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Book Review | October 01, 1999

Women and Substance Abuse: Gender Transparency ? Women, Drug Use, and HIV Infection

Patrice M. Muchowski, Sc.D.

Psychiatric Services 1999; doi:

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edited by Sally J. Stevens, Ph.D., and Harry K. Wexler, Ph.D.; Binghamton, New York, Haworth Press, 1998, 277 pages, $59.95 hardcover, $24.95 softcover • edited by Sally J. Stevens, Ph.D., Stephanie Tortu, Ph.D., and Susan L. Coyle, Ph.D.; Binghamton, New York, Haworth Medical Press, 1998, 237 pages, $49.95 hardcover, $19.95 softcover.

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The perspective of both these books is refreshing, as general books on substance abuse provide little information on women's needs, and most books on women and substance abuse are not research focused.

The first book, Women and Substance Abuse: Gender Transparency, consists of 15 research papers in five sections. Section 1 focuses on HIV risk behaviors and includes useful statistical information about substance abuse among women and HIV infection. The authors make the point that effective intervention programs must understand cultural needs. The chapter by Weeks and associates does the best job of developing recommendations from the research reported. As welcome as the research focus is, the chapters are somewhat laborious to read, although useful information is available in each.

The second section consists of three articles that illustrate the heterogeneity of women drug abusers. Again, the authors state that racial-ethnic factors must be understood if outreach, intervention, education, and treatment services are to be effective. Although women substance abusers as a whole tend to be stigmatized, stigma is expressed in different ways in different cultures. Wechsberg and Cavanaugh's article underscores the heterogeneity of women substance abusers and suggests that no one program or modality will be beneficial to all women.

Section 3 addresses sexually transmitted diseases and violence. Murphy and associates' paper, "Women and Violence: A Different Look," examines women as perpetrators as well as victims of violence. The recommendation that treatment programs need to address the problem of violence by women through skills training is very useful. Three research papers on the physician's role in assessing women, including pregnant women, for substance abuse constitute section 4. The findings reinforce previous reports of underdiagnosis of substance abuse by health care professionals.

In section 5, which examines treatment, Lockwood and associates usefully identify specific changes carried out in a prison-based therapeutic community model to make it more sensitive to and appropriate for women. Studies by Wexler and others and by Stevens and Patton examine the benefits of including children along with their mothers in treatment settings. These articles are helpful, as women often cite children as a barrier to gain access to treatment.

Women and Substance Abuse: Gender Transparency emphasizes several important points for understanding women and substance abuse. First, female substance abusers are a heterogeneous population. Second, they continue to be at great risk for HIV infection despite increased media attention and community education. And finally, different strategies for engaging and retaining women in treatment need to be developed for different groups of women.

The book provides useful data for anyone who works with female substance abusers. However, it could have increased its value by analyzing the implications of the research studies and by developing recommendations for practitioners.

The second book, Women, Drug Use, and HIV Infection, comprises 13 research papers from a multisite project on HIV infection that was sponsored by the National Institute on Drug Abuse. The editors present an excellent overview of HIV prevalence among women drug users as well as major HIV risk factors for this group. The risk factors are divided into sex-related factors—unprotected sex, multiple sex partners, or sex with high-risk males—and drug-related factors, such as frequency of use and sharing of needles and other equipment. In addition, the authors have expanded the concept of risk to include individual, relational, social, environmental, and cultural factors, thus providing a working model for designing intervention programs for women.

The book is organized in sections on changing specific risk behaviors, descriptions of two intervention programs, contextual variables in women's risk behavior, and gender differences in HIV risk behavior. A final section discusses female prostitution and its impact.

One of the two papers in the behavior-change section indicates that a standardized two-session intervention significantly reduced sex-related and drug-related risk. The second paper describes an enhanced intervention program that also demonstrated positive results, but with the greatest gains for subjects with less risky behaviors.

Singer and associates offer a useful discussion of the relationship between risk perception and risk behaviors. They report findings from studies of other diseases that clients initiate behavior change only after seeing personal, serious risk. In their sample the authors noted a high rate of incongruence between the women's risk factors and their behaviors. The more isolated the women were, the greater the discrepancy was. On a positive note, women who perceived themselves at high risk lowered their risk. It would have been valuable if the authors had presented specific methods to help women personalize their risk.

Two papers address condom use. Fenaughty and associates suggest that to tailor interventions to promote condom use, practitioners must clarify the reasons that condoms are not used, such as fear of retaliation from one's partner, embarrassment, or inability to purchase them. Wood and associates add that a woman's beliefs about condom use constitute a positive or negative factor in enhancing use. Readers gain a greater perspective on the complexity of designing effective interventions to reduce sex-related risks.

In the section on contexual variables, Cattarello and associates note that a one-size-fits-all prevention message will not succeed. The size of the city in which the intervention is planned, the primary drugs used in that city, and women's immediate survival needs must be taken into account. Metsch and others examine the impact that a woman's living situation has on HIV risk.

An especially thought-provoking paper on the relationship between violence and HIV risk-taking behavior is presented by contributors He and colleagues. However, specific prevention methods for such at-risk women are not provided.

The rate of HIV infection among women continues to rise, and prevention methods developed for men are not applicable to most women. Women, Drug Use, and HIV Infection provides useful data and thought-provoking strategies. The authors state clearly that intervention efforts need to be targeted to both sex-related and drug-related risk behaviors.

Because all the chapters are research papers, some readers may find them difficult to read. However, the majority present implications of their findings in the discussion section, offering much food for thought for practitioners. Women, Drug Use, and HIV Infection is a valuable resource for any practitioner working with women.

Dr. Muchowski is vice-president of clinical services for AdCare Hospital of Worcester, Inc., in Worcester, Massachusetts.

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Patrice M. Muchowski; Women and Substance Abuse: Gender Transparency ? Women, Drug Use, and HIV Infection. Psychiatric Services. 1999 Oct;50(10):1370-1371.

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