Topic at a glance:
Addiction is Not Just a Problem for Men
No doubt about it – both men and women suffer greatly from the damaging effects of addiction to alcohol and drugs. Up until recent years, substance abuse has been considered mainly a male problem. While it is true that men still outnumber women when it comes to alcoholism and illegal drug use, women are catching up. In fact, the number of female drug abusers has increased significantly. The latter, unfortunately, also includes an increasing number of pregnant users and mothers.
Research Suggests Significant Differences in the Needs of Men and Women Seeking Addiction Treatment
Nevertheless, most research and treatment programs remain geared to male participants. In recent years, important studies have found that significant gender differences exist as to addiction and its treatment. Women face particular problems, issues and barriers when it comes to the disease of addiction, whether related to seeking or obtaining treatment, or in regards to maintaining sobriety. A gender sensitive approach to addiction rehabilitation and recovery is therefore becoming essential in any treatment program.
What is Gender Responsive Treatment?
Gender responsive or sensitive treatment acknowledges and addresses women’s very different experiences, including internal and external barriers. These include factors such as:
Biology as a Barrier
Women’s alcohol and illegal substance use differs greatly from men’s in a number of ways such as:
Women present with greater medical needs compared to their male counterparts when entering treatment. In addition to negative physiological impact as a consequence of using, women may face medical problems that actually paved the way for substance use in the first place. For example, research shows that women tend to suffer disproportionally from chronic pain, chronic fatigue or fibromyalgia, and women’s substance use may therefore be an attempt of coping with these chronic conditions. Whether or not a medical condition preceded or is the result of problematic alcohol and substance use for women, the bottom line is that these illnesses ought to be addressed as part of treatment. Failure to do so may increases women’s risk of relapse.
Hidden Barriers: Relationships as Pathways, Barriers and a Relapse Factor
Many researchers examining women’s use have acknowledged the significant role women’s relationships play in the initial substance use, as well as its maintenance, escalation, or renewed use following treatment completion. For example, unlike men, women’s problematic use often starts at the encouragement of male friends or a boyfriend.
Women are less likely to seek and access treatment for problematic use if their partner is unsupportive.
Female teens are the only age group among women at par with men’s rates of problematic alcohol and/or illegal substance use. Female heroin users tend to be introduced, coaxed or pressured into intravenous use by their male partners. Women are more likely than heroin addicted men to die in the first year of intravenous use, and those that survive tend to suffer from greater rates of Hep C, TB and sexually transmitted diseases compared to men. Unwanted pregnancies are also common. Women are less likely to seek and access treatment for problematic use if their partner is unsupportive. Not surprisingly, their likelihood of staying clean and sober even if they manage to complete treatment is also decreased if their partner continues to use, or proves unsupportive of, or indifferent to a sober lifestyle. Researchers have those pointed out correctly that women’s substance use often starts or is maintained mediated by a wish to seek, maintain or deepen human connections.
Perhaps the Most Significant Barrier: Interpersonal Violence
Most women entering substance use treatment are victims of child sexual abuse, or other forms of interpersonal violence, such as spousal assault (often also referred to as ‘domestic violence’), sexual harassment or rape. Studies suggest that such trauma affects women well into adulthood, and in fact tends to precede women’s initial alcohol or substance use. Many women are also subjected to violence in the context of alcohol or drug use. For example, rape, date rape and marital rape tend to happen when either victim or perpetrator are intoxicated. In the case of date rape, women don’t necessarily consume alcohol themselves, but are made defenseless through involuntary administration of odor and tasteless drugs such as GHB.
Sexual Assault and Drug Use
More than 90% of all sexual assaults and rapes are said to involve the consumption of alcohol, and most of these remain unreported or underreported. Finally, women are also more likely to experience severe and repeated sexual and physical violence as a result of excessive alcohol and illegal drug use compared to male addicts. The experience of being violated, sometimes repeatedly, brutally and over many years specifically by those charged with caring and protecting girls and women, has many devastating effects that can translates into barriers to substance use treatment:
The impact of Interpersonal Violence and Sexual Assault
1. Survivors of interpersonal violence have problems trusting others. This makes forming or maintaining close relationships challenging , including those with helping professionals. Studies have repeatedly revealed that the strongest predictive factor for a positive treatment outcome is the therapeutic alliance with the assigned therapist. In other words, the quality of the relationship between the substance using woman and her addictions therapist or counselor.
2. Many women experience shame and guilt as a result of being sexually violated, somehow believing that they at least contributed to, if not caused, this to happen. As a consequence, they unfortunately suffer in silence, attempting to deal with the aftermath of such horrific experiences in the secrecy of their minds rather than seeking professional help.
3. Women experience many devastating and often long-lasting effects as a consequence of interpersonal violence. Sexual childhood abuse in particular has been shown to affect women’s physical and mental health negatively up to fifty (!!) years later. Survivors suffer disproportionally from various somatic complaints, but also from increased mental health problems such as depression, anxiety, post-traumatic stress disorder or personality disorders such as Borderline Personality Disorder.
4. Female addicts tend to suffer from mental health issues to a far greater extend than their male counterparts. Research has shown that a failure to address the co-occurrence of mental health and substance use ought to be treated concurrently, or at least simultaneously and in an integrated fashion if sobriety is to last. Unfortunately, many substance use treatment centers lack the resources, such as highly trained staff, to deliver such specialized treatment.
Internal Barriers: Fear of Stigma
Notwithstanding the aforementioned background of female substance use, women tend to experience far greater negative judgment by family and friends alike. Women are well aware of the social shame and the possible disapprovals they may experience from friends, family, co-workers, employers if they do reveal their addiction problem, thus staying clear of any possibility to seek treatment.
Women with addiction are seen as a “fallen woman” and parents as ‘unfit mothers’. As such, they are deemed incapable fulfilling usual responsibilities as a loving mother, wife, daughter, or grandmother. She may be ashamed of her behavior and thus refrain from seeking help for her addiction. As a substance using woman, she is less likely to fit in the female norm of society as the nurturer and caregiver for her loved ones, capable to put her own needs on the backburner. Women who are abusing drugs may live in constant fear of losing their job, their housing, their friends, their children.
Women More Like to be Judged Harshly
While men’s open confession to having a problem with addiction may be met with support and encouragement to seek treatment, women are more prone to receive harsh judgment and stark disapproval, especially by those closest to them. This is a significant barrier to treatment, as women tend to define their lives and personal worth by the quality of their relationships. The support and continued love by those they are close to are therefore crucial for success in treatment, and in continued recovery. Stigma is especially harsh for those among substance users who are mothers, as they rightfully fear to lose their children. Many women entering substance use treatment are mothers who are mandated by child welfare services, or motivated by child custody proceedings initiated by concerned family members. Contrary to popular belief that someone ‘has to be ready to get clean’, suggesting that mandated treatment is not effective, research suggests the contrary.
Fear of Negative Judgment Means Women Downplay their Problem
In order to avoid harsh judgment by loved ones and society at large, women may be very much inclined to downplay their use. In fact, an expectation to receive negative judgment may also be the culprit in regards to denial, the soil in which any and all addictive behavior flourishes so well. For example, increasing amounts of alcohol at the end of the day be justified as a way of ‘taking the edge of’, ‘coping with stress’, or function as a nightcap to induce sleep. Women may tell themselves that they can easily ‘kick the habit’ once the stress is gone, and life has miraculously and effortlessly found its way back into balance. Women may only admit to problematic alcohol misuse once the disabling effects are clearly visible in their day-to-day functioning, such as repeated lateness or absences from work, failure to bring young children to school, or alcohol related car accidents.
Obvious Societal Barriers: Socio-Economics
In general, research shows that women who become addicted to drugs and alcohol have lower levels of education, and are often unable to pay for privately funded substance use treatment. It may be for this reason that women show a tendency to seek publically funded mental health rather than substance use treatments, as the former tends to be more readily available, and to no cost for participants. Finances also pay a role in women’s ability to access ongoing after care treatment, for example for chronic mental health problems requiring specialized, long-term or ongoing professional care such as the case with severe trauma, or Borderline Personality Disorder.
Women also have more family responsibilities than men. A woman is more often the one who raises children, even if she is still married or lives with a partner. Leaving the children in order to attend to her addiction may not be an option at all. Even women who are working may not find it possible to leave their work, or put their children in day care in order to attend regular appointments, or a residential treatment center. The challenge as to who takes over? equally arises for women responsible for elder care, or those volunteering in community agencies, as these are often dependent on such unpaid and dedicated work.
Women also have more family responsibilities than men.
Closely related to lack of finances, women are more likely to face uncertain or unpaid employment, and difficulties with affordable housing. Until today, women tend to receive lower pay compared to men for equal work. Recent headlines bear witness to this fact, reporting that female employees of one of the UK’s largest banks, Barclays Bank, make up to 43% less compared to their male colleagues.
The Not-So-Obvious Societal Barrier: Ignorance
The fear of being judged and rejected also coincides with health professionals, friends and families alike missing signs of addiction in women. For example, mood swings, one of the most common telltale signs of a progressive addiction may prompt others to suspect increased substance use in men rather readily, while women may be suspected of being ‘hormonal’ instead. Unsuspecting family doctors may therefore prescribe increased amounts of opioids to ease pain, or tranquilizers or benzodiazepines to ease anxiety or induce sleep, unknowingly becoming women’s legal drug dealer.
Women are in fact much more prone to misuse prescription drugs than men, but few family doctors are sufficiently trained in the field of addiction to recognize warning signs in their female patients. As a result, female patients tend to have no problems getting repeat prescriptions for highly habit-forming medications. A smooth, legal and socially accepted path to prescription drug addiction is formed. As such, women’s addiction may progress undetected, at least in the early stages, and receive attention only when she decides to reach out for help. Others may only notice when their addiction is already ruling their lives, and until then women suffer in silence and miss opportunities for treatment. In fact, women’s addiction may become only known when they no longer can fulfill the role society still prescribes to them: that of caregivers for children and elderly family members. Fact is that most women entering treatment for substance abuse are actually mothers, many of them receiving mandatory treatment courtesy of involvement with child protection services. Losing custody of their children is the biggest motivation for going into treatment.
Minority Status as Barrier to Treatment
Such inequalities affect minority women particularly strong. Women of African American or Native American or Canadian descent, women with disabilities, or those identifying as transgender, bisexual or lesbian may be at greater risk of poverty, violence, mental health issues and problematic substance use. Ethnic minority women are at greater risk of being victimized in human and drug trafficking alike. If they do make it into treatment, which research suggests is rather unlikely, their ethnic identities and cultural practices are typically not reflected in conventional addictions programming. For example, the definition of family according to some of the Aboriginal North American communities involves not only extended family members, but their community at large.
Culturally appropriate treatment of an addicted individual would thus involve traditional healing circles and practices as much as the participation of this larger circle of support, including their elders. It is thus important to remember that women amongst themselves are a diverse group, with individual women differing greatly as to their ethnic, socio-economic and relational circumstances and treatment needs.
Implications for treatment
So, if women’s substance use, their background and circumstances differs so significantly from men’s, what are the implications then for treatment providers?
Most generally, treatment programs that acknowledge and reflect an understanding of the multiple and complex ways in which female substance use differs from those of their male counterparts, are likely to show increased positive treatment outcomes for women. For example, studies showed higher rates of long-term sobriety for female program participants if services providers offered assistance with finances, housing, transportation and childcare. Programming that helps addressing problems confounding women’s substance use, such as enduring mental health problems or trauma, may translate into increased hopes of women affected by these multiple difficulties that treatment will bring about long-lasting change for the better. This also goes for significant medical problems, such as HIV or HEP C, or other life diminishing physical conditions such as chronic pain or fibromyalgia. Comprehensive treatment in such cases involves collaboration between short- term addictions focused treatment organizations with medical and/or community professionals involved in women’s lives and women’s care long-term.
Gender responsive treatment
Many residential addiction treatment centers remain mixed, geared towards both men and women. While this may make sense in logistically and economically from a service providers’ point of view, it fails to take into account the many needs women bring to treatment that are so different from those of men seeking recovery. For example, research has shown that women who have experienced abuse from a male perpetrator may not feel comfortable with male co-participants in group therapy, or with male therapist. Additionally, women also experience barriers to recovery as many approaches to addictions treatment are based on research with male participants, and/or on male centered viewpoints. Alcoholics Anonymous (AA), for example, one of the most well known and most widely applied addictions treatment philosophy, was developed by two white middle class men. Steps one and two can be experienced as detrimental for women who have experienced trauma in their lives, given that they seek empowerment due to having felt powerless most of their lives.
In opposition, gender responsive and trauma informed treatment reflect understanding and validation of women’s complex realities, and acknowledge the fact that most of these women continue to suffer from the devastating effects of interpersonal violence. Offering women only groups in which women are offered a safe space to explore aspects of their experience they are ready to explore and/or share with other trauma survivors, are reflective of such an understanding.
Relationships play a key role in women’s initial and escalating substance use, as well as her success or failure in recovery. Women are much more likely to identify relationships as source of identity, support and strengths. As such, it is important that loved ones are involved in a woman’s treatment, to the extent it is deemed safe and practical. Additionally, as many women with traumatic backgrounds typically lack healthy relationships, an exploration as to interpersonal violence, healthy versus unhealthy relationships, personal boundaries and co-dependency may prove helpful in paving the way to building a healthy and lasting support network. Given the diversity of women seeking addictions treatment, the most important implication is perhaps for treatment providers to involve women in exploring and addressing what is important to them. This will put power of these women’s lives back to where it belongs: into their own hands.
As free of costs, recovery communities may play a very important role in the treatment and long-term support of marginalized women, given their economic limitations of accessing paid community resources. Those fulfilling women’s need in addressing and connecting with others facing multiple barriers may be of particular value. For women of indigenous background, an exploration of and reconnection with culturally appropriate healing practices, such as sweat lodges in North American Native cultures for example, may prove an immeasurable source of strength and identity.
Involving women’s communities, and society at large is paramount in addressing some of the root causes and wider issues women with addiction are facing. To attribute problematic substance use to individual moral shortcomings, genetic pathology or a lack of will is an easy cop out. It fails to address the myriad of external factors contributing to the growing and very costly health problem that addiction is. Oppression of marginalized women, societal stigmata, culturally sanctioned use of alcohol, all forms of –isms (racism, ageism, able-ism, homophobia etc), drug availability, violence against girls and women, as well as lack of gender or trauma sensitive treatment resources all contribute to women’s initial, escalating or continued substance use. Thus, addressing the root causes of addiction requires a concerted effort on the individual, familial, cultural and societal level. Together we can.
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