Guidelines

on drug prevention and treatment

for girls and women
UNITED NATIONS OFFICE ON DRUGS AND CRIME
Vienna

Guidelines on
Drug Prevention and
Treatment for
Girls and Women
© United Nations Office on Drugs and Crime. April 2016.

The designations employed and the presentation of material in this publication do not imply the
expression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning
the legal status of any country, territory, city or area, or of its authorities, or concerning the
delimitation of its frontiers or boundaries.

Information on uniform resource locators and links to Internet sites contained in the present
publication are provided for the convenience of the reader and are correct at the time of issue. The
United Nations takes no responsibility for the continued accuracy of that information or for the
content of any external website.

This publication has not been formally edited.

Acknowledgements

The United Nations Office on Drugs and Crime (UNODC) would like to acknowledge the
following for their invaluable contribution to the process of publication of this publication:

The Department for Anti-Drug Policies of the Presidency of the Council of the Ministers of the
Government of Italy for supporting the project.

Ms. Karol Kumpfer, Professor, Health Promotion And Education, University of Utah, USA and
Ms. Catia Magalhaes, Adjunct Professor, Polytechnic Institute of Viseu, Portugal for researching
and drafting the section on prevention.

Ms. Hendree Jones, Professor, Department of Obstetrics and Gynecology, University of North
Carolina (UNC) and Executive Director, UNC Horizons for the overview of the scientific
literature and the draft guidelines on treatment of drug use disorders.

The following Member States and individual scientists that provided comments to the first draft of
these guidelines: China, Croatia, France, Guatemala, Mexico, Portugal, as well as Mr. Gregor
Burkhart, EMCDDA; Ms. Heather Clark, CCSA; Ms. Colleen Dell, Canada; Ms. Anju Dhawan,
India; Ms. Julia Franklin, USA; Ms. Sonali Jhanjee, India ; Ms. Karol Kaltenbach, USA; Ms. Irma
Kirtadze, Georgia; Ms. Ingunn Olea Lund, Norway; Ms. Methinin Pinyuchon, Thailand; Mr.
Alessandro Pirona, EMCDDA; Ms. Nancy Poole, Canada ; Ms. Maria Renstrom, WHO; Mr.
Steven Schinke, USA.
Table of Contents
INTRODUCTION.......................................................................................................................................... 1
I. PREVALENCE, TRENDS AND AETIOLOGY OF SUBSTANCE AND DRUG USE DISORDERS AMONG GIRLS
AND WOMEN ............................................................................................................................................. 4
1. AFRICA ................................................................................................................................................... 5
2. NORTH AMERICA...................................................................................................................................... 6
3. CENTRAL AMERICA, THE CARIBBEAN AND SOUTH AMERICA .............................................................................. 7
4. EUROPE .................................................................................................................................................. 9
5. NORTH AFRICA AND THE MIDDLE EAST ....................................................................................................... 10
6. ASIA..................................................................................................................................................... 11
II. AETIOLOGY ...................................................................................................................................... 13
1. PERSONAL CHARACTERISTICS ..................................................................................................................... 13
2. MICRO-ENVIRONMENT: FAMILY, SCHOOLS AND PEERS.................................................................................... 15
3. MACRO-ENVIRONMENT ........................................................................................................................... 16
III. EFFECTIVE DRUG PREVENTION AMONG GIRLS................................................................................. 17
1. THE SCIENTIFIC LITERATURE....................................................................................................................... 17
2. GUIDELINES ON PREVENTING SUBSTANCE AND DRUG USE DISORDERS AMONG GIRLS ............................................. 29
IV. EFFECTIVE TREATMENT, CARE AND REHABILITATION OF SUBSTANCE USE DISORDERS FOR GIRLS
AND WOMEN ........................................................................................................................................... 31
1. WOMEN-CENTRED TREATMENT: ACCESSIBLE, RESPONSIVE TO INDIVIDUAL NEEDS, STRENGTH-BASED, AND WITH ACTIVE
PATIENT INVOLVEMENT..................................................................................................................................... 31
2. TREATMENT THAT IS BASED ON THEORY AND EVIDENCE .................................................................................. 34
3. STAFF DEMONSTRATING RESPECT AND EMPATHY FOR THEIR PATIENTS ............................................................... 37
4. CONTINUOUS TREATMENT PLANNING, FROM SCREENING TO DISCHARGE ............................................................ 38
5. ADDRESS ISSUES OVER AND BEYOND SUBSTANCE USE DISORDER, IN PARTICULAR HISTORY OF ABUSE AND PSYCHIATRIC
CO-MORBIDITY ................................................................................................................................................ 40
6. INCLUDE INTERACTIVE SKILLS TRAINING AND PRACTICE TO IMPROVE SELF-EFFICACY AND COMPETENCE ..................... 41
7. RECOGNIZE AND ADDRESS THE UNIQUE NEEDS OF WOMEN DURING PREGNANCY AND THE POST-PARTUM PERIOD....... 42
8. ADAPT THE DELIVERY OF TREATMENT TO THE ETHNIC, CULTURAL, AND SOCIO-ECONOMIC CONTEXT OF THE PATIENT ... 44
9. INCLUDE FREQUENT AND SYSTEMATIC MONITORING AND EVALUATION COMPONENTS........................................... 45
REFERENCES AND IMPORTANT LITERATURE ............................................................................................ 46
Introduction

Although overall drug use remains low among women, with men three times more likely than
women to use cannabis, cocaine or amphetamines, women are more likely than men to misuse
prescription drugs, particularly prescription opioids and tranquillizers (UNODC, 2015). In
addition, as described later in the document, there are indications that this ‘gender gap’ might be
closing among girls. Yet, as it will become clear, only a very limited number of substance use
prevention strategies target girls specifically and it cannot be assumed that existing evidence-based
substance use prevention strategies benefit girls as much as they do boys. Moreover, it is estimated
that, while one out of three drug users is a woman, only one out of five drug users in treatment is a
woman. (UNODC, 2015).

The enjoyment of the highest attainable standard of health is one of the fundamental rights of
every human being (WHO, 1946), and access to health care services should be provided on a basis
of equality of men and women (UN, 1976). These principles have recently been re-iterated by the
Member States of the United Nations in the context of the Sustainable Development Goals.
Sustainable Development Goal 3 is to “ensure healthy lives and promote well-being for all at all
ages”, and one of its targets is to “strengthen the prevention and treatment of substance abuse”
(target 3.5). As all the Sustainable Development Goals are “integrated and indivisible”, the
attainment Goal 3 and its targets should be accomplished together with Goal 5 to “achieve gender
equality and empower all women and girls” (UN, 2015). The guidelines also respond to Resolution
55/5 inviting “the United Nations Office on Drugs and Crime to work with relevant United
Nations agencies, including the United Nations Interregional Crime and Justice Research Institute,
to assist and support Member States in developing and adapting measures and strategies, at the
national, regional and international levels, addressing the specific needs of women as an essential
element of more effective, just and human rights-based policies;”.

In this context, the overarching aim of this document is to inform and encourage governments,
policy–makers, and other partners to take the necessary actions to implement evidence-based
prevention strategies and treatment services for substance use disorders in order to provide
everybody, girls as well as boys, and women as well as men, with the skills and opportunities to
prevent the initiation of unhealthy behaviours and, in case of individuals who use drugs and suffer
from drug use disorders, with the optimal support for improving their life circumstances.

This document is a component of Project DAWN - Drugs, Alcohol and Woman Network,
implemented by the United Nations Interregional Crime and Justice Research Institute (UNICRI)
with the support of the Anti-Drug Policies of the Presidency of the Council of the Ministers of the
Government of Italy. The aim of the project has been to establish a network of experts on gender
differences in substance use and addiction recovery, who can advocate and assist in the
development and implementation of evidence-based interventions, policies and best practices
which are tailored to the particular needs of women. The network has been initially active in Italy
(with the creation of the national network DAD.Net) and in the Mediterranean region in
collaboration with the Pompidou Group. In addition, it has documented best practices in drug
prevention and treatment (UNICRI, 2015) and, to complement this publication, UNODC has
developed these guidelines.
Overview of the document
The document first briefly discusses the alcohol and drug use prevalence and trends for girls and
women worldwide, as well as the research on the factors of vulnerability and resilience that are
specific to girls and women. The following section contains the results of a review of the literature
on the effectiveness among girls and women of different kinds of drug prevention strategies and
identifies indications on how to maximize their effectiveness among girls as much as among boys.
The final section of the document summarizes current scientific evidence in a series of principles
and guidelines on how to treat drug use disorders effectively among both girls and women.

Methodologically, the content of the document has been developed on the basis of a summary of
the scientific literature undertaken by two consultants in 2013. A draft of the guidelines was
published in 2014 as a Conference Room Paper to the 57th Session of the Commission on Narcotic
Drugs (E/CN.7/2014/CRP.12) and was shared with all the Member States of the United Nations,
as well as with recognized scientists and practitioners in the field of prevention of drug use and of
treatment, care and rehabilitation of drug use disorders. This final version takes into account the
comment received in this context, as well as some major publications that appeared in the
meantime.

Scope and limitations

The document attempts to provide guidelines to improve outcomes of drug prevention, treatment
and care for girls and women. In this context, some limitations must be acknowledged. The first
limitation is with regard to the lack of research in general. As it will become more clear in the
following sections of the document, there exists many research gaps on how drug use and drug use
disorders affect girls and women differently from boys and men and on how to address this
phenomenon. Moreover, as it is the case in many other fields, research is overwhelmingly based in
few high-income countries. In addition, even in the context of these countries, existing research
explores the impact of other socio-economic characteristic only to a limited extent, e.g.
marginalisation due to poverty and/or ethnic identity. Notwithstanding these serious issues, there
exist at least some research available that the document attempts to summarise with a view to
providing useful indications.

Secondly, it is recognised that each culture possesses its own specificity in the way it assigns roles
in the society to individuals born of female or male sex (gender roles). The document does not
attempt an in-depth analysis of how gender roles shape the initiation and use of drugs, the
development of drug use disorders and the relationship to prevention, treatment and care services.
It should also be remembered that, in each culture, gender roles also vary accordingly to socio-
economic status, as well as the relation of the different ethnic groups within the society at large. A
comprehensive analysis would need to take also these dimensions into account. Such an analysis
would be of great benefit, but also of great complexity and is unfortunately beyond the scope of
this document. In this context, the document limits itself to summarise the existing research as to
differences in the epidemiology and aetiology of drug use and drug use disorders between girls
and boys, as well as between women and men, as well as in the effectiveness of drug prevention
strategies and drug treatment and care services. Even this basic analysis provide useful indications
that, if implemented, monitored and evaluated, could result in better outcomes for girls and
women.

Finally, it should be noted that the document does not include examples of best and successful
practices, as these have been already extensively presented in “Promoting a gender responsive

2
approach to addiction” (UNICRI, 2015), the collection of best practices examples published by
UNICRI that is a companion to these guidelines.

For clarification, there are several terms that were selected for use throughout the document. First,
the term substance or drug use disorder was selected and has been uniformly used to indicate the
spectrum of problems with substances for which women need to be provided with treatment and
care services. This is both a scientific term and accepted nomenclature that encompasses the
widest spectrum of problem substance use (APA, 2013). In this context, it should also be noted
that the term ‘drug use’ is employed to refer to the use of drugs controlled by the three
international drug conventions for non-medical purposes1.

In general, it is understood that female children (0-10 years of age) and adolescents (11-18 years of
age) are girls and older female individuals are women. These are to be considered broad indicative
categories, as the issue of both chronological and developmental age, as well as cultural
differences all need to be taken into account. Medically, puberty is the defining characteristic for
categorizing females into girls or women. Before completing puberty a female is a girl. A female
is a woman when she is physically an adult, and old enough to marry and bear children. Many
cultures have rites of passage to symbolize a girl's coming of age, i.e. when she becomes a woman.
Different cultures also recognize different ages of girls reaching sexual maturity or womanhood.
Thus, the expected age of sexual initiation marriage and first childbirth varies by culture. It is
important to note that while a girl may have the physical capacity for reproduction, it does not
mean she has the emotional and mental maturity to consent to sex or marriage. These changes in
chronological age as well as developmental age and corresponding cognitive abilities and cultural
expectations need to be taken into account when planning and providing services for girls and
women.

1
Single Convention on Narcotic Drugs of 1961 as amended by the 1972 Protocol; Convention on Psychotropic
Substances of 1971; and United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic
Substances of 1988.

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I. Prevalence, trends and aetiology of
substance and drug use disorders
among girls and women

This first section discusses the current use prevalence and trends in tobacco, alcohol and drug use
in adolescents, with an emphasis on determining differences in use prevalence for girls as
compared to boys. The general situation with regard to drug use and drug use disorders worldwide,
as well as to the health and social consequences, has been exhaustively described in other
publications and will not be repeated here.

In general, compared with drug use among men, overall drug use remains low among women. At
the global level, men are three times more likely than women to use cannabis, cocaine or
amphetamines. By contrast, women are more likely than men to misuse prescription drugs,
particularly prescription opioids and tranquillizers (UNODC, 2015). Globally, the gaps in
reporting on the drug use situation are considerable and it should be considered that this is
particularly the case with regard to girls and women, which are sometimes more difficult to reach.
In addition, in many cases epidemiological tools do not take into account that women absorb and
metabolize some substances differently and generally have less body mass than men.
Epidemiological tools that do not use sex specific criteria (e.g. for ‘heavy episodic alcohol use’)
underestimate the proportion of girls and women who engage in this behaviour (Poole et al.,
2014).

Also among girls and boys, this traditional gender gap of prevalence being higher among boys
than among girls appears to still largely exist. Figure 1 below summarises data from two different
WHO surveys among students 13-15 years old indicating where the prevalence of lifetime
cannabis (or drugs) use is significantly higher for boys, roughly the same or is significantly higher
for girls. Although the data is not strictly comparable, as the surveys have taken place between
2001 and 2013, it is useful to provide a general idea of the situation.

However, substance use prevalence for girls has been increasing in the past two decades in some
high-income countries, particularly with regard to the non-medical use of prescription drugs. In
addition, in few countries (13 out of 82), the Global school-based student health survey (GSHS)
was undertaken twice and in most cases for which the data is available (16 out of 23), the gender
gap (i.e. the difference between the prevalence of a substance among boys and girls) has in fact
been closing with prevalence among girls either decreasing less than the one among boys or
increasing more. The following section provides a summary of the available data. As it will
become clear, the gaps in the data are profound and allow only for a very general picture to be
painted.

4
 Figure 1. Higher or lower prevalence of lifetime use of cannabis
(drugs) among boys and girls

Note: LIGHTEST grey: prevalence among boys is higher than among girls, MIDDLE grey: prevalence among boys and
among girls is approximately the same, DARKEST grey: prevalence among girls is higher than among boys.
Source: GSHS National Fact Sheets (see references), HSBC report for the survey 2009/10, Secretaria de Salud, (2011).

1. Africa
The table below reports the data collected in various African countries by WHO through the
Global School-based Student Health Survey. Although the surveys were undertaken in different
years, this data is useful to provide a partial picture of the use of some substances in the countries,
bearing in mind that these are percentages among the school population and 13-15-year old youth
who are not in school are not represented.

Table 1. Percentage of 13-15-year old students

using various substances in African countries

Country Drugs Alcohol Tobacco Year

(used drugs once or (really drunk once or (smoked cigarettes on one or
more during more during their life) more days in the last 30 days)
their life)
Girls Boys Girls Boys Girls Boys
Benin 0.9% 1.5% 11% 14.3% 1.6% 3.3% 2009

Botswana -- -- 17.4% 24.9% 14% 9.4% 2005

Djibouti 6.7% 6.5% -- -- 2.8% 3.7% 2007

Ghana 24.8% 24.6% 33% 32% -- -- 2007

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 Country Drugs Alcohol Tobacco Year
(used drugs once or (really drunk once or (smoked cigarettes on one or
more during more during their life) more days in the last 30 days)
their life)
Girls Boys Girls Boys Girls Boys
Kenya 12.7% 13.5% 33% 24.4% 10.7% 17.3% 2003

Malawi -- -- 2.3% 3.4% 3.8% 5.9% 2009

Maldives -- -- 2.2% 6.1% 4.3% 13.9% 2009

Mauritania 8.7% 7.3% -- -- 16.8% 17.2% 2010

Mauritius 2.4% 8.9% 13.5% 20.8% 9.4% 23.3% 2011

Namibia 26.6% 31.3% 28.9% 35.4% 14.2% 18.2% 2004

Senegal 0.8% 1.7% 2.1% 6.6% 2.7% 9.1% 2005

Seychelles 6.8% 19.6% 50% 56.2% 10.8% 24.1% 2007

Swaziland 5.3% 10.3% 15.9% 23.7% -- -- 2003

Tanzania 4.8% 6.8% 3.4% 7.5% 2% 5.3% 2006

Uganda 7.5% 9.4% 13.9% 16.6% 2.6% 6.2% 2003

Zambia 39.3% 36.7% 46.5% 38.6% -- -- 2004

Zimbabwe 3.6% 12.1% 13.8% 19.4% 2.2% 9.6% 2003

Source: GSHS National Fact Sheets as detailed in the references and as available online at
http://www.who.int/chp/gshs/en/

In all these countries, tobacco, alcohol and drugs were used more by boys than girls. This is with
the notable exception of the use of drugs in Djibouti, the use of alcohol and drugs in Ghana and the
use of tobacco in Mauritania, the prevalence of which was fairly similar between boys and girls. In
Zambia, both the use of drugs and alcohol was reported to be significantly higher among girls. It is
not clear why this might be the case. However, this resonates with other data collected by WHO,
reporting that in all African region countries, alcohol use in the past month was more common
among boys, except the Seychelles (WHO, 2011).

2. North America
In the early 1990s, prevalence of current smoking (30-day, daily, and half pack or more per day) in
USA rose more among boys than girls, and boys have reported consistently slightly higher
prevalence since 1991 among 12th graders. In the lower grades, the genders have had similar
smoking prevalence since their use was first measured in 1991, although in the past couple of
years a small difference has emerged, with slightly more boys smoking than girls. Among college
students, since about 2001 there has been little consistent gender difference in smoking among

6
college students (Monitoring the Future, 2011). In Mexico, among adolescents between 12 and 17
years of age, boys still smoke twice as much as girls (Secretaria de Salud, 2011).

Since the beginning of the US school-based surveys in 1975, called Monitoring the Future (MTF),
boys have had slightly higher alcohol and drug use prevalence than girls. However, this gender
gap has been narrowing in the past decades with 30-day alcohol use in girls being about 13%
lower in 1975 than boys, but only 5% lower in 2012. When considering daily drug use including
marijuana boys exceed girls’ use by two to three times among 8th, 10th, 12th grades. This is
because in 2012, as in prior years, the rate of daily marijuana use in high school senior boys was
almost three times higher at 9.1% for boys and only 3.6% for girls. However, if you consider drug
use excluding marijuana, 8th and 10th grade girls’ use has been higher since first measured in
1990. By 1995, 8th grade girls exceeded boys in their use of cigarettes, methamphetamines,
amphetamines, cocaine, crack, inhalants, and tranquilizers and by 2002 in 30-day alcohol use. By
2005 10th grade girls also exceeded boys in 30-day alcohol use until a slight decrease beginning
four years ago.

Eighth grade boys have higher prevalence of heavy drinking; however, in their 30-day prevalence
of alcohol use at 8th grade, girls surpassed the boys in 2002 and have had higher prevalence since.
At 10th grade, girls caught up to the boys by 2005, but boys have had higher 30-day prevalence of
alcohol use for the past four years. Among 12th graders, the prevalence in 2011 were 18% for girls
versus 26% for boys. This difference has generally been diminishing since MTF began; in 1975
there was a 23-percentage-point difference, versus an 8-point difference in 2011. College males
report considerably higher prevalence of daily drinking than college girls (6.2% vs. 2.3% in 2011).
A similar gender difference also exists in the non-college group (6.3% vs. 3.8% in 2011).

Frequent alcohol use tends to be disproportionately concentrated among boys. Daily alcohol use,
for example, is reported by 2.9% of 12th-grade boys versus 1.2% of 12th grade girls. Boys are also
more likely to drink large quantities of alcohol in a single sitting: 26% of 12th-grade boys reported
drinking five or more drinks in a row in the prior two weeks versus 18% of 12th-grade girls. The
rate among 12-17-year-old in Mexico was 17.3% for boys and 11.7% for girls (Secretaria de
Salud, 2011). Girls in 8th grade showed about the same rate of being drunk in the prior 30 days as
did boys (4.2% versus 4.4% for boys), whereas in 12th grade the rate for boys (28%) was higher
than the rate for 12th-grade girls (22%).

The annual prevalence for 12th-grade boys, compared to 12th-grade girls, are more than twice as
high for hallucinogens, LSD, hallucinogens other than LSD, salvia, heroin, heroin with a needle,
Rohypnol, GHB and steroids. In 8th grade, girls actually have higher prevalence of use for some
drugs, including inhalants. Prevalence of amphetamine use are fairly close for both genders in all
grades. Girls have higher prevalence of tranquilizer use in all three grades and this is of great
concern given that the non-medical use of prescription or over-the-counter drugs to get high is
second only to marijuana use (University of Michigan, Monitoring the future 2012). In the case of
Mexico, boys (12-17) report twice as much use of any drug (2.2% including prescription drugs) as
girls (1.1%) (Secretaria de Salud, 2011).

3. Central America, the Caribbean and South America

The table below reports the data collected in various countries of Central America, the Caribbean
and South America by WHO through the Global School-based Student Health Survey. Although

7
the surveys were undertaken in different years, this data is useful to provide a partial picture of the
use of some substances in the countries, bearing in mind that these are percentages among the
school population and 13-15-year old youth who are not in school are not represented.

Table 2. Percentage of 13-15-year old students using different substances in various

countries of Central America, the Caribbean and South America

Country Drugs Alcohol Tobacco Year

(used drugs (really drunk once (smoked cigarettes on
once or more or more during one or more days in
during their life) the last 30 days)
their life)

Girls Boys Girls Boys Girls Boys

Antigua and Barbuda -- -- 19.5% 26.1% 6.1% 8.2% 2009

Argentina 6.5% 10.6% 26.8% 28.9% 20.5% 17% 2012

Barbados 11.2% 17.8% 19% 29% 6.6% 12.7% 2011

Belize 7.4% 15.6% 15.5% 21.1% -- -- 2011

Bolivia 2% 2.9% 9.3% 12.8% 8.9% 15.7% 2012

British Virgin Islands -- -- 20.7% 17.7% 4.3% 7.3% 2009

Chile 9.3% 9.7% 21.1% 22.1% 33.5% 24.7% 2005

Colombia 8.3% 13.7% 43.3% 47.2% 20.1% 20.2% 2007

Costa Rica -- -- 15.6% 15.8% 8.4% 10.1% 2009

Dominica -- -- 28.8% 37.6% -- -- 2009

Ecuador 4.1% 7% 24.2% 31.2% 10.6% 14.5% 2009

Grenada 7.8% 21.9% 22.1% 33.9% 3% 7% 2008

Guatemala -- -- 8.8% 13.1% -- -- 2009

Guyana -- -- 24.5% 34.7% 6.8% 17.4% 2010

Honduras -- -- 10.6% 10.7% 11.1% 14% 2012

Jamaica -- -- 27% 43.5% 16.9% 31% 2010

Peru 1.9% 5.7% 10.2% 16.8% 11.9% 22.9% 2010

Saint Vincent and the Grenadines 13.4% 26.9% 30% 40.3% 5.1% 12% 2007

St. Lucia 15.8% 29.7% 30% 41.5% 6.2% 9.8% 2011

Suriname -- -- 9% 21% 8.6% 12.5% 2009

Trinidad and Tobago 3.8% 11% 22.2% 25.3% 6.9% 13.6% 2011

8
 Country Drugs Alcohol Tobacco Year
(used drugs (really drunk once (smoked cigarettes on
once or more or more during one or more days in
during their life) the last 30 days)
their life)

Uruguay -- -- 24.7% 24.5% 12.6% 8% 2012

Venezuela 1.7% 4.7% 15% 25.5% -- -- 2003

Source: GSHS National Fact Sheets as detailed in the references and as available online at
http://www.who.int/chp/gshs/en/

Also in this region, the ‘gender gap’ appears to be largely the norm as in most countries the
prevalence of use of substances among 13-15-year old students was significantly higher than that
of girls. In a few countries, the picture was slightly different, with girls smoking significantly more
than boys in Argentina, Chile and Uruguay and more or less the same in Colombia. With regard to
alcohol, prevalence were reported to be similar between boys and girls in Chile, Costa Rica,
Honduras and Uruguay. In another WHO survey, in Central America and the Caribbean, alcohol
use in the past month was more common among boys, except Costa Rica (23.6% of girls vs 23.4%
of boys), Saint Vincent and the Grenadines (53.5% of girls vs. 52.6% of boys) and Trinidad and
Tobago (42.0% of girls vs.39.6% of boys) (WHO, 2011).

4. Europe
The average figures for lifetime, past 12-months and past 30-day alcohol use prevalence are about
the same for adolescent girls and boys, but for more frequent drinking within each time frame,
boys have higher consumption. Boys in most EU countries drink about one-third more than girls
per drinking episode (2011 averages of 5.8 versus 4.3 centilitres of 100% alcohol). However in a
couple of countries (Iceland and Sweden) the average quantities were about the same among girls
as among boys. In a large majority of the countries, beer is the dominant beverage among boys.
Spirits are the most frequently used beverages among girls in just over half of the European
countries.

The “heavy episodic drinking” in the past 30 days in girls had increased dramatically from 29% in
1995 to 41% in 2007, but slightly decreased to 38% by 2011. Among boys this alcohol binge
drinking rate was slightly higher in 2011 (43%) than in girls, and it has remained relatively stable
since the 1995 rate of 41%. However, alcohol-related problems are more common among boys in
terms of physical fights and trouble with the police. In a WHO survey, in most European countries
and on average, the prevalence of being drunk more than once in a lifetime among 13-15-year-old
students was still higher among boys than girls. However, 9 countries reported a higher prevalence
among girls in 2010, compared to 4 in 2001. Moreover, in 25 out of 31 countries, the ‘gender gap’
narrowed between 2001 and 2010.

There were small gender differences in 30-day cigarettes use in 2011. At the aggregate country
level, the sex differences in 2011 were negligible for smoking in the past 30 days. So girls were
smoking more since in 1995 and 1999 when slightly more boys were smokers. However, in 2011
some individual countries had large sex differences with higher figures for girls in Bulgaria,

9
Monaco, France, Slovenia, Faroe Islands and Ireland and higher figures for boys in Albania,
Cyprus and Moldova, Ukraine and Montenegro.

In European teens, reported use of drugs varies considerably across the countries with higher
lifetime experience reported by boys than girls (19 % vs 14 %) and drug use significantly higher
for boys in 27 countries (EMCDDA, 2012).

Annual cannabis use was reported as 15% among boys and 11% among girls, while 30-day use
was reported by 8% of the boys and 5% of the girls. Regular 30-day marijuana use is higher in
boys than girls (EMCDDA, 2012). Lifetime use of cannabis was reported by more boys (19%)
than girls (14%), and the figures were significantly higher for boys in 27 countries. The average
lifetime prevalence in 15-year-old students in the HSBC survey of WHO, which covers mostly
European countries, fell a bit faster for boys (from 26% to 20%) than for girls (from 19% to 15%)
between 2001/2 and 2009/10.

While, more boys than girls have tried drugs other than cannabis, 7% versus 5% in 2011
(EMCDDA, 2012), more girls (8%) than boys (5%) report non-medical use of prescription drugs.
Lifetime use of tranquillizers or sedatives without a doctor´s prescription, together with mixing
alcohol and pills, are the only substance-use behaviours that have been more common among girls
than boys (EMCDDA, 2012). The use of inhalants increased equally in both sexes to 10% in 2011
for the first time.

5. North Africa and the Middle East

The table below reports the data collected in various countries of North Africa and the Middle East
by WHO through the Global School-based Student Health Survey. Although the surveys were
undertaken in different years, these data are useful to provide a partial picture of the use of some
substances in the countries, bearing in mind that these are percentages among the school
population and 13-15-year old youth who are not in school are not represented.

Table 3. Percentage of 13-15-year old students using different substances in various

countries of North Africa and the Middle East
Country Drugs Alcohol Tobacco Year
(used drugs (smoked
once or more (really drunk cigarettes on
during once or more one or more
their life) during their days in the last
life) 30 days)

Girls Boys Girls Boys Girls Boys

Algeria 0.3 4 -- -- 1.4 18 2011

Egypt -- -- -- -- 1.4 5.8 2011

Iraq -- -- -- -- 4.6 12.1 2012

10
 Country Drugs Alcohol Tobacco Year
(used drugs (smoked
once or more (really drunk cigarettes on
during once or more one or more
their life) during their days in the last
life) 30 days)

Jordan -- -- -- -- 7.6 17.7 2007

Kuwait -- -- -- -- 7.5 23.7 2011

Lebanon 1 6.3 16 27.1 -- -- 2011

Libya -- -- -- -- 1.1 7.1 2007

Morocco 1.3 4.1 -- -- 2.3 7.4 2010

Qatar -- -- -- -- 10.8 25.3 2011

Sudan -- -- -- -- 3.6 8.5 2012

Syria -- -- -- -- 4.8 16.2 2010

Tunisia 1.9 5.7 -- -- 2.7 12.7 2008

United Arab Emirates -- -- -- -- 5.8 15.6 2010

Source: GSHS National Fact Sheets as detailed in the references and as available online at
http://www.who.int/chp/gshs/en/

In the countries of this region, less data was collected with regard to both alcohol and drugs.
However, for those countries that did collect the data, and with regard to tobacco use, in all cases
the prevalence among boys was significantly higher than the prevalence among girls.

6. Asia
The table below reports the data collected in various Asian countries by WHO through the Global
School-based Student Health Survey. Although the surveys were undertaken in different years, this
data is useful to provide a partial picture of the use of some substances in the countries, bearing in
mind that these are percentages among the school population and 13-15-year old youth who are
not in school are not represented.

11
 Table 4. Percentage of 13-15-year old students
using various substances in Asian countries
Country Drugs Alcohol Tobacco Year
(used drugs once or (smoked cigarettes on one or
more during (really drunk once or more days in the last 30 days)
their life) more during their life)

Girls Boys Girls Boys Girls Boys

Cambodia 1.2% 1.2% 2.9% 6.2% 2.4% 2.9% 2013

China 0.7% 1.2% 4.8% 11.9% 2.4% 15.3% 2003

Fiji -- -- 8.3% 17.3% 7.4% 16.2% 2010

India -- -- -- -- 0.2% 1.9% 2007

Indonesia 0.3% 0.6% 0.5% 4.8% 0.9% 22.1% 2007

Kiribati 1.6% 6.8% 10.4% 35.4% 19.5% 34.4% 2011

Malaysia 0.4% 1.4% 3% 6.8% 1.9% 14.3% 2012

Mongolia 0.9% 1.5% 4.7% 8.5% 3.5% 8.3% 2013

Myanmar 0.5% 0.4% 0.3% 2.6% 0.6% 3.4% 2007

Nauru -- -- 15.9% 24.5% 24.5% 19.5% 2011

Pakistan -- -- -- -- 1% 9.9% 2009

Philippines -- -- 13.6% 17.8% 6.4% 18% 2011

Tajikistan 0.7% 1.5% 0.5% 2% 0.6% 1.1% 2006

Thailand 2.4% 15.8% 14.8% 25% 1.5% 10.8% 2008

Vanuatu 1.9 5 5.8 10.3 8.2 19.4 2011

Viet Nam 0.2 0.5 8.1 17.7 1.2 3.6 2013

Source: GSHS National Fact Sheets as detailed in the references and as available online at
http://www.who.int/chp/gshs/en/

Also in the Asian countries, the ‘gender gap’ is still substantially present, with a significantly
larger percentage of boys using various substances than girls and with the exception of the use of
drugs in Cambodia and Myanmar that, whilst low, is substantially similar between girls and boys.

12
II. Aetiology

Currently, the reasons for different prevalence of the use of substances and drugs by girls and boys
(generally lower in girls), as well as for the rise of substance and drug use in girls in some
countries (particularly in earlier teens and with regard to some specific substances) remain unclear.
However, this section summarizes the available evidence to provide some indications as to the
factors that might make girls and boys vulnerable or resilient to start using substances and drugs,
as well as to other risky behaviours. This chapter is not meant as an in-depth discussion of the
aetiology of substance use disorders, as this would warrant a publication of its own. Rather, it will
highlight where the factors of vulnerability and resilience between girls and boys and women and
men differ.

Several explanations for the gender gap in substance use have been advanced including the
increased genetic risk in boys and recent family environmental risks in girls with rapid changes in
social roles. Biological and socially constructed gender differences do appear to produce unique
development trajectories for boys and girls, with concomitant vulnerability and resiliency factors
that lead to different substance use behaviours and different motivations for using substances
(Chesney & Pasko, 2004; Guthrie & Low, 2000).

This section discusses different influences on substance and drug use starting with personal
characteristics and moving into ‘micro’ influences close to the life of the individual (family,
school, peers), as well as into ‘macro’ influences in the larger environment (social and physical
dimensions of the community, the neighbourhood, the society at large).

1. Personal characteristics
There is evidence that boys have twice as high a genetic risk of alcohol dependency compared to
women according to early twin adoption studies conducted in Sweden, Denmark and USA
(Pickens et al, 1991). In certain Northern European families, there is a type of alcoholism called
“Type II Alcoholism or Male Limited Alcoholism” characterized by early onset of use and many
male relatives who become alcoholics (Vaillant, 1995). A study of college males with this family
history and found that they had rapid brainwaves, increased emotional liability and autonomic
nervous system (ANS) hyper- or over-reactivity (Schuckit, 2009). Consuming alcohol smoothed
out their brainwaves and emotional over reactions. These genetic risks help to explain why
addiction appears to be a “family disease” with children of parents with substance use disorders at
much higher genetic risk.

In addition, among the different personal characteristics that are linked to the initiation of
substance and drug use and dependence, depression and aggressiveness in the first grade appear to
have stronger predictive power for boys than girls, while conduct disorder and higher anxiety
response have stronger predictive power for girls. Current research has not yet explained these
differences.

13
 Table 5. Vulnerability factors for drug use in adolescence as it relates to gender
Vulnerability factors for drug use in Girls Boys
adolescence that are more relevant
for …

Depression √

Conduct disorder √

Cigarette use √

Maternal alcoholism √

Maternal drug use disorder √

Low parental attachment √

Low parental monitoring √

Low parental concern √

Unstructured home environment √

Dysfunctional family √

Smoking During Pregnancy √

Aggressiveness in first grade √

Higher Anxiety Response √

Peer Difficulties √

Childhood Sexual Abuse √

Source: Lee Wetheringtn (2012)

High prevalence of comorbidity exist between substance use and depression in girls (Kloos et al.,
2009; Lillehoj et al., 2004). Substance abusing girls are more likely to be depressed than boys
(Chander & McCaul, 2003). Likewise, depression leads to increased substance use disorders,
reduced self-esteem, and increased suicide attempts for girls (Kloos et al., 2009). Girls who
believe that drinking alcohol reduces depression report more alcohol use. More girls than boys (as
young is the 6th grade) believe in self-medicating powers of alcohol to reduce depression, anger or
frustration even before they begin to drink. Other drugs such as ecstasy and marijuana are also
used by girls to reduce depression (Smith et al., 2002).

Delinquency and substance misuse have been associated with low levels of self-esteem in teenage
girls (Wild et al., 2004). Girls who at age 12 with low self-esteem were nearly 2.5 times more
likely to engage in heavy alcohol use at age 15 than those higher in self-esteem; no such
relationship was found in boys (Young et al, 2012; Emler, 2011).

Finally, during puberty, both girls and boys must adopt new behaviours to comply with gender
expectations inherent to their culture. Some girls experience low self-esteem and loss of "voice" as
a result of social conditioning to suppress their self-expression as a means of maintaining
important relationships (Spira, et al. 2002).

14
With regard to the development of substance use disorders, it is a medically established and widely
recognised fact that substance use can progress into alcohol and drug use disorders more quickly
for adolescent girls than for boys, even when using the same or lesser amounts of a particular
substance.

2. Micro-environment: family, schools and peers

As indicated in Table 5, girls appear to be more affected by family problems than boys. This is
also apparent in one of the few tested causal models by gender, the Social Ecology Model of
adolescent vulnerability to substance use. Using Structural Equation Modeling (SEM) statistical
analysis of a database of about 10,000 youth from multiple ethnicities in the USA, the researchers
found that the pathways to drug use were fairly similar for girls and boys (CSAP, 2001; Kumpfer
et al., 2003; Sales et al. 2003), with a strong pathway between family bonding and academic
performance.

Figure 1. - Social Ecology Model (SEM) of substance use by gender

Note: In this chart F = girls and M = boys and the numbers are beta weights.
The higher the number or size of the arrows, the stronger the causal influence.

However, as it can be understood from Figure 1., the family pathway from parent/child bonding
and attachment, to better parental supervision, to communication of positive family values and
reduced substance use was stronger in girls than boys, whereas the community environment path
was slightly stronger in boys. The final pathway to drug use collapsed into combining parental and
peer values/norms as a factor because of the close association and was equally powerful for girls
and boys. Lack of behavioural and emotional self-control had a slightly larger role in later drug use
in boys, possibly because boys have a higher incidence of emotional and impulse control
disorders. Girls were more influenced by their academic performance and self-efficacy than boys.

A similar SEM model was tested for school failure, delinquency, and teen pregnancy as well as
alcohol and drug use with similar results (Ary et al.,1999). Moreover, it has been found that low
parental supervision had a greater influence on adolescent girls’ alcohol and drug use than on boys
(Fothergill and Ensminger, 2006).

Peer pressure may be more strongly associated with drinking for girls than it is for boys. Middle
school girls who report high levels of peer pressure to drink are twice as likely to use alcohol than
those who report less peer pressure; this relationship between peer pressure and alcohol is not

15
found for boys. When several of a girl´s closest friends smoke or drink, they are more than seven
times more likely to drink and smoke, whereas, boys are only three times more likely. Finally,
early maturing girls who have older friends appear to be a group at an elevated risk for substance
misuse, truancy, delinquency and sexual activity (Caspi et al., 1993; Lanza & Collins, 2002).

Sexual abuse and violence appears to be a stronger risk factor for girls and women, possibly due to
the higher prevalence of victimization. One out of every three girls and women are victims of
violence. The percentage of women in drug treatment facilities that were sexually abused as a
child is high: 55% to 95% (Kumpfer & Bays, 1995). In the USA, the prevalence of sexual abuse
was reported to be 60% for incarcerated adolescent girls and 20% for adolescent boys, with the
prevalence of physical abuse being about 40% to 50% for both genders (Dembo et al., 2000).
Finally, youth who misuse alcohol, marijuana, or drugs are at increased risk of victimization, with
girls that use substances at particularly elevated risk of sexual assault (Testa & Livingston, 2009).

3. Macro-environment
Exposure to media messages that normalize or even glamourize drug and substance use, as well as
to environment where psychoactive substances are easily accessible is a risk factor for both girls
and boys. However, in many societies, girls are being exposed to media and societal pressures to
conform to an unrealistically thin body ideal (Reel & Beal, 2009; Sypeck et al., 2004).
Significantly more girls than boys begin using tobacco and drugs because they believe it helps
them to keep their weight down. In the USA, the use of amphetamines among Caucasian girls is
linked to the desire to lose weight (NCASA, 2003b). In general, reasons for girls´ use of harmful
substances were found to include concerns about weight and dieting (NCASA, 2003a). Girls ages
10 to 15 who report being highly concerned about their weight are nearly twice as likely to get
drunk as those who are less concerned about their weight. Up to 50% of girls with eating disorders
misuse alcohol or drugs compared to 9% of the general population and up to 35% of substance
abusing girls also have an eating disorder (Piran and Gadalla, 2007). In another study, about 25%
of US college women were skipping meals to save on calories and get drunk quicker. Girls who
combine disordered eating with binge drinking are also more at risk for violence, risky sexual
behaviour, alcohol poisoning, substance use and chronic diseases later in life, and cirrhosis of the
liver (Baker et al., 2010). This phenomenon has also been reported in other countries of Latin
America. Hispanic girls in the USA report disordered eating at higher prevalence than Caucasian
or African-American girls.

16
III. Effective drug prevention among girls

1. The scientific literature

In the past twenty years research on the effectiveness of prevention strategies has reported that
several programs demonstrate consistent positive findings when implemented completely and with
fidelity (UNODC, 2013). While a variety of school-based, family-based and community-based
programs have been effective at changing adolescent health behaviours, little is known on the
effectiveness of these strategies by gender or on how programs can be tailored to be more gender-
aware or gender-specific (Blake et al., 2001; Fothergill & Ensminger, 2006). The few studies that
have examined gender differences directly have found mixed results, with some showing effects
among girls, but not boys and vice versa (Vigna-Taglianti et al., 2009, Flay et al., 2004).

This chapter presents the results of a review undertaken in 2013 of two online databases of
evidence-based programmes: the National Registry of Evidence-based Programs and Practices
(NREPP) of the Substance Abuse and Mental Health Services Administration (SAMHSA) of the
USA and the Exchange on Drug Demand Reduction Action (EDDRA) of the European
Monitoring Centre for Drugs and Drug Addition. Each database includes programmes in
accordance to established criteria with regard to the evaluation and, in the case of NREPP, also the
results of the programme. The databases were searched for programmes categorised as
‘prevention’, including universal, selective and indicated prevention. In turn, the results were
searched for results disaggregated by gender. In addition, a questionnaire was sent to all the
contact persons of drug prevention programmes as described above soliciting unpublished results
disaggregated by gender. Only a few prevention program developers reported that they have
conducted sub-group analyses for effectiveness by gender and the results are presented below.
About one-third of those that did conduct analysis by gender found that boys and girls do, in fact,
respond differently to prevention interventions.

School- and community-based programmes

The results with regard to the 11 school- and community-based programmes that conducted an
analysis of the effectiveness by gender are reported in Table 6. Four (4) reported positive results
for boys, but no significant positive results for girls, 1 reported positive results for boys, but
negative results for girls, 3 reported positive results for girls, and 3 programs (Keepin’ it REAL,
Al’s Pal and a culturally tailored intervention for Native American youth) reported no gender
difference. Two (2) of the programs that worked for girls only (SMART and ALERT) reported
results only for tobacco and cannabis. In addition, a school-based gender specific programme
targeting female athletes (ATHENA) reported positive results for girls.

In some cases these gender differences were only in sub-groups. In the case of ALERT, the more
positive results for girls were only in high risk girls. The Keepin’ it REAL programme showed no
overall gender difference for substance use. Subgroup analysis by ethnicity revealed gender
effects, but only among less acculturated Latino youth. These gender effects were found for larger

17
positive changes in alcohol and cigarette use, and anti-drug norms among the boys, but not as
much for girls.

One of the programmes reporting no gender differences in results (Al’s Pals) was targeting a very
young children and focusing heavily on their personal and social skills with a strong parenting
component.

The European Drug Abuse Prevention (EU-Dap) curriculum ‘UNPLUGGED’ is a school-based

12-session teacher-led social skills programme for students including 3 meetings with parents. It
was evaluated in seven European countries with 6,600 students. Baseline use prevalence revealed
that boys were more likely than girls to have used cannabis and other drugs; whereas girls had a
higher prevalence of cigarette smoking. There was a significant association between the
programme and a lower prevalence of all behavioural outcomes, and a delay in onset of use. Boys
benefited significantly more than girls, but both did have reduced frequency of use.

Finally at the school level, ATHENA, a gender-specific programme for female high school
athletes, was found to increase the knowledge of drug consequences and intentions not to use as
well as decreasing use of drugs compared to a no-treatment control group (Elliot et al., 2002).

At the community level, The 48 Community Partnership Cross-Site Study included a 10% sample
of the 240 communities with a drug prevention coalition matched with a similar community in
their state without a coalition. The results from this study revealed that statistically significant
positive effects were found for 8th grade and 10th grade boys and adult men in reducing drug and
alcohol use, but no positive effects for girls or women. In fact, a significant negative effect on 8th
grade girl´s use of drugs was discovered (Yin & Ware, 2000). This may be due to the fact that
these programmes tend to focus more on environmental policy changes like access to tobacco and
alcohol for minors and enforcement of laws and ordinances that may have more of an impact on
boys rather than girls.

Family-based programmes
Our survey of evidence-based prevention programs revealed that of the 7 evidence-based family
programmes who had done a gender analysis all reported equally effective results for girls and
boys and one reported better results for girls –Treatment Foster Care (see Table 7. below). In
addition, 5 gender-specific family-based programmes for girls reported positive results for girls.

A recent gender analysis of a large Strengthening Family Program (SFP) normative database of
over 4,000 families from SFP groups worldwide found that SFP is equally effective for girls as for
boys and in some cases even more effective for girls despite lower base prevalence of risk factors,
possibly because girls are more influenced by family relationships (Magalhães, 2013).

Of the three gender-specific programmes, randomized control trials of the mother-daughter

substance use prevention programme delivered through CDs or internet showed good results for
reducing HIV risk, alcohol and drug use among inner city Hispanic, African American and Asian
American girls (Fang & Schinke, 2013; Schinke et al. 2009 and 2011; Schwinn et al., 2010). Two
gender and ethnic adaptations of Strengthening Families Program 6-11 Years (SFP) targeting
mothers and daughters also reported positive results for Hawaiians, (Kameoke, 1996) and Hispanic
mothers and daughters (Alvarado, ***).

18
The general positive results of family-based programmes is consistent both with the brief
discussion above of factors of vulnerability and resilience that are particular to girls, and with
other general reviews of the effectiveness of family-based programmes (Petrie et al., 2007).

19
 Table 6. Gender differences in outcomes of school and community-based prevention programs
Name of Brief description of Age group Dosage or Level of Effect on use No gender Better for Better for
programme and content number of risk by youth difference girls boys
references sessions

Peer pressure resistance

Self-Management
training and normative
and Resistance
education, plus affective 7th grade Tobacco
Training (SMART) 12 sessions Universal
education, stress management students Marijuana
(Graham et al.,
and negative self-image
1990)
enhancement.

Tobacco and
ALERT (Donaldson 14 sessions, Tobacco: -0%; cannabis.
et al, 1994) and Drug prevention curriculum 11 delivered Alcohol: -0%; NOTE: at
7th and 8th
ALERT Plus based on social learning in 7th grade Universal Cannabis: -4%; risk girls
grades
(Longshore et al., theory. and 3 in 8th Other drugs: - only, no
2007) grade 4% effect in
boys.

Tobacco,
alcohol, drugs
Oslo Youth Study NOTE: Effects
Social influences-based 5th to 7th
Smoking Prevention Universal only on non-
smoking prevention program grades
Program smoking boys
and no effect on
girls

Is a school- and community-

based smoking prevention
10 sessions: 3
program using a social
in 7th grade, 5
North Karelia Youth influence approach. Students Tobacco,
13-15 years in 8th grade, Universal
Programme are taught about social alcohol, drugs
and 2 in 9th
pressures and are trained by
grade.
demonstration and role
playing to deal with them.

20
 Name of Brief description of Age group Dosage or Level of Effect on use No gender Better for Better for
programme and content number of risk by youth difference girls boys
references sessions

Students are educated on the

consequences and
misperceptions associated
Tobacco: -0%;
with drug use. Interactive
Alcohol: -0%;
Project Towards No sessions provide motivation Tobacco,
14-19 years 12 sessions Universal Cannabis: -0%;
Drug Abuse and decision making skills alcohol, drugs
Other drugs: -
targeting the use of cigarettes,
4%
alcohol, cannabis and other
drugs, and violence related
behaviour.

Risk assessment, decision

making, where to go for Better for boys
Keepin’ it REAL
support, and communication 7th and 8th Alcohol: - 11% ; No gender in less
(Kulis et al., 2007 10 sessions Universal
skills such as conflict grades Cannabis: - 5% difference acculturated
and 2005)
resolution and drug refusal Latinos
skills.

Reduced
European Drug alcohol and
Abuse Prevention Involves students in an cannabis best
12 sessions
(EU-Dap) interactive curriculum with some
for students
curriculum designed to improve and Reduced alcohol reduction in
12-14 years plus 3 Universal
‘UNPLUGGED’ develop life skills, based on a and drug use. tobacco and
sessions for
(Fiaggano et al., comprehensive social other drugs.
parents
***; Vigna-Taglianti influence model. Best in boys
et. al., 2009) and higher
frequency users.

21
 Name of Brief description of Age group Dosage or Level of Effect on use No gender Better for Better for
programme and content number of risk by youth difference girls boys
references sessions

This is a resiliency-based,
early-childhood prevention
curriculum and teacher
training programme that
develops personal, social and
emotional skills. It includes a
component on building
positive relationships between
Al’s Pals: Kids parents and children, which 46 lessons As effective
Making Healthy reinforces Al’s Pals concepts 3-8 years lasting 10-15 Universal for girls as
Choices at home. It is designed to help minutes each. for boys.
children gain the skills they
need in order to express
feelings appropriately, relate
to others, accept differences,
use self-control, resolve
conflicts peacefully, cope and
make safe and healthy
choices.

22
 Name of Brief description of Age group Dosage or Level of Effect on use No gender Better for Better for
programme and content number of risk by youth difference girls boys
references sessions

This is a neighbourhood-
based, school-centred
program aimed at preventing
substance use and
delinquency among high-risk
adolescents and reducing
CASASTART Cannabis: - Negative
drug-related crime in their Positive effects
8-13 8 sessions Selective 0.4%; Other effects for
neighbourhood, working with for boys
drugs: -8.6% girls
schools, law enforcement
agencies, and social service
agencies to create a network
allowing every child the
opportunity for healthy
development.

3.5-yr sig.
reductions in 6-
Intervention was derived from 15 sessions 12 month
Culturally tailored
a conventional theoretical each 50- alcohol,
intervention for
model of life skills training minute weekly marijuana, and As effective
Native American
and culturally tailored for youth with 2 booster Universal smokeless for girls as
youth (Schinke,
Native American. 50 minute tobacco cigarette for boys.
Tepavac & Cole,
Recruitment was done sessions semi- consumption.
2000)
through schools. annually

GENDER
Targets female athletes SPECIFIC
improving nutrition and with
ATHENA Adolescents Selective
exercise to prevent drug positive
misuse and eating disorders. results for
girls.

23
 Table 7. Gender differences in outcomes of family-based prevention programs
Name of Brief description Age Number of Level of Effect on use No gender Better for Better
programmes and group sessions risk by youth difference girls for
references boys

Tobacco: -7%;
Alcohol: -6%
Parent education to make Four booklets mailed 3 & 6 months
Family Matters follow up As effective
parents more aware of factors 12-14 home with follow-up
(Bauman et al., Universal indicated for girls as
related substance use among years calls by health
2002) reduction in for boys
adolescents. educators.
alcohol
consumption &
smoking

Programme designed for

parents and youth which offers
training modules for both.
Content: communication,
conflict resolution, peer
resistance coping mechanisms Targeted
to resist negative social couples
Creating Lasting As effective
influences; practice effective are 18
Family Connections 10 sessions for girls as
refusal skills for both parents years of
(Strader) for boys
and youth; engender self- age or
knowledge, personal older
responsibility, and respect for
others; and impart knowledge
and understanding about the
use of tobacco, alcohol and
drugs.

24
 Name of Brief description Age Number of Level of Effect on use No gender Better for Better
programmes and group sessions risk by youth difference girls for
references boys

The course of Reduced

Multisystemic treatment ranges from substance use
Intensive family- and
Therapy for three to five months; and criminal
community- based treatment As effective
Delinquents and 12 - 17 the intensity of the behaviour among
for juvenile offenders who Indicated for girls as
Substance Abusing years treatment varies young persons
have committed serious for boys.
Youth (Borodin, according to clinical and the number
offences and their families.
et.al, 1995; Haggler) need (from 2 to 15 of juveniles
hours per week). placed in care.

A community-based
alternative to placement in
group or residential care for
More
children and adolescents with Prevents ongoing
Multidimensional effective for
severe emotional and delinquency,
Treatment Foster girls with
behavioural problems. incarceration,
Care Middle School 9-18 regard to
Coordinated interventions in 6–9 months Selective and associated
Success years preventing
the home, with peers, in behavioural
(Chamberlain, P., tobacco,
educational settings, and with problems for
***) alcohol and
the child or adolescent’s birth adolescents.
drug use.
parents, adoptive family, or
other long-term placement
resource.

25
 Name of Brief description Age Number of Level of Effect on use No gender Better for Better
programmes and group sessions risk by youth difference girls for
references boys

1. Parent skills training: goals,

increasing positives, Each session consists
communication skills, and, of the whole family
effective discipline. 2. attending 3 separate 1
Tobacco: -7;
Strengthening Children or teen skills hour classes held on
Universal Alcohol: -18%; As effective
Families Program training: goals, speaking and 0-17 same night. Number
and/or Cannabis: -15%; for girls as
(SFP), (Kumpfer, listening, peer refusal, anger Years of sessions varies by
selective Other drugs: - for boys.
Magalhães, 2013) and coping, etc. 3.Family version, level of risk
11%
skills training parent/child and age of the
positive time, family meetings, children from 7 to 14
chore charts, discipline sessions.
practice sessions.

MDFT is a manual-driven
intervention with specific
assessment and treatment
modules for drug abusing
youth. MDFT helps the youth Delivered across a
Multidimensional
develop more effective coping flexible series of 12 As effective
Family Therapy 12-18 Decreased drug
and problem-solving skills for to 16 weekly or twice Indicated for girls as
(Liddle, et al., Years use
better decision making and weekly 60- to 90- for boys.
2001,2009, 2011)
helps the family improve minute sessions,
interpersonal functioning as a
protective factor against
substance use and related
problems.

26
 Name of Brief description Age Number of Level of Effect on use No gender Better for Better
programmes and group sessions risk by youth difference girls for
references boys

Number and delivery

of the sessions vary
Parenting skills tiered Universal,
Triple P: Positive according to the level As effective
programme targeting different selective
Parenting Program 0-18 of risk ranging from for girls as
level of risks and different and
(Sanders et al.) media messages to 1 for boys
ages. indicated.
– 10 group or
individual sessions.

A curriculum each for parents,

teachers and children, based
on cognitive social learning Approximately 20 Universal, As effective
Incredible Years
theory, which emphasizes the 0-12 sessions each for selective, for girls as
(Webster-Stratton)
importance of the family and parents and children indicated. for boys
of teacher socialization
processes for young children.

Mothers and
Daughters Gender-specific, online
2-month follow- GENDER
(Computer interactive program for 9 web-delivered 35-
up sig. SPECIFIC
Mediated) mothers and daughters to 45 minute mother and
10-14 Universal reductions in 3- FOR GIRLS
complete. Dyads are recruited daughter interactive
Schinke, Cole, & 6-12 month with positive
from Craigslist. Gift cards for lessons.
Fang (2009) alcohol misuse. results
survey completion.

Asian American 2-yr sig.

Online interactive program for
Mothers and reductions in 3-
Asian American mothers and 9 web-delivered 35- GENDER
Daughters Program, 6-12 month
daughters to complete. Dyads 45 minute mother and SPECIFIC
alcohol,
Schinke, Cole, & are recruited from social 10-14 daughter interactive Universal FOR GIRLS
marijuana, and
Fang (2009) media and community lessons. Average 5.8 with positive
prescription drug
Fang & Schinke, agencies. Gift cards for survey months to complete results
misuse, but not
2013. completion
smoking.

27
 Name of Brief description Age Number of Level of Effect on use No gender Better for Better
programmes and group sessions risk by youth difference girls for
references boys

Improved social
Two different culturally GENDER
Strengthening skills, decreased
adapted family group SPECIFIC
Family Program 6-11 conduct
curriculums for Hawaiian and 6-11 14 sessions Universal FOR GIRLS
years (Kameoke, disorders,
Hispanic Families of the SFP with positive
Alvarado) depression and
(See description above). results
other risk factors

6-month follow-
up showed
12 web delivered 25 reduction for 30-
Gender-specific, interactive
minute interactive day GENDER
Internet based program. Girls
RealTeen program sessions. Average 6 SPECIFIC
were recruited through the 13 -14 alcohol use,
(Schwinn,Schinke & weeks to complete at Universal FOR GIRLS
youth-oriented website. years marijuana use,
Noia, 2010) the rate of 2 sessions with positive
9 theory-based sessions along poly drug use,
per week results
with introduction and quizzes. and total
substance use.

Post and 2 year

outcomes
indicated lower
Gender specific CD-ROM
Mother daughter reports of girls'
intervention among or internet based program for alcohol use GENDER
Black and Hispanic mothers and daughters. SPECIFIC
10 -13 10 interactive and in their
Recruited from postings on Universal FOR GIRLS
Adolescent Girls years sessions lower
craigslist.org and from with positive
(Schinke, Fang, & expectations of results
advertisements in New York
Cole, 2009; 2011) future tobacco,
City newspapers.
alcohol, and
prescription drug
use.

28
2. Guidelines on preventing substance and drug use disorders
among girls

A gender-aware approach does appear to be necessary to prevent drug and

substance use among girls and women
Whilst the research base is very limited, it does point in the direction of the necessity of a gender-
attentive approach. There are factors of vulnerability and resilience that are specific to girls and
women and there are indications that drug prevention strategies do not necessarily benefit girls and
boys equally. A gender-attentive approach might implement gender-specific strategies for girls.
Alternatively, it might try and insert components in universal programmes addressing factors of
vulnerability and resilience that are specific to girls and women and to their development. In
addition, the cultural adaptation research suggests that enrolment and retention can increase
dramatically with adaptations (UNODC, 2009 family) and this might conceivably apply also in the
case of gender.

On the basis of the current research, family-based interventions appear to

be a promising strategy to prevent drug and substance use as well among
girls as among boys.
The limited research indicates that, whilst family-based strategies are almost consistently
providing as good effects for girls as for boys, school- and community-based strategies often fail
girls. These results are also consistent with family factors of vulnerability and resilience with girls
more affected by family problems and more protected by family bonding and supervision.

Developing new strategies to respond to other factors of vulnerability and

resilience that are specific to girls is crucial.
As girls suffering from or at risk of depression and anxiety appear to be more vulnerable than boys
with the same characteristics, it might be worth exploring programmes targeting girls screened for
these factors and providing them with the skills to cope with negative emotions in a healthy and
constructive way.

This is based on the significance of low self-esteem, depression, anxiety and substance use by
peers (particularly significant others) in the vulnerability of girls to drug and substance use.
Moreover, topics to include in adolescent programming that might have a particular effectiveness
for girls are: dealing with stress, depression, social assertiveness, body image and improving
relations and communication with parents and other significant others.

Modules on dating, meaning of love and sexual relationships, date rape, unwanted pregnancy, and
sexually transmitted diseases would be helpful for young girls as well as boys. Having a time for

29
boys and girls to have their own separate groups, but then working together might be a good
format to use in gender-specific prevention programmes.

Given the importance of abuse, and particularly sexual abuse, as a very strong vulnerability factor
in the development of substance use disorders, especially among girls and women, programmes to
prevent such abuse and, particularly, to support the victims and to address post-traumatic stress
disorders appear to be essential.

Finally, the association between eating and substance use disorders in some countries would
suggest some promising strategies with regard to addressing the factors of vulnerability of
adolescent girls and women to eating disorders (such as societal pressures on girls and women to
conform to unrealistically thin body ideals in some countries) and with regard to screening eating
and substance use disorders concurrently. Such components could be conceivably included
interventions in all major domains (school, media, community, family).

Monitoring and evaluation are more essential than ever, including gender
disaggregated data collection and analysis and the dissemination of results
Worldwide, the effectiveness of only a very limited number of drug prevention strategies is
evaluated and, of these, only a miniscule number collects data that are disaggregated by gender
and conduct the relevant analysis. This means that in practice, we know very little about the
effectiveness (or otherwise) of the vast majority of drug prevention interventions and policies that
are implemented globally, let alone about whether they benefit girls as well as boys. Moreover,
this serious situation is particularly the case (although it is by no means limited to) low- and
middle-income countries. That is why any strategy aiming at preventing drug and substance use
among girls and/or boys should include a systematic and scientific monitoring and evaluation
component. In the case of non-gender specific programmes, this should include sex disaggregated
data collection and analysis. For existing evidence-based programmes, secondary data analyses
could be conducted on all major prevention program data sets to determine their effectiveness for
girls as compared to boys. In all cases, results, including negative results, should be disseminated
widely, for the benefit of the drug prevention community globally.

Additional research is absolutely necessary

The limited existing research provides some precious indications as to how to maximize the
effectiveness of drug prevention strategies for girls as well as boys, but it is simply not enough.
This should not prevent us from acting now. However, in addition to the systematic evaluation of
interventions and policies as noted above, there is the absolute necessity of a deeper understanding
of which factors of vulnerability and resilience are really specific to girls and women and whether
and how this varies across cultures. Moreover, component analysis are needed to determine which
aspects of the interventions contribute the most to the effectiveness for girls and boys. In general,
we need to identify which aspects of the development, vulnerability and resilience factors and
patterns of use of girls and women need to be addressed and how in order to be prevent drug use
effectively among girls, or among girls as well as boys.

30
IV. Effective treatment, care and
rehabilitation of substance use
disorders for girls and women

Unlike the case of prevention, an increased awareness of women's complex treatment needs in the
context her substance use disorder led to the provision of funding for special services and
programs designed specifically for women in the 1980s. By now there is an established corpus of
scientific evidence and the purpose of this section is to summarize it in 10 basic principles,
including specific guidelines for both girls and women. It should be emphasized that once in
treatment, being biologically male or female does not predict drug dependence treatment outcome.
However, several established predictors of drug dependence treatment outcomes may vary in
prevalence, severity, or significance by sex, and these predictors may have a different level of
importance for drug treatment outcomes for women than men. The general principles of evidence-
based treatment, care and rehabilitation are well established (UNODC/WHO, 2016) and will not
be repeated here.

1. Women-centred treatment: accessible, responsive to

individual needs, strength-based, and with active patient
involvement
It is well established that girls and women have differences in the contexts in which they initiate
drug use, maintain their drug use and enter treatment for such use. For example, girls and women
are more likely to first try drugs in the presence of intimate male partners in their life. In contrast,
boys and men more often start drug use in the presence of peer relationships. Women commonly
begin using substances later in life than do men, report different reasons for maintaining the use of
the substances, and enter treatment earlier in the course of their illnesses than do men (e.g., Brady
and Randall., 1999). Women also tend to have a higher prevalence of comorbid psychiatric
disorders (e.g., depression and anxiety) than men. Although women may present to treatment with
more complex issues, women typically do as well as men in treatment.

Research and clinical experience has shown that women and girls respond well to treatments that
are women-centred. In fact, they have better treatment outcomes if they are in a women-only
treatment rather than a mixed-gender program (e.g., Hser et al., 2011). A women-centred program
is defined as having everyone in the program working to take into account the issues that girls and
women face in their lives. These issues include, but are not limited to, challenges to treatment
access and engagement. Specifically, women-centred treatment programs take into account social
and structural barriers limiting accessibility to treatment services and acknowledge the fact that
girls and women are both viewed as and serve the role of the predominant caregivers. Women-
centred care includes a trauma-informed program and provides trauma-specific interventions to
women who have such needs. Each patient is seen to have her own unique strengths and
vulnerabilities and treatment serves to promote her strengths and reduce vulnerabilities. Within a

31
woman-centred program, a patient is empowered to make informed decisions about her treatment
and is actively involved in all aspects of her care. The principles of women-centred treatment
shown below are based upon the premise that all health care practitioners will be sensitive to the
needs of girls and women.

Guidelines for adolescent girls

Provide treatment to girls that is based on their developmental age, not just their
chronological age.
Youth treatment providers should be sensitive to the developmental differences among girls and
make the necessary adjustments to accommodate such differences. The treatment of a 13-year-old
girl should not be identical to that of an 18-year-old girl. For example, treatments that rely on more
abstract thinking may not be as useful for girls who are just acquiring this type of thinking.
General developmental features that tend to distinguish younger from older girls, as well as some
guidelines pertaining to professional behaviour and attitudes that reflect these differences can be
found in the Treatment of Adolescents with Substance Use Disorders: Treatment Improvement
Protocol (TIP) Series 32 (Substance Abuse and Mental Health Services Administration, 2008).

Girls need special attention in terms of their stage cognitive development, coping skills
development and educational desires.
Girls entering treatment for substance use disorders often present to treatment with a cumulative
impact of psychological, health, and social consequences. Girls and boys may be poorly motivated
for treatment and have problems in the domains of mental health, academics, family, and
behaviour. They often have a limited range of coping and social skills. They may lag behind non-
drug using peers in achieving important developmental tasks, including individuation, moral
development, and conceptualization of future educational, vocational, and family goals (Rutter,
Giller, & Hagell, 1998). The complexity of the problems girls typically bring to treatment for
substance use disorders underscores their need for multimodal treatment approaches that address a
broad range of mental health and psychosocial problems beyond the treatment of the substance use
disorder (Riggs, 2003).

Based upon the developmental age of the patient, different services at different stages of
her life are needed.
For example, girls may need age-appropriate comprehensive sex education and youth-friendly
sexual and reproductive health services. For girls in their reproductive years, they may need family
planning and maternal health care as a part of treatment for substance use disorders. They may also
need support in defining what healthy relationships are and how to minimize the likelihood of
emotional, physical, and/or sexual abuse.

Keep girls separated from boys in treatment.

Programs for substance use disorder treatment need to recognize that mixing girls and boys within
a program risks harms to girls, as they may be harassed, may feel less comfortable to talk openly
about issues, and may feel less safe physically and emotionally in their treatment environment.

32
Identify multiple pressures girls have in their lives and help them develop positive coping
mechanisms to address them.
Girls who have a substance use disorder face unique challenges to their self-confidence, sense of
personal power, and ability to process emotional issues. Girls tend to be more sensitive to family
conflicts, and thus crave a stable social support network. Girls are more prone to depression than
boys. Thus, each of these factors deserve consideration in developing a treatment plan that is
responsive to each girl’s individual needs, building on her unique strengths and how to best
actively engage her in the treatment process.

Give girls the emotional support they need to feel physically and emotionally safe in
treatment.
Girls undergo different physical, social, and emotional changes than do boys and they are often not
given adequate support to deal with these changes. Treatment can be a time for girls to have a safe
space to develop and learn healthy behaviours that can promote transition into adulthood.

Treatment goals need to be clear, dynamic and collaboratively set with the girl.
Treatment will be most effective for girls when they take an active part in their treatment planning,
when goals are achievable and made clear, and when they receive constructive feedback on their
progress in treatment.

Guidelines for adult women

Create a treatment environment that empowers women.
One overarching barrier that women face in accessing treatment for substance use disorders is that
they may be living in very deprived circumstances. This deprivation is characterized by poverty,
inadequate basic health care and reproductive care, low literacy rates, lack of access to household
money and being victims of interpersonal violence. In some societies, women may have little
power or resources to change their life circumstances. Women need to be empowered by society to
take steps to change their life circumstances and minimize or eliminate the impact of gender
inequality in their life.

Review all structural aspects of the program to ensure as many barriers are minimized so
that women can access treatment.
Examples of structural barriers include the cost of treatment, the lack of treatment availability, and
the lack of access to transportation to and from treatment, because treatment may not be located in
an accessible part of her local community. Some programs refuse to accept patients who are
concurrently treated for psychiatric disorders. This limitation may have a greater impact on women
than men because women have higher prevalence of some psychiatric disorders such as anxiety,
depression and posttraumatic stress disorder and greater prevalence of use of psychoactive
medication. Many women with substance use disorders are at heightened vulnerability to
interpersonal violence (e.g., women exchanging sex for food, drugs, housing and or clothing) and
the lack of physical and emotional safety inside and outside the treatment program can be a barrier
to entering and remaining in treatment. The treatment schedule also needs to be flexible so that
treatment is compatible with her daily life activities. Women often have the primary childcare
giving responsibilities and on-site childcare for women to bring their children while they are in
treatment should be viewed as mandatory for any treatment program that is women-centred.

33
Train staff so that stigma, shame, guilt and fear can be quickly minimized for women in
treatment.
Examples of societal barriers that can impede women from seeking treatment for substance use
disorders include stigma, shame, and guilt related to substance use disorders. Women with
substance use disorders are typically more stigmatized than men with such disorders. This stigma
from family, friends and society creates the context for shame and guilt that women experience
about their substance use and their “failure” to live up to society’s expectations of being a good
daughter, wife and mother. These feelings may be even greater for women engaged in commercial
sex work due to the need for economic survival. In some societies, women have a real fear of
losing custody of children.

Women who are pregnant or parenting are often fearful of disclosing that they have a substance
use problem and are seeking treatment. They have an often well-founded fear that they will be
deemed an unfit mother and lose custody of their children. Women often lack of support from
family and/or a husband/partner in their life. Studies have documented that women are more likely
than men to have a substance using sexual partner and to have families of origin who have
substance use problems. Because relationships play such a significant role in women’s lives,
women living with a substance-using partner may be deterred from seeking treatment because they
fear the loss of the relationship. In some cultures, women may be forbidden to leave their homes to
go to treatment, or husbands may not support their wives leaving family and household
responsibilities. In these circumstances, family members may only bring women to treatment when
they are unable to fulfil their family responsibilities or are very sick.

For many women, substance use serves as a way to self-medicate emotional problems or the
experience of living in conditions of extreme distress. For example, some women are in
relationships that are characterized by shared substance use, physical and sexual abuse, HIV and
other infectious diseases and, sometimes, coercion into sex work and/or drug trade. In such
situations, women may feel overwhelmed by their life circumstances and unable to see a way out.
Research on women’s perceptions of treatment indicates that some women feel that they can
handle the problems themselves and/or lack confidence in the effectiveness of treatment. When
treatment is made more women-centred, the effectiveness of treatment can be improved.

Treatment goals need to be clear, dynamic and collaboratively set with the woman.
Treatment will be most effective for women, when they take an active part in their treatment
planning, when goals are achievable and made clear and when they receive positive feedback on
their progress in treatment.

2. Treatment that is based on theory and evidence

The most effective treatments for substance use disorders are those treatments that have a
foundation in theory, because theory provides a framework for all aspects of patient care.
However, even treatments provided based on a theoretical framework need to have accumulated
scientific knowledge, an evidence base, to support their use. The high standard of an evidence base
for many medical disciplines (e.g., cardiology) needs to be applied uniformly in the drug
dependence field. It is important to note that while treatments have been found to be efficacious
for girls and women, the majority of the research on substance use disorders and their treatment
has been conducted with men. Among the research on women, much of this literature is focused

34
on pregnant and parenting women. Thus, future research needs the active involvement of women
researchers and a focus on girls and women of all age ranges and across the life span.

Guidelines for adolescent girls

Pharmacotherapy to treat substance use disorders should be used with girls only after carefully
evaluating and discussing with the girl the risks and benefits of the medication. Many medications
commonly used to treat adult substance use disorders have not been studied in controlled trials
with adolescents. There is some support for the use of opioid agonist, especially methadone in
adolescents when they are considered able to consent to such treatment and it should be used for
adolescents with severe drug use disorder and high risk for continuing drug use. The consent
should be provided also by the parents and in compliance with national legislative policies.
Adolescents with a short duration of opioid use disorder who have a lot of family and social
support may respond to opioid withdrawal with or without naltrexone as a relapse prevention
strategy. Appropriate pharmacotherapy should also be used to treat co-occurring psychiatric
disorders as a part of integrated treatment plan that also involves psychosocial treatments
(UNODC, 2016). If medications are used in treating adolescents, they must be used with caution,
careful monitoring, and consideration of the developmental characteristics that distinguish girls
from women, such as developing hormones, brain development, greater impulsivity and polydrug
use (Riggs, 2003).

Evidence-based psychosocial interventions are effective and expected standards of

treatment for substance use disorders. `
Research on psychosocial interventions for adolescents with substance use disorders has made
significant advances in the past decade. Controlled trials now provide good evidence that several
psychosocial treatment approaches can be effective in treating girls and boys with substance use
disorders and other associated problems. Several of these interventions are based on modalities
that have been effectively used with adults and modified substantially to make them
developmentally appropriate for adolescents (Deas, Riggs, Langenbucher, Goldman, & Brown,
2000; Drug Strategies, 2002; Wagner, Brown, Monti, Myers, & Waldron, 1999). Behavioural
therapy has been shown to help adolescents become drug-free and to improve problems in other
areas, such as employment, school attendance, family relationships, conduct problems, and
depression (Azrin, Donohue, Besalel, Kogan, & Acierno, 1995; National Institute on Drug Abuse,
1999).

Family-based interventions should be used with girls as a component of treatment for

substance use disorders.
Family based interventions include structural strategic family therapy, parent management training
(PMT), multisystemic therapy (MST), and multidimensional family therapy (MDFT). They are
based on family systems theory and share the assumption that dysfunctional family dynamics
contribute to adolescent substance use disorders and related problems. In practice, clinicians
perform a functional analysis to identify problem behaviours, and relationship patterns that are
then targeted with restructuring interventions. Parents are taught better monitoring skills and basic
behavioural management principles to improve their adolescent’s behaviour and reduce drug use
together with strategies to improve overall family functioning and sustain the gains of treatment
(Drug Strategies, 2002; Wagner et al., 1999).

35
Cognitive-behavioural therapy can be used with girls.
Cognitive-behavioural therapy based on learning theory, also has been shown to be effective in
treating adolescent substance use disorders (Drug Strategies, 2002; Wagner et al., 1999). Evidence
exists to support both girls and women benefitting from cognitive-behavioural intervention
approaches where there is a functional analysis of substance use (e.g., understanding substance use
as it relates to the antecedents and consequences of substance use) and training patients in skills to
support abstinence (e.g., recognize and avoid times or occasions when there is a risk of substance
use and learn and apply coping skills if avoidance of these situations is not possible) (Carroll,
1998). Despite the emerging empirical support for use of cognitive-behavioural therapy among
girls and women, additional research is needed to best understand how it works for special
populations.

Motivational enhancement therapy can be a helpful adjunct to treatment but should not
be used as a stand-alone treatment for girls.
Motivational enhancement therapy has been used both as a stand-alone, brief intervention (for
example, among adolescents presenting to emergency rooms with alcohol-or drug-related injuries)
and integrated with other modalities such as cognitive-behavioural therapy (Monti, Barnett,
O'Leary, & Colby, 2001) 2001). Recent controlled trials indicate that treatment of co-morbid
psychiatric disorders alone is not likely to significantly reduce substance use or induce abstinence
in dually diagnosed adolescents e.g., (P.D. Riggs, Mikulich, & Hall, 2001)].

Guidelines for adult women

Women’s treatment needs to address women's specific needs.
These include childcare assistance, pregnancy, parenting, interpersonal violence, sexual trauma
and victimization, psychiatric co-morbidity, housing, income support, and social services. To date,
most substance use treatment models have been designed for men and based predominantly on
evidence from research with male participants. However, gender-specific interventions that are
designed to deliver information and services tailored for women are beginning to emerge in
response to mixed-gender programs, which often fail to address women's specific needs, such as
childcare assistance, pregnancy, parenting, interpersonal violence, sexual trauma and
victimization, psychiatric co-morbidity, housing, income support, and social services (Orwin,
Francisco, & Bernichon, 2001).

Pregnant women should not be turned away from treatment for substance use disorders.
In a meta-analysis examining single-gender treatment of women, Orwin and colleagues (Orwin et
al., 2001) concluded that single-gender treatment was effective and its strongest effect was on
pregnancy outcomes, psychological well-being, attitudes/beliefs, and HIV risk reduction.

Additional research is needed to determine which women will benefit from which
treatments.
Additional research is also necessary to elucidate gender differences in response to specific
pharmacotherapy and behavioural treatments, to identify subgroups of women who can benefit
from single-gender versus mixed-gender treatments, and to improve understanding of the
effectiveness and cost-effectiveness of gender-specific versus standard treatments (Greenfield et
al., 2010).

36
3. Staff demonstrating respect and empathy for their patients
All staff working with girls and women need to have the appropriate training, experience and
qualifications to work with girls and women who have substance use disorders. While this
background is critical for treatment, it is equally important to interact with patients in ways that are
respectful. Being respectful entails explicitly stating and maintaining the boundaries of patient
confidentiality and allowing patients to be autonomous, and have control over all aspects of her
care. The staff needs to work with an orientation of justice, beneficence, and without maleficence.
Patients respond best to staff who demonstrate empathy, the ability to see the patient’s views, and
create a treatment program that responds to these views. Program leadership has the responsibility
of ensuring that staff receives appropriate training, supervision, and ongoing support for
maintaining respect and empathy. Ideally staff should be trained and skilled in the unique needs of
girls and women; however, if the staff lacks such training, this absence of training should not be
used as a reason for excluding girls and women from treatment. There is a need to balance
adequate training with the need to provide services to girls and women.

Guidelines for adolescent girls

Treatment providers must be sensitive to motivational barriers to change at the outset of
intervention.
There are several strategies suggested by Miller and Rollnick for encouraging reluctant clients to
consider behavioural change (Miller and Rollnick, 1991).

The style and personality of the health care provider and the philosophy of care are
considered to be very important in the care of girls with substance use disorders.
The clinician needs to be genuinely interested in girls as individuals first, then in their problems,
and also in their parents. The clinician needs to genuinely feel at ease with girls and be able to
communicate well with her patients and the parents or caregivers. The clinician should help to
enhance family communication while assuring confidentiality when requested around personal
issues.

The clinician should establish rapport by listening and displaying interest.

It is important but not always easy to establish rapport with a girl during the first visit or several
visits. Listening closely to the girl can be a key to developing rapport, as is demonstrating concern
and interest with a non-judgemental attitude. The adolescent should also have time to ask
questions.

The clinician should ensure confidentiality.

It is critical to insure a sense of confidentiality with any patient, but most particularly with a girl.
The clinician should be familiar with those laws and regulations that cover consent and
confidentiality among minors in their particular locality. The limits of confidentiality should also
be discussed. Parents should also be aware of these confidentiality guidelines.

37
The clinician should act as an advocate.
Because a girl may have had encounters with some adults who have been non-supportive, an
opportunity presents itself for the clinician to stress the girl's positive attributes, characteristics and
abilities. This is not the same as supporting high-risk behaviours.

Guidelines for adult women

Staff should be trained in how to deliver treatment to women with respect and empathy.
Demonstrating respect and empathy towards women in every interaction is very much at the core
of women-centred treatment (discussed above).

Treatment needs to allow active and interdependent roles for women.

Treatment in this context takes into account gender roles and female socialization. It does not
allow sexual harassment while it supports active, interdependent roles for women. Treatment
emphasizes mutuality and empathy and empowers women not with power over others but with
power with others. Staff will also address women’s unique treatment issues, such as trauma,
parenting skills, coping mechanisms, and self-worth. Women feel more able to share power for
constructive, creative ends.

4. Continuous treatment planning, from screening to

discharge
Before a patient can receive appropriate treatment, the presence and severity of the alcohol and/or
drug disorders must be determined. Given that girls and women will very likely have multiple
treatment needs that span physical, mental and social domains, screening is needed to identify the
areas where help may be needed. Next, an assessment process is needed to determine the extent
and the severity of any problem that was initially identified in any domain of the screening. The
screening and assessment findings then form the basis of a personalized treatment plan to engage
the patient into treatment and address her issues. The intensity and duration of treatment should be
adequate to the patient’s needs. Numerous research studies support that patient outcomes are
improved if the modality and intensity of treatment matches the intensity of her pre-treatment drug
use and other psychosocial needs relative to every patient getting the same modality and level of
treatment. Treatment planning needs to be a dynamic process, taking into account the severity of
each problem that a patient has, as well as of each strength with which she presents to treatment.
Deciding and reviewing treatment goals best proceeds as a cooperative and interactive process
with the patient. Treatment planning needs to adjust as the patient progresses in treatment and
discussions regarding where the patient will receive continued services once treatment is
completed should be started well in advance of her discharge.

38
Guidelines for adolescent girls and adult women
Programs need a plan to reach girls who cannot easily access care.
For many locations in the world, women are a hidden and under-recognized population of people
with drug use disorders. Women often find treatment by word of mouth from other women drug
users. Thus, outreach from social workers and trusted community representatives can be helpful in
reaching women to educate them about the treatment services available and to provide them with
basic survival needs as they consider treatment options. In addition, outreach is often needed to be
able to reach hidden populations such as girls, who may not be able to access or easily engage in
structured forms of treatment.

Screening and assessment methods are important for determining the need for and type
of services for substance use disorders.
Screening and assessment tools for substance use disorders and other mental health issues for
women are available. These tools are also available for pregnant women. There are fewer reliable
and valid screening and assessment measures for youth, including girls, than there are for adults,
including women. Screening and assessment tools only for girls do not appear to be available.
When possible and appropriate, the girl’s parents or caretakers should be present at her initial
clinical interview. Their presence enables the counsellor to establish the rules of confidentiality
(including that reports of abuse, neglect, or threats of harm to self or others must be disclosed),
obtain early development history, and assess family dynamics. Subsequently, a private interview
with the adolescent is important to facilitate a strong treatment alliance and elicit candid
information about substance use and behaviour problems that the patient may not be comfortable
disclosing with parents present.

Consider the unintended consequences of labelling with diagnoses.

Even more than with boys and men, there may be unintended consequences of diagnosis of
substance use disorders and other co-morbid issues with women in that these labels may place
them at risk for harm in other areas of their life including family and others close to them. Being
identified as a drug user may also jeopardize the parental rights of women regarding their children
as well as any current employment. Although this might not be always the case, this consideration
should be kept in mind.

Take the time needed to build rapport and a solid trusting relationship
Engaging girls in treatment requires rapport to be built between a girl or a woman and the health
professional. She must trust that care will be given in a professional, confidential and respectful
manner. Girls and women are more likely to engage in treatment if the health care provider shows
empathy and therapeutic alliance with her. Further, providing women-centred care (described
above) will increase the likelihood that women will engage and continue in treatment.

Empowering increases the chances of a successful outcome

Treatment planning with girls and women is more likely to be successful when they are active
partners in setting goals and have a voice in their course of treatment. Treatment planning needs to
be a cooperative, collaborative effort between the girl/ woman and her provider; she needs
feedback and the opportunity to change treatment planning aspects that are not working for her.
Retention in treatment will be most likely to occur if the she feels empowered by the treatment
staff to make life changes.

39
Start thinking and preparing for discharge well before the expected last day of treatment.
Discharge planning needs to start early so that the patient is well prepared to leave the treatment,
put her new life skills to use, and have a smooth transition into their community.

5. Address issues over and beyond substance use disorder, in

particular history of abuse and psychiatric co-morbidity
Compared to boys and men with substance use disorders, girls and women with substance use
disorders tend to have greater medical, childhood, lifetime and/or current trauma and interpersonal
violence histories, as well as more current mental/psychological and social problems. Thus, these
multiple domains need to be considered as a part of complete treatment. While this document is
focused on a discussion of issues related to being an adolescent girl or woman, it is also critically
important that treatment be appropriate for a patient’s developmental stage in life, as well as
sensitive to such potentially important characteristics such as her ethnicity and culture, family
history, and sexual orientation.

Guidelines for adolescent girls

Emotional and physical neglect and/or emotional, physical and sexual abuse are very
likely in girls with substance use disorders and these issues must be concurrently treated.
As noted in the introduction, substance use disorders occur in the context of complex life issues.
These issues can include poverty, deprivation, poor nutrition, in the midst of environmental
disparity (e.g., no access to clean water), exposure to multiple forms of violence, forced work or
forced exclusion and untreated comorbid psychiatric disorders. For girls, there must be a keen
awareness of possible childhood and/or current trauma in terms of emotion and physical neglect or
emotional, physical and sexual abuse. These issues needs to be treated concurrently and integrated
into the substance use disorder treatment and not in parallel.

An integrated treatment strategy to treat the substance use disorder concurrent with the
co-morbid psychiatric issues is important for improving treatment outcome. Co-morbid
psychiatric issues of ADHD, depression, bipolar disorder, anxiety disorders and eating
disorders are prevalent in girls with substance use disorders.
Until very recently, little was known about the safety and efficacy of medications for treatment of
psychiatric disorders in adolescents with substance use disorders or the potential for adverse
interactions with used drugs. Thus, clinicians have been understandably reluctant to treat
psychiatric disorders with medications in this population, often referring youths for substance use
treatment before considering treatment of psychiatric co-morbidity. This sequential approach is
cautious, but it perpetuates a clinical conundrum. Treatment for the co-morbid disorder is withheld
pending successful drug treatment and achievement of abstinence, but the untreated psychiatric
illness significantly diminishes the likelihood of successful drug treatment. While caution is
reasonable and abstinence ideal before initiation of pharmacotherapy for a co-morbid disorder,
treatment risks must be balanced against the potential consequences of leaving psychiatric illness
untreated. Although there is not yet consensus on “best practices” for the use of medications to
treat co-morbid disorders for adolescents’ dual diagnosis, these recent advances offer preliminary

40
evidence for an integrated treatment strategy, moving current practice standards forward until
research can guide further refinement.

Bipolar disorder can be treated while the girl is in treatment for substance use disorders.
Data with adolescent girls and boys supports treating bipolar disorder in the context of concurrent
treatment for substance use disorders.

Adolescent girls with severe depression often need to receive both psychotherapy and
pharmacotherapy.
Current practice guidelines recommend that adolescents with severe depression receive both
psychotherapy and pharmacotherapy, while those with mild or moderate symptoms may be offered
a trial of psychotherapy alone before medications are considered (Birmaher, Brent, & Benson,
1998). Both cognitive behavioural therapy and interpersonal psychotherapy have demonstrated
efficacy for depression in adolescents without substance use disorders (Birmaher et al., 1998).
Cognitive behavioural therapy may also be helpful in treating anxiety disorders, including
posttraumatic stress disorder, in this adolescent girl population (Najavits, 2003). Medications to
treat anxiety disorders in substance abusing adolescents has not been well studied. However, some
girls may benefit from medication treatment of anxiety disorders in dually diagnosed adolescents
in conjunction with substance use disorders treatment, given the available data (from previously
mentioned depression studies) that fluoxetine (an SSRI) appears to have a favourable safety profile
even in adolescents who use drugs (Lohman, Riggs, Hall, Mikulich, & Klein, 2002).

Guidelines for adult women

Women need a holistic approach that includes addressing physical and mental health.
Like girls with substance use disorders, women face many of the same challenges. There is a need
to focus on a holistic approach to include both survival needs, basic health care, gynaecological
and psychological health as well as recovery from trauma (childhood and current), the ability to
become economically independent, live in safe housing, establish and maintain healthy
relationships and provide nurturing care for children. Build good working relationships with a
comprehensive list of community services. Referrals to other specialised and general services may
be needed.

6. Include interactive skills training and practice to improve

self-efficacy and competence
Outcomes for treatment of alcohol and/or substance use disorders will be improved if women are
given both knowledge of and support to change their substance use behaviour, as well as the
knowledge and opportunity to practice skills related to reducing other risky behaviour and problem
areas in their lives. With skills practice in a safe environment, girls and women may gain self-
efficacy, the belief that they can make meaningful changes in their lives, and the confidence and
competence to make these changes.

41
Girls need developmentally appropriate positive models and practice of skills such as conflict
negotiation, communication, drug refusal skills, and risky behaviour reduction. Providing
homework outside of the treatment day can also reinforce skills. The homework used in cognitive-
behavioural therapy has also been an active ingredient for reducing substance use among women.

In addition, women deserve to have accurate information about sexual and reproductive health and
the materials and skills to protect themselves. Women have been shown to benefit from learning
new knowledge and practicing skills such as condom use to reduce risky sexual behaviour.

7. Recognize and address the unique needs of women during

pregnancy and the post-partum period
While the vast majority of girls and women who enter treatment for alcohol and/or drug use
disorders during pregnancy were using substances before they became pregnant, pregnancy can be
a time that adolescent girls or women may be open to receiving treatment for their substance use
disorder due to their concern over the health of the unborn child. For in-depth guidance on the
management of substance use disorders during pregnancy, the reader is referred to the recently
published guidelines by WHO (WHO, 2014).

A pregnant adolescent girl or woman should receive prenatal care and not be forced to terminate
her pregnancy or feel stigmatized by any health care provider. Pregnant girls and women should be
offered counselling if they do not want to end a pregnancy. For pregnant girls and women, the
stigma of having a substance use disorder, the fear of losing custody of her child, and the threat of
incarceration and/or being mandated to enter treatment often pose insurmountable barriers to her
seeking treatment. Creating a treatment environment that is welcoming, non-judgmental, and
supportive is essential to overcoming such barriers.

A pregnant adolescent girl or woman deserves to receive treatment that matches the severity of her
alcohol and/or drug use disorder. For heroin, opiate, opium and prescription-opioid-dependent
patients, methadone and buprenorphine pharmacotherapy have been shown to improve maternal
and infant outcomes compared to no treatment for the substance use disorder. In most cases,
detoxification from opioids followed by no medication or the tapering of methadone or
buprenorphine will result in relapse to opioid use unless patients have strong psychosocial
resources and high motivation to remain opioid-free. In any case, programmes should expect that
poly-drug use is the norm, not the exception and treat multiple drug use in an integrated manner.
Although there are medical complications associated with specific drugs, it is rare that a pregnant
woman’s substance use disorder will include only one drug. As a result, there are both multiple
medical risks and cumulative medical risks due to concomitant substance use and these need to be
taken into account.

In addition to medical care, patients will need specific educational information about several
issues. It is helpful to discuss with the patient the scope of prenatal care in terms of what to expect
at each visit and the reasons for certain procedures and tests. The discussion should also include
the specific risks of substance use and particularly drug interactions (e.g., methadone and
benzodiazepines). Prenatal health education should be provided through classes conducted by
nursing staff, videos, and/or printed booklets. Any printed materials must be written at the
appropriate reading level for patients. Opioid-dependent pregnant patients should have a thorough

42
understanding of the risks and benefits of medication-assisted treatment in pregnancy. The
adequacy of the methadone or buprenorphine dose should be discussed so that the patient
understands the difference between symptoms of withdrawal and normal discomforts of
pregnancy; how a therapeutic dose varies for each individual so that the appropriate dose for her
may differ from that of her fellow patients; how her dose may need to be increased as her
pregnancy progresses; how to recognize foetal stress if she begins to experience withdrawal; and
the risk to both her and her foetus of continued substance use. She should understand that upon
delivery her opioid agonist medication dose may need to be tapered down, and she should request
a decrease if she feels overly sedated. Patients being treated for substance use disorders have a
great deal of misinformation about sexuality, pregnancy, labour and delivery, birth control, and
breastfeeding. Education about these aspects of care can be provided individually or in group
formats.

Great care needs to be taken in ensuring that girls and women are informed about any medical
procedure before it occurs giving them power and decision making can help avoiding re-
traumatizing those who have a history of victimization. Pain management during labour and
delivery needs to be taken seriously as many individuals with substance use disorders have
increased sensitivity for pain. For opioid users, they may need more pain medication to achieve
pain relief than their non-opioid using counterparts. For prenatally opioids exposed babies, they
should be evaluated for neonatal opioid withdrawal and a protocol needs to be in place for
assessing and treating such babies. Recent research has also found that mothers and babies have
better outcomes if the mother and baby are kept together and not separated due to neonatal opioid
withdrawal monitoring or treatment.

Guidelines for adolescent girls and adult women

Pregnancy in adolescence requires special care
Girls are at higher risk of obstetrical problems than women Moreover, even more so than in the
case of adult women, they need to be prepared for labour and delivery, as well as about caring for
themselves and their baby before and after birth.

Programs should have a good working relationship with social and child protective
services.
The legal framework and the organisation of services for the protection of children can vary
greatly globally and drug treatment and care programs and staff must always be clear of their
responsibilities as health care providers in this respect. In this context, and as appropriate, they
should provide the support, clinical services, and referrals necessary to eliminate or reduce the
chances that the mother will need to be reported to child protective services.

Pregnant girls and women with substance use disorders should not be turned away from
obstetrical care.
Obstetrical complications that occur in pregnant girls and women with substance use disorders are
similar to those observed in pregnant women who do not receive prenatal care, such as
spontaneous abortion, stillbirth, placental insufficiency, intrauterine growth retardation, premature
labour/delivery, premature rupture of membranes, anaemia, preeclampsia, and abruptio placentae
(Curet & Hsi, 2002; Finnegan, 1979). Therefore, pregnant girls women with substance use
disorders must receive appropriate screening and assessment. They must be engaged in treatment

43
services as early in gestation as possible, and treatment programs must provide coordinated
services that include both prenatal care and substance use treatment.

Obstetrical and drug treatment services are most beneficial for girls and women when
they are provided in an integrated manner.
Coordinated services can be provided in different settings: prenatal and obstetrical care can be
integrated within a comprehensive substance use treatment program (Finnegan, Hagan, &
Kaltenbach, 1991), or substance use treatment can be part of a comprehensive perinatal care
program for women in treatment for substance use disorders (Curet & Hsi, 2002).

8. Adapt the delivery of treatment to the ethnic, cultural, and

socio-economic context of the patient
Drug treatment for girls and women has a greater opportunity to be effective if it is adapted to the
local situation and circumstances of girls and women in the local community. While there are
many different treatment modalities and evidence-based approaches available, these methods need
at least minimal adaptation to be accepted, utilized, and effective in different treatment contexts.

Great care needs to be taken in both the selection of treatment modalities and evidence-based
approaches, as well as how the methods are refined for the local situations and circumstances. A
careful, sensitive and thorough process of verification needs to be undertaken to ensure that any
adaption of a treatment still retains the essential elements of that evidence-based intervention and
that this adapted treatment meets the actual needs of the girls and women.

Girls and women who are ethnic minorities may encounter additional barriers when accessing
substance use disorder treatment services, including language difficulties and or incompatible
aspects of treatment with religious or spiritual practices. Ethnic, cultural, and religious diversity
needs to be taken into consideration when providing treatment. Cultural mediators may need to be
involved as outreach for these patients in order to help them in attending and engaging in
treatment.

Guidelines for adolescent girls and women

Consideration of the ethnic and cultural status of girls and women and honouring and integrating
these aspects into their care may help increase treatment engagement, especially in the case of girls
and women who belong to ethnic minorities. For example, using traditional stories or learning
about the traditions or history of her culture or ethnicity.

44
9. Include frequent and systematic monitoring and evaluation
components
It is the treatment program’s responsibility to ensure that quality care is being provided to patients.
Evaluation and feedback on service and system performance for quality is needed from the staff,
the patients and the larger community. A regular monitoring and evaluation system is needed
because the types of drugs and consequences of drug use change over time as does the patient
population seeking treatment. Thus, programs need to keep current with changing trends in drug
use patterns and psychosocial functioning to best meet patient needs.

Guidelines for adolescent girls and women

Treatment for girls and women needs to include feedback from them about the process
and experience of treatment.
Girls and women should be given opportunities to provide feedback about the program in a safe
way where there is no fear of negative consequences based on a negative evaluation of the
program. Conducting focus groups, in-depth interviews or surveys about the likes and dislikes and
satisfaction with services as well as suggestions for improvement can help the treatment program
stay current in providing what patients need.

Adolescents in particular can benefit from concrete feedback and monitoring.

Girls are often very relational in their life orientation and having the chance to see how they are
progressing in treatment, getting praise or gentle corrective feedback about what can be done in
the future can help her modify future behaviour.

Adolescents in particular can provide useful information for the planning of treatment
services.
Asking girls about the latest drug trends, how drugs are being used, what drugs are being used,
what new trends they are seeing can help the treatment system prepare for new emerging drugs
which may require different treatment responses.

45
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