Sex, gender and substance use has a relationship that is complex and multifaceted, requiring a lens of compassion and understanding. In previous years, male experiences were the main focus for all areas of research. This is problematic, as the sex and gender gap in substance use disorders (SUDs) is narrowing, with women displaying increased instances of opioid use and high-risk drinking over the past decade (Harris et al., 2022). More researchers are advocating to recognize that SUDs affect people of all sexes and genders differently. With an in-depth analysis, an enhanced perspective can allow for better support of individuals seeking help while actively working to reduce harmful stigma.
It is now relevant to appreciate the difference between sex and gender: sex is the biological traits assigned to an individual at birth, whereas gender is a social construct. Sex can influence biological interactions and tendencies with substances, whereas gender can be associated with certain stigmas and social expectations that can affect patterns of substance use. SUDs reveal significant sex and gender differences. For this blog, the female and male sexes, and masculine and feminine genders will be discussed, while recognizing that sex and gender are diverse, and do not always follow this binary.
Numerous biological differences exist between males and females regarding the effects of substances, and these differences reflect sexual dimorphisms in the brain, endocrine, and metabolic systems (McHugh et al., 2018). Among the most consistent findings in this area is that females and males metabolize alcohol differently. Females exhibit lower levels of alcohol dehydrogenase (the enzyme that metabolizes ethanol) activity in the gastric mucosa relative to males (McHugh et al., 2018). Combined with lower total body water relative to males, this results in higher blood alcohol concentrations in women, even after consumption of equivalent quantities of alcohol. This metabolic difference induces a higher degree of intoxication for females compared to males when the same amount of alcohol is consumed (McHugh et al., 2018). Additionally, females metabolize nicotine more rapidly than males and exhibit higher peak plasma levels of cocaine, which may be modulated by ovarian hormones (McHugh et al., 2018). The pharmacokinetics of substances cannot be assumed to be consistent for the sexes based on these biological factors.
Sex differences in the acute subjective effects of substances have yielded equivocal results. As an example, lower doses of THC and d-amphetamine have demonstrated greater tendencies toward the drug effect among females, whereas males appear to be more sensitive to the rewarding and reinforcing properties of these substances at higher doses (McHugh et al., 2018). Subjective drug effects may be further influenced by variation in ovarian hormones, which are often overlooked and thus may present a source of variability among females that obscures true sex differences. Research regarding the menstrual cycle phase found that the follicular phase is associated with greater reports of drug liking and pleasant subjective effects relative to the luteal phase, and articles evaluating the exogenous administration of ovarian hormones have observed progesterone administration associated with acute decreases in substance cravings (McHugh et al., 2018). Among postpartum women, progesterone treatment has been associated with less cocaine relapse (McHugh et al., 2018). Neuroimaging research has identified sex differences in brain volume and function in response to various substances. Both females and males with cocaine use disorder exhibited lower gray matter volume relative to controls, but the regions exhibiting these volumetric differences varied. Females may be more susceptible to the negative effects of chronic cocaine and alcohol use on brain volume, and neural response to substance-related cues has found that women demonstrate greater neural activation to cocaine cues relative to males (McHugh et al., 2018). Striatal dopamine release, which is involved in the reward system pathway of the brain, is higher in males relative to females in response to stimulants, alcohol, and nicotine (McHugh et al., 2018).
The SUD prevalence between men and women is narrowing at a global level, and this may be the result of culture and policies influencing the access to and acceptability of using substances. Lower gender role traditionality is associated with a smaller men-to-women gap in SUDs. Men are generally more likely to have access to substances in comparison to women, which has been a main cause of the gender disparity (McHugh et al., 2018). This is seen, as when controlling for access, the likelihood of substance use often does not differ between men and women. Illicit drug use is significantly more prevalent among men than women overall, but adolescents of both genders report similar rates of past-month illicit substance use, driven by higher prescription drug use among adolescent girls (McHugh et al., 2018). In the adult demographic, prescription drugs are among the only substance class for which past-month prevalence of use is similar across genders. The peak risk period for onset of substance use is late adolescence, with women using substances at a later age than men. People who identify as women have a faster onset of SUDs from the initiation of a substance compared to people who identify as men (McHugh et al., 2018).
Women in SUD treatment consistently report a higher degree of impairment in areas such as employment, social/family, medical, and psychiatric functioning, whereas males face more legal problems (Harris et al., 2022). SUDs are associated with significant mortality for both genders. While overdose deaths are more common among men, overdose fatalities are rising more rapidly in women, especially when considering prescription opioid overdoses. Comorbidities also appear to differ between genders, with higher rates of anxiety and depressive disorders in people identifying as women, and higher rates of externalizing disorders in people identifying as men (McHugh et al., 2018).
By understanding these sex and gender differences while maintaining a commitment to reducing stigma, we can create more effective, accessible, and compassionate support systems for all individuals experiencing challenges with substance use. This understanding allows us to better serve everyone seeking help while working toward a society where seeking support for SUDs carries no more shame than seeking help for any other medical condition. With Stigma Ends at CU, we try to minimize stigma and create a safe support system for those of all sexes and genders.
Author: Laura Cross
References:
McHugh, R. K., Votaw, V. R., Sugarman, D. E., & Greenfield, S. F. (2018). Sex and gender differences in substance use disorders. Clinical psychology review, 66, 12–23. https://doi.org/10.1016/j.cpr.2017.10.012
Harris, M. T., Laks, J., Stahl, N., Bagley, S. M., Saia, K., & Wechsberg, W. M. (2022, January). Gender Dynamics in Substance Use and Treatment. Medical Clinics of North America, 106(1), 219–234. https://doi.org/10.1016/j.mcna.2021.08.007
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