In Cambridge, a woman named Kristin sits down on a stone bench to talk about a common, but rarely discussed injury during the opioid epidemic: rape. We've agreed to use just Kristin's first name because she's a victim of this crime. Kristin says she, like many women who live on the streets, cope with the daily fear of an attack that they are too sedated to fend off -- or of waking up to find their pants pulled down, bruises and other signs of an assault. It's an assault active drug users often don't report out of shame, distrust of police or fear they'll be labeled a "cop caller" and have trouble buying heroin. It's an injury women say they can't figure out how to prevent. And it's one few doctors think to ask about, and thus do not treat. The road to trouble starts many mornings, says Kristin, when she wakes up, sick and desperate for heroin but afraid to shoplift, sell the goods, and seek a dealer on her own. So she finds a male buddy, someone she calls a running partner. "It’s just safer, people are less likely to beat you, rob you, sell you fake drugs if you’ve got a strong, well-known man with a reputation, a good reputation, you know," says Kristin, 32, who still has the lanky body of a high school backstroke champion. She's been addicted to opioids since she was 13 and prescribed them to relieve pain after shoulder surgery. Sometimes that strong man with a good reputation turns out to be another danger. Kristin cringes at the memory of falling into a drug-induced sleep near a running partner she’d come to trust. "I woke up to him on top of me, with my pants off, pretty much demanding that we have sex," Kristin says, the emotion draining from her voice. "I’m weak because of the drugs I’ve taken, so I’m trying to push him off. I can’t do it. I grab my phone and just kind of barrel roll off the bed, pull my pants up, and run outside." This time Kristin got away. In two other attacks she did not. She has story after story of unwanted kissing and groping. She says that for many women there is steady pressure from those they partner with to perform sexual favors. After the attempted rape, Kristin pressed charges. Shortly before trial, the man died of a drug-related heart infection.

"In hindsight, it’s like crazy, you look back and you’re like red flag, red flag, red flag." Kristin

Women interviewed for this story say they rarely seek help from police because they are worried investigators will turn on them and seek drug charges. Sometimes women are alert and recognize or can recall their assailant. Other times they only realize they’ve been raped because their clothes are torn, they have cuts or bruises and a sore vagina. To prevent attacks, some women travel in pairs but say that doesn't protect them from gang rape. They may arrange to ride out a high in view of a security camera, hoping someone would see and stop an assault. After each assault, Kristin would try going solo on the streets. But then she’d get robbed or sold fake drugs and decide to find a new running partner. Kristin says she still attaches herself to men who she knows are not safe. The addiction, she says, overpowers fear and common sense warnings. "In hindsight, it’s like crazy, you look back and you’re like red flag, red flag, red flag," Kristin says. "I’m even noticing it in real time and pushing it aside because there’s a high waiting for me at the end." Two women who were sitting with Kristin and nodding while she spoke have drifted away. She glances over her shoulder when I ask if her experience is unusual. "Between the other two women that were sitting here with me and the few that are across the street, combined, we probably have about 20 to 25 assaults or rapes," Kristin says, her voice rising in anger. "It’s almost become normalized, and that’s messed up." There’s little data about sexual assault during the opioid epidemic, but Gina Scaramella, director of the Boston Area Rape Crisis Center, says she isn’t surprised by Kristin’s account. "I would almost be surprised if that wasn’t the case, to be 100 percent honest," Scaramella says. That’s because some assailants seek women and men who they expect will be unconscious or semiconscious. Drug users may already be hiding from public view, and many have lost connections that might offer protection. "Like a job, stable housing, people that know where they are and care where they are," Scaramella says. "The isolation piece is a huge vulnerability for sexual violence because the offender will see that as an opportunity." One of Scaramella's staff members is taking a course in substance use intervention as the center tries to address rape during the opioid epidemic. Researchers are beginning to document the problem. One study, published two years ago, asked 164 young adults in New York who were addicted to opioids about rates of sexual violence. Forty-one percent of women and 11 percent of men said they had been forced to have sex while using drugs. Authors urge more focus on prevention, but not just for potential victims. “A lot of the focus is on telling people how to be safer when they are using or not impairing their judgment, but what we found was that there were people who were actively seeking out drug users, and more focus needs to be on them,” says study author Lauren Jessell.

One Boston physician says virtually all of her patients, mostly homeless women, have stories about sexual assaults.