TV show Efter tio: “A mother should be there for her children, in a way. […] There’s just something so pathetic about a drunk woman!” (2015, p. 124). Analysing the cultural framework within which women drink alcohol, Wiklund and Damberg arrive at the following conclusion: “The right to make a fool of oneself when drunk is far from gender equal. A drunk woman is judged much more harshly than a drunk man” (ibid., p. 188). To which they add: “Chipping away at the taboo on women and alcohol is a way of showing that women and men do not have different roles: all human beings should be allowed to engage in every aspect of life” (ibid., p. 191).

In other words, Wiklund and Damberg suggest that it is self-evident that gender equality is best achieved through a freer approach to alcohol and women, making the right to drink a feminist issue. But the same gender balance would be achieved by increased taboos around men’s drinking, which could, for example, have a dampening effect on men’s violence. A report from BRÅ states that, in nine cases out of ten, men are the perpetrators of assault, threats, personal robbery and sexual offences, and that in more than half of these cases, regardless of the type of offence, they have been drunk (Olseryd 2015). However, the link between violence and alcohol or other drugs is strongest in the case of men’s offences against other men. In any case, the relationship between intoxication and feminist strategies aimed at gender equality is not straightforward. On the one hand, women’s freedom and self-esteem are affected by stigma and taboo; on the other hand, alcohol can be linked to health risks and violence.

This book focuses mainly on illegal drugs. But anyone who imagines that there are clear demarcations between illegal and legal drugs, or that illegal drugs have been relegated to a dark, well-defined corner on the fringes of society, may find the following text disturbing. The further the work has progressed, the more the boundaries between different drugs have appeared vague and elusive, based on cultural beliefs rather than chemical composition.

This is not just the case with drugs, however, and should perhaps not come as a surprise to a cultural researcher. Ethnologist Gabriella Nilsson has analysed popular medical texts with a focus on ideas related to healthy and unhealthy food (Nilsson 2011b). She shows how the cultural charge of food, rather than its nutritional content, is crucial to perceptions of its health aspects. Small-scale production compared to mass industrial processes and ideas linked to a safe “past” compared to a risky “present” are key concepts that sort food into good and bad based on what she believes is an underlying critique of modernity. This is a criticism that developed in line with industrialisation and tends to romanticise earlier societies, when the supply was smaller and locally produced, and portrays industrialised and urban life as threatening and hazardous to health (see also Nilsson 2011a; Johannisson 1995). In his thesis The Threat of Pleasure: Establishing Drug Use as a Social Problem 1890–1970⁴ (1993), sociologist Sven-Åke Lindgren argues that drugs, such as pills, were constructed as a target for criticism during the period under study. He argues that drugs, with their connotations of pleasure and immoderation, manifested the artificial in contrast to the natural.

In the popular medicine texts studied by Gabriella Nilsson, modern society is presented in a way that parallels Courtwright’s (2002) impressions at the airport:

Cheap food and drink is available around the clock, wherever we are. Children can consume sweetened drinks and energy-dense food anywhere, anytime and at almost no cost. Society is deregulated and virtually invaded by opportunities for unhealthy consumption. (Nilsson 2011b, p. 208)

Whether the discussion centres on food or drugs, the modern world seems to be a place where the sheer amount of unhealthy goods is overwhelming and threateningly in one’s face. Illegal drugs and the illegal drug market are part of that picture (EMCDDA 2022, p. 4). Under the headline “This Is Where Drugs Are Sold in Town—Right in Front of Your Eyes”, local Stockholm newspaper Mitt i interviews police officers who specialise in narcotics about the prevalence of drugs in the city (Bonnichsen 2017):

In back alleys, in parks and in bars. Here, drugs are openly sold in the centre of town. “They’re everywhere,” says police officer Lennart Karlsson, who specialises in narcotics. […] The drugs being sold and bought include everything from cannabis and prescription pills to harder drugs like heroin. Cocaine is most common out in bars. [n.p.]

According to the quotes, opportunities for unhealthy consumption, including all kinds of drugs, are “everywhere”. But cultural beliefs, and thus everyday decisions, are different in different social contexts. Some people struggle with daily decisions about whether or not to use heroin and, if so, in what quantity. Others struggle with the question of whether to eat chocolate with their afternoon coffee and, if so, how big the piece should be, and still others worry about both of these issues. Anthropologist Richard Wilk writes that the moral regulation of consumption is fundamental to modern consumer cultures: “[…] if there are any universal characteristics underpinning consumer cultures it is the desire for the moral balancing of virtue and excess” (2014, p. 1).

But the fact that the everyday regulation of virtue and pleasure applies to a wide range of substances does not mean that there are no differences between chocolate and heroin. In fact, the differences between the popular confectionery ingredient and one of the world’s most deadly and addictive drugs are vast. They look different, are used in different ways, can be linked to different effects and have different cultural and legal status. But so do the differences between many different illegal drugs, between different types of legal drugs and between the same drugs, i.e. the same active substances, prepared in different ways (Nutt et al. 2010; Olsson 2017, p. 28; Schivelbusch 1993). The ambiguities surrounding drugs and possible approaches to them have often been overwhelming in their scope, and I am not the first author to face this elusiveness. The philosopher, cultural theorist and novelist Sadie Plant, in the introduction to her 1999 book Writing on Drugs, aptly expresses how I have also felt:

To write on drugs is to plunge into a world where nothing is as simple or as stable as it seems. Everything about it shimmers and mutates as you try to hold its gaze. Facts and figures dance around each other; lines of enquiry scatter like expensive dust. The reasons for the laws and the motives for the wars, the nature of the pleasures and the trouble drugs can cause, the tangled web of chemicals, the plants, the brain, machines: ambiguity surrounds them all. (p. 248)

Plant puts her finger on how prior knowledge, research and thinking about drugs repeatedly reach points where they seem to dissolve into too many conflicting fragments to be grasped. Where do we draw the line between frightening and non-frightening? Who determines it and why? What is sick and dangerous and what is human and healthy?

But does the accessibility of a wide range of substances automatically lead to problematic consumption? It would hardly be fair to regard the last 500 years, i.e. the period that Courtwright calls the psychoactive revolution, as a period in which health-related living conditions have deteriorated. Life expectancy has increased dramatically and there are now many more medical aids available for life crises, pain, anxiety and behavioural problems (cf. Johannisson 1990). But problems in the wake of drug use are also very present as both global and local issues.

1 Drug Laws and Drug Culture

What the trade in psychoactive substances looks like depends on which substance is being traded. A number of singled-out substances are subject to narcotics laws—either as controlled prescription medications or as illegal goods. Historians Brian Cowan (2005), Virginia Berridge (2013) and the abovementioned David T. Courtwright (2002) are just some of the researchers who have sought to explore why different substances and products (including opium, alcohol, coffee and tobacco) have attained such different legal and cultural statuses, and why these statuses have changed over time. To answer these questions, they highlight complex webs of international and national trade relationships, political battles, temperance movements and beliefs surrounding sickness and health, and the ways in which these factors have resulted in different regulatory systems. Berridge points out that very few substances have been subject to total prohibition: selling opiates and amphetamines, for example, is not illegal, as long as the substances are produced by registered pharmaceutical companies and prescribed by licensed healthcare providers (2013, p. 7). When I write “illegal drugs”, I am thus referring to drugs that have been illegally acquired—not necessarily drugs that were also illegally produced or for which every link of the sales process was illegal.

Another example of how substances are regulated is through sales restrictions. Alcohol, which from the Middle Ages onwards has continued to be a popular substance among all social classes in Sweden, has been and still is characterised by restrictive regulations. Above all, efforts to curb its use have focused on discouraging women and workers from drinking (Jönsson and Tellström 2018, pp. 154f.; Berridge 2013). Ethnologist Håkan Jönsson and food researcher Richard Tellström describe how extensive drinking among the working class began to be regarded as a social problem in the nineteenth century. It could lead to fines or imprisonment (2018, pp. 116f.). Exactly how large the consumption was is difficult to say because the information available does not seem reasonable, which Jönsson and Tellström believe indicates that the alcoholic strength of different drinks was not the same as today. They take an example from a consumption regulation dated 1770 that specifies suitable travel costs for a traveller in a horse-drawn carriage. A journey of seven miles was considered to require two jugs of spirits per person, which is equivalent to more than five litres per traveller. “The journey could take between one and two days, depending on the nature of the road”, write Jönsson and Tellström, and the researchers conclude that it was probably not 40% brandy, as such a level of consumption could have been fatal. Nevertheless, alcohol consumption seems to have been high.

In Sweden, alcohol consumption is nowadays regulated through Systembolaget—a government-owned chain of off-licences, with branches in all Swedish towns. The very first such store opened its doors in Dalarna in 1850, with the intention of curbing the alcoholism that was inflicting considerable damage on society. The mine owners united and set up a system for the sale of alcohol, perhaps more out of economic interest rather than any genuine concern for their workers’ health.⁵

At the time, the temperance movement was rapidly attracting followers. These initial attempts to regulate the sale of alcohol were followed by others. The Bratt System (in which bars had to observe stringent restrictions and those who were allowed to consume alcohol were given a motbok—a booklet in which a stamp was added each time the owner bought anything at an off-licence) was implemented across the nation in 1919. The measure revealed that gender and class, rather than alcoholic drinks themselves, were believed to be the main driver of alcohol abuse (see Jönsson and Tellström 2018, p. 205; Edman 2019, pp. 15, 27). Women who cohabited with a man—regardless of whether they lived with their parents or husband or were live-in housemaids—were not given their own motbok, because they were then included in the men’s household. Women living alone could get a motbok, but usually only a half ration. While the motbok system made it very difficult to obtain brandy or beer, wine—which was expensive and mainly consumed by the bourgeoisie—could be purchased in almost unlimited quantities. Jönsson and Tellström describe Bratt’s view of working-class intoxication in relation to that of the bourgeoisie, as though sobriety and drunkenness had nothing to do with alcohol per se but were about certain forms of preparation in certain bodies.

Bratt and his allies viewed bourgeois society’s wine-drinking and frequent lavish business dinners in private homes and restaurants as something fundamentally different than the working class’s getting drunk; as a result, it did not need to be curtailed to achieve their goal of a soberer society. (2018, p. 205)

The Bratt system affected the amount of alcohol consumed. Jönsson and Tellström report that, in 1878, before the Bratt system was established, 6.5 litres of spirits per inhabitant were being served in company pubs in Stockholm. By 1915—when the Bratt system had been implemented in some cities—only 0.3 litres were being served, and the decline was almost as great in Gothenburg (ibid., p. 206). Systembolaget has survived until our day, with a majority of the Swedish people on its side, although it has come close to losing its popularity several times.⁶

In other words, the efforts to regulate alcohol have always ended up in its authorised sale to some pleasure-seekers, while drugs, i.e. the myriad of substances that now come under drug legislation, have travelled a different path. Drugs used for pleasure are criminalised, while controlled medicines constitute a large market. Courtwright (2002) and Schivelbusch (1993) argue that it was simply the extent of the use of tobacco, coffee and alcohol that made the sale of these drugs impossible to ban, while opium, cocaine and cannabis were only used by a small number of people, which enabled strict legislation. The word “narcotics” was first used to refer to substances such as opium that could induce anaesthesia, but as the drug conventions were expanded, it came to include psychoactive drugs “with addictive properties or euphoric effects” (SFS 1968:64, §8). However, certain preparations with such properties, such as tobacco and alcoholic beverages, have never been defined as narcotics, even though they fulfil the definitional criteria. The Swedish National Encyclopaedia puts it simply: “Traditionally, however, the addictive substances alcohol, nicotine, caffeine and organic solvents are not considered narcotics” (Nationalencyklopedin, n.d. “Narkotika”).

Opium, which was the main reason for the first international control agreement, the International Opium Convention, signed on 23 January 1912 in The Hague,⁷ is an example of how the meaning of a psychoactive substance can change across time. The first evidence of opium use dates back around 6,000 years, and opium played an important role in Greek, Roman and Arabic medicine (Berridge 2013, p. 9). The drug spread across Europe during the fourteenth century and, in Sweden, opium preparations such as laudanum could be bought over the counter well into the twentieth century, writes economic historian Daniel Berg (2016). Sociologist Börje Olsson writes that opium was mainly discussed in positive terms in Swedish medical journals throughout the nineteenth century (1994, pp. 50–52, 59).

According to Berridge (2013), Courtwright (2002), Shivelbusch (1993) and Berg (2016), what then unfolded and led to international agreements on increasingly powerful regulation was largely based on trade disputes between major powers (primarily Great Britain’s massive and aggressive sale to China of opium grown in colonised India, but also the involvement of the USA) and the economic interests of various actors, the impact of Western temperance movements and professional battles between pharmacists and doctors. The potent opioids morphine and, later, heroin were developed in 1804 and 1899, respectively, and were widely distributed through pharmacies, before the intravenous use of morphine and heroin in particular led to a noticeable addiction problem that became too extensive to be ignored.

However, this was not the case in Sweden, where it was not until the mid-1970s that the use of heroin became a more significant problem (Olsson 2017, p. 29). For a long time, in Sweden, intravenous use of amphetamines was the most problematic drug use, which criminologists Leif Lenke and Börje Olsson argue is remarkable in an international comparison, and it is difficult to find the reason (2002). Around the 1920s, aspirin began to replace opium when the purpose of the medication was to reduce pain. Around the middle of the twentieth century and onwards, opium and alcohol appear in some respects to switch places in the social order in Sweden. Berg describes how, until then, opiate-dependent people were primarily understood as lonely and socially harmless and in need of individual care, rather than as a social problem (2016, pp. 49f.). Historian Jenny Björkman argues that, until the 1960s in Sweden, doctors and bohemians were examples of groups that were assumed to use narcotics:

Drug users, unlike alcoholics, were assumed to come from the middle or upper class and, partly because of this, were not considered threatening or dangerous. They were not perceived as a threat to society because they were not seen as violent or untrustworthy. Quite often they were assumed to be doctors or possibly bohemians moving in the subcultures of the growing metropolises. Rather than dangerous, they were considered to be ill and, unlike alcoholics, drug addicts were consequently offered medical and hospital care. (Björkman 2002, p. 47)

In other words, people who use drugs were not stigmatised, but were seen as sickly representatives of the middle and upper classes. Meanwhile, alcoholics, according to Björkman, represented a loud, immoral and outgoing working class:

Alcoholics were assumed to be working-class men who were usually considered dangerous both to their neighbours and to society in general. They often lacked both work and housing, exploited their surroundings and were often described as wife beaters. They thus posed a threat to a normal and socially acceptable life. Consequently, measures and treatment were aimed both at protecting society and at returning addicts to a sober life. The vagrant and anti-social alcoholics represented everything that society needed to be cleansed of, and for them compulsory care and institutionalisation were considered necessary. Through hard work and fresh air they were to be restored to sober and orderly citizens. (ibid., pp. 44–47)

According to Björkman, the alcoholics were male representatives of the working class. In Björkman’s description of alcoholics, women are only mentioned as the wives who were abused by this socially dangerous group. Drugs were, she writes, “more attractive to women” than alcohol (ibid., p. 44). The article characterises societal perceptions of two almost completely different groups, but was there no overlap between them at all? Sven Åke Lindgren’s thesis describes certain problematic drug use, such as morphine abuse, as more common among women than men (1993). This also applied to sleeping pills and anxiolytics, which were not classified as narcotics at the time. He writes that doctors in the 1950s were concerned about the “mass consumption” of barbiturates, a now-banned anxiolytic, and that this was described as “a new form of alcoholism” (Lindgren 1993, p. 152). While Lindgren neither considers his data from a gender perspective nor draws any conclusions from these particular findings, I would say that these examples suggest that the dividing line between society’s view on alcoholism and other problematic types of drug use, as well as women’s and men’s use of psychoactive products at the time, was not quite as sharp as Björkman’s article represents it to be.

One of the many aspects that can be confusing when discussing drugs or narcotics is that there are two main markets for them, which overlap and in which the substances that are being sold are often the same. Sweden’s Penal Law on Narcotics defines narcotics as “medicines or goods that constitute a health hazard and that have addictive properties or euphoriant effects, or goods that can easily take on such properties or effects” (SFS 1968:64, §8). One of the two markets for such goods consists of the legal pharmaceutical industry, while the other is the illegal drugs market. In the former, controlled substances are sold through pharmacies to people who have been to see a doctor and given a prescription. But legally produced goods can be sold on illegally and thus cross over from one market to the other. The second market is a shadow one that mainly operates through illegal production, smuggling and dealing. One might perceive these two markets as vastly different, because they have radically different cultural meanings. But, in terms of their history, the products they sell and the pharmacological characteristics of those products, they are intricately linked with one another (see also the appendix Drugs and Medicines). A metric such as “drug-related deaths” (DRD), for example, which the Swedish Public Health Agency monitors and compares to similar data for other European countries compiled by the EMCDDA (European Monitoring Centre for Drugs and Drug Addiction), calls to mind illegal drugs. “Drug-related deaths” connotes unregulated products that lead to overdoses in public toilets. One of Sweden’s biggest daily newspapers, Svenska Dagbladet, reported on drug-related deaths in Sweden under the headline “Knark kills record number of Swedes” (Ögren 2019). Even more clearly than the term DRD, this phrase signals that the products in question are illegal.

But Swedish DRD statistics include all lethal cases of drug toxicity, and the majority of the substances listed as having caused those deaths can have been legally produced (Swedish National Board of Health and Welfare 2016, pp. 17ff.; 2022). Victims also often legally acquired the substance they ingested, overdosing on medication they themselves had been prescribed (Swedish National Board of Health and Welfare 2016). In many cases, these overdoses are also intentional: according to the above report, suicide is the number one cause of drug-related deaths among women. “Suicide with the aid of medication” paints a completely different picture of drug-related deaths than the image conjured up by Svenska Dagbladet. The deceased may not have consumed excessive amounts of drugs at all during their lifetime and might have decided on a different way to end their lives if they had not had access to certain medicines.

When there is a spike in sales in the legal market, companies grow and become more successful and shareholders receive a dividend, and when psychoactive products get a foothold somewhere, this usually means they will be around for generations (Courtwright 2002, p. 98). While the illegal market is kept in check by the police, new products still manage to become popularised in this way. But, historically, illegal drugs have often made their way into society and become a set part of everyday life through pharmacies. Even the meaning of a notorious drug like heroin, which for years has been seen as unequivocally illegal and taboo, has changed over time. Just like many other drugs that are illegal today, heroin was originally developed as a medicine by a team of enthusiastic chemists, after which it found its way across the globe, prescribed and sold by doctors and pharmacies. The chemist Jie Jack Li describes how, when heroin (diacetylmorphine) was first produced in Germany, in 1897, it was regarded as a non-addictive substitute for morphine (Li 2006, pp. 162f.). It was in fact believed to be so harmless, he writes, that it was sold over the counter for the first few years, prescription-free. Ironically, aspirin—an invention of the same chemist, Felix Hoffman—was only available on prescription, as it was thought to increase the risk of heart failure. To this day, the controlled drugs that are responsible for the most deaths in Sweden, especially among women, are still largely sold at pharmacies (Swedish National Board of Health and Welfare 2016: 7; 2022). Illegally sold controlled drugs have also become more popular in Sweden; when viewed as a single group, they were the most common kind of illegal drugs in the country in 2017 (CAN 2019, p. 18).

2 Women and Medication

I argue that the meaning of this trend, as well as its future implications, is an understudied aspect of drug use in Sweden, and one that it is important to address, not least from a gender perspective. While more men than women use illegal drugs, women are more likely to use controlled drugs (Swedish National Institute of Public Health 2010, p. 12; Swedish National Board of Health and Welfare 2016; the Board’s statistical database on medication at socialstyrelsen.se). Thus, the use of illegally or legally sold controlled medicines is a type of drug use that affects more women than men. The gender gap is so significant that there is reason to believe, based on these figures alone, that gender identity matters for how drugs are used and vice versa (cf. Measham 2002; Moore and Measham 2013, p. 16). We could interpret these statistics as suggesting, for example, that men mainly use narcotics to get high, while women use them for medical purposes. Why would men and women use the same substances for different purposes?

As described at the beginning of this chapter, intoxication among women, especially working-class women, has historically been frowned upon and stigmatised in ways that are different from attitudes to men’s intoxication (Wiklund and Damberg 2015). Wiklund and Damberg quote a former bartender as saying that, up until the 1980s, women would not go out drinking unless they were accompanied by men, because “they would be told off or made to feel they had to leave” (Wiklund and Damberg 2015, p. 26). Even in the twenty-first century, the authors say, working-class women drinking alcohol is portrayed as a real problem—in spite of low levels of problematic drinking among this section of the population and negligible instances of alcohol-related crime. Of all women, highly educated women are the ones who drink the most (ibid., pp. 74, 136f., 181). Wiklund and Damberg write that this shows that drinking alcohol is something that goes against gender norms in this particular group—but it is something these women are able to get away with due to their capital. Still, of all the women who drink, working-class women are the ones who most noticeably defy societal norms: when drinking, they go against what is expected of them, in terms of both class and gender, and risk losing their respectability (cf. Skeggs 1998). But, while women’s intoxication and night life have been discouraged, medical treatments using psychoactive substances in the home and in hospitals have, conversely, been common and encouraged.

Throughout history, women’s mental states have been medicalised—something to which the historian of ideas Karin Johannisson has dedicated several books.⁸ In The Wounded Diva: On the Aesthetics of the Psyche (and on Agnes von K., Sigrid H and Nelly S),⁹ published in 2015, Johannisson takes her point of departure in the case studies of three well-known female artists to describe how female madness has been constructed throughout the ages, both to preserve repressive ideas on what constitutes “normal” femininity and by the so-called madwomen themselves. The artists Johannisson writes about are the author Agnes von Krusenstjerna (1894–1940), painter Sigrid Maria Hjertén (1885–1948) and the Nobel Prize-winning author Nelly Sachs (1891–1970). All three of these women were diagnosed with psychological ailments and treated accordingly; Sigrid Maria Hjertén died as the result of a lobotomy. Johannisson illustrates how constricting society’s norms around femininity were in the nineteenth and early twentieth centuries: they made self-actualisation impossible for women and contributed to the ease with which women could be considered psychologically ill (or view themselves as such). Women diagnosed as mentally ill during the first half of the twentieth century had their human dignity violated in brutal ways: they could be locked up in mental hospitals, treated with a cocktail of alcohol, psychotherapy, ECT, lobotomy and drugs like morphine and ether. Many more women than men were lobotomised: between 1944 and 1945, for example, 58 of the 65 people who underwent a lobotomy in Sweden were women. Side effects were severe and irreversible, and the surgery often resulted in death (Johannisson 2015, pp. 139f.). Yet some patients enjoyed certain treatments, Johannisson writes:

[The doctors’] experiments seem utterly arbitrary […]. Patients are given large doses of sleeping aids like chloroform, chloral [hydrate], Veronal and Medinal, sedatives like bromide and the heavier opiates morphine and opium. Agnes von K loves them all. […] Chemical experiments were part of daily life at the hospital, including extreme ones like prolonged sleep treatments. Large doses of sedatives (starting with opium or morphine) were intramuscularly injected for seven to fourteen days in a row. A patient could be kept asleep for up to 20 hours a day […] Sometimes, Agnes von K begs to be artificially put to sleep like this. (2015, p. 133)

Agnes von Krusenstjerna’s fondness for these drug treatments illustrates the shifting boundary between the medical use of controlled drugs and their use for pleasure’s sake (cf. Race 2009). Johannisson writes that the entire pathology—including hysteria, a typically “female” diagnosis at the start of the twentieth century—was partially an aesthetic construct that reflected the Zeitgeist. But it did not only oppress women: some of them also used it to their advantage. Acting out one’s diagnoses, Johannisson argues, can be interpreted as a “language of liberation” (Johannisson 2015, p. 16), but only under certain class-related circumstances. According to Johannisson, the symptoms of hysteria were in line with a certain aesthetic of nervosity and decadence promoted by the literature, photography, expressionist art and films of the time. Jerky movements, trembling and twisting bodies, autistic introspection and catatonic rigidity were all visual expressions of hysteria and madness (ibid., pp. 78f.). But while the misogynous pathologising was of course repressive, Johannisson points out that women’s symptoms and their demands for drugs and treatment made them more difficult to deal with, not meeker.

Sociologist Beverley Skeggs shows how the pathologising of the working class has been key to the creation of the middle class (2004, pp. 4ff.), while Johannisson posits that women of all social classes have been forcibly pathologised, albeit with major differences in the ways in which this occurred and the grounds given for it. “Gender, class, convention and culture determine when a condition tips over into sickness, or when it can be tolerated as a personality trait, a quirk or a creative resource” (Johannisson 2015, p. 58).

Embracing one’s diagnoses and exploiting them in creative ways, as Agnes von Krusenstjerna did, may be a privilege of certain classes only. But the intoxicating potential of drugs is accessible to anyone. How did women without any interest in or access to decadent aesthetics express their experiences of controlled drugs? Was there a similar language of liberation spoken by working-class women? One kind of medication that is often described in pejorative terms when it is used by women is sedatives in pill form. Miltown was the first benzodiazepine to be put on the market, in 1955. In the USA, it came to be associated with women, and housewives in particular—as the Rolling Stones’ song “Mother’s Little Helper” from 1966 exemplifies. The lyrics comment on the assumed lack of any underlying disease:

Verse

Verse Mother needs something today to calm her down And though she’s not really ill, there’s a little yellow pill She goes running for the shelter of her mother’s little helper And it helps her on her way, gets her through her busy day

Why did women take pills like Miltown if they were not really ill? Or, if they were, what was this illness they had? Social psychology researcher Jonathan Metzl (2003) does not find it difficult to understand why women have been culturally associated with benzodiazepines: advertisements for these drugs targeted women in particular, and many more women than men were prescribed Miltown, which was said to cure frigidity, anxiety and mood swings, among other issues. But the medicine’s popularity had little to do with female neurology, Metzl argues: it was based on the unreasonable ideal of the perfect housewife, which was all about men’s satisfaction. Women were not just expected to perform the right kind of femininity at home; there was also significant opposition to their participation in the workforce. Metzl suggests that Miltown entailed a shift from problematic gender analyses based on psychoanalysis that did not make women more compliant in any demonstrable way, to a medicalisation that targeted a neurological function that does not differ between men and women. This, he writes, reveals that social constructs were the problem all along (2003, pp. 261f.).

The situation seems to have been somewhat different in Sweden. In her thesis The Problem That Had No Name: Neurosis, Stress and Gender in Sweden 1950–1980,¹⁰ Maria Björk (2011) describes the ideal 1950s housewife as the ultimate “Woman”, a natural being who represented intimacy and purity and kept the family together. But these housewives were not associated with mental illness (ibid., p. 116) because a Woman with a capital W was the antithesis of the modern world. Fulfilling their role as the anchor of the family shielded women from industrialism and the stress and hectic pace of urban life, and therefore from the main causes of psychiatric disorders. Women who not only ran a household but also had a paid position had a worse lot: Björk describes how they were trapped in an overworked Catch-22. Both jobs had to be accomplished, and both were seen as the lot of women, so women became burnt out and fell ill as a result (ibid., p. 101).

At the same time, Sven-Åke Lindgren writes (1993, p. 152), daily newspapers and trade journals fiercely debated Swedes’ popping of pills, including barbiturates, sleeping aids and benzodiazepines (e.g. Miltown). Benzodiazepines were dubbed “penicillin for the soul”, Lindgren writes, and sold as a cure-all for, among other ailments, insomnia, PMS, muscle cramps, headaches, behaviour problems in children and psychosis (ibid.). As for barbiturates, Lindgren states that, of those addicted to them and treated at Karolinska University Hospital’s psychiatric clinic in Stockholm between 1941 and 1950, 60 were men and 120 were women.

Eventually, however, outrage over pill-popping was overshadowed by politicians decrying young people’s use of amphetamines, which then became the most pressing issue of the day (ibid., p. 156; see also Olsson 1994, p. 179). Lindgren describes this evolution as a juxtaposition between a desire for pleasure and the fulfilment of duties, whereby chasing pleasure was seen as entailing an infinitely greater risk to society than pill-poppers’ longing to soothe, sedate, anaesthetise and desensitise themselves (1993, pp. 199f.). Ever since, women have continued to consume psychoactive medicines, including controlled drugs, in larger quantities than men. In 2022, roughly 15% of women in Sweden used antidepressants, compared to 8% of men; 10% of women used sedatives and anti-anxiety medication, compared to 6% of men; and 7% of women used prescribed opioids, compared to 5% of men, according to the Swedish National Board of Health and Welfare’s statistics.¹¹

Both sociologist Nikolas Rose (2019, pp. 42, 45f.) and writer Lisa Appignanesi (2008, pp. 513ff.) caution against carelessly interpreting gendered differences in depression, anxiety and medication statistics without taking social conditions into account. These diagnoses are overrepresented among groups that are economically and socially vulnerable and, as Appignanesi points out, there are other factors that may underpin women’s closer relationship to the healthcare sector. Seeing a doctor becomes routine for many women when they are in their teens and start using oral contraceptive pills or medication to relieve PMS; later in life, they might give birth in hospital. Medicine and public health researcher Therese Kardakis’ study from 2008, “Does Gender Play a Role in the Prescription of Medication?”,¹² shows that doctors are more likely to prescribe medication to women than to men with similar ailments. Kardakis argues that there is reason to believe that such discrepancies stem from a stereotypical idea that women are sicklier and more sensitive to pain, while men are tougher. Sociologist Elizabeth Ettorre is critical of doctors prescribing sedatives to women. A feminist perspective, she argues, should take into account that such medication makes patients passive and dependent:

While these drugs might help her to “stop making a fuss” […] she is levelled out, unable to fight back and separated off from any positive form of resistance. Rather than being empowered she is “depowered”. (1992, p. 70)

Ingrid Lander problematises how women’s liberation is sometimes said to entail a risk that women’s consumption of drugs will start to resemble men’s (2003, pp. 78ff.). She argues that such a line of thought is based on a view of men as the norm (see also Measham 2002), and also cites the feminist objection that women’s drug use has historically gone hand in hand with them being prescribed legal medication to help them put up with life (see also Malloch 1999, p. 353; Laanemets 2002, pp. 251ff.). This suggests that women would no longer have to use drugs if gender roles were erased—although that is based on the assumption that the motive to use them is to experience the pleasure of being numb, not pleasure as an enriching experience in a situated context. Could one kind of pleasure turn into another, and vice versa? Why, for instance, do highly educated women drink more alcohol than other women? Women’s widely divergent motives for drug use appear to include both numbing and pleasure, as well as additional motives that cannot conclusively be linked to either of these—such as exploring one’s self, establishing an identity or rebelling (Hilte 2019).

Criminologist Fiona Hutton (2006) and cultural studies researcher Maria Pini (2001) are two of the scholars who have shown that different drugs can play different roles in women’s lives. In their ethnographic studies, they argue that the women they interviewed tended to avoid traditional spaces for alcohol consumption, because they felt that the men in these spaces acted boorishly, in line with typical gender roles. Drunkenness, the women claims, made both their own and men’s behaviour more difficult to handle. Instead, the interviewees socialised in spaces where drugs like ecstasy are consumed, as this creates a different kind of environment. Still, Hutton writes, other social codes—like hugs and touching being seen as part of the experience, and the assumption that someone who is high on ecstasy will want to have sex—meant that these environments were not free from unwanted advances either (2006, pp. 44, 79ff.).

2.1 Women’s Physical Morality

How does health relate to illness (an experienced lack of wellness) and disease (a diagnosed condition)? In the relationship between these two terms, illegal drug use occupies a paradoxical position. Legal use as a consequence of disease becomes illegal if a patient exceeds the prescribed consumption of their medication or offers that medication to someone else. Such illegal use can also be described as abuse and linked to sickness. When precisely illegal drug use is considered abuse varies from country to country, but in Sweden any use of non-prescribed drugs is defined as abuse, regardless of the user’s intention or the amount they take (Olsson 1994). A person who follows their doctor’s advice, on the other hand, taking their medication correctly and consistently, does so in order to cure illness (or at least get better). This implies that someone could just as well acquire and ingest the same product or substance illegally, with the aim of improving their health.

Many controlled substances, regardless of whether they come into someone’s possession legally or illegally, are used to improve one’s health and enhance one’s performance (Iversen 2012; Lanni et al. 2008). Sleep, alertness, appetite, mental acuity, endurance and mood are all examples of abilities that drugs can affect in one way or another. Several substances, including amphetamines, have effects that make it easier to lose weight, for example, and achieve, as the ethnologist Fredrik Nilsson describes it, a “moral body” that, through its particular shape, embodies the bourgeois ideal of taking responsibility for one’s health through exercise and diet (2011a, p. 13). Ever since the 1950s, when the first amphetamine-based diet pills came onto the market, the promise of slimness has tempted many, especially women, into the use of amphetamines (Olsson 1994, p. 74). Rigorous body ideals have remained inescapable and have led to class-based investments in the self to increase one’s value (Skeggs 2004, p. 146). In this sense, efforts to create a valuable and moral body can, paradoxically, come to encompass drug use.

In her autobiographical novel, The Rock Blaster’s Daughter Who Exploded (2007),¹³ actor, playwright and author Lo Kauppi portrays her childhood and adolescence in Stockholm and London, including her use of amphetamines. Growing up, Kauppi’s life is overshadowed by her father’s alcoholism. She later travels to England as a teenager, where she lives in squats and struggles with her weight, with her relationships to drugs and to other people, and to make a living. It is a fast-paced book about an existence on the margins and the struggle for personal value and meaning. Stories of theft, burglary, drug use, life-threatening physical conditions and drug smuggling are interspersed with descriptions of vulnerability, love, friendship, persistent hairdressing training and work. In this way, the novel can be said to represent a language of working-class liberation that is also expressed in images through a punk aesthetic and lifestyle, but it is an ambivalent language. She felt that amphetamines were necessary to keep her body thin enough, and lack of these drugs led to desperation, with a focus on body shape.

When I went without amphetamines for a few days, it was like my entire body shut down. I became very bloated, tended to get cold sores, my asthma got worse and I’d be hungry all the time, except when I was binge-eating. My clothes felt all wrong. They would roll up like sausages. I wanted to slap myself and I was so incredibly tired, as though I were a hundred years old. (ibid., p. 172)

The thin body, whose ideal is based on exemplary health habits, is thus represented in Kauppi’s case by someone who takes other, often dangerous, paths towards the moral body, which thus loses its connection to health. This thin body simultaneously revolts against certain societal norms and risks its life to follow others. At the same time, the above quote shows how the experience of stopping drug use seems to make her sick.

Women’s use of drugs has thus, to a greater extent than men’s, been characterised by conflicts between adaptation and survival. Amphetamines, tranquillisers, morphine, etc., are examples of drugs that can be used strategically to comply with or break norms. The properties of drugs to make one sick or healthy, adapted or unadapted, moral or immoral—without being entirely predictable—complicate them and contribute to the difficulties of managing them, both personally and culturally. In the following section, I outline how drugs have come to be viewed since the middle of the twentieth century, and how this has changed the lives of those who use them.

3 Sweden’s Drug Problem from the 1960s Onwards

Although opium could be used in Sweden without anyone raising an eyebrow until at least 1923 (Berg 2016), the reputation of drug use changed over the following decades. In the USA, in June 1971, Richard Nixon declared drug abuse “public enemy number one” (see, e.g., Nelson 2021), and this also marks a time of change in Sweden. Historian Johan Edman and sociologist Börje Olsson (2014) write that, since the “drug problem”, i.e. problems identified as the consequences of amphetamine and morphine use in particular, was seen as an individual medical problem in Sweden until the mid-1960s, the solutions until then were based entirely on healthcare in the form of detoxification and treatment (cf. Björkman 2002). According to Edman and Olsson, however, the problem was reformulated at that time as a public and social issue, partly because amphetamines began to be used by criminals and young people (Edman and Olsson 2014, p. 509). Moral condemnation of criminals was, they argue, transferred during that movement to people who use drugs in general (ibid., p. 523).

The sociologist Dolf Tops shows how the Swedish Narcotics Care Committee of 1965–1968, whose members were primarily professionals in medical disciplines, described contemporary drug use as an epidemic, which Tops believes was a concept that had a major impact on Swedish drug policy (2001, p. 23). Psychiatrist Nils Bejerot, who inspired the police’s work towards zero tolerance and control of people who use drugs (Johnson 2021; Lenke and Olsson 2002), made extensive use of epidemiological models. In his book The drug issue and society¹⁴ (1969), he describes drug addiction as an infectious disease: “No debutant learns the advanced intravenous injection technique without another addict introducing him [sic] to it; it is thus a question of ‘contact contagion’ in a new sense” (Bejerot 1969, p. 111). Bejerot formulates a five-point action plan based on the need to eliminate drugs “as far as possible”, to block the routes of transmission and to implement preventive measures “for the susceptible and at-risk but not yet infected population groups” (ibid., pp. 456–458). Those already affected were to receive treatment and “the highly infectious” were to be subjected to compulsory care and isolation (ibid.).

During this period, drug use quickly became more strictly regulated and also more highly stigmatised (Träskman 1981). In 1968, the Narcotics Penalty Act (SFS 1968:64) was adopted, which criminalised people who sold drugs rather than those using them. The maximum penalty was four years’ imprisonment, but in the following year this was increased to six years and in 1970–1972 the penalty was increased further (Tham 2003). I perceive the concepts of epidemic and contagion as central both to how the criminal laws were regarded as reasonable responses to a threat to society, and to how the drug addict was symbolically stigmatised as the embodiment of this threat.

Rebecka Lennartsson describes the function of a stigma as indicating the limits of what is normal, acceptable and desirable in a society. The relationship of stigma to the law and society functions, she argues, as a way to neutralise accepted threats:

A stigma must simply have a framework of understanding based on accepted norms, truths and laws. Stigma is used to marginalize, “defuse”, distinguish and often physically separate and brand individuals and groups that are perceived as different and often threatening or dangerous. (Lennartsson 2019, pp. 35f.)

Sociologist Imogen Tyler writes that stigma is “a form of power that is written on the body” (2021, p. 9). She argues that Ervin Goffman's classic research on stigma (Goffman 1963) overlooked stigma's political role as a tool for repression (Tyler 2021, pp. 95ff.). Tyler describes stigma as a machinery that is necessary for an unjust society to be kept in place, and it fortifies social hierarchies and aids the flow of wealth upwards. Power relying on stigma is thus embedded in political economies; it distributes material resources and transforms cultural values (ibid., p. 26). Following Tyler norms, truths and laws are then not simply a cultural web that happens to produce stigma, but they have a direction, and they are a tool for statecraft intended to induce shame (see also Addison 2023).

Being subject to stigma has major consequences for the stigmatised person. Lennartsson describes “[…] reduced life chances, a judgmental attitude from society, an invalidation of experiences, opinions and competencies, and a treatment as if you were a carrier of something infectious” (2019, p. 36).

In the case of drug addicts, notions such as contagion and epidemic thus constitute both the social threat of which they themselves are victims and also what makes them threatening to society. This in turn places them in stigmatised and vulnerable social positions. Being categorised as contagious thus functions performatively, regardless of whether drug use is contagious or not. This assumed infectiousness leads to treatment as though infectiousness actually exists, reduced life chances, etc., through cultural notions as well as the institutionalised exercising of power (cf. Skeggs 2004, p. 45).

Talk of the uncontrolled spread and risk of infection signalled by the concept of an epidemic creates concern (Chitwood et al. 2009) and constitutes instructions on how people should orient themselves. If infection is spreading through society, ordinary people should keep their distance and professionals must approach those infected. Thus, there is an inherent message about the health-motivated exclusion of people who use drugs from society’s everyday social life and, at the same time, the need for social intervention. The concepts of contagion and epidemic are taken from the medical field and have continued to be used for certain drug events, such as the current “opioid epidemic” in the USA (see New York Times¹⁵; Centers for Disease Control and Prevention 2022), which has led to a huge increase in overdose deaths in the 2000s. The historian of science Nancy D. Campbell (2000, p. 194) argues that women are interpreted as infectious in drug contexts to a greater extent than men, not least due to the risk of “infecting” children through reproduction (Campbell and Ettorre 2011, pp. 157ff.). Being perceived as a female drug addict is in turn a deviation that is linked to the ever-present threat of attracting the whore stigma for women, which is not based on the sex trade but on norm deviation (Ettorre 1992, p. 78; Du Rose 2015).

Thus, in the case of women, this underlying millennial stigma is combined with drug stigma, creating specific, gendered conditions for women who use drugs (Lander 2003, p. 86; Malloch 1999, p. 352; Ettorre 2007; Moore and Measham 2013). The relationship between gender and drugs is in turn further complicated by other socio-cultural structures, such as class and race (Addison 2023).¹⁶ All four of these categories are particularly important in relation to conceptions of people who use drugs (Moore and Measham 2013; Campbell and Ettorre 2011). In this book, the focus is on the relationship between gender, class and drugs, but this does not mean that other power perspectives are irrelevant, quite the contrary. Relationships to other categorisations are crucial to what gender, class and drug use mean. That the women who are interviewed in this book are white, for example, affects how they are stigmatised and their resources to avoid stigmatisation in profound ways (cf. Addison 2023). In the same way as we can know something about class (Skeggs 2004, p. 27), knowledge about gender and race as well as drugs is produced through overlapping knowledge systems that are linked to moral systems, and that first and foremost says something about the perspective through which the knowledge is produced. In other words, in the case of people who use drugs, they came to function in the same way as whores have functioned for a long time: as representations of a lack of respectability, morality and decency (cf. ibid., p. 39). That is, the perspective is about establishing a civilised middle class, defined by its difference from the working class, as well as from drug addicts and whores, more specifically (cf. ibid., p. 118).

During the 1980s, anti-drug campaigns intensified in Sweden and criminologist Henrik Tham write that both the drug debate and official guidelines took a “hard line” (Tham 1995). This concept is also used by criminal justice researcher Per Ole Träskman: “The characteristic of Swedish drug control can be said to be that a ‘hard’ line has been chosen at all levels” (2003, p. 19). This hard line is thus about punishability; for example, the fact is that in Sweden it is punishable to be under the influence of drugs. Imprisonment has been included in the penalty scale since 1993 and is a prerequisite for the police to be granted extended powers to stop suspects and check their bodily fluids. This is a law that has attracted a lot of criticism (Gynnå Oguz 2017; Träskman 2003; BRÅ 2000), among other things due to the proportion of positive results in relation to the violation of integrity that a check entails. For example, only half of the young people aged 15–17 who are checked are found to be under the influence of drugs (BRÅ 2018).¹⁷

The social work researcher Philip Lalander also highlights the impact of the law on socially marginalised groups of people who use drugs. He believes that the fines imposed on them are counterproductive from a societal perspective, as they are often accumulated in the form of debts that will later constitute a major problem for those trying to become drug-free (2016, p. 110). The laws and their relationship to stigma and vulnerability are a constant topic of debate and, during the time when my study was being conducted, which began in the autumn of 2015, debate articles and editorials were being published in the daily press presenting arguments for a “softer” approach, which often means taking the view that people who use drugs should receive care rather than punishment.¹⁸ This is a debate that has recurred throughout history (see, e.g., Berridge 2013): Are drug addicts (and alcoholics) sick, or are they legitimate cases for the legal system? A follow-up question that may be worth asking is whether the perspective of drug use as a disease is an argument against the view of drug use as an epidemic and hence contagious or whether, on the contrary, it is a prerequisite. This follow-up question reveals several problematic and contradictory relationships involving both cultural and medical relationships between drug use (including narcotic drugs), disease, crime and stigma. However, it does not have any definite answers. Is it more or less stigmatising to be perceived as a sick drug user than a criminal? (cf. Ettorre 2015). Is it more dangerous, i.e. more “contagious”, for the rest of society to include people who are sick or socially deviant? If the person who uses drugs is ill, when and why did they fall ill and what treatment is preferable? In Sweden, during the twenty-first century, the regulatory framework has slowly shifted towards a more and more caring and harm-reducing approach but, in practice, people who use drugs all over the world are managed through various combinations of care and punishment. It is a somewhat contradictory approach, about which Nancy D. Campbell and sociologist Elisabeth Ettorre comment:

drug users are morally reprimanded and culturally disciplined for having a “disease of addiction” that is somehow embedded in their brains and bodies. (Campbell and Ettorre 2011, p. 14) [cf. Lalander 2016; p. 110; Edman 2019]

Campbell and Ettorre’s argument, which strongly criticises the disease perspective and the medicalisation of drug use, but at the same time presents a feminist and anti-repressive approach to people who use drugs, complicates the opposition between disease and reprehensible social deviation. Instead, they call for research—especially regarding women’s drug use—that is based on feminist theory and a power-critical focus on social differences. They argue that both drug research and drug policy measures are characterised by epistemological ignorance about the needs of people who use drugs, and that drug research must develop beyond the achievements of neurochemical research, which focuses on the brain’s anatomy and chemical reactions. Instead, they need to see drug use in its context in order to move forward.

[There is a] pressing need for new knowledge about social relations in post-disciplinary societies stratified by race, class, gender, and other modes of difference, but also stratified, increasingly, by health status and categorization within multiple biomedical diagnoses and classificatory systems. (2011, p. 6)

Campbell and Ettorre’s perspective is thus critical of both drug research and policy. But they also see future research as (partly) responsible for renewing and improving the conditions for people who use drugs, especially women. In Sweden, however, a large amount of research has been carried out that has not had any major political impact, which suggests that research alone cannot change the conditions for people who use drugs. Leif Lenke and Börje Olsson describe the relationship between research and politics in Sweden as hampered by an ideologically influenced political climate that has emerged in part due to the broad popular support of the temperance movements. This climate, they argue, has not allowed for the discussion of research results.

Researchers and other drug policy experts were in many ways placed in intellectual quarantine where they remain to this day. […] The political parties either try to avoid the topic – the left-wing parties – or take the opportunity to gain votes – the Conservatives – by sharpening their law-and-order profile. Thus, the incentives for experts to try to introduce relevant facts into the debate are rather limited. One consequence is that public awareness slowly withers away, and anything can be presented as a fact in the debate without the risk of scrutiny. (Lenke and Olsson 2002, p. 75; see also Edman 2019, p. 38)

These researchers thus believe that drug debates in Sweden are characterised by a lack of knowledge, not only in politics but also among the public, due to an unwillingness to change views. This is a situation that has been investigated by several researchers, mainly in the fields of criminology, medicine, law, sociology and social work. This research is often highly critical of Swedish drug policy and argues for life-saving interventions and access to care (e.g. Johnson 2005; Heilig 2004, 2015, 2017; Olsson 2017; Kakko 2011, 2017) and that repressive measures have not resulted in reduced use (Tham 1995, 2003; cf. Träskman 1981, 2003). Another direction is analyses of how drug policy has been designed and is represented (e.g. Månsson 2017; Månsson and Ekendahl 2015; Edman and Olsson 2014) and the frameworks within which various social institutions operate as a result of how policy is designed (e.g. Tops 2001; Mattsson 2005; Petersson 2013; Nordgren 2017).

Researcher in social work Bengt Svensson writes in his book Drugs Policy and Debate (2012¹⁹; see also Svensson and Svensson Drugs Policy 2022²⁰), the purpose of which is to provide a neutral account of Swedish drug policy, that most of the research conducted in Sweden is based on an anti-prohibitionist perspective, at the same time as this runs counter to Sweden’s prohibitionist political stance, and that this can create problems for drug researchers’ career opportunities (2012, pp. 85ff.). However, I do not perceive that the terms anti-prohibitionism and prohibitionism reflect what the two approaches stand for or the reason why they clash. Prohibitionism is about prohibition, but the question of whether drugs should be regulated by law is a different discussion from the one about how people who use drugs should be treated, whether care or other treatment should be offered and, if so, under what conditions. Instead, the point where drug research and drug policy collide seems to be about whether people can live valuable lives while using drugs, or whether drug use must cease in order for life to be considered valuable. This leads to questions about whether or not a person who uses drugs should be entitled to life-saving interventions, and, if so, under what conditions.

The combination of people and drugs is valued in my study in the same way as people who have not taken drugs. From an ethnological point of view, I have investigated people’s everyday lives in a world where different forms of psychoactive substances are already part of everyone’s bodily and psychological life and cultural lived realities (cf. Race 2009). The same substances, such as opioids, affect people in different contexts, and from my perspective, the human being themself cannot be valued differently depending on whether a substance was purchased illegally or not. I do not see how such a position could be defended.

4 Qualitative Research on People Who Use Drugs

Research on drug policy and its implementation and representation in Sweden serves as a starting point in this book for understanding how social institutions—such as the legal system, social authorities, healthcare and academia—relate to drugs, drug use and people who use drugs. But what do the people who use drugs themselves have to say in previous Swedish research? Swedish ethnographies on drug use are, with few exceptions, focused on problematic use. One such exception is the recent dissertation In Her Words: Women’s Accounts of Managing Drug-Related Risk, Pleasure, and Stigma in Sweden by sociologist Oriana Quaglietta (2022), in which she seeks to counter both the marginalisation of women in drugs research and the marginalisation of pleasure and meaning in how drug use is understood and conceptualised. In order to achieve this aim, she has interviewed women who use drugs as well as dealers, with varied backgrounds and with various views on their current or previous drug use.

This focus on a deeper and more nuanced understanding of drug use, acknowledging its societal spread, is in line with my own dissertation: “It would never have happened otherwise”: On women, class and drugs²¹ (Eleonorasdotter 2021), on which this book is based. But while previous researchers have mainly avoided the topic of socially integrated middle-class consumption, class and gender have been addressed by several authors. Philip Lalander’s ethnographies of heroin use and street culture (2001, 2009, 2016) are one set of examples. His aim is to understand life from the point of view of marginalised people who use drugs, and hence to understand drug policy implementation, as well as the motives and effects of drug use from within. This provides a picture of how the repressive drug policies, which are disputed by researchers in the previous section, are lived as stigmatised and constrained lives.

An example of a feminist, ethnographic study is the aforementioned criminologist Ingrid Lander’s thesis The Flying Mara²²: A Study of Eight Drug-Using Women in Stockholm²³ (2003). By taking a social constructivist perspective, the aim is to study how the eight women relate to constructions of them as “abusing women” (ibid., pp. 4f.) and how the conditions under which they live affect them. In other words, there is a critique built into the purpose, which concerns constructions of the interviewees as less worthy. They all have experience as clients of the social services, the prison service and/or the drug addiction service. Based on Simone de Beauvoir’s thesis that one is not born a woman but becomes one (de Beauvoir 1993/1949), Lander shows how these women internalise the social institutions’ conceptions of them as drug-abusing women, which places the responsibility for the stigmatised social deviation on themselves (see, e.g., Lander 2003, p. 255; cf. Du Rose 2015). But Lander also shows how the women learn to “play their cards” (ibid., p. 267) according to the authorities’ rules of the game, and in various ways to live their lives within the framework of constant control (cf. Johannisson 2015). The thesis thus provides a picture of how the exercise of authority towards these women is fundamentally interwoven into their lives and constitutes the prerequisite for how the construction of social deviance takes shape, both when the women follow the guidelines and when they try to escape punishment or gain something by deviating.

Leili Laanemets’ dissertation, The Creation of Femininity: About Women in Substance Abuse Treatment²⁴ (2002), is a sociological study of women in treatment, which has a descriptive and visualising purpose (ibid., p. 15). This study also approaches marginalised women for whom drug use is part of their difficult life situations. Laanemets interviews both practitioners and clients and, just as Tina Mattsson in her study In the Desire to Make Normal: A Critical Study of the Gender Perspective in Substance Abuse Treatment²⁵ (2005), takes a critical look at how the women are constructed within the care institutions and, like Lander, reflects on how these women become a specific type of woman, drug abusers, in the treatment contexts. Laanemets includes “drugs” in her study, as meaningful and complex objects that can involve both positive and negative opportunities and consequences for the women (Laanemets 2002, pp. 250ff.). This provides opportunities for effectively dissolving the category of drug-abusing women by demonstrating personal intentions and choices. She writes, for example:

Several spoke about the fact that the reason they started using drugs was curiosity. They wanted something else and were looking for something new. (ibid., p. 191)

According to Laanemets, one interviewee, Anja, did not want to be a “perfect housewife” like her mother, but instead wanted to smoke hashish with the boys at the recreation centre.

She described her early years as one big party and, like some of the other interviewees, said that she had lived “the happy days of life” with the help of alcohol, hashish and amphetamines. The intoxication was liberating and intense (ibid.).

Curiosity and resistance to limited women’s roles give “the abusing woman”, to use Lander’s term, a power of action that was not initially destructive, but self-affirming. However, all the interviews in the study were conducted in institutions, including one compulsory care institution, where the women were housed due to their serious problems with drugs. The study thus provides a picture of the reverse potential of drugs, as limiting and harmful, as well as of the powerful control measures that can be deployed against a woman who has channelled her curiosity and desire towards violating norms in this way.

Ethnologist Anette Rosengren has studied drug-using women in relation to homelessness in her book Between Anger and Hope: On Homelessness, Drugs and Women²⁶ (2003). This is another example of ethnographic studies on women who use drugs with the purpose of analysing power. Rosengren states that she followed more than 60 women in Stockholm, mainly aged 40–60 years. Above all, the material was collected in shelters and on the streets. She writes that she wanted to seek knowledge about these women’s everyday lives, beyond statistics and stereotypes, and thus contributes in a similar way to Lander and Mattsson, and to some extent Laanemets, to the fieldwork-based research that reveals the gap between research and policy. In this study, Rosengren alternates the women’s statements with socially critical analyses, and drug use often appears as a reasonable action in vulnerable life contexts. For example, she writes about women’s anger and resistance to social service interventions:

The rhetoric surrounding drug use, which both the women and the staff [social services] use, includes saying that it was the craving for drugs or alcohol that took over. I myself see it as an understandable consequence of demands and violations. (2003, p. 82)

Rosengren thus complicates the relationship between vulnerability and drug use and also describes how drugs sometimes facilitate life as a homeless person. If drug use can be an “understandable consequence” of the actions of the authorities, then some of the responsibility for drug use is shifted from the person who uses drugs to the representatives of the state. If drugs can also be helpful in coping with underprivileged living conditions, they become a tool with constructive potential. Such a view differs from, for example, Trulsson’s study “It’s My Child Anyway!” A Study on Being a Drug Abuser and a Mother Separated from Her Children²⁷ (1997), about women who use drugs and whose children have been taken into care by the authorities. Trulsson describes the perception that substance abuse is the reason why the women’s children have been taken into care and drug use is described as “freezing” their emotional lives (ibid., p. 98). If substance abuse is the cause of the children being taken into care, even though the substance abuse is described as having been the result of social difficulties, then the state’s responsibility for the resulting trauma is concealed.

Unlike Tina Mattsson, who argues that the drug abuse is relegated to the background in Trulsson’s study (2005, p. 41), I see it as foregrounded. The women’s reasons for resorting to drugs in their psychologically, socially and materially vulnerable situations appear to be anything but strange; rather, they are often rational survival strategies, an “understandable consequence” of the women’s circumstances. Trulsson signals astonishment when she describes her realisation that abusing women also care for their children (1997, p. 1). I take this to be based on a notion of “abusing women” as fundamentally different from other women, even though Trulsson questions certain aspects of these women’s deviance and finds explanations for it. I therefore interpret it as a contrarian study in relation to that of Ingrid Landers. The latter deconstructs how women are made into “abusing women”, while Trulsson “makes” the abusing woman.

Both Rosengren and Trulsson highlight the deficiencies of social institutions and the needs of women from their respective perspectives, but in Rosengren’s study, drug use becomes an often understandable and sometimes constructive act. In Trulsson’s study, on the other hand, drug use comes into focus as a problem. In this case, the removal of the women’s children appears reasonable, even though most of these already vulnerable women are described as going into crisis as a result of the loss (see, e.g., Du Rose 2015, 2017). But is it reasonable? Is there really no other conceivable solution than to expose mothers who use drugs to what many would consider to be the worst thing imaginable?

Research on the authorities’ actions in relation to the children of women who use drugs matters in this study because one of the interviewees has lost her children, and another is worried that this will happen. The historian Nancy D. Campbell and the sociologist Elizabeth Ettorre address the emotional impact it has on women, when their children are taken into care by the authorities, or when they are at risk of this happening, and describe the contexts of mothers who use drugs as characterised by grief (e.g. 2011; see also Du Rose 2017; Boyd 2004). Ettorre uses the term abuse to describe the type of intervention that child removal constitutes (2017, p. 368). She writes herself into the research in her article “Feminist Autoethnography, Gender, and Drug Use: ‘Feeling About’ Empathy While ‘Storying the I’” (2017), in which she draws parallels between the societal deviance of women who use drugs and her own deviance as a queer female drug researcher. In a field-journal entry after a harrowing encounter with women who had lost or were at risk of losing their children, she writes:

I am a privileged White woman, an academic researcher. I may feel I work in a bullying, sexist, male dominated environment, but I’m deeply aware that I don’t have the same hurdles that these women must overcome. It feels as if the whole patriarchal, treatment system is against them. (2017, p. 365)

The restrained rage, focusing on power structures, that characterises both Ettorre’s and Campbell’s work is similar to that of Rosengren and criminologist Natacha Du Rose. In Du Rose’s book on women’s experiences of drug policy (2015), she describes this policy as contradictory, punitive and pathologising, and as a hopeless starting point, based as it is on a view of women who use drugs as simultaneously vulnerable victims and punishable criminals (see also Boyd 1999; Anderson 2008; Chang 2020). Above all, these researchers describe living conditions and state interventions that no one, with or without amphetamines, opioids or other substances in their bodies, could be expected to accept. At the same time, there seems to be a cultural, political, ideological and social consensus that people who use drugs must be treated differently from other people (cf. Keane 2002; Fraser and Moore 2011). However, as I have shown above, this consensus runs counter to much of the research that has been carried out, even though it is often pointed out that gender perspectives are missing from drug research (e.g. Rosenbaum 1981; Ettorre 1992; Campbell 2000; Boyd 1999, 2004; Anderson 2008; Campbell and Ettorre 2011; Moore and Measham 2013). But, even where it intends to critically illuminate power differences, research on socially vulnerable people who use drugs is in line with a historical, classified direction of interest running from those who consider themselves to possess knowledge, i.e. researchers, towards those who are being studied, the “strangers” (Skeggs 2004, p. 130). This, Skeggs argues, inevitably involves moral values:

Underlying the perspective that is taken (the interests that are held) is not just power but also morality. How people are valued (by different symbolic systems of inscription; by those who study them; by systems of exchange) is always a moral categorization, an assertion of worth, that is not just economic (e.g. good or bad; is or ought). (2004, p. 14)

Although, Skeggs writes, even if relations between researchers studying marginalised groups are problematic from a power perspective, to avoid researching such groups would mean that few people would know anything about them. Instead, she insists that the researcher must take responsibility for her position, her perspectives and the knowledge produced (ibid., pp. 130f.). In this context, I wonder what the significance is of a focus on the morally charged use of drugs when it is linked to socially vulnerable groups. That is, what knowledge is produced through this inscription?

Campbell is critical of what she calls “state ethnographies” (2000, pp. 200ff.). She argues that realistic depictions of vulnerable and stigmatised people, from the perspective of researchers and in the service of the state, run the risk of reproducing stereotypes, and thus power relations, against the will of the researcher. This is simply because some realistic depictions of drug use in socially vulnerable environments speak a highly charged symbolic language to which the academic reader cannot relate. In a similar vein, Skeggs writes that the perspectives of different actors play a fundamental role in how class is made, i.e. how class differences as such are created (2004, p. 45). “Superior” perspectives, such as those of the middle class, thus construct the working class by constructing themselves as something else (2004, p. 118). How can drug use be understood as anything other than deviant if it is exclusively studied as confined to marginalised social groups (cf. Quaglietta 2022; Taylor 1993), and alienated from the moral class? Skeggs, like Campbell, argues that linguistic signs attached to certain social groups are morally evaluative:

Attempts by the state to deflect attention away from class inequalities, through rhetorical signs of “lone mother”, “smoker”, “unhealthy school”, create moral divisions between worthy and unworthy recipients, the respectable and good citizen and the socially irresponsible and excluded. (ibid., p. 60)

I find that studies of “the abusing woman” run the risk of falling into the very trap of reproducing stereotypes as described by Campbell, when addiction is interwoven with descriptions of social vulnerability on all fronts. In Lander’s book, for example, abuse is studied through a filter of social vulnerability and a specific approach to large quantities of drugs. A specifically Swedish conceptual ambiguity plays a role in this, as was mentioned in the introduction. The concept of drug abuse has no clear definition, but usually refers to any and all use of substances classified as drugs and not prescribed by a doctor (Olsson 1994, p. 5). In other words, drug-abuse research could encompass a vast amount of extremely varied drug use. Yet, for obvious reasons, sociologists usually focus on drug use as a social problem, medical researchers focus on use leading to medical problems, and so on.

But criminologist Lander and ethnologist Rosengren have also chosen to study socially vulnerable people who use drugs. These choices of perspective give their work a contradictory character: at the same time as conceptions, stereotypes and categorisations are deconstructed, people who use drugs are simultaneously constructed by the Swedish researchers discussed in this section in terms of class, even though these ethnographers have been careful to reflect human complexity. However, the problem is not, as I see it, in the individual research—how could the drug-abusing woman be deconstructed without such studies?—but arises as a result of the power imbalance of the research situation, combined with the lack of research on drug use in other social groups. By reproducing a socially anchored image of drugs as linked to certain bodies, a considerable proportion of the drug use that takes place in Sweden is thus concealed. Overall, the perspective recreates a division that is reminiscent of the Bratt system’s distinction between problematic and non-problematic drunkenness, depending on class affiliation. I argue that drugs, with their links to immorality, risk, crime and disease, cannot be unproblematically linked to certain social groups in this way. In whose interests is the image that drugs are the concern of the socially vulnerable maintained? (cf. Addison 2023, p. 310).

How are drugs used when they are not part of socially vulnerable lives, and have not led to addiction? What is it that attracts people then, how do drugs change perspectives, and how are risks negotiated? What are the meanings of addiction for people who use drugs, and how is addiction avoided? Other questions that I perceive as important involve how positions and perspectives of people who use drugs, for example in terms of class, can be affected by drugs. These are questions to which I have sought answers and that I have generally found lacking in studies of women who use drugs.

The initial ideas for this thesis were inspired by the work of British criminologists Fiona Measham and Karenza Moore. They both start from an interest in how drugs are used for entertainment and depict drug use as a common phenomenon, in need of in-depth study, not least through a feminist lens (Moore and Measham 2013). What interested me was precisely these researchers’ feminist and power-critical approach, which, in relation to drugs considered as everyday objects, is an unusual combination in a Swedish context. This book aims to start filling this gap.