Chapter 1. Introduction

Gender is an important variable to consider when designing and analyzing studies in all areas and at all levels of biomedical and health-related research (Wizemann & Pardue, 2001). Consideration of gender and dissemination of data regarding gender differences, or lack thereof, has been recommended by the Institute of Medicine (IOM). Gender is especially important in substance abuse treatment services research because the background characteristics, substance abuse patterns, and personal histories of female substance users may differ from those of males. As such, treatment programming designed specifically for women is needed to address not only women's substance abuse-related problems but also their special needs and barriers to treatment. Although many service providers acknowledge and address gender differences among substance abuse treatment clients, these differences and the programming that addresses them have not been adequately studied. At the national, State, and local levels, policymakers and service providers need new knowledge to understand how male and female substance abuse treatment clients differ in terms of sociodemographic and substance use characteristics and retention in treatment. Information about the availability and effectiveness of substance abuse treatment programming for women can help guide public policy about how the treatment system should be structured.

This report discusses the need for substance abuse treatment programming for women and summarizes evidence about the effectiveness of such programming. The report compares characteristics of male and female clients discharged from substance abuse treatment and estimates the availability of substance abuse treatment programming targeting women's needs. Finally, the report provides new information about the relationship between gender, substance abuse treatment programming for women, and retention in treatment.

This chapter includes a brief history of how gender has been addressed or ignored in sentinel substance abuse treatment research studies. The chapter examines current data about gender differences in substance abuse treatment utilization, substance use epidemiology, social context and etiology of substance use, barriers to receiving treatment, physiological consequences of substance use, and retention in substance abuse treatment. In addition, a brief introduction to the Alcohol and Drug Services Study (ADSS) is presented, followed by an overview of the remaining chapters in this report.

Gender Differences Among Substance Abuse Treatment Clients

Early substance abuse treatment studies—including the Drug Abuse Reporting Program (DARP) and the Treatment Outcome Prospective Study (TOPS)—did not fully analyze male-female differences in substance abuse treatment data (Kandall, 1996; Sells, Demaree, Simpson, & Joe, 1978; Simpson & Sells, 1982). Analyses of important outcome measures were not reported by gender, and in some instances, female research subjects were excluded from analyses. The National Treatment Improvement Evaluation Study (NTIES), conducted from 1993 to 1995, and the California Drug and Alcohol Treatment Assessment (CALDATA), conducted from 1992 to 1994, analyzed treatment outcomes by gender and reported many similarities among females and males (Gerstein & Johnson, 2000; Gerstein et al., 1994). Gender differences among treatment clients also have been analyzed using data from the Drug Abuse Treatment Outcome Study (DATOS) (Grella & Joshi, 1999; Wechsberg, Craddock, & Hubbard, 1998).

The proportion of substance abuse treatment clients who are female has increased moderately over the past decade (Figure 1.1). In 2002, according to the Treatment Episode Data Set (TEDS), about 30 percent (565,000) of admissions to substance abuse treatment facilities were females, up from 28 percent in 1992 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2004).

Figure 1.1 Numbers of Substance Abuse Treatment Admissions, by Gender and Year: TEDS, 1992-2002.

Figure 1.1 D

Source: SAMHSA, Office of Applied Studies, Treatment Episode Data Set (TEDS, 1992-2002)

It is important to consider the proportion of female substance abuse treatment clients in the context of gender differences in the epidemiology of substance use and dependence (e.g., Walter et al., 2003; Weiss, Kung, & Pearson, 2003). According to the National Survey on Drug Use and Health (NSDUH, formerly the National Household Survey on Drug Abuse [NHSDA]), the proportion of females to males engaging in binge alcohol use (having five or more drinks on the same occasion on 5 or more days during the past 30 days) in 2003 was similar to the above proportion of females to males in substance abuse treatment (Table 1.1; Office of Applied Studies [OAS], 2004a). However, the proportion of females (7 percent) to males (10 percent) engaging in past month illicit drug use was higher than the proportion of females to males in substance abuse treatment. The rate of substance dependence on an illicit drug was even more similar between females (1.5 percent) and males (2.2 percent) (Table 1.2; OAS, 2004a). Furthermore, research has shown that women who used psychotropic drugs, such as sedatives or tranquilizers, were significantly more likely than men to develop dependence on those drugs (Kandel, Warner, & Kessler, 1998).

**Table 1.1 Alcohol Use in Past Month among Persons Aged 12 or Older, by Gender: Percentages, NSDUH, 2003**
Gender	Binge Alcohol Use ¹	Heavy Alcohol Use ²	Any Illicit Drug Use ³
Male	30.9	10.4	10.0
Female	14.8	3.4	6.5
¹ Binge Alcohol Use is defined as drinking five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days. ² Heavy Alcohol Use is defined as drinking five or more drinks on the same occasion on each of 5 or more days in the past 30 days; all Heavy Alcohol Users are also Binge Alcohol Users. ³ Any Illicit Drug includes marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or any prescription-type psychotherapeutic used nonmedically. Source: SAMHSA Office of Applied Studies, National Survey on Drug Use and Health, 2003.

**Table 1.2 Substance Dependence among Persons Aged 12 or Older, by Gender: Percentages, NSDUH, 2003**
Gender	Alcohol	Any Illicit Drug ¹
Male	4.3	2.2
Female	2.2	1.5
Note: Dependence is based on the definition found in the 4^th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). ¹ Any Illicit Drug includes marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or any prescription-type psychotherapeutic used nonmedically. Source: SAMHSA Office of Applied Studies, National Survey on Drug Use and Health, 2003.

Rates of substance use among adolescents show fewer gender differences. For example, in the 2003 NSDUH, among adolescents aged 12 to 17, an estimated 11.4 percent of boys and 11.1 percent of girls had used an illicit drug during the past month (OAS, 2004a). According to the 2003 Monitoring the Future national survey, the rate of past year use of any illicit drug other than marijuana was slightly higher for girls than for boys (Johnston, O'Malley, Bachman, & Schulenberg, 2003). There was little male-female difference in 8th and 10th grades in rates of past year use of LSD, cocaine, crack, heroin, Ritalin, Rohypnol, and GHB. Furthermore, rates of past year inhalant, amphetamine, and tranquilizer use were slightly higher among females than among males in 8th and 10th grades. While these rates of substance use among adolescent females raise concerns about risks for substance abuse and addiction in adulthood, additional complexities have been identified for women in relation to substance use, including substance use during pregnancy, economic considerations, physiological differences from men, co-occurring psychological problems, traumatic experiences, family and partner influences, social stigma and discrimination, and barriers to retention in substance abuse treatment.

Substance Use and Pregnancy

Among females, rates of substance use and treatment among pregnant women are of special concern (Ebrahim & Gfroerer, 2003). The 2002 TEDS estimated that 4 percent of females admitted to treatment were known to be pregnant when admitted (SAMHSA, 2004). Compared with nonpregnant female admissions aged 15 to 44, pregnant admissions of similar age entering treatment were more likely to report cocaine/crack (22 percent vs. 17 percent), amphetamine/methamphetamine (21 percent vs. 13 percent), or marijuana (17 percent vs. 13 percent) as their primary substance of abuse (OAS, 2004b). Among pregnant women responding to the 2002 and 2003 NSDUHs, 10 percent reported alcohol use, 4 percent reported binge alcohol use, and almost 1 percent reported heavy alcohol use in the month prior to the survey (OAS, 2004b). The 2000-2001 Pregnancy Risk Assessment Monitoring System (PRAMS) estimated that the prevalence of alcohol use during pregnancy ranged from 3 percent to 10 percent (Phares et al., 2004). Women aged 35 or older, non-Hispanic women, women with more than a high school education, and women with higher incomes reported the highest prevalence of alcohol use during pregnancy. The 1992 National Pregnancy and Health Survey found that 19 percent of females used alcohol during pregnancy, and 5 percent of females used an illicit drug at least once during pregnancy, including marijuana (3 percent), psychotherapeutic medication without a prescription (2 percent), and cocaine (1 percent) (National Institute on Drug Abuse [NIDA], 1996). More recent data from the Maternal Life Study, which oversampled very low birth weight infants, found that 35 percent of pregnant females at four study sites reported alcohol use and 8 percent reported marijuana use during pregnancy (Lester et al., 2001). Meconium toxicology screens were positive for cocaine or opioids in 11 percent of infants screened.

In studies of substance abuse treatment among women, pregnancy and childbearing are important events because they may represent barriers to seeking, receiving, or completing treatment. Women with substance use disorders may avoid seeking treatment for fear of losing custody of their children (Ayyagari, Boles, Johnson, & Kleber, 1999; DeAngelis, 1993; Finkelstein, 1994; Grella, 1997), due to well-publicized cases of drug use during pregnancy resulting in prosecutions for child abuse, delivery of drugs to a minor, and other charges (Associated Press, 2003; Chavkin, Breitbart, Elman, & Wise, 1998; Paltrow, 1992, 1998). For example, 14 states consider substance use during pregnancy to be child abuse under civil child-welfare statutes, and 9 states require health care professionals to report suspected prenatal substance abuse (Figdor & Kaeser, 2005).

Women in treatment are more likely to be responsible for the care of children, to have more children living in their homes, and to be more concerned about issues related to children than men (Brady, Grice, Dustan, & Randall, 1993; Wechsberg et al., 1998; Wong, Badger, Sigmon, & Higgins, 2002). Responsibility for children, coupled with little access to child care services, is one of the most significant and most frequently cited barriers among females who seek treatment (Allen, 1995; Copeland, 1997; Grella, 1997; Kaltenbach & Finnegan, 1998; van Olphen & Freudenberg, 2004), and women with substance use disorders often perceive that many substance abuse treatment programs fail to provide such services (Nelson-Zlupko, Dore, Kauffman, & Kaltenbach., 1996). Referrals for substance abuse treatment programs in the past often have neglected to accommodate the needs of low-income women with children, such as by providing child care and transportation (Johnson & Meckstroth, 1998).

Economic Considerations

In addition to legal consequences and logistical difficulties, pregnant and parenting women may experience economic consequences from treatment seeking. Recent studies have estimated that between 5 and 35 percent of women receiving Temporary Aid to Needy Families (TANF) have a substance abuse problem that can impede their ability to work (Klein & Zahnd, 1997). The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) required TANF recipients to work 20 hours per week or to be engaged in job training or job readiness activities. If appropriate substance abuse treatment is not received, substance abusing women are unlikely to find or maintain employment, and their ability to provide care for their children is diminished. Substance abuse treatment participation could be considered an activity counted toward work requirements, although not all States allow this. In February 2003, the House of Representatives and a Senate committee passed bills to reauthorize TANF through 2008. The House legislation increased the work requirements to 40 hours per week (24 hours of direct work activities and 16 hours of approved indirect work activities to be determined by the individual States). In this legislation, substance abuse treatment is considered to be an allowable direct work activity for up to 3 months in any 24-month period. The Senate committee expanded on the House legislation and proposed allowing substance abuse treatment to count toward work requirements for 6 months within a 2-year period, provided that during the second 3 months treatment is combined with work or job-readiness activities. The full Senate has not yet ruled on this legislation.

However, women identified as substance abusers may also have difficulty maintaining eligibility for entitlement programs. Many States either currently screen or plan to implement alcohol and other drug screening of TANF recipients, and some require urine drug testing (Montoya & Atkinson, 2002). The use of urine drug testing within TANF programs is still controversial and has been implemented as a means of sanctioning TANF recipients (Hammett, Gaiter, & Crawford, 1998). In addition, follow-up on referral to treatment often is limited, with many women identified as needing treatment never presenting to receive it (Klein & Zahnd, 1997). Thus, access to treatment may be limited for substance-using females receiving TANF.

Further contributing to economic difficulties is the fact that female substance abuse treatment clients have lower educational attainment and rates of employment than their male counterparts (Wong et al., 2002). In a study of DATOS data, a national study of more than 10,000 substance abuse treatment clients, women were found to be younger, less educated, and less likely to be employed than men (Wechsberg et al., 1998). In a study of Los Angeles substance abuse treatment clients, the average age for females was lower than that for males, and 39 percent of females had less than a high school education compared with 19 percent of males (Hser, Huang, Teruya, & Anglin, 2003). In an Oregon and State of Washington study of health maintenance organization (HMO) clients, women were younger than men entering treatment, had lower incomes, were less well educated, and were less likely to be employed (Green, Polen, Dickinson, Lynch, & Bennett, 2002). Furthermore, although a greater proportion of males than females entering treatment have no health insurance, when insured, females are more likely to have public insurance than private insurance (Wechsberg et al., 1998).

Gender Differences in Physiology

Compared with male substance abusers, female substance abusers may have more physical problems, and females appear to be more vulnerable than males to the physiological effects of substance use. For example, in a study of alcohol problems among trauma center patients, women were significantly more likely than men to have liver disease (Gentilello et al., 2000). Differences in the way women absorb, distribute, eliminate, and metabolize alcohol may increase their vulnerability to alcohol-related problems (Mumenthaler, Taylor, O'Hara, & Yesavage, 1999; Wasilow-Mueller & Erickson, 2001). The female liver appears to be more sensitive to the toxic effect of chronic alcohol intake than the male liver (Colantoni et al., 2003; Mandayam, Jamal & Morgan, 2004; Mann, Smart, & Govoni, 2003). Females develop alcoholic liver disease (i.e., cirrhosis and hepatitis) after comparatively shorter periods and less intense drinking than do males. Although males have higher rates of cirrhosis mortality than women, proportionately, more alcohol-dependent females die from cirrhosis than do alcohol-dependent males (Fuchs et al., 1995; Lieber, 1993; Mann et al., 2003; NIAAA, 1999). One of the reasons for gender differences in alcoholic liver disease is that females achieve higher concentrations of alcohol in the blood than males after drinking equivalent amounts of alcohol (Bradley, Badrinath, Bush, Boyd-Wickizer, & Anawalt, 1998; Frezza et al., 1990; Redgrave, Swartz, & Romanoski, 2003). In a cohort study of over 13,000 men and women in Europe, for example, the relative risk of developing alcohol-related liver disease was significantly higher among women than men for any given level of alcohol intake (Becker et al., 1996). An additional reason for gender differences in alcoholic liver disease is that the level of alcohol dehydrogenase, an enzyme associated with alcohol metabolism, may be lower in females than in males (Baraona et al., 2001; Thomasson, 1995). Estrogen has also been associated with alcohol-related liver disease (Moshage, 2001; Yin et al., 2000).

Although one review reports that evidence of gender differences in alcohol-induced brain damage remains inconclusive (Hommer, 2003), most studies suggest that females are more susceptible than males to the adverse neurologic consequences of alcohol (NIAAA, 1999; Prendergast, 2004; Wuethrich, 2001). In a study of alcoholic and nonalcoholic men and women's brain volumes, for example, the significance of differences in gray and white matter volumes between alcoholic and nonalcoholic men was of a smaller magnitude than the significance of the differences between alcoholic and nonalcoholic women (Hommer, Momenan, Kaiser, & Rawlings, 2001). Females may also be more susceptible than males to alcohol-related cardiac problems (Blum, Nielsen, & Riggs, 1998; Piano, 2002), and women have shown different mechanisms leading to a higher sensitivity to alcohol-induced heart damage (Fernandez-Sola & Nicolas-Arfelis, 2002; Urbano-Marquez et al., 1995). In a study of alcoholic cardiomyopathy, the prevalence of heart disease was similar in alcohol-dependent males and females, yet alcoholic women reported a significantly lower daily dose of alcohol, a shorter duration of alcoholism, and a lower total lifetime dose of alcohol consumption than did alcoholic men (Fernandez-Sola et al., 1997).

These biological differences may be associated with the physical functioning and overall health status of women. In a study that reviewed medical records and interviewed research subjects over a 2-year period, females who abused or were dependent on alcohol reported poorer physical functioning, poorer physical and mental health, and disproportionately more impairment compared with their male counterparts (Grazier, 2001). One report has shown death rates among female alcoholics to be much higher than those of male alcoholics (Walter et al., 2003).

Psychological Problems

In addition to various medical problems, women substance abusers are at increased risk for psychological problems (Alvarez, Olson, Jason, Davis, & Ferrari, 2004; Brady & Randall, 1999; Chander & McCaul, 2003; Chatham, Hiller, Rowan-Szal, Joe, & Simpson, 1999; Gentilello et al., 2000; Mann, Hintz, & Jung, 2004; OAS, 2004c; Phillips, Carpenter, & Nunes, 2004; Wechsberg et al., 1998; Zimmermann et al., 2004). Psychosocial antecedents more likely to be associated with substance use by females than with that of males include comorbid psychiatric disorders, such as depression, anxiety, bipolar affective disorder, phobias, psychosexual disorders, eating disorders, or posttraumatic stress disorder (PTSD) (Boyd, 1993; Brady, Dansky, Sonne, & Saladin, 1998; Denier, Thevos, Latham, & Randall, 1991; Fornari, Kent, Kabo, & Goodman, 1994; Institute of Medicine [IOM], 1990; Mendelson et al., 1991; Merikangas & Stevens, 1998; Najavits, Weiss, & Shaw, 1997; Nelson-Zlupko, Kauffman, & Dore, 1995; Saxe & Wolfe, 1999). For example, an analysis of the relationship of age at first substance use relative to the onset of affective and anxiety disorders found that the onset of psychiatric disorders preceded the onset of substance use disorders more often in females than in males (Kessler et al., 1997). In addition, substance-dependent females have been found to be more likely to need help for emotional problems at a younger age and to have attempted suicide than substance-dependent males (Haseltine, 2000). Unfortunately, females with co-occurring substance abuse and psychiatric disorders face unique barriers to substance abuse treatment, such as difficulty in obtaining a dual disorder assessment and diagnosis, social stigma attached to both conditions, and insufficient knowledge and training among providers of health, mental health, or substance abuse treatment services to manage coexisting disorders (Grella, 1996, 1997).

Trauma

Substance use by females is linked to traumatic events or stressors, including sexual and physical assault or abuse, sudden physical illness, an accident, or disruption in family life (Grella, 1997; IOM, 1990; Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997; Kilpatrick, Resnick, Saunders, & Best, 1998; Martin, Beaumont & Kupper, 2003; Najavits et al., 1997). Females often use alcohol or other drugs to self-medicate in an effort to cope with these traumatic events (Miranda, Meyerson, Long, Marx, & Simpson, 2002; Teusch, 2001; Young, Boyd, & Hubbell, 2002). Women with substance use problems have been found to be significantly more likely than men to exhibit recent physical, emotional, or sexual abuse (Gentilello et al., 2000), and female substance abuse treatment clients report more problems related to physical and sexual abuse and domestic violence victimization than males (Green et al., 2002; Wechsberg et al., 1998). However, some therapeutic approaches, such as confrontational models often used in traditional therapeutic communities, present a special barrier for female substance abusers (Copeland, 1997) because they often "reenact" traumatic experiences and may engender feelings of distress and powerlessness associated with such experiences.

Family and Partner Influences

Female substance abusers are more likely than their male counterparts to report greater dysfunction in the family of origin (Chatham et al., 1999) and lack adequate role models for parenting (Davis, 1990; Sheridan, 1995). Females often are referred to substance abuse treatment through child protective services as a requirement for retaining or regaining custody of children (Clark, 2001). Poor interactions with children can also be a significant source of stress that interferes with female's treatment efforts (Davis, 1990; Greif & Drechsler, 1993). In addition, female substance abusers are more likely than male substance abusers to enter into dependent relationships dominated by their partner (Woodhouse, 1992), hindering their ability to perform basic life skills, such as managing money and planning for the future. Substance-dependent females are more likely than substance-dependent males to have substance-dependent spouses or partners (Amaro & Hardy-Fanta, 1995; Blum et al., 1998; Henderson, Boyd, & Mieczkowski, 1994; Riehman, Iguchi, Zeller, & Morral, 2003; Tuten & Jones, 2003), who may not be supportive of their seeking treatment. Thus, seeking treatment may create a serious problem for the relationship (McCollum & Trepper, 1995). The partner often not only discourages the woman from entering treatment but also may threaten violence or leave the relationship if the woman seeks treatment (Amaro & Hardy-Fanta, 1995), and partner substance use and treatment behavior have been found to be more strongly associated with treatment motivation for females than for males (Riehman, Hser, & Zeller, 2000). In contrast, common reasons for males' entering treatment are family pressure and spousal opposition to substance abuse (Grella & Joshi, 1999).

Social Stigma and Discrimination

Substance use among females is more highly stigmatized than among males (Grella & Joshi, 1999), and social stigma, labeling, and guilt are significant barriers for females to receiving treatment (Ayyagari et al., 1999; Copeland, 1997; Dvorchak, Grams, Tate, & Jason, 1995; Finkelstein, 1994; IOM, 1990; Nelson-Zlupko et al., 1995). Stigma and guilt may foster denial of problems by females, creating a further barrier to treatment (Blume, 1997). In addition, females in a variety of treatment settings have been found to be more likely than males to belong to minority racial/ethnic groups (e.g., Hser et al., 2003). As such, women in substance abuse treatment may have experienced racism and may harbor mistrust of the medical and substance abuse treatment systems, which may compromise provider-patient relationships and hinder treatment and recovery.

Implications for Retention in Substance Abuse Treatment

A number of studies have shown that males remain in substance abuse treatment longer than females (Hser, Evans, Huang & Anglin, 2004; Mammo & Weinbaum, 1993; Petry & Bickel, 2000; Sayre et al., 2002; Simpson et al., 1997a; Simpson, Joe, & Brown, 1997b; Simpson, Joe, & Rowan-Szal, 1997c), even after controlling for other factors (Arfken, Klein, di Menza, & Schuster, 2001; McCaul, Svikis, & Moore, 2001) and regardless of type of care (Arfken et al., 2001). However, relatively few data are available about retention among female substance abuse treatment clients, and findings are not consistent. The Treatment Outcome Prospective Study (TOPS) of clients in treatment during the early 1980s showed that gender differences in length of stay varied by type of care; longer stays in treatment were found for females compared with males in outpatient methadone treatment and outpatient drug-free treatment, but no differences were found among females and males in residential treatment (Hubbard et al., 1989). Some recent studies have reported no gender differences in retention after controlling for other factors (Wickizer et al., 1994), including analyses of DATOS data among residential and outpatient methadone types of care (Broome, Flynn, & Simpson, 1999; Joe, Simpson, & Broome, 1999), and higher rates of retention have been found among females than males in nonmethadone treatment, after controlling for other factors (Broome et al., 1999; Joe et al., 1999).

Other factors associated with retention include age, race/ethnicity, education, marital status, partner's drug use, presenting substance abuse problem at admission, severity of substance abuse, age at first use, psychiatric symptom severity, referral source, type of care, and intensity or level of service (Ashley, Sverdlov, & Brady, 2004; Broome et al., 1999; Green et al., 2002; Grella, Anglin, Wugalter, Rawson, & Hasson, 1994; Grella, Joshi, & Hser, 2000; Haller, Miles, & Dawson, 2002; Hser, Joshi, Maglione, Chou, & Anglin, 2001; Joe et al., 1999; Kelly, Blacksin, & Mason, 2001; Knight, Logan, & Simpson, 2001; Lang & Belenko, 2000); Maglione, Chao, & Anglin, 2000; McCaul et al., 2001; Mertens & Weisner, 2000; Nishimoto & Roberts, 2001; Rowan-Szal, Joe, & Simpson, 2000; Smith, North, & Fox, 1995; Strantz & Welch, 1995; Tuten & Jones, 2003; Veach, Remley, Kippers, & Sorg, 2000; Wickizer et al., 1994; Williams & Roberts, 1991). However, large, nationally representative studies are lacking and knowledge gaps still exist about factors influencing retention in substance abuse treatment, particularly among females.

This report includes analyses of retention among a nationally representative sample of substance abuse treatment facilities serving male and female clients. Treatment retention is measured in two ways in this study: (1) as the percentage of clients who successfully completed treatment and (2) as mean length of stay (LOS) in treatment. Both measures are important because they are associated with improved treatment outcomes, such as reduced drug use, criminality, or unemployment (French, Zarkin, Hubbard, & Rachal,1993; Green, Polen, Lynch, Dickinson, & Bennett, 2004; Hser et al., 2004; Hubbard, Craddock, Anderson, 2003; Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997; Metsch, McCoy, Miller, McAnany, & Pereyra, 1999; Satre, Mertens, & Weisner, 2004; TOPPS-II Interstate Cooperative Study Group, 2004; Wallace & Weeks, 2004; Zarkin, Dunlap, Bray, & Wechsberg, 2002). Longer stays in treatment among pregnant substance abusers have been associated with improved pregnancy and neonatal outcomes (Kissin, Svikis, Moylan, Haug, & Stitzer, 2004). In a drug treatment program for pregnant and postpartum women in New York City, for example, LOS was associated with less maternal drug use and greater mean birth weight and less intrauterine growth retardation among infants (McMurtrie, Rosenberg, Kerker, Kan, & Graham, 1999).

Summary

Women and men with substance use disorders are different. Among clients who present for substance abuse treatment services, women have more children living in their homes, are often younger, have lower incomes, and are less likely to be employed than men. Factors such as the heightened scrutiny of substance use during pregnancy, the lack of affordable child care, and social stigma impact women more than men. There also appear to be different reasons for initiating careers in substance use among men and women. Important differences also appear to exist among adults in the adverse consequences of substance use, although most of the findings of gender differences deal with alcohol use and alcoholism.

Gender differences in social and psychological characteristics have important implications for substance abuse treatment retention for females, although some important studies show conflicting findings about the association between gender and retention. Females have unique treatment needs in contrast to males, and gender-specific approaches to substance abuse treatment have been developed to address these needs.

Alcohol and Drug Services Study (ADSS)

This report utilizes data from the Alcohol and Drug Services Study (ADSS). ADSS was conducted between 1996 and 1999 for the OAS and was designed to collect detailed information on the characteristics of substance abuse treatment facilities and their clients and to study the relationships among facility characteristics, treatment services, and clients in treatment (OAS, 2003). The ADSS sample was selected using a multistaged, stratified design, with selection of 2,395 facilities in Phase I, selection of a subset of Phase I responding facilities, selection of client discharge records in Phase II, and client follow-up in Phase III. Facilities in the sampling frame were stratified by treatment type of care: hospital inpatient, nonhospital residential, outpatient primarily alcohol, outpatient primarily methadone, other outpatient, and combined treatment types (OAS, 2003).

Overview of Chapters

The chapters in this report review existing research and analyze ADSS data to provide important new knowledge:

Chapter 2, "Substance Abuse Treatment Programming for Women: A Literature Review," examines previous research on the availability and effectiveness of substance abuse treatment programming for women.
Chapter 3, "Data and Methods Used in This Report," describes the ADSS data source, measures of key study variables, and statistical methods.
Chapter 4, "Characteristics of Substance Abuse Treatment Clients," summarizes the sociodemographic characteristics of female and male substance abuse treatment clients.
Chapter 5, "Characteristics of Substance Abuse Treatment Facilities Providing Treatment Programming for Women," estimates the prevalence of substance abuse treatment programming for women.
Chapter 6, "Retention in Substance Abuse Treatment: Gender and Substance Abuse Treatment Programming for Women," addresses the relationship between gender and retention in treatment and between types of substance abuse treatment programming for women and treatment retention among women.
Chapter 7, "Conclusions and Implications," summarizes the chief findings of this report and discusses the implications of these findings with suggestions for future research.
The appendix, "Statistical Methods and Limitations of the Data," discusses generalizability of the study findings, suppression criteria for reporting results, response rates, missing data, validity of data, and analytic methodology.

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Yin, M., Ikejima, K., Wheeler, M. D., Bradford, B. U., Seabra, V., Forman, D. T., Sato, N., & Thurman, R. G. (2000). Estrogen is involved in early alcohol-induced liver injury in a rat enteral feeding model. Hepatology, 31, 117-123.

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Zarkin, G. A., Dunlap, L. J., Bray, J. W., & Wechsberg, W. M. (2002). The effect of treatment completion and length of stay on employment and crime in outpatient drug-free treatment. Journal of Substance Abuse Treatment, 23, 261-271.

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Chapter 2. Substance Abuse Treatment Programming for Women: A Literature Review

This chapter summarizes the current literature about substance abuse treatment programming for women. A definition of substance abuse treatment programming for women is presented, and the history and origins of this type of programming are briefly described. Current data are presented about the availability of this type of programming, and selected empirical research is reviewed on the relationship between gender-specific substance abuse treatment programming and treatment outcomes among women.

Comprehensive Definition

There is no universally accepted definition of substance abuse treatment programming for women. In general, this term refers to the delivery of services and treatment that reduce females' barriers to entering substance abuse treatment and/or address their specific substance abuse treatment needs. Such programming includes the following core components, which may be combined:

ancillary services intended to increase female clients' access to substance abuse treatment, such as child care or transportation services;
services intended to address the specific needs of females, such as prenatal and well-baby care, psychosocial education focusing on issues relevant to women or parenting, human immunodeficiency virus (HIV) prevention and risk reduction that targets women, and mental health services that address a woman's history of abuse and trauma; and
programs and services provided for women only, creating a unique treatment environment that is more focused on women's issues than are mixed-gender services.

Although treatment programs addressing females' barriers to treatment or their specific needs differ, they often incorporate one or more of the above components. Substance abuse treatment programming for women may also emphasize a comprehensive service approach to address psychosocial problems, pregnancy education, parenting, employment, housing, and trauma services. Such programming may reflect unique treatment philosophies that serve to empower women and to provide a supportive, nonconfrontational approach to treatment.

Historical Context

Although the substance abuse treatment system has increasingly recognized the need for programming that addresses women's specific substance abuse-related problems and barriers to treatment, women's treatment needs were obscured for many years. Little research can be identified before the 1980s describing substance abuse treatment programming for women, but two seminal studies in this area are highlighted here.

First, an early study of a comprehensive program for substance-dependent women described the Family Center program initiated in Philadelphia in 1969 (Connaughton, Finnegan, Schut, & Emich, 1975). Family Center provided outpatient medical (primarily methadone) treatment and psychosocial services addressing education and treatment to substance-dependent women. Obstetricians and pediatricians provided perinatal medical services, and personnel trained in mother-child interaction and early childhood development subsequently joined the staff. Other services included a clothing bank and a small food bank for registrants, and staff organized women-only and parent education groups.

Second, in 1975, using pregnancy as the focus, the National Institute on Drug Abuse (NIDA) initiated funding for a series of comprehensive drug treatment demonstration grants for women in Detroit; Houston; New York; Philadelphia; Washington, DC; and San Rafael, California (Beschner & Brotman, 1977). The New York City program—the Pregnant Addicts and Addicted Mothers Program (PAAM)—was inaugurated in 1975, emphasizing comprehensive care and providing onsite addiction treatment, medical services, individual and group counseling, child development services, parent education classes, child care, and developmental assessments of infants (Suffet & Brotman, 1984). All services were housed on the same floor of one building, which facilitated communication between providers and patient access to services. PAAM concentrated on helping women addicted to opiates or methadone have a normal pregnancy and deliver a healthy newborn, as well as helping the newborn develop normal cognitive and motor abilities. The comprehensive approach to treatment embedded in the PAAM treatment model demonstrated positive outcomes, such as treatment compliance and favorable newborn outcomes (Suffet & Brotman, 1984). PAAM was initiated at the Center for Comprehensive Health Practice of New York Medical College in 1969 as a pilot project offering obstetrical, pediatric, and psychological services to East Harlem mothers and their children. The program eventually received two successive 3-year NIDA grants (1975-1981) and began operating under contract to the New York State Division of Substance Abuse Services.

The crack cocaine epidemic of the 1980s focused attention on female crack abusers and, in particular, on pregnant women and their children. The media focused on drug-exposed infants, resulting in heightened concern for the devastating and costly effects of prenatal cocaine exposure on newborns (Hartman & Golub, 1999; Lyons & Rittner, 1998). This attention resulted in increased funding for treatment programs serving females. Block grant legislation was amended by the Federal Government in 1984 to require that each State set aside 5 percent of its block grant allocation to provide new or expanded substance abuse treatment services for women. By 1988, this set-aside for women's services had increased to 10 percent, and in 1990 the General Accounting Office (GAO) called for an urgent national response to the growing issue of drug-exposed infants in the United States (Grella & Greenwell, 2004). Within the U.S. Public Health Service (PHS), branches of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), the National Institute on Child Health and Human Development (NICHD), and the Health Resources and Services Administration (HRSA) all implemented special programs for females with substance use disorders.

During the 1980s and 1990s, an increasing number of Federal programs were geared specifically to substance-abusing mothers. The NIDA "Perinatal-20" funded 20 demonstration grant projects in 1989 and 1990 that focused on the treatment of drug-abusing pregnant women and their offspring. The intent of the Perinatal-20 was to conduct treatment research and create new treatment slots for women and their children (Kandall, 1996). Each of the 20 projects was designed to evaluate either a comprehensive treatment program composed of an integrated system of services or a specific targeted therapeutic intervention embedded in a comprehensive continuum of care. Each study targeted in its evaluation drug-abusing women in treatment either with or without their children (Rahdert, 1996). Through these funding and policy initiatives, availability of treatment services for women increased, and this increase enabled researchers and evaluators to study gender-specific treatment processes and outcomes.

The Substance Abuse and Mental Health Services Administration (SAMHSA) and its predecessor, the Alcohol, Drug Abuse, and Mental Health Administration, initiated important programs for women with substance use disorders. One program managed under both agencies, the Pregnant and Postpartum Women and their Infants (PPWI) Demonstration Grant Program, awarded 147 grants in 37 States between 1989 and 1993. These projects provided comprehensive prevention, intervention, and treatment services to substance-abusing pregnant and postpartum women (Carter & Larson, 1997). These programs also provided health care services to the infants of women in treatment. An evaluation of 90 of the 147 demonstration grant projects found them to be highly successful in improving the coordination, availability, and accessibility of health care and alcohol and drug treatment for pregnant and postpartum women, with at least one third of the women treated by these programs reporting a reduction in drug use (Carter & Larson, 1997).

In addition to the PPWI Demonstration Grant Program, SAMHSA's Residential Women and Children (RWC) and the Pregnant and Postpartum Women (PPW) Demonstration Program awarded 5-year grants to 70 projects between 1993 and 1995 (Clark, 2001). Both of these initiatives were designed to support comprehensive residential treatment services, including primary health care, mental health assessments and counseling, and other social services for substance-abusing women and their children. The Center for Substance Abuse Treatment (CSAT) conducted a cross-site evaluation of 50 of these programs. One of the key findings from that evaluation was that between 1993 and 1996, the number of women who reported the use of illicit drugs decreased by between 73 and 80 percent from intake to postdischarge (Carter & Larson, 1997). Other benefits of these programs included reduction of adverse pregnancy outcomes, reduction of criminal involvement, and improvement in retaining custody of children (Substance Abuse and Mental Health Services Administration [SAMHSA], 2001). In addition, 47 of the 50 RWC/PPW projects obtained funding for the continuation of services beyond the original CSAT funding.

Today, SAMHSA, through CSAT and the Center for Mental Health Services (CMHS), continues to fund programs providing comprehensive residential substance abuse treatment services for pregnant, postpartum, and/or parenting women and their minor children. A variety of funding vehicles supports these programs, including Targeted Capacity Expansion, Addiction Treatment for the Homeless, HIV Outreach, and Drug Court grants. An example of one of these programs is the Women, Co-Occurring Disorders and Violence Study, a 5-year initiative jointly supported by the three centers of SAMHSA to study women with substance abuse and mental health disorders who have histories of violence. Knowledge gained from this study is expected to be useful in advancing national, State, and local policy that affects how the various service systems respond to women with co-occurring disorders and histories of violence. As of June 2004, CSAT had funded over 100 grantees targeting women. In addition to SAMHSA's efforts, some states have created or funded treatment programs or provided priority access to treatment for pregnant substance abusers (Dailard & Nash, 2000).

Availability of Substance Abuse Treatment Programming for Women

Limited information is available about the prevalence of components of substance abuse treatment programming for women. Services are not clearly defined, and the services offered may be available to only a limited number of clients because of restricted resources. Nevertheless, the data provide important insight about the types and scope of treatment options for females.

Table 2.1 presents data about the prevalence of child care or prenatal care services offered by substance abuse treatment facilities. Nationally across studies, as shown in the table, 8 percent of substance abuse treatment facilities offer child care services, and 7 percent offer prenatal care services, although the rate in urban settings may be higher.

**Table 2.1 Percentages of Substance Abuse Treatment Facilities Offering Child Care or Prenatal Care Services**
Data Source	Facilities Offering Child Care Services	Facilities Offering Prenatal Care Services
2003 N-SSATS (SAMHSA, 2004)	7.9	Not available
1998 UFDS (OAS, 2000)	8.6	6.5
Opioid Treatment Program Study (CSAT, 2003)	7.5	Not available
1994 Los Angeles Study (Grella, Polinsky, Hser, & Perry, 1999)	Not available	30.4

The 2003 National Survey of Substance Abuse Treatment Services (N-SSATS) found that 14 percent of substance abuse treatment facilities offered special programs for pregnant or postpartum women. Although this figure cannot be compared to percentages from previous years due to a change in the N-SSATS survey instrument, the percentage of facilities offering special programs for pregnant or postpartum women remained relatively stable between 1997 and 2002. The 2003 N-SSATS also found that 35 percent of substance abuse treatment facilities offered special programs for women, a figure that has remained relatively stable ever since an increase from 1998 to 1999 (SAMHSA, 2004). Among the major types of care, special programs for women most often were offered at combined residential and outpatient facilities (Figure 2.1). More than one third of all facilities offered transportation assistance to treatment.

Figure 2.1 Percentages of Facilities Offering Special Programs for Women or Pregnant Women, by Type of Care: N-SSATS, 2003

Figure 2.1 D

Source: SAMHSA, Office of Applied Studies, National Survey of Substance Abuse Treatment Services (N-SSATS, 2003)

In a survey of 172 opioid treatment programs in 15 states, CSAT (2003) found that 49 percent offered special services for women, and 59 percent offered special services for pregnant women. Among a subset of 108 of these programs in 14 states, Wechsberg and colleagues (2001) found that 83 percent provided priority admission for pregnant women, 58 percent offered counseling to families, and 9 percent reported matching female clients with female counselors.

Using Los Angeles County data, a 1994 study of 161 drug treatment programs for adults found that 42 percent provided activities for children, 39 percent targeted pregnant women, and 19 percent served women only (Grella et al., 1999). Compared with mixed-gender programs, women-only programs were more likely to provide priority admission for pregnant women, charge no fees, and plan for longer treatment duration. Women-only programs also were more likely than mixed-gender programs to offer pediatric/well-baby care, children's activities, and housing assistance. In addition, women-only programs were more likely to serve Latinos and Native Americans and to accept Medicaid payment than were mixed-gender programs. The authors stated that the high percentage of women-only programs receiving public funding generally reflected the lower economic status of females.

Effectiveness of Substance Abuse Treatment Programming for Women

Although studies evaluating substance abuse treatment programming for women in the past often lacked control groups or analyzed small samples that limited their conclusions about effectiveness (McCrady & Raytek, 1993), recent research has shown promising results. Studies have demonstrated higher rates of retention when women in residential treatment are allowed to live with their children (Szuster, Rich, Chung, & Bisconer, 1996). Additionally, several studies have demonstrated better outcomes for women in outpatient treatment with comprehensive support services, including pregnancy-related services, parenting/training classes, child care, and family services (Grella & Greenwell, 2004).

This section provides a review of the literature evaluating the effectiveness of substance abuse treatment programming for women. Studies published between 1980 and 2000 of substance abuse treatment programming for women were identified through a systematic literature search. To be included in this review, studies must have explicitly defined the population at risk, described the intervention, and presented outcome measures to evaluate the impact of substance abuse treatment programming. The outcome measures included retention in treatment and changes in substance use, mental health symptoms, perinatal/birth outcomes, employment, self-reported health status, and HIV risk. A total of 37 studies were identified; 7 were randomized controlled trials, and 30 were nonrandomized studies. Detailed methods for this review have been published elsewhere (Ashley, Marsden, & Brady, 2003).

Optimally, health interventions are evaluated through a rigorous randomized controlled trial (or series of trials), the standard for establishing efficacy (Sackett, Haynes, Guyatt, & Tugwell, 1991).¹ The 7 randomized trials differed in interventions and methodologies, while the 30 nonrandomized studies employed a variety of descriptive, cohort, preexperimental, and quasi-experimental study designs. Of the seven randomized, controlled trials reviewed here, Dahlgren and Willander's (1989) study came closest to the optimal study design: females were randomly assigned to treatment in either a regular ward/alcoholism treatment center or a women-only outpatient or residential setting, and results were compared after 2 years.

Across the 37 populations analyzed, 36 studies reported improved treatment outcomes for female clients. All 7 randomized controlled trials showed positive results (Table 2.2), and 29 of the 30 nonrandomized studies showed positive results. The one study that did not report improved treatment outcomes was conducted in Australia. This study found no differences in treatment outcomes among females in a women-only program and in two mixed-gender treatment programs (Copeland, Hall, Didcott, & Biggs, 1993). However, more lesbian women, women with dependent children, and women with a history of childhood sexual abuse or maternal substance abuse participated in the women-only program than in the mixed-gender programs.

This review focuses primarily on three components of gender-specific treatment: child care services, prenatal care services, and women-only treatment. In addition, the effects of two additional components of substance abuse treatment programming for women were examined: mental health programming and supplemental education sessions that address women-focused topics. Transportation was provided infrequently within the studies reviewed and was not evaluated by any study as a primary intervention; therefore, it is not discussed independently from other components.

**Table 2.2 Randomized Studies of the Effectiveness of Substance Abuse Treatment Programming for Women**
Study Citation	N	Population	Interventions	Control Condition	Outcomes
Carroll, Chang, Behr, Clinton, & Kosten (1995)	14	Pregnant, outpatient methadone clinic patients	Prenatal care, therapeutic child care during treatment visits, monetary rewards for abstinence, relapse prevention	Standard methadone treatment	At delivery: Increased gestational length, birthweight, and number of prenatal care visits; no change in maternal drug use

Women in Substance Abuse Treatment:
Results from the Alcohol and Drug Services Study (ADSS)

Acknowledgments

Public Domain Notice

Disclaimer

Women in Substance Abuse Treatment

Table of Contents

Appendix

List of Figures

List of Tables

Highlights

Characteristics of Substance Abuse Treatment Clients

Facilities That Offer Substance Abuse Treatment Programming for Women

Treatment Retention

Chapter 1. Introduction

Gender Differences Among Substance Abuse Treatment Clients

Figure 1.1 Numbers of Substance Abuse Treatment Admissions, by Gender and Year: TEDS, 1992-2002.

Substance Use and Pregnancy

Economic Considerations

Gender Differences in Physiology

Psychological Problems

Trauma

Family and Partner Influences

Social Stigma and Discrimination

Implications for Retention in Substance Abuse Treatment

Summary

Alcohol and Drug Services Study (ADSS)

Overview of Chapters

References

Chapter 2. Substance Abuse Treatment Programming for Women: A Literature Review

Comprehensive Definition

Historical Context

Availability of Substance Abuse Treatment Programming for Women

Figure 2.1 Percentages of Facilities Offering Special Programs for Women or Pregnant Women, by Type of Care: N-SSATS, 2003

Effectiveness of Substance Abuse Treatment Programming for Women

Women in Substance Abuse Treatment: Results from the Alcohol and Drug Services Study (ADSS)

Acknowledgments

Public Domain Notice

Disclaimer

Women in Substance Abuse Treatment

Table of Contents

Appendix

List of Figures

List of Tables

Highlights

Characteristics of Substance Abuse Treatment Clients

Facilities That Offer Substance Abuse Treatment Programming for Women

Treatment Retention

Chapter 1. Introduction

Gender Differences Among Substance Abuse Treatment Clients

Figure 1.1 Numbers of Substance Abuse Treatment Admissions, by Gender and Year: TEDS, 1992-2002.

Substance Use and Pregnancy

Economic Considerations

Gender Differences in Physiology

Psychological Problems

Trauma

Family and Partner Influences

Social Stigma and Discrimination

Implications for Retention in Substance Abuse Treatment

Summary

Alcohol and Drug Services Study (ADSS)

Overview of Chapters

References

Chapter 2. Substance Abuse Treatment Programming for Women: A Literature Review

Comprehensive Definition

Historical Context

Availability of Substance Abuse Treatment Programming for Women

Figure 2.1 Percentages of Facilities Offering Special Programs for Women or Pregnant Women, by Type of Care: N-SSATS, 2003

Effectiveness of Substance Abuse Treatment Programming for Women

Women in Substance Abuse Treatment:
Results from the Alcohol and Drug Services Study (ADSS)