35
CHAPTER OUTLINE
Gender disparities in the treatment of women were largely ignored until the 1970s, when interest grew in the biomedical and psychosocial aspects of women’s use of alcohol and other drugs. Pressed by the women’s movement, the federal government initiated efforts to focus scientific and public attention on women’s issues (1,2). This generated new research and services specifically tailored to women’s needs, new materials for clinicians in the field, and reconsideration of public policy.
However, there still are many ways in which the needs of women in alcohol and drug treatment remain unmet. According to Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Facility Locator (2012 data), only 32% of the 11,000 programs listed offered specific services for women, up from 24% in 2007 (3).
This chapter will discuss treatment issues specific to women, including the relationship of drug and alcohol use problems to psychiatric and medical conditions, and review new findings on gender-specific treatment.
Gender Differences in Alcohol and Other Drug Use
Gender patterns are evolving, with reported rates of use becoming more similar for men and women with each passing decade. Several large-scale epidemiologic studies document gender differences in the use of alcohol and other drugs, generally finding higher rates in men (4,5). The Epidemiological Catchment Area (ECA) study, with data collected in the 1980s, reported that men had five times greater 1-month prevalence rates for alcohol and three times greater 1-month prevalence for other drugs (5). The subsequent National Comorbidity Survey (NCS) (4,5) documented similar differences, but the gap appears to be diminishing. A subsequent National Survey on Drug Use and Health (NSDUH), conducted in 2010, showed smaller gender differences for all age groups except adolescents aged 12 to 17 years. For this group, the gap virtually disappeared for alcohol, marijuana, cocaine, and cigarettes.
Common Psychiatric Disorders in Women with Addictive Disorders
Most men and women in treatment for addictive disorders have at least one coexisting psychiatric disorder, but the pattern differs by gender. Both the ECA study (4,5) and the NCS (4) found that women were more likely to have affective disorders than men (with the exception of mania, for which rates were the same). Women were significantly more likely than men to have experienced a major depressive episode. Data from the NCS showed a lifetime prevalence of 21.3% and a 12-month prevalence of 12.9% for women, compared with 12.7% and 7.7% for men. Dysthymia also was more common in women, with a lifetime prevalence of 8% and a 12-month prevalence of 3% compared with 4.8% and 2.1% for men. Women also had a higher lifetime and 12-month prevalence of three or more disorders. In addition, women who have experienced childhood sexual abuse (CSA) are at greatly increased risk of developing a wide range of psychopathology, particularly bulimia, alcoholism, and other drug dependence (6).
Alcohol
The influence of alcohol on women’s health has been much more extensively studied than other drugs. Although women are less likely than men to drink heavily or even moderately (7), when they do so, they are more vulnerable to alcohol-related liver damage, cardiovascular disease, and brain damage (8). A large prospective study that followed 13,000 adults for 12 years found that women developed alcohol-related liver disease at approximately half the consumption levels of men (9). For women, the risk of alcohol-induced liver disease and alcohol-related cirrhosis rose once consumption levels exceeded 7 to 13 standard drinks (84 to 156 g of alcohol) per week. Alcohol increased women’s susceptibility to myopathy and cardiomyopathy, and studies suggest that alcohol-dependent females suffer from a generalized skeletal fragility that increases their risks of fracture from falls (8).
Negative consequences occur at lower levels of consumption and after much shorter periods of drinking. This is referred to as the “telescoped course” in women. In their 2005 review, Blume and Zilberman (10) note that there is growing evidence that women develop many of the pathologic effects of alcohol more rapidly than men. Their examples include fatty liver, hypertension, anemia, malnutrition, gastrointestinal hemorrhage, and peptic ulcer requiring surgery.
Mumenthaler et al. (11) reviewed studies of alcohol absorption, distribution, elimination, and impairment and explored the mechanisms by which women achieve higher blood alcohol concentrations than men after drinking equivalent amounts of alcohol, even when doses are adjusted for body weight. Women tend to have lower levels of alcohol dehydrogenase and lower volumes of water compartment distribution, leading to an increased effect of alcohol from an equivalent exposure in a man. Their review also noted women’s relatively greater susceptibility to alcohol’s effects on cognitive functions, such as divided attention and impaired memory. They concluded that the menstrual cycle is not likely to affect alcohol pharmacokinetics and is not a significant influence on alcohol’s effects on performance.
The relationship between drinking and breast cancer risk has been also studied since the 1980s. Alcohol consumption raises breast cancer risk even after adjustment for age, family history, and other known dietary and reproductive risk factors (8). The increased risk appears to be modest and dose related, and the form of alcohol appears to be irrelevant. Mechanisms for this increased risk are unknown.
It is important that clinicians make use of opportunities to educate women about their greater risks, even for those who are highly educated and articulate (12). There is still widespread public naiveté about what constitutes moderate-or low-risk drinking. For example, many interpret their increased tolerance or the absence of short-term negative consequences to mean they are drinking moderately. In Green and colleagues’ recent study, none of the 150 respondents discussed gender differences in their in-depth interview, indicating a surprising lack of awareness given how long the public information on differential impact has been available.
Prenatal Alcohol Exposure
Simply stated, there is no demonstrated safe level of alcohol consumption during pregnancy. Drinking during pregnancy remains a serious concern, with physicians in a key position to reinforce social norms that encourage the elimination of drinking during this time. Fetal alcohol syndrome (FAS), a set of birth defects, is considered the single leading nonhereditary cause of mental retardation. The growth deficiency and characteristic set of facial traits tend to appear more normal over time, but the alcohol-induced damage to the developing brain is enduring. These mental impairments include deficits in general intellectual functioning and specific difficulties with learning, memory, attention, and problem solving. In addition, there were impairments in psychosocial skills such as manners and interactions with others. These impairments are dose related and may be evident in children without the distinguishing physical features of FAS (8).
Several terms have been developed to describe alcohol-related conditions. The term “alcohol-related birth defects” refers to alcohol-related physical abnormalities of the skeleton and certain organ systems (e.g., the heart and kidney) that occur in the absence of the characteristic growth deficiency and facial characteristics of FAS. The term “alcohol-related neurodevelopmental disorder” refers to the mental impairments in the absence of FAS. The introduction of a new diagnostic system for categorizing fetal alcohol effects has facilitated more systematic research (13). Neuroimaging studies provide additional specifics about the structural damage to the brain, and specific patterns of behavioral impairment have been more carefully delineated. Heavy prenatal exposure to alcohol leads to neurobehavioral impairment, but the effects of lower levels of exposure are less clear, although documented in some studies (NIAAA, 2000).
Compounding these defects are the caregiving deficits in the child’s immediate family when one or both parents are drinking heavily. These psychosocial deficits include inconsistent nurturance; poor parental support, inconsistent monitoring, and communication; high levels of family conflict; and higher rates of physical and sexual abuse (14). Comprehensive treatment of the substance-abusing woman needs to address these wide-ranging needs and to assess for antecedent traumas, as described later in this chapter.
Drugs
Although evidence for gender differences in the effects of drug use is not as extensive as alcohol at this time, there are indications that gender may be a factor. Greenfield et al. (15) summarize sex differences related to responsivity and to relapse, citing differences in hormonal activity, stress reactivity, and neurobiologic correlates documented in neuroimaging studies.
For example, women may be more at risk for using stimulants due to a combination of susceptibility to their reinforcing effects and the weakening influence of social protective factors (16). A study of treatment-seeking female cocaine users concluded that some women may have greater vulnerability to the effects of cocaine relative to men, resulting in more rapid progression of pathology (17). Mechanisms suggested include female steroid hormones (18), estrogen (19), and differences in receptor function (20). Current investigations of the influence of menstrual cycle phase have yielded contradictory results (21–23). A recent summary of epidemiologic data on methamphetamine concluded that there were no significant gender differences between men and women (24), quite different from the gender breakdowns usually reported.
Unfortunately, there is scant literature examining differing effects of other drugs such as heroin on men and women. However, it is well known that a woman’s substance use is heavily influenced by her male partner (25–28), and she can underestimate her level of harm if her main reference point is her partner’s behavior. For nonmedical use of prescription opioids, risk factors vary by gender. In general, both alcohol and illicit use disorders were associated with nonmedical use of prescription opioids reported within the last year for both men and women. For women, the gender-specific factors were first use of illicit drugs beginning at age 24 or older, serious mental illness, and cigarette smoking (29).
Methadone is considered the gold standard maintenance treatment for opioid-dependent pregnant women (30,31). It is important that the dose is adequate. Contrary to common expectations, higher doses are not associated with increased risks of neonatal abstinence in one study (32). Despite the fact that some of the women were on relatively high doses of methadone (ranging from 25 to 180 mg/d), levels in breast milk were small, and no adverse events were detected. Women should not be discouraged from breast-feeding if they are not using illicit drugs and do not have specific contraindications (33). Stereotypes about methadone being “just another addiction” can have prejudicial influence on medical decisions.
Buprenorphine is approved by the FDA for use in pregnancy, and it, along with methadone, is a category C medication during pregnancy. This allows a risk–benefit clinical decision to start or continue to maintain pregnant patients on sublingual buprenorphine/naloxone when methadone treatment is not an option or is not acceptable to the patient. A large-scale, multisite study (the MOTHER study) to evaluate safety and efficacy of buprenorphine in pregnancy found that compared to methadone, outcomes were largely similar, but the newborns of buprenorphine patients had lower severity of neonatal abstinence symptoms, thus requiring less medication and less time in the hospital (34). However, the retention rates of the methadone-maintained mothers were significantly better than the buprenorphine group (33% vs. 18%), and the careful, hospital-based induction required by the research study may make it difficult to implement in the community. Questions have also been raised about the possible presence of an intrauterine abstinence syndrome that affects the fetus during withdrawal from illicit opiates (35). Existing studies are not adequate to address this issue, and the methodologic problems are daunting.
Inasmuch as women on buprenorphine may become pregnant, or may prefer buprenorphine to methadone, the MOTHER project sought to develop guidelines based on risk–benefit ratios. It is important to use buprenorphine alone rather than the buprenorphine/naloxone combination to avoid prenatal exposure to naloxone.
Transferring a patient receiving methadone to buprenorphine is challenging because of the need for the mother to remain off methadone for a protracted period of time prior to buprenorphine induction and due to the risk of a precipitated withdrawal. There is currently no medication transition procedure that avoids these risks and the associated risks of fetal distress, miscarriage, and stillbirth. In research studies, this transition has been accomplished using intravenous morphine in a hospital (36), but this is not a practical option for community treatment providers. Buprenorphine may also pose complications for pain management during labor and delivery. The same features that produce an enhanced safety profile for buprenorphine may mean that pain medications fail to reach the target receptors. Buprenorphine and methadone in pregnancy are covered in more detail in Buprenorphine and methadone in pregnancy are also discussed elsewhere in this text of this volume.
In summary, although methadone is the treatment of choice for opioid-dependent pregnant women, the use of monobuprenorphine is an emerging option with potential to expand treatment access in rural areas and in other circumstances.
It is especially important to reduce early treatment dropout in pregnant women because participation in treatment is associated with better maternal and neonatal outcomes. Drug craving and withdrawal were important precipitants of relapse, especially for heroin users who did not receive methadone maintenance (37).
Domestic Violence
In 1994, a Bureau of Justice report indicated that more than half a million women were treated in hospital emergency departments for violence-related injuries, usually inflicted by an intimate partner (38). At least 4.4 million women in the United States each year suffer from related health problems. Women who have been battered report that their general health is fair or poor, that they have had sexually transmitted diseases and other gynecologic problems, and that they have needed medical care that they have not received. Chronic headaches, as well as hearing, vision, and concentration problems, can reflect neurologic damage. A variety of stress-related symptoms, such as irritable bowel syndrome, also can manifest. For these reasons, psychosocial treatment efforts must be integrated with good medical care to be fully comprehensive.
It is especially important that residential and outpatient programs without such care on site develop effective case management. Addiction medicine specialists can help such programs develop protocols and procedures to ensure that the counseling staff members are aware of the woman’s medical status and are clear in their role as facilitators of integrated services. Larger programs have found that a “medical coordinator” who functions as a medical case manager can provide more systematic attention to medical concerns.
Violence in the family of origin, antisocial and/or aggressive behavior as a teen, anger, substance abuse, relationship dissatisfaction, psychological aggression, and power/ control tactics have been shown to predict partner violence (39). Careful assessment is needed, since differing levels of intimate partner violence require different types of interventions. The Conflict Tactics Scale is well validated and widely used for identifying partner violence (40). Clinicians need to know how to develop a safety plan with the clients, when and how to treat the substance abuse, when to utilize marital therapy, and how to avoid common mistakes such as confronting the partner directly or allowing the partner to join the medical or psychiatric appointment. They also need to know contact information for local shelters and other community resources (39). They also need to be familiar with state reporting requirements for domestic violence.
There is now very strong evidence that substance abuse plays an important role in interpersonal violence, though it may be only one of many contributing factors. If a comprehensive assessment indicates it is a major factor, integrated substance abuse treatment is likely to yield the best results, though these are relatively rare in community programs (41).
HIV/AIDS
Women account for a steadily increasing proportion of those with HIV infections. In 1985, less than 5% of new HIV infections in the United States were among girls over 13 years old and adult women. By 2005, it was nearly 27%, with women of color heavily impacted. HIV/AIDS is the leading cause of death for African American women aged 25 to 34 (42). Having sex with an HIV-infected male is the most common mode of transmission, followed by sharing injection drug equipment (43). Similar patterns of increase, particularly among women of color, also are beginning to be apparent in the distribution of reported hepatitis C cases.
Socially sanctioned imbalance of power plays a major role in influencing risk reduction behavior in women. Because the condom remains the major method to reduce sexual transmission of HIV, women are at a disadvantage. Women either must gain the cooperation of their male partners in using a condom or must decide not to have sexual relations if the man refuses (44,45). Many women lack the self-esteem and communication skills to negotiate condom use. Young women in particular often lack the fortitude to insist if their partners balk. Addicted women are at an additional disadvantage in attempting to practice safer sex. Many women fear emotional or physical abuse if they do so. Indeed, a woman’s greatest risk of assault is from her male partner (46). The future development of an effective protective method that is under the woman’s control and can be used without the knowledge of her sexual partner is a key goal for reducing women’s risk.
For the HIV-infected women, managing caretaking responsibilities often is an issue added to the physical and psychiatric burdens of the disease. They worry about transmission of the virus to family members and must be both well informed and reassured. They struggle with how to address their health issues and their possible death with their children. Women who have given birth to HIV-infected children have an added layer of anxiety and guilt. After delivery, women in these circumstances are often socially isolated and welcome the opportunity to share with other women in a support group, which can help to bypass their shame and express their feelings more openly, with less fear of rejection (47).
The need for treatment interventions that are sensitive to gender differences has brought increasing attention to co-occurring disorders and their effect on addicted women. Although the addiction treatment field has made great progress in addressing co-occurring disorders in the past decade, advances in understanding and practice vary greatly in their degree of dissemination. Physicians can expect wide variation in sophistication and responsiveness among community providers and should attempt to refer or place the patient where she is likely to get the specific services indicated by her specific conditions and behaviors. These are described in the most recent revision of ASAM’s Patient Placement Criteria (48). Community service levels are described in terms of “addiction treatment only (AOS),” programs that focus primarily if not exclusively on addiction; programs that are “dual diagnosis capable (DDC),” for those whose psychiatric disorders have been stabilized; and those that are “dual diagnosis enhanced (DDE),” for those who are unstable or disabled to the extent of needing specific psychiatric support, monitoring, and accommodation. Many community providers describe themselves as offering treatment for co-occurring psychiatric disorders without actually having the resources to handle the full range of problems (49,50). A clear picture of the strengths and limits of programs available in the community can lead to more appropriate referrals, as well as help in guiding the development of services needed to fill the gaps.
It has become more widely accepted in the addiction treatment community that psychotropic medications are compatible with recovery, especially when prescribed by physicians knowledgeable about addiction. Indeed, appropriately prescribed medications enhance the effects of psychosocial interventions. Effective pharmacotherapy requires careful education and a clear treatment contract. “The essential principles are that pharmacotherapy targets specific symptoms, is time limited, is modified only one change at a time, is monitored for compliance, and is provided only in the context of a comprehensive psychosocial treatment plan” (51). The physician’s role as a member of a multidisciplinary team is crucial to achieving these objectives. Counseling staff members typically are responsible for implementing major elements of the plan, and good communication and a structure for coordination improve patient cooperation with physician recommendations.
The most common psychiatric disorders found in women with substance abuse problems are anxiety disorders (especially posttraumatic stress disorder [PTSD]), mood disorders, eating disorders, and borderline personality disorder.
Anxiety Disorders
As a group, these disorders constitute the most common psychiatric disorders among women, with a total lifetime prevalence of 30.5% and a 12-month prevalence of 22.6% (4). The experience of anxiety is characterized by sensations of nervousness, tension, apprehension, and fear that arise from the anticipation of internal or external danger. These feelings constitute important survival signals (fight/ flight responses), so the task is to distinguish what is normal and appropriate from states that require intervention. Certainly, women in early recovery will experience heightened distress as they try to cope with situations in which they previously relied on alcohol and other drugs and also as they more clearly see the impact of their self-destructive behaviors. However, overwhelming anxiety is debilitating, interferes with new learning, and contributes to relapse. Psychosocial strategies are beneficial for the management of anxiety regardless of whether it is normal or excessive. The task for the woman and the treating clinician is to determine when the level is high enough to impair daily function and to justify medication. Fortunately, the first-line medications for anxiety and panic disorders are no longer the benzodiazepines, but the selective serotonin reuptake inhibitors (SSRIs), historically misunderstood as antidepressants only.
It can be easy to underestimate her level of distress when a woman’s description is viewed as “dramatic”; in earlier eras, women reporting the same symptoms as men often were labeled “hysterics.” Both depression and anxiety can occur in the context of a wide variety of other disorders, and it may be difficult to disentangle the interacting elements and identify the predominant disorders. When anxiety symptoms do not resolve with abstinence, a variety of psychosocial interventions can be used, selected to address the tasks specific to the woman’s stage of recovery. In early recovery, calming reassurance, reality-oriented support, exercise, meditation, breathing management, and other relaxation techniques can be helpful when added to group activities designed to encourage exchange of experiences and transmission of skills.
In the later stages of treatment, a variety of supportive, cognitive, and psychodynamic therapies can be used, but anxiety-arousing explorations should be avoided in early recovery. Insight-oriented therapy should be used in the context of a firm recovery support system (including regular self-help group attendance) by a therapist familiar with recovery issues. Familiarity with relapse hazards, warning signs, and prevention strategies are important. Severe or chronic anxiety can be a significant relapse hazard, so it is important to develop a medication stance that does not make a virtue out of excessive suffering. Some clinicians are too quick to assume the patient is just intolerant of unpleasant feelings and should learn to live with them. However, the patient must develop new ways of coping with everyday distress, and it is undesirable to seek to eliminate most of the unpleasant feeling states that are inevitable in recovery.
Benzodiazepines, commonly prescribed for anxiety disorders, are no longer first-line drugs for the treatment of anxiety; and they can be particularly problematic for those with a personal or family history of addiction. They are best avoided when possible or used in circumscribed situations (52). Nonreinforcing alternatives, such as sedating antidepressants or buspirone (BuSpar) for anxiety or trazodone (Desyrel) for insomnia, and SSRIs are recommended alternatives. Some anticonvulsants or the newer atypical neuroleptic medications can also be used. When reasonable alternatives have failed, benzodiazepines can be used with careful monitoring. This includes consideration of abstinence from substances, adherence to prescribed medication regimens, and participation in recovery efforts (52).
Of all the anxiety disorders, PTSD is arguably the most difficult and complex to manage. In the NCS, the estimated lifetime prevalence of PTSD was 7.8%, with a striking gender difference—a prevalence of 10.4% in women as compared with 5.0% in men (53). This finding is consistent with several studies by Breslau et al. (54–56). Wasserman et al. (57) concluded that the association between female gender and PTSD is robust across patient populations. Rape and sexual molestation were the most frequently reported “most upsetting event(s),” with childhood parental neglect and childhood physical abuse reported more frequently by women. Female victims were more than twice as likely as male victims to develop PTSD (20% compared with 8.2%). A lifetime history of at least one other disorder was present in 79% of women with PTSD, and more than a third of the women with PTSD failed to recover from their PTSD, even after many years and even if they received professional treatment.
Participants in addiction treatment have much higher rates of traumatic experiences and PTSD than the general population. Studies of both residential and outpatient treatment programs that serve both middle-class insured and indigent populations show high levels of childhood abuse and adult trauma (57–63). These findings require treatment providers to equip themselves to meet complex needs. As Brown et al. (64) demonstrated, such a high “level of burden” promotes early dropout, increases the difficulty of treatment in a variety of ways, and makes it more difficult to obtain a positive outcome.
Childhood traumatic experiences set the stage for later manifestation of a wide range of disorders and enhance the likelihood of dysfunctional coping responses in adulthood (65,66). Studies differ in terms of the types of trauma they consider and how they measure it, making it difficult to compare across studies. Russell and Wilsnack (67) discuss the methodologic problems in comparing the studies that started to emerge in the 1990s. They examined available studies using a conservative definition of CSA that and included both intrafamilial and extrafamilial sexual abuse, but excluded noncontact experiences, before the age of 18. By these criteria, in community samples, more than one-third of female children experienced sexual abuse by the age of 18 years. This included incest, defined as sexual abuse by a relative before the age of 18.
Newer studies and reviewers support these findings. In a population-based study of female twins, Kendler and his colleagues (6) found that 30.4% reported CSA of a variety of kinds (sexual invitation, sexual kissing, fondling, exposing, sexual touching) and 8.4% reported intercourse. They analyzed their data to examine the relationship of CSA and common psychiatric disorders and substance abuse, controlling for background familial factors. They concluded that women with CSA are at high risk for developing a wide range of psychopathology. In their NCS, Kessler et al. (53) came to similar conclusions regarding the relationship between sexual trauma, PTSD, and other psychiatric disorders in women. It is also worth noting that the (Adverse Childhood Experiences) study documented that persons exposed to one category of adverse experiences (abuse or family dysfunction) were likely to have been exposed to others and this was associated with greater health risk factors for leading causes of death in adults. These disease factors included heart disease, cancer, skeletal fractures, and liver disease (68). Thus, the impact of abuse goes far beyond psychological injury.
Women in substance abuse treatment show higher rates than the general population (69,70). Addictive disorder is only one of many sequelae. Others include low self-esteem, depression, suicidal thoughts and attempts, anxiety, difficulties in interpersonal relationships, sexual dysfunction, and a tendency toward revictimization (57). These girls are at nearly a fourfold increased risk of any psychiatric disorder and a threefold risk of addictive disorder (71).
It appears that among adult stressors, rape is the most consistently severe in its effect (54) and is associated with a range of psychiatric symptoms (72). Koss and Burkart (73) noted that almost half of the victims of rape seek some type of professional psychotherapy, often years after the assault. Women with histories of sexual assault in both childhood and adulthood reported significantly greater odds of lifetime suicide attempts, controlling for demographic factors and other psychosocial characteristics (74). Intimate partner violence is especially associated with suicidal ideation and other psychiatric symptoms (75).
Mood Disorders
In assessing for depression, it is important to rule out the direct effects of alcohol, illicit drugs, or medications, as well as general medical conditions, such as hypothyroidism. Providers should have protocols for assessing suicide risk and protective factors. These risks are often, but not exclusively, attendant to mood disorders. One may consider suicide out of shame or failure as well as depression.
Pregnant patients with mood disorders fared worse on drug use outcomes than those with an anxiety disorder or no cooccurring disorder (76), highlighting the importance of rapid identification and intervention during pregnancy. There is a substantial literature on known pregnancy risk profiles of common antidepressants (77,78).
For diagnostic purposes, negative mood states that are the direct effect of alcohol or illicit drugs generally clear within 2 to 3 weeks, with symptoms of longer duration suggesting an independent mood disorder (79). Distress or dysphoria or guilt, any of which is not the same as clinical depression, can persist for a long time. It is important to inquire carefully, because women in recovery often use the term “depressed” to describe brooding anxiety, misery, obsessive guilt, apprehension, and other forms of wretchedness that are not synonymous with clinical depression.
It also is important to remember that a sad or depressed mood is only one of many signs and symptoms of a clinically significant depression and may not be the most prominent feature. Other indications include disturbances in emotional, cognitive, behavioral, or somatic regulation. The mood disturbance itself can include apathy, anxiety, or irritability along with, or instead of, sadness. Not all clinically depressed patients feel sad, and many who feel sad are not clinically depressed. Clinicians need to have good skills for drawing patients out and helping them describe their feelings. Women in subcultures that place a high value on functioning can mask depressive symptoms. Those in leadership or caregiver roles can initially manifest depression in more disguised forms, especially if they have a high investment in performance or in continuing to function despite distress. Some depressed women do not describe a low mood, but their interest in or capacity for pleasure or enjoyment may be markedly reduced, making it difficult for them to experience rewards in recovery or to invest in new social relationships with others who do not drink or use drugs.
Eating Disorders
Despite the recognition that eating disorders are relatively common in substance-abusing women, careful assessment is not routine, and integrated treatment is rare. Eating disorders are more prevalent among substance-abusing women than in the general population, and substance-abusing women report more disordered eating behavior than women in the general population. Stimulants and over-the-counter (OTC) diet preparations are particularly appealing to women seeking to lose or control weight.
A review of the comorbidity of eating disorders and addictive disorder (80) indicated that bulimia is more common than anorexia. It appears that women with bulimia and alcohol dependence are more likely to have major depression, drug dependence, tobacco dependence, and obsessive compulsive disorder than women with either disorder alone (81). Krahn et al. (82,83) studied eating abnormalities and substance use (including alcoholism) and suggested that levels of symptoms below the threshold required to meet criteria for eating disorders are important for the clinician to address. They caution that dieting-related attitudes and behaviors in young women may be related to increased susceptibility to alcohol and other drug use.
Among alcohol- and drug-using women, there are many possible relationships between substance use and eating disorders. The eating disorder may present before the onset of alcohol and drug problems. Eating disorders can coexist with substance use in a variety of ways. Some patients report that opioids are appealing because they facilitate vomiting. Drinking alcohol can provide the feeling of release also gained from vomiting. Stimulants are attractive because they make women feel capable and energetic and suppress the appetite. Alcohol can be used to suppress the panic associated with bingeing and vomiting or to quash the shame that follows an episode. Eating disorders also can be part of a pattern of symptom substitution in abstinent substance users. For example, women concerned about weight gain once abstinent from stimulants may begin to vomit or purge to cope with their anxiety about body image.
It is important for providers serving women to develop proficiency in addressing eating disorders and obesity, especially given the demise of many specialized eating disorder programs. Because secrecy is a feature of both disorders, careful inquiry is important during the initial assessment, and observation by staff members is necessary throughout treatment. A woman in treatment may gain or lose 20 pounds without a disorder being assessed and addressed by her individual counselor or in her groups. Eating disorder specialists agree that treatment of these conditions requires specialized training. A thorough medical evaluation should assess possible problems and be part of a plan for nutritional stabilization, including strategies to stop aberrant eating behaviors, as well as medication planning and discharge planning that actively addresses both disorders (84). SSRIs have been shown to be beneficial in treating bulimia, but not restrictive anorexia.
Addiction specialists should avoid the temptation to apply a variant of the 12-step model as the sole treatment for eating disorders and should be selective about which elements are applied. Cognitive–behavioral approaches to eating disorders that are well supported by empirical evidence are designed to reduce dietary restraint (in contrast with promoting abstinence from particular foods), address abnormal attitudes about body weight and shape, and alter thinking about eating and personal control. Psychotherapy to address related personal issues is encouraged much earlier in the recovery process (85,86) than is the case with addictive disorders, and a strong therapeutic alliance increases the likelihood of remission (85).
Borderline Personality Disorder
When receiving a patient with a borderline diagnosis, it is important to review the diagnosis for accuracy. Unfortunately, misdiagnosis of borderline personality disorder is quite common, because of conflation of borderline characteristics with the demanding behaviors exhibited during active alcohol and drug use and early recovery. Although the DSM-IV (APA, 2000) introduced clear criteria for differential diagnosis, patients diagnosed before that time or from settings in which diagnostic rigor is not the norm may be improperly classified. It is often a residual term of art applied to the most difficult of behavioral presentations. Thus, it is advisable to reconsider the diagnosis. This reconsideration is especially important because borderline patients are viewed in many settings as unrewarding to treat. Clinicians treating addictive disorders are accustomed to seeing women present with behaviors consistent with borderline personality disorder, who settle down markedly and look far less pathologic with a year or so of sobriety and a good recovery program.
Enduring characteristics of borderline personality disorder include unstable mood and self-image; unstable, intense, interpersonal relationships; extremes of overidealization and devaluation; and marked shifts from baseline to impulsive outbursts, anxiety states, or other extreme moods. Prevalence of borderline personality disorder is estimated to be about 2% of the general population, 10% of those seen in outpatient mental health clinics, and 20% of psychiatric inpatients. Although it was previously reported that women constitute about 75% of those with the diagnosis (87), more recent studies indicate no differences by gender (88). An estimated 57.4% of persons with borderline personality disorder meet criteria for a substance use disorder, and a significant percentage are women (89).
Initial formulations and discussion of borderline personality disorder emerged from the psychoanalytic tradition and downplayed the possibility that abuse experiences were real, in favor of the view that fantasy distortion, strong impulses in a weak ego structure, maternal conflicts, and separation and loss experiences were decisive. The possibility that fearfulness, anger, and suspicion of the borderline patient might have its roots in real childhood trauma was minimized (90). Cultural denial of childhood abuse was pervasive until the attention to PTSD created a knowledge base that revised earlier notions about abuse as mere fantasy (91,92). Herman, van der Kolk, and others have explored the possibility that actual traumatic experiences play a key role in the etiology of borderline pathology. Subsequently, a literature has emerged that described a relationship between borderline pathology and childhood physical and sexual abuse. Although childhood trauma is not a necessary cause for borderline personality disorder, it can be a sufficient contributing factor (93–96). A history of CSA and a family history of substance use disorder are associated with longer time to clinical improvement of borderline personality disorder (97).
In summary, the prevalence of co-occurring disorders in women underlines the importance of offering psychiatric services, although funding may be more difficult to obtain except for those with severe mental illness. In addition to education about addiction, providers should include material on co-occurring mental disorders and how they can influence relapse and recovery. This education should have many of the same components as substance use topics: (a) nature of the disorders commonly found in women, their usual course, and prognosis; (b) important factors such as genetics, environmental stressors, and traumatic experiences; (c) misunderstandings about medication; (d) relapse warning signs; and (e) how to maximize recovery potential. Patients benefit from clarification of what constitutes effective teamwork with the physician (log of symptoms, notes about MD recommendations, when to call and when to wait, etc.)
Variations in cultural subgroups and sexual orientation also play an important role in treatment. Gender roles vary greatly, especially among immigrant groups, in which the degree of acculturation determines many of the constraints on the woman’s role. Use of alcohol and other drugs may be taboo for women, so recognition of their use, or seeking treatment for problems related to use, may be impossible. Those from patriarchal cultures can face strong taboos about disclosing family secrets, especially around interpersonal violence. Women can fear abandonment if they violate cultural norms. Those disclosing sexual violations can risk severe devaluation within, or expulsion from, their community, and they can lack the hope for improvement that could propel them past this barrier. Many fear institutions such as the police, social services, and mental health agencies might provide alternative resources (98,99). Culturally sensitive and specific education and prevention messages have begun to be developed for women in some subgroups, but much more work in this area remains to be done.
Lesbians are at particular risk because of the extensive use of alcohol and drugs as part of the culture (100). Socializing patterns built around bars and drug sharing increase the risk of addiction but do not necessarily lead to recognition of the attendant problems. These women generally are more dependent on lesbian friendship networks than on families or marital bonds, and their adaptive system of mutual reliance may be inappropriately pathologized as codependence. Historically, lesbian bars were seen as gathering places and safe arenas for self-expression, and, in many areas, they still are the only place where such behavior can occur. Even when problems are recognized, they can avoid treatment agencies if they fear discrimination or lack of understanding about their specific needs (101). However, recent data suggest that lesbian and bisexual women, with and without psychiatric disorders, are quite successful in accessing treatment (102).
In a review of 280 articles published between 1975 and 2005 and a recent review chapter, Greenfield et al. (15,103,104) examined substance abuse treatment entry, retention, and outcomes in women. Most studies report a higher ratio of men to women entering treatment, on average, three to one. Population studies report a smaller gender gap, but this may be in part because of women’s tendency to seek help in medical or mental health settings (105,106). Barriers vary, but include lack of pregnancy services, lack of child care, fears of loss of custody or of prosecution, and inadequate services for women with co-occurring disorders. With respect to treatment retention, Greenfield and colleagues conclude that larger studies suggest gender is not a significant predictor of outcomes overall, but specific treatment elements improve outcomes for various subgroups. For example, inclusion of children enhances engagement and retention for women seeking residential treatment or intensive day treatment. Some of these key issues are explored further below.
Management and Retention Issues
The epidemiologic finding that women have high rates of three or more disorders has consequences for treatment. New work on readiness to change shows promise for improving women’s treatment. Brown et al. (107) noted that candidates for addiction treatment can vary in their commitment to make changes in a variety of areas that will affect their prospects. They have developed a Steps of Change Model that covers four areas in which changes may be relevant: (a) domestic violence, (b) risky sexual behaviors, (c) addictive disorder behaviors, and (d) emotional problems. Their work supports the hypothesis that the most immediate or threatening problems will be what a woman focuses on first, and she selects her treatment modality accordingly. Women with addictive disorders who are in domestic violence situations are relatively resistant extricating themselves and also to addressing their alcohol and drug use. Once they make the decision to move, they are preoccupied with achieving greater safety and see their alcohol and other drug problems as secondary. By contrast, women with other mental health problems are more receptive to treatment for their addictive disorders. Treatment providers need to be willing to start by addressing those problems the woman is most ready to change while cultivating readiness in other areas identified by the clinician as important for long-term success.
The number and severity of problems experienced by women can be translated into a measure of level of burden. In studies of patients with a high burden, such women tend to be at greatest risk of early termination and poor outcomes even when they do remain in treatment for longer periods of time (64). Integrated treatment for multiple disorders thus is especially important in designing or selecting a treatment program to meet women’s needs. It generally is agreed by providers that women-only programs or activities are an important aspect of effective treatment. Current research on this question does not yield definitive findings, and many important questions remain to be carefully explored. An examination of the services offered in women-only programs compared with mixed-gender programs in southern California found that the most consistent difference was the provision of services specific to women’s needs, particularly those associated with pregnancy and parenting (108). These services included parenting classes, children’s activities, and pediatric, prenatal, and postpartum services. Women-only programs also were more likely to assist with housing, transportation, job training, and practical skills training. Thus, even though programs can present themselves as doing individualized treatment planning, women-only programs appear to be better equipped to meet women’s needs. These programs also were more likely to be funded through the Medicaid system instead of fees or private insurance, reflecting the lower socioeconomic status of their client population. Indeed, Greenfield et al. (15) report that women in general are more dependent on public insurance for treatment.
Retention in treatment and provision of specific services appear to be predictors of child reunification. A large-scale study of 1,115 mothers and their children documented that mothers treated in programs with a high level of family-related education or employment services were approximately twice as likely to be reunified with their children. A high-risk group of mothers with employment and psychiatric problems were less likely to be reunified with their children; however, completion of 90 or more days in treatment approximately doubled their rates of reunification (109).
Treatment Outcomes
A prospective longitudinal study examining service needs, utilization, and outcomes in women-only and mixed-gender programs found that those in women-only programs had greater problem severity but better outcomes in the areas of drug use and legal problems (110). This study had a large, ethnically diverse sample of women in community-based treatment in eight different programs in California. The 189 women in women-only programs tended to be in residential treatment, while the 871 women in mixed-gender programs were in outpatient treatment. Those in women-only programs had greater ASI severity scores in the areas of alcohol, drug, family, medical, and psychiatric domains.
In a Stage 1 Behavioral Development trial, Greenfield et al. (111) compared a manual-based 12-session Women’s Recovery Group and a mixed-gender Group Drug Counseling. Both groups reduced drug use while in treatment, but the Women’s Recovery Group demonstrated significant improvement in reducing alcohol and other drug use during the 6-month and posttreatment phase. Although both groups were satisfied with their treatment, women were significantly more satisfied with Women’s Recovery Group.
It appears that gender-specific treatment is also associated with higher rates of continuing care. In a quasiex-perimental retrospective study of women and children in residential treatment, those in specialized, women-only programs who completed the residential phase were more likely to continue appropriate care than those in mixed-gender programs (112).
Aside from the different needs and characteristics of male and female substance abusers, there is reason to think that women-only groups tend to foster greater interaction, emotional and behavioral expression, and more variability in style than mixed-gender groups. Women in mixed groups tend to engage in a more restricted type of behavior, whereas the behavior of the men shows a wider variability (113).
A recent study that recruited and followed 259 women continues the mixed picture about effectiveness of single-gender treatment. Those in women-only treatment reported significantly less substance abuse and criminal activity, but there were no differences in arrest or employment status at follow-up (114).
It is currently not known whether these differences are most influenced by the overall characteristics of the women-only treatment setting or by specific services provided by these programs. As McLellan et al. (115,116) have shown, the tightness of fit between the individual’s problem profile and the actual services received are more relevant than the specific treatment setting. It is also possible that women-only programs create a distinctive type of synergy that makes it difficult to disentangle the active ingredients.
Physical and Sexual Abuse and Domestic Violence
Although more than a third of women with PTSD fail to recover after many years, even with professional treatment, the average duration of symptoms was shorter among women in treatment (53), suggesting that existing treatments did confer some benefit. Co-occurring psychopathology typically is associated with less favorable addiction treatment outcomes. However, in a study by Gil-Rivas et al. (60), abused clients were more likely than their nonabused counterparts to participate in counseling and just as likely to complete treatment and remain drug-free during and up to 6 months after treatment.
Trauma-related difficulties can impair parenting in a variety of ways (66). Women with histories of childhood trauma can have attachment problems that impact their own parenting, particularly their ability to nurture. They often lack appropriate role models, leading to reliance on physical punishment, difficulties setting appropriate boundaries, and neglect. They may be unable to integrate protective discipline and affection. Women with sexual abuse histories may be deeply mistrustful of men but, at the same time, miss danger signs that their children are at risk. Obviously, current alcohol and other drug use will exacerbate these vulnerabilities. It is important to keep in mind that not all women with histories of abuse will abuse their children. Clinicians should be observant but avoid conveying a pessimistic attitude toward a woman’s prospects for being a good parent.
Currently, efforts are underway to modify service systems to meet the needs of clients with histories of abuse and violence. At minimum, these systems need to be trauma informed or knowledgeable about and sensitive to trauma-related issues present in survivors. Most importantly, these services will be delivered in a way that avoids retraumatization and encourages patient participation in treatment. Trauma-specific services include appropriate assessment methods and specific interventions to address trauma issues (117). Parenting classes offered to women should be trauma informed.
Seeking safety (118–120) is a well-accepted and widely disseminated trauma-specific treatment intervention for those with substance abuse and a trauma history. It is an early-stage intervention designed to stabilize the patient (create safety) with respect to both substance abuse and PTSD, integrated within a manualized but flexible treatment approach. It has been unusually well accepted by clinical staff and clients alike. Najavits has been developing a manual and other materials for the second stage, creating change, which focuses on processing trauma issues and forming a new identity (see www.seekingsafety.org).
It has been noted that children with battered mothers experience posttraumatic stress reactions themselves. These children often are subjected to ongoing marital conflict, family dysfunction, dislocations and relocations of home, lack of parental care, economic and social disadvantage, and interactions with the police and court. Preschool children are more vulnerable to the effects of domestic violence (121) than older children.
The extensive variety and complexity of children’s reactions to domestic violence argue for routine assessment and case management for these families. Partnerships between substance abuse treatment programs and organizations focused on children can be excellent ways of bringing specialized services to augment what can be provided in-house. Children can develop a variety of other problems in response to traumatic events, including thought suppression, sleep problems, exaggerated startle responses, developmental regressions, deliberate avoidances, panic, irritability, psychophysiologic disturbances, hypervigilance, and fear of recurrence. Children can engage in repetitive play in which the trauma is reenacted, cope by psychic numbing and withdrawal, show uncharacteristic behavior patterns, and/or become fearful of mundane things. Cognitive and emotional problems include a preoccupation with physical aggression, withdrawal and suicidal ideation, anxiety, depression, and social withdrawal. Behavioral problems include conduct problems, hyperactivity, diminished social competence, school problems, bullying, truancy, clinging behaviors, and speech disorders. Physical symptoms include bed-wetting, sleep disturbances, headaches, gastrointestinal problems, and failure to thrive (121). Women’s programs are encouraged to utilize public funding available to address the needs of at-risk children and integrate their services into adult treatment programs.
Treatment Culture
Women clients and treatment providers have noted that the male-dominated treatment culture characteristic of some programs (particularly many therapeutic communities and veterans’ programs) is not conducive to meeting women’s needs (122). They stress the importance of a more supportive and less confrontational approach to treatment. In addition to the gender imbalance in the client population, reliance on aggressive confrontation contributed to premature dropout and a treatment environment that can be experienced as disrespectful at best and frankly abusive at worst. An emphasis on harsh confrontation is particularly problematic for populations with a high frequency of traumatic experiences. Treatment methods that exacerbate a woman’s sense of powerlessness discourage her from revealing and exploring key issues. In addition, women with severe psychiatric disorders can decompensate and leave treatment if confrontation is too intense. Reducing the emphasis on confrontation and broadening the skill base of clinicians have proved a difficult task in some treatment modalities, particularly those that rely primarily on staff members without advanced professional training. Although these practitioners may have extensive training and many have acquired addiction credentials, the style of intervention they learned first can be difficult to change, particularly if it involves charismatic or dogmatic personal role models of recovery.
Both the National Institute on Drug Abuse (NIDA) and the Center for Substance Abuse Treatment (CSAT) have funded specialized research and treatment demonstration programs focused on women, and these programs have enhanced the development of provider groups committed to improving women’s treatment. Additional resources made available through CSAT’s Addiction Technology Transfer Centers (ATTCs) made it easier to broaden the skill base of frontline practitioners working with an indigent population. There appears to be less coordinated activity focused on women in treatment facilities that serve the insured population. Provider groups serving women also emphasize the importance of female leadership at all levels of the organization to serve as role models and to avoid perpetuating the view that major decision-making influence is reserved for men. Some programs hire only female staff members to facilitate the task of dealing with sensitive issues such as incest, rape, and battering. This eliminates the potential benefits of positive male interactions for the women and their children when included in the treatment. Male staff members in a residential program are in a difficult position and must have clear boundaries and a supervision structure that protects them and the patients from potential boundary violations. This situation also is an issue for female staff members, particularly in areas with a large lesbian population, since boundary violations among women usually are more taboo to reveal.
Women and the Criminal Justice System
Women constitute the fastest growing segment of the criminal justice population nationally and yet have the fewest appropriate social services available to them (123). Women today are more likely than men to serve time in prison for drug offenses (124). Between 1982 and 1991, the number of women arrested for drug offenses increased 89% (123). Since 1991, increasing numbers of women have been incarcerated for crimes committed in the service of drug use. Half the women reported committing their crimes while under the influence of drugs or alcohol, and about 40% reported using drugs daily before arrest. Fifty-three percent of the women in federal prison were unemployed at the time of arrest (124).
Typically, incarcerated women report that they started using drugs at an early age. These women commonly were confronted with obstacles such as absent parents, educational setbacks, parenthood, poverty, drug accessibility, and minimal social resources. Most came from communities in which crime was rampant. Additionally, most were victims of childhood sexual and/or physical abuse, as well as traumatic experiences as adults. Consequently, they had high rates of depressive and other psychiatric disorders (125). They often suffered from low self-esteem, depression, addiction, and shame and frequently attempted to self-medicate their struggle with illicit drugs.
Insufficient job skills as a result of poor education undermine self-esteem in incarcerated women. Low income or poverty results in desperation, thus making illegal activities more acceptable, especially in the service of drug use. Major child-rearing responsibilities with inadequate social support systems contribute to the development of psychiatric disorders in mothers and behavior problems in children (125). Thirty-four percent of the women in US prisons report being sexually abused, and another 34% report being physically abused (124). Women’s social status and gender roles affect sexual risk behaviors and the ability to take steps to reduce the risk of HIV infection (44,45), contributing to the high incidence of HIV in drug-using and incarcerated women. A subsequent study of 3,315 subjects found rates of 7.5% in incarcerated women, several times higher than found in community samples (126).
Intergenerational and familial transmission of drug use and associated criminality make the obstacles confronting these women more debilitating. National data on women in prison show that 40% of the women reported that an immediate family member also was in jail (124). In California, 59% of inmate women reported that family members were currently incarcerated (127). One-third of the inmates reported that a parent or guardian had abused drugs or alcohol. For these and other complex and interwoven factors, it is necessary to intervene decisively in prison prerelease programs to break the cycle of drug use and criminality and to include family members in the treatment experience whenever possible. Various states have invested in treatment in custody and postrelease, but many challenges remain to be surmounted (such as a trained workforce of adequate size), and the data currently support only modest benefits. However, a recent quasiexperimental study of 2,726 women indicated that they did better for psychiatric, trauma, and substance use outcomes with integrated treatment and mandated treatment (128).
Prison-based treatment is growing rapidly, and specialized programs for women are included in this development (129). California has been active in developing and studying gender-responsive treatment. A recent experimental pilot study compared 115 women randomized to a gender-responsive treatment using a manualized curriculum with a standard prison-based therapeutic community, collecting data upon program entry and 6 and 12 months after release. Both groups improved in psychological well-being, but GRT participants had greater reductions in drug use, had better retention in residential aftercare, and were less likely to be incarcerated within 12 months of parole (130).
Both research and clinical experience indicate that community-based services after treatment in prison significantly increase the percentage of offenders who remain drug-free 18 months after release. Thus, programs in large states such as California emphasize the importance of a seamless transition to services in the community and provide substantial funding to accomplish these goals. Although the implementation remains imperfect, segments of the criminal justice system are increasing their understanding of what it takes to achieve and maintain positive outcomes. Drug courts and diversion initiatives such as California’s Proposition 36 (treatment rather than incarceration) have also shown success in reducing recidivism, likely in proportion to their access to psychiatric and social services.
Although gender differences have been well studied in specific areas, there are many gaps in our understanding. Biomedical effects are far better understood for alcohol than for the illicit drugs. Research and treatment funding incentives over the past 20 years have provided a much better understanding of women’s treatment needs and preferences. Removing obvious treatment barriers, such as transportation and child care, increases women’s participation in treatment. Treatment for women must be comprehensive, including their spouses, partners, and children. Research is needed to determine how best to intervene with children to reduce the negative effects of their parents’ addictive disorders. Programs need to be capable of addressing co-occurring mood and anxiety disorders, particularly PTSD and eating disorders. When queried, women report that women-only groups and other activities and role models at all levels of decision making in the organization are important to them. Advocacy is still needed for research to clarify which gender-specific treatment components are most influential in improving outcomes.
With over a million active duty military returning to the United States, community treatment providers will inevitably meet them when they decide to seek help for their substance use problems. Often, this does not happen quickly. It can take a few months or years for veterans to decide that their alcohol and other drug use is actually a problem, and they may be moved along by clinicians treating them for depression, posttraumatic stress disorder (PTSD), or other conditions causing them distress. Although the Veterans Affairs (VA) Medical Centers can offer excellent comprehensive care in many communities, women in particular may refuse to seek help there because they have complex feelings about the sexual trauma they suffered in the military. When these women appear in community settings, or to private practitioners, it is essential that they are met by professionals with some understanding of their issues.
Despite the strong commitment of the Department of Defense (DOD) to address sexual assault, women continue to report devastating experiences of sexual assault and subsequent betrayal by their command when they seek accountability. Emerging data support the view that the problem is complex. These include barriers to reporting, failure to hold perpetrators accountable, and retaliation against victims. Currently the DOD is making comprehensive prevention and intervention efforts (1), but the legacy will remain for some time.
According to the VA, “Military sexual trauma (MST) is sexual harassment and/or sexual assault experienced by a military service member regardless of the geographic location, the gender of the victim, or the relationship to the perpetrator. Both men and women can experience MST, and the perpetrator can be of the same or of the opposite gender. Perpetrators may or may not be service members themselves. (Military Sexual Trauma Course – Department of Veterans Affairs, 2012.)” Estimates range from a quarter to a third, and even higher of active duty women experience such an assault in some form (2). The DOD reports that in 2012, there were 2,939 service member victims (both genders), a 6% increase since 2011 (3). Anonymous surveys suggest much higher rates. A Workplace and Gender Relations Survey of Active Duty Members in 2010 estimated that there were 19,300 victims of “unwanted sexual contact,” based on their anonymous survey (1), and by 2012, this estimate had risen to 26,000. Sadler et al. (6) (2003) report that 37% of women with a history of MST had been raped at least twice during their military service. Recent anonymous surveys of women deployed to Iraq or Afghanistan indicated that 49% experienced sexual harassment while in a war zone, mostly by other service members, almost half of higher rank (4).
BARRIERS TO REPORTING
Many of the barriers to reporting are common to other victims of sexual assault; some are more characteristic of military members. Women may minimize the seriousness of the experience, or be too embarrassed to report it. They may fear not being believed, of being blamed, or of having their reputation suffer. In the military, they may have a well-founded fear of harm or retribution if they report it, as there unfortunately are numerous examples often shared by military members among themselves and discussed in the media (5). They may fear for their career. They may also be concerned that their own behavior, such as alcohol and other drug use and fraternization offenses, may undermine their efforts to hold perpetrators accountable. For all these reasons, they may seek help in community settings once they leave active duty.
MILITARY CULTURE
Clinicians are beginning to acknowledge that the military has a distinctive culture as complex as others routinely discussed under the theme of cultural competence. It is important to make an effort to learn on your own and also let your patient teach you about what was important to her. What branch did she serve in, and what are the distinctive features of that branch? Did she serve in peace time or war time? What was her job? There are great differences between Vietnam-era veterans and those who served in Afghanistan (OEF) and Iraq (OIF). Because of the nature of the wars in Afghanistan and Iraq, it is safe to assume that all veterans who served there are combat veterans, even if that is not in their official job description.
Cultural values in the military include a strong emphasis on honor, respect, and obeying the chain of command. These can be positive forces in treatment. Community programs working with homeless veterans have noted a heartening level of follow-through once treatment plans have been agreed upon. The value placed on “leave no one behind” can be a positive factor in recognizing the value of cohesion in treatment groups and working to promote it. However, military values can also be impediments to seek and utilize help. The value placed on protecting yourself may add to the shame women feel about the sexual assault, and make it more difficult for them to report it. They may feel like they “should have been able to fight him off.” Respect for authority turns to a profound sense of betrayal when officers higher up actively discourage reports, avoid investigating, and fail to impose serious consequences on perpetrators.
CLINICAL ISSUES
It is important to screen for MST when patients seek care for physical or psychiatric conditions. This requires creating a comfortable climate for disclosure, unhurried, with adequate privacy. Interruptions should be minimized as much as possible. In general, patients are willing to answer specific questions if the clinician is perceived as nonjudgmental and potentially helpful. Questions can be asked as part of the social history, explaining to the patient that these experiences are sufficiently common in the military and that the questions are routine. The two questions recommended by VA protocols (2) are
■ Did you receive uninvited and unwanted sexual attention, such as touching or cornering, pressure for sexual favors, or verbal remarks?
■ Did someone ever use force or the threat of force to have sexual contact with you against your will?
It is important to manage and limit the initial disclosure process, to assess current status and safety, and to be prepared to offer mental health services or make an appropriate referral.
One of the most prominent issues these women will present is substance use and PTSD. There are high rates of childhood trauma among veterans in general, particularly those who experience MST (6) (MST slides from Nancy. Merrill et al, 2001, Rosen and Martin, 2006). Multiple traumatic experiences in childhood and adulthood exacerbate the PTSD and often increase the severity of the substance use. In the military, as in other situations, the need to keep seeing and working with the perpetrator adds to the difficulty. Often, the risk is ongoing.
Treatment with these patients is often tempestuous. They are often highly anxious and irritable and may be prone to angry outbursts. It can be difficult to establish a therapeutic alliance, particularly if the therapist is male. Working with a treatment team is helpful, as multiple treatment contacts with different individuals may be necessary for engagement, and these patients may need a higher level of care than a solo practitioner in the community can provide. These women are highly crisis prone, and a treatment team can help sort out their many complexities and arrive at a viable plan. A treatment team can also help the clinician avoid becoming too self-critical and discouraged, while utilizing a forum for self-examination.
Given the potential for severe PTSD symptoms and the high suicide rates of military members, clinicians must address the issue of guns. It is appropriate to assume that she has at least one weapon in her home, and that this weapon is an important part of her identity. Ask specific questions about how she stores the weapon and the bullets. If lethality is an issue, attempt to negotiate storing ammunition with a friend or getting a trigger lock. The VA supplies trigger locks at no charge, and weapons may be turned into the VA police. Put comparable arrangements in place for patients to surrender their weapon if they express willingness to do so.
Women with MST present with a variety of medical problems. They may report chronic pain, such as headaches and back or pelvic pain. They can have a variety of gynecologic problems: sexual dysfunctions, menstrual abnormalities, menopausal symptoms, or reproductive symptoms. Gastrointestinal symptoms include diarrhea, indigestion, nausea, and difficulty swallowing. Other complaints can include chronic fatigue, sudden weight changes, and heart palpitations. These may be the vehicle through which the woman asks for help, as a nurse or primary care physician may be less threatening.
Conducting a physical examination or doing medical procedures can also present challenges. It is important to make the medical encounter as safe as possible by providing a private, calm setting and explaining what to expect. If the patient becomes upset, or begins to dissociate, it is important to stop touching the patient or discontinue the procedure, and then reorient and soothe the patient. A well-established pathway for mental health referrals and a “warm handoff” is part of good care, as these patients may be reluctant to seek this kind of help and give up easily if the referral is not guided at each point that obstacles might occur.
GETTING HELP AT THE VA
Although many women will emphatically refuse to go to the VA, it is important for them to know what it has to offer, particularly if other resources in the community are scarce. A pioneer in the use of electronic records in the 1980s, the VA has used them to identify the factors involved in good outcomes and then formulate and disseminate protocols to improve care across the system. The result is that VA care produces better outcomes for chronic conditions such as diabetes and hypertension than Medicaid and the private sector (7,8). All veterans seen in VA health care are asked if they experienced MST. All treatment for physical or mental health conditions related to MST is free. Every VA health care facility has a designated MST coordinator who serves as the contact person for MST-related issues. Many veterans are confused about their eligibility for benefits and should be encouraged to get into the system (Table 35-1), in case they lose their current insurance or later need care they cannot access in the community.
TABLE 35-1 HOW TO APPLY FOR VA BENEFITS
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