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NEED FOR WOMEN-SPECIFIC PSYCHOSOCIAL INTERVENTIONS FOR SUBSTANCE USE DISORDERS: THE INDIAN SCENARIO

Reni Thomas1*, R Dhanasekara Pandian2
1PhD Scholar, 2Additional Professor
Dept. of Psychiatric Social Work, NIMHANS, Bangalore
*Correspondence: Dept. of Psychiatric Social Work, NIMHANS, Bangalore. E-mail: renithomas33@gmail.com

INTRODUCTION

Research on substance use disorders (SUDs) has historically focused, both in India and the rest of the world, on men. However, in 1980’s and 90’s, clinicians and researchers in the west began to develop a solid body of knowledge on the diagnosis and treatment of women with SUDs.1 Increased understanding of women’s substance use thus gained has dispelled one important myth that SUD is a disease of men. Research from west have also focused on the difference between men and women with SUDs in terms of risk factors and physiological and psychosocial variables.2,3,4 Recent surveys from India too have demonstrated that, compared to the past, the prevalence of SUDs among women is on the increase.5,6,7

EPIDEMIOLOGY OF SUDs IN WOMEN

Epidemiological studies from the west have consistently demonstrated many gender differences in SUDs.8,9 According to an epidemiological survey from US, compared to women, men were 2.2 times more likely to have abused various substances and 1.9 times more likely to have SUDs.9 A recent study from United States revealed that 42% of the 41.2 million people who reported illicit drug use in the previous year were women; 40% of those women were using tobacco and 50% were using alcohol.10 Other evidence from the west shows that prescription drug abuse is higher among women than in men.11 Also reported is the narrowing of gender gap in the rate of SUDs — for example, a study from United States found almost similar rates of SUDs among adolescent boys and girls (9.5% vs 9.8%).12

Till 1990, epidemiological studies from India had shown that SUDs are prevalent only in men.5 However, recent studies have shown that SUDs are prevalent among women too,6,7 and that prevalence rate of SUDs in women range from 2% to 8%. Data also reveal that the substances commonly abused by women are alcohol, tobacco, opioids, and prescription drugs.6,13 While earlier Indian studies had reported negligible rates of drug use among women,14,15,16 according to rapid assessment survey, up to 8% of women have ever used drugs in their lifetime.6 Another Indian study showed that 5.9% of women had consumed alcohol in the previous year, compared to 32.7% of men.7 It is also possible that the available studies have excluded many women due to lack of resources, negative attitude towards women’s SUDs and other methodological problems17 and thus underreported the prevalence of SUDs amongst them.

GENDER DIFFERENCE IN ETIOLOGY OF SUDs

Family history of substance use is a powerful risk factor for SUDs. Most genetic studies had focused only on men, and hence it is difficult to generalize those findings to women with SUDs. However, studies have shown that genetic influence of alcoholism is as strong in women as in men.18

Psychosocial factors too play an important role in the initiation and continuation of substance use in women.19,20 Pathway to SUDs is more complex for women, and is strongly connected with trauma and abuse. Compared to men, women with SUDs are reported to have higher rates of childhood or adult physical or sexual abuse, which could have led to their initiation of substance use.21 Women are more likely than men to have been initiated into substance use by a sexual partner and to continue to use in order to feel connected to the partner and maintain the relationship.21 Women are more likely to have substance using, abusing or addicted partners.22 According to limited Indian data available, reasons for initiation and maintenance of substance use among women include childhood adversities, influence of partner or peers, problems in intimate relationship, role transition, life style changes, and physical and emotional stress.19, 20

Murthy has developed a model of factors that lead to SUDs in Indian women.23 It postulates three possible pathways and their complex interactions: The first pathway is “predisposition and modeling” which includes SUDs among family members, peers, or partners. This, coupled with availability of substances and lack of knowledge, can lead to SUDs. The second pathway is about social disadvantage and social isolation that cause physical and emotional problems and ignorance about treatment. This leads to SUDs, which in turn lead to poor social support and stigma, which yet again worsen the social isolation and social disadvantage in a vicious cycle. The third pathway is that of role transition and life style changes which can cause better availability of drugs and lack of knowledge about their harmful effects. This model is a good initial step which helps not only to understand the complex and dynamic etiological factors of SUDs in Indian women, but also the issues related to treatment seeking, support and prevention. This model also emphasizes the need to shift from a single cause linear model to a multi-cause interactive model to understand women’s vulnerability to SUDs.

GENDER DIFFERENCES IN PSYCHIATRIC COMORBIDITIES

Compared to men with SUDs, women with SUDs are reported to have higher rates of psychiatric comorbidity.24 Depression and anxiety disorders are found to be the most prevalent psychiatric diagnoses in women with SUDs.25,26,27 Another difference noted by researchers has been that, while in women affective disorders like depression may appear prior to the SUD, men are more likely to develop such disorders secondary to SUD.27 It is also evident from the literature that while women with SUD suffer from more of internalizing spectrum problems such as anxiety disorders and mood disorders, men with SUD are more likely to suffer from externalizing spectrum disorders such as anti-social personality.28

GENDER DIFFERENCES IN CONSEQUENCES OF SUDs

Men and women differ significantly in terms of biological and psychosocial consequences of SUDs.

Medical complications: Since the female physiology is more complex, alcohol and other substances affect the female body more quickly.29 For example, women tend to have lower body weight compared to men.30,31 Their body contains comparatively less water and more fatty tissue, and the fat retains more alcohol due to availability of less water in the body.32 Hence, women who drink beget a higher blood alcohol concentration, making them more vulnerable to medical complications of alcohol.32, 33 Presence of relatively lower levels of alcohol dehydrogenase and aldehyde dehydrogenase — enzymes that metabolize alcohol — makes women more vulnerable to medical complications as more alcohol reaches their blood stream.32,33 Women are also reported to progress more quickly from using an addictive substance to dependence on it, and this phenomenon is called ‘telescoping effect’.34,35 Women are also likely to face more adverse effects and develop more medical consequences due to stimulants, opioids, cannabis and nicotine,36,37,38,39 and more prone to get serious physical consequences such as malnutrition, sexually transmitted diseases (STDs) including HIV, respiratory infections, skin infections, and anaemia due to alcohol.40,41

Harms to reproductive health:Compared to other women, women addicted to substances are reported to have more severe gynaecological problems, which include irregular menstrual cycles and early menopause.42,43,44 Heavy alcohol consumption can lead to inadequate absorption of calcium and osteoporosis.42 Substance use can also have potentially overwhelming consequences during pregnancy, the major concern being potential negative consequences to the fetus.45 Exposure of the fetus to any substance is associated with high risks for spontaneous abortion, low birth rate, perinatal mortality, premature birth, and developmental and behavioural problems in children.45

Psychosocial consequences: Women are more susceptible to psychosocial consequences of SUDs.17,46,47 SUDs are reported to increase the risk for physical, sexual and domestic violence in women.48 Other important psychosocial consequences of SUDs in women, especially in developing countries, are unsafe sex, early sexual experiences, sharing of needles, and trading sex for money to get substances.20 These high risk behaviors also make them more vulnerable to STDs, including HIV/AIDS.6 Though both men and women with SUDs face social stigma, its degree is greater for women due to gender-based stereotypes.49 Such stigma causes shame and guilt, which in turn may aggravate mental health problems, increase the risk for relapse, reduce self-esteem, and decrease treatment seeking behavior.50 Women are also reported to face unemployment, financial difficulties, homelessness, and interpersonal difficulties due to SUDs.47

Indian data also indicate that continued and heavy use of substances makes women more vulnerable to drug-related crimes.6,20 Rapid assessment survey revealed that legal problems are prevalent among women with SUDs,6 and other Indian data show that sex work, illicit drug trade, pick pocketing and theft are common reasons for imprisonments in women with SUDs.46 Women with SUDs have poor social support compared to men — while higher rates of marital discord, marital separation and divorce are reported in women, men are noted to retain their marital status despite their SUD.13

NEED FOR A GENDER SPECIFIC APPROACH TO RESEARCH AND PSYCHOSOCIAL TREATMENTS

It is crucial to explore and examine the psychosocial factors that shape alcoholism and other SUDs in Indian women at individual, familial and systemic levels. Such a gender specific approach will provide theoretical insights into psychological and social relationship factors that shape women’s substance abuse behaviors. Such an understanding will help in developing a gender specific psychosocial intervention model that will assist and guide mental health professionals to work effectively with women with SUDs. This is especially important as the existing psychosocial interventions for SUDs are largely male-centric,51,52 as women-specific psychosocial factors are understudied and often ignored in clinical practice, and as the prevalence of SUDs in women is on the rise.21

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