The approach to the use or abuse of psychoactive substances has traditionally been androcentric, and has only taken women into account when the area of sex or reproduction is affected by drug consumption (Haritavorn, 2014). However, over the last two decades, partly due to the increase in studies on gender inequalities in health and their impact on the effects of substance use or abuse, it has become evident that there are distinct patterns of consumption, problems of access to treatment or stigmas derived from abuse which affect men, women, and non-cis-heteronormative people in different ways (Romo-Avilés, 2018). Therefore, one of the areas that require further research is that of the structural elements related to gender inequalities and the impact they have on drug addiction treatment; in other words, the structural nature of gender-based violence (GBV) and the social mechanisms by which women are kept in a position of subordination with respect to men (Council of Europe, 2011).

Thus, our study focuses on analyzing the strategies used to address gender-based violence in drug addiction treatments that include women, taking as reference the definition of gender violence in the Istanbul Convention (Council of Europe, 2011), which considers all forms of violence against women as a crime, including physical, psychological, sexual, economic, partner or ex-partner violence, femicide, sexual assault and abuse, sexual harassment, violence against the sexual and reproductive rights of women, trafficking, sexual exploitation, female genital mutilation, and early or forced marriage. Unfortunately, the term “Intimate partner violence” limits violence to that exercised in the context of the couple, which has been the most visible form of gender violence in Western societies—but is not the only one, and the frequent use of this term reduces the visibility of all the other forms of violence suffered by women mentioned in the Istanbul Convention (Council of Europe, 2011).

Intervention support and treatment are the two most traditional forms of intervention for substance abuse, and their aim is to achieve and sustain abstinence and stabilization, together with initiatives to reduce harm which attempt to reduce the impact and/or harmful effects derived from substance abuse (Bates et al., 2017). Early intervention and treatment form a continuum of intervention (care), with early intervention addressing substance misuse problems or mild disorders and helping to prevent more severe substance use disorders. Treatment engagement and harm-reduction interventions, for individuals who have a substance use disorder but who may not be ready to enter treatment, help engage individuals in treatment and reduce the risks and harms associated with substance misuse. On the other hand, substance-use disorder treatment is an individualized set of evidence-based clinical services designed to improve health and function, including medication and behavioral therapies (Department of Health & Human Services, 2016).

Traditionally, such “Intervention support and treatment” programs are likely to have been planned with a view to the substances consumed by men, and to cater for men’s needs, with little attention paid to the specific needs of women (Andersson et al., 2021; Webb et al., 2022). We now know, however, that there are gender differences that influence consumption and its treatment (Diez et al., 2020; Fonseca et al., 2021). In fact, among people who use drugs, women tend to fall into drug abuse and suffer its negative health impacts at a faster rate than men (UNODC, 2021).

Past research has pointed to specific needs of women which prevent or delay their access to treatment resources. Women who have drug abuse problems suffer greater social stigma than men (Ospina-Escobar, 2020). There is also a fundamental need to adapt the treatment resources to the type of psychoactive substances that are frequently abused, such as psychoactive drugs (Clark, 2015; Romo-Avilés, 2018). The research has also pointed out the specific support needs to facilitate childcare or care for their dependent relatives when women need treatment (Schamp et al., 2022). Other authors have pointed to the high incidence of gender violence and urge it to be included in the treatment of drug addiction in women as a key need among women with addiction problems (de Dios et al., 2014; Pagano, 2014). Finally, recent research has influenced how there are specific mental health needs in women who seek treatment which require a specific approach (Andersson et al., 2021).

A gender perspective is therefore lacking at both the planning and implementation stages of treatment or harm reduction programs; in other words, they do not take women’s needs into account (Huhn & Dunn, 2020; Noori et al., 2019). Sadly, this lack of appropriate models of intervention and treatment procedures for drug addiction in women has existed for decades, since there has been a general ignorance about which programs would be most relevant and could be adapted to them (Prather & Fidell, 1978; Wells & Jackson, 1992). This situation has led to multiple barriers for women to access treatment, related to differences in substance use patterns and the structural gender inequalities they experience (Benoit & Jauffret-Roustide, 2016; Stone et al., 2021).

In addition, more research is needed on the structural elements related to gender inequalities and the impact they have on drug addiction treatment. In this context, studying the impact associated with the multiple forms of GBV, such as physical, sexual, and psychological violence perpetrated by the partner, in the family, in the community and tolerated by the state (United Nations, 1995), is vital if we are to understand the barriers to access and also the keys to successful treatment (Schamp et al., 2021). According to some studies, structural gender inequalities, most importantly gender-based violence, have not been generally considered part of the “world of drugs” (Irfan et al., 2021).

The Council of Europe (Mutatayi et al., 2022) states that “women who report drug-related issues are more likely to be experiencing violence than men, as are transsexual people with drug issues, and some 68% of drug-injecting women have experienced interpersonal violence in a recent intimate relationship.” Also, the latest report of the Macro-survey on Violence against Women carried out in Spain states that one in 4 women who have suffered violence in a couple have used psychoactive substances to help them cope with the experience, a figure which rises to one in three when they suffer physical and/or sexual violence (Delegación del Gobierno contra la Violencia de Género, 2020). This more than underlines the need to take violence against women into account in the approach to drug addiction.

Based on all the above, the main research question posed by this systematic mapping review was what strategies are used to address gender-based violence in drug addiction treatments that include women?

Purpose of the Study

To date, this is the only study to present a review of the strategies used to address gender-based violence in drug dependence/addiction treatment that includes women. Here, we present a systematic mapping review, in which we first pinpoint any gaps in our knowledge and then take a critical look at the research carried out over the last 10 years from a feminist perspective. We also include a visual synthesis of the data, focusing on questions rather than topics, following the guidelines of a systematic mapping review (Akçayır et al., 2022; Calderone et al., 2022).

This study is significant because gender violence is considered a key source of inequality when addressing the treatment of drug addiction in women (Jessell et al., 2022) and it has been shown that gender violence has multiple bidirectional relationships with drug-abuse related problems which should be addressed together (James et al., 2004; Lorvick et al., 2014).

Our review will help us understand how these two problems are interconnected, not only by researchers but also by professionals who work in the treatment, prevention, intervention, and evaluation of drug-dependent women who are also victims of gender violence. It will also enable us to identify more effective solutions, with the subsequent implications for public health in improving the attention paid to these women’s needs.

Methods

Study Design

We carried out a systematic mapping review (Bradbury-Jones et al., 2019). This format involves an exhaustive search in which we describe and categorize the existing literature. The mapping study therefore seeks to present a visual analysis through graphs, maps, and images of the potential information gaps in the subject (Cooper, 2016; Miake-Lye et al., 2016). Visual techniques taken from social research allow us to take a less pragmatic view of the data (Essex et al., 2022; Wall et al., 2012) and emphasize how the visual information supports the human qualitative analysis to generate graphic representations of the results (Miake-Lye et al., 2016). The graphics, images, and maps are, in short, key elements to help us interpret and analyze the generic data (Essex et al., 2022). In addition, to perform a systematic search, as well as the classification, exhibition and synthesis of the results, we have followed the guidelines in Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews (Tricco et al., 2018). The review was registered in the International Prospective Register of Systematic Reviews (PROSPERO), under registration number CRD42022348102.

Data Sources

Four databases (Web of Science, Pubmed, Scopus, and PsycINFO) were used to search for original articles published over the last 10 years, between January 1, 2011, and July 21, 2022. In all the databases, the following common search strategy was used to address our research objective: ((“gender-based violence” OR “violence against women” OR “intimate partner violence”) AND (“drug* addiction*” OR “drug* abuse*” OR “substance* addiction*” OR “substance* abuse*”) AND (treatment* OR intervention* OR therap*)). In the design, we used MESH terms and synonyms connected by Boolean operators. The search was conducted by researchers with experience in the field of social sciences, gender, and drug addiction.

Study Selection: Eligibility Criteria

The studies which were considered eligible for our systematic review met the following inclusion criteria: (a) they presented findings or dealt with the topic of GBV in drug dependency treatments; (b) they used mixed samples of men and women, or exclusively women who suffered or had suffered any type of gender violence, and were conducted among healthcare professionals or in drug treatment centers; (c) they addressed consumers, past or present, of any type of psychoactive substance or drug; (d) they dealt with those undergoing treatment or seeking treatment for drug addiction; (e) they were original articles with quantitative, qualitative, and mixed methodology; and (f) they were written in any language. Articles in which the sample was made up exclusively of men were excluded.

The references obtained were fed into the Mendeley software (version 1.19.4) for subsequent screening. First, any duplicate records were removed, and next, the titles and abstracts of all the identified studies were reviewed, and articles which did not meet the inclusion criteria were excluded. The full texts of the articles were then read and, finally, only studies which met all the inclusion criteria were included. Two reviewers independently performed the search and discussed their results with a third and fourth reviewer. Any discrepancies that arose were resolved in discussions held together.

Data Extraction and Analysis

Significant descriptive and visual analyses were performed to identify gaps in the research. First, the results were extracted into a table and classified into the following categories: authorship, country of publication, methodology, sample, main objective of the study, GBV terminology, and GBV approach in the treatment of drug addiction. Next, these categories were analyzed individually and a visual synthesis was obtained using different graphs for the results or gaps identified in our review: choropleth maps to give the geographic location of the studies included; bar charts showing an overview of types of drug treatment facilities in the total sample of articles; pie charts with an overview of psychoactive substances leading to initiation of treatment in the studies included; column charts giving an overview of the types of drug treatment implemented in the total sample of studies included, and word clouds showing the terms used to refer to Gender-Based Violence in the articles in the review.

Ethical Approval

The authors declare that the work reported here required no ethical approval because it involved no animal or human participation.

Results

Study Selection

The literature search yielded 1135 papers, 570 of which were reviewed after rejecting duplicates, with 697 being excluded after applying the inclusion criteria. A total of 127 full-text articles were read, of which 32 articles were finally included. The screening process is shown below in a PRISMA Flow diagram (Fig. 1).

Fig. 1
figure 1

PRISMA flowchart of study selection

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Descriptive Analysis of the Studies

Table 1 shows the descriptive analysis of the studies based on authorship, country of publication, methodology, sample, main objective of the study, GBV terminology, and the approach to GBV in drug addiction treatment.

Table 1 Description of articles included
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As regards the country of publication, 68.75% of the studies analyzed were published on the American continent (USA 65.66% (studies 1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 21, 22, 23, 24, 25, 27, 28) and Latin America 3.13% (study 20)), followed by Europe (18.75%) (studies 2, 15, 19, 29, 31, 32), of which a large proportion came from Spain (12.5%) (studies 2, 15, 31, 32); finally, a small number were published in Africa (3.13%) (study 4), Oceania (3.13%) (study 30), and Asia (6.26%) (studies 14, 26) (see Fig. 2).

Fig. 2
figure 2

Geographic location of studies included

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As far as the methodology is concerned, 71.87% of the studies were quantitative (studies 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 17, 18, 23, 24, 25, 26, 27, 28, 31, 32), 21.88% qualitative (studies 1, 16, 20, 21, 22, 29, 30), and 6.25% mixed (studies 2, 15, 19).

Most of the samples used in these studies contained women who were under treatment for drug addiction (68.75%) (studies 1, 3, 4, 6, 7, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 23, 24, 25, 26, 27, 29, 31, 32), while only one study (study 29) included a transgender woman in the sample, followed by mixed samples of men and women (15.63%) (studies 2, 9, 10, 19, 28), healthcare professionals (9.37%) (studies 22, 30) and, finally, in 6.25% of the studies, substance abuse treatment centers with an unspecified target population (studies 5, 8).

Characteristics of Drug Dependence Treatment

Regarding the type of psychoactive substance for which the people initiated treatment, in 59.37% of the studies it was not specified, referring only to “drug use” in general. In the research where the type of substance was mentioned, we found that the many dealt with alcohol—25.7% (studies 9, 11, 12, 13, 19, 20, 22, 23, 25), followed by cocaine/crack—20% (studies 9, 11, 12, 13, 19, 20, 32), heroin and other opioids—20% (studies 4, 9, 11, 12, 13, 26, 32), cannabis—14 0.3% (studies 11, 12, 13, 19, 20) and tranquilizers, barbiturates and hypnotics—11.4% (studies 11, 12, 13, 20). To a lesser extent, amphetamines, methamphetamines and other stimulants—5.7% (studies 1, 20) and tobacco—2.9% (study 9) were addressed (Fig. 3).

Fig. 3
figure 3

Overview of psychoactive substances leading to initiation of treatment in the studies included.Note: articles which mention the substance for which treatment is initiated are specifically included in this chart

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As regards the type of treatment used in the research analyzed, the predominant type was psychological (33.35%), with a large part using cognitive-behavioral techniques (studies 7, 23, 24, 19, 31, 14). In second place came pharmacological techniques (23.07%), with methadone (studies 4, 9, 11, 12, 13, 26), substitution with opioids (study 32), specific use of methamphetamine (study 1), and detoxification treatment (study 17). Third were socio-educational techniques (10.25%) (studies 2, 7, 14, 24), and less frequently, residential treatment (5.13%) (study 21). In contrast, 28.2% do not specify the approach or treatment model implemented and refer generically to “substance abuse treatment” (studies 3, 5, 6, 8, 10, 15, 16, 18, 27, 29, 30) (Fig. 4).

Fig. 4
figure 4

Overview of types of drug treatment implemented in the total sample of studies included. Note below Fig. 4: IBT, Individually Based Treatment; IPaViT-CBT, Intimate Partner Violence Treatment with Cognitive Behavioral Therapy; BTC + IBT, Behavioral Couples Therapy plus Individually Based Treatment; CBT-SUD + , Cognitive Behavioral Treatment addressing Substance-Use Disorders; I-Stop, Integrated Treatment for Substance Abuse and Partner Violence; SADV-CBT, Substance Abuse and Domestic Violence Cognitive-Behavioral Therapy; WINGS Project, Women Initiating New Goals of Safety

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Furthermore, 34.4% of the studies do not specify the type of treatment center, indicating simply a “drug treatment facility.” The other treatment centers specified are as follows: methadone treatment clinics (15.62%) (studies 4, 9, 11, 12, 13, 26), residential drug treatment facilities (12.5%) (studies 10, 20, 21, 29), outpatient drug treatment centers (9.37%) (studies 7, 15, 31), harm reduction non-government organizations (6.25%) (studies 14, 32), in-patient detoxification units (6.25%) (studies 17, 15), and finally, 15.6% had various characteristics or belonged to different centers (community-based agencies (study 24), day care centers (study 2), emergency departments (study 25), health care centers (study 30), and outpatient psychiatry departments (study 23)) (see Fig. 5).

Fig. 5
figure 5

Overview of types of drug treatment facilities in the total sample of articles

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Conceptualization of Gender-Based Violence (GBV)

Of the total articles included, only 43.65% define GBV (studies 7, 10, 11, 13, 14, 15, 16, 17, 20, 21, 25, 29, 30, 32), while a total of 73 make different kinds of references to it. The most commonly mentioned are “intimate partner violence,” “partner violence,” “domestic violence,” “physical violence,” “sexual violence,” and “psychological violence” (Fig. 6).

Fig. 6
figure 6

Word cloud of terms used to refer to Gender-Based Violence in the articles in the review

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Measurement and Approach to GBV in Drug Addiction Treatment

Gender violence in its different forms is detected or analyzed in 84.37% of the studies, and in these, validated instruments are used (studies 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 25, 26, 27, 28, 30, 31), the most widespread being the Conflict Tactics Scale (CTS) (studies 11, 12, 13, 14, 17, 18, 19, 25, 27, 28). We also find interviews (studies 1, 2, 20, 21) and other types of ad hoc scales (studies 3, 4, 5, 6, 7, 8, 32).

Only four of the studies included in this review examine the integrated drug abuse treatments and GBV [19, 14, 23, 31], and in these, the approaches mainly involve psycho-social treatment and those focused on the violence produced in the context of the couple. On the one hand, we found effective interventions that led to a reduction in both problems among patients in treatment for substance abuse, such as Integrated treatment for Substance abuse and Partner violence (I-StoP) and Cognitive Behavioral Treatment addressing Substance-Use Disorders, including only one session addressing partner violence (CBT-SUD +) (study 19), and the WINGS Program (Women Initiating New Goals of Safety), governed by social cognitive theory for the treatment of IPV and substance abuse (study 14). On the other hand, there were others which did not produce significant changes or any reduction of the twin problem, such as Seeking-safety, a cognitive-behavioral treatment focused on PTSD for intimate partner violence and alcohol abuse (study 23) or IPaViT-CBT: Intimate Partner Violence Treatment with Cognitive Behavioral Therapy (study 31).

In addition, two of the studies devoted to investigating the percentage of substance-abuse treatment clinics which offer IPV-related services (study 5) or domestic violence services (study 8) reveal the low percentage of centers which include treatment addressing couple-based violence.

When the articles analyze the problem of GBV and drug addiction together, they highlight three key aspects: risk factors, barriers to treatment, and protective factors. First, the risk factors identified are as follows: that both members abuse alcohol and other drugs (study 2), polydrug use (study 12), use of cocaine/crack and alcohol in sexual relations (study 13), lack of social and family support for the victims (studies 2, 12), lack of financial independence (study 2), having dependents (study 23), sexual abuse in childhood (studies 2, 11, 15, 20), recent and lifetime interpersonal trauma (study 7), bullying behavior (study 2), violation of restraining orders (study 2), recent imprisonment 9study 12), mental health problems (studies 27, 12, 15, 10. 11), sex with the risk of contracting HIV (study 12), pregnancy (study 17), and sex work (studies 4, 29).

Secondly, the barriers to treatment mentioned are as follows: that the couple is a drug user (study 4), a lack of security and subsistence in the family environment (study 3), that men could be forcing women to continue using drugs as a means of control (study 4), fear of losing their children (study 21), professional prejudice (study 22), ineffective communication by healthcare professionals (study 22), lack of confidentiality (study 30), and lack of understanding the mechanisms of violence (study 22).

Finally, abstinence (study 7), family support (studies 17, 22), and concern for the well-being of their children (studies 21, 22) are cited as the most important protective factors.

Health Effects Associated with GBV and Drug Addiction

The main effects associated with the twin problem of GBV and drug addiction treatment can be grouped into 3 dimensions: mental health (60%), sexual and reproductive health (25.71%), and general health (14.29%). In mental health, PTSD (studies 4, 7, 10, 11, 12, 13, 14, 21, 23, 24, 26, 32), and depression (studies 6, 9, 11, 12, 13, 21, 24), and various mental health problems (studies 4, 6, 11, 19, 26, 29) are commonest. In sexual and reproductive health, HIV (studies 11, 12, 13, 14, 15, 31, 32) and non-specific symptoms in general health (studies 4, 11, 13,16) are the most frequently mentioned factors.

Discussion

This systematic review has revealed gaps in the research carried out on the strategies used to address gender-based violence in drug addiction treatments that include women.

One of the most crucial and controversial aspects of this review has been the conceptualization of GBV in the 32 studies included. In particular, GBV needs to be contextualized in the area of drug addiction, since over half of the articles include no definition, or address different types of violence without analyzing the multidimensional nature of GBV (Council of Europe, 2011). In the studies analyzed, “intimate partner violence” is the aspect most frequently identified. However, structural gender violence or other multiple types of gender violence affecting women are given little to no mention in the studies.

To measure GBV in cases of drug dependence, the Conflict Tactics Scale (CTS) has mainly been used (Straus, 1979). However, this instrument should be used with caution because, although it has been used widely to analyze intimate partner violence, its conceptual and methodological premises and its construct are based on intrafamily violence, which differs in its characteristics from gender-based violence. The results obtained may therefore be biased by the use of instruments with “gender blindness.” In other words, the studies do not take into account the gender dimension as a significant category for approaching and interpreting research problems, either due to lack of training, because they do not make the connection between gender and the problem in question or for other reasons (including a possible unwillingness to accept this point of view) (Ferrer-Pérez & Bosch-Fiol, 2019).

The GBV approach to drug addiction treatment was only addressed in 18.75% of the studies (Capezza et al., 2015; Cohn & Najavits, 2014; Kraanen et al., 2013; Mootz et al., 2022; Schumm et al., 2018; Tirado-Muñoz et al., 2015). This points to the need to create joint intervention models, and also to a possible reticence about recognizing gender as an analytic category by those who design the intervention and administer the treatment (Owczarzak et al., 2021; Reed, 1985, 1987).

Another aspect to highlight is that 59.37% of the studies address the health impact of GBV associated with drug addiction, with anxiety, depression, and PTSD noted as the main manifestations. This coincides with studies such as Ruiz-Pérez et al. (2018) in the Spanish context, which showed the correlation between mental disorders and intimate partner violence. Also, related to health, it should be noted that pregnancy is a key health factor to take into account in these women. In our review, we have highlighted how it is a risk factor for violence (Abdul-Khabir et al., 2014), as indicated by the WHO (n.d.). Moreover, it is a stage in which women are more vulnerable and when substance use and mental health problems may increase, as shown by the study by Salameh et al. (2021).

In addition, in our descriptive analysis of the studies analyzed, the majority were studies from the Anglo-Saxon world (71.87%), where problematic drug use is related to a highly specific context of consumption, with a greater presence of opiate drugs and cocaine/crack, a situation which cannot be generalized to other geographical areas. In fact, there is hardly any mention of problems related to substance use in different geographical and cultural settings. In addition, the research methodologies used are mainly quantitative, although a few qualitative studies have been found which could bring a broader scope to the factors surrounding this double problem, and potentially generate a better knowledge of the realities of women in different contexts of problematic drug use. Qualitative methods could provide a framework for developing a deeper, more nuanced understanding of meanings and contexts associated with drug use, health service implementation, and experience (Ivsins et al., 2022).

As for the sample, it is noticeable that, in all the studies covered by this review, the women’s identity is standardized, and is limited to simply stating their gender identity (cis women), with the category of transexual women excluded and bypassed in the research. Only in the study by Scicluna and Clark (2019) is one woman identified as transgender. Despite some advances in this respect, most of the evidence relating to gender and drugs in these studies refers exclusively to “women” or the differences between men and women. However, in reality, gender is not a one-dimensional variable; it is a complex concept, pervading our lives and affecting all aspects of our health (Oertelt-Prigione, 2020). Therefore, in the interests of including a wider diversity of gender, the “transgender” category should at least be included, as an umbrella term for a diverse range of people whose gender identity does not correspond to their at-birth sex designation (Mutatayi et al., 2022).

All the above leads us to think that GBV itself is one of the many obstacles women face when accessing treatment, and, as previous research has shown, these barriers are linked to specific consumption patterns permeated by the structural gender inequalities they experience (Benoit & Jauffret-Roustide, 2016; Stone et al., 2021).

Limitations

Like all research, our review has its limitations. The first is that the systematic review has only included original scientific articles, and some relevant information published in the gray literature may therefore have been overlooked. Despite this, the search was carried out over a lengthy period of time, 10 years. Secondly, most of the studies included originate from one specific geographical area, the USA, where there is a highly specific context and approach to drug addiction, therefore making it harder to draw parallels with other countries.

Conclusions

The results of the review show that there are very few GBV-specific treatment experiences in the drug addiction treatment. What is therefore needed, to avoid inequality in health care, is research and interventions which deal with drug dependence treatment and GBV together in a sensitive way which is no longer blind to gender. Public policies aimed at treating different aspects of drug addiction need to include a variable that detects social inequalities, including GBV. It is also crucial to take a multidimensional approach to GBV, in line with the Council of Europe Convention recommendations on preventing and combating violence against women and domestic violence. Furthermore, the different measures presented by the Council of Europe in its “Gender Equality Strategy 2018–2023” should be implemented, such as, for example, designing specific action protocols, carrying out frequent monitoring, or raising awareness among professionals who care for women, amongst others, in order to avoid the existing barriers to treatment and to ensure that the different problems will be addressed with a gender-sensitive perspective.