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Women and Addiction: The Importance of Gender Issues in Substance Abuse Research

Abstract

Substance use was considered to be primarily a male problem, and many substance abuse studies are conducted with a predominance of male participants. However, recent substance abuse research indicates significant gender differences in the substance-related epidemiology, social factors and characteristics, biological responses, progressions to dependence, medical consequences, co-occurring psychiatric disorders, and barriers to treatment entry, retention, and completion. The epidemiology of women's drug use presents challenges separate from those raised by men's drug use. A convergence of evidence suggests that women with substance use disorders are more likely than men to face multiple barriers affecting access and entry to substance abuse treatment. Gender-specific medical problems as a result of the interplay of gender-specific drug use patterns and sex-related risk behaviors create an environment in which women are more vulnerable than men to human immunodeficiency virus. Individual characteristics and treatment approaches can differentially affect outcomes by gender. All of these differences have important clinical, treatment, and research implications.
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Journal of Addictive Diseases,29:127138,2010
Copyright c
!Taylor & Francis Group, LLC
ISSN: 1055-0887 print / 1545-0848 online
DOI: 10.1080/10550881003684582
Women and Addiction:
The Importance of Gender Issues in Substance
Abuse Research
Ellen Tuchman, PhD
ABSTRACT. Substance use was considered to be primarily a male problem, and many substance
abuse studies are conducted with a predominance of male participants. However, recent substance
abuse research indicates significant gender differences in the substance-related epidemiology, social
factors and characteristics, biological responses, progressions to dependence, medical consequences,
co-occurring psychiatric disorders, and barriers to treatment entry, retention, and completion. The
epidemiology of women’s drug use presents challenges separate from those raised by men’s drug use.
A convergence of evidence suggests that women with substance use disorders are more likely than men to
face multiple barriers affecting access and entry to substance abuse treatment. Gender-specific medical
problems as a result of the interplay of gender-specific drug use patterns and sex-related risk behaviors
create an environment in which women are more vulnerable than men to human immunodeficiency
virus. Individual characteristics and treatment approaches can differentially affect outcomes by gender.
All of these differences have important clinical, treatment, and research implications.
KEYWORDS. Gender, women, substance abuse, treatment entry, retention, completion
INTRODUCTION
Historically, in substance abuse research, as
in other fields of public health research, partic-
ipants have largely been male. Emerging evi-
dence in the past few years, however, is clearly
establishing the importance of studying issues
specific to women and studying male-female dif-
ferences in all areas of substance abuse research.
Studying outcomes separately in males and fe-
males expands our knowledge regarding women
and drug abuse to include all areas of drug abuse
and not just issues specific to women.1Accu-
mulating epidemiological and clinical research
indicates that the predictors for and progression
Ellen Tuchman is affiliated with the Silver School of Social Work, New York University, New York, New
Yor k .
Address correspondence to: Ellen Tuchman, PhD, Silver School of Social Work, New York University,
1WashingtonSquareNorth,NewYork,NY10003(E-mail:ellen.tuchman@nyu.edu).
to drug abuse and dependence are often gender-
specific or are gender-sensitive.
Reasons for gender differences in drug abuse
are not yet clear but could have important impli-
cations for the development of substance abuse
treatment interventions and programs. The re-
cent prevalence rates indicate that the number
of female drug abusers is increasing, and the
number of clinical studies in which sex and gen-
der differences in drug abuse are investigated is
steadily increasing.2Evidence presented in this
article shows that there are noteworthy differ-
ences between men and women in the epidemiol-
ogy of substance abuse, biological and subjective
responses to drugs, patterns of use, progression
Downloaded By: [New York University] At: 18:18 19 July 2010
128 JOURNAL OF ADDICTIVE DISEASES
from use to dependence, gender differences in
medical consequences,co-occurring psychiatric
disorders and substance abuse, women’s history
of victimization and violence, midlife and older
women, specific barriers to treatment entry, re-
tention, and completion for women.
EPIDEMIOLOGIC DATA
Epidemiologic data on substance abuse can
provide an important basis for understanding the
implications of drug abuse for women. Differ-
ences in patterns between women’s and men’s
drug abuse are revealed through epidemiolog-
ical data. The National Survey on Drug Use
and Health is a yearly survey conducted through
the Substance Abuse and Mental Health Ser-
vices Office of Applied Studies. The most re-
cent data report that an estimated 20.4 million
people are currently using illicit drugs. Addi-
tionally, the number of people with substance
dependence is 22.6 million in 2006.3Adult men
are more likely than adult women to be cur-
rent illicit substance abusers (10.5% vs. 6.2%,
except prescription medications), alcohol users
(65.9% vs. 57.9%), and tobacco users (36.4% vs.
23.3%).3However, men and women had similar
rates of past month use of stimulants (0.5% for
both), Ecstasy (0.2% for both), sedatives (0.1 and
0.2%, respectively), OxyContin (0.1% for both),
LSD (0.1 and less than 0.1%, respectively), and
PCP (less than 0.1% for both).
Among pregnant women aged 15 to 44 years,
an estimated 11.8% reported current alcohol use,
2.9% reported binge drinking, and 0.7% reported
heavy drinking. These rates were significantly
lower than the rates for nonpregnant women in
the same age group (53.0%, 23.6%, and 5.4%,
respectively).3
Among those ages 50 years and older, men
remain more likely than women to be dependent
or abuse drugs (4.9 vs. 1.5%).3Alcoholism and
prescription drug abuse are the top two chemical
dependency issues for older women.4Under the
Rug: Substance Abuse and the Mature Woman
is a survey of primary care physicians and an
analysis of prescriptions of psychoactive drugs
for women older than 50 years (National Center
on Addiction and Substance Abuse, 1998).
Findings include the following: 1.8 million older
women abuse or are addicted to alcohol, 2.8
million abuse or are addicted to psychoactive
prescription drugs, and 4.4 million smoke
cigarettes.4Of the 1.8 million mature women
who need treatment for alcohol abuse and addic-
tion, only 0.6%, or 11,000 women, are receiving
it. Even when physicians refer midlife and older
adult patients to substance abuse counseling
or treatment, one-fifth say their referrals were
denied because a managed care organization or
insurance company would not cover the costs.
In addition, the study also found that women
older than 59 years are susceptible to abuse
and addiction of alcohol and psychoactive pre-
scription drugs because they get addicted faster
and when using smaller amounts than any other
group.
DEMOGRAPHIC AND CLINICAL
CHARACTERISTICS OF WOMEN
Several demographic and clinical factors that
differentiate women from men with regard to
substance use have been identified. Women are
more likely than men to come from families
where one or more members are also addicted
to drugs or alcohol,5,6attribute the cause of sub-
stance abuse to genetic predisposition, family
history, or environmental stress,7and attribute
their drinking to a traumatic event or stressor.8
Additional research indicates that women
who are addicted have a history of over-
responsibility in their families of origin and
reportedly have experienced more disruption
in their families than their male counterparts.5
Women are al s o m o r e l ikely than me n t o b e
in relationships with drug-abusing partners or
spouses who are drug abusers510 and to identify
relationship problems as a cause for their sub-
stance abuse.7In addition to interpersonal stres-
sors, women are more likely to experience affec-
tive disorders, whereas men who are addicted are
more likely to engage in sociopathic or criminal
behavior. Although many women support their
habits through prostitution or petty larceny, men
are more likely to rely on robbery, con games,
and burglary to support their substance abuse.7
Several differences between older male and
female alcohol abusers have been reported.
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Ellen Tuchman 129
Women are mo r e l i k e l y than men to be w i d -
owed or divorced, to have had a problem drink-
ing spouse, to have experienced depression, and
to report more negative effects of alcohol.11
Older women have later onset of alcohol
problems,12,13 more vulnerability to addiction
stigma, greater use of prescribed psychoactive
medications,14 and are more likely to abuse mul-
tiple substances.5,7,10 Women are mo r e l i k e l y
to combine their prescription drug abuse with
marijuana, cocaine, or other drugs.6,10 Investi-
gators also find that women may view substance
abuse more negatively and that the social stigma
attached to the substance dependence may act
as a deterrent for women, leading them to ob-
taining their drugs from legitimate sources such
as physicians.5,7,10 These factors may have im-
plications for understanding the effects of gen-
der and widowhood on the development of late-
onset problem drinking.
It is well documented that women face
greater medical exposure to psychotropic drugs
than men, but little research examines whether
women also have increased use of prescrip-
tion drugs with abuse potential.15 Data about
women’s abuse of or dependence on prescription
medications are virtually nonexistent. This is
significant considering that women, particularly
midlife and older women, are the largest con-
sumers of prescription painkillers, antidepres-
sants, and benzodiazepines. Clinical evidence
reported in the literature suggests that prescrip-
tion drugs, especially benzodiazepines, seda-
tives, and hypnotics, are frequently prescribed
for and abused by older women. Older women
are prescribed benzodiazepines more than any
other age group.16 Age-related changes in drug
metabolism, interactions with other prescrip-
tions, and over-the-counter drugs and alcohol
contribute to greater risks for cognitive impair-
ment, dementia, and falls.16
Women incarcerated for drug-related offenses
represent one of the fastest growing popula-
tions in jails and prisons. Women confined in
prison increased from 7.8% in 1974 to 10.3%
in 2001, and more than half of the incarcer-
ated women surveyed by the Bureau of Jus-
tice Statistics reported that they committed
their offenses under the influence of drugs or
alcohol.17
GENDER DIFFERENCES IN
BIOLOGICAL RESPONSE
Research suggests that men and women dif-
fer in their biological and subjective responses
to abused drugs. Women initiate cocaine use
sooner, take less time to become addicted to
cocaine,18 and report less euphoria and dyspho-
ria compared to men.19 Women and me n g iven
equal doses of cocaine experience the same car-
diovascular response despite the fact that blood
concentrations of cocaine did not rise as high in
women as in men. In studies involving long-term
cocaine users, women and men showed similar
impairment in tests of concentration, memory,
and academic achievement following sustained
abstinence, even though women in the study
had substantially greater exposure to cocaine.20
Women cocaine users also were less likely than
men to exhibit abnormalities of blood flow in the
brain’s frontal lobes. These findings suggest a
sex-related mechanism that may protect women
from some of the damage cocaine inflicts on the
brain.20
Biological indicators point toward clear dif-
ferences between men and women in the
metabolism21 and other physiological effects
of alcohol.22 Women become intoxicated af-
ter drinking smaller quantities of alcohol
than men and achieve higher blood alcohol
concentrations.23 Retrospective reports from al-
coholics reveal that women consume lesser
amounts and are less likely than men to drink
daily or to engage in binge patterns of alcohol
use.24 This may be related to the fact that women
have less total body water than men of compara-
ble size, meaning that they achieve higher blood-
alcohol concentrations than men after drinking
equivalent amounts of alcohol.
Important gender differences also exist in the
physiologic effects of nicotine. Women and men
are equally likely to become addicted to nico-
tine, yet women typically smoke cigarettes with
lower nicotine content than those smoked by
men, smoke fewer cigarettes per day, and in-
hale less deeply than men.20 Females report pos-
itive mood increases to a greater extent after
nicotine smoking and show a great decline in
positive mood during smoking abstinence that
men.25
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130 JOURNAL OF ADDICTIVE DISEASES
PROGRESSION TO DEPENDENCE
Research is beginning to show that the pro-
gression, or developmental stages, of drug in-
volvement is not identical for men and women.
In the progression from legal drug use to illicit
drug use, for example, cigarette smoking plays
arelativelylargerroleforwomenthanformen,
and alcohol use plays a relatively larger role for
men than for women.
Studies of self-quitters find that women are
less likely to quit initially26 or to remain absti-
nent at follow-up.27,28 Perkins’ review of cessa-
tion trials with nicotine replacements reports on
9 of 10 studies that provided sex-specific out-
come results and found poorer absolute absti-
nence rates in women, although one study found
equal outcomes at a later follow-up.25 Possi-
ble explanations for this sex difference have
been suggested, such as women’s greater con-
cern about weight gain, greater difficulty with
negative mood (and higher prevalence of affec-
tive disorders), greater need for social support to
quit smoking, and the effects of cigarette adver-
tising targeted at women.29,30
The progression to dependence, particularly
alcohol-use disorder, also seems to be different
for women than for men. The interval between
the age of first drinking and treatment-seeking
tends to be shorter for women than for men.31
In addition, women progress between landmarks
associated with the developmental course of al-
coholism (e.g., regular drinking or loss of con-
trol) sooner than men.32 These findings have led
to the theory that “telescoping” may occur in
women. This theory posits that there may be a
shorter timeframe for the development of med-
ical consequences and behavioral and psycho-
logical factors characteristic of an alcohol de-
pendence disorder.
With regard to initiation into illicit drugs, data
suggest that women are more likely to begin or
maintain cocaine use to develop more intimate
relationships, while men are more likely to use
the drug with male friends and in relation to
the drug trade. Kosten et al. found that female
cocaine abusers had more severe cocaine use and
significantly shorter periods of time of cocaine
abstinence compared to when they abstained
from using cocaine, and male cocaine abusers
were more likely to abuse alcohol to intoxica-
tion. However, female cocaine abusers used opi-
ates longer, which is another example of their
more severe drug use problem.18
Westmeyer an d B o e d i cker compare d m e n a n d
women as to patterns of tobacco, caffeine, alco-
hol, cannabis, opiate, sedative, cocaine, inhalant,
amphetamine, hallucinogen, and phencyclidine
(PCP) use and found that women used each drug,
except cocaine, for a shorter time period com-
pared to men. However, rates of dependence
were similar between women and men, suggest-
ing that women take less time to progress to
dependence than men.33
GENDER DIFFERENCES IN
MEDICAL CONSEQUENCES
Women who abuse d r u g s h av e b e e n f ound to
get sicker more quickly and suffer higher rates
of liver problems, hypertension, anemia, and
gastrointestinal disorders than male drug users.
Women also exp e r i e nce gender-spe c i c m edical
problems as a result of their addiction, such as
ahigherriskforinfertility,vaginalinfections,
repeat miscarriages, and premature delivery.5,6
Despite lower levels of alcohol intake and
shorter periods of drinking, women suffer more
severe medial consequences than men, including
liver cirrhosis.34 Postmenopausal women who
drink moderate to heavy amounts of alcohol
also have other health problems, including breast
cancer. They are at higher risk for breast cancer
and heart disease even if the amount they drink
is less than that of their male counterparts.3537
Women who chronically abuse alcohol have
death rates 50% to 100% higher than men who
have the same alcohol use patterns.38
Some research suggests that the impact of
a given amount of smoking on lung cancer
risk may be greater among women than men,
and that exposure to environmental tobacco
smoke may be associated with increased risk
for breast cancer.39 Particularly alarming is that
women may be at even greater risk than men
for smoking-related diseases, including lung
cancer40,41 and myocardial infarction.42 Men
have higher prevalence rates of chronic obstruc-
tive pulmonary disease than women, which has
Downloaded By: [New York University] At: 18:18 19 July 2010
Ellen Tuchman 131
been attributed tothe historically higher rates
of cigarette smoking in men. However, the in-
creased rates of cigarette smoking in women
within the past several decades have been as-
sociated with steadily increasingrates of chronic
obstructive pulmonary disease in women.43
The interplay of gender-specific drug use pat-
terns and sex-related risk behaviors creates an
environment in which women are more vulner-
able than men to infection with the human im-
munodeficiency virus (HIV).44,45 Wom en using
intravenous drugs are at higher risk than men
for acquiring HIV.46 Women a r e m o r e likely
than men to inject drugs, use drugs with many
partners, share paraphernalia with an injection
partner, exchange sex for money or drugs, and
have difficulty negotiating condom use with
their sex partners.44 Wom en account f o r 2 6 %
of all reported adult AIDS cases in the United
States, which represents a doubling over the past
decade. High-risk heterosexual contact was the
source of 80% of newly diagnosed infections.
However, an estimated one in five new HIV di-
agnoses for women are related to injection drug
use.46
CO-OCCURRING PSYCHIATRIC
DISORDERS AND SUBSTANCE ABUSE
It is well established that women with sub-
stance abuse disorders present for treatment with
significant psychiatric co-morbidity. Women
show higher rates of certain co-occurring psychi-
atric disorders compared to men, such as major
depression, social phobia, post-traumatic stress
disorders, and eating disorders.4754Gender dif-
ferences in depression are generally thought to
be related to the interaction of biological and
psychosocial factors. Higher rates of depression
occur among women who are poor, less ed-
ucated, welfare-dependent, and unemployed.54
Although depression is common among women
with drug abuse problems, it often goes unde-
tected in this population.
Gender differences in the relationships be-
tween depressive symptoms and drinking be-
havior have been reported in problem drinkers,
indicating that depression can play a dual role,
at least for women.55 More specifically, if men
and women are motivated to stop drinking, de-
pression can trigger a change in the beginning
of treatment of both genders. However, follow-
ing treatment, depression seems to be associated
with relapse, primarily in women.
Studies of comorbid psychiatric disorders
in opiate56 and cocaine57 abusers have shown
higher percentages of affective and anxiety dis-
orders in women than in men. In a recent study of
treatment-seeking opiate abusers, lifetime psy-
chiatric comorbidity was more than twice as
common in women compared with men.56
Women dependent on methamphetamine
are more likely to report depression, suici-
dal ideation, and a need for psychiatric assis-
tance than men. Increased risk for depressive
symptoms was observed for both women and
men reporting methamphetamine dependence
compared to those not reporting dependence.
Furthermore, women, but not men, reporting
methamphetamine dependence were more likely
than those not reporting methamphetamine de-
pendence to report suicidal ideation and a need
for psychiatric care.58
HISTORY OF VICTIMIZATION AND
VIOLENCE
Another area of particular importance for
women is substance abuse and victimization and
violence. Prevalence rates of intimate partner vi-
olence among women in drug treatment have
been found to range between 25% and 57%.59
These rates of intimate partner violence are sub-
stantially higher than the range of 1.5% to 16%
prevalence rates found in epidemiological sur-
veys of community-based samples of non-drug
using women.60,61 Furthermore, a growing body
of evidence suggests that interpersonal stress and
relationship conflicts are major triggers for re-
lapse among women in drug treatment and that
intimate partner violence may result in contin-
ued drug use and relapse.62
MIDLIFE AND OLDER WOMEN
Because of the projected growth of the
midlife and older adult population in the coming
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132 JOURNAL OF ADDICTIVE DISEASES
decades, the treatment of substance abuse prob-
lems among midlife and older women is of in-
creasing interest. With the aging of the drug
using population, a majority of women in sub-
stance abuse treatment are perimenopausal or
menopausal.63 Risk factors for a more com-
plicated menopausal transition (e.g., alcohol,
smoking and illicit substance use, medical co-
morbidities, HIV/AIDS and hepatitis, premor-
bid and current psychological distress, few so-
cial and economic resources, and negative life
events) are fairly widespread in substance abus-
ing women.64 The rate of HIV infection in
midlife women, 15% of all cases among women
older than 50 (a number that has doubled in the
past 12 years), is attributable to the risk behaviors
associated with their drug use or sexual practices
with heterosexual partners.65
No longer concerned with pregnancy preven-
tion, postmenopausal women may not continue
barrier methods of contraception, which may in-
clude diaphragms, condoms, and cervical caps,
and face increased risk of sexually transmitted
diseases, including HIV from male sex partners
who have a current or past drug history.66 Fur-
thermore, many of the symptoms associated with
menopause (hot and cold flashes, sweats, fatigue,
loss of libido, menstrual irregularity, and sleep
disturbances) are similar to those associated with
substance abuse, especially opiate withdrawal
and methadone treatment with improper doses.63
Those women who are sensitive to these symp-
toms and experience increased levels of physical
discomfort, insomnia, irritability, anxiety, and
depression may be at a high risk for relapse to
drug use and HIV sexual risk behaviors.
SPECIFIC BARRIERS TO
TREATMENT ENTRY FOR WOMEN
Women are underrepresented in substance
abuse treatment programs. In 2002, 30% of the
admissions to substance abuse treatment pro-
grams were women, but the ratio of women to
men with dependence on illicit drugs is larger.4
Research indicates that women seek treatment
for substance abuse less often than men.67,68
The low rates of substance abuse treatment entry
among women may reflect the specific barriers
they face. Barriers for young women that have
been documented in the past two decades in-
clude pregnancy, lack of services for pregnant
women, fear of losing custody when the baby is
born, or fear of prosecution, voyeurism, and sex-
ual harassment.6973 Perhaps the most substan-
tial obstacle for these young women is avail-
able, affordable childcare.74,75 Few treatment
programs provide on-site childcare or provide
assistance with making child care arrangements.
Even when women are able to make alternative
arrangements, they are likely to face resistance
or hostility from family members.5
Women seek i n g t r eatment have been f o u n d
to have more substance-related problems, and
those problems tend to be more severe than
those of men entering treatment.76,77 For in-
stance, women are more likely to encounter dif-
ficulty with transportation to treatment sites,71
inadequate health insurance, poverty,75 deal-
ing with a relationship with a drug-abusing
partner,57,9,10,74 and being less likely than their
male counterparts to have someone actively sup-
porting them in treatment.
Wechsberg et al. found that women entering
substance abuse treatment were younger, had
lower education and employment levels, were
more concerned about child-related issues, were
less likely to be married, had more health and
mental health problems, had greater exposure to
physical and sexual abuse, and had greater con-
cerns about issues related to children compared
with men.78 Women ente r t r e a tment with p r o b -
lems related to health, higher HIV/AIDS risk,
and family and employment situations79,80
Treatment entry for men seems to be facili-
tated by social institutions such as employers or
the criminal justice system, whereas for women
treatment entry more often results from social
work referral, suggesting that contact with social
agencies eases women’s entry into treatment.81
TREATMENT RETENTION AND
COMPLETION
Controversy exists as to whether research
varies as to whether greater treatment retention
is achieved for women or men. Some studies
have positive findings for women. For instance,
Downloaded By: [New York University] At: 18:18 19 July 2010
Ellen Tuchman 133
women remain in treatment longer82 and were
less likely to drop out or not complete treat-
ment compared with men.83 Other studies have
negative findings. For example, women were
more likely than men to drop out of substance
abuse treatment,76 women attend fewer treat-
ment sessions than men, 84 and women with
substance use disorders differ significantly from
men with substance use disorders in terms of the
risk factors for, and natural history of, substance
use problems, reasons for relapse, presenting
problems, and motivations for treatment.8589
However, no gender differences in treatment re-
tention or length of stay were shown in three
studies.9092
Sayre et al. examined factors affecting treat-
ment attrition in individuals seeking treat-
ment for cocaine dependence. Sixty-five percent
dropped out before completing all 20 therapy
sessions. Treatment dropouts were more likely
to be women, to be separated from their spouses,
to have poorer family/social functioning, and to
have fewer years of education. Individuals with
higher education levels and those with poorer
psychiatric functioning tended to remain in treat-
ment longer.93 Treatment program characteris-
tics may be associated with retention and com-
pletion rates among women. These findings have
direct implications for identifying individuals
at higher risk for attrition from outpatient sub-
stance abuse programs.
Women repo r t t h a t services su c h a s h e alth
care, domestic violence counseling, transporta-
tion, and child care, along with relationships
with individual counselors, are the primary rea-
sons they remain in treatment.94,95 Wom en’s
failure rates in treatment programs have been
attributed in part to the fact that traditional pro-
grams are designed by and for men and that
their approaches have been informed by re-
search conducted on the male substance-abusing
population.5,9,75 Previous research indicates that
male clients are more likely to evidence greater
denial of their drug problem. As such, tradi-
tional treatment programs are centered on ag-
gressively confronting the addict about his abuse
and resulting consequences. Relapse is often
met with a punitive response instead of an ex-
ploration of possible environmental factors that
may have contributed to recurring drug use. In
contrast, women are more likely to experience
higher levels of guilt and shame in acknowledg-
ing their substance abuse. Therefore, confronta-
tional approaches, which serve to enhance guilt
and shame, have been found to be ineffective
with female clients.5,75
Nearly all prison-based substance abuse treat-
ment programs have also been designed with
male prisoners in mind, and little research is
available describing the effectiveness of inter-
ventions developed for substance abusing fe-
male prisoners. Two studies examined county
jail inmates in a 6-week residential substance
abuse treatment program and federal prison-
ers who participated in a 9- or 12-month res-
idential substance abuse treatment program,
respectively.96,97 Both studies reported gender
differences: female prisoners had more serious
patterns of drug use, were more likely to have
grown up in homes where drug use was present,
were more likely to have experienced physical
and sexual abuse as children, and were more
likely to have mental and physical health prob-
lems compared to male prisoners.96,97 If treat-
ment services in criminal justice settings are not
expanded to address the needs of female sub-
stance abusers, large numbers of these individu-
als will continue to be involved in drug-related
crime and will return to the criminal justice sys-
tem.
Whether women should be in women-specific
versus mixed-gender groups is an issue of
debate.98,99 An evaluation of women-only ver-
sus mixed-gender addiction groups found that
women identified several issues that they would
discuss only in women’s groups, including guilt
regarding being an inadequate mother.5An-
other study found superior outcomes for women
treated in specialized women’s programs versus
mixed-gender programs100 while other studies
found no differences.101,102
A meta-analysis examining effectiveness of
single-gender substance abuse treatment for
women concluded that single-gender treatment
was effective, but that its strongest impact was
on pregnancy outcomes. Psychological well-
being, attitudes and beliefs, and HIV risk re-
duction were also substantially improved by
treatment but psychiatric outcomes improved
only modestly. Treatment resulted in only small
Downloaded By: [New York University] At: 18:18 19 July 2010
134 JOURNAL OF ADDICTIVE DISEASES
improvements in alcohol use, other drug use,
and reduced criminal activity.24 However, few
studies in this meta-analysis compared gender-
sensitive or gender-specific treatment to mixed-
gender programs, making conclusions tentative,
suggesting the need for additional research on
women’s outcomes.
Several studies have suggested that gender
differences in interaction styles and men’s tradi-
tional societal dominance may negatively affect
women in mixed-gender group treatment.103105
As a result, it is generally asserted that substance
abuse treatment for women, particularly preg-
nant women and women with dependent chil-
dren, must differentially address these complex
psychosocial issues.106109 As such, treatment
programming designed specifically for women is
needed to address not only women’s substance
abuse related problems, but also their special
needs and barriers to treatment.
FUTURE RESEARCH DIRECTIONS
Evidence indicates there are significant gen-
der differences in the epidemiology of substance
use disorders, social factors and characteris-
tics, biological responses, patterns of use, pro-
gressions to dependence, health consequences,
co-occurring psychiatric disorders, and factors
related to treatment entry, retention, and com-
pletion.
The epidemiology of women’s drug use
presents challenges separate from those raised
by men’s drug use. High-risk subpopulations of
women (homeless, mentally ill, HIV positive,
violence victims, incarcerated, and midlife and
aging) necessitate more intensive and special-
ized services.
Progression, or developmental stages, of drug
involvement is not identical for men and women.
If the phenomenon of telescoping is, in fact,
common to most drugs of abuse, further research
is needed. Areas for exploration include patho-
physiology to determine whether biological or
hormonal differences in response to drugs, so-
cietal differences regarding entry into treatment,
or gender differences in seeking medical treat-
ment explain the shorter time course for women
than men. It may also imply that women have a
smaller window of opportunity for intervention
before the disease progresses, which has impli-
cations on programming and treatment proto-
cols.
Gender-specific medical problems as a result
of the interplay of gender-specific drug use pat-
terns and sex-related risk behaviors create an
environment in which midlife and older women
are more vulnerable than men to HIV. There
is a need to develop, engage, and test effective
treatments for women across the life cycle with
substance use disorders, particularly midlife and
older women.
There is a dearth of research related to the ef-
fectiveness of treatment interventions designed
specifically for women who abuse substances.
Although many service providers acknowledge
and address gender differences among clients
in substance abuse treatment, these differences
and the programming that addresses them have
not been adequately studied. Because women re-
main under-represented in substance abuse treat-
ment programs, new studies on treatment effec-
tiveness are needed to assess gender differences
in response to different treatment strategies. In
addition, there is a need to develop and examine
gender-specific assessment scales and treatment
protocols to optimize treatment effectiveness.
Future research should be theoretically based
and methodologically sound to advance the ev-
idence base of substance abuse treatment for
women.
At the national, state, and local levels, policy-
makers and service providers need new knowl-
edge to understand how male and female clients
differ in terms of sociodemographics, substance
use characteristics, treatment entry, retention,
and completion. Future research examining the
factors that underlie gender differences may
allow for the development of safe and ef-
fective gender-specific interventions for drug
abuse.
The research evidence makes it clear that
there are significant gender differences in drug
abuse and that more research is necessary.
The translation of these research findings to
the treatment community to improve treatment
outcomes for both sexes will be an excit-
ing challenge for the field. Increased and im-
proved policies, services, and new research will
Downloaded By: [New York University] At: 18:18 19 July 2010
Ellen Tuchman 135
continue to improve the lives of women sub-
stance abusers.
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... Though limited, evidence suggests that older women who use drugs may be at risk of earlier onset of menopause than those in the general population (14) and issues related to the menopause can be complicated by methadone treatment (15). Symptoms such as hot flushes resemble symptoms of opiate or methadone withdrawal (16,17). Women with drug using histories experiencing increased levels of physical discomfort, insomnia, irritability, anxiety, and depression during their menopausal transition may be at higher risk of relapse (15). ...
... And I thought that's what it was." (Jennifer, age 44, recovery 10½ years) While Jennifer attributed her low mood to the changes that come with (peri-) menopause, her experience echoes those of women elsewhere with regard to health concerns diagnosed as psychogenic by medical practitioners (16,45). Jennifer felt that the menopause was an issue that needed to be discussed with women in recovery: ...
... The women in this study discussed their menses and (peri-) menopausal symptoms, shedding further light on a neglected aspect of research in the addiction literature. Adding to the work of Tuchman (16) and Johnson et al. (17), the women confirmed the "felt" similarities between the effects of drug use and withdrawal and the symptoms of pre-menstrual tension and the peri-menopause/menopause. They further reveal how these symptoms can be particularly challenging for women in early recovery. ...
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Background Health-related research on women who use drugs (WWUD) tends to focus on reproductive and sexual health and treatment. Missing from the picture is an exploration of mid-life and older women's bodily experiences of transitioning from long-term substance use into recovery. While there are a growing number of studies that explore the intersection of drug use and ageing, the gaps in analysis lie in the intersections between drug use, recovery, ageing, gender, and the body. Methods In-depth qualitative interviews were undertaken with 19 women in the UK who self-identified as “in recovery” from illicit drug use. The interviews were transcribed verbatim and analysed using Braun and Clarke's thematic analysis techniques. The study received ethical approval from the University of Glasgow. Results Key findings from the interviews relate to the women's personal sense of power in relation to current and future health status, the challenges they endured in terms of ageing in recovery and transitioning through the reproductive life cycle, and the somatic effects of trauma on women's recovery. The findings demonstrate that health in recovery involves more than abstinence from drugs. Discussion Moving from the body in active drug use to the body in recovery is not without its challenges for mid-life and older women. New sensations and feelings—physical and mental—must be re-interpreted in light of their ageing and drug-free bodies. This study reveals some of the substantive sex-based differences that older women in active drug use and recovery experience. This has important implications for healthcare and treatment for women in drug services and women with histories of drug use more generally.
... The pattern remained the same at one-year follow-up, with girls, to a greater extent than boys, displaying indications of mental health problems. This is consistent with earlier research showing that young women in substance use treatment report higher rates of co-occurring psychiatric problems than do young men [51,[54][55][56]. It has also been found that although depression is common among women in substance use treatment, it often goes unnoticed [56]. ...
... This is consistent with earlier research showing that young women in substance use treatment report higher rates of co-occurring psychiatric problems than do young men [51,[54][55][56]. It has also been found that although depression is common among women in substance use treatment, it often goes unnoticed [56]. These findings might explain the higher levels of mental health problems among girls at follow-up. ...
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Background Although several studies have found a high incidence of coexisting mental health problems among adolescents with substance use problems, follow-up studies addressing how these conditions change over time are rare. The study will describe and analyze indications of mental health problems and how various risk factors predict outcomes 1 year after initial treatment contact. In addition, gender-specific risk factors are explored. Methods A clinical sample of 455 adolescents (29% girls, median age 17 years) answered a structural interview at baseline and were followed up using official records 1 year after initiated treatment. Bivariate associations and logistic regressions were conducted to analyse the links between risk factors at the individual, social, and structural levels as well as links between various mental illness symptoms at treatment start and indications of mental health problems 1 year later were analysed. Results The results show that mental health problems among adolescents largely persisted 1 year after start of outpatient care for substance use problems. Forty-two per cent of the sample displayed indications of mental health problems at follow-up, and registrations for both outpatient treatment and psychiatric medication were more common among the girls. Girls also reported more mental illness symptoms at treatment start than boys did, especially anxiety. Depression and suicidal thoughts had predictive values regarding indications of mental health problems and small cumulative effects were found for 6–10 co-occurring risk factors. Conclusions Adolescents with depression and suicidal thoughts at treatment start should yield attention among clinicians as these general risk factors could predict indication of mental health problems at 1 year follow-up effectively. Also, patients with more than six co-occurring risk factors seem more vulnerable for continued mental health problems. Generally, girls displayed a greater mental health and psychosocial burden at treatment initiation and were more likely to show indication of mental health problems at follow-up. These results suggests that girls are more likely to get psychiatric out-treatment parallel to, or after, substance abuse treatment. We recommend further investigation of gender differences and gender-specific needs in substance use treatment.
... In addition, many mothers avoid making their pathology public and, consequently, do not seek treatment due to the associated stigma, or even for fear of losing custody of their child [8]. In addition, the lack of gendersensitive treatment and other facilitating resources, such as childcare, prevent some women from feeling supported and engaging in existing treatment programs [9,10]. Finally, it is necessary to consider various structural problems, such as the time needed for clinical appointments and the treatment costs [1]. ...
Article
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Motherhood has been proposed as an internal facilitating factor for the recovery of women with mental disorders. However, at the same time, there are significant barriers that may be interfering with the access and adherence to treatment for these women. The present longitudinal study aimed to deepen the sociodemographic and clinical profile of women with children and compulsive buying–shopping disorder (CBSD), and to explore the association between motherhood and response to treatment. The total sample included 77 women with a diagnosis of CBSD (n = 49 mothers) who received cognitive behavioral therapy (CBT) for 12 weeks. No association between psychopathology and motherhood was observed. The group of mothers reported an older age of onset of the CBSD, a lower amount of money spent per compulsive-buying episode, and a higher likelihood of family support for the CBSD. Moreover, this group showed lower risk of relapse. The findings support the theoretical proposal that considers motherhood as an internal facilitating factor for recovery and treatment adherence of mothers with addictions.
... Mothers with addiction issues are more likely than fathers to be primary carers (38) therefore they are more likely to experience removal of children and may be at greater risk of these subsequent issues following removal. In addition, service users in addiction and recovery services are predominately male (39) so services may not be focused on or aware of gender-specific issues that are more likely to have an impact on women, such as parenting issues or the impact of child removal into care (17,39,40). Exploring the impact of gender on child removal and associated factors could lead to increased understanding, improved mental health and reduced suicidality in women attending addiction services, new service developments and improvements in service delivery, especially for those women who are mothers. ...
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Introduction Parental addiction can result in harm to children and removal of children by the Local Authority. Less is known about the impact of removal of children on their parents and whether gender has a role in this process. Methods Data on 736 service users were obtained from the caseloads of 8 nurses and 12 social care workers from an Alcohol and Drug Recovery Service in Scotland. Gender differences in prevalence/patterns of child removal, associations between child removal and parental factors and the relationship between removal and suicidality were examined. Results Mothers were more likely to have had one or more children removed compared to fathers (56.6 vs. 17.7%; p < 0.001) and were more likely to have a series of individual child removals (22.5 vs. 4.3%; p = 0.014). In addition to female gender, younger age, drug use, mental health and suicide attempts were also associated with child removal. Mothers who had children removed and women who were not mothers were more likely to have made an attempt to end their lives than women who had children but had not had them removed. Conclusion Gender differences were apparent in prevalence and patterns of child removal. Mothers were six times more likely to have children removed compared to fathers. Child removal occurred alongside other risk factors suggesting that families need holistic support for their multiple areas of need. Services should be aware of the link between child removal and suicide and provide additional support to mothers during and after removal.
... Consumption rates in women are double or even triple those of men in all age groups, women experience a more rapid progression towards addiction than men [20], and most prescriptions are chronic or long-term [21]. Research carried out from a gender perspective shows the influence of gender stereotypes on prescription and consumption [22,23]. ...
Article
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Sexual satisfaction (SS) is defined as an affective response arising from one's subjective evaluation of the positive and negative dimensions associated with one's sexual relationship. It is an important indicator of health. In women, SS has an important personal component consisting of the physical experiences of pleasure and the positive feelings and emotions that they experience in their affective-sexual relationships. The socioeconomic position is determined by income, educational level, and work, and it conditions women's sexual health. We aimed to assess whether social determinants of health (income, education, work, and gender) are associated with women's sexual satisfaction and to identify whether the impact of social determinants on sexual satisfaction differs with psychotropic consumption. We conducted a cross-sectional study designed to assess the association between variables related to the social determinants of health (work, education, income, and gender) and sexual satisfaction in women of reproductive age in La Rioja (Spain). The women in this study ranged in age from 17 to 52 years, with a mean age of 33.4 (Standar Deviation 8.6). Most were Spanish (82.9%), had undertaken non-compulsory specialized education (84%), and worked (72.7%). Regarding their relationships, 87% maintained monogamous relationships, 84.5% had stable relationships, and 65.7% lived with their partners. In total, 12.3% of the women were taking psychotropic drugs prescribed for the treatment of anxiety and/or depression. We observed that SS is significantly lower among women who have only undertaken compulsory education (Student-t = −4.745; p < 0.01), in those who have unstable affective-sexual relationships (Student-t = −2.553; p < 0.01), and in those who take psychotropic drugs (Student-t = −4.180, p < 0.01). We conclude that the social determinants of health such as education, not continuing to study beyond compulsory education , gender, and taking psychoactive drugs have a significant impact on women's degree of satisfaction with their sexual life. Keywords: orgasm; health behavior; psychotropic drugs; social determinants of health Citation: Ruiz de Viñaspre-Hernán-dez, R.; Santolalla-Arnedo, I.; Garrido-Santamaría, R.; Czapla, M.; Tejada-Garrido, C.I.; Sánchez-González, J.L.; Sapiña-Beltrán, E.; Iriarte-Moreda, V.; Colado-Tello, M.E.; Gea-Caballero, V.; et al. Impact of Social Determinants of Health on Women's Satisfaction With Their Sexual Life and Its Relationship With the Use of Psychotropic Drugs: A Cross-Sectional Study. Publisher's Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons At-tribution (CC BY) license (https://cre-ativecommons.org/licenses/by/4.0/).
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Medication for Opioid Use Disorder (MOUD) helps individuals safely withdraw from opioids. Though MOUD is effective, women stop using MOUD prematurely. The present study examined family relationships in relation to MOUD treatment acceptability among women. A convergent mixed methods research design was used in which 62 participants completed surveys and 23 participated in focus groups. Integrating qualitative data, convergence was found across two domains: 1) MOUD was perceived as acceptable and beneficial to recovery for the participants, and 2) Family support and desire for family services in MOUD treatment. Implications for MOUD treatment policy and future research are discussed.
Article
Alcohol‐related mental health burden and suicidality impose heavy burdens on global public health. This study measured the sex‐specific incidence and risk profiles of suicide mortality in individuals with alcohol dependence in a non‐western context. In this prospective cohort study, individuals with alcohol dependence who were enrollees in Taiwan’s National Health Insurance Research database were followed‐up over an almost 15‐year period. Their data were linked to the national mortality registration database. Taiwan. In total, 278 345 patients with alcohol dependence were enrolled and followed‐up from 1 January 2001 to 31 December 2016. We calculated the incidence and standardized mortality ratio (SMR) of suicide in the cohort and stratified the suicide methods by sex. Sex‐specific risk profiles (based on demographic characteristics and physical and psychiatric comorbidities) were generated through Cox proportional hazards regression. The suicide rates of men and women were 173.5 and 158.9 per 100 000 person‐years, respectively (P = 0.097). The SMR of suicide mortality was more than two times higher in women than in men (6.6 versus 15.0). Women and men adopted different suicide methods. A multivariable Cox proportional hazards regression with a time‐varying model revealed that depressive disorder was a common risk factor for suicide in both men and women [adjusted hazard ratio (aHR) = 3.03, 95% confidence interval (CI) = 2.77‐3.31 versus aHR = 5.46, 95% CI = 4.65‐6.40]. For men, receiving a diagnosis of alcohol dependence between the ages of 25 and 44 years, being unemployed and having schizophrenia, drug‐induced mental disorder or sleep disorder were risk factors for suicide. In Taiwan, the incidence of suicide in patients with alcohol dependence is substantially higher than that of the general population. The standardized mortality ratio of suicide in women with alcohol dependence is more than twice that of men with alcohol dependence.
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Increasing emphasis has been placed on the development of gender-specific treatment programs to address the unique needs of women substance abusers. Some authors have suggested that this task can be accomplished by simply providing single-gender programs; yet others have argued that simply segregating substance abuse clients by gender has no effect on outcomes. The latter have suggested that in addition to providing women-only programs, different treatment approaches must be adopted. The purpose of the study described in this article was to investigate the effect of one agency's change from mixed-gender to single-gender treatment on client retention and treatment completion. Data were collected on 305 men and 102 women who were treated in either mixedgender or single-gender settings. Results indicate that substance abuse treatment provided in single-gender settings does not significantly increase treatment retention and completion. These findings lend support to the contention that to improve treatment outcomes for women substance abusers, gender-specific treatment must do more than provide traditional treatment in a single-gender environment.
Chapter
Study of women and alcohol may involve a female/male comparison or comparison among subgroups of women. Epidemiological study over the last decades has not supported the hypothesis of convergence of male and female drinking rates, but changes in women’s drinking patterns have occurred. Problem drinking and alcohol abuse in men and women are compared: genetics, vulnerability to liver damage, age at onset, spouse’s drinking, use of other drugs. A critical issue is the public/private nature of drinking and the consequences which follow from that. Major antecedents to female problem drinking appear to be difficulties in impulse control, depression, and the earlier appearance of other diagnostic syndromes such as eating disorders or phobia. The consequences of problem drinking and alcoholism—interpersonal, legal, occupational, and medical—are discussed. In spite of the increase in gender-related research reports, women remain “the second sex” in theory development and diagnostic definitions.
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Nicotine replacement is less effective for smoking cessation in women than men. A possible explanation is that nicotine intake may be a less reinforcing consequence of tobacco smoking in women versus men, whereas nonnicotine aspects of smoking may be more reinforcing. Recent research suggests that nicotine self-administration is less robust in women, that women may reduce their smoking to a lesser degree following nicotine preloading, and that women may be less sensitive to interoceptive stimulus (or subjective) effects of nicotine. There does not seem to be a generalized insensitivity or hypersensitivity to nicotine in women. In contrast, women may be more responsive to the nonnicotine stimuli of smoking. These findings are consistent with other research indicating that women are less able than men to detect interoceptive stimuli (physiological changes). If confirmed, these sex differences could have important clinical implications; nicotine replacement may warrant a less important role in smoking cessation, whereas interventions to counter the nonnicotine aspects of smoking may need to be emphasized. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Objective.— To assess the risk of invasive breast cancer associated with total and beverage-specific alcohol consumption and to evaluate whether dietary and nondietary factors modify the association. Data Sources.— We included in these analyses 6 prospective studies that had at least 200 incident breast cancer cases, assessed long-term intake of food and nutrients, and used a validated diet assessment instrument. The studies were conducted in Canada, the Netherlands, Sweden, and the United States. Alcohol intake was estimated by food frequency questionnaires in each study. The studies included a total of 322647 women evaluated for up to 11 years, including 4335 participants with a diagnosis of incident invasive breast cancer. Data Extraction.— Pooled analysis of primary data using analyses consistent with each study's original design and the random-effects model for the overall pooled analyses. Data Synthesis.— For alcohol intakes less than 60 g/d (reported by >99% of participants), risk increased linearly with increasing intake; the pooled multivariate relative risk for an increment of 10 g/d of alcohol (about 0.75-1 drink) was 1.09 (95% confidence interval [CI], 1.04-1.13; P for heterogeneity among studies, .71). The multivariate-adjusted relative risk for total alcohol intakes of 30 to less than 60 g/d (about 2-5 drinks) vs nondrinkers was 1.41 (95% CI, 1.18-1.69). Limited data suggested that alcohol intakes of at least 60 g/d were not associated with further increased risk. The specific type of alcoholic beverage did not strongly influence risk estimates. The association between alcohol intake and breast cancer was not modified by other factors. Conclusions.— Alcohol consumption is associated with a linear increase in breast cancer incidence in women over the range of consumption reported by most women. Among women who consume alcohol regularly, reducing alcohol consumption is a potential means to reduce breast cancer risk.
Article
Objective. —To identify trends in smoking initiation among persons aged 10 to 20 years that might reflect the impact of specific targeting of tobacco advertising to women.Design. —Data from the National Health Interview Surveys on age of initiation of smoking (survey years 1970, 1978, 1979, 1980, 1987, and 1988) were used to construct age-specific rates of smoking initiation for males and females aged 10 to 20 years from 1944 through the middle 1980s. The raw rates were smoothed to allow trends to be more easily identified.Participants. —Information from 102 626 respondents was used.Results. —In 18- to 20-year-old women, initiation rates peaked in the early 1960s and steadily declined thereafter. In girls younger than 18 years, smoking initiation increased abruptly around 1967, when tobacco advertising aimed at selling specific brands to women was introduced. This increase was particularly marked in those females who never attended college (1.7-fold higher). Initiation rates for females younger than 18 years peaked around 1973, at about the same time sales of these brands peaked. After a steep postwar (1944 to 1949) decline, initiation rates in 18-to 20-year-old men did not decrease until the middle to late 1960s. Initiation rates for boys younger than 16 years showed little change during the entire study period.Conclusions. —The tobacco advertising campaigns targeting women, which were launched in 1967, were associated with a major increase in smoking uptake that was specific to females younger than the legal age for purchasing cigarettes.(JAMA. 1994;271:608-611)
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Drawing on both domestic and global international perspectives, this special issue is devoted to articles that confront the challenges of understanding, preventing, and intervening, with HIV/AIDS as an epidemic that carries increasingly serious consequences for a growing number of adults who are 50 years of age or older. This issue builds on papers first presented at an HIV/AIDS and aging conference sponsored in the fall of 2000 by the National Institute on Aging of the National Institutes of Health. The editors have selected articles that focus dually on what is currently known and what needs to be known to successfully address the needs of persons 50 years of age or older who are vulnerable to the virus's effects. This special issue is organized around a series of subsections representing key issues and research findings related to HIV/AIDS and aging issues, including the epidemiology of HIV/AIDS and aging, HIV/AIDS risk and risk behavior, settings and situations as social contexts of risk, clinical challenges with older populations, living with and managing HIV/AIDS, interventions and research methods, new frontiers and challenges, and strategies for action. Some articles are data driven, whereas others are reflective pieces that recount personal experiences in living with the virus or point to new directions for research and practice. In this introduction, the editors highlight findings and approaches from each article and further add to our knowledge by setting these articles within the context of major themes relevant to the study of HIV/AIDS in an aging population.