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Women and Substance Abuse: Gender,Age, and Cultural ConsiderationsSally J. Stevens a , Rosi A. C. Andrade a & Bridget S. Ruiz aa Southwest Institute for Research on Women, University of Arizona ,Tucson, ArizonaPublished online: 18 Aug 2009.

To cite this article: Sally J. Stevens , Rosi A. C. Andrade & Bridget S. Ruiz (2009) Women andSubstance Abuse: Gender, Age, and Cultural Considerations, Journal of Ethnicity in Substance Abuse,8:3, 341-358, DOI: 10.1080/15332640903110542

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Women and Substance Abuse: Gender,Age, and Cultural Considerations

SALLY J. STEVENS, ROSI A. C. ANDRADE, and BRIDGET S. RUIZSouthwest Institute for Research on Women, University of Arizona, Tucson, Arizona

Historically, data has shown that a smaller percentage of womenuse alcohol and illicit substances compared to men, and thatfrequency of use has been lower among women compared to useamong men. Although this data on usage may be true, researchersalso acknowledge that substance use among women has been ahidden issue, one not realistically acknowledged by society, espe-cially prior to the mid-1960s. Along with this, more recent dataindicates that rates of substance use among women are increasing.Factors contributing to this increase in substance abuse havebegun to receive considerable attention, and recent research sug-gests that many issues exist that are unique to substance useamong women. The purpose of this article is to discuss genderspecific considerations in women’s substance abuse by examiningthe history of substance use among women; analyzing gender-specific factors, including physiological factors, trauma-relatedfactors, mental health issues, and cultural considerations thatimpact on women’s substance use; articulating treatmentapproaches 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 MentalHealth Services Administration (SAMHSA)–Center for Substance Abuse Treatment (CSAT)(grant numbers H79 TI 14452, KD1 TI 11892, KD1 TI 11422, and 5 HD8 TI00383), andSAMHSA–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 reflectthe official positions of NIH–CNIDA, SAMHSA–CCSAT, or SAMHSA–CSAP.

Address correspondence to Sally J. Stevens, Executive Director, Southwest Institute forResearch on Women, The University of Arizona, 1443 E. 1st Street, Tucson, AZ 85721-0403.E-mail: sstevens@dakotacom.net

Journal of Ethnicity in Substance Abuse, 8:341–358, 2009Copyright # Taylor & Francis Group, LLCISSN: 1533-2640 print=1533-2659 onlineDOI: 10.1080/15332640903110542

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INTRODUCTION

Alcohol and drug use among women has been studied by researchers frommultiple disciplines primarily because the issues that substance using womenface are multi-faceted and complex. This article addresses some of theseissues by focusing on the historical, physiological, social, and behavioralfactors relevant to women and substance abuse. In addition, this article offersthe reader information about effective treatments for substance abusingwomen, including descriptions of appropriate theoretical models to guidetreatment. The article will conclude with a discussion of the research needsand 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 anddrugs. In the United States, marijuana was used by or given to women in the1600s for treatment of labor pains, uterine hemorrhages, postpartum psycho-sis, and other illnesses. During the 1700s, use of opium among womenincreased dramatically. During the Revolutionary War, the production ofopium significantly increased because it was used to treat wounded soldiers.Given its availability and acceptance, it was common for women to useopium and syringe kits were openly available for sale. Moreover, for thosewho were addicted to ‘‘distilled spirits,’’ Dr. Benjamin Rush, a leader inalcohol treatment at this time, recommended beer, wine, or opium as analternative furthering the use of opium (White, 1998). By the end of the1800s, two-thirds of the nation’s opium and morphine addicts were women(Kandall & Petrillo, 1996). Besides the use of alcohol and opium, women’suse of cocaine also increased during the 1800s (Stevens, 2006).

With the onset of the temperance movement in the 1850s and thesubsequent 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 womenand children, including separate meetings for freed African American slaves.At these meetings, women were encouraged to eliminate alcohol from theirhomes (White, 1998). Although alcohol and drug use became increasinglymore concealed, use was also made easier with the increasing productionof alcohol based ‘‘medicines’’ (White & Kilbourne, 2006). Drug use bywomen became even more invisible on the passing of the HarrisonAnti-Narcotic Act of 1914, which focused on supply and crime versus perso-nal use and treatment.

Women’s alcohol and drug use varied through the 20th century; itincreased during the Prohibition era (e.g., in nightclubs and cabarets),

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decreased in the 1940s and 1950s, and again increased during the women’smovement in the 1960s and 1970s. The increase in the visibility ofwomen’s drug use in the 1960s was in part due to the shift in nationalpriority from a focus on supply and crime to a focus on mental healthand 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 sub-stance use portfolio (White & Kilbourne, 2006). This harsh treatment ofwomen runs parallel with society’s expectation for women to providethe moral foundation for the family, yet their own virtue is continuallyheld in suspect (Lanzetta, 2005).

History of Prescription Medications

Historically, doctors have consistently prescribed drugs more often forwomen than for men. In part, this was due to the perception thatwomen could not become addicted to alcohol or drugs. Women werethought to have problems or illnesses that could be treated openly(Brown, 2006), hence the visible flask of alcohol or the syringe thatoften hung from the bodice of a women’s dress. In the 1800s, doctorscommonly prescribed cocaine for ‘‘neurasthenia,’’ or what was thenthe considered a nervous weakness (Kandall & Patrillo, 1996; Stevens,2006). Lydia Pinkham’s Vegetable Oil which had 30% alcohol contentwas commonly used for many ailments by women who did not ‘‘drink’’(Brown, 2006).

Unfortunately, prescription drug use has remained a problem forwomen from all ethnic backgrounds. Although advertising for over the coun-ter drugs, including cigarettes, has targeted women, pharmaceutical repre-sentatives 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 inadvertisements for antidepressants in two journals, the American Journal ofPsychiatry and the American Family Physician, was 5:1 and 10:1 respectively(Hansen & Osborne, 1995). Although use of prescribed psychoactive drugs isappropriate in certain circumstances in the treatment of some mental healthproblems, its over-use has taken its toll—keeping women sedated and numbfrom their thoughts and emotions and resulting in their inability to under-stand 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 fromethnic minorities differ from that of Caucasian women (Stevens, Estrada,

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Glider, & McGrath, 1998). Although Kandall and Patrillo (1996) foundreports on the use of substances by African American women as earlyas the 1800s, the use of alcohol was so moderate among AfricanAmericans that many thought that they were immune to its influences(White, 1998).

Historically, American Indian women used substances derived fromvarious botanicals for ceremonial and medicinal purposes (Schultes &Hoffman, 1992), although use varied considerably by tribe. Although a fewtribes prepared alcohol-based beverages as a part of seasonal ceremonies,the widespread use of alcohol among American Indians can be traced tothe influence of Europeans and the displacement of Natives from theirculture and land during the 1800s (Berkowitz, Peterson, Smith, Taylor, &Brindis, 1998). Alcohol use crossed both gender and age boundaries withboth men and women involved not only in the use of alcohol, but also inthe liquor trade as well (Mancall, 1995).

For Mexican-origin Hispanic women, herbs were and still are widelyused for medicinal purposes (Yount, 2006). However, use of illicit substanceshas, for the most part, been more closely associated with acculturation.Chambers (2005), for example, found that increased alcohol use amonglow-income Latinas was impacted by speaking English and by acculturation,and Nu~nno, Romero, Orduna, Estrada, and Stevens (2006) found thatthird-generation Hispanic and American Indian youth were more likely toreport having used alcohol compared to those who had recently immigratedfrom Mexico to southern Arizona.

Prevalence of Substance Use Among Adult Womenand Adolescent Girls

Current data indicates that an estimated 6.5 million (5.9%) of women 18years of age or older, met the criteria for past year abuse or dependenceon 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%) abusedor were dependent on illegal drugs. This same report illustrates that thereis a decrease in their substance abuse and dependence as women age.Approximately 15% of women aged 18 to 25 years abused or were depen-dent on alcohol or illicit drugs compared to almost 9% of women aged 26to 34 years. It is noteworthy that although 6.5 million women met criteriafor abuse or dependence, 92% did not receive treatment services (DASIS,2005a; National Center on Addiction and Substance Abuse, 2006). This dis-parity 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 criminaljustice system (DASIS, 2005a).

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Substance Use and Ethnicity

A DASIS (2005a) report also showed that current illicit drug use wasassociated with race=ethnicity. Rates were lowest among Asians (3.1%). Rateswere 12.8% for American Indians and Alaska Natives, 12.2% for personsreporting two or more races, 9.7% for non-Hispanic Blacks, 8.7% for NativeHawaiians or Other Pacific Islanders, 8.1% for Whites, and 7.6% forHispanics. Data from treatment and community based projects working withactive drug users in southern Arizona indicate that not only type of drug use,but also frequency of drug use varies by race=ethnicity. African Americanwomen had the lowest rate of injection drug use at two days per month,compared to Hispanics at seven days per month, Caucasians at nine daysper month, and American Indian women at ten days per month (Stevenset al., 1998).

GENDER-SPECIFIC ISSUES IN WOMEN’S SUBSTANCEUSE: 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), theprimary women-specific issues to be examined in this article include phy-siological factors, trauma-related issues, mental health status, and culturalconsiderations.

Physiological Factors

Physiological factors that impact substance abuse among women includegender differences in physiology, women’s menstrual cycle, and pregnancy.Several studies have found differences in the way men and women meta-bolize alcohol and other drugs. Blood alcohol levels for women are higherthan blood alcohol levels in men with the same height=weight ratio andamount of alcohol consumed. A variety of physiological factors account forthese differences, including women’s higher body fat-over-water ratio,reduced liver-mass-over-body weight ratio, fewer stomach enzymes to breakdown alcohol, and estrogen-induced effects (Stevens, 2006; Ward & Coutell,2003). These physiological factors may be one reason that, as noted in aNational Center on Addiction and Substance Use (2006) report, womenbecome addicted in shorter period of time compared to men even whenusing less alcohol or drugs. Women also suffer more severe brain damagefrom substance use and they develop substance-related diseases such as lungcancer more quickly.

Recent research using new imaging techniques has revealed differencesin brain composition and activity of drug users compared to non-drug users.

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For example, a study comparing methylenedioxymethamphetamine (Ecstasy)users and non-users revealed smaller concentrations of greymatter in the Ecstasyusers compared to non-users. These subtle but statistical differences were evi-denced in the neocortex, which may be involved in word definition; the brainstem, which controls respiration and heart rhythms; and the cerebellum, whichcontrols movement, motor learning, and special sense (Cowen et al., 2003).

Gender appears to influence biological responses to nicotine and othersubstances. When women smoke cigarettes, they take fewer and shorterpuffs. Women experience improvements in mood that men do not, whichis perhaps one reason that women are not as successful as men at quitting.Women and men may process cocaine cues differently as well. A studyby Whitten (2004) shows increased activity in the right nucleus accumbensfor both men and women when they crave cocaine but differences in acti-vity in the amygdala, dorsal anterior cingulated cortex, ventral anteriorcingulated cortex, and frontal cortex. These findings suggest that bothwomen and men have an expectation of pleasure when they crave cocainebut have different expectations in the outcomes of use, leading researchersto think that women may use drugs for different reasons than men. Socialscientists have long thought that men are more likely to use drugs to ‘‘havefun,’’ whereas women may be more likely to use drugs to feel closer toothers, to secure good feelings in an intimate relationship, and to reduceinhibitions (Stevens, 2006).

Studies also indicate that a woman’s menstrual cycle influences herconsumption of alcohol and illicit drug use, which also impacts relatedconsequences of use (e.g., mental health issues, criminal behavior, and HIV-risk behavior) (Schnoll & Weaver, 1998; Stevens & Estrada, 1999). During thefollicular phase (before ovulation), women report higher ratings of ‘‘good’’drug effects and ‘‘liking and using’’ the drug more. In studies on cigarettesmoking, women in the follicular phase reported less cigarette smokingand cravings, but weight gain, reduced desire to smoke or relieve negativeaffect, fewer withdrawal and depressive symptoms, and better abstinencewhen cessation were initiated during this phase. In the luteal phase, womenhave reported significantly more drug cravings (Wetherington, 2006). In part,due to physiological effects, birth control pills have been associated withincreased blood alcohol levels; other studies have shown that women absorbalcohol more rapidly when they are premenstrual (Stevens, 2006).

In a study with women actively using drugs, participants reported thattheir menstrual cycle not only affected their drug use, but also their druguse affected their menstrual cycle. Sixty percent reported that their menstrualbleeding or cramps stopped, 26% reported that menstrual bleeding orcramps decreased, and 32% reported that they had experienced an increasein bleeding or cramping due to their drug use. Type of drug use was relatedto these reported effects. For example, heavy methamphetamine and cocaineuse was generally associated with missed periods (and significant weight loss)

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as well as increased cramping with periods, whereas use of narcotics andalcohol was associated with decreased cramping and pain associated withcramping (Stevens & Estrada, 1999).

Pregnancy can serve as both a motivator and a barrier to enteringsubstance abuse treatment or addressing one’s use of substances. The desireto have a healthy baby can be a powerful motivator for behavior change(Reed, 1985; Stevens, Murphy, & McGrath, 2000). Unfortunately, manysubstance using women report not receiving information about substanceabuse from their medical providers (Salmon, Joseph, Saylor, & Mann,2000). The likelihood that a pregnant woman will be screened for druguse may increase if there are medical complications with the pregnancy, ifthe woman is seen at a public versus private provider, or if she is an ethnicminority (Chassnoff, Landress, & Barrett, 1990; Weir, Stark, Fleming, He, &Tesselaar, 1998). Although recent changes in medical practice have increasedscreening for substance use, the lack of screening presents a missedopportunity to educate pregnant women about the adverse effects ofprenatal 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 totreatment entry for women (Greenfield, 2006). Women frequently reportissues concerning child custody, including custody of those yet to be born(Bogart & Stevens, 2004), and difficulty with transportation and childcareas 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 oftraumatic stress (Stevens & Bogart, 1999). The use of drugs can affect awomen’s judgment about whether a situation is safe, reduces their inhibitionsleading to risky social situations, creates a physical and psychological drugdependency that results in dangerous exchanges of sex for money or drugs,and may impact women’s decision to engage and remain in a violent partnerrelationship.

In studies of the relationship between stress and drug usage, womenreported that traumatic experiences occurred first (Stevens et al., 2000). Inone 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 firstconsensual sex was 15.1 years. Losing one’s virginity can be a traumaticexperience for many women, whether the loss of virginity was due to beingraped or was consensual. In a sample (N¼ 500) of women in substanceabuse treatment, Andrade, Cameron, Stevens, and Ruiz (2006) found that

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53% of American Indian, 39% of bi- or tri-racial, 34% of Hispanic, 31% ofAfrican American, and 27% of Caucasian women reported that losing theirvirginity was ‘‘considerably’’ to ‘‘extremely’’ upsetting.

Andrade et al. (2006) also found that different types of trauma vary forwomen from different racial or ethnic backgrounds. For example, althoughnot having a stable place to live at some point in their lifetime was equallyupsetting for women of all ethnicities (84% to 87% ‘‘considerably’’ to ‘‘extre-mely’’ upsetting), the reported frequency of not having a stable place to livevaried 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 deathof 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% ofCaucasian women. Being a victim of a crime was reported by 85% ofCaucasian, 64% of bi- or tri-racial, 63% of African American, 62% of AmericanIndian, and 59% of Hispanic women.

Moreover, historical trauma experienced particularly by women fromethnic minority backgrounds may impact substance abuse. Brave Heart(2003) described historical trauma among American Indians as an accu-mulation of psychological and emotional wounding across generationsarising from group trauma experiences. This is particularly noteworthy forAmerican Indians, who suffered ongoing and extensive trauma with regardto 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 andrelated problems.

Data from adolescents (N¼ 372) in substance abuse treatment indicatehigh levels of traumatic stress. As reported by Stevens, Murphy, andMcKnight (2003), adolescents who report having greater symptoms oftraumatic stress (e.g., trouble concentrating or trouble sleeping) entertreatment with significantly greater problems associated with lifetimesubstance abuse, worse problems associated with general mental health,higher levels of depressive symptoms, and greater homicidal andsuicidal ideation. In addition, gender differences are also present, with girlsevidencing worse scores in all of these areas.

Mental Health Issues

Gender differences in the mental health of adult substance abusers indicatethat women have mental health disorders such as depression, anxiety, stressdisorders eating disorders, and low self-esteem more frequently than men. Incomparison, men typically have more trouble with functional living and withissues such as work, money, and legal problems (Substance Abuse andMental Health Service Administration, 2005). Fortunately, outcome data from

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women who have participated in substance abuse treatment show thattreatment is not only effective in assisting women in reducing substanceuse, but also mental health problems are also reduced following treatment(Wexler, Cuadrado, & Stevens, 1998).

In a national study of adolescents (N¼ 1,207) enrolled in substanceabuse treatment, Stevens, Estrada, Murphy, McKnight, and Tims (2005)compared the baseline data of boys and girls. Baseline substance usefrequency, problems associated with substance abuse, and behavioral com-plexity (e.g., external behavior such as attention deficit disorder or conductdisorder) were higher for girls than boys. In addition, girls’ scores on generalmental health were almost twice as high (severe) for girls as they were forboys. Fortunately, outcome data 3, 6, 12, and 30 months after substance abusetreatment demonstrated a significant reduction in substance use from baselineto 3 and 6 months, followed by a slight increase at 12 months and again at 30months, but never returning to the baseline level of severity. General mentalhealth problems and behavioral complexity reduced from baseline to 3, 6, and12 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 andethnicity, but also patterns of use and contextual issues associated with usevary between women from different racial and ethnic backgrounds. Datafrom several women’s intervention projects located in southern Arizonashow that, on average, African American adolescent girls initiate alcoholand drug use 1 to 3 years later at or about the age of 15 years (Andradeet al., 2006; Stevens et al., 1998). In addition, data on Hispanic womenreveals a consistent pattern across data bases and programs with regard toa rapid trajectory from age of first alcohol and marijuana use to hardcore druguse such as heroin and cocaine when compared to other racial or ethnicgroups (Andrade, Stevens, & Ruiz, 2005; Stevens, Ruiz, Romero, & Gama,1995). Given these differences, one may look at protective or contributingfactors involved in substance use based on cultural considerations. Culturaland social expectations of African American young women as a source ofstrength in the family may contribute to empowerment in their teens andresiliency to using substances. Meanwhile, the rapid trajectory from alcoholand marijuana use to hardcore drug use for Mexican-origin Hispanic womenmay imply a conflict between cultural expectations and behavior—that oncea 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 ethnicitywith White women typically having achieved a higher level of education.

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Andrade et al. (2006) reported that of 495 women in treatment, AmericanIndian 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 themost likely to be unemployed (68%) compared to the other racial orethnic groups (average of 78%). Other disparities include homelessness,with twice as many (61%) African American women perceiving themselvesas homeless as other racial or ethnic groups (average of 35%). Disparitieswere also found for the number of times arrested; American Indianwomen reported fewer arrests (3.3 times) compared to other women(average of 5.5 times).

In another study, twice as many American Indian women reportedhaving health insurance (typically through Indian Health Services) comparedto other ethnic groups, but approximately half (47%) reported being home-less (Stevens, Estrada, & Villareal, 2003). Women who lack education oremployment skills, are homeless, or may have probation violations for a pre-vious arrest may remain in drug or violence plagued living environments forshelter because working or earning a livable wage may not be a option(Stevens & Bogart, 1999). These issues have substantial implications withregard to both access to substance abuse treatment and the need forgender-specific treatment.

WOMEN AND SUBSTANCE ABUSE TREATMENT

The proportion of substance abuse treatment clients who are female hasincreased moderately over the past decade. According to the DASIS report(2005a), approximately 30% (565,000) of admissions to substance abusetreatment facilities were women, up from 28% in 1992. Among individuals12 years or older in 2004, men were 2.5 times as likely as women to havereceived treatment for an alcohol or an illicit drug use problem in the pastyear (2.3 vs. 0.9, respectively) (National Survey on Drug Use and Health,2005). Women in treatment were more likely to enter treatment for opiateor cocaine use or abuse and less likely to be in treatment for alcohol ormarijuana use as compared to men. Women also tend to be younger thanmen 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 abusetreatment, but also in regard to reasons for treatment entry, retention intreatment, and treatment outcomes. Grella and Joshi (1999) conductedanalysis on the Drug Abuse Treatment Outcomes Study data (N¼ 7,652)and found that men enter treatment more frequently under pressure fromfamily, an employer, or the criminal justice system, and women are more

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often self-referred or social worker referred, with influencing factors such astrading sex for money or drugs, mental health problems, and singleparenting issues. Although treatment retention appears to be the same forwomen as it is for men, individual characteristics such as personal stability,psychological functioning, and number of children are predictors ofretention and completion among women (Greenfield, 2006). Treatmentoutcomes suggest similar or better outcomes for women when comparedto men even across treatment modalities (Greenfield, 2006). However,psychosocial contextual issues such as mental health status, trauma, griefand loss, and family=spouse characteristics have been found to contributeto treatment success (Stevens, 2006).

Examination of gender differences between adolescents enteringsubstance abuse treatment suggests similar trends and may, in fact, be morepronounced. Treatment admissions data show that 70% are boys. In examin-ing gender differences in adolescents enrolled in substance abuse treatment,Stevens et al. (2005) found that girls enter treatment with higher levels ofsubstance 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 respondto 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 treatmentadmissions by race=ethnicity clearly exist. American Indians and AlaskanNatives were more likely to report alcohol as their primary substance ofabuse compared to admissions of other racial or ethnic groups (63% versus42%). Interestingly, a higher proportion of American Indians and AlaskanNatives admissions were women compared to admissions from other racialor ethnic groups (36% versus 30%). For non-Hispanic Blacks, approximatelytwo-thirds of the treatment admissions were for alcohol or cocaine use. From1994 to 1999, non-Hispanic Blacks admissions into treatment decreased by15%. As compared to Black men, Black women were more likely to entertreatment for the use of harder drugs (e.g., cocaine or opiates). Asian=PacificIslanders were more likely to enter treatment for either marijuana or metham-phetamine=amphetamine use than other racial or ethnic groups. Only 28% ofAsian=Pacific Islander treatment admissions were women. Individuals ofHispanic=Latino ethnicity were more likely to report opiate abuse thannon-Hispanic admissions (28% versus 16%) and the majority of theseadmissions were men (78%).

Among the adolescent population, White youth report more family andmental health problems, whereas Hispanic youth report more legal problemsand issues and more experiences of trauma (Murphy & Stevens, 2001).Among Hispanic adolescents, traditional gender norms have been shown

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to be a protective factor for substance use, although not a protective factorfor risky sexual behavior (Luther, Stevens, Bracamonte Wiggs, & Ruiz, 2005).

THEORIES AND METHODS FOR WORKING WITH FEMALESUBSTANCE ABUSERS

Many researchers and clinicians argue for gender-specific treatment that notonly includes addressing substance abuse, but also addresses social,economic, medical, and legal constraints thought to be related to substanceuse (Stevens & Bogart, 1999). In addition, providing childcare, life-skillstraining, transportation, and special programming for minority women arealso thought to be critical to women’s treatment and recovery (Greenfield,2006; Wechsberg, Lam, Zule, & Bobashev, 2004). Several treatment modal-ities exist, such as residential treatment with and without children, day treat-ment, outpatient treatment, and peer support. Within treatment modalities,both mixed gender and women’s only groups are offered. Outcomes fromthese different modalities and group composition are mixed, although thereis 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-specificfactors (e.g., physiological, trauma-related, mental health, and culturalconsideration) that impact women’s substance use suggests that addictionamong women is closely connected to negative and sanctioned socializationand with personal experiences of disempowerment (Stevens & Bogart, 1999;White & Kilbourne, 2006). Throughout history, women have experiencedvaried forms of oppression from structural (economic) to personal (loss ofidentity) to specific (abuse). These varied forms of oppression injure womenin unique and particular ways, damaging the receptive aspect of women’snature (Lanzetta, 2005). Oppression invades a women’s psyche at such adeep level that women are often unable to identify the source of their pain.Unidentified, unspoken, denied, and dismissed, women may react inunhealthy ways, such as protecting their oppressor (Lanzetta, 2005) or bynumbing feelings through the use of prescribed, legal, or illicit substances(Stevens, 2006). Because of women and girls’ societal status and lifecircumstances, we need gender-appropriate theories and methods to guidewomen’s treatment, regardless of treatment modality. Among these theoriesand methods are the following five approaches: social ecology model,empowerment theory, relational model, feminist theory, and participatoryaction research.

Social ecology is an overarching framework for understanding the inter-relations among diverse personal and environmental factors in human healthand illness. It integrates person-focused efforts with environment-focusedinterventions (Stokols, 1996). Thus in working with women, the researcher

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must consider that the context of the each woman’s life is critical, andsuccessful substance abuse treatment needs to change both personal andsocial vulnerabilities.

Empowerment theory compels researchers and service providers tothink in terms of wellness versus illness, competence instead of deficits,and strengths versus weaknesses. Programs need to provide opportunitiesfor women to establish a sense of self-empowerment, self-efficacy, andself-control and to assist these women in gaining the skills and resources thatthey need to take control of their lives (Belenky, Clinchy, Goldberger, &Tarule, 1986).

The relational model is a theoretical paradigm for women’s psychologi-cal development and well-being. Hypothesizing that women’s developmentis embedded in relationships and that relationships with others are primary toa women’s health and well-being, treatment providers using this model paysubstantial attention to developing healthy family, peer, and significant otherrelationships (Belenky, Bond, & Weinstock, 1997).

Feminist theory examines substance abuse from the point of view ofoppression and attempts to engage women in larger causes. A feministapproach raises the issue of subjectivity versus objectivity and stressesworking with women in an equal capacity, challenging the typical powerrelationship between the researcher and the researched (Bowles & Klein,1983).

Participatory action research is a collaborative approach that equitablyinvolves all partners and recognizes the unique strengths of each participant.Substance abuse treatment based on this framework would involve thewoman specifically in the development of her own treatment, reflecting,planning, and implementing her own treatment plan based on her uniquestrengths (Kaplan & Alsup, 1995; McTaggart, 1997; Pederson, 1988; Sissel,1996).

FUTURE DIRECTIONS IN SUBSTANCE ABUSETREATMENT 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 considerablegaps in knowledge and many questions yet to be answered. Topics that needcontinued investigation include factors that contribute to young girls’initiation into substance use, gender differences in the physiological effectof substance use, and facilitators and barriers to substance abuse treatmententry. Also needed are in-depth process and outcome studies on substanceabuse treatment that take into account gender-specific needs, utilizewomen-centered approaches, and provide concurrent treatment forco-morbid disorders. Examination of what happens following treatment is

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also critical and includes studies on physiological changes followingabstinence from substance use, factors associated with continued abstinenceor that lead to relapse, and cost-benefit analysis of providing treatmentcompared to no-treatment or incarceration for drug and drug-relatedconvictions.

Within the overarching theme of research on women and substanceabuse, additional research is required that takes into consideration women’sposition in society, culture, family, and contextual issues such as abusehistory, grief and loss, and economic factors. Careful consideration of howwomen’s oppression contributes directly or indirectly to substance use(prescribed, legal, and illicit) may further illuminate strategies that not onlyimprove treatment effectiveness but reveal needed structural changes toimprove women’s well-being. Although current research suggests that cultu-rally driven treatment approaches seem to be effective, articulating what thetreatment is and for whom it works would further the field. Family-centeredapproaches such as family drug courts and residential treatment for pregnantand 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 theexamination of family-related issues that may be associated with substanceuse, treatment entry, and treatment success as well as expansion of thesefamily treatment approaches to include the extended family network.Because current data points to the impact of contextual issues on the initia-tion of substance use, treatment needs, and treatment outcomes, researchthat focuses on how various contextual issues are intertwined with substanceuse, along with the relative effectiveness of concurrent treatment approaches(e.g., trauma with substance use or grief and loss with substance abuse), isspecifically needed.

Finally, in any study on substance abuse treatment, fidelity in the deliveryof the intervention is imperative so that when successful outcomes are docu-mented, there is a clear understanding of what the treatment consisted of andhow it was delivered. The importance of achieving follow-up rates at or above90% is also vital so that confidence in the findings is achieved. Most impor-tantly, as the field of women and substance abuse advances and the under-standing of the issues affecting this population further emerge, advocacy atthe policy and funding level will be critical to move new research findings intosubstance abuse prevention and treatment practice.

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