There are important distortions in the article "Substance Abuse in Women: Does Gender Matter?" (Psychiatric Times, January 2007, page 48). My concerns regard the political assumptions made (rather than those based on science) that put a spin on data rather than letting the data stand alone.
The article stated, "While much past research in addiction focused on men, there is now recognition that biological and psychosocial differences between men and women influence the prevalence, presentation, comorbidity, and treatment of substance use disorders."
This is simply not true. During my career and study—well over 50 years—biological and social differences between the sexes have been considered. When I studied basic psychology in 1950, differences between sexes were considered important and were always highlighted.
In the past, research on addiction has been conducted using both sexes; if there was any numerical emphasis on men it was because addiction habits of men were more visible than those of women and data were easier to obtain because of links to the criminal justice and Veterans Affairs systems. There was no attempt to exclude women, and case-finding efforts in women were extensive and growing.
In fact, I occupied one of the first funded outpatient psychiatric positions serving adults in Massachusetts in 1962, but this was many years after the state was riddled with maternal and child guidance centers in which substance abuse counseling was freely available to women and not men. We were all taught in medical school that substance use disorders in women presented far differently from those in men and how to look for these differences. Even cinema from the 1930s through the 1950s showed these differences fully in empathic and informed ways.
It is not surprising that there has been "a tremendous increase in attention to gender differences in the literature during the past 15 years" because there is great pressure to do so and it is thought to be politically correct. This resulted more from considerable political pressure than from the dictates of science or the motivation of individual interest.
Since society will never pay for research in all areas of unknowns at the same time (such a society would soon be broke), there is a selection process as to which areas seem most important, and scientists must place emphasis there. While we know more about substance abuse as it applies to women (and even here certain key areas are left unstudied, such as why so many women abuse substances while pregnant despite the horrific consequences), we know less than we might about its role in children and adolescents; less about its role in racial and ethnic minorities (which is tearing these communities apart); less about its relationship to crime; less about its genetics and relationships to inborn temperament; less about its role in bipolar disorder and attention-deficit/ hyperactivity disorder (ADHD); and much less about its role in poor, homeless, and uneducated persons, for whom there is absolutely no funding available for in-depth study.
Emphasis on which areas need to be studied and funded and to what extent should come from reasonable discussion and inquiry based on societal needs and the extents of community suffering and not on superimposed notions of rightness coming from small but very vocal parts of our society.
When discussing comorbidities, no mention was made of the terrible toll of ADHD—far more common in men—and its role in the development of a substance use disorder. Instead, antisocial personality disorder (itself subject to immense bias in definition) is noted as a precursor to substance use disorders and as a comorbid condition in men. The relationship between substance abuse and trauma in men, as well as war and combat—an ever-growing crisis in our country—is ignored. The article mentions "victimization" in relation to women only, despite a number of studies linking early abuse and neglect to the development of subsequent depressive, anxiety, and substance use disorders in men.
Arnold Robbins MD, FAPA
Boston
The authors respond:
We appreciate the response and opinions of Dr Robbins. Certainly, we did not mean to imply that there has been no attention given in the past to gender differences in substance use disorders, only that attention to this issue has increased over time.
Likewise, we did not mean to imply that women were deliberately excluded from research in the past. We regret that some information (eg, the co-occurrence of ADHD and substance use, victimization among men) was omitted, but given the brief scope of our article, we were simply unable to address exhaustively all issues related to gender and substance abuse, important as they may be.
We agree with Dr Robbins that there are a number of understudied areas related to substance abuse that deserve to be given greater attention in future investigations.
Sudie E. Back, PhD, Regana Contini, MD, and Kathleen T. Brady, MD, PhD
Charleston, SC
Dr Back is assistant professor, Dr Contini is a postdoctoral fellow, and Dr Brady is professor and director, division of clinical neuroscience, Medical University of South Carolina, Charleston.
