This article was downloaded by: [Dalhousie University] On: 09 October 2014, At: 03:51 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Ethnicity in Substance Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wesa20
Women and Substance Abuse: Gender, Age, and Cultural Considerations a
a
Sally J. Stevens , Rosi A. C. Andrade & Bridget S. Ruiz
a
a
Southwest Institute for Research on Women, University of Arizona , Tucson, Arizona Published online: 18 Aug 2009.
To cite this article: Sally J. Stevens , Rosi A. C. Andrade & Bridget S. Ruiz (2009) Women and Substance Abuse: Gender, Age, and Cultural Considerations, Journal of Ethnicity in Substance Abuse, 8:3, 341-358, DOI: 10.1080/15332640903110542 To link to this article: http://dx.doi.org/10.1080/15332640903110542
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Ethnicity in Substance Abuse, 8:341–358, 2009 Copyright # Taylor & Francis Group, LLC ISSN: 1533-2640 print=1533-2659 online DOI: 10.1080/15332640903110542
Women and Substance Abuse: Gender, Age, and Cultural Considerations SALLY J. STEVENS, ROSI A. C. ANDRADE, and BRIDGET S. RUIZ
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Southwest Institute for Research on Women, University of Arizona, Tucson, Arizona
Historically, data has shown that a smaller percentage of women use alcohol and illicit substances compared to men, and that frequency of use has been lower among women compared to use among men. Although this data on usage may be true, researchers also acknowledge that substance use among women has been a hidden issue, one not realistically acknowledged by society, especially prior to the mid-1960s. Along with this, more recent data indicates that rates of substance use among women are increasing. Factors contributing to this increase in substance abuse have begun to receive considerable attention, and recent research suggests that many issues exist that are unique to substance use among women. The purpose of this article is to discuss gender specific considerations in women’s substance abuse by examining the history of substance use among women; analyzing genderspecific factors, including physiological factors, trauma-related factors, mental health issues, and cultural considerations that impact on women’s substance use; articulating treatment approaches for working with substance abusing women and girls; and providing recommendations for further research in this area. KEYWORDS culture physiology, mental health, substance use, theory, trauma, treatment, women Supported by the National Institutes of Health (NIH)–National Institute on Drug Abuse (NIH) (grant numbers 1 R01 DA 10651 and 1 U01 DA 07470), the Substance Abuse and Mental Health Services Administration (SAMHSA)–Center for Substance Abuse Treatment (CSAT) (grant numbers H79 TI 14452, KD1 TI 11892, KD1 TI 11422, and 5 HD8 TI00383), and SAMHSA–Center for Substance Abuse Prevention (CSAP) (grant number 5 U79 SPO7940). The opinions expressed in this article are those of the authors and do not necessarily reflect the official positions of NIH–CNIDA, SAMHSA–CCSAT, or SAMHSA–CSAP. Address correspondence to Sally J. Stevens, Executive Director, Southwest Institute for Research on Women, The University of Arizona, 1443 E. 1st Street, Tucson, AZ 85721-0403. E-mail: [email protected] 341
342
S. J. Stevens et al.
INTRODUCTION
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Alcohol and drug use among women has been studied by researchers from multiple disciplines primarily because the issues that substance using women face are multi-faceted and complex. This article addresses some of these issues by focusing on the historical, physiological, social, and behavioral factors relevant to women and substance abuse. In addition, this article offers the reader information about effective treatments for substance abusing women, including descriptions of appropriate theoretical models to guide treatment. The article will conclude with a discussion of the research needs and priorities in this critical area.
HISTORY OF SUBSTANCE USE AMONG WOMEN Visibility of Women’s Substance Use Historically, women at all levels of society have used and abused alcohol and drugs. In the United States, marijuana was used by or given to women in the 1600s for treatment of labor pains, uterine hemorrhages, postpartum psychosis, and other illnesses. During the 1700s, use of opium among women increased dramatically. During the Revolutionary War, the production of opium significantly increased because it was used to treat wounded soldiers. Given its availability and acceptance, it was common for women to use opium and syringe kits were openly available for sale. Moreover, for those who were addicted to ‘‘distilled spirits,’’ Dr. Benjamin Rush, a leader in alcohol treatment at this time, recommended beer, wine, or opium as an alternative furthering the use of opium (White, 1998). By the end of the 1800s, two-thirds of the nation’s opium and morphine addicts were women (Kandall & Petrillo, 1996). Besides the use of alcohol and opium, women’s use of cocaine also increased during the 1800s (Stevens, 2006). With the onset of the temperance movement in the 1850s and the subsequent establishment of the Women’s Christian Temperance Union, social stigma and shame became part of the life of an addicted woman. The Martha Washington Society organized special meetings for women and children, including separate meetings for freed African American slaves. At these meetings, women were encouraged to eliminate alcohol from their homes (White, 1998). Although alcohol and drug use became increasingly more concealed, use was also made easier with the increasing production of alcohol based ‘‘medicines’’ (White & Kilbourne, 2006). Drug use by women became even more invisible on the passing of the Harrison Anti-Narcotic Act of 1914, which focused on supply and crime versus personal use and treatment. Women’s alcohol and drug use varied through the 20th century; it increased during the Prohibition era (e.g., in nightclubs and cabarets),
Women and Substance Abuse
343
Downloaded by [Dalhousie University] at 03:51 09 October 2014
decreased in the 1940s and 1950s, and again increased during the women’s movement in the 1960s and 1970s. The increase in the visibility of women’s drug use in the 1960s was in part due to the shift in national priority from a focus on supply and crime to a focus on mental health and substance abuse (Kandall & Petrillo, 1996; Stevens, 2006). Since then, women’s treatment needs have received considerably more attention, although social stigma and shame continue to be a part of women’s substance use portfolio (White & Kilbourne, 2006). This harsh treatment of women runs parallel with society’s expectation for women to provide the moral foundation for the family, yet their own virtue is continually held in suspect (Lanzetta, 2005).
History of Prescription Medications Historically, doctors have consistently prescribed drugs more often for women than for men. In part, this was due to the perception that women could not become addicted to alcohol or drugs. Women were thought to have problems or illnesses that could be treated openly (Brown, 2006), hence the visible flask of alcohol or the syringe that often hung from the bodice of a women’s dress. In the 1800s, doctors commonly prescribed cocaine for ‘‘neurasthenia,’’ or what was then the considered a nervous weakness (Kandall & Patrillo, 1996; Stevens, 2006). Lydia Pinkham’s Vegetable Oil which had 30% alcohol content was commonly used for many ailments by women who did not ‘‘drink’’ (Brown, 2006). Unfortunately, prescription drug use has remained a problem for women from all ethnic backgrounds. Although advertising for over the counter drugs, including cigarettes, has targeted women, pharmaceutical representatives have gone to great efforts (e.g., samples, promotional materials, incentives, etc.) to influence physicians to prescribe medications for women. White and Kilbourne (2006) found that the ratio of women to men shown in advertisements for antidepressants in two journals, the American Journal of Psychiatry and the American Family Physician, was 5:1 and 10:1 respectively (Hansen & Osborne, 1995). Although use of prescribed psychoactive drugs is appropriate in certain circumstances in the treatment of some mental health problems, its over-use has taken its toll—keeping women sedated and numb from their thoughts and emotions and resulting in their inability to understand and resolve issues such as self-worth, anxiety, and depression (Stevens, 2006).
Ethnicity and Substance Abuse Patterns and prevalence of alcohol and drug use among women from ethnic minorities differ from that of Caucasian women (Stevens, Estrada,
Downloaded by [Dalhousie University] at 03:51 09 October 2014
344
S. J. Stevens et al.
Glider, & McGrath, 1998). Although Kandall and Patrillo (1996) found reports on the use of substances by African American women as early as the 1800s, the use of alcohol was so moderate among African Americans that many thought that they were immune to its influences (White, 1998). Historically, American Indian women used substances derived from various botanicals for ceremonial and medicinal purposes (Schultes & Hoffman, 1992), although use varied considerably by tribe. Although a few tribes prepared alcohol-based beverages as a part of seasonal ceremonies, the widespread use of alcohol among American Indians can be traced to the influence of Europeans and the displacement of Natives from their culture and land during the 1800s (Berkowitz, Peterson, Smith, Taylor, & Brindis, 1998). Alcohol use crossed both gender and age boundaries with both men and women involved not only in the use of alcohol, but also in the liquor trade as well (Mancall, 1995). For Mexican-origin Hispanic women, herbs were and still are widely used for medicinal purposes (Yount, 2006). However, use of illicit substances has, for the most part, been more closely associated with acculturation. Chambers (2005), for example, found that increased alcohol use among low-income Latinas was impacted by speaking English and by acculturation, and Nu~ no, Romero, Orduna, Estrada, and Stevens (2006) found that third-generation Hispanic and American Indian youth were more likely to report having used alcohol compared to those who had recently immigrated from Mexico to southern Arizona.
Prevalence of Substance Use Among Adult Women and Adolescent Girls Current data indicates that an estimated 6.5 million (5.9%) of women 18 years of age or older, met the criteria for past year abuse or dependence on alcohol or illicit drugs (Drug and Alcohol Services Information System [DASIS], 2005b). Of these women, it is estimated that 5.2 million (4.7%) abused or were dependent on alcohol and that 2 million (1.8%) abused or were dependent on illegal drugs. This same report illustrates that there is a decrease in their substance abuse and dependence as women age. Approximately 15% of women aged 18 to 25 years abused or were dependent on alcohol or illicit drugs compared to almost 9% of women aged 26 to 34 years. It is noteworthy that although 6.5 million women met criteria for abuse or dependence, 92% did not receive treatment services (DASIS, 2005a; National Center on Addiction and Substance Abuse, 2006). This disparity could be attributed to the way that men and women enter treatment. Women are most frequently referred to treatment through self-referral, whereas men are most frequently referred to treatment through the criminal justice system (DASIS, 2005a).
Women and Substance Abuse
345
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Substance Use and Ethnicity A DASIS (2005a) report also showed that current illicit drug use was associated with race=ethnicity. Rates were lowest among Asians (3.1%). Rates were 12.8% for American Indians and Alaska Natives, 12.2% for persons reporting two or more races, 9.7% for non-Hispanic Blacks, 8.7% for Native Hawaiians or Other Pacific Islanders, 8.1% for Whites, and 7.6% for Hispanics. Data from treatment and community based projects working with active drug users in southern Arizona indicate that not only type of drug use, but also frequency of drug use varies by race=ethnicity. African American women had the lowest rate of injection drug use at two days per month, compared to Hispanics at seven days per month, Caucasians at nine days per month, and American Indian women at ten days per month (Stevens et al., 1998).
GENDER-SPECIFIC ISSUES IN WOMEN’S SUBSTANCE USE: PHYSIOLOGICAL, TRAUMA-RELATED, MENTAL HEALTH, AND CULTURAL ISSUES Although many factors may impact substance use among women (e.g., socioeconomic status, education, parenting issues, domestic violence), the primary women-specific issues to be examined in this article include physiological factors, trauma-related issues, mental health status, and cultural considerations.
Physiological Factors Physiological factors that impact substance abuse among women include gender differences in physiology, women’s menstrual cycle, and pregnancy. Several studies have found differences in the way men and women metabolize alcohol and other drugs. Blood alcohol levels for women are higher than blood alcohol levels in men with the same height=weight ratio and amount of alcohol consumed. A variety of physiological factors account for these differences, including women’s higher body fat-over-water ratio, reduced liver-mass-over-body weight ratio, fewer stomach enzymes to break down alcohol, and estrogen-induced effects (Stevens, 2006; Ward & Coutell, 2003). These physiological factors may be one reason that, as noted in a National Center on Addiction and Substance Use (2006) report, women become addicted in shorter period of time compared to men even when using less alcohol or drugs. Women also suffer more severe brain damage from substance use and they develop substance-related diseases such as lung cancer more quickly. Recent research using new imaging techniques has revealed differences in brain composition and activity of drug users compared to non-drug users.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
346
S. J. Stevens et al.
For example, a study comparing methylenedioxymethamphetamine (Ecstasy) users and non-users revealed smaller concentrations of grey matter in the Ecstasy users compared to non-users. These subtle but statistical differences were evidenced in the neocortex, which may be involved in word definition; the brain stem, which controls respiration and heart rhythms; and the cerebellum, which controls movement, motor learning, and special sense (Cowen et al., 2003). Gender appears to influence biological responses to nicotine and other substances. When women smoke cigarettes, they take fewer and shorter puffs. Women experience improvements in mood that men do not, which is perhaps one reason that women are not as successful as men at quitting. Women and men may process cocaine cues differently as well. A study by Whitten (2004) shows increased activity in the right nucleus accumbens for both men and women when they crave cocaine but differences in activity in the amygdala, dorsal anterior cingulated cortex, ventral anterior cingulated cortex, and frontal cortex. These findings suggest that both women and men have an expectation of pleasure when they crave cocaine but have different expectations in the outcomes of use, leading researchers to think that women may use drugs for different reasons than men. Social scientists have long thought that men are more likely to use drugs to ‘‘have fun,’’ whereas women may be more likely to use drugs to feel closer to others, to secure good feelings in an intimate relationship, and to reduce inhibitions (Stevens, 2006). Studies also indicate that a woman’s menstrual cycle influences her consumption of alcohol and illicit drug use, which also impacts related consequences of use (e.g., mental health issues, criminal behavior, and HIVrisk behavior) (Schnoll & Weaver, 1998; Stevens & Estrada, 1999). During the follicular phase (before ovulation), women report higher ratings of ‘‘good’’ drug effects and ‘‘liking and using’’ the drug more. In studies on cigarette smoking, women in the follicular phase reported less cigarette smoking and cravings, but weight gain, reduced desire to smoke or relieve negative affect, fewer withdrawal and depressive symptoms, and better abstinence when cessation were initiated during this phase. In the luteal phase, women have reported significantly more drug cravings (Wetherington, 2006). In part, due to physiological effects, birth control pills have been associated with increased blood alcohol levels; other studies have shown that women absorb alcohol more rapidly when they are premenstrual (Stevens, 2006). In a study with women actively using drugs, participants reported that their menstrual cycle not only affected their drug use, but also their drug use affected their menstrual cycle. Sixty percent reported that their menstrual bleeding or cramps stopped, 26% reported that menstrual bleeding or cramps decreased, and 32% reported that they had experienced an increase in bleeding or cramping due to their drug use. Type of drug use was related to these reported effects. For example, heavy methamphetamine and cocaine use was generally associated with missed periods (and significant weight loss)
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
347
as well as increased cramping with periods, whereas use of narcotics and alcohol was associated with decreased cramping and pain associated with cramping (Stevens & Estrada, 1999). Pregnancy can serve as both a motivator and a barrier to entering substance abuse treatment or addressing one’s use of substances. The desire to have a healthy baby can be a powerful motivator for behavior change (Reed, 1985; Stevens, Murphy, & McGrath, 2000). Unfortunately, many substance using women report not receiving information about substance abuse from their medical providers (Salmon, Joseph, Saylor, & Mann, 2000). The likelihood that a pregnant woman will be screened for drug use may increase if there are medical complications with the pregnancy, if the woman is seen at a public versus private provider, or if she is an ethnic minority (Chassnoff, Landress, & Barrett, 1990; Weir, Stark, Fleming, He, & Tesselaar, 1998). Although recent changes in medical practice have increased screening for substance use, the lack of screening presents a missed opportunity to educate pregnant women about the adverse effects of prenatal drug use and to provide appropriate referrals and assistance. Although pregnancy can be a motivator to address one’s drug problem, both pregnancy and parenting have been and continue to be barriers to treatment entry for women (Greenfield, 2006). Women frequently report issues concerning child custody, including custody of those yet to be born (Bogart & Stevens, 2004), and difficulty with transportation and childcare as factors for not entering substance abuse treatment (MacMaster, 2005; Wechsberg, 1995).
Trauma-Related Factors There is a strong relationship between substance use and the experiences of traumatic stress (Stevens & Bogart, 1999). The use of drugs can affect a women’s judgment about whether a situation is safe, reduces their inhibitions leading to risky social situations, creates a physical and psychological drug dependency that results in dangerous exchanges of sex for money or drugs, and may impact women’s decision to engage and remain in a violent partner relationship. In studies of the relationship between stress and drug usage, women reported that traumatic experiences occurred first (Stevens et al., 2000). In one study, of the 80 women enrolled in substance abuse treatment, 74% reported having been raped at an average age of 12.6 years, and 80% reported having been physically assaulted at an average age of 12.9 years. The average age of first drug use was 13.7 years. Interestingly, age of first consensual sex was 15.1 years. Losing one’s virginity can be a traumatic experience for many women, whether the loss of virginity was due to being raped or was consensual. In a sample (N ¼ 500) of women in substance abuse treatment, Andrade, Cameron, Stevens, and Ruiz (2006) found that
Downloaded by [Dalhousie University] at 03:51 09 October 2014
348
S. J. Stevens et al.
53% of American Indian, 39% of bi- or tri-racial, 34% of Hispanic, 31% of African American, and 27% of Caucasian women reported that losing their virginity was ‘‘considerably’’ to ‘‘extremely’’ upsetting. Andrade et al. (2006) also found that different types of trauma vary for women from different racial or ethnic backgrounds. For example, although not having a stable place to live at some point in their lifetime was equally upsetting for women of all ethnicities (84% to 87% ‘‘considerably’’ to ‘‘extremely’’ upsetting), the reported frequency of not having a stable place to live varied from 79% of African American women to 76% of bi- or-racial women, 71% of Caucasians, 68% of American Indian, and 66% of Hispanic women. Examples of other traumas that differed by race=ethnicity included death of a close family member, which was reported by 92% of African American, 89% of American Indian, 87% of Latina, 80% of bi- or tri-racial, and 73% of Caucasian women. Being a victim of a crime was reported by 85% of Caucasian, 64% of bi- or tri-racial, 63% of African American, 62% of American Indian, and 59% of Hispanic women. Moreover, historical trauma experienced particularly by women from ethnic minority backgrounds may impact substance abuse. Brave Heart (2003) described historical trauma among American Indians as an accumulation of psychological and emotional wounding across generations arising from group trauma experiences. This is particularly noteworthy for American Indians, who suffered ongoing and extensive trauma with regard to themselves, their children, and their communities (Simoni, Sehgal, & Walters, 2004). Responses to historical trauma have included low self-esteem, anger, self-destructive behavior, mental health issues, and substance use and related problems. Data from adolescents (N ¼ 372) in substance abuse treatment indicate high levels of traumatic stress. As reported by Stevens, Murphy, and McKnight (2003), adolescents who report having greater symptoms of traumatic stress (e.g., trouble concentrating or trouble sleeping) enter treatment with significantly greater problems associated with lifetime substance abuse, worse problems associated with general mental health, higher levels of depressive symptoms, and greater homicidal and suicidal ideation. In addition, gender differences are also present, with girls evidencing worse scores in all of these areas.
Mental Health Issues Gender differences in the mental health of adult substance abusers indicate that women have mental health disorders such as depression, anxiety, stress disorders eating disorders, and low self-esteem more frequently than men. In comparison, men typically have more trouble with functional living and with issues such as work, money, and legal problems (Substance Abuse and Mental Health Service Administration, 2005). Fortunately, outcome data from
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
349
women who have participated in substance abuse treatment show that treatment is not only effective in assisting women in reducing substance use, but also mental health problems are also reduced following treatment (Wexler, Cuadrado, & Stevens, 1998). In a national study of adolescents (N ¼ 1,207) enrolled in substance abuse treatment, Stevens, Estrada, Murphy, McKnight, and Tims (2005) compared the baseline data of boys and girls. Baseline substance use frequency, problems associated with substance abuse, and behavioral complexity (e.g., external behavior such as attention deficit disorder or conduct disorder) were higher for girls than boys. In addition, girls’ scores on general mental health were almost twice as high (severe) for girls as they were for boys. Fortunately, outcome data 3, 6, 12, and 30 months after substance abuse treatment demonstrated a significant reduction in substance use from baseline to 3 and 6 months, followed by a slight increase at 12 months and again at 30 months, but never returning to the baseline level of severity. General mental health problems and behavioral complexity reduced from baseline to 3, 6, and 12 months, followed by an increase in these problems at 30 months. However, severity at 30 months was still substantially lower than severity at baseline.
Ethnic and Cultural Considerations As noted previously, the type of substance use not only varies by race and ethnicity, but also patterns of use and contextual issues associated with use vary between women from different racial and ethnic backgrounds. Data from several women’s intervention projects located in southern Arizona show that, on average, African American adolescent girls initiate alcohol and drug use 1 to 3 years later at or about the age of 15 years (Andrade et al., 2006; Stevens et al., 1998). In addition, data on Hispanic women reveals a consistent pattern across data bases and programs with regard to a rapid trajectory from age of first alcohol and marijuana use to hardcore drug use such as heroin and cocaine when compared to other racial or ethnic groups (Andrade, Stevens, & Ruiz, 2005; Stevens, Ruiz, Romero, & Gama, 1995). Given these differences, one may look at protective or contributing factors involved in substance use based on cultural considerations. Cultural and social expectations of African American young women as a source of strength in the family may contribute to empowerment in their teens and resiliency to using substances. Meanwhile, the rapid trajectory from alcohol and marijuana use to hardcore drug use for Mexican-origin Hispanic women may imply a conflict between cultural expectations and behavior—that once a young woman uses illicit substances, she has violated cultural expectations, which then thrusts her on a course to further drug use (Andrade & Stevens, 2004). Contextual issues of substance-using women vary by race and ethnicity with White women typically having achieved a higher level of education.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
350
S. J. Stevens et al.
Andrade et al. (2006) reported that of 495 women in treatment, American Indian women were the least likely to have a high school education (21%) as compared to bi- or tri-racial (46%), Hispanic (47%), African American (53%), and White (67%) women. American Indian women were also the most likely to be unemployed (68%) compared to the other racial or ethnic groups (average of 78%). Other disparities include homelessness, with twice as many (61%) African American women perceiving themselves as homeless as other racial or ethnic groups (average of 35%). Disparities were also found for the number of times arrested; American Indian women reported fewer arrests (3.3 times) compared to other women (average of 5.5 times). In another study, twice as many American Indian women reported having health insurance (typically through Indian Health Services) compared to other ethnic groups, but approximately half (47%) reported being homeless (Stevens, Estrada, & Villareal, 2003). Women who lack education or employment skills, are homeless, or may have probation violations for a previous arrest may remain in drug or violence plagued living environments for shelter because working or earning a livable wage may not be a option (Stevens & Bogart, 1999). These issues have substantial implications with regard to both access to substance abuse treatment and the need for gender-specific treatment.
WOMEN AND SUBSTANCE ABUSE TREATMENT The proportion of substance abuse treatment clients who are female has increased moderately over the past decade. According to the DASIS report (2005a), approximately 30% (565,000) of admissions to substance abuse treatment facilities were women, up from 28% in 1992. Among individuals 12 years or older in 2004, men were 2.5 times as likely as women to have received treatment for an alcohol or an illicit drug use problem in the past year (2.3 vs. 0.9, respectively) (National Survey on Drug Use and Health, 2005). Women in treatment were more likely to enter treatment for opiate or cocaine use or abuse and less likely to be in treatment for alcohol or marijuana use as compared to men. Women also tend to be younger than men when they enter treatment (33 years versus 34 years, respectively), yet women initiate substance use at an older age (20 years versus 18 years, respectively) (DASIS, 2005a). Gender differences exist not only in the utilization of substance abuse treatment, but also in regard to reasons for treatment entry, retention in treatment, and treatment outcomes. Grella and Joshi (1999) conducted analysis on the Drug Abuse Treatment Outcomes Study data (N ¼ 7,652) and found that men enter treatment more frequently under pressure from family, an employer, or the criminal justice system, and women are more
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
351
often self-referred or social worker referred, with influencing factors such as trading sex for money or drugs, mental health problems, and single parenting issues. Although treatment retention appears to be the same for women as it is for men, individual characteristics such as personal stability, psychological functioning, and number of children are predictors of retention and completion among women (Greenfield, 2006). Treatment outcomes suggest similar or better outcomes for women when compared to men even across treatment modalities (Greenfield, 2006). However, psychosocial contextual issues such as mental health status, trauma, grief and loss, and family=spouse characteristics have been found to contribute to treatment success (Stevens, 2006). Examination of gender differences between adolescents entering substance abuse treatment suggests similar trends and may, in fact, be more pronounced. Treatment admissions data show that 70% are boys. In examining gender differences in adolescents enrolled in substance abuse treatment, Stevens et al. (2005) found that girls enter treatment with higher levels of substance use, report more problems with use, and report harder drug use (e.g., cocaine or opiates) as their primary substance compared to boys. Moreover, girls have significantly worse mental health problems, yet respond to treatment and have just as good or better outcomes compared to boys.
Women, Ethnicity, and Treatment According to several DASIS reports (2002, 2005b, c, d), differences treatment admissions by race=ethnicity clearly exist. American Indians and Alaskan Natives were more likely to report alcohol as their primary substance of abuse compared to admissions of other racial or ethnic groups (63% versus 42%). Interestingly, a higher proportion of American Indians and Alaskan Natives admissions were women compared to admissions from other racial or ethnic groups (36% versus 30%). For non-Hispanic Blacks, approximately two-thirds of the treatment admissions were for alcohol or cocaine use. From 1994 to 1999, non-Hispanic Blacks admissions into treatment decreased by 15%. As compared to Black men, Black women were more likely to enter treatment for the use of harder drugs (e.g., cocaine or opiates). Asian=Pacific Islanders were more likely to enter treatment for either marijuana or methamphetamine=amphetamine use than other racial or ethnic groups. Only 28% of Asian=Pacific Islander treatment admissions were women. Individuals of Hispanic=Latino ethnicity were more likely to report opiate abuse than non-Hispanic admissions (28% versus 16%) and the majority of these admissions were men (78%). Among the adolescent population, White youth report more family and mental health problems, whereas Hispanic youth report more legal problems and issues and more experiences of trauma (Murphy & Stevens, 2001). Among Hispanic adolescents, traditional gender norms have been shown
352
S. J. Stevens et al.
to be a protective factor for substance use, although not a protective factor for risky sexual behavior (Luther, Stevens, Bracamonte Wiggs, & Ruiz, 2005).
Downloaded by [Dalhousie University] at 03:51 09 October 2014
THEORIES AND METHODS FOR WORKING WITH FEMALE SUBSTANCE ABUSERS Many researchers and clinicians argue for gender-specific treatment that not only includes addressing substance abuse, but also addresses social, economic, medical, and legal constraints thought to be related to substance use (Stevens & Bogart, 1999). In addition, providing childcare, life-skills training, transportation, and special programming for minority women are also thought to be critical to women’s treatment and recovery (Greenfield, 2006; Wechsberg, Lam, Zule, & Bobashev, 2004). Several treatment modalities exist, such as residential treatment with and without children, day treatment, outpatient treatment, and peer support. Within treatment modalities, both mixed gender and women’s only groups are offered. Outcomes from these different modalities and group composition are mixed, although there is mounting evidence that for pregnant and parenting women in particular, residential treatment enhances treatment success (Greenfield, 2006). The history of substance abuse among women and gender-specific factors (e.g., physiological, trauma-related, mental health, and cultural consideration) that impact women’s substance use suggests that addiction among women is closely connected to negative and sanctioned socialization and with personal experiences of disempowerment (Stevens & Bogart, 1999; White & Kilbourne, 2006). Throughout history, women have experienced varied forms of oppression from structural (economic) to personal (loss of identity) to specific (abuse). These varied forms of oppression injure women in unique and particular ways, damaging the receptive aspect of women’s nature (Lanzetta, 2005). Oppression invades a women’s psyche at such a deep level that women are often unable to identify the source of their pain. Unidentified, unspoken, denied, and dismissed, women may react in unhealthy ways, such as protecting their oppressor (Lanzetta, 2005) or by numbing feelings through the use of prescribed, legal, or illicit substances (Stevens, 2006). Because of women and girls’ societal status and life circumstances, we need gender-appropriate theories and methods to guide women’s treatment, regardless of treatment modality. Among these theories and methods are the following five approaches: social ecology model, empowerment theory, relational model, feminist theory, and participatory action research. Social ecology is an overarching framework for understanding the interrelations among diverse personal and environmental factors in human health and illness. It integrates person-focused efforts with environment-focused interventions (Stokols, 1996). Thus in working with women, the researcher
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
353
must consider that the context of the each woman’s life is critical, and successful substance abuse treatment needs to change both personal and social vulnerabilities. Empowerment theory compels researchers and service providers to think in terms of wellness versus illness, competence instead of deficits, and strengths versus weaknesses. Programs need to provide opportunities for women to establish a sense of self-empowerment, self-efficacy, and self-control and to assist these women in gaining the skills and resources that they need to take control of their lives (Belenky, Clinchy, Goldberger, & Tarule, 1986). The relational model is a theoretical paradigm for women’s psychological development and well-being. Hypothesizing that women’s development is embedded in relationships and that relationships with others are primary to a women’s health and well-being, treatment providers using this model pay substantial attention to developing healthy family, peer, and significant other relationships (Belenky, Bond, & Weinstock, 1997). Feminist theory examines substance abuse from the point of view of oppression and attempts to engage women in larger causes. A feminist approach raises the issue of subjectivity versus objectivity and stresses working with women in an equal capacity, challenging the typical power relationship between the researcher and the researched (Bowles & Klein, 1983). Participatory action research is a collaborative approach that equitably involves all partners and recognizes the unique strengths of each participant. Substance abuse treatment based on this framework would involve the woman specifically in the development of her own treatment, reflecting, planning, and implementing her own treatment plan based on her unique strengths (Kaplan & Alsup, 1995; McTaggart, 1997; Pederson, 1988; Sissel, 1996).
FUTURE DIRECTIONS IN SUBSTANCE ABUSE TREATMENT AND RESEARCH Most research on women and substance abuse, including gender differences, has been conducted in the past 15 years, and thus there are still considerable gaps in knowledge and many questions yet to be answered. Topics that need continued investigation include factors that contribute to young girls’ initiation into substance use, gender differences in the physiological effect of substance use, and facilitators and barriers to substance abuse treatment entry. Also needed are in-depth process and outcome studies on substance abuse treatment that take into account gender-specific needs, utilize women-centered approaches, and provide concurrent treatment for co-morbid disorders. Examination of what happens following treatment is
Downloaded by [Dalhousie University] at 03:51 09 October 2014
354
S. J. Stevens et al.
also critical and includes studies on physiological changes following abstinence from substance use, factors associated with continued abstinence or that lead to relapse, and cost-benefit analysis of providing treatment compared to no-treatment or incarceration for drug and drug-related convictions. Within the overarching theme of research on women and substance abuse, additional research is required that takes into consideration women’s position in society, culture, family, and contextual issues such as abuse history, grief and loss, and economic factors. Careful consideration of how women’s oppression contributes directly or indirectly to substance use (prescribed, legal, and illicit) may further illuminate strategies that not only improve treatment effectiveness but reveal needed structural changes to improve women’s well-being. Although current research suggests that culturally driven treatment approaches seem to be effective, articulating what the treatment is and for whom it works would further the field. Family-centered approaches such as family drug courts and residential treatment for pregnant and parenting women have shown promising outcomes (Green, Furrer, Worcel, Burrus, & Finigan, 2007; Stevens & Patton, 1998; Wexler et al., 1998). Future research within family-driven approaches might focus on the examination of family-related issues that may be associated with substance use, treatment entry, and treatment success as well as expansion of these family treatment approaches to include the extended family network. Because current data points to the impact of contextual issues on the initiation of substance use, treatment needs, and treatment outcomes, research that focuses on how various contextual issues are intertwined with substance use, along with the relative effectiveness of concurrent treatment approaches (e.g., trauma with substance use or grief and loss with substance abuse), is specifically needed. Finally, in any study on substance abuse treatment, fidelity in the delivery of the intervention is imperative so that when successful outcomes are documented, there is a clear understanding of what the treatment consisted of and how it was delivered. The importance of achieving follow-up rates at or above 90% is also vital so that confidence in the findings is achieved. Most importantly, as the field of women and substance abuse advances and the understanding of the issues affecting this population further emerge, advocacy at the policy and funding level will be critical to move new research findings into substance abuse prevention and treatment practice.
REFERENCES Andrade, R., & Stevens, S. (2004, October). Understanding the lives of Latinas at risk for HIV=AIDS. Paper presented at the National AIDS Awareness Day Symposium, Tucson, AZ.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
355
Andrade, R., Cameron, M., Stevens, S., & Ruiz, B. (2006). Women and substance abuse. Fifth Annual Women’s Mental Health Symposium, January 7, 2006, Tucson, AZ. Andrade, R., Stevens, S., & Ruiz, B. (2005). Understanding the lives of women at-risk for HIV=AIDS. Bridging Science and Culture to Improve Drug Abuse Research in Minority Communities: 2005 Health Disparities Conference. October 24–25, 2005. Atlanta, GA. Belenky, M. F., Bond, L. A., & Weinstock, J. S. (1997). A tradition that has no name: Nurturing the development of people, families, and communities. New York: BasicBooks, Inc. Belenky, M. F., Clinchy, B. M., Goldberger, N. R., & Tarule, J. M. (1986). Women’s ways of knowing: The development of self, voice, and mind. New York: BasicBooks, Inc. Berkowitz, G., Peterson, S., Smith, E. M., Taylor, T., & Brindis, C. (1998). Community and treatment program challenges for chemically dependent American Indian and Alaska Native women. Contemporary Drug Problems, 25, 347–371. Bogart, J. G., & Stevens, S. J. (2004). Legal systems issues among drug-involved women enrolled in a community based HIV prevention program. In K. Knight & D. Farabee (Eds.), Treating addicted offenders: A continuum of effective practices. Kingston, NJ: Civic Research Institute. Bowles, G., & Klein, R. D. (1983). Theories of women’s studies. Boston: Routledge & Kegan Paul. Brave Heart, M. Y. H. (2003). The historical trauma response among natives and its relationship with substance abuse. Journal of Psychoactive Drugs, 35, 7–13. Brown, S. (2006). Women, addiction and recovery: A new self. Counselor, 7, 12–18. Chambers, C. D. (2005). Alcohol consumption among low-income pregnant Latinas. Alcoholism: Clinical and Experimental Research, 11, 2022–2028. Chassnoff, I. J., Landress, H. J., & Barrett, M. E. (1990). The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. The New England Journal of Medicine, 322, 1202–1206. Cowen, R. L., Lyoo, I. K., Sung, S. M., Ahn, K. H., Kim, M. J., Hwang, J., et al. (2003). Reduced cortical grey matter density in human MDMA (ecstasy) users: A voxel-based morphometry study. Drug and Alcohol Dependence, 72, 225–235. Drug and Alcohol Services Information System (DASIS). (2002). Black admissions to substance abuse treatment: 1999. The DASIS Report. SAMHSA, OAS, March 1, 2002. Drug and Alcohol Services Information System (DASIS). (2005a). A comparison of female and male admissions: 2002. The DASIS Report. SAMHSA, OAS, May 20, 2005. Drug and Alcohol Services Information System (DASIS). (2005b). Hispanic substance abuse treatment admissions: 2003. The DASIS Report. SAMHSA, OAS, August 19, 2005. Drug and Alcohol Services Information System (DASIS). (2005c). Substance abuse treatment admissions among American Indians and Alaskan Natives: 2002. The DASIS Report. SAMHSA, OAS, February 11, 2005. Drug and Alcohol Services Information System (DASIS). (2005d). Substance abuse treatment admissions among Asians and Pacific Islanders: 2002. The DASIS Report. SAMHSA, OAS, June 10, 2005.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
356
S. J. Stevens et al.
Green, B. L., Furrer, C., Worcel, S., Burrus, S., & Finigan, M. W. (2007). How effective are family treatment drug courts? Outcomes from a four-site national study. Child Maltreatment, 12, 43–59. Greenfield, S. F. (2006, July). Substance abuse treatment outcomes for women. Paper presented at A National Conference on Women, Addiction, and Recovery: News You Can Use, Anaheim, CA. Grella, C. E., & Joshi, V. (1999). Gender differences in drug treatment careers among clients in the national drug abuse treatment outcome study. American Journal of Drug and Alcohol Abuse, 25, 383–404. Hansen, F. J., & Osborne, D. (1995). Portrayal of women and elderly patients in psychotropic drug advertisements. Women and Therapy, 16, 129–141. Kandall, S. R., & Petrillo, J. (1996). Substance and shadow: Women and addiction in the United States. Cambridge, MA: Harvard University Press. Kaplan, S. J., & Alsup, R. (1995). Participatory action research: A creative response to AIDS prevention in diverse communities. Convergence, 28, 38–56. Lanzetta, B. J. (2005). Radical wisdom: A feminist mystical theology. Minneapolis, MN: Fortress Press. Luther, K., Stevens, S. J., Bracamonte Wiggs, C., & Ruiz, B. (2005, April). Perception of gender roles among Latino=a adolescents at-risk for HIV and substance use. Paper presented at the Epidemiology in Arizona Forum, Tucson, AZ. MacMaster, S. A. (2005). Experiences with, and perceptions of, barriers to substance abuse and HIV services among African American women who use crack cocaine. Journal of Ethnicity in Substance Abuse, 4, 53–75. Mancall, P. C. (1995). Men, women, and alcohol in Indian villages in the Great Lakes Region in the early republic. Journal of the Early Republic, 15, 425–448. McTaggart, R. (1997). Participatory action research, international contexts and consequences. Albany, NY: State University of New York Press. Murphy, B. S., & Stevens, S. J. (2001, April). Environmental stress among Latino and non-Latino adolescent substance abusers enrolled in a residential substance abuse treatment program. Paper presented at the National Association for Chicana and Chicano Studies National Conference, Tucson, AZ. National Center on Addiction and Substance Abuse. (2006). Women under the influence. Baltimore, MD: The Johns Hopkins University Press. National Survey on Drug Use and Health. (2005). Gender differences in substance abuse dependence among women. The NSDUH Report. Published by OAS, SAMHSA, September 16, 2005. Nu~ no, T., Romero, A., Orduna, M., Estrada, A., & Stevens, S. (2006, November). Taking a closer look at health disparities within Mexican descent adolescent substance use. Paper presented at the 134th Annual Meeting & Exposition of the American Public Health Association, Boston, MA. Pederson, C. (1988). Nunca antes me habı´an ensen~ado eso, Capacitaci on feminista: Metodologı´a=comunicaci on= impacto. Me´xico: Edici on Carolina Carlessi. Reed, B. G. (1985). Drug misuse and dependency in women. International Journal of the Addictions, 20, 13–62. Salmon, M. M., Joseph, B. M., Saylor, C., & Mann, R. J. (2000). Women’s perception of providers, social, and program support in an outpatient drug treatment program. Journal of Substance Abuse Treatment, 19, 239–246.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
357
Schnoll, S. H., & Weaver, M. F. (1998). Pharmacology: Gender-specific considerations in the use of psychoactive medications. Drug Addiction Research and Health of Women, 223–228. National Institute on Drug Abuse. Schultes, R. E., & Hoffman, A. (1992). Plants of the gods: Their sacred, healing and hallucinogenic powers. Rochester, VT: The Healing Arts Press. Simoni, J. M., Sehgal, S., & Walters, K. L. (2004). Triangle of risk: Urban American Indian women’s sexual trauma, injection drug use, and HIV sexual risk behaviors. AIDS and Behavior, 8, 33–45. Sissel, P. A. (1996). A community-based approach to literacy programs: Taking learners’ lives into account. San Francisco: Jossey-Bass Inc. Stevens, S. (2006, January). Women and substance abuse: A gendered perspective. Paper presented at the Fifth Annual Women’s Mental Health Symposium, Tucson, AZ. Stevens, S. J., & Bogart, J. G. (1999). Reducing HIV risk behaviors of drug involved women: Medical, social, economic, and legal constraints. In W. N. Elwood (Ed.), Power in the blood: AIDS, politics and communication (pp. 107–120). Mahwah, NJ: Lawrence Erlbaum. Stevens, S. J., & Estrada, B. D. (1999, June). Substance involved women: Ethnic differences, contraceptive practices and HIV sex risk behaviors. Paper presented at the Society for Menstrual Cycle Research: Cycling Towards the Millennium: Interdisciplinary Research on Women’s Health, Tucson, AZ. Stevens, S. J., Estrada, A. L., Glider, P. J., & McGrath, R. A. (1998). Ethnic and cultural differences in drug-using women who are in and out of treatment. Drugs & Society, 13, 81–95. Stevens, S. J., Estrada, B., Murphy, B. S., McKnight, K. M., & Tims, F. (2005). Gender differences in substance use, mental health, and criminal justice involvement of adolescents at treatment entry and at 3, 6, 12, and 30 month follow-up. Journal of Psychoactive Drugs, 36, 13–25. Stevens, S. J., Estrada, B. D., & Villareal, V. V. (2003). Health disparities and their impact on HIV prevention among an ethnically diverse sample of drug using women living north of the US=Mexico Border. In Conference Proceedings for the XIV International AIDS Conference, 150–154. Stevens, S. J., Murphy, B. S., & McGrath, R. (2000, August). Residential treatment for substance involved women and children: Outcome findings. Paper presented at the Bridging the Gap: Research and Practice of Substance Abuse Services in Arizona, Prescott, AZ. Stevens, S. J., Murphy, B. S., & McKnight, K. (2003). Traumatic stress and gender differences in relationship to substance abuse, mental health, physical health, and HIV risk behavior in a sample of adolescents enrolled in drug treatment. The Journal of Child Maltreatment, 8, 46–57. Stevens, S. J., & Patton, T. (1998). Residential treatment for drug addicted women and their children: Effective treatment strategies. Drugs & Society, 13, 235–250. Stevens, S. J., Ruiz, D., Romero, O., & Gama, D. (1995, February). HIV prevention and education: Street outreach for special populations. The Crack Addicted and Intravenous Drug Users. Paper presented at the National Update on AIDS, San Francisco, CA.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
358
S. J. Stevens et al.
Stokols, D. (1996). Translating sociological theory into guidelines for community health promotion. American Journal Health Promotion, 10, 282–298. Substance Abuse and Mental Health Service Administration. (2005). Substance abuse treatment for persons with co-occurring disorders: A Treatment Improvement Protocol (TIP 42). Washington, DC: U.S. Department of Health and Human Services. Ward, R. J., & Coutell, C. (2003). Women and alcohol susceptibility: Could difference in alcohol metabolism predispose women to alcohol-related diseases? Archives of Women’s Mental Health, 6, 231–238. Wechsberg, W. (1995). Strategies for working with women substance abusers. In B. S. Brown (Ed.), Substance abuse treatment in the era of AIDS (pp. 119– 152). Rockville, MD: Substance Abuse and Mental Heath Services Administration. Wechsberg, W. M., Lam, W. K. K., Zule, W. A., & Bobashev, G. (2004). Efficacy of a woman-focused intervention to reduce HIV risk and increase self-sufficiency among African American crack abusers. American Journal of Public Health, 94, 1165–1173. Weir, B. W., Stark, M. J., Fleming, D. W., He, H., & Tesselaar, H. (1998). Revealing drug use to prenatal providers: Who tells or who is asked? In S. J. Stevens & H. K. Wexler (Eds.), Women and substance abuse: Gender transparency (pp. 161–176). New York: The Haworth Press. Wetherington, C. L. (2006). Substance abuse: Does gender matter? A National Conference on Women, Addiction, and Recovery: News You Can Use, July 13, 2006, Anaheim, CA. Wexler, H. K., Cuadrado, M., & Stevens, S. J. (1998). Residential treatment for women: Behavioral and psychological outcomes. Drugs & Society, 13, 213–234. White, W. L. (1998). Slaying the dragon: The history of addiction treatment and recovery in America. Bloomington, IL: Chestnut Health Systems. White, W. L., & Kilbourne, J. (2006). American women and addiction: A cultural double bind. Counselor, 7, 46–50. Whitten, L. (2004). Men and women may process cocaine cues differently. NIDA Notes, 19, 4–5. Yount, S. M. (2006). Use of manzanilla tea during the childbearing period among women of Mexican origin who reside in the U.S.–Mexico border region. Doctoral dissertation, University of Arizona, Tucson, AZ.
Journal of Ethnicity in Substance Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wesa20
Women and Substance Abuse: Gender, Age, and Cultural Considerations a
a
Sally J. Stevens , Rosi A. C. Andrade & Bridget S. Ruiz
a
a
Southwest Institute for Research on Women, University of Arizona , Tucson, Arizona Published online: 18 Aug 2009.
To cite this article: Sally J. Stevens , Rosi A. C. Andrade & Bridget S. Ruiz (2009) Women and Substance Abuse: Gender, Age, and Cultural Considerations, Journal of Ethnicity in Substance Abuse, 8:3, 341-358, DOI: 10.1080/15332640903110542 To link to this article: http://dx.doi.org/10.1080/15332640903110542
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Ethnicity in Substance Abuse, 8:341–358, 2009 Copyright # Taylor & Francis Group, LLC ISSN: 1533-2640 print=1533-2659 online DOI: 10.1080/15332640903110542
Women and Substance Abuse: Gender, Age, and Cultural Considerations SALLY J. STEVENS, ROSI A. C. ANDRADE, and BRIDGET S. RUIZ
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Southwest Institute for Research on Women, University of Arizona, Tucson, Arizona
Historically, data has shown that a smaller percentage of women use alcohol and illicit substances compared to men, and that frequency of use has been lower among women compared to use among men. Although this data on usage may be true, researchers also acknowledge that substance use among women has been a hidden issue, one not realistically acknowledged by society, especially prior to the mid-1960s. Along with this, more recent data indicates that rates of substance use among women are increasing. Factors contributing to this increase in substance abuse have begun to receive considerable attention, and recent research suggests that many issues exist that are unique to substance use among women. The purpose of this article is to discuss gender specific considerations in women’s substance abuse by examining the history of substance use among women; analyzing genderspecific factors, including physiological factors, trauma-related factors, mental health issues, and cultural considerations that impact on women’s substance use; articulating treatment approaches for working with substance abusing women and girls; and providing recommendations for further research in this area. KEYWORDS culture physiology, mental health, substance use, theory, trauma, treatment, women Supported by the National Institutes of Health (NIH)–National Institute on Drug Abuse (NIH) (grant numbers 1 R01 DA 10651 and 1 U01 DA 07470), the Substance Abuse and Mental Health Services Administration (SAMHSA)–Center for Substance Abuse Treatment (CSAT) (grant numbers H79 TI 14452, KD1 TI 11892, KD1 TI 11422, and 5 HD8 TI00383), and SAMHSA–Center for Substance Abuse Prevention (CSAP) (grant number 5 U79 SPO7940). The opinions expressed in this article are those of the authors and do not necessarily reflect the official positions of NIH–CNIDA, SAMHSA–CCSAT, or SAMHSA–CSAP. Address correspondence to Sally J. Stevens, Executive Director, Southwest Institute for Research on Women, The University of Arizona, 1443 E. 1st Street, Tucson, AZ 85721-0403. E-mail: [email protected] 341
342
S. J. Stevens et al.
INTRODUCTION
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Alcohol and drug use among women has been studied by researchers from multiple disciplines primarily because the issues that substance using women face are multi-faceted and complex. This article addresses some of these issues by focusing on the historical, physiological, social, and behavioral factors relevant to women and substance abuse. In addition, this article offers the reader information about effective treatments for substance abusing women, including descriptions of appropriate theoretical models to guide treatment. The article will conclude with a discussion of the research needs and priorities in this critical area.
HISTORY OF SUBSTANCE USE AMONG WOMEN Visibility of Women’s Substance Use Historically, women at all levels of society have used and abused alcohol and drugs. In the United States, marijuana was used by or given to women in the 1600s for treatment of labor pains, uterine hemorrhages, postpartum psychosis, and other illnesses. During the 1700s, use of opium among women increased dramatically. During the Revolutionary War, the production of opium significantly increased because it was used to treat wounded soldiers. Given its availability and acceptance, it was common for women to use opium and syringe kits were openly available for sale. Moreover, for those who were addicted to ‘‘distilled spirits,’’ Dr. Benjamin Rush, a leader in alcohol treatment at this time, recommended beer, wine, or opium as an alternative furthering the use of opium (White, 1998). By the end of the 1800s, two-thirds of the nation’s opium and morphine addicts were women (Kandall & Petrillo, 1996). Besides the use of alcohol and opium, women’s use of cocaine also increased during the 1800s (Stevens, 2006). With the onset of the temperance movement in the 1850s and the subsequent establishment of the Women’s Christian Temperance Union, social stigma and shame became part of the life of an addicted woman. The Martha Washington Society organized special meetings for women and children, including separate meetings for freed African American slaves. At these meetings, women were encouraged to eliminate alcohol from their homes (White, 1998). Although alcohol and drug use became increasingly more concealed, use was also made easier with the increasing production of alcohol based ‘‘medicines’’ (White & Kilbourne, 2006). Drug use by women became even more invisible on the passing of the Harrison Anti-Narcotic Act of 1914, which focused on supply and crime versus personal use and treatment. Women’s alcohol and drug use varied through the 20th century; it increased during the Prohibition era (e.g., in nightclubs and cabarets),
Women and Substance Abuse
343
Downloaded by [Dalhousie University] at 03:51 09 October 2014
decreased in the 1940s and 1950s, and again increased during the women’s movement in the 1960s and 1970s. The increase in the visibility of women’s drug use in the 1960s was in part due to the shift in national priority from a focus on supply and crime to a focus on mental health and substance abuse (Kandall & Petrillo, 1996; Stevens, 2006). Since then, women’s treatment needs have received considerably more attention, although social stigma and shame continue to be a part of women’s substance use portfolio (White & Kilbourne, 2006). This harsh treatment of women runs parallel with society’s expectation for women to provide the moral foundation for the family, yet their own virtue is continually held in suspect (Lanzetta, 2005).
History of Prescription Medications Historically, doctors have consistently prescribed drugs more often for women than for men. In part, this was due to the perception that women could not become addicted to alcohol or drugs. Women were thought to have problems or illnesses that could be treated openly (Brown, 2006), hence the visible flask of alcohol or the syringe that often hung from the bodice of a women’s dress. In the 1800s, doctors commonly prescribed cocaine for ‘‘neurasthenia,’’ or what was then the considered a nervous weakness (Kandall & Patrillo, 1996; Stevens, 2006). Lydia Pinkham’s Vegetable Oil which had 30% alcohol content was commonly used for many ailments by women who did not ‘‘drink’’ (Brown, 2006). Unfortunately, prescription drug use has remained a problem for women from all ethnic backgrounds. Although advertising for over the counter drugs, including cigarettes, has targeted women, pharmaceutical representatives have gone to great efforts (e.g., samples, promotional materials, incentives, etc.) to influence physicians to prescribe medications for women. White and Kilbourne (2006) found that the ratio of women to men shown in advertisements for antidepressants in two journals, the American Journal of Psychiatry and the American Family Physician, was 5:1 and 10:1 respectively (Hansen & Osborne, 1995). Although use of prescribed psychoactive drugs is appropriate in certain circumstances in the treatment of some mental health problems, its over-use has taken its toll—keeping women sedated and numb from their thoughts and emotions and resulting in their inability to understand and resolve issues such as self-worth, anxiety, and depression (Stevens, 2006).
Ethnicity and Substance Abuse Patterns and prevalence of alcohol and drug use among women from ethnic minorities differ from that of Caucasian women (Stevens, Estrada,
Downloaded by [Dalhousie University] at 03:51 09 October 2014
344
S. J. Stevens et al.
Glider, & McGrath, 1998). Although Kandall and Patrillo (1996) found reports on the use of substances by African American women as early as the 1800s, the use of alcohol was so moderate among African Americans that many thought that they were immune to its influences (White, 1998). Historically, American Indian women used substances derived from various botanicals for ceremonial and medicinal purposes (Schultes & Hoffman, 1992), although use varied considerably by tribe. Although a few tribes prepared alcohol-based beverages as a part of seasonal ceremonies, the widespread use of alcohol among American Indians can be traced to the influence of Europeans and the displacement of Natives from their culture and land during the 1800s (Berkowitz, Peterson, Smith, Taylor, & Brindis, 1998). Alcohol use crossed both gender and age boundaries with both men and women involved not only in the use of alcohol, but also in the liquor trade as well (Mancall, 1995). For Mexican-origin Hispanic women, herbs were and still are widely used for medicinal purposes (Yount, 2006). However, use of illicit substances has, for the most part, been more closely associated with acculturation. Chambers (2005), for example, found that increased alcohol use among low-income Latinas was impacted by speaking English and by acculturation, and Nu~ no, Romero, Orduna, Estrada, and Stevens (2006) found that third-generation Hispanic and American Indian youth were more likely to report having used alcohol compared to those who had recently immigrated from Mexico to southern Arizona.
Prevalence of Substance Use Among Adult Women and Adolescent Girls Current data indicates that an estimated 6.5 million (5.9%) of women 18 years of age or older, met the criteria for past year abuse or dependence on alcohol or illicit drugs (Drug and Alcohol Services Information System [DASIS], 2005b). Of these women, it is estimated that 5.2 million (4.7%) abused or were dependent on alcohol and that 2 million (1.8%) abused or were dependent on illegal drugs. This same report illustrates that there is a decrease in their substance abuse and dependence as women age. Approximately 15% of women aged 18 to 25 years abused or were dependent on alcohol or illicit drugs compared to almost 9% of women aged 26 to 34 years. It is noteworthy that although 6.5 million women met criteria for abuse or dependence, 92% did not receive treatment services (DASIS, 2005a; National Center on Addiction and Substance Abuse, 2006). This disparity could be attributed to the way that men and women enter treatment. Women are most frequently referred to treatment through self-referral, whereas men are most frequently referred to treatment through the criminal justice system (DASIS, 2005a).
Women and Substance Abuse
345
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Substance Use and Ethnicity A DASIS (2005a) report also showed that current illicit drug use was associated with race=ethnicity. Rates were lowest among Asians (3.1%). Rates were 12.8% for American Indians and Alaska Natives, 12.2% for persons reporting two or more races, 9.7% for non-Hispanic Blacks, 8.7% for Native Hawaiians or Other Pacific Islanders, 8.1% for Whites, and 7.6% for Hispanics. Data from treatment and community based projects working with active drug users in southern Arizona indicate that not only type of drug use, but also frequency of drug use varies by race=ethnicity. African American women had the lowest rate of injection drug use at two days per month, compared to Hispanics at seven days per month, Caucasians at nine days per month, and American Indian women at ten days per month (Stevens et al., 1998).
GENDER-SPECIFIC ISSUES IN WOMEN’S SUBSTANCE USE: PHYSIOLOGICAL, TRAUMA-RELATED, MENTAL HEALTH, AND CULTURAL ISSUES Although many factors may impact substance use among women (e.g., socioeconomic status, education, parenting issues, domestic violence), the primary women-specific issues to be examined in this article include physiological factors, trauma-related issues, mental health status, and cultural considerations.
Physiological Factors Physiological factors that impact substance abuse among women include gender differences in physiology, women’s menstrual cycle, and pregnancy. Several studies have found differences in the way men and women metabolize alcohol and other drugs. Blood alcohol levels for women are higher than blood alcohol levels in men with the same height=weight ratio and amount of alcohol consumed. A variety of physiological factors account for these differences, including women’s higher body fat-over-water ratio, reduced liver-mass-over-body weight ratio, fewer stomach enzymes to break down alcohol, and estrogen-induced effects (Stevens, 2006; Ward & Coutell, 2003). These physiological factors may be one reason that, as noted in a National Center on Addiction and Substance Use (2006) report, women become addicted in shorter period of time compared to men even when using less alcohol or drugs. Women also suffer more severe brain damage from substance use and they develop substance-related diseases such as lung cancer more quickly. Recent research using new imaging techniques has revealed differences in brain composition and activity of drug users compared to non-drug users.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
346
S. J. Stevens et al.
For example, a study comparing methylenedioxymethamphetamine (Ecstasy) users and non-users revealed smaller concentrations of grey matter in the Ecstasy users compared to non-users. These subtle but statistical differences were evidenced in the neocortex, which may be involved in word definition; the brain stem, which controls respiration and heart rhythms; and the cerebellum, which controls movement, motor learning, and special sense (Cowen et al., 2003). Gender appears to influence biological responses to nicotine and other substances. When women smoke cigarettes, they take fewer and shorter puffs. Women experience improvements in mood that men do not, which is perhaps one reason that women are not as successful as men at quitting. Women and men may process cocaine cues differently as well. A study by Whitten (2004) shows increased activity in the right nucleus accumbens for both men and women when they crave cocaine but differences in activity in the amygdala, dorsal anterior cingulated cortex, ventral anterior cingulated cortex, and frontal cortex. These findings suggest that both women and men have an expectation of pleasure when they crave cocaine but have different expectations in the outcomes of use, leading researchers to think that women may use drugs for different reasons than men. Social scientists have long thought that men are more likely to use drugs to ‘‘have fun,’’ whereas women may be more likely to use drugs to feel closer to others, to secure good feelings in an intimate relationship, and to reduce inhibitions (Stevens, 2006). Studies also indicate that a woman’s menstrual cycle influences her consumption of alcohol and illicit drug use, which also impacts related consequences of use (e.g., mental health issues, criminal behavior, and HIVrisk behavior) (Schnoll & Weaver, 1998; Stevens & Estrada, 1999). During the follicular phase (before ovulation), women report higher ratings of ‘‘good’’ drug effects and ‘‘liking and using’’ the drug more. In studies on cigarette smoking, women in the follicular phase reported less cigarette smoking and cravings, but weight gain, reduced desire to smoke or relieve negative affect, fewer withdrawal and depressive symptoms, and better abstinence when cessation were initiated during this phase. In the luteal phase, women have reported significantly more drug cravings (Wetherington, 2006). In part, due to physiological effects, birth control pills have been associated with increased blood alcohol levels; other studies have shown that women absorb alcohol more rapidly when they are premenstrual (Stevens, 2006). In a study with women actively using drugs, participants reported that their menstrual cycle not only affected their drug use, but also their drug use affected their menstrual cycle. Sixty percent reported that their menstrual bleeding or cramps stopped, 26% reported that menstrual bleeding or cramps decreased, and 32% reported that they had experienced an increase in bleeding or cramping due to their drug use. Type of drug use was related to these reported effects. For example, heavy methamphetamine and cocaine use was generally associated with missed periods (and significant weight loss)
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
347
as well as increased cramping with periods, whereas use of narcotics and alcohol was associated with decreased cramping and pain associated with cramping (Stevens & Estrada, 1999). Pregnancy can serve as both a motivator and a barrier to entering substance abuse treatment or addressing one’s use of substances. The desire to have a healthy baby can be a powerful motivator for behavior change (Reed, 1985; Stevens, Murphy, & McGrath, 2000). Unfortunately, many substance using women report not receiving information about substance abuse from their medical providers (Salmon, Joseph, Saylor, & Mann, 2000). The likelihood that a pregnant woman will be screened for drug use may increase if there are medical complications with the pregnancy, if the woman is seen at a public versus private provider, or if she is an ethnic minority (Chassnoff, Landress, & Barrett, 1990; Weir, Stark, Fleming, He, & Tesselaar, 1998). Although recent changes in medical practice have increased screening for substance use, the lack of screening presents a missed opportunity to educate pregnant women about the adverse effects of prenatal drug use and to provide appropriate referrals and assistance. Although pregnancy can be a motivator to address one’s drug problem, both pregnancy and parenting have been and continue to be barriers to treatment entry for women (Greenfield, 2006). Women frequently report issues concerning child custody, including custody of those yet to be born (Bogart & Stevens, 2004), and difficulty with transportation and childcare as factors for not entering substance abuse treatment (MacMaster, 2005; Wechsberg, 1995).
Trauma-Related Factors There is a strong relationship between substance use and the experiences of traumatic stress (Stevens & Bogart, 1999). The use of drugs can affect a women’s judgment about whether a situation is safe, reduces their inhibitions leading to risky social situations, creates a physical and psychological drug dependency that results in dangerous exchanges of sex for money or drugs, and may impact women’s decision to engage and remain in a violent partner relationship. In studies of the relationship between stress and drug usage, women reported that traumatic experiences occurred first (Stevens et al., 2000). In one study, of the 80 women enrolled in substance abuse treatment, 74% reported having been raped at an average age of 12.6 years, and 80% reported having been physically assaulted at an average age of 12.9 years. The average age of first drug use was 13.7 years. Interestingly, age of first consensual sex was 15.1 years. Losing one’s virginity can be a traumatic experience for many women, whether the loss of virginity was due to being raped or was consensual. In a sample (N ¼ 500) of women in substance abuse treatment, Andrade, Cameron, Stevens, and Ruiz (2006) found that
Downloaded by [Dalhousie University] at 03:51 09 October 2014
348
S. J. Stevens et al.
53% of American Indian, 39% of bi- or tri-racial, 34% of Hispanic, 31% of African American, and 27% of Caucasian women reported that losing their virginity was ‘‘considerably’’ to ‘‘extremely’’ upsetting. Andrade et al. (2006) also found that different types of trauma vary for women from different racial or ethnic backgrounds. For example, although not having a stable place to live at some point in their lifetime was equally upsetting for women of all ethnicities (84% to 87% ‘‘considerably’’ to ‘‘extremely’’ upsetting), the reported frequency of not having a stable place to live varied from 79% of African American women to 76% of bi- or-racial women, 71% of Caucasians, 68% of American Indian, and 66% of Hispanic women. Examples of other traumas that differed by race=ethnicity included death of a close family member, which was reported by 92% of African American, 89% of American Indian, 87% of Latina, 80% of bi- or tri-racial, and 73% of Caucasian women. Being a victim of a crime was reported by 85% of Caucasian, 64% of bi- or tri-racial, 63% of African American, 62% of American Indian, and 59% of Hispanic women. Moreover, historical trauma experienced particularly by women from ethnic minority backgrounds may impact substance abuse. Brave Heart (2003) described historical trauma among American Indians as an accumulation of psychological and emotional wounding across generations arising from group trauma experiences. This is particularly noteworthy for American Indians, who suffered ongoing and extensive trauma with regard to themselves, their children, and their communities (Simoni, Sehgal, & Walters, 2004). Responses to historical trauma have included low self-esteem, anger, self-destructive behavior, mental health issues, and substance use and related problems. Data from adolescents (N ¼ 372) in substance abuse treatment indicate high levels of traumatic stress. As reported by Stevens, Murphy, and McKnight (2003), adolescents who report having greater symptoms of traumatic stress (e.g., trouble concentrating or trouble sleeping) enter treatment with significantly greater problems associated with lifetime substance abuse, worse problems associated with general mental health, higher levels of depressive symptoms, and greater homicidal and suicidal ideation. In addition, gender differences are also present, with girls evidencing worse scores in all of these areas.
Mental Health Issues Gender differences in the mental health of adult substance abusers indicate that women have mental health disorders such as depression, anxiety, stress disorders eating disorders, and low self-esteem more frequently than men. In comparison, men typically have more trouble with functional living and with issues such as work, money, and legal problems (Substance Abuse and Mental Health Service Administration, 2005). Fortunately, outcome data from
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
349
women who have participated in substance abuse treatment show that treatment is not only effective in assisting women in reducing substance use, but also mental health problems are also reduced following treatment (Wexler, Cuadrado, & Stevens, 1998). In a national study of adolescents (N ¼ 1,207) enrolled in substance abuse treatment, Stevens, Estrada, Murphy, McKnight, and Tims (2005) compared the baseline data of boys and girls. Baseline substance use frequency, problems associated with substance abuse, and behavioral complexity (e.g., external behavior such as attention deficit disorder or conduct disorder) were higher for girls than boys. In addition, girls’ scores on general mental health were almost twice as high (severe) for girls as they were for boys. Fortunately, outcome data 3, 6, 12, and 30 months after substance abuse treatment demonstrated a significant reduction in substance use from baseline to 3 and 6 months, followed by a slight increase at 12 months and again at 30 months, but never returning to the baseline level of severity. General mental health problems and behavioral complexity reduced from baseline to 3, 6, and 12 months, followed by an increase in these problems at 30 months. However, severity at 30 months was still substantially lower than severity at baseline.
Ethnic and Cultural Considerations As noted previously, the type of substance use not only varies by race and ethnicity, but also patterns of use and contextual issues associated with use vary between women from different racial and ethnic backgrounds. Data from several women’s intervention projects located in southern Arizona show that, on average, African American adolescent girls initiate alcohol and drug use 1 to 3 years later at or about the age of 15 years (Andrade et al., 2006; Stevens et al., 1998). In addition, data on Hispanic women reveals a consistent pattern across data bases and programs with regard to a rapid trajectory from age of first alcohol and marijuana use to hardcore drug use such as heroin and cocaine when compared to other racial or ethnic groups (Andrade, Stevens, & Ruiz, 2005; Stevens, Ruiz, Romero, & Gama, 1995). Given these differences, one may look at protective or contributing factors involved in substance use based on cultural considerations. Cultural and social expectations of African American young women as a source of strength in the family may contribute to empowerment in their teens and resiliency to using substances. Meanwhile, the rapid trajectory from alcohol and marijuana use to hardcore drug use for Mexican-origin Hispanic women may imply a conflict between cultural expectations and behavior—that once a young woman uses illicit substances, she has violated cultural expectations, which then thrusts her on a course to further drug use (Andrade & Stevens, 2004). Contextual issues of substance-using women vary by race and ethnicity with White women typically having achieved a higher level of education.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
350
S. J. Stevens et al.
Andrade et al. (2006) reported that of 495 women in treatment, American Indian women were the least likely to have a high school education (21%) as compared to bi- or tri-racial (46%), Hispanic (47%), African American (53%), and White (67%) women. American Indian women were also the most likely to be unemployed (68%) compared to the other racial or ethnic groups (average of 78%). Other disparities include homelessness, with twice as many (61%) African American women perceiving themselves as homeless as other racial or ethnic groups (average of 35%). Disparities were also found for the number of times arrested; American Indian women reported fewer arrests (3.3 times) compared to other women (average of 5.5 times). In another study, twice as many American Indian women reported having health insurance (typically through Indian Health Services) compared to other ethnic groups, but approximately half (47%) reported being homeless (Stevens, Estrada, & Villareal, 2003). Women who lack education or employment skills, are homeless, or may have probation violations for a previous arrest may remain in drug or violence plagued living environments for shelter because working or earning a livable wage may not be a option (Stevens & Bogart, 1999). These issues have substantial implications with regard to both access to substance abuse treatment and the need for gender-specific treatment.
WOMEN AND SUBSTANCE ABUSE TREATMENT The proportion of substance abuse treatment clients who are female has increased moderately over the past decade. According to the DASIS report (2005a), approximately 30% (565,000) of admissions to substance abuse treatment facilities were women, up from 28% in 1992. Among individuals 12 years or older in 2004, men were 2.5 times as likely as women to have received treatment for an alcohol or an illicit drug use problem in the past year (2.3 vs. 0.9, respectively) (National Survey on Drug Use and Health, 2005). Women in treatment were more likely to enter treatment for opiate or cocaine use or abuse and less likely to be in treatment for alcohol or marijuana use as compared to men. Women also tend to be younger than men when they enter treatment (33 years versus 34 years, respectively), yet women initiate substance use at an older age (20 years versus 18 years, respectively) (DASIS, 2005a). Gender differences exist not only in the utilization of substance abuse treatment, but also in regard to reasons for treatment entry, retention in treatment, and treatment outcomes. Grella and Joshi (1999) conducted analysis on the Drug Abuse Treatment Outcomes Study data (N ¼ 7,652) and found that men enter treatment more frequently under pressure from family, an employer, or the criminal justice system, and women are more
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
351
often self-referred or social worker referred, with influencing factors such as trading sex for money or drugs, mental health problems, and single parenting issues. Although treatment retention appears to be the same for women as it is for men, individual characteristics such as personal stability, psychological functioning, and number of children are predictors of retention and completion among women (Greenfield, 2006). Treatment outcomes suggest similar or better outcomes for women when compared to men even across treatment modalities (Greenfield, 2006). However, psychosocial contextual issues such as mental health status, trauma, grief and loss, and family=spouse characteristics have been found to contribute to treatment success (Stevens, 2006). Examination of gender differences between adolescents entering substance abuse treatment suggests similar trends and may, in fact, be more pronounced. Treatment admissions data show that 70% are boys. In examining gender differences in adolescents enrolled in substance abuse treatment, Stevens et al. (2005) found that girls enter treatment with higher levels of substance use, report more problems with use, and report harder drug use (e.g., cocaine or opiates) as their primary substance compared to boys. Moreover, girls have significantly worse mental health problems, yet respond to treatment and have just as good or better outcomes compared to boys.
Women, Ethnicity, and Treatment According to several DASIS reports (2002, 2005b, c, d), differences treatment admissions by race=ethnicity clearly exist. American Indians and Alaskan Natives were more likely to report alcohol as their primary substance of abuse compared to admissions of other racial or ethnic groups (63% versus 42%). Interestingly, a higher proportion of American Indians and Alaskan Natives admissions were women compared to admissions from other racial or ethnic groups (36% versus 30%). For non-Hispanic Blacks, approximately two-thirds of the treatment admissions were for alcohol or cocaine use. From 1994 to 1999, non-Hispanic Blacks admissions into treatment decreased by 15%. As compared to Black men, Black women were more likely to enter treatment for the use of harder drugs (e.g., cocaine or opiates). Asian=Pacific Islanders were more likely to enter treatment for either marijuana or methamphetamine=amphetamine use than other racial or ethnic groups. Only 28% of Asian=Pacific Islander treatment admissions were women. Individuals of Hispanic=Latino ethnicity were more likely to report opiate abuse than non-Hispanic admissions (28% versus 16%) and the majority of these admissions were men (78%). Among the adolescent population, White youth report more family and mental health problems, whereas Hispanic youth report more legal problems and issues and more experiences of trauma (Murphy & Stevens, 2001). Among Hispanic adolescents, traditional gender norms have been shown
352
S. J. Stevens et al.
to be a protective factor for substance use, although not a protective factor for risky sexual behavior (Luther, Stevens, Bracamonte Wiggs, & Ruiz, 2005).
Downloaded by [Dalhousie University] at 03:51 09 October 2014
THEORIES AND METHODS FOR WORKING WITH FEMALE SUBSTANCE ABUSERS Many researchers and clinicians argue for gender-specific treatment that not only includes addressing substance abuse, but also addresses social, economic, medical, and legal constraints thought to be related to substance use (Stevens & Bogart, 1999). In addition, providing childcare, life-skills training, transportation, and special programming for minority women are also thought to be critical to women’s treatment and recovery (Greenfield, 2006; Wechsberg, Lam, Zule, & Bobashev, 2004). Several treatment modalities exist, such as residential treatment with and without children, day treatment, outpatient treatment, and peer support. Within treatment modalities, both mixed gender and women’s only groups are offered. Outcomes from these different modalities and group composition are mixed, although there is mounting evidence that for pregnant and parenting women in particular, residential treatment enhances treatment success (Greenfield, 2006). The history of substance abuse among women and gender-specific factors (e.g., physiological, trauma-related, mental health, and cultural consideration) that impact women’s substance use suggests that addiction among women is closely connected to negative and sanctioned socialization and with personal experiences of disempowerment (Stevens & Bogart, 1999; White & Kilbourne, 2006). Throughout history, women have experienced varied forms of oppression from structural (economic) to personal (loss of identity) to specific (abuse). These varied forms of oppression injure women in unique and particular ways, damaging the receptive aspect of women’s nature (Lanzetta, 2005). Oppression invades a women’s psyche at such a deep level that women are often unable to identify the source of their pain. Unidentified, unspoken, denied, and dismissed, women may react in unhealthy ways, such as protecting their oppressor (Lanzetta, 2005) or by numbing feelings through the use of prescribed, legal, or illicit substances (Stevens, 2006). Because of women and girls’ societal status and life circumstances, we need gender-appropriate theories and methods to guide women’s treatment, regardless of treatment modality. Among these theories and methods are the following five approaches: social ecology model, empowerment theory, relational model, feminist theory, and participatory action research. Social ecology is an overarching framework for understanding the interrelations among diverse personal and environmental factors in human health and illness. It integrates person-focused efforts with environment-focused interventions (Stokols, 1996). Thus in working with women, the researcher
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
353
must consider that the context of the each woman’s life is critical, and successful substance abuse treatment needs to change both personal and social vulnerabilities. Empowerment theory compels researchers and service providers to think in terms of wellness versus illness, competence instead of deficits, and strengths versus weaknesses. Programs need to provide opportunities for women to establish a sense of self-empowerment, self-efficacy, and self-control and to assist these women in gaining the skills and resources that they need to take control of their lives (Belenky, Clinchy, Goldberger, & Tarule, 1986). The relational model is a theoretical paradigm for women’s psychological development and well-being. Hypothesizing that women’s development is embedded in relationships and that relationships with others are primary to a women’s health and well-being, treatment providers using this model pay substantial attention to developing healthy family, peer, and significant other relationships (Belenky, Bond, & Weinstock, 1997). Feminist theory examines substance abuse from the point of view of oppression and attempts to engage women in larger causes. A feminist approach raises the issue of subjectivity versus objectivity and stresses working with women in an equal capacity, challenging the typical power relationship between the researcher and the researched (Bowles & Klein, 1983). Participatory action research is a collaborative approach that equitably involves all partners and recognizes the unique strengths of each participant. Substance abuse treatment based on this framework would involve the woman specifically in the development of her own treatment, reflecting, planning, and implementing her own treatment plan based on her unique strengths (Kaplan & Alsup, 1995; McTaggart, 1997; Pederson, 1988; Sissel, 1996).
FUTURE DIRECTIONS IN SUBSTANCE ABUSE TREATMENT AND RESEARCH Most research on women and substance abuse, including gender differences, has been conducted in the past 15 years, and thus there are still considerable gaps in knowledge and many questions yet to be answered. Topics that need continued investigation include factors that contribute to young girls’ initiation into substance use, gender differences in the physiological effect of substance use, and facilitators and barriers to substance abuse treatment entry. Also needed are in-depth process and outcome studies on substance abuse treatment that take into account gender-specific needs, utilize women-centered approaches, and provide concurrent treatment for co-morbid disorders. Examination of what happens following treatment is
Downloaded by [Dalhousie University] at 03:51 09 October 2014
354
S. J. Stevens et al.
also critical and includes studies on physiological changes following abstinence from substance use, factors associated with continued abstinence or that lead to relapse, and cost-benefit analysis of providing treatment compared to no-treatment or incarceration for drug and drug-related convictions. Within the overarching theme of research on women and substance abuse, additional research is required that takes into consideration women’s position in society, culture, family, and contextual issues such as abuse history, grief and loss, and economic factors. Careful consideration of how women’s oppression contributes directly or indirectly to substance use (prescribed, legal, and illicit) may further illuminate strategies that not only improve treatment effectiveness but reveal needed structural changes to improve women’s well-being. Although current research suggests that culturally driven treatment approaches seem to be effective, articulating what the treatment is and for whom it works would further the field. Family-centered approaches such as family drug courts and residential treatment for pregnant and parenting women have shown promising outcomes (Green, Furrer, Worcel, Burrus, & Finigan, 2007; Stevens & Patton, 1998; Wexler et al., 1998). Future research within family-driven approaches might focus on the examination of family-related issues that may be associated with substance use, treatment entry, and treatment success as well as expansion of these family treatment approaches to include the extended family network. Because current data points to the impact of contextual issues on the initiation of substance use, treatment needs, and treatment outcomes, research that focuses on how various contextual issues are intertwined with substance use, along with the relative effectiveness of concurrent treatment approaches (e.g., trauma with substance use or grief and loss with substance abuse), is specifically needed. Finally, in any study on substance abuse treatment, fidelity in the delivery of the intervention is imperative so that when successful outcomes are documented, there is a clear understanding of what the treatment consisted of and how it was delivered. The importance of achieving follow-up rates at or above 90% is also vital so that confidence in the findings is achieved. Most importantly, as the field of women and substance abuse advances and the understanding of the issues affecting this population further emerge, advocacy at the policy and funding level will be critical to move new research findings into substance abuse prevention and treatment practice.
REFERENCES Andrade, R., & Stevens, S. (2004, October). Understanding the lives of Latinas at risk for HIV=AIDS. Paper presented at the National AIDS Awareness Day Symposium, Tucson, AZ.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
355
Andrade, R., Cameron, M., Stevens, S., & Ruiz, B. (2006). Women and substance abuse. Fifth Annual Women’s Mental Health Symposium, January 7, 2006, Tucson, AZ. Andrade, R., Stevens, S., & Ruiz, B. (2005). Understanding the lives of women at-risk for HIV=AIDS. Bridging Science and Culture to Improve Drug Abuse Research in Minority Communities: 2005 Health Disparities Conference. October 24–25, 2005. Atlanta, GA. Belenky, M. F., Bond, L. A., & Weinstock, J. S. (1997). A tradition that has no name: Nurturing the development of people, families, and communities. New York: BasicBooks, Inc. Belenky, M. F., Clinchy, B. M., Goldberger, N. R., & Tarule, J. M. (1986). Women’s ways of knowing: The development of self, voice, and mind. New York: BasicBooks, Inc. Berkowitz, G., Peterson, S., Smith, E. M., Taylor, T., & Brindis, C. (1998). Community and treatment program challenges for chemically dependent American Indian and Alaska Native women. Contemporary Drug Problems, 25, 347–371. Bogart, J. G., & Stevens, S. J. (2004). Legal systems issues among drug-involved women enrolled in a community based HIV prevention program. In K. Knight & D. Farabee (Eds.), Treating addicted offenders: A continuum of effective practices. Kingston, NJ: Civic Research Institute. Bowles, G., & Klein, R. D. (1983). Theories of women’s studies. Boston: Routledge & Kegan Paul. Brave Heart, M. Y. H. (2003). The historical trauma response among natives and its relationship with substance abuse. Journal of Psychoactive Drugs, 35, 7–13. Brown, S. (2006). Women, addiction and recovery: A new self. Counselor, 7, 12–18. Chambers, C. D. (2005). Alcohol consumption among low-income pregnant Latinas. Alcoholism: Clinical and Experimental Research, 11, 2022–2028. Chassnoff, I. J., Landress, H. J., & Barrett, M. E. (1990). The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. The New England Journal of Medicine, 322, 1202–1206. Cowen, R. L., Lyoo, I. K., Sung, S. M., Ahn, K. H., Kim, M. J., Hwang, J., et al. (2003). Reduced cortical grey matter density in human MDMA (ecstasy) users: A voxel-based morphometry study. Drug and Alcohol Dependence, 72, 225–235. Drug and Alcohol Services Information System (DASIS). (2002). Black admissions to substance abuse treatment: 1999. The DASIS Report. SAMHSA, OAS, March 1, 2002. Drug and Alcohol Services Information System (DASIS). (2005a). A comparison of female and male admissions: 2002. The DASIS Report. SAMHSA, OAS, May 20, 2005. Drug and Alcohol Services Information System (DASIS). (2005b). Hispanic substance abuse treatment admissions: 2003. The DASIS Report. SAMHSA, OAS, August 19, 2005. Drug and Alcohol Services Information System (DASIS). (2005c). Substance abuse treatment admissions among American Indians and Alaskan Natives: 2002. The DASIS Report. SAMHSA, OAS, February 11, 2005. Drug and Alcohol Services Information System (DASIS). (2005d). Substance abuse treatment admissions among Asians and Pacific Islanders: 2002. The DASIS Report. SAMHSA, OAS, June 10, 2005.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
356
S. J. Stevens et al.
Green, B. L., Furrer, C., Worcel, S., Burrus, S., & Finigan, M. W. (2007). How effective are family treatment drug courts? Outcomes from a four-site national study. Child Maltreatment, 12, 43–59. Greenfield, S. F. (2006, July). Substance abuse treatment outcomes for women. Paper presented at A National Conference on Women, Addiction, and Recovery: News You Can Use, Anaheim, CA. Grella, C. E., & Joshi, V. (1999). Gender differences in drug treatment careers among clients in the national drug abuse treatment outcome study. American Journal of Drug and Alcohol Abuse, 25, 383–404. Hansen, F. J., & Osborne, D. (1995). Portrayal of women and elderly patients in psychotropic drug advertisements. Women and Therapy, 16, 129–141. Kandall, S. R., & Petrillo, J. (1996). Substance and shadow: Women and addiction in the United States. Cambridge, MA: Harvard University Press. Kaplan, S. J., & Alsup, R. (1995). Participatory action research: A creative response to AIDS prevention in diverse communities. Convergence, 28, 38–56. Lanzetta, B. J. (2005). Radical wisdom: A feminist mystical theology. Minneapolis, MN: Fortress Press. Luther, K., Stevens, S. J., Bracamonte Wiggs, C., & Ruiz, B. (2005, April). Perception of gender roles among Latino=a adolescents at-risk for HIV and substance use. Paper presented at the Epidemiology in Arizona Forum, Tucson, AZ. MacMaster, S. A. (2005). Experiences with, and perceptions of, barriers to substance abuse and HIV services among African American women who use crack cocaine. Journal of Ethnicity in Substance Abuse, 4, 53–75. Mancall, P. C. (1995). Men, women, and alcohol in Indian villages in the Great Lakes Region in the early republic. Journal of the Early Republic, 15, 425–448. McTaggart, R. (1997). Participatory action research, international contexts and consequences. Albany, NY: State University of New York Press. Murphy, B. S., & Stevens, S. J. (2001, April). Environmental stress among Latino and non-Latino adolescent substance abusers enrolled in a residential substance abuse treatment program. Paper presented at the National Association for Chicana and Chicano Studies National Conference, Tucson, AZ. National Center on Addiction and Substance Abuse. (2006). Women under the influence. Baltimore, MD: The Johns Hopkins University Press. National Survey on Drug Use and Health. (2005). Gender differences in substance abuse dependence among women. The NSDUH Report. Published by OAS, SAMHSA, September 16, 2005. Nu~ no, T., Romero, A., Orduna, M., Estrada, A., & Stevens, S. (2006, November). Taking a closer look at health disparities within Mexican descent adolescent substance use. Paper presented at the 134th Annual Meeting & Exposition of the American Public Health Association, Boston, MA. Pederson, C. (1988). Nunca antes me habı´an ensen~ado eso, Capacitaci on feminista: Metodologı´a=comunicaci on= impacto. Me´xico: Edici on Carolina Carlessi. Reed, B. G. (1985). Drug misuse and dependency in women. International Journal of the Addictions, 20, 13–62. Salmon, M. M., Joseph, B. M., Saylor, C., & Mann, R. J. (2000). Women’s perception of providers, social, and program support in an outpatient drug treatment program. Journal of Substance Abuse Treatment, 19, 239–246.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
Women and Substance Abuse
357
Schnoll, S. H., & Weaver, M. F. (1998). Pharmacology: Gender-specific considerations in the use of psychoactive medications. Drug Addiction Research and Health of Women, 223–228. National Institute on Drug Abuse. Schultes, R. E., & Hoffman, A. (1992). Plants of the gods: Their sacred, healing and hallucinogenic powers. Rochester, VT: The Healing Arts Press. Simoni, J. M., Sehgal, S., & Walters, K. L. (2004). Triangle of risk: Urban American Indian women’s sexual trauma, injection drug use, and HIV sexual risk behaviors. AIDS and Behavior, 8, 33–45. Sissel, P. A. (1996). A community-based approach to literacy programs: Taking learners’ lives into account. San Francisco: Jossey-Bass Inc. Stevens, S. (2006, January). Women and substance abuse: A gendered perspective. Paper presented at the Fifth Annual Women’s Mental Health Symposium, Tucson, AZ. Stevens, S. J., & Bogart, J. G. (1999). Reducing HIV risk behaviors of drug involved women: Medical, social, economic, and legal constraints. In W. N. Elwood (Ed.), Power in the blood: AIDS, politics and communication (pp. 107–120). Mahwah, NJ: Lawrence Erlbaum. Stevens, S. J., & Estrada, B. D. (1999, June). Substance involved women: Ethnic differences, contraceptive practices and HIV sex risk behaviors. Paper presented at the Society for Menstrual Cycle Research: Cycling Towards the Millennium: Interdisciplinary Research on Women’s Health, Tucson, AZ. Stevens, S. J., Estrada, A. L., Glider, P. J., & McGrath, R. A. (1998). Ethnic and cultural differences in drug-using women who are in and out of treatment. Drugs & Society, 13, 81–95. Stevens, S. J., Estrada, B., Murphy, B. S., McKnight, K. M., & Tims, F. (2005). Gender differences in substance use, mental health, and criminal justice involvement of adolescents at treatment entry and at 3, 6, 12, and 30 month follow-up. Journal of Psychoactive Drugs, 36, 13–25. Stevens, S. J., Estrada, B. D., & Villareal, V. V. (2003). Health disparities and their impact on HIV prevention among an ethnically diverse sample of drug using women living north of the US=Mexico Border. In Conference Proceedings for the XIV International AIDS Conference, 150–154. Stevens, S. J., Murphy, B. S., & McGrath, R. (2000, August). Residential treatment for substance involved women and children: Outcome findings. Paper presented at the Bridging the Gap: Research and Practice of Substance Abuse Services in Arizona, Prescott, AZ. Stevens, S. J., Murphy, B. S., & McKnight, K. (2003). Traumatic stress and gender differences in relationship to substance abuse, mental health, physical health, and HIV risk behavior in a sample of adolescents enrolled in drug treatment. The Journal of Child Maltreatment, 8, 46–57. Stevens, S. J., & Patton, T. (1998). Residential treatment for drug addicted women and their children: Effective treatment strategies. Drugs & Society, 13, 235–250. Stevens, S. J., Ruiz, D., Romero, O., & Gama, D. (1995, February). HIV prevention and education: Street outreach for special populations. The Crack Addicted and Intravenous Drug Users. Paper presented at the National Update on AIDS, San Francisco, CA.
Downloaded by [Dalhousie University] at 03:51 09 October 2014
358
S. J. Stevens et al.
Stokols, D. (1996). Translating sociological theory into guidelines for community health promotion. American Journal Health Promotion, 10, 282–298. Substance Abuse and Mental Health Service Administration. (2005). Substance abuse treatment for persons with co-occurring disorders: A Treatment Improvement Protocol (TIP 42). Washington, DC: U.S. Department of Health and Human Services. Ward, R. J., & Coutell, C. (2003). Women and alcohol susceptibility: Could difference in alcohol metabolism predispose women to alcohol-related diseases? Archives of Women’s Mental Health, 6, 231–238. Wechsberg, W. (1995). Strategies for working with women substance abusers. In B. S. Brown (Ed.), Substance abuse treatment in the era of AIDS (pp. 119– 152). Rockville, MD: Substance Abuse and Mental Heath Services Administration. Wechsberg, W. M., Lam, W. K. K., Zule, W. A., & Bobashev, G. (2004). Efficacy of a woman-focused intervention to reduce HIV risk and increase self-sufficiency among African American crack abusers. American Journal of Public Health, 94, 1165–1173. Weir, B. W., Stark, M. J., Fleming, D. W., He, H., & Tesselaar, H. (1998). Revealing drug use to prenatal providers: Who tells or who is asked? In S. J. Stevens & H. K. Wexler (Eds.), Women and substance abuse: Gender transparency (pp. 161–176). New York: The Haworth Press. Wetherington, C. L. (2006). Substance abuse: Does gender matter? A National Conference on Women, Addiction, and Recovery: News You Can Use, July 13, 2006, Anaheim, CA. Wexler, H. K., Cuadrado, M., & Stevens, S. J. (1998). Residential treatment for women: Behavioral and psychological outcomes. Drugs & Society, 13, 213–234. White, W. L. (1998). Slaying the dragon: The history of addiction treatment and recovery in America. Bloomington, IL: Chestnut Health Systems. White, W. L., & Kilbourne, J. (2006). American women and addiction: A cultural double bind. Counselor, 7, 46–50. Whitten, L. (2004). Men and women may process cocaine cues differently. NIDA Notes, 19, 4–5. Yount, S. M. (2006). Use of manzanilla tea during the childbearing period among women of Mexican origin who reside in the U.S.–Mexico border region. Doctoral dissertation, University of Arizona, Tucson, AZ.
