Abuse of Psychoactive Substances by Women and Treatment Difficulties

Harmful drug use by women is a growing problem. The objective of this study was to identify and discuss the relationship between gender inequality and the factors that lead women to abuse psychoactive substances, as well as the difficulties encountered in the performing treatment. This is a qualitative study, in which a semi-structured interview was conducted with seven women undergoing treatment at the Psychosocial Care Center for Alcohol and Drugs CAPS ad in Manaus, Brazil. The results indicated some issues related to gender inequality as influencing the maintenance of drug abuse by women, discussed in five categories: 1st Notions about gender inequality; 2nd use of drug abuse; 3rd lived social vulnerabilities, 4th Difficulties in treatment; 5th Perception of public policy for women with drug problems. Thus, it is concluded the importance of discussions and new research with a feminist context to address this problem, in order to think about better forms of prevention and treatment aimed at women and their particularities. Keywords— Gender Inequality; Drugs, Treatment.


I. INTRODUCTION
Although female visibility in the context of psychoactive substance (PS) use has increased in recent decades, research and care are predominantly focused on the male public. As stated by Menezes Alves and dos Santos Rosa (2016), the meanings related to "being a woman" vary according to the socio-cultural and historical context, and these are neglected when it comes to investigating drug interventions or policies. It is noteworthy that the current Brazilian drug law, no. 11,343 / 2006, makes no distinction focusing on the perspective of gender and human rights, working without considering the reality of women regarding the historical, socioeconomic and cultural aspects.
In order to contextualize as pects about gender differences, it is important to mention that, according to Zanello e Silva (2012), the concept "gender" was introduced in the science debates through feminist movements, as a category of description and analysis of interactions. as oppos ed to biological determinism and the duality of the sexes. Scott (1991) explains that American feminists used the term "gender" to emphasize the fundamentally social character of gender distinctions, indicating a rejection of biological determinism implicit in the use of the terms "sex" or "sexual difference." According to Diniz (2017), gender refers to the construction of roles, social places and attributions for each sex, whether in marriage, family, insertion and / or social structuring. The development of the term brings the idea of a social concept, which can be used to understand social relations from the perspective of power relations established between men and women, according to the cultural elaborations of the assumptions about what it is to be each one of them. sexes. Gordon (2002) refers to a possible gender equality in drug use as a trend, which is justified by changes in women's lifestyles, which today are more active in the labor market and independent, having as consequence higher charges .
to or higher than men. It has been observed that the trend towards increased rates of alcohol, cocaine, cannabis and opioid use for women is faster than for men, as is the development of disorders as a consequence of the use of drugs. Bastos and Bertoni (2014) state that women who use drugs can have a life history that is crossed by gender inequality more intensely and cruelly, becoming even more adverse when there is abus e as well as drug dependence. Nascimento and Paiva (2007) show that in some peripheral communities in Brazil, crack use has been surpassed by women, especially by sex workers. This picture facilitates the low value of the drug, as well as the acceptance of sexual relations or favors as a bargaining chip. According to Menezes Alves and dos Santos Rosa (2016), because of physiological issues, where female metabolism is less tolerant to the effects of psychoactive substances, female users are more vulnerable to personal injury and harm, in addition to sociocultural issues about femininity, which generally influence male-oriented decision-making power in heterosexual relationships with regard to condom use, for example, in cases where men do not want to use protection, leading to a higher risk of HIV infection.
According to the research by Andrade et al (2016), health services are predominantly sought by women, however, for the treatment of drug addiction or other problems related to drug use, women are still among the smallest. According to the authors, throughout the historical process, the female gender was characterized by pre-established behavioral patterns that linked the figure of women to maternal activities, resulting in the lack of care for themselves, since there is the idea of the obligation of taking care of the other.
In the research conducted in the State of Ceará (Brazil), by Lima et al (2011), the authors identified that the predominance in the search for treatment for drug dependence at the Psychosocial Care Center for Alcohol and Drugs -CAPS ad is male and that women, although also seek, remained in treatment for less time. Thus, this situation contributes to the vulnerability in the social, occupational, family, physical and legal fields, which are possible spaces of violence. Andrade et al. (2016) explains that women who use drugs are doubly stigmatized, both because, in a way, they escape the conventional role of women, and because they use drugs. According to Lima et al. (2011), some factors that interfere with accessibility to health services and quality care for women are related to the environment being predominantly male. In addition, prejudice and discrimination are present, as well as the fact that there is a space that often does not guarantee the necessary reception, making it difficult for women to express themselves.
This study aims to contribute to research related to gender issues in the context of psychoactive substance use by women and also raise questions and concerns regarding the forms of care and attention to the female category and its particularities in mental health. . Its main objective is to reach an understanding of the relationship between socially constructed gender differences and the reasons or circumstances that lead many women to practice drug abuse, in addition to the difficulties these women encounter in dealing with this problem in the city of Manaus, in the state of Amazonas, with patients undergoing treatment at the Psychosocial Care Center for Alcohol and Drugs -CAPS ad.

II. METHOD
This work followed all the ethical criteria proposed in Brazilian Resolutions Ethics 466/2012 and 510/2016, and can be consulted through the code approved by the Research Ethics Committee, number 006140/2019 (CAAE 06522919.6.0000.5016). This is a qualitative, exploratory study, defended by Markoni and Lakatos (2008). From the Consent Form for submission to the research ethics committee, provided by the Municipal Health Secretariat -SEMSA, the contact with the direction of the Dr. Afrânio Soares Psychosocial Care Center III, Alcohol and Drugs (CAPS ad), was made. It is a 24-hour institution with the purpose of offering specialized services to users of alcohol and other drugs.
Survey participants were women who were being treated at CAPS ad. The proposal suggested by the CAPS ad team was to take advantage of the presence of patients on the days and times that were scheduled clinical appointments. The team provided a list of 10 patients undergoing treatment, containing dates and times of consultations to be held. There was no previous contact with them, so the invitation to participate in the research was made shortly before each consultation, so that after the consultations the patients could answer the interview.
It was possible to contact only 7 women and all agreed to participate in the survey. As an inclusion criterion, women who were already undergoing treatment at CAPS ad participated in the study, and those who would be attending appointments for the first time were excluded. A semi-structured interview was conducted, which had a script of questions , built on the research of Maragoni and Oliveira (2013).
The interview was recorded and duly discarded after transcription, with sociodemographic questions and eleven questions that addressed topics such as: perception of gender inequality, drug use and abuse, social vulnerabilities and treatment. Data were collected between March and April 2019, most of the time in the rooms that were available at CAPS ad, allowing a placeholder and individualized dialogue with each participant. After explaining the purpose of the research and signing the Informed Consent, lasting 10 to 15 minutes. The collected data were analyzed in the light of the content analysis foundation of Bardin (2011).

III. RESULTS AND DISCUSSION
Regarding the characterization of the participants, the age range ranged from 23 to 43 years. Out of the seven interviewed, six are single, two live with their respective partners and one is married. With the exception of one, all women have at least 1 child, ranging from 1 to 9 children, but only three have their children under their care.
Three have incomplete high school education level, three with incomplete elementary school and one with incomplete higher education. Regarding the economic aspects, only two reported exercising some kind of paid activity and two claimed to receive government assistance.
Regarding aspects related to drug use, the age of start varies between 11 and 34 years. The obtained results made possible the division of the approached themes in five categories, that will be discussed next: Notions about gender inequality; Drug use and abuse; Lived social vulnerabilities; Difficulties in treatment; Perception of public policies for women with drug problems.

Understandi ng Gender Inequality
The notions of gender inequality that the interviewees showed are related to the perception of prejudice that has with women in general. The first conversation about this theme is related to the lack of equality in the workplace, which, for one of the participants, the discrimination that occurs with women compared to men is evident, highlighting the social role attributed to women in housework.
-There are times when men still have some prejudice with women about working as a security guard in the banks, because they think that women were only made to work at home, they are always on the stove and like that [ Another point about discrimination against women in the labor market is mentioned by another participant, referring to the weakened credibility regarding work ability and responsibility: "I think that men have more rights sometimes, in terms of work, in terms of responsibility, thinks the woman has no ability to have responsibility "(Interviewee 7, 38 years old).
The discrimination cited in the interview is justified by the perception of gender differences imposed by a Judeo-Christian society. According to Simões and Hashimoto (2012), this society establishes a traditional family system, where there is a configuration of division of labor with socially and culturally established roles. The man / father is seen as the sole provider and the woman / mother as solely responsible for household chores as well as the needs of the offspring.
Participants also associated gender inequality with the lack of respect and bad image associated with women who use drugs compared to men: "For women it is even harder, right. [...] If she falls today, tomorrow she can get up but continue ... the people will talk about her past. The man doesn't, gets drunk in the gutter, gets up and remains a man, right. "(Interviewee 3, 32 years old).
Medeiros et. al (2017) in their study showed that the representation of the image of female drug users is linked to a deteriorated and disqualified image, associated with the naturalized idea that women who use drugs are saneless, impulsive, unpredictable and being incompatible with what society expects according to the social role assigned to women. The discourse associated with the social roles assigned to women is also present in the interviewees' statements as something naturalized. They acknowledge that inequality exists, but hold women accountable for having to achieve gender equality. They talk about types of women, and that the way to look at inequality is backwards, as there are growing rights achievements. According to Rocha-Coutinho (2004), due to the occurrence of changes in cultural representations spreading at a certain speed, there is the illusion of a unified identity, as a result of overestimating the depth of these changes, believing that gender inequalities are eradicated. Beyond this view, in the perception of some participants, women need to "respect themselves" to be respected. According to Rocha-coutinho (2004), although social discourse has incorporated the new role of professional and independent women and questioning the doctrine of motherhood as an essence, in practice the definition of being a woman has changed very little, as this discourse continues to attribute to women the obligations related to the home and family, characteristics considered essential to the feminine. It is then believed that female identity has only been expanded and this new role included. Thus, for many women, even if they have to sacrifice job satisfaction, for example, the family remains a priority. As a consequence, even without realizing it, the woman in this configuration ends up contributing to the preservation of the macho system that prevailed in the system of a traditional society. It is interesting to discuss and reflect on the machismo reproduced by women as a result of a conditioning of thoughts with internalized macho ideals from birth in a patriarchal society, which benefits men and brings no privilege to women. Some contradictions in the interviewees' statements demonstrate the lack of knowledge about gender inequality as a structural problem.

Drug use and abuse
According to Menezes Alves and dos Santos Rosa (2016), women can start their relationship with PSs in general as a result of traumatic experiences, in addition to the pressure of socially imposed determinations on women. In this category, regarding the type of drugs used by the participants, the interviewees reported having used various types of psychoactive substances: The statements corroborate the studies by Dias Cruz et al. (2014), which elucidate as one of the motivations for women to start and maintain illicit drug use is often related to having a romantic relationship with a partner who also makes use of substances. What may lead some women to monitor their partner's consumption is a possible affective dependency as well as the need to feel emotionally accepted.
As for abuse, according to Dias Cruz (2014), some women also become abusive users because they consume the substance in order to accompany partners, and because they become their main suppliers, which would prevent their exposure to trafficking places and the community itself.
One of the participants mentioned her partner as the cause of her addiction: This result is similar to the study by Maragoni and Oliveira (2013), where they showed that women started drug use in adolescence, being more vulnerable to external influences, a fact that occurred, above all, in situations distant from the working models of the adult, as in the last report: in the street. Substance abuse is also associated with street life. Participants reported that they began to use drugs after living on the street or having a more active life outside the home: "It was when I went to live on the street, and then when I started using 24 hours, It didn't stop. It was too much. " (Interviewee 1, 23 years old) The perception of abuse as the "time to seek help" came from the moment when women identified that they were using drugs beyond what they considered normal:  2018), drug use may increase the chances of suicidal behavior and is considered a risk factor for this behavior, especially in the female context, and may be associated with the presence of chronic mental disorders, the most common being depression and depression. schizophrenia. The realization that she needed help was also due to her shaken relationship of respect with her children, for fear of setting a bad example for them: My daughter is already going to be 13  In this case, having children means a protective factor against drug abuse, but it is determined by the fear and guilt about being a woman and mother with the problem of substance use. According to Medeiros et al. (2017), the female drug user is considered a major social threat to the model of mother, wife and sexuality. This argument is supported by the repetition of the discourses posed in the society of drug user incompatibility and inadequacy to these previously defined feminine roles and roles.
Regarding maternity and drug use / abuse, as already mentioned in the interviewees' characterization, of the seven participants, six have children, and of the three children are not under their guardianship. Corroborating with the study by Maragoni and Oliveira (2013), where some users reported having difficulties in performing maternal activities, leaving their children alone for long periods or else under the responsibility of other family members to go looking for the drug, facilitating the loss of guardianship. Substance abuse, for some interviewees, was associated with personal, affective and social problems.
Regarding this problem, the participants reported that they realized that drug use was being abused when they had serious mental and physical health problems:  (2015) pointed out that alcohol use among women may influence some factors: childhood marked by alcoholism of family members; alcohol consumption since childhood; presence of physical or sexual violence in the life course. The last report quoted above is from an alcohol abuser interviewee and the next category to be discussed is about the social vulnerabilities experienced by these women throughout their lives. The following report by the same participant corroborates the notes of Silva (2015).

Social vulnerabilities experienced
When I was little I was abused, because as I grew up, I'm an older sister and my mother always had to take my two sisters, she ran away from my alcoholic father, so I always stayed behind, the older one turns around , "You know how to take care of yourself", since I was a little girl, 5 years old the first time she left me at a neighbor's house saying she was going to pick me up and I stayed there a few months, my aunt who came to rescue me, then I stayed at the house from another aunt that her husband was abusing me, that's how it was, I grew up from house to house (Interviewee 6, 24 years old) Women reported being victims of various social vulnerabilities: drug-related crime, family conflicts before and during the relationship with psychoactive substances, and life-long violence without and with drugs, including childhood sexual violence such as case of the last report. According to Maragoni and Oliveira (2013), the family may represent a risk or protection factor for drug use.
One of the most relevant risk factors is parental conflict as it exposes children and adolescents to hostility, destructive criticism and anger. While setting up an environment that is conducive to drug use depends on many factors, the family is one of the most important. Family conflicts and domestic violence or drug-related violence are present in most of the interviewees' experiences: "Everything. Violence mainly in the street. Family conflicts too. "(Interviewee 7, 38 years old); "I got involved with a boy and jumped out of the car because this boy was more drugged than me and he wanted to kill me, gave him a crisis [...] I only know that he wanted to kill me. Domestic violence has already suffered with my ex. "(Interviewee 5, 27 years old).
According to Maragoni and Oliveira (2013), the existence of physical and verbal abuse and / or sexual abuse in families is considered a factor that contributes to trigger the problem of drug use and that domestic violence and these family conflicts They are often experienced by people with a history of drug problems. Deprivation of access to basic social systems (housing, family, health, work, etc.) is a dynamic resulting from social exclusion and, according to Maragoni and Oliveira (2013), is part of the process that influences the life of the subject who has harmful relationship with drugs. The research by Lopes et al. (2010) shows the association between drug use and crime, which can be exemplified by the speech of one of the participants, about her experience with crime while living on the street:

Difficulties in treatment
The participants associated the difficulties in treatment with prejudice related to the image of women who use drugs before society: "It is because, like this, society thinks that men can and women cannot. Most people think that way. "(Interviewee 5, 27 years old).
In addition, they cited the limited availability of exclusive treatment for women and their particularities.
"What is missing is more clinical, more police station of Maria da Penha (Brazilian law which protect women against male aggression). (...) More recovery clinic for women is lacking. "(Interviewee 4, 43 years old).
As well as lack of money to travel to the treatmen t site. The difficulty that I really have is just transportation to come here, understand? (...) We women have a lot of prejudice, right, the person like that looks right because she is a woman "credo, that woman drinking there, that woman drugged there", people talk a lot, understand? More so for that too, god forbid. Look, I'm standing today, but no one will see me as if I had a stop, it's always going to be that junkie, because I'm a woman, you know? Discrimination ... (Interviewee 3, 32 years old) They also reported obstacles to work where there is doubt and distrust about the ability to change behavior and responsibilities: "Work like this is one of the difficulties because there is so much discrimination. People's lack of trust with us because they don't believe us, they don't think we have a chance to change or have responsibility. "(Interviewee 7, 38 years old) According to Medeiros et al. (2017), the fact that women engage in activities considered socially transgressive results in the collective thinking of estrangement, being seen as "social failure" in the face of the expected female public in society and, in this case, drug use is seen. as a "transgressive" activity. Some participants reported not experiencing difficulties in treatment, nor because of being a woman, associating the responsibility of not allowing this to happen, in order to show imposition and non-submission:

Perception of Public policy for women with drug problems
The interviewees reported that they find good public policies aimed at treating women with drug problems, but also that there are few treatment options and that there should be more recovery clinics and more dissemination of specialized services, since not all people who have access to treatment availability information, as well as the precariousness of medication needed: When asked about possible improvements of the institution, as in the study by Leal (2009), the participants stated that they did not think about it, or that they think everything is fine so far, that they have nothing to complain about, except abou the need for greater dissemination of the service, so that other people can have access to treatment. No issues or considerations were specifically cited regarding the gender issue to be addressed in public policy assistance for the treatment of female drug users, other than the problem of poor availability of specific services for the female public. The fact that the interviewees do not cite too much criticism does not necessarily mean that there are no problems related to gender inequalities. According to Leal (2009), this lack of criticism and other demands demonstrate and reinforce the illusion they may have about the understanding of their needs and rights, as a consequence of the absolute subordination to the norms and values of a society that ends up excluding women of fairer care.

IV. FINAL CONSIDERATIONS
The data collected and analyzed in this study made it possible to understand the issues related to drug use and abuse by women, especially the relationship established with gender inequality.
Regarding the first category analyzed, it is noted that the notion about gender inequality that women have is related to the prejudice against women in general, the lack of equality in the workplace, weak credibility about responsibilities, lack of respect and the lagged image that is associated with women who use drugs compared to men. Regarding drug use and abuse, it was found that women have already used various types of psychoactive substances and relate the beginning of drug use with their relationships with partners or former partners, with the curiosity to experience the sensations caused by the drugs. substances, influence from friends, and having a more active life outside the home, whether working in the street as a teenager or not having a family structure that would allow life away from the streets.
Possible reasons for drug abuse are also related to street living, as well as relationships with other people who abuse drugs, as well as personal, affective and social problems. The perception of abuse as the time to seek help came when women identified that they were using drugs beyond what they considered normal after suicide attempts, because of the relationship of shaken respect with their children and health problems related to their use. use of substances. Regarding social vulnerabilities, it was found that all participants suffered or suffer some kind of risk situation such as physical and / or verbal violence, drug-related crime, sexual violence, domestic violence and various family conflicts.
As far as the treatment and the possible difficulties, the obstacle of prejudice against women drug users in society, the lack of money to access the place of treatment, problems with the work environment, in the sense of poor credibility, were identified. on the ability to change behavior related to drug use and responsibilities, as well as the limited availability of exclusive treatment to address particularities related to women. Participants' perceptions of public policies for specific treatment for female drug users are basically associated with poor availability of specialized institutions, demonstrating some compliance regarding their rights, as all appear to be satisfied with the treatment setting.
The statements of the interviewees referring to CAPS ad demonstrated the need for this welcoming, the importance of a humanized look at the individual with drug problems, since the result is positive in the sense of valuing these people as beings worthy of good monitoring and attention. However, it is questioned the poor adherence of women in treatment facilities for drug addiction or drug abuse and the interaction regarding discussions from a gender perspective in general care.
Thus, more studies are needed, more perspectives with this perspective relating gender with the possible reasons for the low adherence of women, since in this research, for example, it was difficult to contact more women who were following in the institution, since The female audience is actually much lower than the male audience.
It is necessary to understand more and more how gender inequality can influence psychological problems, which is one of the main reasons for the inclusion of women to harmful drug use, emphasizing that the biggest problem is not the use of drugs themselves, but the relationship that is established with the substance, considering the need to maintain consciousness in an altered state, most likely not to have to deal with so many sufferings consciously. It is believed that discussions with a feminist context can positively influence ques tions related to ways of treatment for women facing drug problems, in order to think about the particularities, the reasons for the gender inequality that lead these women to do. the harmful use of psychoactive substances, generating possible ways to prevent or reduce the damage of psychological aspects that may be associated with the maintenance of this problem. It is important to highlight the need for further research on the relationship between gender inequality and harmful drug use by women, as this study was a cut-off from a perspective on this complex issue and other points need to be identified in order to make it possible. a better understanding of this relationship.