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A growing literature suggests that women continue to be the "second sex" in substance abuse treatment theory development, diagnostics, access to treatment, and delivery of substance abuse services. Studies show that men are nearly 10 times as likely to enter treatment than women, have longer lengths of stay, and have greater rates of treatment completion. Research suggests that at least some of the gender differences in treatment outcomes are due to differences in family roles that can hinder a woman's ability to access, enter, and complete drug abuse treatment.
Ingersoll, Lu, and Haller studied 64 predominantly polysubstance abusing (86%) perinatal women admitted for the first time to intensive outpatient treatment. They found that having fewer children increased the probability of women staying in treatment longer even among those who relapsed during treatment. Although the female-specific treatment program they studied included medical care and ancillary services for women and their dependent children, having more children tended to undermine treatment completion for women substance abusers. In a five-year review of outcomes for postpartum female substance abusers in mixed-sex treatment programs in which women-only support groups were available, Strantz and Welch also found that the fewer children a woman has, the longer she is likely to stay in voluntary day treatment. However, the number of children was negatively associated with length of stay for women in both court-mandated or voluntary outpatient treatment. Problems associated with child care were greatest for women with three or more dependent children. Women who retained custody of their infants stayed longer in the intensive day treatment program, particularly if they had fewer other dependent children.
A study of 172 outpatients (40% women) in alcoholism treatment found that contradictory factors predicted failure to complete treatment. While having no dependents discouraged women from initiating or completing outpatient treatment, the same women were more likely to complete inpatient treatment. An Australian study found that the fewer dependents a woman had, the more likely she was to return to heavy drinking, but no similar relationship between number of dependents and treatment outcomes was observed among men.
In addition to having children, being pregnant can make it more difficult for women to get and complete substance abuse treatment because many facilities do not have the means to support pregnant women in their care. For example, a study of 163 pregnant and postpartum women found that those who were younger and who referred themselves to treatment were more likely to fail to complete treatment even though these women sought treatment initially. Many have suggested that women-only treatment programs are the best way to address the special needs of women, particularly those who are pregnant, postpartum, or who have a history of being sexually abused. There is some evidence that women-only treatment programs can be more effective. One study found that women in women-only treatment were more than twice as likely to complete treatment than women in mixed-gender programs. The women in the women-only programs were more likely to be younger, pregnant, and homeless. The researchers concluded that if the treatment environment is more focused on the special needs of women substance abusers, women who otherwise are at a greater risk of dropping out can complete treatment at higher rates.
Asking for help for substance abuse can put women in jeopardy of losing custody of their children. For many states, habitual or addictive use of alcohol or drugs is evidence of child abuse and neglect. Although there have been changes in some state policies regarding separation of families when parents enter treatment, the presumption of abuse and neglect triggers assessment and frequent placement of dependent children with other family members or in foster care settings, particularly for single mothers who abuse alcohol or drugs.
The law's tragic effect is that children of substance abusers are subject to permanent removal from their families as a result of their parents' efforts to recover from addiction. Instead of strengthening and keeping families together, the law serves to tear families apart. (p. 339)
Because substance abuse is more likely to be detected among participants in social service programs for economic aid and child care, many of the children who are placed in foster care come from disadvantaged households headed by single, unemployed mothers. These women have limited social and economic resources to help them recover and care for their children. A few states have revised their definitions so that addicted parents who voluntarily participate in a program of recovery are not automatically presumed guilty of child abuse or neglect unless there is additional evidence to support abuse or neglect charges. Here, the decision by child protective service agencies to leave children with their parents often is determined by whether there is a supportive home environment available to foster the substance abuser's attendance in treatment. If not, alternate caregivers must be found for the children, either with members of the client's family or with a foster family until treatment is completed.
Messer, Clark, and Martin found that African American women were more likely to enter treatment than were women of other races but also were more likely to not show up for treatment after intake and to not complete once they initiated treatment. This suggests that, once they enter treatment, African American women's needs may not be adequately addressed. Because African American women are more likely to have their families at a younger age, they may be entering the treatment system with more dependent children. Studies have found that as the number of children increases so does the likelihood that a woman will not complete treatment. Other studies suggest that it is the type of treatment setting that may be determining treatment retention. African American women report a preference for residential treatment, whereas White and Hispanic women prefer outpatient care.
A further confound to our understanding of the relationship between ethnicity and treatment outcomes is differences in drug of choice. African American women are more likely to report cocaine as their drug of choice than are women of other ethnic groups. Numerous studies have found that cocaine addicts, a predominantly African American subgroup of the treatment population, are less likely to complete treatment than are alcohol abusers, who are usually Caucasian.