Exploring the level of gender mainstreaming in the working agenda of substance use treatment centres in Italy
Sara Rolando1, Alice Rena2, Alessandra Liquori O’Neil2, Franca Beccaria1, Cindy J Smith3
1. Eclectica, Institute for training and research, Italy;
2. United Nations Interregional Crime and Justice Research Institute, Italy;
3. Director, United Nations Interregional Crime and Justice Research Institute, Italy.
Received 18 October 2016; accepted 16 January 2017.
Summary. Introduction. Gender responsive approaches are relatively new in the substance use field, although many studies highlight barriers to women’s access to substance use services. The aim of this exploratory study was to investigate to what extent a gender responsive approach is applied in the Italian substance use treatment services and to explore the professionals’ opinions regarding the advantages and the challenges of applying such approach. Methods. Administration of a structured questionnaire sent by e-mail to public and private non profit substance use treatment services (n = 329). Results. The majority of professionals recognize the importance of including a gender responsive approach in their working agenda, and the need for specific training. Overall, the gender-responsive approaches are limited to pregnant women and mothers. A subset considered this approach counterproductive as compared to individualized treatment options. Discussion. Results seem to indicate a general lack of understanding and awareness among professionals about the potentials of applying gender responsive approaches and about the social, economic and cultural factors that determine health inequalities and influence women’s access to services. A reductionistic interpretation of the gender responsive approach seems to prevail, which limits women’s needs to those of pregnant women and mothers.
Key words: substance use, gender.
Esplorazione del livello di gender mainstreaming nell’agenda dei servizi per le dipendenze italiani
Riassunto. Introduzione. L’approccio di genere è un tema relativamente recente nell’ambito delle dipendenze, nonostante in numerosi studi si evidenzino barriere all’accesso delle donne ai servizi rispetto agli uomini. Lo studio intende indagare in che misura questo approccio sia presente nei servizi per le dipendenze italiani, e i vantaggi e le criticità percepiti da professioniste e professionisti. Metodi. Somministrazione di un questionario strutturato inviato via e-mail a servizi pubblici e privati per le dipendenze (n = 329). Risultati. Dai dati emergono barriere che riguardano l’utenza potenziale, ma anche una non piena consapevolezza da parte dei servizi dell’opportunità di adottare un’ottica di genere, al di là dell’approccio individualizzato. I servizi genere-specifici sono in larga parte dedicati alle madri o alle donne in gravidanza. Discussione. I risultati sembrano indicare una scarsa comprensione dei fattori sociali, economici e culturali che determinano le disuguaglianze di salute e di accesso delle donne ai servizi per le dipendenze. Sembra inoltre prevalere un’interpretazione riduzionista dell’approccio di genere, che limita i bisogni delle donne a quelli legati al loro ruolo di madri.
Parole chiave: consumo di sostanze, gender.
Introduction and objectives
In the addiction research field, gender-based studies are quite recent and are affected by several methodological weaknesses. This scarcity has recently received the attention of the international community, whereas the United Nations Member States have agreed on several solutions requesting to intensify efforts aimed at understanding women’s substance use and to identify the most appropriate responses to meet their specific needs1.
According to a recent review2, the lack of a gender perspective in the field of substance use is due primarily to the widespread notion that women are less at risk than men. However this belief is only partially justified by the epidemiological data, since risk exposure changes per the observed behaviour, age, geographic area and ethnicity. In addition, women’s lower propensity to risk behaviours is counterbalanced by a faster progression to heavy consumption in a shorter time (telescoping), which also may be related to differences in metabolism. Furthermore, women have been traditionally under-represented in clinical research studies2.
Several studies have focused on the barriers to the use of specialized substance use services by women, by considering the “double standard”3 of judgment, which is applied to women who use substances and the stigma deriving from that.
Barriers that limit women’s access to specialised services can be internal - such as denial, feelings of shame and guilt, a negative view of the treatment, privacy concerns, fear of losing custody of children - and external, such as logistic and economic barriers (long waiting lists, lack of flexibility in opening hours, lack of sensibility by staff on gender differences)4. In general, women often find it difficult to reconcile their role as caregivers, primarily towards their children, with their treatment needs5.
In addition to “entry barriers”, gender-specific barriers have been identified that affect retention in treatment. Psychiatric co-morbidity, previous traumatic experiences such as sexual abuse and violence, civil status (married, divorced, single etc.), level of education and income are among the barriers that influence retention to treatment6,7, as well lack of integration between services8.
To date, prevention, treatment and rehabilitation strategies continue to be offered with little consideration to women’s specific needs and are mostly built around male substance use models. In addition, notwithstanding the recognition of gender-specific factors impacting on the development of substance use disorders between men and women, the literature does not provide consistent indications on the effectiveness of gender-specific treatment, including data on relapses and outcomes5. Existing studies provide some evidence for what works for special populations (pregnant women, mothers and women who have suffered a trauma). Such studies highlight the need to ensure a better adhesion of women to treatment, through programs that consider the health and body image, offer specific counselling in cases of eating disorders, violence and psychiatric comorbidity and provide logistic support (transportation, baby sitting etc.) to ensure continuity of care10. Regarding treatment groups, there are arguments in favour of both homogeneous groups and gender-mixed treatment strategies11, 12, 13.
As mentioned, the lack of randomized studies, the numerically limited samples and the scarcity of follow-up studies9 are some of the methodological limitations that account for the scarcity of established evidence in this research area.
Sample and methods
A survey was carried out to explore opinions, attitudes and behaviours regarding the adoption of a gender responsive approach by professionals working in the prevention, treatment and rehabilitation of substance use disorders in Italy. The questionnaire composed by 19 questions, mainly closed ended, was sent by email to public substance use treatment services and to non-profit private services offering prevention, risk reduction and rehabilitation programmes. The delivered emails were approximately 1,290. Assuming this figure as a target population, the response rate was 25.5% (n = 329). Returned questionnaires covered all 20 Italian regions, with a slight prevalence of respondents from the Northern regions.
Among the respondents, 66.8% belongs to public services, 18.2% to private non-profit organizations, and 15% to private healthcare providers contracted by the national health system. Most of the sample is made up of public substance use treatment services (60%), followed by therapeutic communities (29.4%). Alcohol units – which are usually included in the public substance use services but sometimes are independent services – and risk reduction services (also including low-threshold services) represent respectively 5.2% and 2.3% of the sample.
Almost all the services included in the sample (96.1%) provide treatment, two thirds (65.9%) also provide prevention and social rehabilitation, and about half (50.8%) provide mixed-services.
Overall, male clients represented the majority of patients, with women being 18.6% of the services total users. This figure dropped to 15.6%, in the case of the therapeutic communities and rose to 25.1% in harm-reduction services.
Attitudes towards the inclusion of a gender responsive approach
Approximately 63% of respondents consider it to be useful or extremely useful the adoption of a gender responsive approach in the treatment of substance use disorders, 27.1% are uncertain, and nearly 10% considers its adoption having little or no relevance. Non-profit organizations are less favourable (about 53%), while public and risk reduction services show a more positive attitude.
According to approximately one in four respondents, professionals working in the substance use field are not fully aware of the importance of gender mainstreaming and the majority of them (70%) think that including specific training on this topic would be useful or very useful. The latter opinion is particularly frequent among professionals from the public services.
Only 56.2% of the services working in the prevention area declare specific attention to gender vulnerabilities. Gender specific prevention activities mainly consist of peer education (49.6%) and medical and psychological consultations (38.9%).
Almost all professionals (94%) declare they inform their female clients about risks of drug/alcohol consumption during pregnancy, mostly through individual consultations with medical doctors and psychologists (79.4%). Other activities include the distribution of leaflets and information material (19.6%) and training (15.9%).
Only one out of three (32.3%) services provides gender-based treatment. These are mainly aimed at facilitating access for women, reducing stigma (59%) and verifying previous traumatic experiences before establishing the treatment protocol. One-third of respondents (33.2%) report gender related challenges with patients from different nationalities and/or religions − mainly represented by Muslims from North Africa, Romanians and Albanians.
While professionals recognize the complexity of those cases where women have been victims of violence, they also admit that very few programs are designed in collaboration with anti-violence centres (35.8%). The most common activities specifically addressed to women are programs for pregnant users (67.4%). The most diffused programs are those designed to ensure continuity of care during pregnancy (63.6%) and information activities aimed at increasing women’s awareness about the negative consequences of substance use on the foetus (60.8%). Another activity specifically addressed to women is the screening for infectious diseases linked to drug use (74.2%). According to our respondents, the possibility of losing the custody of children can be perceived by service users either as an incentive to stop using drugs (45.7%) or as a barrier (33.4%) to service access.
The support to drug addicted women in prison or under other judiciary measures is quite common among treatment services. Indeed, 85% of services provides therapeutic continuity and or/psychological support for women under judiciary measures. However, in-prison therapeutic programs are far less mentioned (25%) than out-of-prison programs (71.5%) and post release programs (61%).
Only 55.5% of respondents reported the adoption of measures to ensure that the organizational setting addresses gender specific needs. This translates mostly in dedicated women female professionals (31%) and efforts in adapting the timetable and the spaces to the needs of pregnant women or children (24.5%).
Services report quite a good capacity (81.6%) to refer their users to other social and health services (93.7%), while legal services (36%) and work-related services (31.2%) are far less reported.
Only approximately half of the professionals (49.7%) report having received specific training on gender related substance use issues.
Strengths and weaknesses of mainstreaming gender in substance use services
The questionnaire also included a few open-ended questions aimed at exploring the respondents’ opinions about strengths and weaknesses related to the adoption of a gender-responsive approach in substance use services. In this regard, 35.8% of the sample provided responses on the strengths and 44.7% on the weakness of this approach.
Among the most reported points of strength of applying a gender responsive approach were greater appropriateness and efficacy of treatment. On the contrary, gender approaches were considered useless or less valuable or weaker than individualized approaches. These were reported as more effective in identifying and addressing the individual’s specific needs. Some respondents even underlined the risks and dangers of creating reverse gender discrimination when applying gender responsive approaches.
Overall, a gender approach is considered successful in enhancing women’s access to services and reducing stigma, but again its advantages are mostly linked to specific targets, such as pregnant women and mothers. Other advantages, not directly linked to the service users, include the possibility to increase professional competence and understanding, as well as enhance collaboration with other services.
The most important challenge in the adoption of a gender responsive approach is identified in the lack of economic and human resources, as well as lack of adequate working spaces. In addition to being understaffed, professionals underlined the need for regular training opportunities.
The results confirm internal and external barriers to the implementation of gender responsive approaches and the need to enhance a gender mainstreaming culture in the Italian substance use services.
Overall, the results reflect the evidences emerging from the literature5.
Gender responsive approaches are mostly limited to pregnant women and mothers, which could be due to lack of resources and policy prioritization, but also due to a consideration of women’s needs as limited to their reproductive sphere.
While the results of the survey indicate an overall recognition of the added value of a gender responsive approach to substance use treatment, it may be useful to further investigate the results from the small percentage of respondents, who not only considers the adoption of a gender responsive approach useless, but in fact dangerous, in favour of an individualised approach. In our opinion, the emphasis on the individual treatment should not prevent professionals from also considering a whole set of factors, such as gender, ethnicity, race economic status, education and other social determinants that can heavily influence the onset, career and outcome of substance use in men and women14.
As evidenced in other studies, the “individualization” of substance use15 may emphasise the individual responsibilities, thereby reducing the attention on the social determinants of health inequalities, of which gender is one16. Enhancing the capacity of substance use professionals to understand the different “roots” and “routes” of men’s and women’s substance use is crucial, especially in light of the latest epigenetic studies, showing the closely intertwined relation between the biological and social factors that are capable of shaping our DNA responses.
Building the capacity of professionals in gender mainstreaming might likely contribute to reducing the barriers to the accessibility, affordability and acceptability of services. This might hopefully trigger a redirection of policies and practices, toward reconsidering the overall role and model of substance use services17 and strengthen dissemination of gender mainstreaming culture.
1. Commission on Narcotic Drugs. [Internet] Resolution 55/5. Promoting strategies and measures addressing specific needs of women in the context of comprehensive and integrated drug demand reduction programmes and strategies. 2012. Available from: https://www.unodc.org/documents/commissions/CND/Drug_Resolutions/2010-2019/2012/CND_Res-55-5.pdf
2. Affronti V, Camera L, Frossi M, Gonella R, Scaroina E. Analisi della letteratura scientifica. In AAVV. Consumo e comportamenti di dipendenza con e senza uso di sostanze nel genere femminile: progetto per un percorso conoscitivo nella Regione Piemonte. Rapporto di ricerca, 2014: pp 69-108.
3. Erickson PG, Murray GF. Sex differences in cocaine use and experiences: a double standard revived? Am J Drug Alcohol Abuse 1989;15(2):135-52.
4. Ait-Daoud N, Bashir M. Women and substance abuse: Health considerations and recommendations. CNS Spectrums 2011; 16: 37-47.
5. Green CA. Gender and use of substance abuse treatment services. Alcohol Res Health 2006; 29: 55-62.
6. Hogan SR, Unick GJ, Speiglman R, Crim D, Norris JC. Gender-Specific barriers to self-sufficiency among former supplemental security income drug substance use and alcoholism beneficiaries: Implications for Welfare-To-Work Programs and Services. J Soc Serv Res 2011; 37: 320-37.
7. Vigna-Taglianti FD, Burroni P, Mathis F, et al. Gender Differences in Heroin Substance use and Treatment: Results from the VEdeTTE Cohort. Subst Use Misuse 2016; 51: 295-309.
8. Schmidt LA, McCarty D. Welfare Reform and the Changing Landscape of Substance Abuse Services for Low-Income Women. Alcohol Clin Exp Res 2000; 24:1298-311.
9. Claus RE, Orwin RG, Kissin W, Krupski A, Campbell K, Stark K. Does gender-specific substance abuse treatment for women promote continuity of care? J Subst Abuse Treat 2007; 32: 27-39.
10. Ashley OS, Marsden ME, Brady TM. Abuse, effectiveness of substance abuse treatment programming for women: a review. Am J Drug Alcohol 2003; 29: 19-53.
11. Van De Mark NR. Policy on reintegration of women with histories of substance abuse: A mixed-methods study of predictors of relapse and facilitators of recovery. Subst Abuse Treat Prev Policy 2007; 2: 28.
12. Bright CL, Osborne VA, Greif GL. One dozen considerations when working with women in substance abuse groups. J Psychoactive Drugs 2011; 43:64-8.
13. Greenfield SF, Trucco EM, McHugh RK, Lincoln M, Gallop RJ. Dependence, The Women’s Recovery Group Study: a stage I trial of women-focused group therapy for substance use disorders versus mixed-gender group drug counseling. Drug Alcohol Depend 2007; 90: 39-47.
14. Liquori O’Neil A. and Lucas, J. (editors) Promoting a gender responsive approach to addiction. Turin: UNICRI Publication n. 104, 2013.
15. Hellman M. Construing and defining the out of control: Addiction in the media (Doctoral dissertation). University of Helsinki: Swedish School of Social Science, 2010.
16. Costa G, Bassi M, Marra M, et al. L’equità nella salute in Italia. Secondo rapporto sulle disuguaglianze sociali in sanità. Milano: Franco Angeli, 2014.
17. UNODC. Guidelines for drug prevention and treatment for girls and women. UNODC, 2015.
Conflict of interest statement: none to declare.
Acknowledgements: this research survey was possible thanks to the support of the Department for Drug Policy of the Government of Italy.
© 2017 United Nations Interregional Crime and Justice Research Institute (UNICRI). The views expressed are those of the authors and do not necessarily reflect the views of the United Nations or the organizations with which the authors are affiliated. Moreover, the views expressed do not necessarily reflect those of the sponsoring States. Contents of this publication may be quoted or reproduced, provided that the source of information is acknowledged.UNICRI would like to receive a copy of the document in which this publication is used or quoted. The designation employed and presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning the legal status of any country, territory, city or area of its authorities, or concerning the delimitation of its frontiers or boundaries.