Men have historically used substances more than women, and so, existing addiction services and policies are more often designed with men in mind or take a gender-neutral approach. However, because women face unique concerns when it comes to substance use disorder (SUD) that are influenced both by gender identity and biological sex, the call from addiction specialists to consider women-specific treatment is growing louder.
Women face different risk factors for developing SUD than men and different barriers to accessing necessary care and treatment. Women tend to have a shorter timespan between the first use of a substance and addiction. Relative to men, women with SUD report additional struggles with employment, family, and psychiatric wellness. Additionally, women who are pregnant are less likely to seek treatment for their addiction due to fear of arrest or child removal, perpetuating the problem even further.
Miriam Harris, MD, MSc, a primary care doctor at Boston Medical Center and addiction expert at BMC's Grayken Center for Addiction who provides addiction treatment in the Women’s Health Unit, co-authored a recent journal article describing gender differences in substance use and treatment. The article focused on women’s experiences with SUD and typical unmet needs of being in treatment facilities not tailored for women.
We spoke with Dr. Harris about the realities for women with addiction, challenges and solutions of current available treatment options, and the urgent need to make a change.
HealthCity: What is the biggest harm for women in addiction treatment facilities, or going through other treatment models, that aren't designed specifically for women?
Miriam Harris, MD, MPH: When it comes to social determinants of health, women have greater vulnerabilities that prevent them from even getting in the door for treatment, such as transportation and different access to and control of finances. If they do get in the door for treatment, those barriers persist and remain unaddressed in existing models.
Women also have multiple other responsibilities—in particular, parenting or navigating the child protective system, which is incredibly complicated and stressful. Existing services aren't necessarily putting those considerations at the forefront of our delivery models.
HC: It's important to recognize that even though someone can identify as a woman, there are different identities within that category. How do you think racism and public conceptions of drug use play a factor in the treatment of women of color with substance use disorder?
MH: The intersectionality piece is critical and can't be lost. Women are a diverse group of people, just like Black people and Latinx people are incredibly diverse groups. It's helpful and harmful to just say "women." Thinking about all the unique barriers that exist for women trying to access addiction services, that's compounded tenfold to twentyfold for Black, Indigenous, Latinx women, and for transgender women. They're experiencing multiple levels of structural racism and stigma.
Our systems at the policy level drive a lot of these barriers in service access for women; they were designed with a racist lens. Punitive policies, which are driving barriers for substance use and addiction for women, are exacerbated when you have an intersectional identity. There needs to be big and immediate policy-level action to start to dismantle these.
HC: Your article states that 50% to 70% of women in substance use treatment programs have children to care for. What can we learn from this data, and how can treatment models be better designed with this in mind?
MH: We, as a culture, have a tendency of focusing on women as vessels for fetuses or only as parents. If we just take a step back and try to think of the whole continuum of a woman's life, our services would do a much better job of providing care to women.
At the front end, thinking about how to incorporate sexual health services—and how to do it thoughtfully, without it being coercive—includes ensuring access to reproductive health services that facilitate women controlling timing of pregnancy and other sexual health needs, such as cervical cancer screening. For pregnant people, we must ensure there are places for them to access care. For example, there aren’t very many beds or programs for people who are pregnant and also have substance use disorder. Lastly, we must think about how to design addiction programs with the family in mind and how to enhance supports for families and parents—for example, by offering childcare within addiction programs.
HC: You discuss how women with SUD often have co-occurring health problems, including trauma from intimate partner abuse. In your opinion, what is the best way to reach women who are reluctant to seek care for their substance use because of these added concerns?
MH: We have to meet them wherever they're going, and then, we have to actually be able to offer something. Many of the services for women experiencing intimate partner violence do not take into account the needs of women who use drugs. Yet these are the people who often need the services the most.
Why would a woman experiencing violence come to the emergency department or primary care if these places don’t have mechanisms to connect her with intimate partner violence services? Many times, when women do come to seek help to escape violence, our responses are inadequately based on what servicers are available. For example, in the middle of a crisis, often the best we can offer is, "Here is a list of shelters that you can call every day for the next two weeks, and perhaps a bed will become available. Oh, and by the way, you can't use drugs when you get that bed, even though you have an addiction and substance use may be how you cope with the violence you're experiencing."
We must break down silos between services for intimate partner violence and substance use. Measures to address this problem right now could include ensuring staff who work in addiction services are asking about intimate partner violence and are aware of current community resources. Similarly, intimate partner violence programs should be aware of addiction services and have mechanisms in place to support women accessing these.
Punitive policies, which are driving barriers for substance use and addiction for women, are exacerbated when you have an intersectional identity. There needs to be big and immediate policy-level action to start to dismantle these.Click To Tweet
HC: Advocating for change, especially at the policy level, can be overwhelming when there's so much work to be done. As a healthcare professional, where is the best place to start?
MH: We have a lot of power as healthcare professionals to engage with policy, but not necessarily a lot of support or a clear path. Personally, it has been surprising how much power your voice can carry when given the opportunity, for example, to testify or to help construct a bill that might dismantle a policy that's adversely affecting women. Connecting with local advocacy organizations or lawyers doing this work can be a great place to learn about what’s happening and how to support policy change.
As providers, we also have opportunities to create programmatic changes. For example, methadone programs or residential treatment programs could make an effort to offer gender-concordant providers. Services could create women-only groups, because there is a lot of research showing that women find them safer and more beneficial.
HC: Are you hopeful that these steps can help make addiction treatment equitable for women specifically?
MH: I'm an internal optimist; being cynical is a privilege we do not have. I am hopeful because I think everyone is recognizing the enormity of this problem. There's investment and interest in changing how we do things. It's going to be slow and so hard, but I think we're at a moment where we have an opportunity to talk about these issues at the policy level and have those things be heard in a different way than perhaps five to 10 years ago.
For example, the Massachusetts ACLU put a bill forward to request a change to state law about mandated reporting for babies born with physical dependence upon an addictive drug at birth. It was voted favorably out of committee, which is so exciting. So, progress can be made. But, I want to emphasize that it's not being done fast enough and the real-time consequences of that are enormous.