Gender-Responsive Considerations for Substance-Using Adolescent Girls

by Sneha Thamotharan, MA, and Selby Conrad, PhD

Gender-responsive considerations for substance-using girls CABLThe abuse of tobacco, alcohol and illicit substances continues to be a leading cause of death and disability among youth and places a significant strain on our nation, with costs related to crime, lost work productivity and health care exceeding more than $700 billion annually. Substance use is a growing health concern among adolescent girls, who are beginning to surpass boys in their use. For instance, early-adolescent girls drink alcohol and use inhalants and stimulants more than boys. Additionally, girls have different pathways to substance use than boys, including the perception of potential benefits such as “self-medicating” to deal with problems, to forget past traumatic experiences and to relieve stress related to interpersonal relationships. 

CABL logoThis article was published in the Brown University Child and Adolescent Behavior Letter in cooperation with Bradley Hospital.

Approximately 6.6% of girls and women ages 12 and older report illicit drug use in the past month. While girls are equally as likely to develop substance use disorders, research suggests that they develop substance use disorders in less time, are more likely to become dependent, have increased vulnerability to relapse, and have more complications from use than boys. Such gender-specific complications include reproductive consequences; osteoporosis; greater susceptibility to alcohol- induced brain damage, lung damage and STIs; and higher rates of drug-related suicide. In addition, earlier patterns of substance engagement has been shown to be predictive of more severe substance use during adulthood. These findings highlight the need for focused intervention efforts that are thoughtful about the unique differences and experiences of substance-using adolescent girls. Multiple etiologic studies have focused on how biological, psychosocial and behavioral factors related to the presentation, comorbidity and treatment of substance use disorders differ by gender. Girl substance users are more likely to report psychiatric distress, including anxiety, depression, poor self-concept and eating disorders, as well as a past history of trauma and victimization — many of which are exacerbated by puberty. This population is also more vulnerable to the effects of low parental attachment, poor parental monitoring, and chaotic home environments than boys. Further, girls’ initiation and pattern of use are significantly related to their interpersonal relationships — significant others, family members, and close friends. For example, girls are often introduced to substances by romantic partners and relatives and are more likely to use when their close friends are users. This is especially important because girls often struggle with severing relationships with peers who use and fostering recovery-oriented relationships.

Moreover, there are often many obstacles and challenges to seeking treatment, such as stigma related to treatment engagement and fear of being taken away from their parents or losing their children. Treatment options frequently are not comprehensive and do not extend beyond standard care to address the specific needs of girls, pregnant teens, and young mothers. It is difficult for girls seeking treatment to find coordinated care and case management that address medical and mental health concerns, health promotion, life skills, child care assistance, sexual trauma, and victimization. The majority of substance use treatment programs for youth have been designed for boys. Consequently, girls are less likely to enter substance abuse treatment than boys; and when they do enter treatment, many programs are mixed-gender, even though it has been shown that girls benefit more from same-sex groups.

Support, Not Confrontation

As a result, in recent years, more attention has been given to developing effective gender-responsive treatment programs that deliver information and services tailored to girls. Services should include outreach that can connect substance-using girls to treatment regardless of their point of entry (e.g., dating violence program, STI treatment, or homeless shelter). Using other health care facilities and the community can promote awareness, identify substance-using girls, and increase referrals.

Gender-responsive treatment programs emphasize safe and therapeutic environments of care using supportive, collaborative, and empowering approaches that build upon strengths rather than traditional confrontational approaches used for the treatment of male substance users. These confrontational approaches can be particularly troublesome in cases of youth with past trauma and victimization. The treatment focuses on encompassing a nonjudgmental, optimistic spirit, while demonstrating an interest in learning about the girls, their treatment needs, and what they feel may be the best intervention for them. The goal is to enhance the competency and self-efficacy of girl substance users. These programs also incorporate mental health, interpersonal relationships, family therapy, sexuality, and co-occurring disorders as means to improve engagement. Addressing trauma and victimization is especially important since most substance-using girls are survivors. This is reflected in a shift away from sequential treatment — substance use treatment then trauma — toward concurrent services or trauma-informed substance use treatment. 

Substance-using girls have unique client-therapist expectations and relational needs as well. The importance of the therapeutic alliance is not unique to girls. However, girls frequently emphasize the need for trust and warmth, whereas boys emphasize the need for problem-solving skills. Thus, it is important for treatment providers to be non-authoritarian, confident in the girls’ ability, and have unconditional acceptance. This relationship is also integral during continuation of care and relapse prevention. Girls are more likely to relapse during this transition to continuing care, because they report feeling disconnected with new providers. Some discussion has also ensued on whether the gender of providers impacts treatment for girls. Girls do indicate having a preference for women providers, and having a female counselor may allow for positive modeling of empowerment, strength, and success. Unfortunately, prior research is almost nonexistent on the impact of gender differences within the client-counselor relationship.

Treatment Retention

Other services and engagement/retention strategies include phone call reminders, transportation, family planning, parent training, vocational training, accessing social services, fostering assertiveness skills, psychoeducation, nutrition and developing healthy relationships. The duration of these services should not be limited, because girls greatly benefit from longer durations in treatment, more so than boys. This is especially true for girls involved in the juvenile justice system. 

With regard to retention, there are a number of barriers that are not just specific to girls — low parental support, younger age, and not yet completing high school. Fortunately, gender-specific programs may offset these issues, as they have higher retention and completion rates, higher satisfaction, and greater reduction in substance use. Secondary outcomes to gender-specific programs include better psychological well-being, changes in attitudes and beliefs, and HIV risk reduction. And girls are more likely than boys to have positive treatment outcomes such as lower incarceration rates and higher rates of later employment. 

Gender-responsive substance use treatment holds promise as a way to address the unique needs of substance-using girls. The literature related to adult women suggests that gender-responsive programming holds promise. Currently, there is little published information about the efficacy of these programs, as intervention research in this area is scant. While a great deal of work is needed to improve the understanding of gender-responsive treatments and how they may advocate for the needs of adolescent girl substance users, evidence suggests that providers need to be sensitive to the role of gender when providing substance use treatment to adolescent girls.

Sneha Thamotharan, MA, is a clinical psychology resident at The Warren Alpert Medical School of Brown University. 

Selby Conrad, PhD, is a staff psychologist with the Rhode Island Hospital department of child and adolescent psychiatry and Bradley/Hasbro Children’s Research Center, and a clinical assistant professor at The Warren Alpert Medical School of Brown University. She earned her graduate degree in counseling psychology at the University of Kansas and completed her pre-doctoral internship at the Boston Consortium in Clinical Psychology.

References

CBS News. More teen girls trying drugs than boys; 2006.

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National Institute on Drug Abuse. Substance use in women: Other sex and gender issues for women related to substance use; 2015. 

National Institute on Drug Abuse. Trends & statistics: Brief description; 2015. 

Office of National Drug Control Policy. Women, girls, families and substance abuse; n.d. 

Partnership for Drug-Free Kids. National study: New data show teen girls more likely to see benefits in drug and alcohol use; 2010. 

Schinke SP, Fa L, Cole KCA. Substance use among early adolescent girls: Risk and protective factors. J Adolescent Health 2007; 43(2):191–194.

Substance Abuse and Mental Health Services Administration. Substance abuse treatment: Addressing the specific needs of women: A treatment improvement protocol, TIP 51; 2014. Rockville, MD: Author.

The Brown University Child and Adolescent Behavior Letter, written by a team of researchers, clinicians and medical writers from Bradley Hospital and Brown University, features the latest research findings on behavioral issues among troubled children and adolescents.