No Addict Left Behind

I’m in the process of applying for SSDI, so the last month of my life has been largely deciphering the obscurant bureaucratic apparatus that is the Social Security Administration. (The website How to Get On is a great source for this: I especially recommend it to anyone who's seeking disability because of ME/CFS, Ehlers-Danlos syndrome, Fibromyalgia or a similarly misunderstood condition). In the process of reading up on SSDI and SSI guidelines, trying to figure out how best to craft my own application, I learned that people who use drugs—or rather, people whose medical or criminal records show that they use drugs—are automatically denied disability if the SSA determines that their drug use is "material to" their disability claim. This doesn't mean that people who use drugs are always ineligible for disability, but it adds an extra hoop for criminalized/medicalized drug users to jump through.

This can be complicated to prove, because many of the reasons why disabled people use drugs are paradoxically conditions that can be exacerbated by drug use or by the withdrawals from certain drugs. This isn't only true for criminalized drugs - famously, SSRI antidepressants can increase suicidality in some people, and SSRI discontinuation syndrome can cause symptoms of depression and anxiety that are more extreme than the original symptoms for which the drugs were taken. But depressed SSI/SSDI applicants do not have to prove that their SSRI use is immaterial to their depression in order to qualify. People with disabling chronic pain, who have opioid-related drug convictions or a diagnosis of Opioid Use Disorder on their record, do.

From 42 U.S. Code § 12211 — (b) Certain conditions:

Under this chapter, the term “disability” shall not include—

1. Transvestism, transsexualism, pedophilia, exhibitionism, voyeurism, gender identity disorders not resulting from physical impairments, or other sexual behavior disorders;
2. Compulsive gambling, kleptomania, or pyromania;
3. Psychoactive substance use disorders resulting from current illegal use of drugs.

In 2022, the 4th U.S. Circuit Court of Appeals ruled that "gender dysphoria" (the DSM 5 diagnosis most commonly used to bill for transition-related medical procedures) is distinct from the DSM 4 diagnosis of "gender identity disorder", and that people with gender dysphoria are therefore entitled to ADA protections. The Supreme Court recently declined to review this decision, meaning that the ruling stands, but remains binding only in Maryland, North Carolina, South Carolina, Virginia and West Virginia (the states covered by the 4th Circuit). This decision has immediate implications for trans people incarcerated in those five states; the plaintiff, Kesha Williams, sued after being detained in a Fairfax County men's prison. But it's also part of a broader legal strategy, analogous to the use of Title IX as the basis for gay and trans rights decisions before the 2017 Trump Administration reversal.

A crucial component of the court's decision lies in the specific wording of the initial ADA exclusion. It refers to "gender identity disorders not resulting from physical impairments" (presumably intended as an awkward attempt to differentiate between intersex people and non-intersex trans people). According to the 4th Circuit Court, gender dysphoria—unlike Gender Identity Disorder before it—refers not solely to cross-sex identification, but to disabling symptoms of distress. While transsexualism and transvestism are simply immoral behaviors, dysphoria is impairing and therefore counts as disabling. To be honest, I don't think the argument holds up, but thankfully I'm not on the Supreme Court.

I've argued before that while the statement itself is true, constant reminders that "you don't need to medically transition to be trans" are misguided in a world where access to HRT, blockers, and surgeries are under attack; trans people face immense societal pressure not to transition medically. I stand by that sentiment. But on the flip side, I'm extremely wary of hedging transgender legal protections on the embodied distress of dysphoria.

Part of this is a matter of principle. None of us — especially those of us who are incarcerated — should have to prove sufficient suffering in order to earn equal treatment. (Needless to say, no trans or cis person should be incarcerated at all.) But I also think it's a strategic question; when we separate gender dysphoria from the "immoral behaviors" of transsexualism and transvestism, and protecting the former but not the latter, are we setting ourselves up for failure? Considering how proponents of conversion therapies have already started to speak in terms of "alternative treatments for dysphoria", I have my suspicions.

There is already abundant precedent for how these distinctions play out, as seen through another "immoral behavior" cited as an exemption. Just as the medicalization of transness is hotly contested, so is the medicalization of drug use. The disease model of addiction is unpopular among drug user liberationists and many harm reductionists, in part due to its roots in 12-step programming and its ubiquity within the recovery industry. But while drug use is not protected under the ADA, the underlying "disease" of addiction is. It is 100% legal for your landlord to evict you for shooting dope in your apartment (and if you live in publicly-funded or tax-credit housing, they're legally required to). It's illegal for them to evict you for going to rehab, assuming you still pay rent while you're there. Love the sinner, hate the sin.

I’m in the process of co-creating a basic trans training for the National Survivors Union (NSU), the U.S.’s only national drug users’ union. NSU has a lot of trans members, but a lot of us are mostly just active on the Sex Worker Call (a biweekly subgroup meeting), and the broader union remains very cis. As part of this process, a bunch of us are putting together Narcofeminism Storyshare narratives on the intersection of our transness and our drug use. If any of that becomes publicly available, I’ll of course share it.

I often refer to NSU as "my favorite disability organizing space". This is somewhat tongue-in-cheek, a reference to my disillusionment with most disability identity politics. But it's also real. NSU is almost entirely virtual, and is more accommodating of my flare-ups than any org I've ever been a part of. I'm pretty sure most of us in the union deal with some kind of chronic physical or mental illness, we just don't all conceptualize it that way.

For ten years, I’ve lived with disabling chronic pain and fatigue, which I manage with a few scheduled substances. I've joined a dozen or so chronic pain support groups, online and off, and tried for many years to take part more explicitly politicized disability activism*. Unfortunately, many chronic pain patient advocates have chosen to respond to the state's deadly war on opioids by doubling down on a politic of medicalized legitimacy, from which drug users are once again excluded. The phrase "[we're] Patients Not Addicts" is a prime example.

(*I’m intentionally not specifying a distinction between disability rights and disability justice here. Unfortunately, self-identification with the disability justice tradition doesn't guarantee an anti-carceral analysis around drugs and drug users. I do think that a serious commitment to DJ criticisms of the medical-industrial complex, and of police and prisons, leads naturally to drug user liberationist conclusions. But many people are unserious.)

A year or so ago, I got in a Twitter fight about this with a tenured disability lit professor. I don't normally remember the arguments I get into online unless they were especially distressing or especially annoying: this one was the latter. I'd criticized her use of the phrase, or a phrase similar to it, and we had some back and forth. I explained that many people who use criminalized drugs do so to treat pain, that the categories of "patients" and "addicts" are normative rather than descriptive. She told me: "I don't identify as an addict, and don't consent to being described as one"—as if most people described as addicts have consented to it!

While I don't take opioids for my pain, I do take benzos for anxiety. Much to my chagrin, my current psychiatrist wants to taper me off of them. When I think about that, my mind automatically goes to "actually despite clinical guidelines suggesting short-term use only, research shows long-term benzodiazepine use is clinically appropriate for severe, treatment-resistant anxiety". The same kind of thing pain patients do. It makes sense; we're being denied a safe supply of a drug we depend on, and denied the autonomy to make our own decisions about whether the risks of outweigh benefits. Playing by the clinic's rules and speaking its language are survival strategies we learn to keep our meds from being taken.

But when you internalize those logics and turn them against people who depend on the same drugs, you aren't just hurting others: you're dooming your organizing efforts. Methadone advocates organize against the same draconian laws and practices that harm chronic pain patients: the same invasive and irrelevant drug tests, forced dose tapering, medical discrimination, refusal of care. The policy arm of the war on drugs has targeted methadone, and methadone patients, for decades before all the glossy magazine articles on the pill-mills-to-heroin-pipeline.

I've given up on a politics of chronic pain qua chronic pain. At least in the US, where our health system is so stratified, it seems structurally inevitable that movements organized along illness lines will select for people with enough insurance coverage, job flexibility, reliable transportation etc. to regularly make specialty medical appointments. People who would never think twice about the drug war if it was not suddenly impacting them personally.

But solidarity isn't just for the selfless. As the drug warriors continue to ramp up their attack on prescribed opioids, people who take them are faced with a choice: taper off their drugs and face debilitating chronic pain, or navigate the same poisoned drug supply and violent criminalization as my comrades who use opioids without a script. Similarly, as more states criminalize medical transition in part or whole, trans people must navigate underground economies and rely on mutual aid to access our hormones, even moreso than we do already.

Trying to distance ourselves as worthy, distant from the junkies and criminals among us, hasn't kept us safe. Only a broad-scope struggle for trans and disabled and drug user liberation, against capitalism and the carceral state, will protect us from the right-wing wave.

We can build drug user unions, organize for safe supply and safe consumption sites, and learn from the efforts of drug user organizers before us. We can organize in our workplaces, especially at sites of social reproduction, to resist enforcement of transphobic/ableist/prohibitionist policy. We just can't afford to leave anyone behind.

I’m Reading
This Is Real and You Are Completely Unprepared by Alan Yew
Last year during the high holidays, I fasted from food but not drugs, stayed up too late with my friends celebrating something unrelated, had a 4 am existential crisis, then missed Yom Kippur services because I was too sleepy and hungry and high. I’m not going to do that this year!

On My Mind
A few weeks ago, a dear comrade of mine got bombarded by prison-preservationist YIMBYs* over their beautiful essay about getting their rapist to pay for their therapy as restitution. The essay is over two years old, but they shared it in response to these same YIMBYs misogynistically hounding other abolitionists with accusations of "wanting to decriminalize rape".

At the risk of being screenshot, I'll admit it: I do want to decriminalize rape. I want to decriminalize murder, and grand theft auto, and dealing the "bad" drugs that you think nobody should ever touch. But most of all, I want to deinstitutionalize rape. I want us to stop keeping human beings in cages for guards to violate at will. Outside the logic of the prison state, there is no situation in which being forced to strip and squat at gunpoint is not sexual abuse. Prisons do not prevent rape, they inculcate and systemize it.

Abolitionists have a lot more to learn about how to respond to gendered violence. Unlike prison-preservationists — who also offer no real answers for stopping rape and abuse— we are willing to admit what we don't know. I don't know how to stop all rape, though I know many ways to help keep survivors safer. I've been on a few community accountability processes, organized to vacate criminal records of trafficking survivors, and processed trauma with probably a hundred different abolitionists; just casually as friends. But in the end, all I really know is: if we closed all prisons tomorrow, there would be less rape in the world. Even if we did nothing else at all! That's reason enough for me.

*Stands for "Yes In My Backyard". Endonym for a weirdly aggressive cluster of pro-developer zoning law reform nerds.

On a Brighter Note
I live in a small apartment building with a shared yard. One of my upstairs neighbors has an 11 year old dog named Daisy, who wanders freely between their apartment and the yard. Since I have trouble walking most days, my neighbor recently offered to walk Piero while she walks Daisy. Now they're best friends and cuddle up to each other like this: