Highs & Lows: Introduction

Lorraine Greaves and Nancy Poole

Overview of Women’s Substance Use

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 (Adrian et al., 1996) and The Hidden Majority: A Guidebook on Alcohol and Other Drug Issues for Counsellors Who Work with Women (CAMH, 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 (United Nations Office on Drugs and Crime, 2004).

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 (Canadian Tobacco Use Monitoring Survey, 2006). 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 (Johnson et al., 2004).

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 [National Center on Addiction and Substance Abuse, 2006].)

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 per cent higher than the rate among men (Spittal et al., 2002).

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. We discuss these below.

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 to this book 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 this 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. In this book, 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 this 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.

Overview of the Book

Section 1: Taking the measure

In Section 1, we outline data from the 2004 Canadian Addiction Survey (CAS) and the GENACIS, and identify key substance use issues for women. The CAS reports on current substance use patterns across Canada, while the GENACIS study provides a province-by-province perspective on women, girls and substance use. Both studies enable us to differentiate more clearly between patterns of use by women, by men and by the population as a whole; and they suggest critical sex- and gender-based questions that should be asked of the data. The findings of these key studies also help shape future research across Canada - along with a range of other forms of evidence that follow in this book, reflecting the different “ways of knowing” that shape our understanding of the substance use issues that affect girls and women.

Section 2: Locating women’s substance use

In Section 2, we reflect on the various “locations” of women and girls and their communities, and how these elements of diversity influence substance use patterns and the availability of appropriate responses. There are particular issues to consider in understanding and responding to women - whether through treatment, policy or research - depending on whether a woman lives in a rural or an urban area, lives with disabilities or does not, is young or old, is Aboriginal, or is culturally diverse. We examine program providers’ and clinicians’ responses to the range of issues that women face, and the interconnections between these issues. The specific situations of various groups of women, and their unique experiences and histories, have long been ignored, but in recent years are increasingly considered in the development of programs tailored to groups’ particular needs. Equally important is the integration of such sensitivity into mainstream programming and general systems of research, care and policy-making. Both these approaches must be pursued in prevention, treatment and research, if we are to care effectively for women of all backgrounds, as they come forward with specific issues.

Section 3: Interconnections

In Section 3, we introduce the complex, interconnected issues that women and girls using substances may face. Trauma, violence, sexual abuse and mental health challenges are part of many women’s everyday experience, and it is important that we understand how they interact with substance use - unidirectional explanations of causation are clearly inadequate. These interconnections suggest a clear need for shifts in practice and policy, and for more multifaceted research.

Section 4: Pregnancy and mothering

In Section 4, we discuss the specific issues of pregnant women and mothers who use substances. We have a long way to go to improve not only our responses to women in these situations, but also our attitudes. The stigma that affects most people who are seen to use substances is especially heightened for women, and even more so for

pregnant women, who have long been vilified for substance use. A general lack of compassion and sympathy for the situation of pregnant women and mothers who use substances both adds to their pressures and, often, keeps them from seeking help.

Section 5: Responding with programs

In Section 5, we examine some creative and innovative approaches to programming in response to girls’ and women’s substance use. Often, new approaches emerge from the ground up, and rely on later evaluation and research data to support them; it is an ongoing challenge for practitioners to accumulate the resources to plan and evaluate evidence-based programs from the outset. Nonetheless, it is through these ground-up innovations that new dimensions of programs (such as incorporating harm reduction and relapse prevention) get worked out, and the full range of determinants of women’s health is integrated.

Section 6: Challenges and opportunities

We end the book with a taste of some of the challenges and opportunities that face us in the future. How do we incorporate better practices, emerging evidence and practical innovations? How do we embrace new paradigms of thinking with healthy criticism and open minds? How can we push ourselves into new domains, such as tailoring

policy and programming or creating frameworks that truly put women front and centre? How do we anticipate future issues, substances of concern, diverse needs or interconnections? How can we be better prepared with research, other forms of evidence and, most importantly, the right questions? What advocacy challenges still face us?

These are all daunting challenges for the years to come. How could Jody’s story, in the narrative that precedes this introduction, change over the next decade? 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.

References

Adrian, M., Lundy, C. & Eliany, M. (Eds.). (1996). Women’s Use of Alcohol, Tobacco and Other Drugs in Canada. Toronto: Addiction Research Foundation.

Canadian Tobacco Use Monitoring Survey (CTUMS). (2006). Ottawa: Health Canada. Available: www.hc-sc.gc.ca/hl-vs/tobac-tabac/research-recherche/stat/ctums-esutc/2006/index_e.html. Accessed January 31, 2007.

Centre for Addiction and Mental Health. (1996). The Hidden Majority: A Guidebook on Alcohol and Other Drug Issues for Counsellors Who Work with Women. Toronto: Author. Johnson, J., Tucker, R.S., Ratner, P.A., Bottorff, J.L., Prkachin, K.M., Shoveller, J. et al. (2004).

Socio-demographic correlates of cigarette smoking among high school students: Results from the British Columbia Youth Survey on Smoking and Health. Canadian Journal of Public Health, 95 (4), 268–271.

National Center on Addiction and Substance Abuse at Columbia University. (2006). Women under the Influence. New York: Johns Hopkins University Press.

Spittal, P., Craib, K., Wood, E., Laliberte, N., Li, K., Tyndall, M. et al. (2002). Risk factors for elevated hiv incidence rates among female injection drug users in Vancouver. Canadian Medical Association Journal, 166 (7), 894–899.

United Nations Office on Drugs and Crime. (2004). Substance Abuse Treatment and Care for Women: Case Studies and Lessons Learned. Available: www.unodc.org/pdf/report_2004-08-30_1.pdf. Accessed December 15, 2004.