"It's almost a life and death sentence": Stakeholder perspectives on determinants of substance use risks and treatment access for individuals convicted of sexual offenses.

Sex offender registration and notification (SORN) policies have significantly destabilizing material and psychosocial collateral consequences for people required to register. There are strong theoretical and anecdotal reasons to believe that SORN policies likely increase substance-use-related harms for registrants. However, no research has directly examined relationships between SORN policies and substance-use-related harms. 20 qualitative semi-structured interviews were conducted with criminal legal, substance use, and forensic stakeholders who work with people required to register in Philadelphia. Interviews investigated how multilevel SORN consequences structure substance use risk environments for registrants. Through inductive and deductive coding, six broad themes emerged: "Sex offender" is an extremely stigmatized and villainized identity; SORN related restrictions transform the social and material context of reentry; SORN restrictions and the "sex offender" label have "devastating" impacts on mental health and self-concept; these material and psychosocial consequences of SORN increase substance use risk; SORN related policies severely restrict access to court-referred drug treatment; and this overall landscape of deprivation and restriction has dangerous and destructive implications, especially for overdose risk. Results suggest that sex offender registration and notification laws operate as social determinants of poor health for registrants, and are previously unstudied collateral consequences of sex offender criminalization. These findings provide evidence for providers, funders, policy advocates, and officials on the need to reform harmful and ineffective policies and improve access to treatment services for people required to register.