Providing culturally and clinically competent mental-health and addiction services requires clinicians to meet their patients in the reality of the patient’s life with compassion and empathy for their unique needs. Central to these needs are an understanding of and sensitivity to gender differences and related power dynamics.
Historically, treatment programmes failed to properly address identity constructs which deviate from a normative standard of a middle-aged, white male demographic (research ref 1 in footnotes). True cultural and clinical competency must address the following.
The sociocultural framework in which patients live. This includes the dominant cultural view of gender and the zeitgeist surrounding gender expression and gender roles. This analysis must include the impact of patriarchy and an understanding of feminist theory.
Their family of origin. In addition to obtaining a thorough medical and psychological history, clinicians must get a sense of how gender roles manifested in the patient’s family of origin.
The interpersonal relationships. Gender roles historically come with prescribed power structures. It is critically important that clinicians understand the pathological power dynamics that are supporting the patient’s illness in order to fashion appropriate interventions and support the patient’s long-term recovery.
Their intrapersonal relationship. Everyone has an internal dialogue and self-concept. Men tend to value themselves for “what can I get” while, in contrast, women tend to define their value by “what can I give”.
In addition, effective and competent treatment requires clinicians to understand and incorporate the following evidentiary findings relating to addiction and gender differences into their treatment plans.
Men are more likely than women to become addicts 2. In 2008, the US National Survey on Drug Use and Health found that 11.5% of males aged 12 and older had a substance abuse or dependence problem, compared with 6.4% of females. Women, however, face tougher challenges to getting treatment. It is important to note this gap is narrowing.
Women suffer from a phenomenon know as telescoping. Women progress more quickly from using an addictive substance to dependence, addiction and treatment then men. Women who enter treatment do so with a more severe clinical profile than men despite having used less of the substance or having used the substance for a shorter time compared with men 3. This means they present with more severe medical, behavioural, psychological and social problems.
Hormonal differences impact substance responsiveness. Oestrogen, progesterone, metabolites of progesterone and negative allosteric modulators of the GABA-A receptor, such as DHEA, can influence the behavioural effects of drugs 4.
Younger women and older men develop more medical consequences of addiction than men. This is a function of key enzymes – dehydrogenase and aldehyde dehydrogenase – and body composition. These two enzymes break down alcohol in the stomach and liver. Younger women and older men have less of these enzymes in their system. As a result, younger women (<50) and older men (>70) absorb alcohol into the bloodstream more quickly and intensely 5. In addition, compared to a man’s, a woman’s body contains less water and more fatty tissue. Alcohol-related problems such as brain atrophy and liver damage occur more rapidly in women than in men.
Women develop more social consequences from addiction than men. There is much greater stigma attached to a woman’s use and abuse of alcohol and drugs than a man’s. Women – and, in particular, mothers – are subjected to shame and ridicule. As a result, their use tends to be more “hidden” than it is among men.
Women suffer from higher rates of mood and anxiety disorders than men. Lifetime rates of mood and anxiety disorders are significantly higher among women than men, with and without substance-use disorders 6. The most common mood disorder among women was reported as major depressive disorder (15.4%) and the most common anxiety disorder was specific phobia (15.6%) 7.
When provided with the proper social and therapeutic supports, women are just as likely to recover as men. A comprehensive review in the American Journal of Drug and Alcohol Abuse of the literature concluded that, although women with alcohol problems were less likely to enter treatment, once they began treatment they were just as likely as men to recover. But this review also concluded that programmes which provided perinatal care, childcare and other family services would better facilitate women to enter treatment 8.
Gender specific programs are generally no more effective than mixed-gender programmes for alcohol dependence. However, there is greater efficacy for subgroups of women with a history of trauma or abuse, or who have other psychiatric disorders 9.
Family and couples therapy is highly effective. Women have been found to consume mood and mind altering substances in response to family and relational conflict at higher rates than men 10. In addition, their relapse rates are more likely to increase if they are in a relationship with a partner who abuses substances 11.
Gender differences between female and male substance-abuse patients are impacted by a host of biological, emotional, cultural and socioeconomic factors. Central to a patient’s success in recovery is their ability to establish a reparative psychotherapeutic relationship with his or her clinical team. Effective treatment demands that clinicians understand their patients’ unique needs and meet them with cultural and clinical sensitivity.
- Greenfield SF, Grella CE. Alcohol & drug abuse: what is “women-focused” treatment for substance use disorders? Psychiatric Services 2009;60:880–2
US Substance Abuse and Mental Health Services Administration Office of Applied Studies. Results from the 2008 National Survey on Drug Use and Health: National Findings (Department of Health and Human Services, 2008).
- Hernandez-Avila CA, Rounsaville BJ, Kranzler HR. Opioid-, cannabis-, and alcohol-dependent women show more rapid progression to substance abuse treatment. Drug Alcohol Dependence. 2004;74(3):265–72.
- Newman JL, Mello NK. Neuroactive gonadal steroid hormones and drug addiction in women. In: Brady KT, Back SE, Greenfield SF, editors.
- Women and addiction: a comprehensive handbook. Guilford Press; New York: 2009. pp. 35–64.
- Seitz HK, Gerer GE, Simanowsk, UA, Waldherr RW, Eckey R, Agarwal DP, Goedde HW. Human gastric alcohol dehydrogenase activity: Effect of age, sex and alcoholism. (1993) Gut; 34, 1443-1437.
- Conway KP, Compton W, Stinson FS, et al. Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry. 2006;67:247–57.
- Goldstein RB. Comorbidity of substance use with independent mood and anxiety disorders in women: results from the National Epidemiologic Survey on Alcohol and Related Conditions. In: Brady KT, Back SE, Greenfield SF, editors. Women and addiction: a comprehensive handbook. Guilford Press; New York: 2009. pp. 173–92.
- Ashley OS, et al. Effectiveness of Substance Abuse Treatment Programming for Women: A Review, American Journal of Drug and Alcohol Abuse (Jan-Feb 2003): Vol. 29, No. 1, pp. 19–53.
- Greenfield SF, et al. Substance Abuse Treatment Entry, Retention, and Outcome in Women: A Review of the Literature, Drug and Alcohol Dependence (January 5, 2007): Vol 86, No 1, pp. 1-21.
- Annis HM, Graham JM. Profile types on the Inventory of Drinking Situations: implications for relapse prevention counseling. Psychology of Addictive Behaviour. 1995;9:176–82.
- Connors GJ, Maisto SA, Zywiak WH. Male and female alcoholics’ attributions regarding the onset and termination of relapses and the maintenance of abstinence. Journal of Substance Abuse. 1998;10:27–42.