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I Drug Use by Young Females
Health Education Unit
The University of Sydney
This report was produced by the Staff of the Health Education Unit, The University of Sydney.
Principal Author: Tess McCallum
Research and editing: Audrey Christie, Jane Ashfield, Meg Pickup, Alf Colvin, Jenni Bonnitcha & Maryanne Bohr
Word processing: Maryke Sutton
The research project on which this report is based was commissioned by the Commonwealth Department of Health and Family Services, as part of the National Initiatives in Drug Education (NIDE) Project.
Opinions expressed in this publication are those of the authors and do not necessarily represent those of the Commonwealth Department of Health and Family Services.
This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source and no commercial usage or sale.Requests for reproduction for other purposes should be addressed to The Director, Health Education Unit, Faculty of Education, Building A35, #328, The University of Sydney, NSW 2006. The Health Education Unit is funded by the NSW Health Department.
This report investigates the nature of, and trends in, drug use (including alcohol, tobacco, medicinal drugs, illicit drugs) by young females with specific reference to the Australian situation. Although it is now widely recognised that females, as well as males, are drug users, historically gender has not been considered to any great extent or included in the research on drug use and abuse/or related harm. This investigation therefore comprises:
- a gender-specific Literature Review to identify the major variables relevant to understanding the complex nature of gender differences in drug use amongst young people;
- a series of interviews with Key Informants working in the field; and
- a number of Recommendations emanating from the findings of the Review and interviews.
The Literature Review examines a concept of female gender and drug use based on the interaction of biological and psychosocial factors, and how this concept is influenced by social norms (including those norms of sub cultures) and perpetuated by the media. The reasons for drug use and patterns of use are examined. It will consider psychosocial, personal, biological, socio-cultural and environmental factors relating to young female drug use.
Interviews with the Key Informants largely confirm the findings of the Literature Review and pinpoint issues relevant to the Australian setting. As a result of the Literature Review and Key Informant interviews, Recommendations are made which are in accordance with the accepted criteria for reducing the harm of drug use, specifically among young females.
Summary of Recommendations v
DRUG USE BY YOUNG FEMALES: 1
A LITERATURE REVIEW
The Research 1
The Meaning of Gender 2
Biological Factors 3
Social Factors 4
Convergence of Male and Female Drug Use? 9
Young Females in Custody 12
Female Pressures and Coping Strategies 12
The Importance of 'Staying in Control' 18
Stereotypes Refuted 22
A Healthy Combination of Masculine and Feminine Traits? 23
Advertising and the Media 25
Eating Disorders and Substance Use 27
Violence and Sexual Abuse 30
SUMMARY OF MAIN POINTS FROM INTERVIEWS
WITH KEY INFORMANTS: IDENTIFIED ISSUES AND
SUGGESTED STRATEGIES 35
Key Informants Interviewed 39
DISCUSSION AND RECOMMENDATIONS 41
Information Retrieval 66
Summary of Recommendations
1. Target biological differences in education and health promotion.
2. Present harm from drug use in a positive, non-judgemental and credible manner.
3. Acknowledge the benefits of drug use as perceived by young females.
4. Seek the acceptance of female drug use by the community.
6. Seek the adoption by all stakeholders of common approaches to drug issues relevant to young females.
7. Educate the educators about gender specific issues related to female drug use.
8. Introduce mental health education for young people.
9. Correct distorted perceptions of young people's drug use.
10. Utilise culturally appropriate settings to educate young females about drugs.
11. Ensure that drug education and drug policy in schools is mandatory.
12. Target post-school young female groups in appropriate settings.
13. Target smoking and passive smoking with health promotion.
14. Encourage a healthy balance of 'masculine' and 'feminine' traits amongst young women.
15. Provide opportunities for leisure activities and sport for girls.
16. Encourage early (or potentially early) school leavers to stay at school.
17. Recognise the needs of, and increase support for, homeless young females.
19. Identify 'drug cultures' and friendship groups, and provide relevant drug education programs to meet their needs.
20. Utilise females as peer educators in drug education for young females.
21. Recognise the needs of, and increase support for, young lesbians.
22. Initiate programs, campaigns and legislation to counter the impact of advertising and the media on young females.
23. Challenge the dominant 'body image' stereotype which can perpetuate the misuse of drugs by young females.
24. Recognise the relationship between sexual abuse in childhood and young females' drug use, and take appropriate action.
25. Restrict young people's access to tobacco.
26. Provide adult drug education and encourage parents and others to attend.
Drug Use by Young Females
A Literature Review
The intention of this literature review is to identify major variables relevant to understanding gender differences in drug use amongst young people - with particular reference to young females. Although drug use by males is still generally higher, it appears that the gap between the sexes is narrowing (Amos, 1996; Gfellner & Hundleby, 1994; Hanson, 1994; Rienzi, McMillin, Dickson, Crauthers, McNeill, Pesina & Mann, 1996; Robbins & Martin, 1993; Waldron, 1991; Wilsnack, Wilsnack, & Hiller-Sturmhoffel, 1994; ). There is a consistent trend world-wide of an increase in drinking, smoking and other drug use amongst young women. Therefore, it is important to ask the question: how do we account for this? As with most human behaviours, there is no single cause, or simple explanation, for drug use. However, despite some convergence with cannabis, alcohol and tobacco use (McAllister & Makkai, 1991), males still outnumber females in prevalence of alcohol and other drug use (Gullotta, Adams & Montemayer, 1995; Lammers, 1995).
The growing body of research literature which demonstrates that alcohol and other drug use, and their health-related problems, are increasing among young women, reveals a complex issue. This complexity arises out of the multiple biological and psychosocial factors which influence gender alone, not to mention their interaction with the dynamics of drug use. Drug use itself is complex. As Broom (1994) succinctly puts it in her book 'Double Bind', "When gender is introduced it must not be reduced to a simplistic addition to the complex dynamics of drug use" (p. 205). That is, if we are to understand the role of gender in drug use we need to see it "as a dynamic construct that itself varies across ethnic groups and social classes and works in complex interactions with other physiological and social factors" (Rodin & Ickovics, 1990, p. 1026). Understanding the relationship between gender and drug use, therefore, is not simply a matter of 'add gender and stir'.
An important starting point is to acknowledge that historically, gender has been a 'blindspot' in much of the research on drug use and abuse (Lammers & Schippers, 1991). That is, most research up until the 1980s was based on male perceptions and male constructs of drug use, which by its very nature, neglected female drug use (Davey, 1994; Temple-Smith & Hamilton, 1991). Some studies ignored women entirely, others included women but ignored gender, simply combining men and women in the analysis. Authors of many studies thus generalised from male subjects to 'people', and those which addressed women's drinking focused on alcoholism rather than social drinking in the general population. As Henderson (1993, p. 127) says: "It is a familiar sentiment by now that the literature on drugs is limited when it comes to the subject of gender and drug use. All too often studies have ignored gender as a factor influencing drug use and extrapolated from the male experience." Thus the literature on women's drug use is still comparatively small, and, if the subject on drug use and pregnancy were excluded, much smaller.
Lammers and Schippers (1991) suggest that this bias in respect to gender is not so much an attitude of individual researchers, but is a structural problem - that female drug use, in particular drinking, has not been seen as relevant. If we take the word 'relevant' here to mean 'visible', or 'recognised', perhaps this seeming 'invisibility' of women's drug use can be explained by social conventions and sanctions.
Traditionally male drug use, especially drinking, has been public and social, which suggests it was socially sanctioned. Female drug use, on the other hand, has usually been much more covert and private (particularly with some drugs, and in some cultures) which suggests it was socially unsanctioned. Gomberg (1982) and others have argued that females have traditionally been encouraged to use drugs in medicinal, therapeutic ways, while males have been encouraged to use drugs for recreation and pleasure (Swift, Copeland, & Hall, 1995).
This could well explain why most studies have concentrated on male drug use, and it partly explains the differences in drug use between the genders. Perhaps it also begins to give an explanation of how these differences came about in the first place and begins to give an insight into the current increase in drug use among females as compared to males (ie, the social sanctions for females are being lifted while they remain the same for males?). However, it gives us no insight into the complexity of the relationship between drug use and gender. (Cooney, Dobbinson, & Flaherty, 1993; Corti & Ibrahim, 1990; Gfellner & Hundleby, 1994).
THE MEANING OF GENDER
A clue to this can perhaps be found in the meaning of the word 'gender'. Gender is said to mean more than just male or female. Rather it is a description of the traits and attributes which society ascribes to each sex. That is, gender is socially constructed. It transforms female to mean 'feminine' and male to mean 'masculine', and by so doing it defines our expectations of both male and female behaviour.
The implications of 'masculinity' and 'femininity' for drug-related behaviour are therefore potentially very illuminating. Unfortunately, little research has been done on this, to the detriment of both sexes. Although most research has concentrated on male drug use, it has not acknowledged the 'masculine' nature of its subject matter, or rather, ". . . the implications of masculinity for drug-related behaviours and harm were not looked at . . . ." (Broom, 1994, p.200). Therefore, this author concludes, "Ignoring the relevance of masculinity goes along with ignoring the relevance of femininity; they are two sides of the one coin" (Broom, 1994, p. 200). Even attempts to address this imbalance in gender focus, by specifically highlighting women's drug use have meant that "male experience has once more escaped exploration as such and remained in its generalised and generalizable state - a fact sometimes not so widely recognised" (Henderson, 1993, p. 127).
Also, how data has been collected is relevant here - for example often from people in treatment, the nature of which has resulted in fewer women being 'eligible' for inclusion in a study (usually due to the stigma attached). A social construction of gender which is limited to a description of traits and attributes, therefore does not sufficiently explain the implications of 'masculinity' and 'femininity' for drug related behaviour.
A further problem with simply looking at gender as 'a single variable' is that of 'false universalism'. Concentrating on a gender dichotomy assumes that all members of one sex are essentially similar and therefore a unified social category. This not being the case, it is necessary to consider 'within gender-group' variability and not to oversimplify when looking at gender differences in drug use.
The reasons for the variability between male and female drug use may be biological or behavioural, or most likely, be an interaction of both at several levels. Therefore, when ascribing gender differences in drug use to socialisation, it is important to acknowledge the extensive biological differences that contribute to differences in how sex roles are defined. For example, biological factors mean that females have a lower tolerance of alcohol than males and therefore reach the same blood alcohol levels with a lesser amount of alcohol consumed. Females' lower average body weight and the lower percentage of water in their bodies (51% v. 65%) mean that their blood alcohol level will be higher with the same amount of alcohol consumed. Also, first-pass metabolism (absorption of part of alcohol in the stomach) functions less strongly in females than in males, or not at all (Swift et al., 1995).
To add to this complexity, women's absorption rates and blood alcohol levels are more variable than males and are affected by progesterone levels that fluctuate across the menstrual cycle (rising after ovulation and before onset of menses) (Lex, 1991). According to Blume (1990) the reported increases in alcohol's effect during the pre-menstrual phase may be a function of menstruation dysphoria rather than a response to the cycle itself. Females are also more susceptible to alcohol-related brain injury, and develop dependency at lower levels of use and in a shorter time (Copeland, 1995a).
In the past, heavy emphasis has been given to the effects of drugs on women's reproductive functions and the foetus. Now a broader literature exists, particularly on women and alcohol, which tends to incorporate a wider range of variables and address a larger number of issues (Blume, 1990; Gomberg & Nirenberg, 1993). Also, to focus on 'drugs in pregnancy' as the primary concern with women's drug use reinforces the 'other than self' role of females, which further reinforces female drug use as 'deviant'. If the main reason for females to refrain from drug use is the impact on the foetus (or child), how are females who are not pregnant (or already mothers) to be addressed? Does the social stereotypical expectation that they will become mothers reinforce their 'other than self' role and therefore their drug use as deviant? This is not to say that drug use by pregnant teenagers should be ignored - drug use which affects the well-being of the foetus and the pregnant female definitely needs to be addressed. It is also noteworthy that pregnancy has been found to motivate long-term change in substance use by young females.
Other biological variables such as female fat tissue affect the metabolism of different drugs, eg. cannabis. Female cannabis use and effects fluctuate more than males. This may reflect social influences (females smoke mostly at weekends) but it may also be related to the greater amount of lipid (fat) tissue in females which can store and gradually release THC (Lex, 1991) - ie, THC stays in the female body longer. The same applies to the benzodiazepines (minor tranquillisers) which are lipid-soluble and therefore have longer half-lives in females, which means the effects last longer (Blume, 1990).
With tobacco the situation is similar to alcohol - evidence exists that males metabolise nicotine more quickly than females, and females are more sensitive to nicotine than males (Carton, Jouvent & Wildocher, 1994; Gray, Cinciripini, & Cinciripini, 1995; Krupka & Vener, 1992; Winstanley, Woodward, &Walker, 1995; ). Additionally, females are at risk from a number of sex-specific problems due to smoking, such as decreased fertility, irregular or absent periods, harm to the foetus if pregnant, and a tenfold increased risk of a heart attack for a female who smokes and also takes the contraceptive pill (Winstanley et al., 1995).
It is not only smokers, however, who are at risk, but also females exposed to passive smoking. Research findings from Australia and overseas have confirmed that passive smoking increases the risk of heart disease, even in the teenage years, and is the third leading preventable cause of death (Winstanley et al., 1995). A NSW study has shown that passive smoking more than doubles the risk of heart disease among women (Kawachi, Colditz, Speizer, Manson, Stampfer, Willett, & Hennekens, 1997). Passive smoking also increases the tendency of absent or irregular periods, and during pregnancy is a risk factor for Sudden Infant Death Syndrome, lower birth-weight babies, higher risk of miscarriage and stillbirth. The evidence that passive smoking is harmful to females is increasing (Winstanley et al., 1995).
It can be concluded from the above, therefore, that females are at an increased risk of adverse health effects from most drugs because of male-female metabolism differences (Blume, 1990; Opland, Winters & Stinchfield, 1995). Unfortunately, many females do not know about their lower tolerance to alcohol, and that they cannot adopt masculine styles of drinking because their bodies are different. In fact, young females' knowledge of gender-specific harms from drugs in general highlights the deficits in their knowledge.
There is a need, however, to incorporate a broader understanding of the lives of females at risk, and it is the social and psychological variables important in the development of female problem drug use that are more completely and specifically addressed in the broader literature (Fillmore, 1987; Wilsnack, Klassen, Shur, & Wilsnack, 1991). The social norms of femininity and masculinity are significant in shaping young people's drug use. However, as the social norms operating for both male and female drug use become more alike, females, because of biological factors, may be exposing themselves to increased risk.
Drinking norms are associated predominantly with male characteristics. "There is still a sense of bravado and machismo about going out and getting drunk with a group of friends, and this is a frequent behaviour of some young males" (Lowe, Foxcroft, & Sibley, 1993, p. 107). Males generally are expected to drink in our society (Broom, 1994; Bui, 1993; Peake, 1994; Thomas, 1995). Drinking is seen as confirming adulthood and displaying masculinity (Broom, 1994), even to the extent of getting drunk as being a 'rite of passage' to adulthood. This rite of passage, according to one author (Peake, 1994), has replaced traditional puberty rites whereby the boy is initiated into manhood by tribal 'elders'. Through elaborate trials and initiation rites the symbolic death of the child enables the birth of the adult. 'Binge drinking' is also a way of male bonding in our culture, and this isn't just confined to getting drunk together. Apparently, (for some) a good vomit together is also seen as a bonding experience (Bui, 1993).
There seems to be no equivalent 'rite of passage' which confers adult status on young women. Girls mature earlier than boys, and have the ability to reproduce before they are recognised as adults - yet there is no formal recognition of this change in status, or their increasing independence (Banwell & Young, 1993). Femininity certainly does not endorse things like drunkenness as a sign of adulthood. It seems that girls have to create their own signs, and this is possibly one reason that they turn to smoking. Smoking can be seen as an 'anticipatory rite of passage' - ie, seizing adult status in advance. Smoking doesn't affect respectability in the same way that drinking does. "Thus, for females, cigarettes may offer an alternative substance which is not restricted socially or physically in the same way alcohol is. Smoking by younger females could be an important, although potentially harmful, 'equal opportunity' substance use strategy" (Lowe et al., 1993, p.108).
This is not to say that girls are not drinking. There is considerable consensus in the literature that while males still drink more than females (Cooney et al., 1993; Corti & Ibrahim, 1990; Gullotta et al., 1995), the gap is in fact narrowing (Gfellner & Hundleby, 1994; Gullotta et al., 1995). A large proportion of younger women are now drinking at hazardous levels (Gomberg & Nirenberg, 1993) as well as exceeding boys in the use of cigarettes (Gfellner & Hundleby, 1994).
Similarly, the social milieu surrounding the use of illicit drugs, such as cannabis and heroin, appears to vary as a function of gender. Girls who consume illicit drugs receive a more extreme and negative societal reaction than boys (Erikson & Murray, 1989).
A powerful determinant of any behaviour, including drug use, is its social context, meaning and function. For example, young people have been found to use drugs to promote an image which facilitates their membership to a chosen peer group (Odgers, 1996). While this can apply to different groups of young women, as described, it can just as easily apply to young males. Social expectations, especially in relation to drinking, govern much of male drug use. The relationship, however, is not as uni-directional as it seems. Some findings are showing that young males don't just drink because it is expected of them, but many also drink to 'facilitate social contact and to reduce social tension' - especially with the opposite sex (Gullotta et al., 1995; Rabow, Watts, & Hernandez, 1992; Thomas, 1995; Wilson, 1988).
The picture is similar for male use of the illicit drugs. For example, there are clear gender differences in the reasons males and females use heroin. Females give more psychological reasons, such as depression, whereas males give more physiological reasons, as well as for loosening up in social situations (Binnion, 1982; Turner, Norman, & Zunz, 1995).
To reiterate a central theme here, females often use drugs to cope with very real
pressures and the underlying tensions of their lives, and males drink and use other drugs to deal with external pressures and to feel disinhibited (Buelow &Buelow, 1995; Lammers and Schippers, 1991; Winstanley et al., 1995). Winstanley et al. (1995) adds that females are more likely to relapse with drinking and other drug use when feeling sad or depressed, and males when dealing with external pressures. There is a specific Australian study which also supports this (Saunders, Baily, Phillips & Allsop, 1993). With male heroin users, their greatest difficulties appear to be with external societal forces, such as school, poverty and street life (Lammers & Schippers, 1991; Thomas, 1996).
Social freedom and equality for women
In acknowledging the influence of gender expectation in the differences in drug use by both sexes, one cannot ignore the influential role that greater social freedom and equality for women has had on drug use. Expressing greater independence and confidence, female drug use is often seen as a symbol of emancipation and sexual equality, such as it was with smoking in the 1920s and 30s (Graham, 1993). The impact of greater social freedom on drug use has taken several forms.
Rebellion is one. Smoking, as well as girls' binge drinking, which is on the increase, are signs of rebellion and one reason given for this is simply 'because it is bad' (Banwell & Young, 1993; Best, Brown, Cameron, Manski, & Santi, 1995) and 'the wholesome good girl just isn't a turn on.' Banwell & Young (1993) argue that young women attain adult status by the construction of a social identity around popular stereotypes of femininity which fall into the familiar categories of 'good' or 'bad' women. Smoking is seen as a symbolic statement of the 'bad' woman, and it is interesting to note that the decision to smoke or not smoke is made before trying cigarettes. These girls may well have already decided which 'group' they belong to, according to the 'image' or identity they choose for themselves.
An example of this can be found in a study by the Tasmanian Education Department, where smoking was associated with resistance to the 'good girl' image fostered by the school. In the words of one teacher: "I've got a couple of Year 9 girls this year who are really 'bad'. They tell lies, they're really mischievous outside school, they wag and they smoke" (DEET, 1992, as cited in Wearing, Wearing, & Kelly, 1994, p. 632).
Another way that this rejection of the traditional female role is reflected is in the rather 'opportunistic' style of drug use by some young women (not unlike the style of young male drug use). One recent study found that "use was sometimes planned and sometimes just happened" and that "whatever anyone's got, that's what we do". Alcohol use, however, was much more planned: "we decide before we go out so we can make sure we have enough money" (Odgers, Houghton, & Douglas, 1996). Young women who reject significant components of the traditional female role have often been found to be heavier drinkers than their more traditional counterparts (Davey, 1994; Rabow et al., 1992).
One interpretation of this 'change in traditional female image' is that it has created conflict in women about how they should behave. Increased alcohol consumption, for example, may reflect a change from traditional stereotyped behaviours, but some recent research suggests that it also reflects "a lack of contemporary cultural or social benchmarks for young women's alcohol consumption" (Davey, 1994). Thus in the absence of alternative models, women may adopt masculine styles of drinking. This also means increased visibility of female's drinking - 80% of young people's alcohol consumption is done in public places, especially on weekends. This suggests that the social importance of drinking situations may be more important than the drinking itself: both males and females "appreciate the social opportunities drinking situations offer to such an extent that they tend to define drinking itself as a side activity to the social interactions with the other participants" (Oostveen, Knibbe & De Vries, 1996, p. 195). This can be problematic for young people who have a greater degree of ambivalence towards alcohol use, because it is even harder to develop norms about drinking, and this may lead to more harm. Also, girls tend to associate with boys older than themselves and may therefore engage in more drug use at an earlier age (Gullotta et al., 1995).
While young women are certainly drinking, and some at hazardous levels, stereotypes of female drinkers as impoverished and secretive drinkers still persist in some areas of society. This is despite data which challenges this, such as drinking more in licensed premises with friends. These situations are potentially more hazardous in many ways, for example, they can join in 'shouts' with their male and female companions or simply drink 'to keep up with the boys' (Banwell & O'Brien, 1993).
Drug use is often seen as a 'rite of passage', with major benefits. However, if creative outlets that allow for celebration, fun, bonding and self-expression are also available, these may be viable alternatives to the benefits offered by drugs.
A particularly interesting reaction that greater social freedom and equality has had on drug use is that women are reclaiming the right to pleasure, and this has been well documented. According to Ettorre (1992, p. 147), pleasure challenges feminine stereotypes because females are now demanding the same right to pleasure as males.
Klein (1993), talks of the dark beauty, the negative aesthetic pleasure and the 'indispensable moment of menace' which people gain from smoking. He also speaks of a new Puritanism directed against any form of pleasure, and particularly the pleasure that women find in cigarettes, which he says is probably doing more to encourage smoking than to discourage it. In countries where smoking is now socially unacceptable, girls can adopt a rebellious, outsider stance, even when they feel marginalised as smokers. This same new Puritanism can be found scattered amongst other recent reports about alcohol, which imply that 'alcohol is fun and therefore bad.' In fact the pleasures relating to all drug use are generally less sanctioned for females. Klein (1993) claims that the aim of his book is certainly not to encourage smoking, but to acknowledge the perceived benefits attached to cigarettes, as opposed to the 'current moralising' against them.
Banwell &Young (1993) agree: "Health messages can be seen as an attempt to discourage young women who have chosen a social identity that includes smoking as part of their repertoire of self-preservation, from attaining a status that is socially valued. Health promotion is sometimes seen as negative, moralistic and controlling. The need for the encouragement and promotion of alternative activities to smoking, rather than relying on anti-smoking health messages, is underscored by the belief of smokers from this study that they are being denied their rights to an activity which they enjoyed and through which they expressed themselves" (p. 383).
There is much to be gained by viewing young women's drug use as a legitimate pleasure pursuit, rather than any pleasure-seeking being reduced to a sign of deviance. For a start, it helps us to understand the different cultures of drug use, such as the 'dance drug' culture, and to see young women's drug use as mainstream rather than deviant or marginal. It also offers a view of women as active participants in drug use, rather than passive victims, and that their drug use is based in the reality of women's everyday experiences. The recreational aspects of drug use, the role of drugs within our culture and the pleasure principle involved are all overlooked particularly with regard to women (Henderson,1993a).
The focus in the past has often been on 'negative' reasons for using drugs which gave males and females little credit for the active choices they make. It also often excluded pleasure and humour and carried with it its own implicit moral judgement. Now
"drug use puts pleasure squarely back in the equation. The benefits of drug use as perceived by drug users have received little attention, yet have clear gender implications" (Henderson, 1993b, p.16). Health education should address itself to promoting positive images for women.
Avoiding negative and moralising messages
Girls' use or non-use of drugs needs to be their choice, not organised by adults. Traditionally, drug education has tended to impose messages on young people based on adult concerns. Therefore, the exploration of alternative activities for young women which enable them to devise their own messages and express their social identity may be worthwhile alternatives to conventional drug education campaigns.
Schools also need to adapt. In a DEET funded project resulting in the publication of Telling Tales : girls and schools changing their ways (Telling Tales, 1994), an issue which emerges is that too often, schools don't like girls to have fun: "While boys' interests such as sport, action films and science fiction are accepted, girls' interests are often individualised and criticised . . . . Teachers can be very authoritarian, saying, "Girls, you shouldn't want to be into fashion; you shouldn't enjoy reading Dolly; you shouldn't do this, that and the other" (Telling Tales, 1994, p.4). This study also noted that "In schools, girls who wear jewellery, paint their nails, etc. are often punished."
While fashion and Dolly may often perpetuate stereotypes, Telling Tales suggests that schools need to discuss the concept of pleasure a lot more. Teachers working with girls could ask questions such as "How do our pleasures oppress us? How do they benefit us? And what might be more life enhancing pleasures?" (again, returning to the idea of alternatives).
Telling Tales recommends more dialogue between schools, school systems and researchers. By operating from a basis which is more in touch with the reality of females' everyday experience, a more 'user-friendly' approach could evolve which moves beyond stereotypes and in so doing 'normalises' females who use drugs and commands their active engagement in reducing the harms from their drug use. (Henderson, 1993, p. 128).
This has implications for how to present harm from drug use to young women. For example, a 1995 Health Education Authority survey in England of 5,000 young people across the country indicated that 61% of respondents would be encouraged to stop using drugs if they were convinced of the health concerns (Health Education Authority, 1996). About 31% claimed not to know of any health risks involved with ecstasy, and 42% did not know of any health risks associated with LSD. The same situation has been found in Australia. In a survey of school students in Perth, Western Australia, the most common answer to the question of why someone might stop using substances was because they "worked out what it was doing to their body" (P. Odgers, personal communication, June 12, 1996). In Copeland's Australian study (Copeland, 1995a) health was also cited as the main reason for stopping drug use (although long term health issues were not the concern that short term ones were).
Similarly, an American study by Thomas (1995) noted that drops in use of illicit drugs have been associated with adolescents' increased perceptions of genuine harm from them. Presenting knowledge of drug-related harm, therefore, will be ineffective if the focus is on 'negative reasons', if it ignores the benefits of drug use, or if it carries an implicit moral judgement.
In a study done by US researchers in France where smoking is still more acceptable (Carton et al., 1994), smoking is associated with sensation-seeking amongst smokers of both sexes, although smoking females scored particularly highly on the 'experience seeking' component of sensation-seeking. ('Experience seeking' is defined as the desire to try new experiences.) The authors speculate that because nicotine has stimulant properties and produces cortical arousal, it would have particular appeal to sensation seekers. The authors talk emphatically about nicotine's stimulating reward, for both sexes. "In the general population, smoking to increase stimulation, typically in conditions of boredom and inactivity, has been repeatedly identified as a motive for smoking" (Carton et al. 1994, p. 225). This may be particularly relevant to young females as they were found to want to try new experiences more than males. Carton et al. (1994) speculate that tobacco advertising which targets young women and links smoking to independence and experience-seeking, enhances the lure of smoking for women high in the 'experience-seeking' factor.
CONVERGENCE OF MALE AND FEMALE DRUG USE?
Although the findings world-wide about convergence of male and female drug use are inconsistent, there is some evidence for convergence among young people (Gfellner & Hundleby, 1994; Hanson, 1994; Lammers, 1995; Robbins & Martin, 1993; Waldron, 1991; Winstanley et al., 1995). It is important to note here that most of the research into convergence focuses on alcohol, tobacco and cannabis, perhaps because these are the most widely used drugs by young people.
A recent WHO study of ten European countries indicated that over a third of girls have tried smoking by the age of 13 and this has increased to 60% by the age of 15 (Amos, 1996). If this current trend continues, smoking prevalence between the sexes should be reaching parity. This is supported in much of the literature. "Smoking rates among women continue to increase, whereas smoking rates among men are decreasing substantially . . . . This has resulted in converging rates of smoking for women and men" (Waldron as cited in Rodin & Ickovics, 1990, p. 102). Similarly, in a Norwegian study it is stated that "While the decrease in prevalence has continued among boys, an increase in the proportion of daily smokers among 15 year old girls was observed in the period 1985-1990" (Hafstad, Aaro, & Langmark, 1996, p. 30). Clayton (1991) and Amos (1996) also maintain there are equal or near equal smoking rates amongst men and women in the USA and UK.
In the USA, the narrowing gap in smoking rates between men and women in the 1980s was due, in part, to increasing initiation rates among less educated women. (Berman & Gritz, 1991). This is supported in recent Australian National Surveys as well, although there is some recent evidence of a decrease in smoking prevalence among young females aged 14-19 (Commonwealth Department of Health and Family Services [CDHFS], 1996). Winstanley and colleagues (1995) found that teenagers who leave school early tend to have a higher prevalence of smoking, which is linked to their being lower achievers and having a greater exposure to tobacco use (especially if unemployed - this is a definite risk factor for smoking). These surveys also indicate that young females are taking up smoking at a far earlier age than in previous decades. Among 12-15 year olds, the proportion of secondary school students who are current smokers has increased since 1990, amongst both boys and girls, but with a higher prevalence amongst girls. This higher prevalence of smoking amongst girls is not unique to Australia but has been noted in a number of western countries (Rienzi et al., 1996; Winstanley et al., 1995). The influence of 'targeted promotion' is believed to be relevant here (see later section 'ADVERTISING AND THE MEDIA').
With alcohol, Neve, Drop, Lemmens, & Swinkels (1996) quote several studies from the Netherlands, Denmark and Norway which support the thesis that young females are catching up with males' alcohol use, and this is said (in these countries) to be due to an increase in wine consumption by females. Also, younger women are increasingly engaging in heavy episodic drinking (Wechsler, Dowdall, Davenport & Rimm, 1995). In this study of American college drinkers, 39% (an increased percentage since the late 1980s) of females were binge-drinkers. This has implications for education. The researchers conclude that "While blaming the victim is poor social policy, it is entirely appropriate to educate women to protect their own health in an environment in which gender-neutral drinking norms actually put them at higher risk than men" (p. 984).
This study also makes the important point that although college females drink as heavily as college males, their recognition of alcohol problems lag compared with males. "Among drinkers who binged 3 or more times in the past two weeks, 22% of men described themselves as heavy or problem drinkers compared with only 8% of the women" (p. 984). With this increase in binge-drinking, there has been a concomitant increase in drink-driving among younger women (Wilsnack et al., 1994).
In Australia, the 1995 National Drug Strategy household survey (CDHFS, 1996) reports similarly high rates of binge-drinking amongst young people, with a third of females aged 14-19 having drank heavily in past two weeks before the survey. The survey also found that 50% of teenage girls had their first drink by the time they were 15, almost as high as for boys, and two-thirds of young females were heavy drinkers, the highest incidence of any population survey.
Female cannabis use has increased as well, especially since the late 1980s, and there is evidence that increased tobacco use among young women is associated with this increase in cannabis use. However, despite some convergence with cannabis, alcohol and tobacco use (McAllister & Makkai, 1991), males still outnumber females in prevalence of alcohol and other drug use (Gullotta et al., 1995; Lammers, 1995). In Australia, the 1995 National Drug Strategy Household Survey [CDHFS], 1996) not only found that more teenagers of both sexes are using cannabis, but that one in four teenage girls who have experimented with cannabis did so before the age of 13. The concern, therefore, with increasing female cannabis use is the younger age of uptake, its association with tobacco, the fact that THC is fat-soluble and therefore stays in the female body longer, and its synergistic interaction with other depressant drugs, such as alcohol.
The question which now presents itself is: if girls are engaging in more drug-using behaviour than in the past, does this mean they are taking more risks? There is no consensus in the literature about this, and many researchers maintain that girls still take fewer risks, which mediates their drug use (Thomas, 1995). Traditionally, girls have been less willing than boys to take drug-related risks, but recent findings reveal some new trends. An Australian study of girls in custody found much higher levels of heroin use and HIV risk-taking among girls than among boys who are in custody (Copeland, Howard, & Fleischman in press). In an investigation of risk-taking and drug use by Smith & Rosenthal (1995), girls' responses to 'perceived risk to self', rated most activities as more risky than boys, except for drinking wine, spirits, smoking and using inhalants. In answer to 'perceived risk to others' girls consistently rated binge-drinking, smoking cannabis, drink-driving and sex without a condom as a higher risk than did the boys. The boys attributed greater pleasure or benefit to all activities, except for drinking spirits and smoking cigarettes. It would seem then that girls perceive drinking spirits and smoking as less risky to themselves and, unlike the boys, presumably beneficial and pleasurable activities!
Risk-taking thus includes the social context of adolescent risk perception. This challenges the assumption that the perceived danger associated with particular activities is the only determinant of risk practise. So, given the different socialization of boys and girls differences in perceived risks are not unexpected. (Smith & Rosenthal, 1995).
Young females in custody
A study which sampled 166 adolescents (126 males, 40 females), identified that among adolescents in custody who had ever used alcohol and other drugs, the levels of use prior to incarceration were extremely high. There were significant gender differences among the sample, where girls were more likely to be injecting drugs, particularly heroin, to be sharing injecting equipment and taking benzodiazepines than were boys. There were continuing deficits in the sample's knowledge of HIV, and in particular of the even more immediate health risks of hepatitis B/C, which was more pronounced among the girls despite their higher rates of potential exposure to these viruses.
Denton (1994) in another report on the drug use of women in Victorian prisons, identified 61% of women in the prison population as having a pre-arrest substance dependence disorder. The predominant pre-arrest substances on which women were dependent were opiates, benzodiazepines, amphetamines, cannabis and alcohol.
In general the women in the sample (Denton, 1994) were young, single, unemployed mothers. They were usually sole heads of households and living in rental accommodation. Their health was mostly poor health and many had been physically and sexually abused.
FEMALE PRESSURES AND COPING STRATEGIES
Younger onset of drug use is a frequent correlate of heavier or more frequent drug use for adolescents of both sexes (Robbins & Przybeck, 1985; Thomas, 1996). Today, earlier puberty is associated with a younger onset for both drinking and smoking amongst adolescent girls (Wilson, Killen, & Taylor, 1994). This point takes us back to the issue of 'rite of passage' to adulthood for females, where Professor David Bennett, of the Adolescent Health Unit at the Children's Hospital, Westmead, has expressed an interesting view:
"Adolescence has always been difficult, but the problems were never this bad.
. . . . Things were clearer in the past. Children hit a certain age and there was a rite of passage where they became an adult. Now, adolescence is a prolonged period of limbo-time in which they haven't got clearly defined rights and responsibilities.
. . . . The dangers facing today's teen girls are also a lot greater than ever before. . .
Kids as young as 13 and 14 are going to rave parties, . . . . there are drugs, unemployment and the spectre of AIDS if you have unprotected sex" (Gripper, 1996 p. 9).
Many studies support this view and agree that girls could be using drugs to cope with very real pressures and the underlying tensions of their lives. Drug use as a form of self-medication, ie, to relieve emotional discomfort, stress, and to escape/cope emotionally, is well documented (Lammers, 1995; Opland et al., 1995; Windle & Barnes, 1988). This appears to apply particularly to smoking, where recent evidence suggests that females are more likely to smoke as a way of coping with stress or negative mood states (Waldron, 1991; Winstanley et al., 1995). Some women, however, continue to smoke simply because they are addicted and the pleasure may be contorted because of the guilt they may be experiencing.
Similarly, with social change, some women, drink more today as a form of self-medication (Beck, Tombs, Mahoney, & Fingar, 1995; Lammers & Schippers, 1991) which follows on from the high incidence of other drug use such as analgesics. This is still not sanctioned in the same way as male drinking in pubs, where alcoholic escape is public and social and therefore acceptable. The social norm of women's role as caregivers (or potential caregivers) is related to societal disapproval of women seeking the same 'alcoholic escape' as males and intoxication is definitely inconsistent with the nurturant role expectations of females (Broom, 1995). The fact that nurturant role expectations encourage females to see their morality and their own self worth as tied to an ideal of 'caring for others', is in itself a risk factor.
In the past, analgesics and tranquillisers were seen as 'acceptable' drugs for women to use to help them function and 'cope'. Minor tranquilliser and analgesic use by women, however, are virtually absent from the traditional research literature, despite the fact that it was, and still is, an important part of female drug use (Broom, 1995; Rienzi et al., 1996; Rodin & Ickovics, 1990). It is only now that minor tranquillisers are on the agenda as an important part of women's drug use. In Sibthorpe's study (1995) of homeless and potentially homeless youth in Australian cities, significantly more females reported using pain-relievers and sleeping pills than males. Similarly, in a recent Australian report on injury among women (Kreisfeld & Moller, 1996), it shows girls aged 10 - 14 are treated in hospital for overdoses of painkillers 14 times more often than boys. The report shows a similar problem with the use of tranquillisers, where the rate of hospitalisation for an overdose is 5 times higher for girls. So, not only are women (of all ages) the primary users of prescription and OTC (over-the-counter) drugs such as painkillers, but the question which needs to be asked is: why are females so willing to take them?
The concern, as one author puts it, is not simply the large numbers of females using (and dependent upon) these drugs, but the social context, meaning and function of the use. In some ways these substances may actually foster the adaptation of women to destructive social circumstances, because their use is covert and private and defined as the product of women's inability to cope. "The problem is defined as residing in the woman, not in her isolation, poverty or misery" (Broom, 1995, p. 413). It helps women deny the very real stresses and disadvantages residing in the circumstances of their lives. The practical result of the intense social stigma applied to women seeking escape through drugs is to keep them in hiding, thus the stereotype keeps women's drug use invisible.
Females' lives still appear to be more restricted than males', both in the domestic sphere and by the cultural restraints of femininity (Banwell & Young 1993; Daykin, 1993; Lammers & Schippers, 1991; Sibthorpe, Drinkwater, Gardner, & Banner, 1995). The danger for girls, it would seem, both symbolically and pragmatically, stems from their ability to reproduce and be sexual beings before they are recognised as adults.
Finding a positive side to disadvantage - smoking to overcome disadvantage
Smoking appears to be associated in several different ways with the construction of an adult female social identity. Some women see smoking as a symbol of power and independence (Grunberg, Winders & Wewers, 1991) other young women explain their smoking as 'taking time out' within the usual routine, or creating a space just for them. They see cigarettes as their only luxury, the only thing they do for themselves. Smoking is also said to be a class issue for females in that it offers a rare pleasure and luxury to many low income females - to the extent that increases in the price of tobacco may not stop these women from smoking (Greaves, Jordan, & McLellan, 1994). This would appear to be an expression of independence, while still adhering to the norms of femininity.
In fact a great deal of evidence suggests that females are more likely to smoke as a way of coping with stress, poverty, and the demands of domestic and caring roles (Baum & Grunberg, 1991; Krupka & Vener, 1992; Waldron, 1991; Winstanley et al., 1995). This is also linked to lower achievement at school. Young women with low educational attainment, low life satisfaction, and from disadvantaged backgrounds are at particularly high risk for smoking initiation and continuation (Berman &Gritz, 1991; Hover & Gaffney, 1988; Schorling, Gutgesell, Klas, Smith, & Keller, 1994; Winstanley et al., 1995).
Previous research findings confirm this link between smoking and socio-economic disadvantage. Graham (1987) discusses the lifestyle of working class women and their sense of dependence on cigarettes for mood control and as a mechanism for coping with stress. "It has been noted that women who smoke tend to view smoking as a symbol of power and independence." This, Romans, McNee, Herbisan, & Mullen (1993) maintain, provides further objective evidence that smoking may actually benefit women and that women are correct when they think that smoking helps them deal with depression and anxiety and is used to alleviate dysphoric mood states. The unexpected finding by Romans et al. (1993) was the higher rate of recovery from depression and anxiety states amongst women who smoked.
Smoking also is often a way of women tolerating social norms and expectations while meeting their own needs. For example, love and relationships are said to be central to the female identity, and smoking is not seen to sabotage this. Another way of putting it is to say that smoking doesn't interfere with the social norm of women's roles as caregivers. Cigarettes are clearly an outlet for some women who feel bound by the restrictive female image, even to the extent of allowing them to 'dream'. In the words of one woman: "Piles and piles of little possible reasons can be found for our piles of cigarettes... Abandoning the butt deflates the delicate mood that the cigarette installs and restores the reality principle - stubs out the little dream that the cigarette elicited" (Leclerc as cited in Klein, 1993, p.193).
Women, therefore, who are considered to be at high risk of smoking are:
- have low socio-economic status;
- are disadvantaged;
- are poorly educated; and
- are dissatisfied with female caring roles and being in financial strife.
Also, in many countries, the highest smoking rates are found amongst disadvantaged ethnic minorities. For example, in New Zealand, Maori women smoke more than white women and have one of the highest smoking rates in the world (Amos, 1996). Again, women with low academic achievement, and underprivileged ethnic women, often continue to smoke at a cost to their health and finances because they believe cigarettes help them to cope.
It is salient at this point to note the complexity of reasons that young women may smoke. As the research has shown, the reasons may be intertwined with disadvantage, rebellion, liberation, sexual equality, independence, conformity, poverty, pleasure, leisure, self-esteem, emotional control, coping and so on. Given the complexity of smoking behaviour, many elements have had some degree of influence on women's smoking. The issue here is not to oversimplify when making recommendations for strategies and approaches which address the problem of young women's smoking.
Young women from culturally and linguistically diverse backgrounds
As ethnic minority groups of women who are disadvantaged have the highest rate of smoking in many countries in the world (Amos, 1996), there is no reason to believe it is any different for ethnic minorities in Australia (although there are only a limited number of studies and a varying quality of research available - Spathopoulos & Bertram, 1991). "Despite widespread focus on the prevalence and predictors of cigarette smoking among adolescents in Australia, no literature is available for non-English speaking background (NESB) adolescents" (Tang, Rissel, & Fay, 1996,
p. 215). Even the studies that have undertaken this task fail to consider the heterogeneity within the different cultural groups (Swift et al., 1995). However, a Drug and Alcohol Directorate (1993, p. 8) policy document does state that there is a wide agreement (in the limited number of studies) on three main issues:
- Culturally and linguistically diverse communities have poor knowledge
regarding the effects of alcohol and other drugs. This not only reflects
linguistic differences but also the fact that psychoactive substances may have
quite different cultural meanings and may not be perceived as drugs at all
- There is little understanding of what constitutes hazardous consumption of drugs - particularly with prescribed and over-the-counter (OTC) medication
- Culturally and linguisically diverse communities tend to equate the "drug
problem" only with illicit drugs
The Drug and Alcohol Multicultural Education Centre (DAMEC) have conducted some small surveys of alcohol and OTC drug use amongst some ethnic groups in Sydney (DAMEC, 1993 as cited in Swift et al., 1995). Their trends are mostly similar to the general population of young females - such as high use of analgesics, alcohol, diet tablets, amphetamines and cigarettes (for weight control). There is also a rising rate of smoking uptake and an increase in heroin use and cannabis use amongst young women from culturally and linguistically diverse backgrounds. It may also be significant that for many young females who become heroin users their path is firstly smoking it, then dealing, then injecting. One study (Maher, 1996) found that over 50% of the participants started using heroin by smoking, because they felt it was a 'user friendly' method.
The reasons for use are also similar to young females in general, including fun, rebellion, boredom, lack of recreational activity, peer conformity and family substance use. Societal images of thinness are a pressure, but an extra pressure is that feelings of depression and anxiety can also be accompanied by feelings of cultural displacement and discrimination. Generational and cultural conflicts with parents are common as well, often leaving young females feeling doubly alienated. In a study of young heroin smokers in Cabramatta (Le, 1996), social and family problems were perceived as playing a major role in their decision to use heroin. These young people felt trapped by cultural and language barriers with society in general, and their parents in particular, so peer conformity was an important factor in their drug use.
The National Health and Medical Research Council [NH & MRC] (1991) states that many young women from diverse cultural backgrounds have special difficulty gaining access to mental health services which may help them to cope with emotional problems. While low levels of English proficiency may contribute to these problems, it is also the case that some concepts are simply not translatable culturally and/or linguistically.
On-going liaison between schools and community agencies is essential if "local" issues and behaviours are to be addressed. For example, with the high use of heroin in south-west Sydney, the potential for use by school students in the area is high (Maher, 1996). There is also the question of providing a safe injecting space for girls, given the levels of injecting drug use in some areas, and the harm that can come from injecting itself. Boys need this too of course, but girls should be provided with a safe environment in which to inject, without the stigma, danger and associated violence.
As well as possible language and literacy problems, there are a wide variety of different ethnic groups with different cultural issues. For example, there is a distinction between first and second generation ethnic communities, in terms of their level of acculturation. That is, their level of adaptation to the attitudes, values and behaviour of the population they have entered can predict their level of drug use (Le, 1996).
The National Drug Strategy household survey (CDHFS, 1996) found that adolescent girls who frequently socialize with older males may be attempting to match the drug use patterns of their male companions. Paradoxically, in most culturally and linguistically diverse communities, drinking, smoking and other drug taking is acceptable for males but not for females, which can lead female drug users in these communities to be very critical of themselves and other female drug users. Drug use by females is also a taboo topic in many cultures, and this forces girls to be discreet and secretive, thereby creating a cycle of silence which can be harmful in itself - for example, no knowledge of safe practices, no safe places to use drugs.
Young Aboriginal women
In her report on the health of Aborigines aged 12-25, Brady (1991) states that "The social oppression of Aboriginal people is viewed by many to be an overall explanation for the overuse of drugs and alcohol" (p.23. Hazlehurst (1994) agrees with this, maintaining that "the afflictions which beset indigenous people . . . are ills of a dispirited and conquered people" (p.5).
Brady (1991) however, warns that while these factors underlie the lives of all Aboriginal people, there is a need to consider other variables as well. This is supported by the Australian Royal Commission into Aboriginal Deaths in Custody (1991) which also stresses the inadequacy of single factor explanations, and the 'multiplicity of factors' present.
Brady (1991) believes that the most compelling factor in young Aboriginal drug and alcohol use is probably the desire to be part of the peer group. Although this is not specific to Aborigines, but relevant to most young people (Odgers et al., 1996), it is nevertheless of particular significance with Aboriginal and Torres Strait Islander people. This is supported in the limited available literature, with the consensus that peer culture has an enormous influence on drug use by young Aboriginal and Torres Strait Islander people - to the extent that those who strive to be different, in whatever way, are seen to be "whites" by their peers, and thus alienated.
Although there is very little gender-specific information available, the Australian Royal Commission into Aboriginal Deaths in Custody (1991) does state that young Indigenous women are subject to structural disadvantages that affect Aboriginal and Torres Strait Islander people as well as the structural disadvantages that affect women in general. It also recommends more gender specific research on young Aboriginal and Torres Strait Islander women's needs.
It is generally agreed in the literature that young Aboriginal and Torres Strait Islander women's drug use is as diverse, if not more diverse, than male drug use. There is certainly more pill use, especially analgesics and 'benzos' (tranquillisers). Anecdotal evidence also suggests that paracetamol/codeine medication is much abused, and media influence is cited as one reason for this high level of analgesic use. Alcohol (there is also a high level of binge-drinking), smoking and marijuana are the most heavily used drugs among young Aboriginal and Torres Strait Islander females, although sniffing is popular too.
As in the general population of young women, body image and eating disorders are becoming prevalent among young Aboriginal females, and according to Brady (1992) this is linked particularly with petrol sniffing. In her study on the social meaning of petrol sniffing in Australia, Brady (1992) states that there is evidence to suggest that some "sniffers do not like to be fat, desire thinness, and achieve this through inhaling petrol" (p.81). "Anorexia, or loss of appetite is frequently associated with petrol sniffing, both in medical research reports and in informal observations in the field. Aboriginal health workers, nursing staff in community clinics and the parents of sniffers all note that sniffers 'get skinny' " (Brady, 1992, p.78).
Again, the media is thought to be an influence on this in that it 'normalises' a desirable slim image, and the drug use which accompanies it. Like their non-indigenous counterparts, Aboriginal and Torres Strait Islander girls are reportedly succumbing to advertising images and are using various drugs to keep their weight down. Smoking, in particular, is popular.
With petrol sniffing, two other factors are significant: 1) that the current generation of sniffers are second generation sniffers, and 2) sniffing increases when the levels of family drinking/violence is at its heaviest. This ties in with other reasons for young female drug use, such as a means of escape from abusive families, childhood abuse, poverty, homelessness, lack of control over their lives, high unemployment and, in the Aboriginal and Torres Strait Islander population, a high birthrate (and lack of support from a partner, if one exists).
In some communities there is also a high level of drug use amongst adults, so the lack of 'non-using role models' can result in it being difficult for young Aboriginal females to see high levels of drug use as problematic (Brady, 1991).
THE IMPORTANCE OF 'STAYING IN CONTROL'
It is important to reiterate the central theme of this review, which is that social norms and gender expectations shape much of young women's drug use. Related to this gender expectation is the essential image for young women of being in control - and this relates to drinking, smoking and the use of various illicit drugs. With drinking being in control is also, like smoking, a way of coping with the restrictive female image. Being in control of themselves, in one study, is described as not doing anything embarrassing (like vomiting) or something they would regret (like having sex), which, above all, means 'not getting a reputation' (Bui, 1993).
Recent research also supports the importance of reputation in the lives of young women. A study by Odgers et al. (1996) on substance use and reputation enhancement, the types of reputations which male and female school students were trying to attain were found to be quite different. Although not consistent with all the literature, Odgers and colleagues' (1996) finding that males generally preferred a more non-conforming reputation, while females preferred a more conforming reputation is generally supported by the literature. This is consistent with conforming to the social norm of femininity, and 'not getting a reputation'.
It is important to point out that the word reputation is being used in two different ways here. Odgers et al. (1996) are using it to mean image (ie, conforming to peer group norms), whereas reputation in relation to the social norm of femininity, is used to mean a reputation of sexual promiscuity. Getting a reputation, in fact, is seen as one of the biggest harms that can result from girls drinking too much, or losing control from any drug use.
Such statements about sexual disinhibition and promiscuity being seen as the worst possible consequence of drinking are common in the research literature, "whether anthropological, psychological or sociological writings - and normally appear without comment or citation" (Leigh, 1995, p.416). In one study adolescent females nominated sexual vulnerability as the main problem for them in alcohol situations (Munro, 1993). In another, girls identified the risk of having sex when drunk as the main harm linked to drinking (Bui, 1993). They said that boys will use alcohol as a means to have sex with girls. Young girls drinking with older boys can, at the same time, be naive socially and sexually, as well as naive regarding alcohol and other drugs. This places them in double jeopardy.
Girls also perceive a link between alcohol and violence towards women, and in one study about a quarter of the sample had experienced some form of violence (Copeland, 1995b). It is interesting to note that both male and female students recognised the sexual vulnerability of girls when drinking alcohol. This is recognised as a problem not just in girls' schools. In one study a boys' school requested help within the context of alcohol education, to 'teach' boys the need to respect girls and their rights and wishes (Ling, 1995).
There is a strong association between losing control through alcohol use and the qualities of sexual disinhibition and promiscuity. Sexual behaviour and disinhibition in females is seen amongst young people as the worst possible consequence of drinking. A thorough study of the subject by one researcher has found only one reason for this: "It is not because a drunk woman is more irresponsible, dishonest or selfish than a drunk man, but because she should not be drunk" (Knupfer, 1982, as cited in Leigh, 1995 p.418). This author could only conclude that it is men's image of women as pure and virtuous that makes this so. In fact, disapproval of female drunkenness has pervaded western societies throughout history. In answer to the question of why this is so, several researchers (Davey, 1994; Leigh, 1995; Robbins & Martin, 1993) have concluded that: a) intoxication is inconsistent with the very nature of women's roles, ie. nurturant role expectations, and b) female sexual virtue is essential to the moral and social order of society.
Cocaine and heroin
Women who use the illicit drugs cocaine and heroin, face the same disapproval (as women who lose control through drinking). "From opium use to crack, gender roles and expectations have shaped explanations of women's involvement in drugs for over a century" (Fagan, 1994, p. 181). Thus women have been, and continue to be, viewed through the lens of gender-role deviance. Fagan (1994) argues that this has been viewed as double deviance: social deviance from normative behaviours and gender-role deviance from the expected female role of nurturer. Many of the physical ill effects of illicit drugs are not from their pharmacological actions but from the lifestyle surrounding the use of the drug, as well as specific behaviours. Illicit drug use by women further violates gender roles (Fagan, 1994) because of the associated sexual promiscuity. Even girls who smoke marijuana can be perceived as therefore sexually active (Rienzi et al., 1996). Paradoxically, at the turn of the century, patent medicines containing large and usually unspecified amounts of alcohol, opiates and/or cocaine, were widely used by women. The message was "you may not indulge in use of this or that substance for pleasure or for 'highs' or for erotic enhancement, but you may take medicine" (Erickson & Murray, 1989, p.137).
The underlying theme remains today - females may use drugs as medicine, so long as there is no accompanying 'loss of control'. Even current use of heroin and cocaine by young women receives considerable public attention, with much being made in the media of the claim that females rarely have to buy these drugs (ie, they trade sex for drugs). While it is true that men are often the suppliers of drugs to women/their girlfriends (and this reflects more about society's values and beliefs about the appropriate role of women), Fagan (1994) maintains that women in this environment have had little choice in their source of income! In his work on female heroin use, Fagan says that women's involvement in heroin use has traditionally meant "social immersion in street drug networks where available roles were highly gendered" (Fagan, 1994, p.183).
Illicit drug use, especially heroin, is still mostly invisible among young women. They have to keep it secret, otherwise they are marginalised by their peer groups and families. Although females' source of heroin is generally through 'significant males', if they inject they are often subject to violence by boyfriends and families. Only smoking or dealing heroin is respectable (Maher, 1996). This is particularly the case with the Indo-Chinese community (Maher, 1996).
An understanding of women's use of illicit drugs like heroin and cocaine also involves an understanding of the context of their use. Previous research findings with women who use opiates indicate that women's drug use is often associated with their relationships with men (Henderson et al., 1994). The authors maintain that as with heroin use, women's use of crack also involves their relationships with men, including being supplied with the drug by men. It is interesting to note that these findings are consistent with previous research comparing male and female heroin and crack use - that significant, opposite-sex relationships are more important in women's use than men's use (Henderson et al., 1994).
On the other hand, Fagan (1994) and Maher (1995) argue that this is slowly changing and that young women using illicit drugs are finding ways of earning money that protect them from dependence on men, prostitution and exploitation (eg. drug selling). A recent Australian survey on illicit drug users (Hando, O'Brien, Darke, Maher & Hall, 1997) found that an increasing number of younger heroin users were entering the market and there was a trend towards more female injecting.
These findings not only challenge the stereotypical 'heroin junkie', but also reflect recent statistics that heroin use is increasing in Australia, as are the number of heroin-related deaths (Australian Bureau of Criminal Intelligence, 1997). Recent research also indicates that while smoking is a common route of heroin administration in SW Sydney, the rapid transition to injecting is made by many users. (Maher & Swift, 1997). There has, in turn, been a transition from injecting amphetamine use to heroin use (Hando, 1996).
Ways of 'staying in control'
While it is still the case, however, that the status of females goes down after drunken sex, or trading sex for illicit drugs, being in control remains critical to their image and reputation. And as Copeland & Hall (1995a) point out, the heightened stigma attached to out of control drug use also delays women seeking help. "In short, being out of control could be defined in terms of social consequences of young women's behaviour involving two central themes of image and sexuality" (Davey, 1994, p. 30).
With alcohol, one way that girls are dealing with this problem of getting a reputation
(a sexually promiscuous reputation) is not necessarily to reduce their alcohol consumption, but simply to do it in safer settings. For some this may mean drinking with people they know and feel safe with, or planning how they will get home before they begin drinking, or even becoming more informed about how to drink socially (Broadbent, 1994). Girls also plan to look after each other in drinking situations, which they mostly do (although there are the occasional 'bitch fights' between girls at parties!) (Ling, 1996).
Thus it is now realised that peer intervention is an essential aspect of alcohol education as well. ". . . more than any other age group, teens are more apt to intervene in drinking and driving among their peers." (McKnight, 1986, as cited in Rienzi et al., 1996, p. 344). These strategies enable girls to drink, and even binge drink, while still adhering to the norm of femininity by not being out of control.
This is also a way of girls coping with the stringent appearance norms by which females are judged - that an intoxicated female looks bad. Robbins & Martin (1993) have speculated that it is a perception that it is worse for females to drink excessively. "Perhaps the societal belief that it is worse for a woman to drink excessively influences internalised norms and drinking practices, but does not necessarily result in greater social rejection of women who break these norms. . . . especially when she does not match the cultural stereotype as uncaring, unkempt or unvirtuous" (p. 307). That is, female intoxication may be tolerated so long as it is not associated with 'unfeminine behaviour'.
It is also pertinent to mention here that female drug use is inhibited by religious beliefs. This is particularly so with smoking (Ely, 1994; Marcos & Bahr, 1995; Smith & Rosenthal, 1995), although religious commitment also has a significant direct effect on amphetamine use by females (Taub & Skinner, 1990). Whether religion is seen as a powerful control agent, or simply a mediating influence, it is obviously helpful to females wishing to stay in control, which is something positive for them.
Ecstasy, LSD and the 'party drugs'
The use of Ecstasy, amphetamines, acid, etc. can also be seen as a way of staying in control and conforming to the feminine stereotype. The use of party drugs like Ecstasy ('E') is increasing, partly because sensationalised media coverage has made them more mainstream and therefore no longer a part of a small subculture. It is a leisure pursuit: "The recreational aspects of drug use, the role of drugs within consumer culture and the pleasure principle involved are all overlooked particularly with regard to women" (Henderson, 1993a, p.128).
Also, Ecstasy or 'E' use appears to be a relatively low risk drug in that it normally does not lead to experimentation with (the perceived) more powerful and addictive substances like heroin. Many Ecstasy users are strongly anti-heroin and anti-alcohol, and see these drugs as causing more physical and social damage (Henderson, 1993a). This perception needs to be interpreted cautiously, however, as although the total number of deaths from Ecstasy is very small, it is young women who seem to be more vulnerable to harm. This harm may be related to the fact that because Ecstasy is an illegal drug, there is no quality control over the dose and purity of what is being sold as Ecstasy, or the harm may be related to the way the drug is used, or both.
In Britain, harm minimisation is practised widely, with information leaflets being very popular: those people who had used Ecstasy, and who had read [the leaflet] 'Chill Out', were generally pleased with its use of language and impressed with its overall tone. It was said to be effective, credible, and to use the language that many young people use. (Todhunter & Foley, 1992).
Also, despite 'E' being called the 'love drug' there is only a very low risk of increased sexual promiscuity. Raves are less concerned with sexual gratification and more concerned with gratification brought about by the intensity of music and dancing
(Henderson, 1993a; Todhunter & Foley, 1992). Could this be yet another way that girls are staying in control? Also, there is a tendency for users to regulate and limit their use.
In a study in Britain on Ecstasy use Henderson, (1993) found that most 'E' users supplemented their intake with amphetamines and LSD ( which are seen as similar in terms of effects and safety). The majority smoked tobacco and cannabis on a regular basis. Alcohol was the least preferred drug - because of its effects and the cultures of use. The use of 'E' is only one element of a culture - other components include music, dancing, group experience, ways of dressing, world views, etc. The main attraction was having fun. "The combination of music, dancing and group feeling, and their enhancement by mainly Ecstasy . . . was cleary the key". (p. 124) "The fact that the scene had provided a social space for young women to pursue these pleasures without uninvited sexual attention from males was referenced widely in the interviews . . . young women occupied this social space with confidence" (p. 125).
As noted earlier by Fagan (1994) and Maher (1995) the association between young women's drug use and sexual promiscuity is slowly changing in some areas. Although inconsistent with the findings of Henderson, (1994) that women's heroin and cocaine use are inextricably linked to their relationships with men, Maher's (1995) study of young female cocaine users in New York found that drug use 'in the name of love' simply did not capture the range and complexity of women's experiences. Maher (1995) argues that women, like men, choose to use drugs, and that "we need to begin to examine the role of women's peers and friendship groupings. These are things that are done almost without question for men" (p. 161). This is particularly the case here given that women in this sample overwhelmingly initiated smokeable cocaine in the company of women!
This is consistent with other research evidence of broader contexts framing women's use of illicit drugs (Ettore, 1992; Fagan, 1994; Morgan & Joe, 1996). "Ethnographic studies found that women had rationales for use outside the role of men, that women often control their context of use, and that they play a larger role in the illicit drug economy than previously thought (Rosenbaum 1981; Mieczkowski 1992; Maher 1992)" (Morgan & Joe, 1996, p. 126). Women, therefore, are not always acting as defined by traditional gender roles. Maher (1995) thus concludes:
"Despite the fact that there is no essential female drug user, conventional understandings of women's reasons for initiating use are underpinned by stereotypical images of women. The woman drug user - at home, on the street, in the treatment centre, and in the literature - remains overdetermined by her identity as a sexual partner" (p. 162).
A HEALTHY COMBINATION OF MASCULINE AND FEMININE TRAITS?
Thus it would seem that both males' and females' drug use should be seen as a legitimate pursuit of pleasure, and choice. Unless it is acknowledged thus, those who feel pressured to conform to the socialised norm of maleness, or femaleness, will continue to turn to drug use either as a way of conforming to that norm, or rebelling against it. Interestingly, one study of gender difference found that young people who have a mixture of both masculine and feminine traits, and who freely adopt male-typed or female-typed behaviours (regardless of their sex) have the least problematic drug use (Rabow et al., 1992). Although this finding is only suggestive, it would seem that a mixture of masculine and feminine traits in an individual is a more protective factor for healthy behaviours than is intense gender identity, ie. intensely masculine or intensely feminine.
Self-esteem and identity
Several recent studies support the above finding. Turner, Norman, & Zunz, 1995 looked at enhancing resiliency (to destructive behaviours) in both girls and boys, note that while there is some agreement that adolescence takes a huge toll on girls' sense of self-esteem and self-efficacy, there is little concurrence as to why 12 and 13 year old girls suddenly start to think so poorly of themselves and lose confidence in their abilities. Turner et al. (1995) suggest that as girls become subjected to traditional gender values and expectations, they become more subdued and unsure of themselves. Banwell and Young (1993) agree: "We suggest that the structural position of women in their early teens contributes to their vulnerability to social pressure to comply with constructions of the feminine" (p. 377).
Turner et al. (1995) speculate that as girls enter adolescence they struggle to hold on to their own experience and perceptions and instead begin to live under the tyranny of the perfect girl. The authors refer to a study (Schultz, 1990) which found that twice as many girls as boys experience high levels of stress, that girls were four times more likely to have a negative body image, and that girls were twice as likely to attempt suicide. "In response to stress girls tend to self-destruct with quietly disturbed behaviors rather than act out as boys do" (Schultz, 1990, as cited in Turner et al., 1995, p. 30). Turner et al. (1995) therefore conclude from this research that girls who possess androgynous traits (ie, both masculine and feminine) had a greater sense of self-esteem and resilience to stress and self-destructive behaviours.
A further study which supports this finding, specifically looked at the relationship of masculinity and femininity to alcohol abuse in women (Sorell, Silvia, Busch-Rossnagel, 1993). Wilsnack, Klassen and Wright (1985) and Wilsnack, Wilsnack and Klassen (1987) (as cited in Sorrell et al., 1993) found the lowest drinking levels and problems among women who scored highly on both masculinity and femininity scales - again suggesting that androgyny protects females from alcoholism. But Sorell et al. (1993) are cautious to say that it is not a simple relationship - that it has to include self-esteem as well. Non-alcoholic females were high on both self-esteem and high levels of masculinity. Low masculinity was the most prominent factor setting the alcoholic women apart from the non-alcoholic women. Similarly, a recent Australian study quotes research which found that non-alcoholic women with high self-esteem were masculine sex-typed , ie, they possessed typically masculine traits (Swift et al., 1995). Thus it may not be androgyny per se that lowers a female's risk for alcoholism - it may be that viewing the self as high in sex-role masculinity, with or without high femininity is what reduces potential for alcohol abuse. There is an obvious need for further research on this.
Self esteem is obviously important too, as was found in other studies (Amos, 1996; Thornton & Leo 1992; Turner et al., 1995). Research has repeatedly found that girls with low self-esteem are more likely to take up smoking and to feel that they have little control over their lives (Amos, 1996). This supports Thornton and Leo's (1992) important work on self-esteem in relation to androgyny. They found both androgyny and masculinity frequently associated with lower levels of depression among young women, but they found neither to be a direct consequence. High self-esteem had to be evident. Other aspects of the self considered central to a woman's sense of identity had to be included - it was the balance inherent in androgyny which was critical to women's well-being.
Although there is evidence that changes in drinking and other drug use are linked to non-traditional gender role orientation, it is an erroneous conclusion that increased alcohol use and abuse is the price of women's liberation from traditional feminine roles. The relationship between drinking behaviour and androgyny tells us more about women's drinking (Wilsnack et al., 1985 as cited in Sorell et al., 1993). Androgynous women are most represented in light drinking and least represented in the heavy drinking categories. Thus androgyny is a buffer, whereas female adherence to masculine values alone may increase risk-related behaviours (Rodin & Ickovics, 1990).
Although many researchers consider experimenting with drugs, in particular cannabis, a normal adolescent behaviour, cannabis use by adolescents of both sexes seems also to reflect a mixture of masculine and feminine traits among users. In the late 1960s and early 1970s cannabis use was a symbol of rebellion against conventional norms and the established order. The orientation was towards the gentler values of society, peace, love and understanding and these feminine features of the cannabis culture are still thought to prevail today (Pape, Hammer, & Vaglum, 1994). In contrast to the acting-out effects of alcohol, cannabis appears to cause a peaceful and introspective form of intoxication that seems to be opposed to typical masculine behaviour. Thus in a review of international studies on cannabis (Pape et al., 1994), the cannabis-using males were found to be less typically masculine in their values and preferences than other males.
Cannabis use does not conform with the traditional sex role of females either. In an earlier Norwegian study (Hammer & Vaglum, 1989 as cited in Pape et al., 1994) cannabis-using females tended to have a masculine drinking pattern and their overall level of drinking was also much higher than that of other females. This extensive use of alcohol by female cannabis users, plus the fact that these females were disproportionately young when they experienced their first intoxication did not, however, reflect a rejection of traditional feminine values in general.
There is a high incidence of substance abuse amongst lesbians. It is estimated that about one third (25-35%) of all lesbians abuse substances, often beginning in adolescence (Shifrin &Solis, 1992; Skinner, 1994; Underhill & Ostermann, 1991). This incidence is high, given that lesbians and gays are estimated to comprise 10% of the general population. Their substance abuse is reportedly due to the heterosexual prejudice they experience within the dominant culture. "Lesbians are truly an invisible minority who exist within a biased and largely hostile environment. . . . The social factors which every lesbian must contend with, consciously or unconsciously on a daily basis, produce fertile ground for problems with drugs and alcohol" (Underhill & Ostermann, 1991, p.71).
There are several known risk factors for this high rate of serious alcohol and other drug problems amongst lesbians (and these form the basis of developing effective prevention programs). These factors include:
- minority group status, lack of a defined societal role, and discrimination
- the role of bars in the lesbian and gay community
- a denial defence mechanism developed to survive in a hostile world
- a lack of services to meet their needs in general
- stress which underlies the lives of all lesbians because of the myths and lack of
understanding surrounding the lesbian lifestyle
- denial of lesbians by society
- low self-esteem and 'internalised homophobia' (Shifrin
&Solis, 1992; Underhill & Ostermann, 1991).
"The internalization of homophobia may be even more deadly and insidious than external social homophobia . . . the enemy outside becomes the enemy within" (Underhill & Ostermann, 1991, p.72). This can result in lowered self-esteem, self-hatred, shame and guilt, which leads to substance use to anesthetize this internal pain. Isolation can also cause young lesbians to seek a sense of comfort and well-being through alcohol and other drug use. A lack of public lesbian role-models is also said to contribute to the detrimental effects of the lack of a defined societal role for lesbians.
ADVERTISING AND THE MEDIA
Any investigation of the gender differences in drug use cannot afford to ignore the influence of advertising - not least because the alcohol and tobacco companies certainly haven't. The media is particularly problematic because of its focus on sensationalism and atypical cases, and the fact that these provide informal drug education to the public. The drug companies know the powerful influence of the media and advertising on young people (Flay, 1993, as cited in Camp, Klesges, & Relyea, 1993, p. 24). Young males have always been targeted by both the alcohol and tobacco industries (eg. the Marlboro Man, 'I feel like a Tooheys', etc.). In Australia, young women have been recognised by both the tobacco and alcohol industries as a large potential market for expansion. (Blume, 1990; Swan, Melia, Fitzsimons, Breeze & Murray, 1989).
Females have a role in males' sport, and again the tobacco companies know it. While adolescent boys tend to play sport, the girls tend to watch (although this is not a consistent finding in the literature). In one Australian study (Dempsey, 1989
as cited in Wearing et al., 1994) 92% of adolescent boys (average age 15-16) played football and 80% of girls (same age) watched it on Saturdays. The girl's gender identity (as well as her drug use) was associated with the boy she was with, and his leisure and sporting interests. This is despite documented evidence that sport is good for girls - that it leads to higher self-esteem and less depression (Turner et al., 1995). The girls smoked for their leisure (a symbol of resistance to the 'good girl' image). Smoking is pleasurable leisure, and this study maintains that the tobacco companies successfully target the restrictive nature of women's leisure and leisure spaces.
Advertisements appealing to women's new freedom and independence, as well as sexual attractiveness and slim image, were prominent in the 1980s For example, special 'female brands' of cigarettes came on to the market such as Virginia Slims ('You've come a long way baby') and Elle. "Smoking has been inextricably linked with perennially successful themes - style, sex appeal, and more recently, success and emancipation. . . . Clever promotions . . . have paradoxically juxtaposed women's emancipation with women's enslavery to the desire for slimness" (Winstanley et al., 1995, p. 323). This is further reinforced by the fact that many super models smoke.
Advertising knew its market well. As one study states: "The tobacco advertising campaigns targeting women, which were launched in 1967, were associated with a major increase in smoking uptake that was specific to females younger than the legal age for purchasing cigarettes" (Pierce, Lee, & Gilpin, 1994, p. 608). This same study notes that the advertising budgets for women's brands of cigarettes increased through to 1979, by which time sales of these brands reached a peak that coincided with the observed peak in smoking initiation in under-aged girls. The authors therefore conclude: "In this study, we have demonstrated that tobacco advertising has a temporal and specific relationship to smoking uptake in girls younger than the legal age to purchase cigarettes. Our findings add to the evidence that tobacco advertising plays an important role in encouraging young people to begin this life-long addiction before they are old enough to fully appreciate its long-term health risks" (p. 611). (Even if they did appreciate the long-term health risks, young people tend to only have short term time perspectives.) The fact that the female market has grown in importance for the tobacco manufacturers is acknowledged by the industry (Winstanley et al., 1995).
Health advertising and sponsorship of sporting and cultural events for young people should be continued as counter measures to alcohol/tobacco promotion and the sensationalised media coverage of drug issues. This has been done effectively in the past through State health promotion foundations (Holman, Donovan, & Corti, 1994).
Advertisements for males and females
Advertisements for alcohol largely promote beer for guys and spirits and special drinks for girls (Banwell & O'Brien, 1993). These portray an image of glamour for girls and sport heroism for boys. Young women these days are 'free' to choose their own drink, thus advertisements target images of independence and sexiness, and they show it by girls drinking cider, vodka and designer drinks. The advertisements for beer, on the other hand, feature males - particularly athletic, sporty males.
Advertisements for alcohol reflect the reality of extremely marked differences in beverage preference between the sexes. Mostly it's beer for guys and spirits, wine and special drinks for girls (Banwell & O'Brien, 1993), but wine is drunk by both sexes at meals and at home with the family. Beer and spirits are drunk more with mixed sex peer groups at bars, friends' places, etc. There are also drinking patterns dictated by particular beverages. For example, for beer and wine, Friday to Sunday drinking is common for both sexes. With females, spirit-drinking is mostly done on Friday and Saturday nights, although it is also popular after Thursday night shopping (Wilks & Callan, 1990).
The reasons for such marked gender differences in choice of beverage are not completely understood, although social expectations and norms are thought to be influential. The symbolic meaning of drug use for the different sexes is therefore not lost on the advertisers. In the words of one research group, "It is remarkable how sex-based preferences for styles of drink emerge so strongly in people so young. It suggests, of course, that the cultural value of drinking for adolescents is very great. Drink is used not merely for pleasure, not even to create an occasion for conviviality. It confers an adult status that is at once recognisable in a way that is appropriate to their sex" (Marsh, Dobbs, & White, 1986, p. 21). Designer drinks like 'alco-pops' are very popular amongst young females. Also, alcohol is promoted in particular ways to young females, eg. happy hours, cocktails.
EATING DISORDERS AND SUBSTANCE USE
Advertisers rely heavily on the importance of body image to young people, again particularly females. The main health concerns of girls are linked to their appearance, namely their weight, their skin and wanting to look attractive to boys (Banwell & Young, 1993). Society reinforces the importance of appearance for females, and for many young women this can become an obsession, and lead to a self-damaging preoccupation with weight control (Patton, 1994, Amos, 1996). "In our society a female without 'the perfect body' is urged to do whatever it takes to achieve this impossible ideal" (Rienzi et al., 1996, p.341). This has not escaped the attention of the tobacco companies, who target girls under pressure to conform to the 'tyranny of slenderness'. As stated by Broom (1995), "Tobacco marketers have been much quicker than the health sector to identify and capitalise on the fact that smoking has different meanings and symbolic power among different sectors of the population, and some of these differences are gendered" (p. 414). Specific brands and marketing strategies recruit females to smoking through the promise of freedom, self-confidence and slimness.
Weight control - Tobacco and the amphetamines
In a society obsessed with female slenderness, concern over bodyweight and its potential control through cigarette smoking has long been recognised as a particular health issue for women (Gritz & Crane, 1991). The research is consistent in its findings that teenage girls who express weight concerns are more likely to smoke, and to see smoking as a means of weight control, with the health dangers of smoking far less relevant to them than their appearance (Camp et al. 1993; Evans , Gilpin, Farkas, Shenassa, & Pierce, 1995; Gritz & Crane, 1991; Waldron, 1991; Winstanly et al., 1995). (Once again this is an indication of young people's short-term time perspectives, with important implications for educational initiatives) The effect of smoking on bodyweight is, unfortunately, not just a perception. Girls know that nicotine affects body metabolism and food intake, and that smokers weigh on average less than non-smokers (Gray et al., 1995; Winstanley et al., 1995). Smoking, therefore is not so much a factor in initiating weight control, as in maintaining it, and is a strong factor against cessation.
Tobacco, however, is not the only substance used in pursuit of the thin ideal. Perceived physical attractiveness is correlated with amphetamine use as well, particularly amongst underweight girls (Page, 1993). These are mostly the illicit amphetamines, but the licit appetite suppressants (diet pills), as well as caffeine are also used (Gritz & Crane, 1991). It is interesting to note the double standard which some researchers found - that it is acceptable for boys to use diet pills to get high (ie. non-medical use of stimulants), but it is only acceptable for girls to use them for weight control. This again "illustrates the historical view that women must not use drugs for pleasure, but only for medical purposes" (Gomberg, 1982 as cited in Rienzi et al., 1996, p. 345).
Consistent with a growing literature is also the correlation between adolescent females (as well as males), who smoke and those who use any illegal substances
(Evans et al.1995; Gritz & Crane, 1991; Morgan & Joe, 1996; Schorling et al., 1994). Schorling (1994) comments that while there are a variety of reasons for cigarette smoking being related to alcohol and illicit drug use, "one reason is lower perceived risk of drug use by smokers" (p. 113). An Australian study also found that "adolescent smokers perceived themselves to have less personal risk, less severe health consequences from smoking, greater benefits relative to risks, less control over their smoking, and were less able to picture harmful consequences to themselves than were non-smokers" (Smith & Rosenthal, 1995, p. 231).
Alcohol, bulimia and dieting
Overweight girls, alternatively, tend to rely more on food as a coping mechanism for dealing with negative feelings about their body image. This can lead to bulimia which is a common eating disorder amongst young women and now thought to be reaching epidemic proportions (Bayer & Baker, 1985; Beebe et al., 1995; McCrady & Raytek, 1993). Also, there is a high correlation between eating disorders, such as bulimia, and alcohol problems (McCrady & Raytek, 1993; Patton, 1994; Turner et al., 1995). There is also a higher rate of smoking documented amongst bulimics (Gritz & Crane, 1991; Swift et al., 1995).
The most common behavioural antecedent of eating disorders in young women is dieting, the prevalence of which is about 35-45% (Patton, 1994). In the Victorian Adolescent Health Survey (Hibbert, 1996) it was also found that smoking rates in young dieters were twice those of non-dieters. Again, the messages society gives to young females have to be questioned. Dr David Bennett maintains that there is a powerful 'body-hating' culture which is harming Australian teenage girls. "Being thin, having sex, drinking alcohol and having purchasing power sends young girls the message that these things lead to the good life, to being popular. It's the main message from TV, radio and magazines" (Gripper, 1996, p. 9).
Underlying factors in eating disorders and substance abuse
The links between eating disorders and substance abuse therefore go beyond similarities in patterns of behaviours - they include high rates of co-occurrence. Again, we can only speculate about underlying factors, but several mechanisms are at work - for example, there is considerable agreement in the literature that impulsivity is an underlying factor in both eating disorders and substance abuse, as is underlying depression. Depression is often cited as a reason for female substance use. In fact depression is well-documented as a pre-disposing factor in heavy drug use by females (Blume, 1990; Boyd, 1993; Turner et al., 1995). Alternatively, depression has been found to be the result of substance abuse, particularly among adolescents (Robbins & Martin, 1993) - mainly due to the stigma, and criticism by significant others.
In two American studies of young female cocaine users, depression was given as one of the main reasons for use - perhaps because cocaine is a stimulant drug? (Boyd, 1993 ; Lex, 1991). Can the use of food and substances be explained as an urgent attempt to numb the pain? To 'escape' is often the actual reason given by females for sudden use of food or substances. One study done in Perth (WA) recently, on psycho-stimulant bingeing by young women found poly-drug bingeing to be quite a prevalent
behaviour; the reasons given for this behaviour are rather vague, being escapist-type ones, such as 'numbing-out' (feeling nothing) and boredom (Ovenden & Loxley, 1994). Also, both eating disorders and substance abuse are correlated with childhood sexual assault (Jarvis , Copeland, & Walton, 1995).
Beebe and colleagues (1995) investigated the 'escape' model of binge-eating in an analysis of college women. This model notes that binge-eaters compare themselves against perfectionist standards, which in turn leads to 'aversive self-awareness' and thus depression and anxiety. The binge is therefore used to temporarily alleviate this 'aversive self-awareness'. These young women were also found to be chronic dieters, which highlights the binge-eating paradox: those females who strive hardest for the thin ideal are the most likely to binge. It also has to be recognised that for many women a small weight gain is a high cost to pay in terms of their self image. Therefore, strategies for reducing drug use that involve weight gain may be unacceptable for many young women (Amos, 1996).
In the study by Beebe et al., (1995) binge-prone females were not perfectionist in all areas of their lives - mainly body image and eating behaviour. It would appear that binge prone women take a very extreme stance. Their strong focus on body shape and weight provides them with a structure for their lives. They believe that thier lives would be greatly enhanced if they had a better body.
Certainly feelings of isolation and loneliness accompany eating disorders, and feelings of loss of control are common. It has been hypothesised that these young women are trying to gain back control by being in complete control of one area - the physical body. This, of course, is the paradox of addiction - that while trying to gain control, once addicted, the person is really not in control. There is also the issue of being in control of the mind, as well as the body, and this is where mood altering substances such as alcohol come in. They are often used by people as a way of coming to terms with negative thoughts and feelings about themselves. An important aspect of substance use is, after all, the immediate sense of well-being. For many young women this sense of well-being meets their need for validation (Ettorre, 1992).
VIOLENCE AND SEXUAL ABUSE
The chances of hazardous use of drugs are greatly increased among adolescents of both genders if they come from families where there has been a lot of parental neglect and abuse of children (Foxcroft & Lowe, 1993; McCallum, 1994; Turner et al., 1995).
This is particularly high amongst female problem drug users, where there is a strong correlation between heavy drinking and earlier sexual assault, rape or incest. (Boyd, 1993; DeFronzo & Powlak, 1993; Lundy, 1987; Pedersen & Skrondal, 1996). This raises the question: is the increase in female drug use linked to an increase in female childhood sexual abuse, or have both simply been underreported and therefore less known about? Boyd's answer reflects a general view: "Most experts agree that experiences of childhood sexual abuse are underreported. Despite these underreportings, there are indications that the incidence of childhood sexual abuse and sexual trauma in populations of alcoholic or drug-addicted women are very high" (Boyd, 1993, p. 434). It has been estimated that 70 to 80% of women with serious drinking problems are victims of some form of childhood sexual abuse, (Boyd, 1993; Broom, 1995; Pedersen & Skrondal, 1996) although not all researchers report such a high direct correlation (Maher, 1996).
These are not isolated findings. In a large study in the United States (Wilsnack et al, 1991) at least twice as many female problem drinkers reported childhood sexual abuse as females without such a history. This is confirmed by other studies (Lammers, 1995; Miller & Downs, 1993; Turner et al., 1995).
Depression and sexual abuse
Depression, as already stated as an underlying factor in eating disorders, is one of the most frequently reported antecedents of female alcohol abuse, and many studies support a direct correlation between childhood sexual abuse and later depression (Boyd, 1993; McCrady & Raytek, 1993; Pedersen & Skrondal, 1996). This has also been found in Boyd's 1993 study of crack-cocaine addicted women, where a significant number of addicts have a history of sexual abuse and depression. These data are consistent with other studies from other populations which have noted high rates of depression and sexual abuse in alcoholic and heroin-addicted women (although the actual word 'depression' is not always used by these women - they don't necessarily call it this or relate to this terminology).
Similarly, in an Australian study (Sibthorpe et al., 1995) homeless and potentially homeless youth (homelessness is on the increase) were not only at increased risk of harmful drug use, but high rates of physical abuse, sexual abuse, family drug and alcohol history and attempted suicide were reported. More females than males had been physically and sexually abused and more females attempted suicide. A strong association was found between attempted suicide, sexual abuse and current binge drinking. In the context of sexual abuse, the authors speculate about whether the harmful pattern of drinking is a coping strategy and/or self-destructive behaviour (consistent with attempts at suicide). Lammers (1995) also speculates about the function of problem drinking amongst women with a history of sexual abuse. She says that these women believe it strengthens their identity and makes men look upon them as equals.
An Australian study of the relationship between child sexual abuse (CSA) and
substance abuse among women supports Lammers' view, adding that as well as the need for building confidence in social situations, many of these women describe the need for confidence in terms of a lack of self-worth or their desire for power (Jarvis et al., 1995). This is not only an insight into substance misuse among women, but also among adolescents who have experienced CSA. "The need for social confidence is a particularly salient need in adolescence and the pressure to use substances to fit in with the peer group an often cited reason for starting to use" (Jarvis et al, 1995, p.57).
Because of the stigma felt by girls who are victims of CSA this need is greatly increased.
Pedersen and Skrondal's (1996) longitudinal study of Norwegian girls looked specifically at thetype of alcohol problems experienced. Female childhood sex victims reported increased alcohol consumption from their mid-teens, with dramatic increases in alcohol-related problems at the end of their teens. This is consistent with other findings. However, even though there is a large body of research in this area, such research is "in its infancy" and the findings are not conclusive. "There is no standard way of collecting information about sexual victimisation. The problems are related to the facts that the acts, situations and relationships in question are extremely heterogeneous" (p. 574). However, what we do know is that child victims of sexual assault abuse alcohol more (than those not victimised) from mid-to late adolescence, and more importantly, victimisation had a very strong effect on alcohol problems. "In other words, it seems to be pathological alcohol use in young women . . . that is influenced by childhood sexual victimisation" (p. 577).
The child victims of abuse are at risk for developing alcohol problems, especially in late adolescence. Alcohol plays a role in masking emotional pain evoked when these girls are about to develop a relationship with boys of their own age. This is supported by Boyd (1993) in her study of female cocaine users, but she also emphasises the combination of parent drug use, neglect and sexual assault which comprises an assault to the child's self. This in turn leads to depression and low self-esteem. Thus a young woman's drug use may function as an attempt to mediate against the feelings which follow hurtful childhood experiences (this is supported by Maher's 1996 findings that child sexual assault alone is not a direct predictor of later substance abuse). While drug and alcohol programs may be set up, to be effective they will ultimately have little to do with substance use per se (Sibthorpe et al., 1995).
Family background and gender differences
Families and levels of support have been measured in relation to teenagers' drug use. Clear gender differences have been found in the relationship between family type and drug use behaviour, family type either being authoritarian/neglecting, or warm/directive, with the latter providing high levels of support. Family type seems to be more influential on drug use by boys than by girls, but the neglecting and authoritarian family types are associated with the higher use of alcohol by both sexes. Thus it seems that family support is a critical factor behind these behaviours, as documented:
"A warm, positive relationship with a caring adult...may be the most
important protective factor" (Turner et al., 1995, p. 31).
"Adolescents who get along well with, and receive praise and understanding
from their parents are less likely to engage in alcohol and marijuana use,
cigarette use, amphetamine and depressant use" (Taub & Skinner, 1990,
"Adolescents who have a closeness to their parents and who feel good
about their relationship with their parents are less likely to report heavy
involvement with drugs, and this applies even when the closeness of the
parent/child relationship would appear to fluctuate with the turbulence of
adolescence" (McCallum, 1994, p. 40).
Foxcroft & Lowe (1993) found that family type has a very important influence on males' levels of drug use. However, "the picture for girls is particularly interesting in comparison with their drinking behaviour, where warm-directive families had a marked positive relation with girls' restrained use of alcohol" (p. 4).
The link is similar with the illicit drugs such as heroin and cocaine. There are important gender differences in illicit drug use and retrospective perceptions of family history and socialisation (Binion, 1982; Fagan, 1994; Henderson et al., 1994). For females, drug use was more closely related to unresolved problems in the family, especially during adolescence - they report having felt unloved and lonely from childhood through adolescence, and expressed difficulty in making friends. In fact, a large study conducted over the past decade of 12,000 young people in the US has confirmed that a sense of 'connectedness' to at least one other significant person is a dominant protective factor against adolescents' problem drug use (Resnick et al., 1997).
Girls who perceived this parent-family connectedness to be weak also felt they were punished more often than other children, and that there was little consistency to this. In an effort to escape problems at home females often turn to boyfriends (who may be illicit drug users or who may subsequently influence them to become involved in drug use) for closeness and affection.
Girls, however, from all family types were equally likely to report that they smoked - which suggests that family type does not play an important role in the socialisation of girls' smoking behaviour.
Family support, however, is not the only variable involved in gender differences and drug-using behaviour. Obviously parental modelling of drug use and a family history of problematic drug use, such as alcoholism, also have an effect. For example, a study by Lex (1991) found that 75% of women with problematic drug use had a family history of alcoholism. Whether this is a direct result of alcoholic role-modelling seems to be dependent on other family factors. Parents who smoke also have adolescents who are more likely to smoke (Amos, 1996). The question which has to be asked is: why do some children model their parents' drinking while others do not? Closeness to parents is one factor which has been shown to reduce adolescent alcohol abuse (McCallum, 1994). Modelling of problem-drinking parents has been found to be contingent on the quality of the parent-child relationship. In fact, many studies indicate that the quality of the parent-child relation is the most influential factor (McCallum, 1994; Velleman & Orford, 1993). Overall, however, parental drinking levels and closeness of their relationship with their children, act together (Bahr, Marcos & Maughan, 1995; Jung, 1995). This is backed up by Buelow & Buelow (1995) and Friedman, Bransfield, Granick, & Kreisher (1995) in their work on female alcoholics coming from more dysfunctional families.
Father-son, mother-daughter influences?
As far as a correlation goes between the sex of the parent problem drinker and the sex of the child problem user, the findings are inconsistent. In Swift and colleagues' Australian study (1995) of women interviewed in treatment agencies, one-quarter reported a maternal history of substance abuse problems and almost one-half reported a paternal history of substance abuse. However, in a large US study, (McGue, Sharma, & Benson, 1996) a significant correlation was observed between the mother's problem drinking and adolescent daughter's alcohol involvement, and between the father's problem drinking and adolescent son's alcohol involvement. There was no correlation between parents and offspring in adoptive studies - so this study's interpretation of the findings is that genetic, not familial factors are at work.
In another study (Jung, 1995) of college males and females a correlation was found between sons' drinking and the drinking of each parent, although the greatest similarity was found between fathers and sons (consistent with other findings). In contrast, college females showed no relationship between the amount of drinking and either parents' drinking levels. The best predictor of daughters' drinking was the relationship with their mothers, and modelling was more likely if there was a positive relationship. This is borne out in another study by Marcos and Bahr (1995) which found that parental attachment predicts female alcohol use better than male alcohol use ie, the closer the attachment between females and their parents the less likelihood of problematic alcohol use amongst adolescent females.
This review has revealed that drug use by young adolescent females is a complex issue, and that many biological and psychosocial variables interact with gender. It is argued that young females' drug use can only be understood in the social context of gendered roles, norms and circumstances of use. These are really 'underlying issues' and if they are not addressed young women are unlikely to experience good long term outcomes from interventions (Sibthorpe et al. 1995, p.255). The literature acknowledges that young women increasingly smoke, drink, and use other drugs, but it also challenges the traditional stereotype of young women.
Thus, parents, teachers, community workers, counsellors and all those involved in the care of young women, must be alerted to the need for education in this field. Education programs should be gender related, culturally relevant and target-specific. Further research needs to be done to ensure that a good understanding of young female drug use underpins intervention strategies. Meanwhile, the media and other powerful social agencies, must take a more responsible attitude in their coverage of, promotion of, and dealing with, drug issues. The needs of certain groups, such as early school leavers, the homeless, the unemployed, the socio-economically distressed and traumatised, and those who have been sexually abused, should be especially acknowledged if these young women are to have any chance of a healthy future.
Summary of main points from interviews with key informants:
Identified issues and suggested strategies
1. There is general agreement that drug use among females has increased:
- in both quantity and frequency
- particularly with tobacco
- increased amphetamine use (dance party drugs) heroin use, and binge
- illicit drug users are mostly poly-drug users
- injecting drug use is increasing
- young women are not a homogenous group of drug users. Different girls,
and different groups of girls, use different drugs, for different reasons.
2. Weight control, body image and drug use was seen as a 'major factor' in young female drug use. Smoking for weight control is very common, although other drugs, such as amphetamines and heroin, are used too. Strategies to combat the use of drugs for weight control include more emphasis for females on exercise, sport and leisure activities; education about body image and norm setting expectations about 'ideal weight'; and health messages on slimness devised by peers and the media. Other strategies to combat the use of drugs for weight control are included in the Recommendations.
3. Child sexual assault was correlated strongly with adolescent substance use, but
two interviewees were adamant that this link reflects a more complex
background of trauma (ie. sexual abuse is one of many contributing factors,
including socio-economic background, deprivation, etc.). The use of drugs is
said to mask the emotional pain of abuse. Heroin and alcohol are used mostly
for escapism, whereas stimulants are used to maintain 'vigilance', as a form of
coping, and for bolstering their confidence and courage. Suggested strategies are:
- counselling for the underlying reasons for drug use, as well as the drug use
- teaching self-defence
- teaching better communication skills
- assertiveness training
- same sex group education to discuss ways of dealing with sexual
- teaching about safer-sex and sexual issues when teaching about drugs
- programs for males (young males encourage females to drink (for sex), and
both males and females are aware of this.)
Friendship networks play a central role in young females' drug use. Females,
like males, choose to use drugs, and therefore use trusted friends during the
planning and negotiating required for providing safety from both the drug use
itself and from predatory males.
Although girls have the skills to say no to sex, but choose not to, new approaches to education programs are needed to discover, acknowledge and embrace alternatives.
5. Female drug use is still less visible and more stigmatised than male drug use.
It was generally agreed by the informants that female drug use needs to be
seen as more normal and acceptable if harms are to be addressed. Young new
injecting drug users often need special strategies, to protect them against male
violence, social stigma, unsafe injecting spaces, etc.
Other suggested strategies are:
- to educate parents and to educate males to view female drug use as 'normal',
or as 'normal' as male drug use
- to provide same-sex groups for young females - they need a safe environment
to discuss external pressures, their own vulnerability and to devise better
strategies for coping.
6. There was an emphasis on boredom, escapism and disadvantage as reasons commonly cited for drug use. 'A lack of connectedness' with the world and other people was commonly referenced. Contact with a significant adult in the young woman's world was considered very important - someone they could trust and someone they could talk to, to give them a feeling of 'connectedness'.
Similarly, offering an alternative world can be effective. For example, taking young urban heroin users fishing has been successful, and the use of wilderness and cultural camps has been suggested for young people from different cultures. It is important to note here, though, that research has shown that while wilderness/outdoor experiences have had excellent short-term benefits there have been little or no long-term benefits unless the young person's home environment has been able to be changed.
Suggested strategies are:
- meaningful recreational options need to be available
- fun activities, exercise, change in lifestyle, and opportunities for leisure and
sport activities need to be offered
- job training and providing employment are important
- providing an 'alternative world', a sense of 'future', and a feeling of
'belonging' all hold promise
- 'the settings' approach is very important. That is, reach young females where
they are - schools, youth refuges, women's refuges, Juvenile Justice Centres,
TAFE, leisure places, and so on.
7. Homeless young females and females who leave school early are at high risk. Because being 'thrown out of school' is a big risk factor, school expulsion policies need to be looked at, more school counsellors may be needed, and counselling services for the homeless. A focus in education could be on these young women's mental health needs as a positive strategy to assist the homeless. Strategies suggested in Recommendation no. 6 apply here too.
- such as smoking education
- same-sex education in schools is beneficial and important for reasons already
- school drug education is vital for teaching about coping strategies,
challenging societal norms, teaching communication and assertiveness skills.
These must be culturally appropriate.
- TAFE is a very important setting for education. Students are an at-risk group
of people, at a high risk age, with greater freedom, etc.
- school drug education is currently too isolated from community health
services, corrective services, etc.
- educators/teachers need specialised training (this was emphasised by many
informants as crucial) and regular 'booster' sessions.
9. The media was generally seen as problematic - not just because of advertising, but because it focuses on sensationalism and unusual cases. Informal drug education by the mass media is often misleading. The media was seen to be influential at a variety of levels, both directly and indirectly - for example, promoting the slim female body.
Media coverage of drugs is for the most part problematic. While a few media outlets present a balanced view of drug issues, most sensationalise the issues. Drugs like Ecstasy, not the legal drugs like alcohol and tobacco which cause the most harm, are highlighted. The fact that the media are a source of informal drug education for many people is a major concern as they provide much 'misinformation'. Educating the media through closer collaboration with educators is recommended.
10. Key informants emphasised the negative influence on young people of
families in which other forms of drug abuse occurred. For example, where
parents draw children into their own drug use/social life, possibly as a way to
validate their own drug use or, with mother and daughter, as a means of
female bonding. Young females are more likely to abuse drugs if their
mothers abuse drugs.
Alcohol use and petrol sniffing by young Aboriginal women has often been
normalised by parental use. That is, parents' use has been seen as a legitimate
response to problems. Other parents however, from culturally and
linguistically diverse backgrounds, view their daughters' drug use with a
"sense of horror". They do not understand Australia's culture of youth drug
Parent education is an important strategy:
- so that parents have more information about the nature of drug use - and
are more likely to accept young people's drug use as 'normal' behaviour
- targeting parents can help gain credibility with young people regarding drug-
- parents often don't understand drug issues, and that their own modelling can
be a contributing factor to young people's drug use
- parent education can be a useful strategy in the rehabilitation of young
females, particularly when family background and abusive relationships have
- parent education may also help to open the lines of communication between
parents and their children.
11. Controlled sale of cigarettes was mentioned by several key informants (that reduced access to cigarettes will reduce smoking). Reduction of 'product placement' or smoking promotions in films and TV programs is recommended.
Some key informants, however, were more cynical, saying that the sale of
products such as marijuana, speed, ecstasy, heroin and so on are already so 'controlled' yet the use of these substances is still on the increase. Young people, they say, will always pursue behaviours or activities which they 'aren't meant to' because it's part of the natural propensity to be involved in risk-taking behaviours.
12. Specific points relating to young females from culturally and linguistically (C&L) diverse backgrounds:
- some drugs may be a taboo subject in some cultures, whereas some illicit
drugs may be considered to be a normal part of some cultures
- in some cases racism further marginalizes females using drugs
- generational and cultural conflicts are highlighted amongst females from
C&L diverse backgrounds
- religious background and tradition may influence attitudes and practices
related to female drug use
- community services for females from C&L diverse backgrounds should be
sensitive and relevant to the needs of the young female drug users.
13. Specific points relating to young females from Aboriginal backgrounds:
- it is apparent that binge-drinking, 'popping pills' and sniffing are problems
that need to be addressed within the Aboriginal community
- young Aboriginal females tend to see the use of drugs as a means of
empowerment and escape from their social isolation and separation from
their cultural heritage
- there is a need for more significant role models within the context of the
family in Aboriginal culture
- the penalties related to young female drug offences appear too harsh when
compared to males
- appropriate referral systems for young Aboriginal female drug users need
to be created and extended.
Key Informants interviewed:
Ms Tracey Jarvis, Cellblock (a youth health centre), Carrillon Ave,
Dr Jan Copeland, National Drug and Alcohol Research Centre, University of NSW.
Mr Jeremy Davey, Queensland University of Technology, Carseldine Campus.
Ms Charlotte de Crespigny, School of Nursing, Faculty of Health Sciences, The Flinders University of South Australia.
Mr Bruce Flaherty, NSW Drug & Alcohol Directorate, North Sydney, NSW.
Ms Julie Hando, National Drug and Alcohol Research Centre, University of NSW.
Ms Tracey Jarvis, Ted Noffs Foundation, Darlinghurst, NSW.
Ms Anne Jones, Action on Smoking and Health, Woolloomooloo, NSW.
Ms Margaret Ling, Australian Drug Foundation, North Melbourne, Victoria.
Ms Jeanne Lorraine, Adelaide Women's Community Health Centre.
Dr Lisa Maher, National Drug and Alcohol Research Centre, University of NSW.
Dr Peta Odgers, Turning Point, Fitzroy, Victoria.
Ms Stella Patete, South West Alternative Progam, Cabramatta.
Ms Melissa Raven, National Centre for Education and Training on Addiction, The Flinders University of South Australia.
Ms Catherine Spooner, National Drug and Alcohol Research Centre, University of NSW.
Ms Wendy Swift, National Drug and Alcohol Research Centre, University of NSW.
Attempts were made to contact Mr Peter Dwyer, Community Programs, Sydney Institute of Technology and other TAFE educators in NSW and Victoria. Unfortunately Peter Dwyer was overseas and the other educators were unable to supply relevant backup material.
Key Informants for Aboriginal young females:
Mr Barry Coe, Drug Education Special Initiative, Department of School Education NSW.
Ms Ellie Ellis, Western Sydney Area Health Services (WSAHS), Westmead Hospital Drug and Alcohol Services, North Parramatta, NSW.
Ms Kim Hargreaves, Aboriginal Drug and Alcohol Council (SA) Inc South Australia.
Ms Fiona McDonald, Danila Dilba Biluru Butji Binnilutlum
Medical Services Darwin, Northern Territory.
Ms Josie Maxted, Social Worker, Carrellis Centre, Western Australian Alcohol and Drug Authority, Western Australia.
Ms Kim Wright, A/S Youth Accommodation and Support Services, Alice Springs, Northern Territory.
Mr Ian Raymond & Ms Amber Rimington Beedre, Centre for Education and Information on Drug and Alcohol, Rozelle, NSW.
Ms Jodie Shoebridge, National Centre for Education and Training on Addiction, Adelaide, South Australia.
Key Informants for young females of culturally and linguistically diverse backgrounds
Dr Jan Copeland, National Drug and Alcohol Research Centre, University of New South Wales.
Ms Elli Ellis, Westmead Hospital Drug and Alcohol Service Western Sydney Area Health Service (WSAHS), North Parramatta, NSW.
Ms Deborah Felton, Drug Referral and Information Centre, Canberra, ACT.
Ms Sirkka Lawson, Migrant Support Worker, Drug and Alcohol Womens Network (DAWN), Campbelltown, NSW.
Ms Teresa Luland, Drug and Alcohol Health Education Officer, Hawkesbury Community Health Centre, Windsor, NSW.
Ms Denise Voros, Hands on Team, HIV AIDS Education Project, Sydney, NSW.
Discussion and Recommendations
The Literature Review and the Interviews with Key Informants have revealed that drug use by young females is a complex issue. Psychosocial, biological, socio-cultural and environmental factors all contribute to the onset and continuation of their drug use. There are also different patterns and levels of use, for example experimental use, social use, regular use, and abuse. Therefore, to encompass these multiple factors, broad recommendations will be made from which specific strategies for addressing female drug use can be developed.
The content of any intervention strategy aimed specifically at young women should be informed by a good understanding of female drug use, although, this understanding is still evolving. Girls' drug use can only be understood in the social context of gendered roles, norms and circumstances of use. These are really underlying issues. If they are not addressed, these young people are unlikely to have a good long-term outcome from interventions.
1. Target biological differences in education and health promotion
Widespread education is needed to inform young women that because their bodies are different from males their metabolic response to most drugs is different. Most drugs exert a stronger effect and the physical consequences are more significant for females. This information is particularly important because of the deficits in young women's knowledge of the harms related to their use of drugs (borne out by both the research and the interviews). For example, young women's rates of both binge drinking and drink-driving are increasing, and this can be lethal when combined with: a) their lack of information about the risks; b) their drinking higher alcohol content drinks.
Educators therefore need to consider programs to alert young women to the heightened risk they run in matching male drinking patterns, especially binge-drinking. Young women's recognition of alcohol problems lags compared to men's. Correcting this underestimation of the extent and seriousness of drinking problems in women is clearly an issue to be addressed. However, while this is highly appropriate and necessary, ideally it should happen within the context of their image of themselves, and the characteristics of the peer group to which they belong.
An additional adverse consequence of drinking for girls is that they experience blackouts more often than boys. Therefore more research on the relationship between gender and blackout needs to be under-taken in this age group.
A young female's sensitivity to alcohol varies at different times of the menstrual cycle. Females need to be made aware of this.
The association of an earlier onset of puberty with a younger age for the initiation of both drinking and smoking among adolescent girls is also a very important issue to be considered. The pattern of pubertal development may also be a useful tool for identifying girls at higher-risk.
2. Present harm from drug use in a positive, non-judgmental and credible
Unless young people are convinced of how drug use can impinge on their health they mostly ignore or reject health information which is presented negatively or proscribes their 'normal' behaviour. They are also unlikely to be influenced by long-term health messages because these are too distant to be relevant. Any message, to be effective, needs to be personally relevant. The issue of adolescents having short-term time perspectives is pertinent as they are more concerned with their reputation (image) and minimising immediate harm. An example of a non-judgemental, harm-minimisation message is the following, aimed at young women who binge on psychostimulants:
*If you use, don't binge
*If you do binge - keep a stock of sterile needles
- have long gaps between binges (Ovenden & Loxley, 1994)
There is also the need to warn young women about the dangers of mixing alcohol and other drugs, especially heroin and the benzodiazepines.
3. Acknowledge the benefits of drug use as perceived by young females
There is a consensus in the literature and among the Key Informants that drug use from the perspective of most young people is highly rational. Thus, until drug use is looked at from a user's point of view, (ie. acknowledging both the benefits and effects) education will not be effective. Education must also be age appropriate and developmentally relevant - that is, a 13 year-old user will have a different perspective to a 16 year-old user.
4. Seek the acceptance of female drug use by the community
Female drug use has to be overtly accepted, 'normalised' (as is the case with male drug use), and addressed from a female user's point of view. Only then can gender-specific and gender-sensitive approaches to drug use be adopted. Minimising the harm from drug use is only possible if female drug use is accepted and therefore visible as this will facilitate the addressing of gender-specific and gender-sensitive approaches to drug education.
5. Acknowledge female drug use as a pleasure/leisure pursuit
Female drug use can be viewed as pleasurable and mainstream rather than deviant and this perspective should inform service responses and policies. An educational approach which refutes stereotypes and "normalises" women who use drugs is more likely to engage women in harm reduction strategies.
6. Seek the adoption by all stakeholders of common approaches to drug issues relevant to young females
Schools, teachers, parents and the whole community must work towards understanding girls' resistance to the 'good girl' stereotype. This reinforces the importance of educating all sectors of the community so that there is an acknowledgment of drug use in general and female drug use specifically. Again this includes accepting as legitimate, girls' rights to choice, pleasure and leisure, and alternative identities.
Activities and outlets which enable females to express their desire to transform and grow, and empower them to resist the traditional female stereotype, must continue to be supported.
Co-operation between schools, health and corrective services needs to be augmented.
With 'at risk kids' and polydrug users, their 'core' problems need to be dealt with first: their drug use is often secondary. As many of these young people are still at school, collaboration between schools and community agencies is essential.
Several key informants also stressed the importance of young people developing a relationship of trust with at least one other significant adult in their lives. Collaboration between education, health and other services in the community is necessary therefore if young people without a sense of 'connectedness' to somebody are to be identified and helped.
There is also a need for collaboration over drug issues. For example, with the high use of heroin among school aged youth in S.W. Sydney, intervention among users is essential. Given the levels of injecting drug use, and the harm that can arise from it, girls should be provided with a safe environment in which to inject.
7. Educate the educators about gender specific issues related to female drug use
In-service training and professional development courses for teachers and educators are essential and must include gender issues. Academics, policy makers and curriculum developers need to work closely with schools so that practical approaches can be developed for teachers to implement.
Key Informants recommend that teachers, educators and significant adults working with young females be made more aware of current thinking regarding young women, and focus on 'relevant' approaches to drug education and issues concerning the changing roles of women in society
Drug use can provide an avenue for young females to satisfy their need for pleasure and to demonstrate their resistance to the more traditional, passive, 'feminine' lifestyles. Educators need to be made aware of this so that they can help young women make sense of their resistance and rebellion. Education strategies which alert young women to the ways in which changing sex roles and cultural expectations contribute to their drug use, will enhance their understanding of these influences.
8. Introduce mental health education for young people
The emotional escape, often referred to as ' numbing out', and self medication aspects of female drug use are closely linked with mental health issues. In fact depression is well documented as a pre-disposing factor in heavy drug use by females. Poly drug bingeing by young women is also associated with boredom and 'numbing-out'. Drug and mental health education therefore need to be integrated, as part of health education.
This is particularly pertinent, but more difficult, for disadvantaged and marginalised young women, therefore both education and health services need to be more culturally sensitive and accessible.
9. Correct distorted perceptions of young people's drug use
Norm setting is another aspect of drug education which should be addressed both in school and non-school settings as young people often overestimate drug use by their peers. Programs that change teenage perceptions of norms about drug use prevalence, and correct distorted perceptions, have had some success (Evans et al., 1995), (although teenage perceptions of drug use are often not as distorted as adults/ and parents' perception of teenage drug use!)
Messages designed to 'produce dissonance' (ie, the disharmony produced between a person's self-image and their actual behaviour) have also had some success, especially with female smokers (Hafstad et al., 1996). An example could be a media advertisement which clearly points out inconsistencies between attitudes believed to be widespread among the target population such as protecting the environment on the one hand, and being a smoker on the other. The success of these messages is attributed to increasing peer discussion of dissonance. This is a critical point, with implications for encouraging young women to devise messages for their peers rather than having messages based on adult concerns imposed on them.
10. Utilise culturally appropriate settings to educate young females about drugs
While it is clearly important to consider the ethnic, linguistic and cultural diversity of the target population, care should be taken to deal with these at a community level. A needs analysis of these young women must be conducted in conjunction with local groups (parents, the church, the community centre), and positive discrimination should be applied in training and employing workers with the appropriate language skills. The logistics of achieving all this, however, may be a large hurdle to overcome.
With young Aboriginal and Torres Strait Islander women, because of the importance of family and culture in their communities, it is advisable that drug and alcohol programs work with the whole community and towards greater empowerment. In terms of young women this means viewing their drug use in the context of adult drug use and values, not as separate from their culture. There is also a need for culturally attuned youth workers, locally run drop-in centres and Aboriginal and Torres Strait Islander youth health services.
Culturally specific community education about young females is needed as well as education for young females. This applies to all cultures.
There is a need for more gender specific research on young Aboriginal and Torres Strait Islander women's health needs, and for Aboriginal and Torres Strait Islander women to develop and deliver more gender specific drug and alcohol programs to the community. Older women/elders are powerful teachers at a local level, so mentor programs for marginalised Aboriginal and Torres Strait Islander youth such as "Big sister, Little sister" hold promise.
Widespread use of ethnic media in ethnic communities and indigenous media in Aboriginal and Torres Strait Islander communities has also been suggested as a way of getting the preventative message across.
11. Ensure that drug education and drug policy in schools is mandatory
To use smoking as an example, although smoking remains problematic for young females and almost always accompanies their other drug use, drug education which focuses specifically on smoking is still not mandatory in schools in all Australian states. A change of policy should be considered, although this should be cognisant of other powerful social and developmental influences on adolescents' to smoke. These influences should not be ignored within this recommendation.
A school drug policy on all drugs should be made mandatory as the absence of a policy may imply that drug use is not an issue, thereby undermining classroom curriculum. Help should be given to schools to assist them in formulating their policy.
12. Target post-school young female groups in appropriate settings
Approaches using specific settings are essential. For education to be effective it must be aimed at, and designed around, the identified needs of specific groups, and it must take place in settings which are convenient to young people. Early school leavers are a very high risk group for drug abuse so it is essential to target this group in non school settings such as drop-in centres.
13. Target smoking and passive smoking with health promotion
A recommendation emanating from both the literature and the Key Informants is to help young women value themselves in whatever way they choose and not according to traditional role expectations. Media campaigns such as Smoking - who needs it? (1993) which encouraged women to be 'who they were' without smoking have been commended. Young Aboriginal and Torres Strait Islander women need to be targeted, especially as more than half of them smoke, yet the dangers of tobacco are very much underrated in their communities.
There is general agreement in the literature that most illicit drug users are regular smokers. This group of smokers could be used as a target for other drug prevention programs given that cigarette smoking, even occasional use, identifies a subgroup of students who are at increased risk of binge-drinking and illicit drug use, particularly as smoking may be more easily identified than the use of other drugs. Young women working in places like the hospitality industry are another important target group. Not only are they often smokers themselves, but they are also exposed to passive smoking. These young women are therefore at an increased risk, especially if they are taking the contraceptive pill or are pregnant.
14. Encourage a healthy balance of 'masculine' and 'feminine' traits amongst
A combination of a high sense of self-esteem and a high level of 'masculine-typed' characteristics in females appears to provide a strong protective factor in relation to drug use. Thus it may not be androgyny per se that lowers a female's risk for drug abuse - it may be that viewing the self as high in sex-role masculinity, with or without high femininity (but combined with high self-esteem), is what reduces the potential for alcohol and other drug abuse. There is an obvious need for further research on this. However it does point to a need for education strategies which help foster healthy androgynous traits such as independence, self confidence, assertiveness and problem solving skills for girls.
Because of the resiliency-enhancing value of androgynous characteristics for both boys and girls, parents and teachers could encourage children to engage in activities which are not narrowly sex-typed. For example, girls could learn karate and judo, boys dance and gymnastics. This may mean re-education for parents and teachers in order to facilitate the encouragement of children to engage in activities which are traditionally for the opposite sex.
15. Provide opportunities for leisure activities and sport for girls
Young women who engage in physical and sporting activities have higher self-esteem and less depression than those who do not and appear to be able to integrate the positive aspects of both male and female identities . Engaging in more physical and recreational activities may also reduce boredom, which is often cited as a reason for drug use.
However, sport should not be reinforced at the expense of stigmatising drug users. Additionally, it must be noted that not all girls want to be 'sport freaks'.
Simply offering an alternative world is important to young drug users. It breaks their daily routine. Creative activities, and even fishing, have been very popular with young heroin users. Similarly, with different cultural groups, offering an alternative world and positive role models can be effective.
16. Encourage potentially early school leavers to stay at school
Girls who leave school early (with low academic qualifications) are at high risk. Education strategies and media campaigns to encourage girls to stay at school and/or improve their qualifications are urgently required to rectify this. Additionally, school discipline policies should be re-assessed so that young people already at risk are not further undermined.
17. Recognise the needs of, and increase support for, homeless young females
Homeless young people are a high risk group. Homelessness among young people is increasing in many Australian cities, and homeless youth have been found to be at increased risk of drug use. Increased funds and support, with a focus on the link between the mental and emotional health needs and drug use of this group, must be secured for this.
18. Provide drug education in same-sex groups where appropriate
Same-sex groups are generally recommended for dealing with many sensitive issues including drug use (Carpenter, 1995; Roberts, 1995). Girls are often unable to talk openly and honestly if boys are present. Same-sex groups provide insights into vulnerability, with girls talking about their reasons for drinking and other drug use, as well as strategies for coping when under the influence. This is especially important with marginal groups such as young women from culturally and linguistically diverse backgrounds and Aboriginal and Torres Strait Islander young women, where a 'cycle of silence' exists.
It is also good if young women can talk in the presence of boys, so perhaps a mixed approach is the ideal - ie. some same-sex groups, some mixed sex groups. Same-sex groups are a sound educational approach, although a 'cross-fertilization' of ideas is also needed so that both sexes are able to comprehend the differences.
19. Identify 'drug cultures' and friendship groups, and provide relevant drug
education programs to meet their needs
Friendship networks play a central role in young females' drug use and provide a measure of safety for women. The dance-drug culture has also highlighted the importance of friendship networks and 'grass roots' peer knowledge in influencing young people's attitudes to drugs like Ecstasy. Young people are interested in factual knowledge about drugs from peers with direct experience. They are sceptical of senstional media reports on the dangers of drug use.
Recreational users of 'E' respect straightforward information which relates to them in their own language and on their terms, and within the framework of their decision to take drugs. This has been a very successful strategy in Britain. In fact, targeting friendship groups for the dissemination of information is seen as an essential strategy both in and out of school as it is a sign of respect for the particular group.
A similar approach (presenting straightforward information to specific 'drug cultures') is recommended for Australia. ''Tip Cards' (S. Patete, personal communication, June 25, 1996) have been said to be successful in Western Sydney. Each card carries a short sharp message for young females who are often new injecting drug users. Because the cards are mainly graphic they are also appropriate for users from culturally and linguistically diverse backgrounds.
20. Utilise females as peer educators in drug education for young females
Peer education is strongly supported by the literature and by the Key Informants. Several recent projects in AIDS Education have demonstrated the effectiveness of this approach. Peer education with young people involves the sharing of information, the discussion of attitudes and ways of behaviour by young people. It is based on the influential role attributed to peers in the socialisation of young people, thus they often learn best from each other.
The influence of peer culture is strong in culturally marginalised groups (commonality of language, culture and values, etc.) and is particularly strong amongst girls from culturally and linguistically diverse backgrounds. Peer education among these groups is therefore strongly recommended.
21. Recognise the needs of, and increase support for, young lesbians
Programs, campaigns, legislation and services need to be established to assist the community to understand and respect the total lesbian lifestyle. If lesbianism is viewed as a lifestyle rather than just a sexual orientation, then many of the related myths may disappear.
Thus, homophobia in society needs to be addressed in order to reduce the harms related to alcohol and other drugs. The stresses of being discriminated against, and the accompanying substance abuse, may be largely alleviated by the community becoming better informed and more tolerant towards lesbians and gays in society.
A more positive gay environment in schools needs to be created. Efforts to counteract prejudice against all minority groups should be part of the curriculum.
A more positive gay identity amongst lesbians themselves needs to be encouraged. This relates to a major issue for all lesbians, which is the process of 'coming out'.
Groupwork is a suggested strategy to support and assist young lesbians to develop a positive gay identity, and to interact with other lesbians. This highlights the need for institutions which are exclusively focused for young lesbians, as well as inclusion and increased visibility in the larger culture. The need for lesbian-only and lesbian-sensitive sevices cannot be overstated, and staff training for this is critical.
Alternative social venues and events are needed. Bars are the focal point of lesbians' social life, so there is much excessive use of alcohol. Because this is the norm it is often not recognised as a problem. Therefore, alternative social venues and events are needed for young lesbians.
22. Initiate programs, campaigns and legislation to counter the impact of
advertising and the media on young females
There is some evidence that widespread restrictions on overt tobacco promotion have resulted in an immediate fall in smoking prevalence among young people, especially young women (Amos, 1996). There is also indisputable evidence that tobacco advertising plays an important role in encouraging young people to smoke before they are old enough to fully appreciate its long-term health risks (Pierce et al., 1994). However, women and girls, who have been identified as a key target group by the tobacco industry, have to be made aware of the ways with which the tobacco industry now promotes its products. Product placement in films and TV dramas is an example.
The actual portrayal of smoking in the media also affects the way in which young people view the habit. A positive strategy could be to increase the media profile of non-smoking popular actors, singers, models, sportswomen and others whom young females admire, and to use young women's magazines specifically to target females.
These strategies are also relevant for countering the promotion of alcohol as well as the 'decoding' of alcohol advertisements. If young women become aware that they are being manipulated, that the 'promise' of advertisements are often not realised, the advertisements could lose their impact.
Media coverage of drugs is for the most part problematic. Educating the media through closer collaboration with educators is thus recommended.
Health advertising and sponsorship of sporting and cultural events for young people should be continued as counter measures to alcohol and tobacco promotion and the sensationalised media coverage of drug issues. Also, widespread use of ethnic media in ethnic communities and indigenous media in Aboriginal and Torres Strait Islander communities should be used for the dissemination of culturally appropriate health promotion messages.
23. Challenge the dominant 'body image' stereotype which can perpetuate the
misuse of drugs by young females
Weight control influences females' drug use, particularly their use of tobacco, amphetamines and heroin (M. Raven, personal communication, June 6, 1996, J. Lorraine, personal communication, June 24, 1996). Strategies to combat the use of drugs for weight control should include more emphasis for females on exercise, sport and leisure activities; education about body image and norm setting expectations about 'ideal weight'; and health messages on slimness devised by peers.
It is not just the attitudes of society, which have to change: it has to be the attitudes of young women towards themselves as well. Educational programs to enhance self-acceptance and self-esteem should be considered as one means of attitudinal change.
The higher rate of smoking amongst young women with eating disorders needs specific attention, particularly as binge-eating is associated with females' aversion to self. The high rate of co-occurrence of smoking and substance abuse with eating disorders also suggests that greater collaboration between people working in these fields would be worthwhile.
24. Recognise the relationship between sexual abuse in childhood and young
females' drug use, and take appropriate action
Abused young females often self medicate to escape the emotional pain and sometimes the physical pain of ongoing abuse. Additionally, both eating disorders and problematic drug use for weight control, frequently co-occur with child sexual abuse.
Intervention strategies may therefore require the collaboration of several different agencies and disciplines in order to meet the needs of these young women. Early recognition and intervention are essential. The strategies needed to influence the relationship between childhood abuse or neglect and later substance abuse are 'systemic' and not specifically related to drugs. It is unlikely that singular interventions will ensure good long-tem outcomes for these young people. The underlying issues also have to be addressed.
Recommendations include appropriate resourcing for identification of troubled families and troubled young females, and appropriate intervention and follow-up strategies. They also include strategies which will help these young women overcome feelings of shame, enable them to communicate more easily when they are afraid, and empower them, for example, through self defence. It may also be useful to promulgate the message to young women that although losing control is not their fault, the reality is that it can lead to victimisation. As with many other sensitive issues it is important that these issues are discussed in same-sex groups, or with same-sex health workers.
With some cultural groups including Aboriginal and Torres Strait Islander groups, encouraging women to speak out may be inappropriate and potentially alienating. It may be far more appropriate, and potentially more successful, if culturally relevant and appropriate strategies were used. This recognises the importance of taking into consideration issues such as age, culture, linguistic background, gender and so on. However, young women from all cultural groups should be made aware that they have some control over their bodies and should be encouraged to seek help through the most appropriate channels. Educating young men against violence and sexual assault is also advocated.
25. Restrict young people's access to tobacco
Stricter enforcement of existing retail legislation for example selling to minors should reduce young people's tobacco use as well as reduce uptake (Amos, 1996). Legislation to impose generic packaging of tobacco products, and to curtail point of sale advertising, may also be deterrents to smoking. Restricting access to tobacco, though, is never going to be easy. It can be argued that young people will gain access to cigarettes despite changes to legislation which supposedly will make the purchasing of cigarettes more difficult for them. Adolescents already demonstrate this through the ease with which they access marijuana, speed, ecstasy, heroin, etc. Price rises, however, are supposedly effective with adolescents!
26. Provide adult drug education and encourage parents and others to attend
Both the literature and the Key Informants agree that parent education is an important aspect of the whole approach to young females' drug use To maintain credibility and a close relationship with their children, particularly during the adolescent years, parents need reliable information about drugs and to learn good communication skills. Parents also need to address their own drug using behaviour, as parental modelling has an important influence on young people's drug using behaviour.
With parents from culturally diverse backgrounds, particular care needs to be taken to address their new fears associated with the Australian lifestyle, as well as cultural and religious factors. This applies to Aboriginal and Torres Strait Islander parents as well, for whom programs which are culturally appropriate, yet socially realistic in a
modern Australian context, should be conducted. Different perceptions of roles and the place of women in different cultures need to be taken into account.
Key Informants noted that in some instances parents from diverse cultures are 'stuck in the old culture' - blaming their children's drug problems on the "new" society. It has to be stressed to these parents that young people need 'middle ground' to maintain communication with parents. One study of young heroin users (Le, 1996) recommends a greater level of involvement between parents and community educators to encourage open discussion on issues previously considered taboo.
Parents should therefore be targetted through drug education programs which focus on the nature of drug use, the need for communication, and the setting of realistic goals for young people. As with all parent groups, addressing drug issues needs to be done sensitively without apportioning blame.
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Information for this review was gathered by the following means-
A search of the Database of the Health Education Unit
A search of the following online databases:
A search of Sociological Abstracts on CD ROM (1986-1996)
A subject search on the Internet