Addiction treatment has traditionally been designed with the assumption that the experiences of men and women are the same. Historically, since the prevalence of addiction has generally been higher among men, treatment programmes were tailored to meet the needs of the typical male client. However, this approach fails to account for the unique challenges and needs women face in their addiction and recovery journeys.
Distinct biological, psychological, and social factors shape substance use disorders in women. Women encounter complexities that differ significantly from those experienced by men. By addressing these differences through gender-sensitive interventions, we would improve recovery outcomes, reduce stigma, and tackle the growing burden of addiction among women.
The Gender Gap in Addiction Treatment
The 2024 European Drug Report published by the EUDA highlights that 23% of drug-induced deaths in Europe were among females, with the mean age at the time of death being 48 years. In women aged 50 to 64, the number of overdose deaths rose by 43% between 2012 and 2024 across EU countries (EMCDDA’s Annual Overview 2024). These figures, which specifically focus on overdose deaths, likely reflect a broader increase in substance use among women over the last decade.
Women constitute approximately one-quarter of individuals with serious drug problems and account for about one-fifth of all entrants to drug treatment programs in Europe (EMCDDA, 2024). They often face significant barriers to seeking treatment, including stigma, economic disadvantage, and limited social support. Many women with substance use disorders come from families with histories of addiction, have substance-using partners, or are caregivers to children, whose needs may directly influence their drug use and recovery process. Furthermore, women experience higher rates of sexual and physical abuse and are more likely to suffer from co-occurring mental health disorders (Chen & Gueta, 2015). These factors highlight the need to address the specific experiences and challenges of women in treating addiction.
Hormonal Influences on Addiction
Estrogen and progesterone play an important role in shaping the experience of women with addiction. These hormones affect women’s stress response, emotion regulation, and susceptibility to relapse by influencing the brain’s reward system.
Heightened Vulnerability
Estrogen enhances dopamine signalling in the brain, particularly in the nucleus accumbens, a region central to reward and reinforcement. This heightened sensitivity to rewards by estrogen makes women more vulnerable to the reinforcing effects of substances such as cocaine, nicotine, and alcohol. Estrogen, which is highest during the follicular phase of the menstrual cycle, is highly correlated with women’s reports of increased cravings and increased responsiveness to drug-related cues, which can complicate treatment efforts (Becker & Hu, 2008; Lynch et al., 2002; Herrera et al., 2016).
Protective Effects
Progesterone, which is more dominant during the luteal phase of the menstrual cycle, seems to counteract some of estrogen’s effects by dampening dopamine signalling. Research suggests that higher levels of progesterone are associated with reduced drug cravings and lower susceptibility to relapse. This protective effect of progesterone may offer insight into gender-specific therapeutic interventions for women struggling with addiction (Carroll et al., 2004; Evans & Foltin, 2010).
Cravings
Studies have demonstrated that hormonal fluctuations throughout the menstrual cycle influence drug cravings and use. Estrogen-dominant phases, particularly the follicular phase, are often linked with heightened drug-seeking behaviours, while the luteal phase, dominated by progesterone, is associated with reduced cravings (Quinones-Jenab & Jenab, 2010; Terner & de Wit, 2006).
Stress and Emotional Regulation:
Estrogen amplifies the stress response by increasing the activity of the hypothalamic-pituitary-adrenal (HPA) axis, making women more sensitive to stress-related triggers for substance use. On the other hand, progesterone has calming effects, which may help mitigate stress and reduce the likelihood of relapse during emotionally charged periods (Becker & Koob, 2016).
Neuroplasticity and Drug Cues
Estrogen promotes synaptic plasticity, which can strengthen associations between drug-related cues and substance use behaviours. This heightened sensitivity to drug cues may make it harder for women to resist cravings and avoid relapse, particularly when exposed to environmental triggers associated with past drug use (Bobzean et al., 2014).
These hormonal differences underscore the need for addiction treatments that consider the physiological and emotional complexities women face. Understanding and integrating hormonal factors into treatment programs could significantly improve recovery outcomes for women.
The Unique Physical and Psychological Challenges for Women
Women face unique health risks related to addiction, including breast cancer, menstrual irregularities, early menopause, fertility issues, and pregnancy-related complications that can also impact their children. Additionally, women are disproportionately vulnerable to HIV due to barriers to pre-exposure prophylaxis, sexual violence, drug-using relationships, and caregiving roles that discourage engagement with health services (Webb et al., 2022).
Psychologically, women are more likely than men to experience substance use as a coping mechanism for emotional pain or interpersonal conflict. For example, women dependent on opioids or nicotine often report greater cravings triggered by negative emotions, increasing their risk of relapse. Intimate partner violence is disproportionately higher among women with substance use disorders, often remaining hidden due to stigma and fear of repercussions (Webb et al., 2022).
Mothers with substance use disorders face additional challenges. They are more likely than fathers to lose custody of their children, which can contribute to feelings of guilt, shame, and increased risk of suicide. Studies also suggest that women may use substances as a form of self-medication. For instance, Brazilian women have reported using crack cocaine as a coping strategy for trauma and negative life experiences. Women are also at greater risk of polydrug use, often involving prescribed anti-anxiety and sedative medications (Fonseca et al., 2021).
Toward a Gender-Sensitive Approach
Given these gender-specific differences, addiction treatment programs must move beyond one-size-fits-all approaches and adopt gender-sensitive, evidence-based interventions.
Trauma-Informed Care
Since many women with substance use disorders have experienced trauma, treatment must include trauma-informed care to address the root causes of their addiction. Programmes should offer safe spaces where women can share their experiences openly, especially in co-ed settings.
Parenting and Family Support
Parenting support is essential to successful recovery for mothers battling addiction. Treatment programmes should consider providing or assisting with childcare services and offer parent sessions and family therapy to increase accessibility. Interventions like these would help address the shame and stigma surrounding addiction while fostering stronger family connections, which often play a crucial role in recovery.
Hormonal and Mental Health Integration
Addiction clinics should also integrate hormonal therapies, such as hormone rebalancing and mental health care, into their treatment programmes for women. Hormonal treatments, such as progesterone-based therapies, could help reduce cravings and stress sensitivity. Simultaneously, addressing co-occurring mental health conditions, such as anxiety, depression, and PTSD, is critical for recovery.
Community and Mutual Aid Support
Going through recovery alone is especially difficult. Treatment programmes should incorporate resources for women to help them establish a community of peers around them. Peer support groups and mentorship programmes also provide encouragement and guidance to those attempting to navigate recovery without a strong support system at home.
Health and Wellness Support
Programmes must address the unique medical needs of women, including reproductive health services and wellness initiatives. For pregnant women or those who are hoping to have children, specialised care is essential to protect both the mother and the developing fetus.
Policymakers, healthcare providers, and communities must recognise that women’s experiences with addiction are fundamentally different from men’s. Gender-sensitive treatment is not just about equity; it is about effectiveness. By addressing the specific needs of women—through trauma-informed care, parenting support, hormonal integration, community, and specialised medical care—treatment programmes can foster lasting recovery and improve lives.
Substance use treatment cannot remain a one-size-fits-all solution. Women need care that reflects their unique challenges and strengths. Tailoring interventions to these differences can create pathways to recovery that benefit not only individual women but also their families and communities.
References:
Becker, J. B., & Hu, M. (2008). Sex differences in drug abuse. Frontiers in Neuroendocrinology, 29(1), 36–47.
Bobzean, S. A., et al. (2014). Sex differences in the neurobiology of drug addiction. Experimental Neurology, 259, 59–70.
Becker, J. B., & Koob, G. F. (2016). Sex differences in animal models: Focus on addiction. Pharmacological Reviews, 68(2), 242-257.
Bobzean, S. A., et al. (2014). Sex differences in the neurobiology of drug addiction. Experimental Neurology, 259, 59–70.
Carroll, M. E., et al. (2004). Influence of sex and ovarian hormones on drug abuse vulnerability: Focus on animal models. Experimental and Clinical Psychopharmacology, 12(1), 17–29.
Evans, S. M., & Foltin, R. W. (2010). Does the response to cocaine differ as a function of sex or hormonal status in humans and non-human primates? Hormones and Behavior, 58(1), 92-103.
Fonseca, F., Robles-Martinez, M., Tirado-Munoz, J., Alias-Ferri, M., Mestre-Pinto, J. (2021). A Gender Perspective of Addictive Disorders. Current Addiction Reports, 8, 89-99.
Lynch, W. J., et al. (2002). Role of ovarian hormones in the acquisition and maintenance of cocaine self-administration in female rats. Neuropsychopharmacology, 27(3), 366–378.
Quinones-Jenab, V., & Jenab, S. (2010). Progesterone attenuates cocaine-induced responses. Hormones and Behavior, 58(2), 314–321.
Terner, J. M., & de Wit, H. (2006). Menstrual cycle phase and responses to drugs of abuse in humans. Drug and Alcohol Dependence, 84(1), 1–13.
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NIDA. Substance Use in Women Research Report. (2020). Available online at: https://nida.nih.gov/publications/research-reports/substance-use-in-women/summary (accessed September 29, 2022)
Riley, A. L., Hempel, B. J., & Clasen, M. M. (2018). Sex as a biological variable: Drug use and abuse. Physiology & behavior, 187, 79-96.
Webb L, Fox S, Skårner A and Messas, G. (2022) Editorial: Women and substance use: Specific needs and experiences of use, others’ use and transitions towards recovery. Front. Psychiatry 13:1078605.
Chen, G., & Gueta, K. (2015). Childhood Abuse and Mental Health Problems: Does Gender Matter? Psychiatric Quarterly. https://doi.org/10.1007/s11126-015-9371-5
Herrera, A. Y., Nielsen, S. E., & Mather, M. (2016). Stress-induced increases in progesterone and cortisol in naturally cycling women. https://doi.org/10.1016/j.ynstr.2016.02.006
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