Access to Services for Under 18s Who Inject Drugs: Age Barriers,Fear of Discovery,Harm reduction Strategies and the Transition to Adulthood

Abstract

Many people who inject drugs begin before 18, while they are still legally minors/children. This age group has not been a specific focus in youth harm reduction research. We explore thresholds for service access for under 18s who inject drugs from the perspectives of both people who inject drugs and service providers. Semi-structured interviews were conducted with 19 people in Sweden, Switzerland and Wales who began injecting drugs before turning 18, exploring their experiences at the time, and the interviews were analysed thematically. Common themes across the three countries were age barriers, fear of discovery, informal harm reduction strategies, the appropriateness of adult services and difficulties in the transition to adulthood. Focus groups were conducted with harm reduction, drug treatment and social work professionals, and analysed deductively based on the previously generated themes. Despite local differences in law and policy, thematic commonalities across three high-income settings provide important points of departure when considering barriers to and enablers of access to services for under 18s who inject drugs.

Introduction

Injecting drug use among young people is associated with serious health and developmental concerns (Abelson et al., 2006; Busza et al., 2013; Degenhardt et al., 2008; Miller et al., 2006). Childhood trauma (Kerr et al., 2009), sexual abuse (Ompad et al., 2005) and suicide attempts (Liu et al., 2014) have all been associated with early injecting, while younger people who inject tend to report more risky practices, less contact with services for their drug use (Bryant et al., 2014) and higher rates of blood-borne viruses (Degenhardt et al., 2008). Early injecting debut tends to be characterized by curiosity, adverse childhood experiences, a social environment in which injecting was normalized and the influence of older acquaintances (Crofts et al., 1996; Guise et al., 2017). Among studies on young people’s injecting drug use, varying age ranges are used, often extending into the early to mid-20s, but the age of majority, typically 18, has rarely been a central focus in harm reduction research. Globally, there are almost no population size estimates for people currently under 18 who inject drugs, and there is scant knowledge about the health and social harms they face (Barrett et al., 2013).

In addition to their differing needs and outcomes, injecting among under 18s becomes a child rights and child protection issue (WHO, 2015), with associated duties and social interactions that differ from adults. Harm reduction services are central to preventing harms associated with injecting drug use. But services overwhelmingly encounter, and therefore tend to be designed for, much older adult participants. Harm reduction for those under 18 remains under-developed in practice and under-theorized in the literature. This is an important gap given the ethical, legal and practical challenges involved in delivering services for under 18s. Barriers to accessing health services include age restrictions, lack of identification with older clients and services unsuited to their needs (Krug et al., 2015). Studies have shown poor knowledge of health risks among under 18s and strong older peer influence in terms of injecting advice (Trudgeon & Evans, 2010). Confidentiality is a key factor for minors (Da Silva et al., 2021), while safety within harm reduction services has also been raised due to concerns about younger people mixing with older clients (Watson et al., 2015). In the absence of access to services, young people adopt informal strategies for harm reduction, such as selective or reduced use (Jenkins et al., 2017). Given these challenges, harm reduction services tailored for youth have been called for (Barker et al., 2015; Jenkins et al., 2017). However, with some notable exceptions (e.g., Krug et al., 2015), the experiences of people who inject drugs in accessing services and support while still legal minors are under-researched.

The present study is part of a mixed-methods project looking into injecting drug use among legal minors (<18) in Sweden, Switzerland and Wales. The point of departure for the project is that the legal age of majority should be an important legal, ethical and practical factor in youth harm reduction work. We therefore set out to explore life circumstances, service access and lived experiences for this age group. Based on semi-structured interviews with people who began injecting drugs before the age of 18 and focus groups with frontline drugs and social work professionals, we explore experiences of accessing formal harm reduction services and support as a legal minor who injects drugs in these countries. We chose three high-income countries with a view to exploring comparisons and commonalities from which to draw legal, policy and/or practical lessons for the present countries and other similar high-income settings.

Study Context

The three chosen countries have similar welfare systems and differing approaches to drug policy and harm reduction. Sweden is prohibitionist in its drug policy, retaining the vision of a drug-free society. Harm reduction has recently become more integrated into policy and practice, including opioid agonist therapy (OAT), needle and syringe programmes (NSP) and naloxone distribution. NSP is delivered by regional health clinics, but the relevant legislation excludes under 18s and does not allow for pharmacy sales (see Barrett, Petersson & Turner, 2022). Voluntary youth drug treatment is mostly run through regional health authorities in collaboration with municipal social services. These services rarely encounter young people who inject drugs (Barrett & Turner, 2025). If staff at treatment or harm reduction services encountered a person under 18 injecting, it would trigger a legislative duty on the part of any staff in contact with that person to report to social services, which can result in compulsory measures, including placement at a residential home run by the Swedish National Board of Institutional Care (SiS in Swedish).

Switzerland is well known for its harm reduction approach. OAT is available but uncommon for under 18s. Switzerland is the only one of the three countries with drug consumption rooms (DCR). Under 18s may not inject on-site at DCRs but may obtain sterile injecting equipment from them. NSP is integrated into DCRs, as well as mobile outreach and some hospital settings. Pharmacy sales and vending machines are available. There are no national protocols for needle exchange for under 18s, leading to variations between cantons (Csák, 2022). Provision of drug treatment varies between cantons and is delivered through a mix of public and private organizations. Voluntary treatment for minors often takes place in institutions that are not specialized in drug use, however, such as supported housing for children (foyer) or psychiatric services. Compulsory treatment for people who use drugs is possible but not common.

Wales is strongly harm reduction oriented (Welsh Government, 2019). OAT is available and can be prescribed to under 18s. Low-threshold NSP is provided through specialist sites, mobile outreach and pharmacies. Wales is the only one of the three countries with national guidance on NSP for under 18s. Those over 16 are deemed capable to consent to access services, while an assessment for NSP for under 16s is grounded in long-established judicial guidelines for determining capacity (Public Health Wales, 2011). Youth drug treatment is mostly run through Child and Adolescent Mental Health Services. Compulsory measures, if employed, would take place under mental health legislation and would be unlikely in cases of drug use alone. As with Sweden, there is a duty to report to social services if harm reduction or drug treatment services encounter under 18s who inject drugs.

It is not possible to estimate how many people currently under 18 inject drugs from registry data in these countries (Barrett & Turner, 2025). However, approximately 29% of people who inject drugs in Sweden and 23% in Switzerland report debut prior to the age of 18. The situation is less clear in Wales as the age of injection debut is not collected in national registers. Stable housing is problematic for this group in all three countries, and there are high rates of psychiatric co-morbidities among them. Many have not completed compulsory schooling. In all three countries, people who begin injecting prior to 18 take longer to access harm reduction services, adding to the potential risks (Barrett & Turner, 2025). In Sweden, those with debut under 18 are more likely to use unsterile injecting equipment and to have taken longer to access harm reduction services. Hepatitis C rates are almost double that of those with debut when they are adult. This group also experiences worse educational outcomes and greater usage of compulsory measures (Turner et al., 2023).

Theoretical Framework

We draw upon threshold theory to explore barriers to and enablers of access to services for under 18s who inject drugs in high-income settings. ‘Low threshold’ services are commonly associated with harm reduction and refer to services that place minimal demands on clients. For example, abstinence is not a requirement to take part, opening hours are flexible and anonymity is guaranteed (Islam et al., 2013). Building on earlier works, Edland-Gryt and Skatvedt (2012) move beyond these specific issues and identify four types of thresholds to be crossed in accessing health and social services. The ‘registration threshold’ refers to clients’ ability to approach services, on the assumption that seeking assistance is an essential first step. This threshold includes factors such as knowledge, resources and emotion. While these are individual factors, they may be influenced by prior encounters with services and macro issues, including law and policy. The ‘competence threshold’ concerns clients’ ability to express their needs. This can be especially difficult in certain healthcare and social care settings, such as with some psycho-social disabilities. Adding to these issues, age is a key factor in relation to perceived competence (capacity) and consent in healthcare and social care, including in harm reduction services (e.g., Barrett, Petersson & Turner, 2022). The ‘efficiency threshold’ refers to how some clients may receive less care due to services providers’ attitudes towards resource allocation and cost. Costs could include potential risk to a service, security or ethical concerns, or additional training needed to properly meet certain needs. Based on their own ethnographic research, Edland-Gryt and Skatvedt (2012) identified the ‘trust threshold’, defined as a lack of trust in the system of care and support, often due to fraught histories within that system. For these authors, trust is the most difficult threshold to cross for people with mental health and substance use issues and is essential for crossing the other three thresholds. Threshold theory can help us to explore social and policy barriers for minors in accessing services with a view to creating an ‘enabling environment’ (Rhodes, 2002) for reducing harm.

Methods

Data Collection and Analysis

Our primary material consists of 19 semi-structured interviews with people who began injecting drugs before they turned 18: 7 in Sweden, 6 in Switzerland and 6 in Wales. Participants had to be over 16 and under 35. Current injecting was not a requirement, as we were interested in experiences while injecting as a minor, even if drug use or injecting had ceased. Ten were female and nine were male. The mean age at interview was 26 (19–34), and the mean age of injecting debut was 16.5. Most participants were recruited via local drug services in urban centres in each country. Two were recruited via social media posts through local drug user groups. Informed consent was obtained verbally and recorded. Recordings were stored on a secure server in line with EU General Data Protection Regulations. Information that could jeopardize anonymity was redacted and pseudonyms were used. Following basic demographic questions and confirming the age of injecting debut, participants were asked open questions about their experiences when first injecting drugs and in accessing services at the time. A thematic analysis was undertaken with an experiential and descriptive orientation (Braun & Clarke, 2019). Coding was conducted by the first and second authors. Theme generation was iterative and collaborative among all three authors, adapting as we engaged with the data. Once themes had been generated, coded passages from each country were arranged under the relevant themes to allow for write-up. Interview coding was inductive; thus, our theoretical framework is applied to help interpret the results, rather than to guide the coding.

Six focus group interviews were undertaken with frontline harm reduction, youth drug treatment and social work professionals—two in each country, with a mix of professionals in each. Focus groups included three vignettes based on lived experiences of some of our interview participants. These provided staff with real-world dilemmas to discuss in terms of how they would react when encountering minors who inject (Petersson et al., 2025). For the present study, the focus groups were a secondary data source. The aim with the focus group data was to explore frontline professionals’ experiences and perspectives through the themes generated from the individual interviews. A protocol was developed from the thematic analysis of the interviews through which focus group transcripts were coded deductively. Passages were extracted and listed according to the relevant theme to allow for connections to be made with the interview data. In this way, the focus group data provide further context and nuance from the other side of the social interaction of service access.

Interviews and focus groups were conducted in Swedish, French and English. French transcripts were translated to English for analysis by a member of the research team. Swedish transcripts were analysed in Swedish with any quoted excerpts translated to English.

Results

Five common themes were generated across the three countries (Figure 1).

Figure 1.

Thematic Map.

Age Barriers, Real and Perceived

This theme refers to actual age restrictions experienced by participants, as well as perceived age barriers irrespective of legal standards. In Sweden, NSP is not permitted for under 18s, so none had attended NSP while injecting as minors (for two participants, NSP was not available for anyone at the time in their city). The registration threshold, considered at the macro level, was therefore as high as it could be. Even if participants had wanted to attend, they were not permitted by law. In both Wales and Switzerland, the situation was more nuanced. Participants expressed an awareness of age-related thresholds, but there was confusion as to what was allowed. John, for example, approached the local drug consumption room in his city in Switzerland when planning to inject for the first time. The age threshold weighed heavily upon him:

[T]hey didn’t give me any injecting equipment because they were really shocked because I was super young, and they didn’t know what to do. They told me, ‘If you’re underage, we can’t do it’. And I said OK, because I didn’t want to lie about my age. Because that could create big problems for them. (John, Switzerland)

John had not wanted to lie about his age. In a similar scenario, however, a harm reduction professional in Switzerland leaned in favour of lying so they could deliver their ‘best work’. The worker explained: ‘Our ignorance around that enables us to have a—how should I say—neutral approach to the situation’ (Harm reduction worker, Switzerland). Thus, there was a willingness to work with someone so young, but only by working around the law, which could carry its own risks. This type of workaround is not possible in Sweden due to registration requirements for NSP and was not suggested in Wales.

Amelia (Wales) had given a false date of birth at NSP aged 17 as she thought under 18s were not permitted. George, meanwhile, felt he had to lie to retain his place in low-threshold homelessness services and worried that a further lie to an NSP would expose him:

I didn’t want to slip up lying about my age. The day centre is an important place when you’re homeless and they wouldn’t have let me in if they knew I was 17. (George, Wales)

George had to balance a roof over his head with easier access to clean needles and chose the former, an age-related threshold that an adult would not encounter. Olivia, on the other hand, had not wanted to embarrass herself by being turned away:

I was 18 when I started going on my own. At 17 I didn’t want to get the needles alone.… It was the worry of them not giving them to me, as I was only 17, and looking like a fool walking in and out. (Olivia, Wales)

Olivia’s account reflects the courage and trust needed to come forward for services in the first place. This can be fragile. A perceived age barrier can be enough to undermine a willingness to come forward.

Importantly, at 17, the Welsh participants would have been legally permitted to access NSP. And in Switzerland, John could have accessed injecting equipment but would not have been permitted to inject on-site. But from their accounts, that was not their understanding of the situation. From a registration threshold perspective, these participants lacked information about their rights regarding access, affecting their decisions about making an approach to their local harm reduction services.

Fear of Discovery

Approaching services due to injecting is a major disclosure on the part of the person involved. If age were removed as a legal barrier, fear of discovery by family and social services would still be an important factor for participants in all three countries. Fear of discovery is a clear example of trust as a threshold to cross before seeking assistance. It has both micro (relational) and macro (legal/policy) elements.

Even when it was known that they were taking drugs, Liam (Sweden) and George (Wales) did not want their families to know they were injecting. For George, this was especially traumatic:

It was the end of the world for me. I’d lay in bed looking at the ceiling … dwelling, crying, worrying that people were going to find out. It wasn’t a nice place … I tried to hide it from my family I suppose. I’d wear a jumper, even in the summer, to hide my arms. (George, Wales)

With that level of fear, an approach to services is unlikely. This is especially true if parental consent is required. Disclosure was not any easier when parents themselves had injected drugs. On the contrary, some participants described hiding their injecting precisely because parents had experienced it:

I did pop to the chemist about once. I’d give [a friend’s] initials. My mum was accessing the needle exchange, so I didn’t want her finding out. (Oliver, Wales)

I was ashamed. It is not something easy to tell one’s parents. Both my parents had been in this world and it’s not an easy thing to tell your parents. (Emma, Switzerland)

Participants also expressed the fear of discovery by social services. In all three countries, participants had experienced some form of care order, evidenced in descriptions of living in care, being removed from the home or living with grandparents or other relatives. Fear of discovery was linked to negative or disappointing previous experiences in these contexts. Oliver (Wales), for example, described contact with social services resulting repeatedly in ‘care home, care home’. Because of these experiences, professionals in Wales recognized the challenge of the duty to report to social services. Telling this to a young person was a ‘game changer’ according to a Welsh harm reduction worker. A youth outreach worker described how he would expect his clients to react, which speaks directly to the trust threshold:

I’d never walk back into that service again and I’d tell everyone I know not to go in because the social will be knocking on my mum’s door.… If you grow up between care, with social services coming to your door every week, you don’t want to be the person whose fault it is that social services is coming to your house. (Youth outreach worker, Wales)

In Swedish accounts, fear of discovery related to experiences of compulsory institutional care. Adam, Maya and Alma (Sweden) all described not wanting to return to compulsory care, which was simply seen as ‘storage’ by the interviewees. This phrase was also used by Swedish focus group participants, referring to compulsory care as little more than a place to hold young people for a period, but without attending to their underlying needs. Vera captured the extent of her fear at the time:

At 16 I had just come out of treatment, which was against my will, and it could not come out that I had started using again because I was scared to death of being brought back there. (Vera, Sweden)

Elin’s (Sweden) early experiences continued to put her off seeking help as a young adult: ‘It’s been forced fucking support, so it hasn’t worked. Now I don’t ask for any help at all’. In focus groups, all Swedish professionals who expressed a view agreed that encountering a minor who injects would lead to an immediate report to social services. This would likely result in compulsory care, due to the perceived severity of injecting as a method of drug use among people so young. As one harm reduction worker stated, ‘we have a duty to report if she crosses that threshold [into injecting]’. From this perspective, injecting by someone under 18 is a clear line that, once crossed, places the young person in a different legal and policy environment, from health to compulsory care.

Relying on Informal Sources of Harm reduction Advice and Equipment

Participants described a range of strategies for accessing injecting equipment while under 18. Pharmacy purchase was possible in Switzerland and Wales. But in all three countries, participants reported similar strategies including online purchase, being given or sold paraphernalia by friends and asking or paying older people to attend services for them:

I was telling people to go to the needle exchange for me. The staff knew me and that I was underage, so they had to keep kicking me out … I’d hang around outside and send people in for me. (Amelia, Wales)

With these various strategies, accessing needles and syringes was not itself a major challenge. But needles are not all that are or can be sought at harm reduction services. Employing informal strategies in response to (real or perceived) barriers to access may lead to missed opportunities for early interactions with healthcare and social care. Moreover, power and relational dynamics in accessing equipment and advice come into focus.

Participants often depended on older people and/or romantic partners when first injecting. Adam (Sweden) and Olivia (Wales), for example, both began injecting with older romantic partners. They relied on these partners for equipment before they were old enough to attend harm reduction services alone. They used what was given to them, reducing the level of control they had in protecting their own health. Injecting advice was not always reliable, but this only became known in hindsight. Noah had begun injecting with his uncle. He described leaning on him not only for needles but also for advice and reassurance about health risks:

I didn’t know where they [needles] were from. I was relying on the more experienced person. I was definitely conscious of it as it was one of the biggest scares for me. Catching something. I was told it was clean. Although I did share once with my uncle, he said, ‘you know I haven’t got anything, you’re my nephew’. His thinking was as we were related it was okay. (Noah, Wales)

While Noah was himself concerned about infection, it was not until he was older that he could distance himself from his uncle and, with a competence gained through age and independence, take more control of his own safe injecting practices and health-seeking behaviours.

Participants knew there were risks associated with injecting, and that generally needle sharing was to be avoided, but they were unsure of the specifics. Vera (Sweden) contracted hepatitis C from the person who introduced her to injecting. She described inaccurate information from her peers and their lack of knowledge about sterile injecting due to an absence of formal information:

People thought maybe you could boil it away. You couldn’t. We had no information. Nobody talked to such young people about this stuff. (Vera, Sweden)

Staff also reflected on risks associated with informal sources of equipment and advice. Harm reduction staff in Wales, for example, had identified that groin injecting was taking place at ever younger ages. As a harm reduction worker noted, ‘that’s directly from learning bad habits, not because they need to or have run out of veins. Purely because they’ve been taught by someone older’. A Swedish professional working at an NSP related these types of risks to the fact that formal services do not reach this age group:

I think that because we don’t reach them … they maybe don’t have the knowledge about infection and safe injecting, they maybe don’t know … they get their equipment from older people which means they get infections and find themselves in situations they wouldn’t have wanted. (Harm reduction worker, Sweden)

As the above quotes illustrate, faced with an unwillingness or inability to come forward, harm reduction professionals voiced concerns regarding where minors would obtain support related to injecting, fearing for the reliability and safety of the equipment or information. This, however, presents a dilemma, because the formal services on offer may also not be appropriate or designed for this age group.

Wanting but not Quite Belonging in Low-threshold Services

Participants described wanting low-threshold services but not quite belonging there since most harm reduction services are designed around an older clientele and may not cater well for minors. This theme related to the registration threshold (in terms of the attractiveness of services to minors) as well as to efficiency (in terms of training and infrastructure) and trust (in terms of younger people’s worries about safety).

At the level of health protection, the principles of harm reduction were supported by participants. Some reported being uninterested in treatment at the time, some were injecting only occasionally and most were not dependent on the drug they began injecting, so harm reduction was important. However, participants directly and indirectly addressed the question of low-threshold service provision, recognizing that minors may not fit the way the services are currently designed. Luca (Switzerland) and Maya (Sweden), for example, supported improved harm reduction access for minors, but with certain caveats:

[T]hey should accept people on a case-by-case basis, on an exceptional basis, people who are not yet of age, who are going through certain things like I was. (Luca, Switzerland)

I think that, if there’s someone who is over 15, 16, who injects, that under certain circumstances you can provide needles. Maybe not as many or maybe they have to use them under supervision of a nurse. (Maya, Sweden)

Both saw access for minors as an exception, requiring a higher registration threshold than for adults, but one that may better serve the needs and safety of very young people.

The social conditions at low-threshold services arose in both Swiss and Welsh accounts. Emma (Switzerland), for example, had just turned 18 when she first approached her local DCR. Even though she had by then crossed the legal age barrier, she recalled that staff still had concerns about her safety due to a sometimes violent and predominantly older male group congregating around the DCR:

There was an interview. I told them I was 18. They hesitated because honestly, it’s a place or a world that is not cool. There is no trust. It is dangerous. (Emma, Switzerland)

George, meanwhile, had lied about his age to access a low-threshold homeless shelter, as we saw above, but had later regretted it, ‘this place is horrible. I don’t think they should put under-18’s [here]’. Both George and Arthur (Wales) had, in fact, first encountered injecting at low-threshold shelters. Local harm reduction staff agreed that some services in Wales are potentially inappropriate settings for minors. They were unsurprised that younger people might not identify with the existing clientele or feel safe attending. This presented a clear dilemma for participants and staff alike. Based on her experiences, Olivia (Wales) instead felt that minors needed to be ‘surrounded by people their own age’, with separate services for them, if possible. This view was shared by participants in both Sweden and Switzerland. However, as a Welsh harm reduction manager put it, ‘it’s also about being realistic about what’s available’. From the perspective of service providers in all three countries, it was not just that harm reduction services might not be tailored for minors but also that social workers or others who would have more contact with this age groups were less comfortable with more serious forms of drug use among them. Age may be an efficiency threshold issue for harm reduction service providers, in that there may be risks to a service or other costs associated with permitting access for very young people. But at the same time, injecting drug use could be an efficiency issue for those supports intended for children and young people, given the perceived seriousness of this method of intake and lack of expertise with it.

Becoming an Adult as a Double-edged Sword

The transition to adulthood was a mix of positive and negative experiences. On the one hand, participants felt they were listened to more as adults than when they were minors and overall experienced an easing of their ability to come forward for harm reduction services and to express their needs (registration, competence thresholds). At the same time, adapting to adult life was a struggle. As the age threshold into adulthood was crossed, they lost important supports they had had as minors.

The competence threshold was a clear issue for participants who described difficulties in making themselves heard in their own healthcare and social care while they were minors. Some felt that staff had not taken their concerns or desires seriously. This had led Mia (Switzerland), for example, to self-medicate for her mental illness using opioids, as her prescribed medication was making her feel unwell, and she did not think this was taken seriously enough by her psychiatrist. Oliver (Wales) felt that his needs were not properly considered by social workers, describing his encounters as simply ‘quite annoying’ with repetitive results. Vera (Sweden), on the other hand, who had feared compulsory care and distrusted the system as a minor, captured the positive transformation she experienced upon turning 18 and being assigned a new adult social worker:

Then she said, ‘What do you want?’ What! There had never been anyone that asked me what I wanted … the only thing I needed was an adult that listened to me and respected me. (Vera, Sweden)

For Mia, Emma and John (Switzerland), being eventually able to legally access medical services through a DCR opened important channels of communication (even as they recognized problems with the social environment surrounding the service). Mia described the change in feeling seen and listened to by staff, in a way that stands in stark contrast to participants’ earlier fear of discovery and reluctance to disclose:

He [doctor] was very open. I don’t know if there’s a doctor as approachable as him and I told him everything. (Mia, Switzerland)

Indeed, even if they did not quite fit in adult-oriented low-threshold settings as minors, the approachability of harm reduction services once participants had turned 18 was a shared positive experience in all three countries. Upon turning 18 and becoming an adult, not only the registration threshold but also the trust threshold was more easily crossed.

However, participants also experienced losses in this transition to adulthood. Matteo (Switzerland) lost his place in sheltered accommodation for youth at a time when he had no income of his own. Becoming an adult, he said, left him ‘in deep shit’ as he did not know where to turn. Unlike Vera’s positive experience of the same transition, Adam (Sweden) felt abandoned by wider social services, even as he gained access to harm reduction:

[L]ots of interventions during the time you have them, then suddenly you turn 18, and you land in the streets. So, you stand there, can I have some help? No, you can’t. (Adam, Sweden)

Upon turning 18, even if participants now were legally adults, there were difficulties in functioning in an adult world, where new competences were required. Amelia (Wales) described responsibility shifting to her as an adult to retain contact with her social workers, which resulted in that contact being mostly lost:

They literally give you money to leave [at 18] and you don’t see them again. I was on a care order until I was 21, so I had a social worker, but I didn’t really see much of her. She wasn’t massively involved unless I rang them. (Amelia, Wales)

Freja (Sweden), meanwhile, described this transition as being marked by ‘potholes’ and ‘gaps in the social safety net’. By the age of 17, ‘so near to adult life’, she had not known how to pay rent and bills, apply for benefits or look for work. These were life skills to be learnt during a ‘normal’ childhood that she had not experienced. By time she turned 18, there was nobody to learn this from. For Maya, what was really lost was the sense of being seen and protected as a child:

I felt strongly after I turned 18 that society didn’t care about me … What I felt when I turned 18 was that I—that people felt they could treat you however they wanted and nobody would care because I am too old for them to help, too old to be saved. At my next birthday I am 21 and that’s the last outpost.… There will be another blow then. I feel [pause] When I was 18, I still felt like a child. (Maya, Sweden)

Her access to NSP was not just for health protection but was also an important emotional and social support.

Professionals discussed the practical and institutional difficulties in working across that transition between child and adult drugs and social services. They also discussed their worries for young people who might fall through communication and organizational gaps:

[W]hat we find sometimes is that lag between adult services picking up young people.… That can be quite extended unless a lot of transition work is done, which isn’t often the case. (Social worker, Wales)

Discussion

We explored the lived experiences of 19 people who began injecting drugs before the age of 18 in accessing services in three high-income countries. We further explored the views and experiences of frontline workers related to our findings from the individual interviews. Our aim was to better understand comparisons and commonalities with a view to deriving practical legal, policy and/or practical lessons for these and similar high-income countries for work with a small, and hidden, group. Our main finding from this study was the commonality of the experiences of people who began injecting under the age of 18, represented in our five themes. While clearly there are individual differences, and differences in the policy settings, these commonalities may provide a solid foundation for these and similar countries when thinking through barriers to and enablers of service access for this group.

An age barrier on access to harm reduction services, whether real or perceived, functions as a clear registration threshold issue for the young person involved, which operates at both macro (the law) and micro (perception of the law by clients and service providers) levels. While the theme is common, it manifests differently in the three countries. Only Sweden had a legal restriction on minors accessing NSP. A recent official evaluation of Swedish drug policy has recognized that this may be problematic (SOU, 2022, p. 659). It suggested retaining the general age restriction but allowing for exceptions, as interview participants also suggested. However, neither our interviewees nor the evaluation articulated what those exceptions might be. It is exactly those types of exceptions, however, that relate to thresholds for access for minors and require further theoretical and ethical work. Of the three countries where participants were based, only Wales has a national guideline or protocol aimed at navigating this dilemma, based on long-standing judicial guidance related to sexual and reproductive health (Public Health Wales, 2011). A similar approach has been suggested for Sweden via individual best interest assessments rather than blanket age restrictions (Barrett, Petersson & Turner, 2022). But while there have been other calls to remove age restrictions (e.g., WHO, 2015), and for low-threshold services for young people (Russell et al., 2019), to date the discussion of thresholds for service access for minors is under-developed.

Perhaps, the most important trust threshold issue participants faced was less about the harm reduction services themselves and more about family or social reactions and the fear of detection by other services (see also Barker et al., 2015; Russell et al., 2019). Again, the common theme reveals different problems or barriers depending on the local context. Fear of discovery was especially stark in Sweden given the more common use of compulsory measures than the other two countries. Anonymity and confidentiality are important elements of low-threshold harm reduction services. They are put in place because of social stigma and lack of trust in services. But anonymity is difficult for minors given the duties to report to social services, evident in all three countries (see also Petersson et al., 2025). Thus, a key principle of low-threshold delivery may need to be rethought for this age group. Even if there was no legal age restriction, a duty to report injecting or other forms of serious drug use to social services was seen by participants as a barrier to disclosure (trust), and by professionals as a clear dilemma for practice (efficiency). In this way, child protection legislation may form part of a macro risk environment for drug-related harm if it deters disclosure while being part of an enabling environment for other crucial goals (e.g., identifying children at risk). This is an exceptionally difficult tightrope to walk, with competing priorities and duties across important policy objectives and types of legislation (health, child protection, drugs). That dilemma has not yet been the subject of sufficient harm reduction or child protection research (see Barrett et al., 2022).

Adult-oriented harm reduction services may not be appropriate for under 18s (see also Watson et al., 2015). On the one hand, young people may not identify with older clientele and avoid those services as a result (Krug et al., 2015). Unlike in Sweden, under 18s could access NSP in both Wales and Switzerland (though they may not inject on-site at DCRs in Switzerland). But as our Swiss and Welsh participants noted, they may also not feel safe, even if they trust the service providers. As such, they may be deterred from presenting at such services. On the other side of the client–provider relationship, staff may not see their service as best suited to the needs of this group, a clear efficiency threshold issue seen in all three countries. Youth-specific services have been called for, but tailored harm reduction services for a very small group of unknown number may not be feasible or affordable. Alternatives may be to better integrate harm reduction into existing youth services and/or to invest in upskilling existing harm reduction staff for encounters with minors to help ease that efficiency barrier (see International HIV/AIDS Alliance, 2015).

Our point of departure in this project has been that the age of majority is a key variable that is often overlooked in youth or adolescent harm reduction work. Our findings draw attention to the age of majority as a key threshold issue, affecting registration, competence, efficiency and trust. The three countries had different approaches to the age at which harm reduction services could be accessed. All three had duties to report to social services if a minor who injects was encountered. The commonality is status as a minor and the different legal, ethical and practical issues that arise when working with legal minors as a subset of ‘youth’ who use drugs. During the period of transition from one stage of life to another, specific risks and challenges emerge (Moyle & Coomber, 2018), during which time legal and organizational boundaries shift. The crossing of a threshold into adulthood affects the other four thresholds—easing all four by leaving ‘childhood’ and the legal and ethical constraints associated with status as a minor. At the same time, however, supports may be left behind and young people may not have developed the competences to express their needs in adult services. This challenge is not unique to drug use and relates to wider literatures on ‘leaving care’ (e.g., Bečević & Höjer., 2024; Harder et al., 2020). However, this period of transition may raise specific challenges for young people who inject drugs in relation to harm reduction services, and further supports may be needed. For example, a high utilization of transitional services to support the move into adulthood (e.g., financial support, independent living, medical services) has been found to be associated with improved social and health outcomes for young people who use drugs, compared to those who had not utilized such services (Barker et al., 2020).

Participants in all three countries discussed an important transformation they experienced when they felt listened to upon reaching adulthood. There may be a dual silencing of younger people who use drugs due to two different perceptions of incapacity affecting their perceived competence to speak on their own behalf—age and drug use. The right to be heard in matters affecting them is a core child rights principle applicable to under 18s (United Nations, 2009). That principle may in future be explored through the competence threshold for service access, in relation to whether clients who do come forward for services are then able to express their own needs and have them taken seriously.

There are limitations to the present study. While we found common themes, our results may not apply to low- or middle-income countries, so dedicated research is required in these settings. A further potential limitation is that for some participants who were recalling events from 10 or more years prior, there could be concern about the accuracy of memories or that the policy contexts might have changed. However, these participants had no apparent difficulty recollecting that period, and we did not find differences between older and younger interviewees.

This study provides new insights into an under-researched youth and harm reduction topic. Within wider youth harm reduction work, the age of majority should be factored in as a key variable. Those under the age of majority (usually under 18) are legally children. A child-centred harm reduction approach is warranted to unpack the specific legal, ethical and practical challenges of responding to drug-related harms among this age group (Barrett et al., 2022). From the present study, while the three countries differ in policy details, and solutions must account for local variations, the key finding was the shared thematic challenges relating to harm reduction for under 18s who inject drugs. These common themes and threshold theory may serve as a basis for adaptation of policy and practice in these and similar high-income settings with a view to creating a more enabling environment for reducing harm among legal minors who inject.