Are We in Denial About Women and Addiction?

Are We in Denial About Women and Addiction?

Ignoring half the world’s population takes concerted effort or at least some level of collusion. Academic attention given to women’s mental health and addiction highlighted by several editorials from leading academic journals over the last year suggest our collective ignorance is no accident. The Lancet Psychiatry editorial draws attention to the way information gathered in clinical trials is based on disproportionate sampling of men. Women were often excluded from trials particularly of new medicines for fear that these substances may be particularly toxic to women. Paradoxically, a greater proportion of women then report adverse reactions to these medicines.

At the same time an editorial in the journal of Addiction mirrored the concerns raised in the Lancet but went further suggesting that the problem was systemic. In that women are underrepresented at every level of scientific enquiry, although the differences are most acute higher up the research community hierarchy. With only 29% of senior editorial positions occupied by women.

Gender differences are common in all areas of health including addiction, but have not routinely featured in evidence gathering and as a consequence policy. For example, a recent review of two decades of research exploring the factors associated with dropping out of treatment, a significant issue for services, found that 48% (n = 64) of studies failed to investigate the association between gender and leaving treatment early .

This problem is compounded when a woman has a combined mental health and addiction problem often referred to as dual diagnosis. Many women have more than one problem as drug use can have an impact on their mental health , likewise mental health problems are associated with drug use.

An example of how little we know about these combined problems for women became apparent when we investigated the sex ratio of people who had been admitted to hospital with a diagnosis of cannabis psychosis. Despite males outnumbering females by a ratio of 2:1 in their use of cannabis this ratio extends to 4:1 for admissions due to cannabis psychosis, as shown in the figure below:

We can only speculate as to why there might be these differences in admissions, it is possible that women have some biological protective factors which reduce the risk of developing psychosis following exposure to cannabis. Or it could be that mental health professionals view men as riskier when psychotic and using drugs, a perception that might lead to hospital rather than community care as a way of managing such a perceived risk.

The relationship between cannabis and psychosis and the role of gender is only one example of where we collectively need to improve our understanding. Much of what would advance knowledge could be done relatively easily. As outlined earlier improved reporting of data routinely collected on women would be a good start and require little in the way of resources. For example, there is now a Drug Treatment Data Monitoring System which provides data on the socio-demographic characteristics of those seeking treatment, substances used, type of treatment accessed and a series of “performance” measures including waiting times, rates of successful completions and indicators of effectiveness. We are fortunate to live in an age when such data are not only publicly available but it is possible to manipulate the data and look at specific subgroups of drug treatment users.

However, the level of detail becomes much less when the data are broken down by sex. A more vivid picture of the characteristics of women who enter drug treatment can be gleaned through the generously-funded drug treatment outcome research studies which have been funded in the past. They have been influential in highlighting the distinct characteristics of women drug users. It is in terms of health—both physical and mental—that we see some of the most striking gender differences with far higher rates of chronic health conditions and mental health problems among female drug users. This hides a more complex picture of women experiencing injuries related to domestic violence, reproductive and sexual health problems, and poor mental health resulting in self-harm, suicidal thoughts and suicide attempts. 

Such studies are now dated and both the nature of the drug problem and policy responses to it have changed significantly. There are now fewer individuals in drug treatment, although the proportion of women has remained much the same at approximately one quarter; there is less emphasis on referring drug-using offenders to treatment, which was arguably a male-focused agenda; and individuals now present with a more diverse range of drug addictions. Nonetheless, more recent academic research point to the need to understand how the small but significant group of women who enter drug treatment are different from their male counterparts. A recent study of the everyday lives of recovering heroin users compares female and male pathways into and out of drug use . Crucially, the researchers argue that while there is strong evidence that gender shapes drug users’ experiences, we should not make assumptions about individuals based upon their gender. Research needs to take account of the many different factors which might be influential; for example, age, ethnicity, socio-economic status and sexual orientation.

All this matters as research informs treatment, policy and commissioning of services. High quality research could reverse the trend for drug policies to be silent on the issue of gender apart from in high selective contexts; for example, relating to pregnancy. The effect of ignoring gender differences within drug policies is to reinstate the male drug user as the norm, with little recognition of the distinctive needs of female and male drug users or the potential for policies to impact differentially on women and men. Moreover, if we gloss over the salience of gender in research and policy this has consequences for the way mental health and addiction treatment is organised and delivered.

Research needs to look beyond the treatment setting, challenging as this might be, there is a pressing need for equality. Attending to women and addiction would paradoxically improve the response and interventions that we could offer to males. As any person who has recovered from a drug problem will testify, until we admit we have a problem, change is unlikely.

Ian Hamilton is a Lecturer in addiction and mental health at the University of York. Ian trained and worked as a mental health nurse in South London, working with people who had a severe mental health problem and used drugs or alcohol problematically. His interest in this client group has continued through his work with teams who come into contact with such clients, and also facilitating sessions in this area.You can follow him on Twitter @ian_hamilton_


Emma Wincup is a Senior Lecturer at the school of law of the University of Leeds. Her most recent research has focused on drug use and its control. This has resulted in a series of publications on drug treatment, the interconnections between welfare and drug policy, and the impact of drug policy on women. More generally, Emma interested in the interconnections between crime and social policy and the policy-making process. You can connect with her on Twitter @dselawleeds



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