For all the numerous risk factors that can lead to the development of substance abuse, the fundamental dynamic of gender has a huge role to play. Whether male, female, or transgender, drug abuse and gender are closely intertwined, which makes a significant difference in how people of respective genders are at risk for addiction, as well as how they are treated.
Does Gender Matter?
Substance abuse is a very complicated issue, and so is gender; put the two together, and more questions are raised. “Why do men take more drugs than women?” asks The Telegraph, while Psychiatric Times puts it another way: “Substance abuse in women: does gender matter?”,  It absolutely matters, according to the review in Psychiatric Times. As a sign of how seriously scientists and researchers are asking the question, 90 percent of scientific and medical literature on the topic of abuse and gender had been published in the 15 years between 1990 and 2005.
A big reason for this new focus is that the gender gap has been declining for the past few decades, prompting speculation that women are on the cusp of earning (or even surpassing) their male colleagues. With this extra spending money comes an increase in social status, which results in “American women […] drinking more like men,” says Newser. This article mentions a 2015 report from the National Institutes of Health, entitled “Male and Female Drinking Patterns Becoming More Alike.” In the mid-2010s, women have more earning power, more access to alcohol, and more advertising and marketing that is catered to the female experience of drinking, even when it comes down to suggesting the kinds of drinks that women should have. According to Attn, “beverage-based gender stereotypes have become an observable norm.”
Bound by Biology
This upward mobility has empowered many women to step out of the shadow of traditional gender roles which bound previous generations, but it also exposes these women to health risks and dangers. Some of those risks are tied to biology; a woman has to consume less alcohol than a man in order for intoxication to take place. This is because women have less total body water than men, writes the Psychiatric Clinics of North America journal, so women achieve greater concentrations of blood alcohol, even if they consume the same amount of alcohol itself. Additionally, women lack an enzyme (gastric alcohol dehydrogenase) that helps them metabolize alcohol as quickly as men, who do not lack the enzyme. One of the researchers who published this finding in the Alcoholism: Clinical and Experimental Research journal commented that the deficiency contributes to the female gender being “more susceptible to toxic amounts of alcohol” than the male counterpart. Similarly, an imaging procedure that creates detailed scans of the human body has shown that it takes less alcohol to affect a woman’s brain than it takes to affect a man’s, according to another study published in the same journal.
Other imaging operations show that the effects are not limited to alcohol. Among people who take cocaine, says Biological Psychiatry, the female brain responds much more actively to the drug than the male brain does.
All the signs point to women being more vulnerable to the consequences of drinking, says the review from Psychiatric Times, which notes that the negative effects are primarily psychological and physiological.
Men and Gender Roles
Women may be at greater risk of suffering the risks of alcohol and drug use, but the question posed by The Telegraph – “Why do men take more drugs than women?” – still lingers. According to statistics published by the British government, men are thrice as likely to regularly consume illegal drugs (everything from marijuana to cocaine) than women.
One government survey found that 27 percent of men had no concerns for their health when it came to smoking cannabis, while only 15 percent of women thought it would be safe to do so. Just 1 percent of women believed it was safe to take cocaine; but among men, that number rose to 5 percent.
Dr. Adam Winstock, a psychiatrist who specializes in drug abuse and addiction, says that men are “more naturally prone to take risks,” which includes the risk of taking dangerous drugs. Men tend to have unhealthier lifestyles than women, to die younger, and to have “less insight into [their] health and wellbeing.” Genetically and evolutionarily, men are “generally predisposed to engage in a whole bunch of risky behaviors,” partly due to gender roles.
Masculine Gender Role Stress
Gender roles are a massive construct in male and female behavior, and this is significantly represented in how either gender responds to substance abuse. In 1998, the Journal of Gender, Culture and Health looked at masculine gender role stress, which develops in men “who are highly committed to the male role.” This involves constant displays of strength (physical, emotional, and otherwise) and hyperavoidance of weakness or femininity. Men who struggled with pressure to display high levels of masculine gender roles were found to have “more severe alcohol [and drug] dependence” than men who had little to no stress related to their perceived gender role. Researchers also discovered that men who displayed masculine gender role stress were more likely to abuse drugs and alcohol as a response to emotions they considered negative, as well as physical discomfort, and to believe that they were in control of their substance abuse.
For men who take drugs or alcohol, the action of doing so reinforces their image of themselves as men, according to the Archives of General Psychiatry. Even the experiences of different substance consumption speak to the distinctiveness of each gender. Men tend to smoke to reduce tension and improve mood; women tend to smoke to bond in social settings. Smoking is an “instant conversation starter” and creates an “immediate bond with strangers,” says the Journal of American College Health. For women, smoking accounted for a “predominant influence” in different social contexts: spending time with other smokers, attracting potential romantic/sexual partners, drinking alcohol, and frequenting places where alcohol is available.
Men, Women, and Drug Use
Gender roles also limit women, even as women (as a demographic) have more spending and cultural power than they did a generation ago. Dr. Winstock tells The Telegraph that there still exists a great deal of stigma around women who take drugs, while male drug abusers receive no such shame. Women who do consume drugs are less likely to tell their friends and family about it, which has the effect of limiting access to more drugs (but also limiting access to help and treatment). But having a male partner who uses drugs is a significant risk factor for whether the female partner in the relationship will pick up the habit; living with a partner with a substance abuse problem presents serious sources of stress and threats to wellbeing, notes the American Journal of Drug and Alcohol Abuse. This can contribute to the development of an addiction with the female partner, and it can also stymie recovery and rehabilitation since the home environment is not conducive to sobriety.
While women in relationships tend to pick up substance abuse through their partner, men, on the other hand, are more likely to start drug use with their peers, which can then develop into a substance abuse problem.
On college campuses, where drug use is widespread in an era of greater acceptance of the use of mind-altering chemicals, almost 40 percent of males reported smoking marijuana, while only 30 percent of women admitted to the same. As a further sign of the risk-taking behavior of men, the Journal of Adolescent Health found that male students who drank alcohol also tended to abuse prescription drugs (such as Adderall, for staying up later and boosting mental acuity); researchers found no such connection existed among female students. Similarly, male students who had previously used drugs had “an increased likelihood of substance abuse of prescription [painkillers] during young adulthood”; but among female students, only previous marijuana use offered any connection to substance abuse.
Menstruation and Drug Abuse
One of the most striking differences between the genders, and one that makes a notable impact in how men and women respond to substance abuse differently, is that of menstruation. Functional magnetic resonance imaging has shown how estrogen and progesterone hormones are not only responsible for ovulation and reproduction, but also how they also impact “a large number of cognitive and affective functions,” says Science Daily. Some of those functions include the regulation of the reward system in the brain, which is how menstruation and substance abuse overlap.
Brain scans show that the regions of the brain that process pleasure, rewards, and the anticipation of receiving more pleasure and reward become significantly more activated during menstruation, when estrogen levels are significantly higher. This may be why women respond to cocaine to a much greater degree than male users of the drug, and why women tend to use cocaine to a “more severe” degree than male users.
The effect is such that even women who are trying to quit cocaine might be more susceptible to relapse during the follicular phase of their cycle, writes Experimental and Clinical Psychopharmacology, simply because they slipped up at the wrong time in their cycle.
Further in the study of how gender-specific hormones might affect substance abuse, Trends in Pharmacological Sciences suggests that women tend to be more aware of the pleasurable sensations of drug consumption, primarily because estrogen activates receptors in the brain that increase the effects of the substances in terms of how quickly and powerfully they are felt.
In fact, the overall temptation of taking dangerous and unhealthy substances “ebbs and flows with a woman’s monthly cycle,” says Scientific American. This means that women could be “uniquely vulnerable” to drug abuse and its effects, because of how powerfully female sex hormones (like estrogen and progesterone) affect the regions of the brain that regulate reward anticipation, and the response to substances that stimulate those regions.
Female hormones don’t affect just the brain systems that control pleasure and rewards. They can make a mess of mental health, says Vice magazine. The Archives of Psychiatric Nursing writes of the “associations between psychiatric disorders and menstrual cycle characteristics.”,  On their own, women can experience any number of effects as part of a normal menstrual cycle, such as mood swings, depression, anxiety, reduced cognitive ability, and sleep disorders. A cycle could exacerbate a pre-existing mental health condition in a woman, which might also contribute to the development (or further exacerbation) of substance abuse. Women are twice as likely as men to suffer from major depression (and twice as likely as men to develop clinical anxiety), but this goes misdiagnosed as much as 50 percent of the time. The American Psychological Association explains that 70 percent of the prescriptions for antidepressants are written for female patients, “often with improper diagnosis and monitoring,” leading to situations where women became addicted to their prescription drugs.
Hormones, Mental Health, and Drug Addiction
Suffering traumatic events can be a direct cause of depression and anxiety, but women are twice as likely to develop post-traumatic stress disorder than men. This is because women have an increased fear response to a traumatic event, due to what the Journal of Psychiatric Research called an “acquisition of conditioned fear.” Again, hormones may play a role in this; research out of Harvard and Emory University suggest that some women’s vulnerability to anxiety disorders may be a result of low estrogen levels, which make women more susceptible to suffering greater degrees of trauma if a distressing event takes place at certain points during their menstrual cycles. High levels of estrogen can offer some measure of protection from emotional upheaval. Researchers theorized that women are most at risk for developing PTSD during periods of low estrogen during their menstrual cycle, which they may seek to self-medicate with the use of drugs and alcohol – the effects of which are magnified by the range of psychological and neurochemical changes brought about by menstruation.
- Treatment and the Male Gender
In the same way that gender roles account for a significant risk factor in determining the likelihood of abuse, they can also influence barriers to and methods of treatment. Men tend to be more reluctant to admit that their drinking or drug use has gotten out of control, and they are thus less likely to seek out help by themselves. The American Psychological Association writes that it usually takes a crisis (a family intervention, a DUI, or a court order) for a man to acknowledge his drug abuse and get treatment for it. The American Journal of Drug and Alcohol Abuse further writes that men usually have better treatment outcomes if there are ultimatums associated with their treatment; that is, facing prison time, divorce, or job loss works well in motivating men to see their treatment through.
For men, a literature review by Westminster College found that male clients responded better to inpatient programs, which are traditionally very structured and organized. Men reported lower rates of relapsing after graduating from such programs; on the other hand, men in outpatient programs, which grant a greater degree of personal freedom, did not fare as well as women. Men who participate in group activities and group therapy relapsed less, likely because sharing their experiences with other men (who made the same mistakes) cultivated a sense of solidarity and community, which treatment programs look to emphasize as part of their rehabilitation paradigm.
Some treatment centers try to use traditional concepts of masculinity to help their male clients overcome the challenges that led to the substance abuse. Adventure therapy, which is primarily outdoors in nature (e.g., camping, hiking, fishing, etc.) encourages men to work together. In this environment, asking for help, trusting others, and honestly admitting weaknesses are the only ways to get things done, and the lessons learned are applied to everyday situations that will help sobriety in the real world.
- Treatment and the Female Gender
When it comes to women, the female gender is often better at distinguishing emotions and then actively doing something to address the problems at hand. However, gender norms can also work against women; the pressure to maintain family duties and obligations, to the point of curtailing treatment by inducing feelings of guilt for being away from children and household work, compels many women to leave treatment early (compared to men who are likelier to remain in treatment for longer once they start). The Journal of Substance Abuse Treatment describes these as “severe problems” that result in women having generally lower treatment completion rates than men.
As a way of working around this problem, some treatment facilities offer childcare as part of their services, allowing recovering mothers to be near their children during counseling and ensuring that the children are given appropriate attention and care when the mother is unavailable. Such services also remove children from environments that threaten their wellbeing – for example, a home environment where there is abuse or easy access to drugs and alcohol. The Gazette writes of a treatment center in Iowa that provides long-term residential services to women and children, as a response to there being a large number of mothers who dropped out of standard residential programs because they did not want to put their children in the state’s foster care program.
Similarly, a facility in Rochester, New Hampshire, offers treatment specifically for pregnant and nursing women. The co-founder of the program told New Hampshire Public Radio that clients will receive group therapy, as well as parenting classes, in a home-like setting that emphasizes nurturing and support.
Drug Abuse and Transgender People
Understanding how men and women respond to substance abuse and treatment has shaped the entire addiction treatment industry. However, a greater (and more recent) focus on issues surrounding transgender and non-binary individuals, whose gender identity does not fit into categories of male and/or female, highlights how the scope of human sexuality and identity is evolving and, with it, how our grasp of addiction science and psychology is also changing.
The Center for American Progress explains that while only approximately 9 percent of the general population abuse drugs and alcohol, the figure rises to 20 percent or 30 percent for gay and transgender people. Specifically, men who engage in sexual activity with other men use marijuana 35 times more than men who engage in sexual activity with women; such men are also 12.2 times more likely to use methamphetamines and 9.5 times more likely to use heroin than their heterosexual counterparts.
LGBT Discrimination and Temptation
The high rates of substance abuse are largely due to LGBT individuals being subject to more frequent and severe forms of sex- and gender-based discrimination than cisgender individuals, resulting in major mental health disorders that compel drug abuse. Compounding the problem is that there is still widespread cultural ignorance of the nature of transgender identity (Live Science noted that the “T” in “LGBT” remains a source of confusion and misunderstanding.) and how best to treat transgendered people who are suffering from addiction. To that point, only 6 percent of substance abuse centers in America (777 out of a total of 13,688) offered specialized programs for LGBT clients, according to a 2010 report from the Substance Abuse and Mental Health Services Administration.
However, there is a strong cultural push toward alcohol and substance abuse from within LGBT communities. Tobacco and alcohol companies market directly to transgendered people through advertisements, using concepts of liberation and individualism to tap into the philosophies that empower many LGBT people to come out while also exploiting vulnerabilities and insecurities by making drugs and alcohol seem like an integral part of life as a transgendered person.
This has had the effect of normalizing drug consumption across LGBT communities, which in conjunction with issues of social stress, harassment, and prejudice typically experienced by members of those communities (sometimes on an everyday basis), dramatically increases rates of addiction among transgendered people.