M44 Gender Responsive Treatment For Women 2023

Executive Summary

• Clinicians and program administrators recognize important gender differences in substance use effects and disorders between women and men.
• Treating women’s unique needs from the outset improves engagement, retention, and outcomes.
• The manual uses a biopsychosociocultural framework grounded in Bronfenbrenner’s ecological model and CSAT’s Comprehensive Substance Abuse Treatment Model for Women and Their Children, emphasizing multisystem context and bidirectional influences on women’s lives.
• Core principles for gender-responsive treatment include socioeconomics, cultural competence, relationships, women’s health, developmental perspective, caregiver roles, stigma reduction, trauma-informed care, strengths-based approaches, integrated multidisciplinary care, gender-responsive environments, and building gender competency.
• The publication comprises eight chapters, plus appendices with screening/assessment instruments and implementation guidance for diverse populations.

Creating the Context

• Gender-responsive treatment is built on a context that includes: a woman’s social/economic environment, relationships, gender, and culture.
• Two systemic models underpin the framework:
  • Bronfenbrenner’s ecological model (multisystem influences on development and behavior).
  • CSAT’s Comprehensive Substance Abuse Treatment Model for Women and Their Children (multisystem, family-centered).
• Key questions addressed: Do gender differences exist in development and patterns of substance use disorders? Do these differences warrant specific treatment approaches?
• Consensus: Yes—women have unique biopsychosocial and developmental factors requiring tailored treatment.
• Core principles (summary):
  • Acknowledge socioeconomic differences among women.
  • Promote cultural competence specific to women.
  • Recognize the role and significance of relationships.
  • Address women’s unique health concerns.
  • Endorse a developmental perspective.
  • Attend to caregiver roles across the lifespan.
  • Recognize gender expectations and stigma across cultures.
  • Adopt a trauma-informed perspective.
  • Use a strengths-based model.
  • Integrate and multidisciplinary approaches.
  • Maintain gender-responsive environments across settings.
  • Develop gender competency among staff.

Women’s Biopsychosocial Uniqueness (Overview)

• The manual asserts that gender differences meaningfully influence risk, progression, treatment engagement, and outcomes.
• The biopsychosocial model is organized into three segments: Biological/Psychological, Social, and Developmental.
• The sections advocate tailoring assessment and treatment to women’s specific health, social, and life-course considerations.

Biological and Psychological

• Women often metabolize and process substances differently, withTelescoping: women progress from first use to health problems more quickly than men, even at lower doses.
• Women tend to experience more acute health complications earlier in the course of use; this includes liver and organ damage, cardiovascular issues, reproductive consequences, cancers (breast), osteoporosis, and neurological effects.
• Differences in metabolism and pharmacodynamics are cited across alcohol, stimulants, opioids, cannabis, and tobacco use; research quality varies, with some gaps in illicit drug data.
• Hormonal factors and menstrual cycle stage can influence drug effects, especially for stimulants and outcomes like withdrawal.
• Pregnancy-related implications are emphasized: prenatal exposure harms, treatment planning, and the need for integrated care during pregnancy.
• For pregnancy: alcohol, tobacco, cocaine, opioids, marijuana, and other substances each have distinct birth outcomes, including fetal alcohol spectrum disorders, low birth weight, prematurity, NAS, and congenital anomalies.
• HIV/HCV co-infection considerations are discussed, with emphasis on transmission risks and pregnancy-related management.

Social

• Relationships and social networks are central to women’s use, maintenance, and recovery; intimate partners often influence initiation and ongoing use.
• Family history and caregiver responsibilities profoundly affect treatment entry, engagement, and relapse risk.
• Socioeconomic status, employment, housing, access to healthcare, and insurance shape treatment access and outcomes.
• Discrimination, acculturation, and language barriers influence health outcomes and engagement with services.
• Women face unique stigma and gender-role pressures, including fears about child custody, which can impede help-seeking.
• Protective social factors include partner support, parental warmth, religious/spiritual practices, and coping skills.

Developmental

• Life-course issues shape risk and recovery: adolescence, parenting, menopause, elder care, and late-life transitions.
• Pregnancy and parenting are emphasized as both challenges and teachable moments for motivating treatment engagement and retention.
• Menopause and aging introduce additional health considerations and metabolic changes relevant to treatment planning.
• Across the lifespan, women may experience greater social stressors and different relapse triggers, requiring lifecycle-informed care.

Patterns of Use: From Initiation to Treatment

• Initiation is often triggered by stress, negative affect, relationship dynamics, and significant relationships (boyfriends, spouses, family members).
• Genetic and familial factors contribute to initiation and progression; parental alcohol use increases risk for alcohol use disorders in some women, with family-of-origin chaos/violence also relevant.
• Relationship dynamics strongly influence initiation and treatment engagement; separated/divorced or never-married women show higher risk patterns than married women.
• Six empirically observed patterns:
  1) Narrowing gender gap in initiation across ethnic groups, especially among youth.
  2) Initiation often through significant relationships; marriage can be protective.
  3) Faster progression from initiation to injection drug use among women; high-risk injection behaviors linked to partners.
  4) Early use patterns predict higher risk of dependence.
  5) Caregiver responsibilities can temporarily alter use patterns.
  6) Women progress more quickly from initiation to substance-related consequences (telescoping).
• Pregnant women often reduce use, but continued use has significant risks for prenatal care and birth outcomes.
• Women in treatment often cite drug use as the main reason for admission, and co-occurring mental health issues are common.
• Patterns by demographic and life-stage: across life span, pregnancy, postpartum, elder-care responsibilities, and widowhood affect risk and treatment engagement.
• The chapter emphasizes that gender does not predict retention by itself, but relationship context, social supports, trauma histories, and comorbidities influence engagement and outcomes.

Chapter 3: Physiological Effects of Alcohol, Drugs, and Tobacco on Women

• Overview: Women are more sensitive to the physiological effects of substances; they reach higher blood alcohol concentrations and experience faster progression to organ damage at lower doses.
• Telescoping: faster progression from initial use to dependence in women compared to men.
• Specific health consequences include liver disease, cardiovascular disease, reproductive issues, breast and other cancers, osteoporosis, neurological effects, and higher susceptibility to infections (HIV/HCV).
• Tobacco: women smokers face greater risks (lung cancer, COPD, cardiovascular disease, reproductive issues, osteoporosis) and may have earlier menopause; nicotine effects differ by sex.
• Pregnancy outcomes: alcohol and drug use during pregnancy increase risk of spontaneous abortion, prematurity, low birth weight, NAS, and fetal abnormalities; tobacco use increases risks including prematurity and low birth weight.
• For different substances: illicit drugs (cocaine, opioids, heroin, methamphetamine, marijuana) have sex-specific effects on cycles, menstrual irregularities, and pregnancy outcomes; Hormonal cycles modulate stimulant effects; opioids can cause menstrual disturbances; methadone exposure during pregnancy has neonatal effects but may reduce maternal withdrawal risk.
• HIV/HCV: injection drug use increases risk; women may face higher perinatal transmission and coinfection challenges; needle-sharing dynamics and partner infection risk are discussed.
• Osteoporosis, cancers, and cognitive effects: alcohol-associated breast cancer risk increases with dose; some data suggest higher risk for postmenopausal cancers with alcohol; cognitive/brain structure differences noted with heavy use.
• Summary of pregnancy-related data: various substances each have particular fetal risks, reinforced by the need for prenatal care, integrated obstetric/substance-use treatment, and careful monitoring during detoxification and treatment.

Chapter 4: Screening and Assessment

• Purpose: Determine extent/nature of a woman’s substance use disorder and its interaction with other life areas; informs diagnoses and treatment planning.
• Screening vs. assessment:
  • Screening: brief, identifies need for further evaluation (yes/no outcome).
  • Assessment: in-depth, evaluates multiple life domains to diagnose SUDs and co-occurring disorders; ongoing process.
• Sociocultural/socioeconomic factors influence screening/assessment choices and interpretation; norms may vary by population group.
• Screening areas to cover include: substance use during pregnancy, mental illness symptoms, safety risks, trauma history, eating disorders, and health screenings