Highs & lows: Canadian perspectives on women and substance use

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It is now well recognized that substance use among girls and women is an important health, economic and social problem in Canada. However, this recognition has not always existed. In 1970, there were fewer than 40 published studies on women and substance use (excluding tobacco use). Later that decade, however, as part of the “second wave” of the women’s movement, agencies and practices began to emerge that focused on providing a feminist response to the issues of substance use and addiction in women. Along the way, books and articles appeared on various aspects of women’s substance use, along with studies of women’s use of particular substances such as alcohol, tobacco and illegal drugs.

Even so, it was not until a quarter-century later that the first major Canadian collections on women and substance use were published by the Addiction Research Foundation (now part of the Centre for Addiction and Mental Health [CAMH]: Women’s Use of Alcohol, Tobacco and Other Drugs in Canada (1996) and The Hidden Majority: A Guidebook on Alcohol and Other Drug Issues for Counsellors Who Work with Women (1996). The first of these books laid a foundation of knowledge about the history and epidemiology of substance use among women in Canada, while the second offered suggestions for responses. Since then, much change has occurred in the field, and contributions to our knowledge have come from many disciplines and professions, from research and practice, and most importantly, from women themselves.

What substances do Canadian women use?
Alcohol remains the substance most commonly used by women and girls. Although women’s drinking rates have historically been lower than men’s, recent studies of international populations show that the gender gap in the prevalence of alcohol use is closing. Further, studies of school-aged children report alcohol use by girls as early as Grade 6. These findings are of particular concern given that the health risks of substance use—including liver damage, brain damage and heart disease—are greater for girls and women.

Tobacco use among girls and women is also a serious problem in Canada. Although overall smoking rates are decreasing, the rate for young women under 24 is higher than that for women as a whole. Girls and boys aged 15 to 17 smoke at roughly the same rates, but girls smoke more cigarettes per day than boys. In addition, the smoking patterns of some subpopulations—such as women with low incomes, lone mothers and young pregnant women—are of key concern. Among Aboriginal teens, not only are smoking rates much higher than among Canadian teens as a whole, but Aboriginal girls are more likely to smoke (48.5%) than Aboriginal boys (42.7%), and a greater proportion of Aboriginal girls than boys begin smoking by age 11.

As with alcohol use, there are sex differences in the health consequences of tobacco use. Women have different patterns than men of developing smoking-related illnesses, and are prone to smoking-related health issues associated with hormonal status and reproductive function. There is also a strong association between smoking and cervical cancer, and an emerging link with breast cancer.

Mood-altering medications are much more likely to be prescribed to women than to men. In fact, women report higher rates of use of most categories of prescription drugs, including sleeping pills, tranquilizers, antidepressants, painkillers and diet pills.

Women and older adults are the two groups most likely to be prescribed benzodiazepines, and the most vulnerable to their adverse effects. (Women of all ages become addicted to both prescription and illegal drugs more quickly than men, and suffer greater physical, psychological and social consequences.)

Illegal drugs pose particular risks and present differing patterns and trajectories of use. Historically, men have been more likely than women to use illegal drugs. However, as with legal drug use, the gender gap may be closing, putting more women at risk. The health effects of illegal drug use vary among women, between women and men, and across the various drugs available. There are reports of increasing cannabis use among both women and men in Canada, and women appear to be accessing treatment for methamphetamine use at a similar rate to men. A study of people in Vancouver using injection drugs found that the rate of HIV infection among women was about 40% higher than the rate among men.

What are the gendered influences on women’s substance use?
Along with many sex-specific factors that affect both women’s substance use and its effects, there are also many gendered influences that determine the course of prevention, use, treatment or recovery. In particular, the pathways to substance use for girls and women are often influenced by gendered experiences. Girls and women experience sexual and physical abuse and trauma—which are strongly related to substance use problems—at higher rates than their male counterparts. Women are also at higher risk for substance use problems due to the greater impact (demonstrated by research) on women of life transitions, and their greater use of substances to cope with emotional and relational problems. Compounding these risks are the gendered marketing practices of the alcohol and tobacco industries, and the societal stigma carried by women—especially pregnant women and mothers—who use substances, which creates enormous barriers to care.

What are the challenges?
Despite significant progress in research, policy and practice over the last 10 years, many challenges remain.

The range of substances. There are many different substances to consider—some newly recognized, such as crystal methamphetamine, and some long-established, such as alcohol or benzodiazepines. Each substance creates different health and social problems, and calls up different social, medical and advocacy responses, forcing government and others to consider new approaches to controls, health promotion or regulation. Legal drugs, such as tobacco and alcohol, are more widely used and cause more damage, though illegal drugs, such as heroin and cocaine, often get more attention. Behind legal drugs are corporations that profit from people’s addiction to their products, and that promote and advertise them aggressively. Illegal drugs depend on criminal activity for distribution and so evoke enforcement and judicial responses, creating another layer of economic and social issues for individuals and society. Equally complex is the challenge of dealing with the overuse of, and addiction to, prescribed drugs—a significant issue for women, and so also for women’s health advocates.

Prevention and treatment. Many of the contributors argue strongly for providing women-centred prevention and treatment responses that empower and strengthen women with substance use issues—but this is not always easy in systems that are complex, traditional, medically oriented and designed for men. Nonetheless, women-centred approaches can be embedded not only in care, but also in program design, research and policy development. There is a rich, ongoing discussion about what this could look like, and how we can collectively move forward to create positive, safe and productive responses to women’s substance use.

The multiplicity of issues. A range of issues—such as mental health concerns, trauma, violence and substance use—often overlap in women’s lives. Problems such as unstable housing, HIV infection or poverty complicate women’s treatment and recovery, and compromise their overall health. Responding adequately to women who may experience a constellation of these issues is complicated, and requires innovation, skill and understanding. A promising avenue is greater integration of services: more comprehensive and appropriate responses to women with substance use issues, in a wider range of agencies and locations, such as shelters, sexual assault centres, community centres and doctors’ offices.

Further evidence. An undercurrent that runs through the book is the urgent need for more research evidence to support our understandings of, and responses to, women’s and girls’ substance use. In Canada, funding agencies increasingly require researchers to consider both sex and gender in their work, which is a helpful development in improving our evidence base. In 2003, the Canadian Institutes of Health Research facilitated the development of a research agenda on addiction and substance use in Canada, including a section on research on sex and gender influences, to create evidence more relevant to women. In addition, the Government of Canada has a requirement for gender-based analysis (GBA) in its policy development, and Health Canada has applied GBA to research and programming.

There are many different ways of knowing, beyond research-based evidence. Chapters from researchers, policy advocates, health practitioners and community-based service providers are presented side by side with pieces from women who have experienced substance use issues first-hand. This presentation recognizes each perspective’s unique and valid contributions to our understanding—and also raises the challenge of how to successfully merge what we “know” from each domain to create more effective solutions for women.

Stigma. Women and girls who use substances are often vilified, both in the media and in everyday conversations. This stigmatization is particularly strong when women who are pregnant or mothering use substances, or when women do not fulfil the gendered expectations of society as a result of their substance use. While the book illustrates some of the great strides that have been made over the last few decades in understanding girls and women and substance use, we cannot assume widespread support. Nor can we assume that there is a general motivation to respond respectfully to women who have substance use problems. Indeed, both public and private opinion often reveal a lack of sympathy and patience with women who struggle with substance use, and “blaming and shaming” is still very much evident in Canadian society. Clearly, advocacy and political action are still needed as part of a positive response to women with substance use issues.

These are all daunting challenges for the years to come. Based on the successes, innovations and tenacity reflected in this book, and assuming an ongoing and thriving women’s health movement, there is much to be optimistic about.

This excerpt is adapted from the introduction of Highs & Lows: Canadian Perspectives on Women and Substance Use, edited by Lorraine Greaves and Nancy Poole and published by the BC Centre of Excellence for Women’s Health (BCCEWH) and the Centre for Addiction and Mental Health (CAMH).

Lorraine Greaves is president of the International Network of Women Against Tobacco and Executive Director at the BC Centre of Excellence for Women’s Health (BCCEWH).

Nancy Poole is a research associate with the BCCEWH and acts as the provincial research consultant on women’s substance use, for BC Women’s Hospital.

Highs & Lows: Canadian Perspectives on Women and Substance Use is available in English only. Order from the Centre for Addiction and Mental Health (CAMH) website http://www.camh.net/

In conversation
Nancy Poole, co-editor of Highs & Lows: Canadian Perspectives on Women and Substance Use discusses the publication with Ellen Reynolds.

ER - Where did the idea for the book come from?

NP – The women’s treatment program, Aurora Centre, based at BC Women’s Hospital hosted a conference on women’s treatment issues in Vancouver in the fall of 2003 and we initially thought we would do conference proceedings. Then we thought there’s so much to be said and wanted to honour the contributions on women and substance use issues in Canada over the past decade, so we thought bigger and it became a book. We were really interested in multiple perspectives—the opinions and work of researchers, of service providers, policymakers, where possible, and especially wanted to make sure the voices of women who had substance use problems were included.

ER - You express the hope in the Preface that Highs & Lows will contribute to the “development of a more women-centred response in Canada and beyond.” Who do you see as the main audiences for this book to be able to achieve that goal?

NP - We were definitely interested in influencing the people in universities and colleges who are learning about how to work with women on these issues. We saw it as important to contribute to their understanding as they are beginning to work in the field. We also felt that it might influence the kind of research questions that are posed by researchers in the future, and as well an opportunity to influence policy and service organizations such as the Centre for Addiction and Mental Health or other leading addiction and health organizations.

ER – In the Introduction, there’s a section devoted to the use of language in the book that explains why some terms such as “substance use” is used and not substance abuse or addiction and the terms “patient” and “client” are used rarely if at all. Why was this important?

NP - Language is really important when working in this area. We were interested in capturing the fact that substance use does appear on a continuum. Not all substance use is harmful and not all problem substance use is actually addiction. We are also really interested in making the differentiation between abuse and substance use and that we use the term “abuse” only when we are talking about violence against women, making “abuse” about people and “problem use” about substances. Since violence against women and problem substance use often occur together, it certainly made it easier in forming the sentences around talking about these multiple intersecting problems. We were also concerned about not using words like “patient” and “client” and encouraging people to talk about women and women to speak to their lived experiences rather than defining themselves in relation to a system.

ER - Can you talk about the role of the narratives in the book?

NP - You can talk about how you need to consider women’s experience of violence and their substance use problems, yet when you hear the stories, it really gives you a different sense of what we need to do and pulls you more forcefully to engage with what we need to do. We felt that the narratives were a really important piece that will guide policy and practice as much as the research.

ER - The final section of Highs & Lows is about ongoing challenges and opportunities—challenges such as the misuse of prescription benzodiazepines and smoking. Do you see these challenges being addressed in the near future?

NP - Gradually we’re going to see many more discrepancies about what we know and what we are doing, or not doing. I think that will create movement, especially in the areas like benzodiazepine use. Look at the chapter “The Silent Addiction” by Janet Currie about benzodiazepines. She and the organization Women and Health Protection have been doing some excellent work on the policy level with governments across Canada and I think that we will begin to see the impacts of that, moving things forward.

ER - At the end of the book, you highlight the work of the Amethyst Women’s Addiction Centre in Ottawa as an advocate for a women-only treatment services as well as two provincial frameworks for treatment in Alberta and Ontario for women-specific programming. Are you optimistic about similar programs becoming the norm in the near future?

NP - A number of governments have approached me about being involved in helping them plan service systems, both territorial and provincial governments in Canada. So, I do think that we will see more of those system-wide frameworks that recommend that we have both women-specific as well as mainstreamed approaches to working with women. I’m quite confident on that level. In terms of the numbers of individual women-specific services like Amethyst, I’m not so sure. I hope that we will see that but it hasn’t been as common in the last decade as we’d like it to be.

Governments have moved more toward frameworks in general. In Alberta, they developed an extra layer to the treatment system called “Enhanced Services for Women” that is more of an outreach approach designed to engage women in care and help them get to treatment or other resources. It’s been a tremendously effective program. So, while it isn’t a women’s stand-alone treatment centre it’s actually a very interesting and creative approach that has won awards in Alberta. If we can do more things like that we’ll be definitely on the road in the next decade.

Ellen Reynolds is Director of Communications at CWHN. This is an excerpt from a radio interview that was broadcast in February 2008 on CFUV Radio in Victoria, BC.