Gender makes a difference

Gender shapes the different ways women and men  access, consume, and become dependent on alcohol and other drugs. Gender is also the dominant lens through which problematic alcohol and other drugs use is judged in society. Men and women:

• are initiated to alcohol and other drugs use differently
• often develop a dependence for different reasons
• will be affected by drugs differently and be drawn to different drugs
• experience stigma and shame differently
• have different vulnerabilities and risks related to their dependence.

It is important that you understand the different ways women and men experience alcohol and other drugs use and what it means for your work with each parent.

'When we experience being the subject of power, abuses of power, oppression, or attacks on our dignity we accept allies because we need them, not because it is safe or because we have reasons for perfect trust. Ally work requires humility and a resistance to righteousness, alongside the skill and moral courage required to name abuses of power from people within the same groups allies belong to.'

Reynolds, V (2013).

Working with women

Understanding how alcohol and other drugs dependence influences women, how they are perceived and what it means for them as mothers guides the way practitioners support them in seeking treatment and recovering. Here’s what we know about women and problematic alcohol and other drugs use:

Accessing treatment for alcohol and other drugs

• Women access alcohol and other drugs treatment at lower rates than men and are under-represented in the drug and alcohol treatment system.
• Women are more likely than men to face multiple barriers to accessing substance abuse treatment and are less likely to seek treatment.
• A range of issues creates barriers for women’s access to alcohol and other drugs services, including social stigma, discrimination, experiences of trauma, childcare and child custody concerns, and financial issues (Taylor, 2010).

Alcohol and other drugs and mental health

• Women who use alcohol and other drugs have a higher prevalence of co-occurring mental health issues such as mood disorders, anxiety, post-traumatic stress and eating disorders than men (Covington, 2008). Affective disorders such as major depression are associated with poorer treatment outcomes and higher rates of relapse.
• Some mental health conditions may go undetected and women may self-medicate rather than seek professional help.
• Women may perceive issues as being related to their mental health rather than alcohol and other drugs use and focus on seeking psychiatric help rather than alcohol and other drugs treatment.
• Women tend to seek care in mental health or primary care settings rather than in specialised treatment programs, which may contribute to poorer treatment outcomes.
• On entering alcohol and other drugs treatment, women present with higher rates of mental health issues, experience of complex trauma as a result of childhood physical and sexual abuse or domestic and family violence, alcohol and other drugs-related risk taking, pregnancy and childcare issues, and greater social and economic disadvantage (Alcohol and Drug Foundation Insights, 2018).

Alcohol and other drugs use and relationships

• Personal relationships and family history appear to be more significant influences on women’s initiation, pattern of use, and continuation of problematic alcohol and drug use than they are for men. For example, women with alcohol and drug problems appear more likely than men to have been raised in a family environment of heavy drinking or problematic drug use (Center for Substance Abuse Treatment, 2009).
• Women with problematic alcohol and other drugs use are more likely to have intimate partners who are substance users (Brady & Ashley, 2005) and appear more likely to report that they have family, friends or partners who use drugs or who support their continued substance use (Greenfield et al. 2007).
• Situations and conditions such as having a stressful marriage and being pressured to use drugs by sexual partners have been found to significantly affect women’s post-treatment relapse to alcohol use (Grella, 2008).
• Low socio-economic status and income inequality are often linked to poor health and wellbeing and have been associated with serious drug-related harms including foetal alcohol syndrome, alcohol-related deaths and drug overdoses (Spooner & Hetherington, 2004, SAMSHA, 2009).

How women experience stigma and shame

Stigma is a concern for parents and their children, and women with problematic alcohol and other drugs use face significant social stigma and discrimination in relation to pregnancy and parenting.

Along with the barriers posed by family responsibilities or lack of childcare options, if mothers seek treatment, the stigma of being a mother who uses substances and the fear of losing custody of children are significant obstacles to treatment entry and engagement (Greenfield et al. 2007).

Typical social roles and cultural expectations placed upon women result in very specific stigma and stereotyping about their alcohol and other drugs use. For example, women often assume, or are expected to assume, caregiving roles in their relationships as mother, partner and daughter. Child protection practice has historically reinforced this by expecting mothers to carry the burden of keeping their child safe, even if they are not the person displaying the concerning behaviour. For example, when there is domestic violence, mothers are often expected to protect the child from their partner's violent behaviour.

A mother with problematic alcohol and other drugs use is frequently stereotyped negatively and viewed as a failure. This stigma and shame makes it harder for a mother to seek treatment and stay drug or alcohol free. Women with children, particularly single mothers, who do enter treatment face further stigma or challenges. These include:

• not being able to secure childcare long enough for inpatient stays
• being too worried to leave their child with their partner because of his violence
• transport and childcare difficulties in attending community programs
• the likelihood of their child coming into care either for a short or long period and having reunification dependent upon the mother showing abstinence for a significant period of time.

All of these issues mean women are likely to hide, deny and minimise their dependence and postpone seeking help.

'Stigma for women who use any licit or illicit drugs is more severe than for men because of women’s ‘place’ in society.'

(Shimmin, 2009).

Isolation, dependence and delay in treatment

Many women with problematic alcohol and other drugs use feel they cannot support themselves and their child without relying on a partner. Their alcohol and other drugs use, finances and day-to-day life feel overwhelming on their own. Experiences of domestic and family violence and mental health complicate this further.

Women with problematic alcohol and other drugs use:

• can be isolated and rely on their partner for physical and emotional support and drug dependence
• are likely to have a limited support network through treatment and early recovery, especially if their partner continues to use substances
• may have a partner sabotage their treatment efforts by threats of abandonment, withdrawal of financial support and manipulation of the woman’s feelings—particularly guilt and shame
• face social isolation and financial dependency, which can leave them vulnerable to entering impulsive and self-sabotaging relationships while in treatment and early recovery.

Women with children often report a delay in seeking treatment because they are worried about the social consequences, which are generally more rigid than for men who are parents. For example, it is less socially acceptable for women to leave their children for long periods, and even treatment stays can be perceived as periods of ‘abandonment’. Overall, mothers are more likely to have remained intricately involved in their children’s lives as primary caregivers, despite their dependence, than fathers who have problematic alcohol and other drugs use have.

The mother and child relationship

Problematic alcohol and other drugs use compromises parenting and parenting tasks; however, it also has major consequences for the parent and child relationship.

Often a mother is the primary carer and the source of attachment for a child. When this is compromised, a child may not feel loved, secure or nurtured by their mother because she:

• may not see, respond to or empathise with the child's cues for attention and care
• may not be emotionally or physically available when her child needs her
• may be erratic and inconsistent in meeting her child’s needs and in the way she interacts with them
• may not be able to provide a consistent routine so the child learns predictability and feels secure
• may be the person a child loves but also the person hurting the child.

Some women you work with may develop or be coerced into relationships with men who are not the father of their child. If alcohol and other drugs use is a feature of this partnership, it can quickly dominate their life and priorities.

If a mother’s alcohol and other drugs use compromises the bonding and attachment with her child, she will be less likely to see, empathise with and respond to safety concerns that others (such as a new partner) may pose. Read more about bonding and attachment in Risk assessment.

How women use alcohol and other drugs to cope and survive

Women are more likely than men to identify relationship issues as a cause for their problematic alcohol and other drugs use. Women in treatment have much higher rates of domestic violence experience than women in the general community (Greenfield 2010).

Women who have been abused are 15 times more likely to abuse alcohol and 9 times more likely to abuse drugs than women who have not been abused. Problematic alcohol and other drugs use may lead to sexual re-victimisation in adulthood as a result of related and contextual individual, interpersonal, community and social factors (Stathopoulos, 2014).

The ways alcohol and other drug use and domestic violence become enmeshed for women include the following:

• Her alcohol and other drugs use:
  • may become a barrier to leave her partner who is violent
  • can influence a woman’s assessment of the level of danger posed by her partner
  •  may make it harder to recognise the cues a child gives her about their safety
  •  may make it harder to follow through on safety plans 
  • can be encouraged or forced on a woman as a way in which her partner controls her
  • may exclude her from support services that she desperately needs for refuge, advocacy or other assistance.
• Her efforts at recovery and abstinence may be sabotaged by her partner.
• Her compulsion to use and the withdrawal symptoms may make it harder for the women to access, seek or stay in a refuge.
• She may find that the stress of securing safety for her and her children leads to relapse.
• If she has used substances in the past or currently uses, she may fear her experience of violence won’t be believed.
• She may worry about calling the QPS after a violent incident, possibly due to shame or memory loss.
• She may fear the QPS and even her own family won’t believe her or take her seriously.

Working with men

With regards to men and problematic alcohol and other drugs use, we know:

• Men have higher rates of use or dependence on illicit drugs and alcohol than women do (Traumatic Episode Data Set, 2012).
• Men are three times more likely than women to be frequent drugs users.
• Men are more likely than women to use almost all types of illicit drugs and illicit drug use is more likely to result in emergency department visits or overdose deaths for men than it is for women drugs (Sex and gender differences in substance use). 
• It is very common for men to try to mask or block out the symptoms of depression or anxiety by using alcohol or other drugs.

"higher rates of drug use we see among men compound a gender disadvantage we have from birth. We get into accidents more regularly, we have more unhealthy lifestyles, we die earlier, we have less insight into our health and wellbeing. We’re generally predisposed to engage in a whole bunch of risky behaviours while being physiologically less equipped to deal with them.'"

(Winstock, 2014).

How men experience stigma and shame

Women and men are socialised to have different roles and attributes within the community, home and family. Cultural and Indigenous backgrounds may also influence these roles. Values about men’s roles shape:

• the way they are initiated to alcohol and other drugs use
• the reasons they develop problematic alcohol and other drugs use
• their ability and willingness to talk about their alcohol and other drugs use
• their ability and willingness to seek and sustain help and recovery.

Initiation

Men are often initiated into alcohol and other drugs use as a way to prove masculinity and as part of celebrations. For example, reaching adult age is sometimes celebrated through excessive drinking, as are job promotions, becoming a father and sports victories. Drinking can mask the real need for connection and communication between men.

To prove their masculinity, some men engage in reckless behaviours, binge drinking and use of illegal drugs. The desire to take risks and the need to avoid showing weakness can affect men's beliefs and behaviours.

When they have grown up with trauma, abuse or neglect, they may be unlikely to talk about their experiences for fear of being seen as weak. If it is unacceptable to talk about emotions and share experiences without fear of losing masculinity, these emotions can manifest into anger and remain unresolved.

Shame and stigma

Men who are affected by dependence can experience shame and stigma for being ‘weak’. They believe ‘real’ men are supposed to be successful leaders, physically and emotionally strong, and capable of handling everything and anything. These beliefs can stop a man from talking about his alcohol and other drugs use and the reasons that have led to it.

The beliefs may also encourage a man to deny, minimise or hide his alcohol and other drugs use from practitioners and other supports. Men experiencing alcohol and other drugs dependence are likely to say that they can handle the problem on their own—and use this as a reason for not seeking treatment. Seeking treatment itself may seem to be a threat to their masculinity. Men often also have concerns about privacy and may need your added reassurance about confidentiality.

Self-sufficiency

A need to be self-sufficient may also result in a false sense of accomplishment or security in their recovery, which may become an unwillingness to follow through with recovery supports. A man may say, ‘I don’t need it’, ‘I don’t need help,’ ‘I can do it’, or ‘I’ve done it’.

Men may resent being told what to do, which means suggestions may need to be reframed in ways that help men to see the choices they have within what needs to be done. For change to begin, we need to find ways of reducing the stigma and shame of weakness men feel because of their alcohol and other drugs use.

The father and child relationship

Many men you work with may have grown up with authoritarian, or even abusive parenting, with little encouragement to show their emotions because ‘boys who cry are weak’. This style of parenting is what they know. Their alcohol and other drugs use may exacerbate this or they may be shocked you are worried about their parenting.

Even in the midst of chronic substance abuse, a positive father-child relationship can help buffer some effects for children. Often bonding and attachment is focused on the mother and child relationship; however, in your work, you will need to spend time seeing and understanding the child-father relationship, no matter what role the father plays.

Talk with men about what their father was like and their ideas on the father they would like to be - these conversations can be cornerstones for change. Help them connect with their role as a father and partner. Talk with them about:

• the wellbeing of their children
• their role in having a close, responsive relationship with their children
• their emotional and practical support to their partners
• contributing financially to the family's welfare.

Men who use violence

Problematic drug or alcohol use is never an excuse for violence. Although men who use violence may be abusive more often or cause worse injuries to mothers and children when they drink or use drugs, the substances themselves are not the cause of the abuse and violence. Men are responsible for the actions they take.

One in 6 Australian women have been subjected, since the age of 15, to physical and/or sexual violence by a current or previous cohabiting partner. In 2017, young women aged 15–34 accounted for more than half (53%, or 11,000) of all police-recorded female sexual assault victims (ABS 2018b). People living outside major cities were 1.4 times as likely to have experienced partner violence since the age of 15 as people living in major cities (ABS 2018a).

Between 2014 – 15 and 2015-16, 1 woman is killed every 9 days and 1 man is killed every 29 days by a partner. Women who identified as lesbian, bisexual, and mainly heterosexual were twice as likely to report physical abuse by a partner as women who identify as exclusively heterosexual (Szalacha et al. 2017).

Source: Family, domestic and sexual violence in Australia, 2018

Men with problematic alcohol and other drugs use who use violence need to access both domestic violence and alcohol and other drugs treatment and supports. When alcohol and other drugs treatment and recovery is occurring can be a risky period where violence may increase. Addressing alcohol and other drugs use on its own will not solve or stop a man using violence towards women and children.

Anger

Anger is a common problem for men with a dependency on alcohol and other drugs, and it can be exacerbated by the stress of the early recovery stage. Because of men's socialisation, anger is often used to cover up other emotions that are uncomfortable to express such as fear, grief and sadness. It is helpful to think about any hostile or aggressive behaviours shown towards you and other professionals as a response to their anxiety or fear.

How men use alcohol and other drugs to cope and survive

Men who have problematic alcohol and other drugs use may have their own stories of coping and survival. Do not define men by stereotypes of masculinity or deny them the opportunity to tell their story. Ask men:

• how they have coped and survived?
• how they have learned the values and skills they have?
• about the role alcohol and other drugs use plays for them.

When men do not talk about their feelings, or if they see past abuse, neglect, pain and suffering as a weakness or failure as a man, alcohol and other drugs use can become a way they ‘stay in control’. Help them redefine their ideas of masculinity or ‘failings’ as men by helping them name resistance and survival techniques they have used. For example, you could say 'So, you feel weak because you did not speak about your mum’s boyfriend abusing you. You said you were worried he would kick your family out. That sounds like an incredibly strong young man to me. A young man who, despite being so badly hurt, was trying to protect his mother and sisters and keep a roof over their heads'.