There are significant differences between men and women with substance use disorders across all realms — from biology to historical and current psychosocial stressors. These differences account for many gender-specific needs in both treatment and attempts to sustain recovery from substance use. They also reflect both the socialization differences between males and females in our culture as well as the inherent biological differences between men and women. All such factors present multiple challenges and barriers to treatment and recovery for women since research and treatment have been traditionally based upon the experiences of men. Since the 1970s, however, more has become known about the growth and development of women in general and substance treatment providers have increasingly focused more upon gender-specific information about the illness of addiction itself as well as the treatment and recovery needs of each gender.
Research and clinical experience have long validated the progression of addictive illness as occurring with a faster development of severe health consequences for women than for men. While women typically begin use with lower amounts of substance than do men, they tend to become substance dependent more quickly and to progress through the stages of dependence more quickly as well. Not only do women become ‘sicker quicker’, but they also appear to have a higher rate of relapse than men. Women tend to enter treatment with more acute psychiatric needs than men and to have more difficulty remaining abstinent with periods of sobriety often undermined by psychiatric symptoms and the stress of various psychological and social factors that men do not typically share.
One of the chief complications for women in both illness development and attempted sobriety is a history of trauma. Generally, women with substance use disorders typically report having experienced trauma such as physical, emotional and sexual abuse. While both men and women with substance disorders are apt to have had such experiences, it appears that women in treatment continue to report these more frequently and to have more acute symptoms of trauma upon entering treatment. For many women, a problematic use of substances seems to begin as a pursuit to manage and ‘numb’ trauma related feelings, thoughts and memories. Such attempts to self-medicate can, over the course of substance use, prolong and intensify trauma symptoms as well as create extreme discomfort in abstinence when they are experienced without the ‘medicinal’ effects of substance use. Such discomfort is often the precipitant to relapse.
Overall, there appears to be a significant correlation between the severity of trauma symptoms and a tendency for women to begin and relapse to substance use. Further, it is more common that women will report having begun substance use in order to cope with the stress of a traumatic event. Men, on the other hand, tend to describe having had more interest in intoxication rather than in managing a stress reaction at the onset of use. For these reasons, many women will require appropriate support to address and manage trauma symptoms in order to successfully navigate periods of abstinence and recovery.
Additionally, the typical social roles and cultural expectations placed upon women result in very specific stigma and stereotyping with regard to substance use. For example, women often assume (or are expected to assume) care giving roles in all their relationships — as mother, partner and daughter. Consequently, an addictive illness and related impairments are frequently viewed as personal failures with significant and negative stereotyping. Women are likely to be perceived as failing morally when experiencing a substance-related illness — for example, to be a “bad” woman, mother, wife or daughter. Such stigma affects the behavior of women in need of treatment and can lead to difficulty maintaining sobriety. Shame in reaction to social and cultural stereotyping is an obstacle for many women who want and need substance treatment.
Women often report having delayed treatment because they believed a disclosure of substance use would result in severe social consequences. This is particularly true for women who have children. The cultural expectations of mothers are generally more exacting than for men who are parents. It is less ‘acceptable’, for example, for women to leave their children for prolonged periods and even treatment stays can be perceived as periods of ‘abandonment’. Overall, addicted women are more apt to have remained intricately involved in their children’s lives as primary caregivers than are addicted men. Women who have children report much shame and guilt about ‘failing’ as mothers when ill with an addiction and in treatment for it. They also report fear of having their children removed from their care by family members or child protection agencies.
Women with children who do enter treatment face multiple challenges. Single mothers, for example, are often unable to secure childcare long enough for inpatient stays. Many also report difficulty attending recovery support groups in the community due to lack of childcare and lack of transportation. Realistically, addicted women do face the risk of having their children removed by child protection agencies with reunification dependent upon a significant period of sustained recovery. All of these issues leave substance dependent women prone to conceal their addictions and to postpone seeking help. Men with substance use disorders are not typically concerned with such issues when considering treatment and tend to report less guilt and shame related to their parental roles than do addicted women.
Relationships with partners can also greatly complicate recovery efforts for women. Addicted women are apt to be financially dependent upon their partners and are more likely than men to be involved with partners who also use substances. Therefore, many women must leave these relationships and achieve financial independence in order to successfully recover. Along with the usual rigors of early sobriety, these tasks can be overwhelming. Halfway houses are stepping stones to independence, but these are not always viable options for women with children. Further, addicted women are likely to have fewer job skills with which to obtain gainful employment and financial independence. Many women with children report that they cannot successfully support themselves and their children without relying upon a partner.
Ironically, women in our culture tend to be defined by their relationship roles more so than men, but women with substance use disorders tend to have a high degree of social isolation. They are more likely, for example, to use in the home as opposed to the more social environment of a bar as men do. Women are also likely to have fewer people to rely upon in treatment and early recovery especially if their partners continue to use substances. Sabotage of treatment efforts by partners who are substance users takes many forms: threats of abandonment, withdrawal of financial support and manipulation of the woman’s feelings, particularly guilt and shame. Consequently, recovery efforts such as inpatient stays and time in halfway houses are sometimes refused or aborted due to this lack of support. Social isolation and financial dependency can also leave women vulnerable for making impulsive and self-sabotaging relationships while in treatment and early recovery.
Women in treatment settings have many specific treatment needs that set them apart from their male counterparts during the course of treatment. For example, gender-specific groups allow a more in-depth and forthcoming exploration of significant relationship issues and trauma. Given that abuse in both childhood and adulthood, particularly sexual abuse/assault and domestic violence, are prevalent among women with substance disorders, treatment groups must provide a safe emotional and psychological atmosphere in which to address these. Because women who have been victimized are likely to have been victimized by men, the presence of men in treatment groups can trigger more acute trauma symptoms for women as well as impede disclosures and processing of these events.
Additionally, a shame-based sexuality is often an integral part of an addicted lifestyle and many women will find it necessary to process such issues in order to fully recover. Difficult sexual experiences during use often bring related sexual difficulties during recovery. Demeaning and/or traumatic events such as engaging in sex for drugs and having experienced miscarriages and abortions are common. Prostitution and other sex-related work, relationships with multiple partners or sexual activity that may have violated a woman’s own usual standards of conduct are not easily addressed in mixed gender groups. Further, the cultural phenomenon of male privilege and status is often exaggerated in addicted lifestyles and can continue in treatment settings. All of these issues can complicate the appropriate processing of experiences in which women have been objectified, demeaned, devalued and dominated before entering treatment. The discussion of sexual concerns that would facilitate a healthy sexuality in recovery can also be hindered in mixed gender groups.
Co-ed treatment groups can also present other challenges for women in treatment due to the differences in socialization of men and women. For example, women will tend to nurture men who are present in their therapy groups. While this additional support often benefits the men who receive enhanced support and encouragement in mixed gender groups, women are likely to be diverted away from stating their own needs and exploring their own issues as they ‘take care’ of male group members. Women are more prone to ‘internalize’ while men will more typically assert themselves or display more aggressive traits in addressing issues. This difference in communication and expressive styles creates an atmosphere in which women will frequently take a ‘backseat’ to the needs of male group members who will be prone to dominate the process and work of therapy groups.