WOMEN’S ISSUES IN RECOVERY: SIMILARITIES AND DIFFERENCES WITH MEN
What we were taught about gender-specific addiction treatment might no longer be valid, according to emerging research. Professor Jo Neale views the latest waves to impact practice.
Download AddictionToday142-Women's issues in recovery
Women who need to recover from addiction must go to specialist treatment – right? They all have the same or similar needs? And they broadly do not share similar needs with male addicts? ...
What we were taught about gender-specific treatment might no longer be valid, according to the latest research.
Earlier this year, I was invited to present at the third annual Action on Addiction lecture, about the differences and similarities between men and women who used drugs and were seeking treatment and recovery. To do this, I went back over the literature – and even re-analysed my own studies, with this particular aspect in mind. To gain context, let’s look first at how gender theory evolved, and drugs literature on women.
BACKGROUND: GENDER THEORY
The first wave of feminism was about women’s right to vote, legal obstacles to gender equality. The second wave was about sexuality, reproduction, the family, the workplace, male violence. In both waves, there were assumptions of patriarchal structure of society, that there were essential differences between women and men, that all women share common experiences and of the essential ‘we’ of womanhood. Then came the third wave of feminism, which was about personal experience, individual agency, diversity, choice, change. Assumptions changed so there was critique of ‘essentialist’ definitions of femininity, and it was recognised that some women share political and economic interests with some men, and that women have diverse experiences. These developments are mirrored in the literature around women and drug use.
WOMEN AND DRUGS LITERATURE
At first, the addiction literature ignored women or portrayed them as ‘bad’, ‘mad’, or ‘sad’. Then early feminist literature on women and drugs highlighted women’s shared experiences of addiction, focussing on sex work, sexual relationships, pregnancy/mothering, abuse. It also highlighted barriers to accessing services faced by women, and the need for specialised women’s services. The latest feminist literature identified women’s diverse needs and experiences, showed similarities between male and female drug users, and located women’s drug use in terms of choice, pleasure seeking and self-fulfillment.
EVERYDAY LIVES OF RECOVERING HEROIN USERS
Recently, Sarah Nettleton, Lucy Pickering and I were funded by the ESRC to undertake The everyday lives of recovering heroin users study. The broad aim was to move away from preoccupations with heroin use as a deviant and risky activity and, instead, focus on the routine and everyday aspects of recovering heroin users’ lives. We conducted 40 interviews with recovering heroin users: 21 men and 19 women, aged 24-50 years; 38 were white british. We later undertook 37 follow-up interviews to explore how their recovery journeys were progressing (20 men, 17 women). Participants included 10 starting opioid substitution therapy, 10 starting detox, 10 starting rehab and 10 opioid-free for longer than two months.
We found that recovery brings many challenges, that women and men encounter many of the same challenges and that women do not all experience the same challenges. We also found that recovery is affected by complex interacting factors, including as readers might expect:
>> individual biographies
>> access to formal and informal support
>> drug use and stage of recovery
>> physical health
>> mental health
>> prescribed medications
>> knowledge and skills
>> having meaningful activity or daily routines
>> housing/ environment
>> income and material resources.
For the Action on Addiction lecture, I re-analysed our data to build a picture of the similarities and differences between men and women. So what is the role of gender?
WHEN AND HOW IS RECOVERY DIFFERENT FOR WOMEN?
The men and women all had poor health at this early stage of treatment- and recovery-seeking. Where they differed was that men tended to have injuries from drug-related assaults, car accidents and fighting while the women had self-harming, suicidal thoughts and actual suicide attempts.
As regards bodily changes, men were unconcerned about putting on weight but had altered libido, either heightened or lowered. Women had high levels of anxiety about increased weight, triggering eating disorders and relapse; menstruation was a shock restart for many.
1 “Unhappy” childhoods
2 Lack of family support
3 Non-resident children
4 Difficulty making new non-using friendships
5 Reliance on NA for friendships
6 Social isolation
1 Childhood physical and sexual abuse
2 Physical violence from spouses/partners
3 More children; and a small number had
4 Concerns about parenting
5 Children motivate recovery
6 Practical & emotional support from relatives
7 Ability to isolate self from drug users and
make new non-using friendships.
When it came to day-to-day care, men tended to be unable to sleep and awoke early while women tended towards excessive sleeping, including daytime sleeping. Men had a fear of dentists/inability to afford dentists/dental work needed while women took more care with tooth brushing/visits to the dentist/had recent dental treatment. Men were less concern with personal appearance while women had increasing concern in recovery with personal appearance, including hair, nails, skin, make-up, clothes.
On the essential issue of where people trying to recover lived, we found that men tended to be homelessness (hostels, shelters, rough sleeping, sofa surfing) while women had more secure accommodation.
Men tended to rely on illicit income while women had a greater reliance on state benefits, family assistance and prostitution. Men tended to have debts and a lack of budgeting skills, while women had more budgeting skills.
Our study had limitations but the data still highlighted gender differences which require consideration in terms of service delivery.
WHEN AND HOW IS RECOVERY SIMILAR FOR MEN AND WOMEN?
Detoxing, craving, (re)lapsing:
fear of the detoxing process
cravings for other substances and behaviours
avoiding ‘using triggers’
relapse and cross-addiction
frequent strained family relationships
intimate relationships complicated by addiction
separation from children
few genuine friends
a spontaneous flood of (often intense and
uncontrollable) returning emotions
Poor physical health:
blood-borne viruses, collapsed veins, abscesses
chest & lung complaints
general health problems
Poor mental health:
depression, anxiety, mood swings, paranoia,
self-harm, suicidal ideation
Day-to-day self care:
sleeping better, eating more regularly
improved personal hygiene
securing a stable home
ensuring a regular income
managing money and paying bills
Filling the void:
boredom/fear of boredom
worries about the future.
FINDINGS FROM DORIS
Doris, the Drug Outcomes Research in Scotland Study, was another study I led a few years ago. It collected data from 1,033 people beginning a new episode of drug treatment in 2001/02: 715 (69%) were male and 318 (31%) female. They were recruited from 33 agencies in rural, urban and inner-city Scotland. It used a structured questionnaire to collect data on drug use and more general life issues. Some findings are below.
Physical abuse by relative
or family friend 16 27
Sexual abuse by either 7 25
Physical abuse by partner 10 51
Sexual abuse by partner -- 15
Ever attempted suicide 28 49
Ever deliberately self-harmed 20 38
Lived in hostel or shelter
in last 6 months 16 16
Slept rough in last 6 months 18 9
Supplied drugs in last 3 months 35 27
Assault in last 3 months 22 10
Theft from a house, last 3 months 12 4
Soliciting in last 3 months 1 10
Conclusions we can draw from Doris are:
>> there are important gender differences between drug users entering treatment, but...
>> gender differences are not always evident
>> male and female drug users entering treatment share many common problems
>> there are many differences between individuals of the same gender.
WOMEN AND RECOVERY CAPITAL
The diagram in the pdf (Download AddictionToday142-Women's issues in recovery) crystallises the relevant areas of ‘recovery capital’ identified by W Cloud and R Granﬁeld in Conceptualising recovery capital: expansion of a theoretical construct (2008; Substance Use and Misuse, 43 (12–13): p1971–1986). How do women trying to recover from addiction fit into this popular concept?
First, let’s look at negative recovery capital. “Discussions of recovery capital in our previous writings implied that it existed on a continuum from none (or zero) to large amounts... A more useful conceptualisation of recovery capital might be to think about it as... a positive and negative continuum. There are situations where recovery capital can be seen as resting on the minus side of zero – negative recovery capital,” Cloud and Granfield explained.
For women, there are more destructive physiological effects of regular ‘heavy’ substance misuse, greater social taboos than men when they have drug problems, and higher rates of mental-health problems.
Social capital was low for our male and female participants. Consistent with the literature, women were more likely to report physical/ sexual abuse in childhood and violence by partners as an adult. But women had more informal support than the men. They found it easier to establish new non-using friends. And they were more likely to state that children motivated abstinence.
Physical capital. Male and female participants reported few resources. Women received more material support, including housing, from family. And they were less likely to be homeless.
Human capital. Men and women had limited education & work experiences. Both had similar modest hopes & aspirations. Both reported poor mental and physical health, although they highlighted different types of health problems. There was wide individual diversity in relation to domestic skills, but women seemed better at budgeting.
Cultural capital. Men and women repeatedly expressed a desire to be ‘“normal”. There was considerable individual diversity in terms of the extent to which participants prioritised personal hygiene and self care. Women were more concerned with outward appearances, especially weight.
Is Cloud & Granfield’s model of recovery capital useful? Yes, but...
>> Cultural capital might be negative, especially for women, so could perhaps be less prominent.
>> Physical capital seems to be misnamed; it should probably be called financial capital.
>> Human capital seems to have too many components; health and heredity could be moved elsewhere giving a new health capital category:
Recovery capital tends to be low for both males and females
Recovery resources vary by individual
We cannot assume that women have less recovery capital than men
Cultural capital can be negative, especially for women
Women are likely to have particular support needs in recovery
We need to enable both men and women to maximize their recovery capital and achieve their recovery potential.
And we need to remember that many of the challenges faced by people in recovery are common to other people, too.
JOANNE NEALE BA(Hons), MA, CQSW, DPhil is professor of public health at Oxford Brookes University. Before this, she was a senior lecturer in Crime in the Department of Social Policy and Social Work at the University of York and a senior research fellow in the Centre for Drug Misuse Research at the University of Glasgow. She has also worked in hostels for homeless people and is a qualified social worker.
Her current projects include a sociological investigation of the everyday lives of recovering heroin users (funded by EMRC, the Economic and Social Research Council); a pilot investigation of problem drug use and physical activity in the prison setting (funded by Oxford Brookes Central Research Fund); a qualitative study of the role of emergency hostels in supporting homeless drug users (funded by the Sir Halley Stewart Trust); and research exploring the delivery of online drug treatment to homeless drug users (funded by Breaking Free Online). She is also working with the Scottish Centre for Social Research on a study evaluating peer to peer education among injecting drug users.