It is clear from epidemiological studies and from studies of developmental psychopathology that substance use disorders are in general much more common in men than in women. In a large international survey–the WHO World Mental Health Surveys across several countries–women were less likely to use alcohol, cocaine, tobacco, and cannabis (Degenhardt et al., 2008). Gender differences were somewhat less pronounced in the United States, Europe, New Zealand, and Israel, compared with South America, Africa, the Middle East, and the People's Republic of China. When combining all countries, and adjusting for covariates, women were between 3 and 5 times less likely to concomitantly use alcohol, cocaine, cannabis, and tobacco. However, the survey also seemed to suggest that the gender gaps for alcohol, cannabis, and cocaine are closing. The fact that the gender gap is different across countries, and is closing with time, suggests that cultural factors are influencing gender differences. In some cultures more than in others, gender roles may prevent the development of problematic substance use, and endorsing traditional gender roles have been shown to protect women from developing alcohol problems (Kubicka and Csemy, 2008). Later in this article, we shall look more into the mechanisms by which female gender roles may be in conflict with substance use.
In developmental psychopathology, it is common to distinguish between externalizing and internalizing psychopathology. Externalizing behaviour problems involve aggressive behaviour, acting out on impulses, and have traditionally been linked with childhood disorders such as attention deficit/hyperactivity disorder, conduct disorder, and oppositional/defiant disorder. Internalizing psychopathology has been linked with anxiety and depression, and with social withdrawal. Lara and colleagues have recently suggested that the distinction between externalizing and internalizing psychopathology is central to understanding the whole field of psychopathology (Lara et al., 2006). Recent research into the nature of alcohol and drug problems has supported the view of addictive disorders as belonging primarily to the externalizing category (Zucker, 2008).
Also, men generally have a lot more externalizing behaviour problems compared with women, whereas women have more internalizing problems, such as depression or anxiety. And a growing body of research suggests that substance use disorders can be considered part of the externalizing behaviour spectrum, as opposed to the internalizing behaviour spectrum (e.g. Kramer et al., 2008).
Internalizing problems such as anxiety, depression, or eating disorders represent ways of turning the pain inward. In most cultures around the world, it is more acceptable for women than for men to be vulnerable, passive, and feeling down.
There are two implications of this robust research finding. The first is fairly obvious: women have fewer direct problems as a result of substance use. Women are less at risk for developing an addiction, and consequently from dying of a substance-related condition. The second is less obvious: once a woman has developed an addiction, she deviates more from the female norm, compared with a man with an addiction. And the consequences of deviating from the norm may be serious. Even in young children in kindergarten, girls who behave aggressively tend to be rejected more by their peers, compared with boys who act equally aggressively (Coplan et al., 2007).
The expectation that women do not display externalizing behaviour problems has serious implications for women with addiction problems. They encounter images held by society (and often by themselves as well) of the alcoholic or drug-dependent woman as a “fallen woman” incapable of living up to the image of a responsible person/mother (Harrison, 1991; Raeside, 2003). Women with drug and alcohol problems have been described as “stigmatized by society in that they are viewed (and often view themselves) as having deviated from the traditional societal norms expected of women in their suitability as mothers and carers” (Toner et al., 2008, p94). This (self-)image is often accompanied by a feeling of shame and guilt, and the woman who encounters general health services or social services can be reluctant to disclose her alcohol or drug problem because she feel ashamed of her behaviour.
Women whose social relations exist in a drug using subculture face several problems, in part as a result of living in a male-dominated environment. Women with drug problems can cope with their life situation by providing sex in exchange for housing, sustenance, and protection, but often suffer violence from sexual partners and are in a situation where they may have to practice unsafe sex (Pinkham and Malinowska-Sempruch, 2008).
Since women with drug use disorders are likely to experience ongoing traumatization, and since many women with drug use disorders have experienced trauma even in childhood, a large number of women with addiction problems suffer co-morbid post-traumatic stress disorder, or what has been labeled “Disorders of Extreme Stress Not Otherwise Specified” (Hien et al., 2005). This group of disorders is associated with severe problems in self-regulatory behaviour: regulation of affective impulses (e.g., difficulty modulating anger), cognitive processes (e.g., disruptions in attention, memory and consciousness), and relationship to others (e.g., problems with intimacy and trust). All these problems may in turn reinforce the problems in the social environment of the woman with substance use disorders.