When it comes to drug addiction, gender does make a difference.

Women start using substances and become addicted differently from men. Their addiction progresses faster, they find it harder to quit, they recover differently from men, and they relapse for different reasons.

These gender differences have a substantial impact on treatment for substance abuse. But when women’s specific needs are understood and addressed from the outset, better treatment engagement and successful outcomes often follow.

Women and Addiction: The Biopsychosociocultural Framework

The Substance Abuse and Mental Health Administration TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women, proposes approaching substance abuse treatment for women from the perspective of “the biopsychosociocultural framework.”

Differences between women and men in genetics, physiology, anatomy, and sociocultural expectations and experiences lay the foundation for women’s unique health concerns related to substance-use disorders (SUDs). The biopsychosociocultural framework encompasses the impact of gender and culture and the contexts of a woman’s life, including her social and economic environment, and her relationships with family and support systems.

Risk Factors for Substance Use in Women

Some factors are associated more strongly with initiation of illicit drug use in women than with progression to abuse. They include risk-taking (as a personality trait), depression, obsessiveness, anxiety, and difficulty controlling behavior (as indicated by temper tantrums or tearfulness).

Genetics and environment both play a role in some risk factors. Parents who abuse substances may pass along a genetic susceptibility. They may also fail to adequately protect their children from abuse by others, and may be of little help to them emotionally. And they may unintentionally pass along the message that it’s okay to use substances to cope with problems.

Among other risk factors:

• Divorce, never having been married, and widowhood (the incidence of SUDs in married women is only 4%)
• Sexual or physical abuse or domestic violence in childhood or adulthood
• A history of having adult responsibilities as a child: caring for younger children, performing household duties, emotionally supporting their parents
• Unemployment or underemployment; low income; low education level
• A partner who abuses alcohol or drugs (some women continue using substances in order to maintain the relationship, a situation that also occurs in some same-sex relationships)
• Sexual preference: lesbians have higher rates of SUDs than heterosexual women; younger lesbians and bisexual women are most likely to abuse prescription drugs

Protective Factors

Factors that help protect a woman against substance use, abuse, and dependence include a good marriage, a supportive partner, parental warmth during her childhood, religious affiliation and beliefs, and deep personal devotion.

Research Results: Characteristics of Women with OUDs

Women face a higher risk of co-occurring mental and physical disorders. A UCLA study examined gender differences in 578 men and women with opioid-use disorders (OUDs), drawn from the National Epidemiologic Survey on Alcohol and Related Conditions. The study found that “women were about twice as likely as men to have either a mood or anxiety disorder.” Women were also “more likely to have paranoid disorder, and men, more likely to have antisocial personality disorder.” Another study, the National Survey on Drug Use and Health, found higher rates of “serious psychological distress” and “cigarette use” related to non-medical use of prescription opioids among women, but not among men. In contrast, “serious psychological distress” was a significant predictor of abuse/dependence for both sexes.

Other studies have found that women are much more likely than men to have co-occurring mental disorders, often three or more, including anxiety disorders, major depression, eating disorders, and post-traumatic stress disorder (PTSD). Typically, PTSD follows trauma, sexual abuse, or violence—events that unfortunately are all too common in women with OUD. Physical disorders in women include gynecological infections, high blood pressure, amenorrhea (absence of menstrual periods) and pneumonia.

In a symposium report, Florence Haseltine, PhD, MD, noted that women tend to take illicit drugs to relieve stress; men, to get a high; women, for self-medication; men, as an adventure.

She added that women with OUDs are more likely to

• Self-medicate, especially using drugs to manage negative moods
• Need help for emotional problems, and at a younger age
• Have attempted suicide

Others have observed that, in addition, women with OUDs tend to use more prescription drugs (and use prescription drugs that can be abused), obtain prescription opioids free from family or friends (men are more likely to buy them), and have partners who use illicit drugs.

Relationships and family history are key factors in women’s—but not men’s—initiation and continued illicit use of opioids and other substances. Women are more likely than men to have a family background of dysfunction and alcohol dependency, and to be brought into and maintained in drug use by a partner or family member. It almost seems that when women start to abuse substances, they already have three strikes against them.

Women are more likely to borrow needles and equipment from the person they inject drugs with. They’re also likely to inject immediately after that person—putting themselves at added risk of HIV and hepatitis infections. Intravenous drug use accounts for up to half the cases of HIV infection among women in the U.S., twice as many as sexual transmission.

But, importantly, women can temporarily change their pattern of substance use to meet caregiver responsibilities involving the family, such as pregnancy.

Looking Back When In Methadone Maintenance Treatment

In gender-specific focus groups in a methadone maintenance clinic at UCLA, comments from participants older than 50 years revealed clear differences between men and women in their views of their previous life in addiction. Women talked about the impact on their families, and their regrets about “. . . not being the mother I should have been.” And their remorse: “I almost lost my family.”  Men typically expressed surprise at still being alive, and previous fears about incarceration.

Pregnancy

If a woman’s menstrual periods stop when she is using opioids, she may assume at first that the early signs of pregnancy are symptoms of withdrawal or underdosing. This often delays her pregnancy diagnosis and prenatal care.

But, as TIP 51 points out, “Women are socialized to assume more caregiver roles and to focus attention on others.” Indeed, once a woman is told she is pregnant, she typically casts aside her vulnerability and regains her traditional role of caregiver. She is likely to accept medical care for herself and her unborn child, and to stop or substantially curtail her use of illicit drugs, alcohol, and cigarettes, throughout her pregnancy.

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This article is the first in a series on the special challenges that make coping with addiction especially difficult for women. Future topics include the barriers women face in seeking and accepting treatment, and the best approaches to treatment for women in medication-assisted treatment programs. Programs need to address the special needs of women by offering auxiliary or wraparound services, or both—such as child care and prenatal services, and workshops on woman-focused topics.

Resources

Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series 51. HHS Publication No. (SMA) 09-4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

Becker JB, Hu M. Sex differences in drug use. Frontiers in Endocrinology. 2008;29:36-47.

Haseltine FP. Symposium Report: Gender differences in addiction and recovery. J Womens Health Gend Based Med. 2000;9(6).

Hamilton AB, Grella CE. Gender differences among older heroin users. J Women Aging. 2009;21(2):111-124.

Grella CE, Karno MP, Warda US, et al. Gender and comorbidity among individuals with opioid use disorders in the NESARC study. Addict Behav. 2009;34(6-7):498-504.

Grella CE, Lovinger K. Gender differences in physical and mental health outcomes among an aging cohort of individuals with a history of heroin dependence. Addict Behav. 2012;37(3):306-312.

Subramaniam GA. Clinical characteristics of treatment-seeking prescription opioid versus heroin using adolescents with opioid use disorder. Drug Alcohol Depend. 2009;101(1-2):13-19.

Back SE, Payne RL, Simpson AN, Brady KT. Gender and prescription opioids: Findings from the National Survey on Drug Use and Health. Addict Behav. 2010;35(11)1001-1007.