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Human beings, since time immemorial, have a natural urge to ‘feel different’ periodically. It has been called the ‘fourth drive’ after food, sex and sleep. Children discover the experience quite early when they playfully spin round and round at an increasing speed, till they feel a head rush. Adults do it by taking mind-altering substances or indulging in certain behaviours which give them a high.
This drive is biological and occurs equally in both sexes. Periodic use of a drug or a behaviour to alter the wake state of consciousness is normal, natural and instinctual. Only in a small number of us, because of genetic factors or a history of trauma during childhood, this use, after some time becomes compulsive and takes precedence over our work, health, family and social relationships, wrecking normal life as we know it. That is when it is called addiction which is a disease very much like hypertension or diabetes.
Not just a male problem...
Historically, drug addiction has been considered a predominantly male problem. The reason is an actual difference in the use of intoxicants between the two sexes because of different role expectations from women. Traditional patriarchal societies make much of male camaraderie and allow men to have their well-deserved fun after a day’s hard work, but expect women to stay stone sober thus stigmatising drinking and drug use for women. Peer pressure and wanting to be part of a group also work more in the case of men.
Venturing out to procure drugs, many of which are illegal, is more of a constraint for women than men. Pregnancy and having to bring up small children are deterrents too.
In India, according to the report of a countrywide 2019 drug use survey, ‘substance use exists in all the population groups, but adult men bear the brunt of substance use disorders’. Thus, while 27.3% of Indian men use alcohol, just 1.6% of Indian women do, which means in India, for every woman who drinks 17 men drink. For cannabis, the percentage of users in India is 5.0% of men and 0.6% of all women. For opioid drugs like heroin and opium, the figures are 4% and 0.2 % for men and women.
When it comes to tobacco, just 1.7% of women smoke tobacco while 15.2% of men do. However, because of stigma and workplace restrictions, far more women, 11.1% in India, chew tobacco. In the context of the treatment of tobacco addiction, nicotine replacement therapy, which is commonly used as gums and lozenges, works less effectively for women than for men.
The gap is narrowing
However, because of changing social roles of women and better acceptance of mixed social groups, this gender difference in both casual usage and addiction has been narrowing world over in recent decades. While alcohol, cannabis and smoking are still a lot more frequent among men, the gender difference in stimulants and prescription opiates dependence has lessened in Western countries. While women still use drugs less frequently, because of physiological reasons they are more likely than men to develop an addiction. Women metabolise alcohol slower than men and for this reason, get more intoxicated with the same amount of alcohol. There is also evidence that ovarian hormones, oestrogen and progesterone, cross the blood-brain barrier and affect brain centres involved in addiction. In some studies, women were found to drink more during the premenstrual phase and women with premenstrual disorder drank even more than those who did not have PMS.
While most of us who drink or take an occasional whiff of cannabis sail through life without any complication, in a small minority, this use escalates quickly from casual use to regular use to addiction. This escalation is called ‘telescoping’ and telescoping occurs quicker in women than in men.
When women take to it...
While a higher number of men initiate drug use to induce euphoria, women use drugs more commonly to relieve pre-existing mental health issues like stress, depression or anxiety. This tendency among female users hoping to feel less depressed or anxious through the use of alcohol or drugs leads to a habit which is more difficult to quit because of the underlying low-grade anxiety or depression still remaining untreated.
The likelihood of addiction in women is multiplied by many times when a woman has a spouse who is an active drug user, engages in domestic abuse, or is engaged in drug trafficking.
While drug addiction has been known for centuries, behavioural addictions with exactly the same underlying mechanism and similar disastrous results have been recognised recently. Here, there are no drugs in sight. You do not need to go out to procure anything and most of these behaviours are legal.
Unlike drug addiction, behavioural addictions occur equally in men and women although the exact behaviours to which the two sexes get addicted differ. Women outnumber men in food addiction, compulsive sexual behaviour, compulsive shopping and compulsive plastic surgery. Yes, the last is a ‘thing’. Men outnumber women in gambling and gaming addictions and addictions to extreme sports like bungee jumping, mountain biking and cliff camping.
Drugs are not a sine-qua-non for addiction
To understand addiction well, one must look at the seemingly radical but already well-proven fact that drugs are not a sine-qua-non for addiction; that addiction can occur without drugs. Out of the two words Drug and Addiction, crucial is the word addiction, not the drug. And that drug addiction is just one form of addiction.
As far as treatment of behavioural addictions is concerned, most people who have these, do not even think these are illnesses which can be treated, even while WHO has included gambling and gaming addictions in its International Classification of Diseases and efforts are on to include food, sex and internet addiction. Television commercials of gaming ads already carry health warnings much like those of tobacco and alcohol.
The gender difference in drug addiction becomes even starker when it comes to seeking treatment for drug addiction.
Most psychiatrists will be able to count on their fingers the number of female patients they treated for addiction in the previous two years. The reason for this scarcity of women in treatment in addition to the low numbers is the stigma of being under treatment for addiction.
This stigma is there for both sexes but is much worse for women. Rather than being seen in a queue of men waiting for their replacement therapy which is mostly what the public health system has to offer, a woman suffering from addiction stays away.
In recent years there have been some attempts at starting exclusive treatment facilities for women with substance use problems. However, according to The Tribune, in two years the Punjab government’s only exclusive women’s rehab facility in Punjab registered 70 clients while 10,000 male drug users were registered at the adjoining district government facility.
(Anirudh Kala is a psychiatrist and author of the recently published book, ‘Most of What You Know About Addiction Is Wrong’ with Speaking Tiger Books.)