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14.2 Addiction Treatment
The rst thing people like Ana, who want to start a treatment, encounter is a lack
of information. They don’t know what a treatment program is, how to access it, how
long it lasts, whether it will cost them money, or what their day-to-day will be like.
The very conguration of treatment programs can in itself be an obstacle to starting
one. Addiction treatment is based on a combination of pharmacological strategies,
psychological interventions, and rehabilitation actions, which vary depending on
the nature of the addiction, the characteristics of the patient, and the available
resources (NIDA, 2018). Moreover, as these are chronic disorders, addictions
require long-term treatments. Care circuits must therefore be designed to offer a
continuous process of care through the different phases of treatment: detoxication,
habituation, and recovery/reintegration into society, counting on primary, special-
ized, and community care services and resources.
The admission criteria for the different treatment programs vary depending
on the nature of the program and the prole of the patient (López-Goñi etal.,
2017). For example, hospital detoxication is aimed at people with high levels
of dependence, or serious medical comorbidities. However, patients with mod-
erate dependence are treated in outpatient care services, with residential pro-
grams for people who have repeatedly failed in outpatient treatments or are at
high risk of relapse.
Treatment programs can be public or private, that is, either funded by the State
or paid for by the users. In any case, even though they may be public, the casuistry
in the eld of addictions is very diverse and, therefore, there are many particularities
due to the prole of the user and their environment that can inuence access to a
treatment program. Certain groups or populations are exposed to greater difculties
in accessing addiction treatment. Among the most vulnerable groups are people in
situations of poverty or exclusion; for example, homeless people (Collard etal.,
2014). This group has a lower probability of accessing socio-health resources,
which complicates both the identication of the addiction and its treatment. The
lack of a stable environment and support also increases the risk of relapse in these
groups (Paquette & Pannella Winn, 2016).
Another particularly affected group is the prison population, given that the inci-
dence of psychoactive substance use in prison is usually high, although the avail-
ability of treatment is limited and focused on immediate abstinence, not on
comprehensive rehabilitation. Therefore, upon leaving prison, many people nd
When Ana starts to think about starting a treatment for her addiction, she gets
chills. She doesn’t know anyone who has gone through it. She imagines it will
be very costly and that it will be an experience similar to being conned in a
penitentiary. She doesn’t know what she’s up against and she’s scared.
14 Accessibility Barriers toTreatment fromaGender Perspective
192
difculties in continuing their treatment, which can lead to an increase in relapses
and, as a result, in criminal recidivism (Leukefeld etal., 2009).
Another vulnerable group is adolescents. At this life stage, emotional and cogni-
tive development can be affected by the onset of an addictive disorder (Anderson
etal., 2006). In addition, the adolescent is often reluctant to seek treatment, due to
a lack of awareness of their problem and fear of stigma.
People with comorbid mental disorders also face specic difculties, as addic-
tions and mental disorders (depression, anxiety, or schizophrenia among others)
interact in complex ways, complicating treatment. Integrated approaches, based on
dual pathology, are essential to improve outcomes (Kelly & Daley, 2013), although
their availability is also often limited.
Finally, we understand that gender is also relevant when identifying vulnerabil-
ities in the treatment of addictions, due to certain specic and differentiated bar-
riers and obstacles that women or people from the LGBTQIA+ community face
throughout the treatment process. Addiction is still perceived in some cases as a
vice or a lack of willpower, rather than a treatable medical disease; therefore,
people who suffer from an addiction, especially women and LGBTIQA+ people,
would be blamed for their situation and deserve to be punished or marginalized
(Siddiqui & Rutherford, 2023). Therefore, these groups, when suffering from an
addiction, are more likely to hide their problem for fear of judgment or rejection.
Often, this social stigmatization is added to having been victims of gender vio-
lence or abuse, which creates a very complex situation to face. The lack of specic
treatment resources and programs that take into account their particular needs,
such as attention to motherhood, the possible loss of custody of their children, or
support in cases of violence, further complicates their access to treatment. This
phenomenon is known as intersectional stigma and is reected in the marginaliza-
tion and discrimination they experience in health services (Paschen-Wolff etal.,
2024). This chapter focuses especially on the attention to the gender perspective
in access to addiction treatment. To do this, we will follow Ana’s thread and the
different types of barriers that a person like her could encounter when accessing
treatment for her addiction, grouping them into two main blocks: barriers related
to the care system and socio- health resources and barriers related to the person
and their environment.
14.3 Barriers Related toSocio-Health Resources
The very socio-health resources dedicated to addressing addictions can in them-
selves, directly or indirectly, constitute a barrier to access to treatment for certain
patient proles, especially women and vulnerable groups. Below, this type of acces-
sibility barriers.
A. V. Infer et al.
193
14.3.1 Informative andAdministrative
The health system does not always provide people with necessary and under-
standable information that allows them to access care, including addiction-related
information, something that conditions effective access to health services. In addi-
tion, although it is not Ana’s case, these difculties should be added to the case
where there are difculties related to language knowledge, or the complicated
bureaucratic procedures, increasingly greater, which are not preceded by adequate
information or training for administrative and health personnel (Médicos del
Mundo, 2022). In cases like these, the main victims of this lack of knowledge are
people belonging to especially vulnerable groups, such as migrants, especially those
in an irregular situation, and the homeless (without these two situations being exclu-
sive), to which other factors such as gender, age, educational level, or social class
are added (Médicos del Mundo, 2022; Nichols & Malenfant, 2022). Additionally, in
these (and other) groups there may also be technological barriers that prevent them
from accessing online administrative procedures, such as the lack of a device to
access the Internet or complete ignorance of electronic processing procedures.
14.3.2 Training andCapacity Building ofProfessionals
The rst contact of people suffering from addiction with the care circuit is not
always made in a specialized resource; in many cases, this contact is made through
primary care resources, although also in other services, such as Cardiology,
Respiratory or Neurology, and even in hospital emergencies. In all these resources,
it is very likely that the staff working there have little training, even nonexistent, in
the management of the patient with an addiction. This can result in difculty in
We already know that the rst barrier Ana encountered was a lack of informa-
tion. Once she overcame her fear, Ana wanted to inform herself, but she didn’t
know how to do it or where to start. Given her emotional state, the fact of
seeing difculties even to nd information on how access to treatment works
made her give up and desist.
To get better informed, Ana has gone to her health center. Once there, she did
not feel condent to talk to the staff who attended her. When she asked, they
responded loudly so that everyone could hear what they were saying, and she
was very uncomfortable with the situation. Again, she thought it would be
best to leave.
14 Accessibility Barriers toTreatment fromaGender Perspective
194
identifying the disorder effectively, making erroneous diagnoses and inappropriate
treatments (Nyaku etal., 2024), or even dismissing the problem, (Adeniran etal.,
2023). In the case of women and LGBTQIA+ people, these types of barriers are
harder to overcome. Women encounter throughout their lives not only more barriers
to health services, but with less understanding and adaptation once they can access
them (Organización Mundial de la Salud, 2018). It is also known that much of the
information, training and clinical perception is insensitive to sex differences and,
above all, gender (Montesó-Curto etal., 2014; Vázquez-Santiago & Garrido Peña,
2016), including aspects related to sexual and gender diversity (Rider etal., 2019;
Valenzuela & Cartes, 2019).
Also, prejudices and lack of skills in managing patient with substance use disor-
der of some health professionals, like the person who attended Ana at the counter
and did not hesitate to speak loudly about her addiction, can represent another sig-
nicant barrier and that their lack of empathy affects the quality of treatment and its
success (Loo etal., 2021). This lack of empathy is particularly severe with bisexual
people, as they are discriminated against both within and outside of the LGBTQIA+
community, a phenomenon called “binegativity,” which increases the propensity to
develop addiction problems and avoids accessing treatment (Rothstein etal., 2024).
It has also been described the convenience of service providers having adequate
training for the management of transgender patients and thus avoid anti-trans stigma
(Baguso etal., 2022). On the contrary, when the staff shows empathy and compas-
sion, the likelihood of stigma is reduced and fear of starting treatment is lost
(Steinhauser etal., 2024)
14.3.3 Geographical
The degree of proximity to a socio-health resource can be determining in the
decision to access a treatment. The areas furthest from urban centers have fewer
resources in general and health and addiction-related services in particular
(Fredericksen etal., 2024). And it is even more complicated to nd providers
trained in gender and sexual diversity issues. This forces patients to travel long
distances to receive care (Parker etal., 2024) or to depend on virtual services,
which are not always accessible. As mentioned earlier, the costs associated with
transportation or the use of a own car can be high and affect not only access to
treatment but adherence to it (Pouille etal., 2024). Also, reasons like the lack of
childcare services, can be denitive in making the decision to start the process.
Likewise, when a displacement is necessary, the partner can also become an
Ana lives in a small city, where there are only two outpatient health centers.
When she obtained information about the treatment, she discovered that the
nearest resource is 40km away.
A. V. Infer et al.
195
interference for the woman to go to the center, especially when she is also suffer-
ing from addiction and does not want her to have access to treatment: for example,
by taking away her car keys or not allowing her to take it to the treatment center
(Fusco etal., 2024).
All of this causes that, when people have low economic income and a lack of
personal and logistical resources, they face additional barriers such as lack of trans-
portation, the cost of medications and lack of health insurance, which directly
affects their ability to access continuous treatment (Adeniran etal., 2023).
Also, the lack of integration between mental health services and addiction treat-
ment programs forces people with dual pathology to seek treatment in different
places, which complicates their access to comprehensive care. Agterberg et al.
(2020) point out that the lack of coordination between these services creates addi-
tional barriers for people who need a treatment that addresses both problems
simultaneously.
The reason that geographical location can be a barrier to access is not solely the
responsibility of the Public Administration. The shortage of health personnel spe-
cialized in addictions is more critical in rural areas; professionals are not always
willing to travel to very distant locations. On the other hand, private companies do
not usually consider it protable to establish specialized resources in these types of
municipalities. This resulting shortage contrasts with urban areas, where there are
multidisciplinary teams that provide comprehensive care for addictions (Parker
etal., 2024). All of this perpetuates to some extent the difculty of access and, at
times, the exclusion from the health system of people who live in these areas (James
etal., 2024).
14.3.4 Structural
One of the most evident structural barriers is the lack of places in treatment cen-
ters, which causes long waiting lists, delays access to treatment and increases the
risk of relapse (Schettini etal., 2024). The lack of adequate infrastructure and com-
plementary services, such as temporary housing or job support, hinders the reinte-
gration of people in recovery. Also negatively inuences the little exibility that
centers sometimes have, when they do not offer schedules that adapt to the needs of
the service users, which decreases therapeutic adherence.
To all this is added that some people who belong to the LGBTIQA+ collective,
especially trans people, face discrimination in traditional treatment centers, which
Ana has made the decision to start a treatment to recover from her alcohol
addiction. After consulting the addiction specialist, they inform her that in her
case she would have to be admitted to a therapeutic community, but there is a
waiting list and it seems that she will still have to wait.
14 Accessibility Barriers toTreatment fromaGender Perspective
196
are designed from a cisnormative and heteronormative perspective, including segre-
gation by sex in facilities such as bathrooms and dormitories, which causes trans-
gender people not to feel safe or comfortable receiving treatment and fear being
discriminated against or not recognized for their gender identity (Matsuzaka, 2018).
In addition, as mentioned earlier, the structural barriers are not only related to the
lack of resources, but also with the invisibility of their needs within conventional
treatment programs. Many trans or non-binary people, for example, may feel that
care services do not respect their gender identity, which can generate great discom-
fort and even previous traumas, such as medical discrimination (Loo etal., 2021).
In the case of patients with comorbidities there is an additional barrier, which is
the lack of coordination between mental health services and other specialties, as
well as the shortage of specialized personnel and resources, all of which hinder their
comprehensive treatment (Knopf, 2024).
14.4 Barriers Related tothePerson andTheir Environment
14.4.1 Economic
As mentioned earlier, people who are in the same situation as Ana barely have
information about the cost of treatment. Ignorance about economic conditions can
be somewhat deterrent. In fact, the cost of rehabilitation programs, both outpatient
and residential, can be prohibitive, especially in private resources or in health sys-
tems where services are not fully covered by public health or medical insurance.
The problem of expenses goes further: for example, the loss of income from being
absent from work (Schettini etal., 2024), or the additional costs of transportation
and accommodation to receive treatment that patients living in areas far from urban
centers must face (Parker etal., 2024). When women have no income, they face
additional nancial barriers that prevent them from paying for treatment or tempo-
rarily leaving work to undergo rehabilitation programs (Greeneld etal., 2007).
Additionally, the difculty in nding suitable services causes non-conforming gen-
der people to often face prohibitive treatment costs, which forces them to seek less
effective alternatives or to not receive treatment at all.
In the case of women and some cases of the LGTBQIA+ collective such as trans
people, economic barriers may be even more accentuated due to the structural
inequalities that exist in regarding income and employment. These populations
often have greater difculties in nding stable and well-paid jobs, which limits their
ability to afford relocation or treatments. Women are often employed in poorly paid
Ana has a doubt. She already knows that she has to enter a treatment program,
but she is not sure if it has a cost, if she will have enough money to travel
every day, if she will be able to continue working or will have to take leave,
etc. In short, she does not know if she can afford it…
A. V. Infer et al.
197
and precarious jobs that do not offer them the necessary economic security to take
a leave to enter a rehabilitation program, and the fear of losing their job or facing
work repercussions for seeking treatment, acts as a signicant barrier (Agterberg
etal., 2020). In addition, trans and non-binary people, in particular, face high levels
of job discrimination, which exacerbates their economic situation.
Finally, the lack of available places and the limited duration of publicly funded
treatments (often insufcient for severe cases of addiction) can prolong the waiting
time and increase the risk of relapse (Schettini etal., 2024).
14.4.2 Cultural andEthnic Barriers
Cultural and ethnic barriers play an important role in the accessibility to treatment,
especially for women from ethnic minorities or migrant backgrounds. What would
happen if Ana were an immigrant, of a different religion or with a skin color differ-
ent from the majority in the society where she lives? In these cases, she would prob-
ably experience, in addition to the stigma that exists toward substance use, the one
related to her cultural or ethnic condition. Social norms within communities can
impose additional restrictions for them to seek treatment, especially when these
norms punish female behavior that deviates from the “expected.” For example,
some migrant women may nd themselves trapped in a situation of nancial and
emotional dependence on their partners, which prevents them from accessing exter-
nal support resources.
In addition, the language barrier and the lack of health staff trained to work with
culturally diverse populations accentuate the exclusion of these women from the
health system (Médicos del Mundo, 2022; Paschen-Wolff etal., 2024). This lack of
inclusive and culturally competent programs reinforces distrust in health services,
leading many people from the LGBTIQA+ community to avoid or delay treatment,
which often results in a worsening of their health problems (Reisner etal., 2015).
14.4.3 Childcare
A signicant obstacle, particularly in the case of women who have children, is
their care. The responsibility they have toward them makes them feel ashamed of
their consumption and fear losing their custody or being perceived as “bad
Ana has to leave her daughter Marta with some neighbors from her farm. She
has no choice, as she has to attend afternoon sessions and has no one else to
leave her with. She also can’t take her with her. She worries, because her
neighbors don’t know the reason for leaving Marta with them, and she fears
that her daughter might tell them by accident, or that they nd out through
other means, and she is saddened by not being able to spend time with her.
14 Accessibility Barriers toTreatment fromaGender Perspective
198
mothers”; all this becomes a signicant psychological and structural barrier (Fusco
etal., 2024), which is even greater if the socio-health center is linked to the Public
Administration (Svensson etal., 2023). Women who face these fears often choose
not to seek treatment until the situation becomes critical; the pressure of caring for
their children, relatives or dependents, limits their ability to fully participate in reha-
bilitation programs and postpones access to treatment (McNeely et al., 2018).
Obviously, in the case of single mothers, everything is more complicated, as they
are the main caregivers in their families. Also, non-conforming gender people face
challenges related to caregiving responsibilities, especially when their gender iden-
tity is not respected by the family or the community, which adds an additional layer
of stress and isolation (Loo etal., 2021)
As mentioned earlier, many women prioritize the well-being of their children
over their own, but treatment programs do not usually offer nurseries or support
services that allow women to participate in treatment sessions without the worry of
who will take care of their children. In short, the dual role of caregiver and patient
with treatment needs creates a conict that many women cannot resolve, especially
in contexts where there is no social or family support to distribute these responsibili-
ties (Sajjad etal., 2024).
14.4.4 Psychosocial
Since the end of the last century, one of the fundamental aspects of addressing
addictions was their progressive medicalization: they gradually stopped being a vice
to be considered as a chronic disease. This change in approach signicantly
improved the application of therapies to address this disorder. Despite this, the tra-
ditional gender expectations can reinforce the stigma toward women, who are often
perceived as “bad mothers” or “neglectful” if they prioritize their health over family
responsibilities (Fusco etal., 2024), which generates shame and guilt, preventing
them from seeking help. Even the very designation as “drug addicts” results in an
increase in perceived stigma, (Goodyear etal., 2018). This stigma not only comes
from society, but also from the patient themselves (self-stigma), and even from
healthcare personnel, which reduces condence in the system and the patient’s will-
ingness to participate in treatment (Luoma etal., 2007). In Ana’s case, she feels
observed and judged, despite not having seen any objective expression of disap-
proval from anyone at the center.
Ana is about to start treatment. For now, it will be outpatient, because there
are no places in the therapeutic community yet. She has to access the center,
but fears that someone might recognize her. In fact, every time she enters the
resource, she has the feeling that they are looking at her and she feels judged.
It is not a pleasant situation and, every day, she thinks about quitting the treat-
ment to avoid the ordeal.
A. V. Infer et al.
199
The family and peers also suffer this shame in relation to the problem, a phenom-
enon also known as courtesy stigma. In the early stages of an addictive process,
there is a denial or lack of awareness about the addiction problem on the part of the
social and family network, which becomes a crucial psychological barrier, delaying
early intervention, key to successful treatment. Moreover, when family and social
support is scarce, the rehabilitation process becomes much more complex, as the
lack of healthy personal relationships can have negative consequences on the emo-
tional well-being of the person suffering from addiction: the social isolation associ-
ated with addiction increases feelings of loneliness and hopelessness, which causes
a greater desire to consume the substance as a form of escape.
A critical aspect in the treatment of women with addictions is the impact of
trauma, especially that related to gender violence. There is a bidirectional relation-
ship between drug use and gender violence, and in the case of women, the consump-
tion of substances such as alcohol is fundamental in the persistence of these types
of violent behaviors and coping with victimization (Shiva et al., 2021). In fact,
women, in particular, are more likely to develop substance use disorders in response
to previous traumas, such as gender violence or sexual abuse, which hinders the
recovery from their addiction by not adequately addressing these traumas in tradi-
tional treatment programs (Romero-Mendoza et al., 2018; Tirado-Muñoz et al.,
2018). In addition, it is worth mentioning the power that their partners exert over
them, sometimes in the form of abuse, which can prevent their women from access-
ing treatment resources; it is their partners who control access to medical services
and the money to pay for them if necessary. All this creates a double barrier: they
not only ght against their addiction, but also against untreated trauma and against
their consumption as a coping method. The fear of revictimization within the health-
care system, especially when a trauma-sensitive treatment approach is not offered,
prevents them from seeking help.
In short, if Ana did not ask for help before, it was because having an addiction is
bad, but it is even worse when it is a woman. This stigma, present both in society
and within families, as a result of cognitive biases regarding gender (Vázquez-
Santiago & Garrido Peña, 2016), reinforces isolation and guilt, preventing many
women from seeking help for fear of being judged, because they are also expected
to assume caregiver roles and, therefore, it is even less understood when they
become addicts. And this process is more pronounced when it comes to transgender
people, where 50% of them feel unmotivated to access treatment programs
(Matsuzaka, 2018).
14.5 Final Considerations: Proposals
toImprove Accessibility
In recent years, the availability of treatments has markedly improved thanks to the
expansion of telemedicine and online care programs, especially due to the pandemic
caused by Covid-19, which have facilitated access, among others, to mental health
and addiction treatment services, especially in areas geographically distant from
14 Accessibility Barriers toTreatment fromaGender Perspective
200
these services. This modality of remote treatment has become an effective tool to
eliminate physical and economic barriers, improving adherence to treatment. In
fact, the use of these approaches can also facilitate access to treatment for women
who either suffer geographical barriers or prefer to be attended without being seen
when accessing resources in person.
Another issue that can be improved is the lack of training of non-specialized
health professionals in addictions. For this, training curricula have been designed
that train this professional group in the management of the patient with substance
use disorder, allowing for effective screening, brief intervention, and referral to spe-
cialized treatment (SAMHSA, 2017). It is therefore necessary to have the largest
number of health professionals for the challenge of an integral intervention aimed at
the person, ensuring that patients not only receive medical treatment, but also com-
prehensive social support in order to effectively connect patients with health ser-
vices (D’Ippolito etal., 2015). Additionally, policies can be developed that include
the creation of nancial incentives to encourage the specialization of professionals
in addiction treatment, as well as the implementation of educational campaigns at
the national level that seek to destigmatize addiction treatment, as well as commu-
nication campaigns to demystify addiction and highlight recovery stories, thus
bringing the problem of addictions closer to the non-specialized health professional
collective and the general public. These policies can help reduce the social and
health stigma that limits access to treatment for many people, especially gender
minorities (Bodkin etal., 2015; Reisner etal., 2015). In this line, the implementa-
tion of programs that integrate a gender approach, such as the use of harm reduction
models and non-judgmental care, has proven to be effective in increasing adherence
to treatment in vulnerable women, such as people in situations of prostitution and
sexual exploitation. These multidisciplinary approaches ensure that patients not
only receive medical care, but also psychological and social support that considers
the complexities of their lives.
The fact of using models considered as asexual, but which are clearly androcen-
tric, has inuenced the creation of clinical frameworks loaded with signicant gen-
der biases, and that is why much of the information, training, and clinical perception
are insensitive to sex differences and, above all, gender (Montesó-Curto etal., 2014;
Vázquez-Santiago & Garrido Peña, 2016). Therefore, initiatives that promote empa-
thy and a greater understanding of the specic barriers that women face (Bodkin
et al., 2015) and the LGBTQIA+ community (Reback etal., 2018) can help to
reduce stigma and foster a supportive and understanding environment. Lastly, the
involvement of translators, cultural mediators, and educational resources adapted to
cultural diversity, to overcome the barriers that arise in cases where there are differ-
ences in culture and language.
Facilitating comprehensive treatment that addresses addictions and mental
pathology can help overcome the structural barriers related to the treatment of dual
pathology, something that according to scientic literature improves adherence to
treatment and reduces relapse rates (Schettini etal., 2024). Likewise, a key aspect is
the design and implementation of policies that promote a gender approach in addic-
tion care. It is essential that governments develop regulatory frameworks that
A. V. Infer et al.