Gender Differences in Substance Abuse Create a Need For Single-Gender Treatment Programs
by Christopher D. Brinkerhoff
Circumstances surrounding the use and abuse of alcohol and other drugs vary a great deal between genders. Hodgins, El-Guebaly, and Addington (1997) claimed that treatment programs are "inappropriately generalized [from male norms] to female substance abusers" (806). This paper addresses their concerns and explores the need for female specific, single-gender treatment programs.
In the literature a plethora of excuses are given for the abuse of alcohol and other drugs, and it is clear that they are different based on gender. For men, the most common reasons for abuse are to work more, to have better sex, or to have a good time (Brecht, O'Brien, Mayrhauser, & Anglin, 2004). For women, the most common motive for abuse is to escape the emotional distress caused by sexual abuse or the occurrence of victimization. The majority of women in treatment have been abused, and often times the more serious an abused woman's substance use, the more traumatizing the nature of the abuse (Baker, 2000; Hernandez-Avila, Rounsaville, &Kranzler, 2004; Hodgins et al, 1997; NeSmith, Wilcoxon, & Satcher, 2000; Opland, Winters, & Stinchfield, 1995). Another common reason women use substances is because their spouse is using. According to Westermeyer and Boedicker (2000), married women are more apt to have a substance-abusing spouse compared to married men. "Females were more likely to be introduced to [methamphetamine] and continue to gain access to [methamphetamine] through spouses/boyfriends than were males" (Brecht et al, 2004, 101). Married women's pattern of use often reflects that of their spouse.
Women see their healthcare providers more frequently than men. Therefore a woman's substance abuse is more likely to be noticed by a professional, or rather the professional is more likely to see the behavioral and emotional effects caused by this abuse and to suggest treatment. Women in treatment will also have co-occurring psychiatric problems more often than men (Hernandez-Avila, 2004). Hodgins et al (1997) found that women were "more likely to seek treatment at mental health settings [for depression] as opposed to... specific treatment [for substance abuse]" (806). Another influence of women's' substance abuse pattern is their biological make-up. The biology of women enables them to experience the same level of intoxication and addiction while using less of the substance. As a result of drug abuse the physically visible health problems more easily become apparent, such as in the methamphetamine using population. In this population, Brecht et al (2004) report that, "females [are] more likely to report skin problems and males [are more likely] to report work problems" (101).
For women, the family is a large influence on their substance abuse pattern. "Negative social and familial attitudes toward women's drug and alcohol use may delay the onset of substance use among women" (Hernandez-Avila, 2004, 266). Researchers disagree about the average age of first use by women. Westermeyer and Boedicker (2000) and Brecht et al (2004) claim there is no gender difference in the age of onset; however, Opland et al (1995), Hser et al (2004) and Hernandez-Avila et al (2004) all claim that men start using at an earlier age. In addition, a shorter lifetime use of substances by women is reported by Westermeyer and Boedicker (2000).
The family and society often put more pressure on substance abusing women to get treatment than they do on men, so usually women will enter treatment sooner after onset of abuse than men. This, along with women needing less of the substance to feel the same level of intoxication as men, contributes to "telescoping," a term coined by Hernandez-Avila (2004) to explain this phenomenon. The possibilities of having a baby or being pregnant are huge motivators for women to enter treatment. Society is not accepting of women's use of drugs during pregnancy. Therefore, this societal pressure becomes the impetus for many women to quit using or enroll themselves into a treatment program for the safety of their baby. Yet, family issues also sometimes prevent substance abusing women from seeking treatment. For example, some women who already have children may not be able to get the treatment they need because they "may not have surrogates who could carry their responsibilities while they enter treatment" (Wetermeyer & Boedicker, 2000, 534). Once women are able to enter a program, they will soon be faced with more hurdles to jump over. Such hurdles as dealing with overlying emotional issues, lack of a job, and trying to receive help from a program made for men, create lower treatment retention rates among women (Hodgins et al, 1997).
It is clear that the current treatment programs are not efficient for treating both genders. Bride (2001) says, "Rates of... retention, and completion are significantly lower for women than for men, and current substance abuse treatment models are less effective for women than for men" (224). It is only been recent that women's issues have been considered in treatment programs. Mixed gender programs are less effective for women due to the male norms that traditional models are based upon. These include patterns of use, motives for coming into treatment, and reasons for relapse. "Acquiescence to issues and topics preferred by men" (NeSmith et al, 2000, 76), is caused by the dominating number of males in existing programs. After seeing the degree of difference between the genders, it is easy to see that "men and women arrive at treatment with different problems and different motives for treatment" (Hodgins et al, 1997). With the vast number of differences, why are women still put into male norm, mixed-gender treatment programs?
The few single-gender style programs that exist seem to affect men and women differently. Women did better in the first 12 months after treatment when in very structured inpatient programs. When men were enrolled in identical programs they eventually fared better, having less relapses than the women in the long run. In less structured outpatient programs women not only had better results than their male counterparts, they also were better served by this program's additional freedom (Hodgins et al, 1997). The effectiveness of presentation and activity style group therapy activities was compared to discussion and talk style group therapy six months into treatment. For men, the group activities and discussion styles of group therapy were correlated with the consumption of less alcohol. Unfortunately women had no such success. Hodgins et al (1997) reported that men do better with this style of treatment because they were more likely to drink in groups, whereas women are more often solitary drinkers, making it harder to discuss their drinking openly. Women had significantly lower alcohol consumption six months after treatment when they were provided with educational lectures and films. For men, these lectures and films seemed to increase their consumption of alcohol.
The positive reasons for creating single-gender programs seem to remedy any negative effects that could come from mixed gender groups. This new single-gender group style would allow women to "concentrate on their needs and desires away from their cultural concerns of social approval and the welfare of others" (Bride, 2001, 224). Having all female groups would also help them work through female-specific problems. Women will discuss issues in women-only groups that they will not discuss in mixed-gender groups (Hodgins et al, 1997; NeSmith et al, 2000; Bride, 2001). Another positive aspect of single-gender programs is that all the members would know that they have something in common. This will "hasten the trust building stage" (Hodgins et al, 1997, 809). Finally, women in single-gender programs would be less likely to suffer sexual harassment that frequently occurs in current programs (Bride, 2001).
Women specific issues must be worked into the design of single-gender treatment programs. First off, the gender of the facilitator must be chosen. This is another issue that is not settled among mental health professionals. Because high levels of victimized and abused women are addicts and were hurt by male perpetrators, having a male facilitator may serve as a negative reminder, as well as an easy target for displaced anger. This anger could detract from treatment progress and hamper group cohesion. NeSmith et al (2000) postulated that female patients may also "not be comfortable sharing with a male therapist the highly personal feelings that are necessary for quality therapy to emerge in a group format" (77). They found no significant negative outcomes associated with having a male facilitator. In fact Hodgins et al (1997) found that, "Male group leaders receive greater positive response for their suggestions from group participants than female leaders" (809). Not only that, a male facilitator appeared to provide healthy interaction with a man in a safe environment, something that many of these women need and may have never experienced.
Single-gender programs need to explore and discuss the different substances abused and the reasons for the abuse of those certain substances. For women, prescription drugs are more often the substance of abuse. These drugs are prescribed for pain, anxiety, and mood disorders. Women use them to deal with different issues so often that using the substances becomes the only way for women to find relief. Stimulants of all sorts are also frequently used by women. Society's attitudes about the weight of women push women to find ways to shed a few pounds. Low self-esteem is a major motivation for women to try extreme and dangerous ways to stay thin. A gender sensitive treatment would provide ways to boost women's self-esteem and confidence. Single-gender treatment programs oftentimes "nurture a sense of empowerment in a safe and supportive environment" (Baker, 2000), which goes a long way to build confidence in women. This confidence is fostered by allowing the patients an opportunity to manipulate the program's message to fit their needs.
Treating women requires that the treatment program provides childcare and parenting skills classes. Since the majority of single parent households are headed by women, it is not as vital for men to have these features in their programs. Baker (2000) and Bride (2001) both include child care services as an essential part of a single-gender treatment program. Baker (2000) even went so far as to identify "childcare as central to the treatment of women with children. Equally important to helping obtain day care for addicts' children in treatment are parenting skills classes and counseling support for those experiencing difficulty with parenting" (872). The classes and counseling are designed to help these mothers see how their substance dependent lifestyle is hurting not only themselves but their children as well.
Counseling would also help with issues such as stress which is a leading cause of relapse. Relapse prevention is essential to any treatment program. The circumstances that bring about relapse are somewhat different for men and women. Males more often relapse because of intrapersonal reasons such as a break-up with a partner or a car wreck. This often leads to depression. Women are more likely to relapse from interpersonal factors such as conflict or stress (Hodgins et al, 1997).
The differences between men and women in substance abuse programs are important and need to be taken into consideration. So many aspects of the substance abusing lifestyle differ between genders, and while these differences may not be capable of being completely addressed in mixed gender programs, single-gender programs provide the therapy required for women to make a full and lifelong recovery. In a gender sensitive group, single-gender discussion will provide members with a more comprehensive understanding of what the other members are dealing with on a daily basis. It will provide a safe environment to address family and social issues, as well as topics specific to the biology of women. Gender-specific treatments now need to be developed and studied to add to what is known, and to increase our understanding of more appropriate methods of ensuring long-term sobriety.
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