Gender stereotypes in psychosocial care for female crack and powder cocaine users

The study analyzed health professionals’ conceptions toward female users of crack and powder cocaine currently receiving psychosocial care, based on a gender perspective. Seventeen health professionals were interviewed, and systematic observations were made of the spaces for collective care in a Center for Psychosocial Care specializing in alcohol and drug addiction in Greater Metropolitan Rio de Janeiro, Brazil. Analysis of the interviews and field diaries using the hermeneutic-dialectic method revealed three categories: frailty as a constitutive attribute of women’s condition, the women’s emotional addiction to crack and powder cocaine use, and gender stereotypes during psychosocial care. The health professionals voiced a traditional view of the heterosexual, docile, and maternal woman and reproduced stereotypical concepts when addressing female crack and cocaine users as sensitive, frail individuals, emotionally dependent on men and more involved in the home and family. These professionals need a more refined understanding of gender issues in the mental health-disease process in order to allow overcoming preconceived notions and reductionist health care practices. Cocaine Crack; Drug Users; Gender and Health; Women’s Health This article is published in Open Access under the Creative Commons Attribution license, which allows use, distribution, and reproduction in any medium, without restrictions, as long as the original work is correctly cited. ARTIGO ARTICLE


Introduction
Illegal drug consumption impacts drug users' lives and health.In 2012, an estimated 162 to 324 million people 15 to 64 years of age had consumed some illegal drug at least once in their lives, representing 3.5% to 7% of the world population.In the Americas, Brazilian data show an increase in drug use, and the country has become the largest cocaine consumption market in South America, in addition to serving as a prime traffic route, given its strategic geographic position for moving the drug to the large consumer markets in North America and Europe 1 .
The Second National Survey on Alcohol and Drugs in 2012 estimated the prevalence of lifetime powder cocaine use in the overall Brazilian population at 3.9%.The prevalence of Brazilians that had used powder cocaine at least once in the previous year was 1.7%.For smoked cocaine (crack), the rates were 1.5% and 0.8% for those who had consumed crack at least once in their lives and at least once in the previous year, respectively 2 .
Men are the main users of crack and/or similar drugs (freebase, etc.) in Brazil, accounting for 78.7% of all users in open crack trafficking and consumption scenes in 2012.The characteristics of female users in these scenes were: mean age 29.6 years, non-white, with low schooling (elementary or less).The mean time these women had used crack was 77.07 months, or a little over six years 3 .
Reported lifetime history of sexual abuse was six times higher in female crack users than in male users, or 46.7% and 7.49%, respectively.Likewise, the majority (55.4%) of female users were involved in sex work or trading sex for money, as compared to 14.6% of male users.Therefore, female cracks users in Brazil suffer precarious social integration and gender inequalities that expose them to additional health risks 3 .
Understanding the repercussions and consequences of these inequalities in drug addiction patterns can be limited if the studies only use comparative approaches to analyze rates in women and men.Such approaches limit the knowledge of this phenomenon, particularly in women 4 .The prejudices and discrimination they face in society cause inequalities that further aggravate the problems resulting from illegal drug consumption in the lives and health of these women 5 .
Gender is a social determinant of health, central to understanding the mental health-disease process in men and women 6 .The concept refers to the socially constructed roles, norms, behaviors, activities, and attributes that a given society considers appropriate for men and women 7 .In predominantly patriarchal societies, such differences cause gender inequalities and affect women's health 8 .
Although gender is a broad, complex theoretical category, patriarchy expresses a social, political, cultural, and symbolic order in the relations of women's subjugation, simply because they are women 9 .This order reproduces the inequalities and violence that women suffer in contemporary societies, such as the difficulties they encounter in education, income, and employment, in addition to workload, violence, sexual abuse, and other problems resulting from gender inequalities 4,5,6,7,8,9,10 .Thus, persistent sexist and misogynous discourses reflect the influence of this patriarchal social order.
There is a dominant view of the underlying gender relations in the phenomenon of crack and cocaine use that stems from the reproduction of male domination in relations, leading to the maintenance of social stereotypes, prejudices, and stigmas associated with women.Thus, female gender issues need greater visibility in the addictions field in order to make public policies more adequate and sensitive to the female population's needs 11,12 .
To analyze the specificities of care for female crack and cocaine users, the point of departure for the current study was the following basic question: How do health professionals view female users of crack and cocaine and their specific issues in psychosocial care?
In order to answer this question, the study aimed to analyze health professionals' conceptions concerning female users of crack and cocaine currently in psychosocial care, from a gender perspective.
This perspective is based on the feminist theoretical school that analyzes gender relations resulting from the social construction of sexual differences, and that defends gender equity, drawing on the conceptual framework of authors such as Joan Scott 9 and Heleieth Saffioti 10 , as well as studies addressing gender issues and crack and cocaine use in the female population.

Method
This was a qualitative study performed in a Center for Psychosocial Care specializing in alcohol and drugs, type II (CAPSad II), situated in a city in Greater Metropolitan Rio de Janeiro, Brazil.The data were collected in May-June 2014.
The city had an estimated population of 873,921 in 2013.Within the network of municipal services for psychosocial care, the CAPSad II is the referral center for specialized care in alcohol and other drugs, with a monthly average of 361 users under its care.
Since this health service's databank did not specify the clientele according to type of drug used, a complementary search of patient records was performed.This stage was performed prior to the data collection per se and allowed a quantitative picture and profile of the female users that attended the CAPSad II regularly during the study period.
Of the total of 152 patient charts of women under psychosocial care for alcohol and other drugs, 113 used powder cocaine and/or crack.In this latter group, nearly all (90.3%) were adult women, with adolescents representing the other 9.7%.The majority (62.8%) lived with their families and had under-age children (55.7%).
Nearly half of the women (47.8%) had no work, followed by those that depended on their families for their living (39%).Informal and formal working women represented 15% and 9.7%, respectively.Women working in prostitution as their source of income represented 12.4% of the total female clientele at the CAPSad II.
The study subjects consisted of the health team professionals providing the psychosocial care who had at least one year of professional experience caring for female crack and cocaine addicts.Three members of the team were excluded: a nurse that did not work directly with the female clientele, a male health professional that had less than one year of experience working with crack and cocaine users, and another who was on medical leave during the data collection period.
Thus, 17 health professionals participated in the study, out of the total of 20 professionals working at this service when the data were collected.These 17 participants included 14 with university training (four social workers, four physicians, four psychologists, an occupational therapist, and a pharmacist) and three elementary-level workers (nurse technicians).
The largest share of these professionals were 50 to 61 years of age (41.2%), had more than 20 years of professional experience (47%), and were women (76.5%).Thus, whenever the article refers to the "health professionals", it should be remembered than more than three-fourths were women.
88.2% of the sample had up to five years' experience caring for crack and cocaine users.None had any specialized training in alcohol and drug addiction.
Two data collection techniques were used: (1) semi-structured individual interviews with the staffers concerning the characteristics of female crack and cocaine users receiving psychosocial care and (2) systematic observation of the group care (spaces for sociability and group therapy/activities) with field diary records on how the health professionals addressed the women's questions and needs in these spaces.
In order to ensure the participants' anonymity, we adopted the code letter "I" for "interviewee", followed by the interview's numerical order from 1 to 17, like I1, I2, I3, and so on.The field diary annotations were numbered by chronological order, from 1 to 10, followed by the location where the observation was made: women's group or social space.
The empirical data were analyzed according to the hermeneutic-dialectic comprehensive-critical approach, which associates comprehension of the texts (as biographies, narratives, interviews, and other documents) with the critical watershed of dialectics, intended to reveal the ambivalences, incompleteness, and contradictory cores of the social phenomenon at hand 13 .
In hermeneutics, the text's comprehension occurs through the language, since the latter is not transparent in and of itself, but displays a philosophical and dynamic nature and involves a process both intersubjective and objective, allowing the connection between thought and language, and the grasp of the meaning of the speech act or symbolic manifestation based on knowledge of the interlocutor's social context 13 .
Dialectics also focuses on the symbolic manifestations' historical context, since human reason can do more than simply comprehend reality; it is capable of producing a synthesis of the processes of Cad.Saúde Pública 2018; 34(5):e00110317 comprehension and critique.Thus, the combination of hermeneutics and dialectics allows unveiling a consensual meaning of the object of our interpretation, establishing a critique of the disagreements and contradictions of the meanings and their relations with the social context 13,14 .
The following operational steps were adopted in the analysis: (a) ordering of the data, including transcription, organization, and systematization of the interviews and field diary records; (b) data classification, exhaustive reading for identification of relevant structures, central ideas, and key moments in the object under study, allowing thematic grouping; and (c) final analysis, when the dialectic movement was established between the empirical material and the study's theoretical perspective, culminating in the elaboration of interpretative syntheses14.
The study complied with the ethical principles set out in Ruling n. 466/12 and was approved by the Institutional Review Board of the State University of Rio de Janeiro (review n. 628.205/2014).

Results
Three categories emerged from the comprehensive-critical analysis: frailty as an essential attribute of women's condition; female dependence related to crack and cocaine use; and gender stereotypes in psychosocial care, addressed below.

Frailty as an essential female attribute
The health professionals described the female crack and cocaine users (compared to male users) as more sensitive, zealous, craving for affection, insecure, emotionally dependent on men and drugs, and less inclined to discuss their drug use, thus framing themselves as victims of their own condition as women.
The health professionals saw these frailties as leaving the women more exposed to oppressive social structures, to the point of negatively impacting their access to addiction services: "Women are more sensitive.Men come across as more independent, even if they're drug users.But women are frailer, lacking independence" (E1)."It's as if they want to improve in order to hold on to their family.It's like a burden they take on themselves (...).I think everything is harder for women, either because it takes them longer to come for treatment, or because they skip appointments.I think they drop out of treatment quicker than men" (E4)."Everything with women is more veiled, because for them to admit they use drugs is more complicated than for men to come here and say it" (E5)."I think many of the women are victims of society, some are victims of marriage, and others are victims of their families" (E6).
When comparing men and women, gender differences are taken for granted as resulting from their different biological makeup.The health professionals express the following notions: "Women are naturally treated differently.That's only natural" (E2)."Men are stronger than women in the world of drugs, where's it's practically every man for himself.Because of their physical frailty, women end up being subjugated" (E12)."You can't overlook the specificity of emotional issues and hormones.Women have emotion, a thing about feelings that's inborn" (E15).
This dominant view that women have a "nature" demarcated by frailty has a direct influence on the relationship in psychosocial care, conceiving women as victims and limited in their ability to develop personal autonomy.This view appears in the following quotes: "Poor thing, she needs help" (E1)."They just wait for the answers to come from us" (E2).
Since the women tend to be shy and reserved, the health professionals need to show sympathy in order to facilitate the therapeutic approach: "The women are more reserved in this process [therapy].In my experience they act more fearfully" (E4)."The men are more easy-going.The men speak up.The women hardly say anything" (E5).
Despite these views among the clinic's staff, the group therapy discussed the prevailing issue of women's "frailty" in society for the female drug users to develop more proactive attitudes to overcome their addiction, encouraging women in their role of raising the children and caring for the family: "The coordinator works with the theme of women's empowerment, scheduled in advance for that day, and encourages them to adopt more confident and autonomous attitudes and avoid seeing themselves as victims of society.However, the orientation to perform their role adequately as mothers, taking responsibility for their children Cad.Saúde Pública 2018; 34(5):e00110317 and family, is used to motivate them to stay clean from drugs, which ends up reinforcing the gender stereotypes" (Observation n. 2, women's group).

Women's emotional dependence related to crack and cocaine use
The power relations identified in the interaction between female drug users and their partners have an impact on the women's psychosocial status, according to the health professionals, who see the women as emotionally dependent on men: "She lives on the street with her husband, I mean, not her husband, the child's father.They [the male partners] say they want to help, but that they aren't able to stay with her at home, not with her, nor with child.And the women stay out on the street to be with their partners, even when they have small children" (E1)."In many cases we see here [at the clinic], we hear the women saying they were doing drugs because their husbands did and forced them to use drugs, too" (E5)."The vast majority were induced [to use drugs] by a man!Out of love!" (E17).
The impoverished conjugal and family relations that were viewed by the health professionals as spaces producing psychological distress and triggering crack and cocaine addiction, resulting from women's emotional deprivation in the domestic setting, were illustrated by these quotes: "The vast majority of the issues have to do with family or marriage, something much more emotional than for the men" (E2)."Some women are victims of the marriage, and others are victims of their families (...) Something exists that makes them want to do drugs" (E6)."These women turned to drugs for some reason, for something they were missing, especially something emotional.It's usually the women who had absent mothers, or had frustrated relationships, or even child custody issues.They're women whose husbands don't pay child support, or that got pregnant and were dumped" (E14).
The story involving a conjugal relationship was also recorded in the field diary: "One of the women said she had spent the last two nights on the street with her boyfriend, since he had been thrown out of his neighborhood and none of his relatives would take him in.She decided she wouldn't leave him alone at such a time, since he was the love of her life.(...) The fact that she was on the street with her boyfriend was seen as lack of self-esteem by the other group participants" (Observation n. 9, women's group).
This emotional dependency, together with the drug addiction itself and women's submission to men's wishes, predisposes them to sexual exploitation in the health professionals' view, as manifested in the following quotes: "Women stay [at the drug scene], and the men want to take advantage of them, abuse them sexually, and there [the next step is] to prostitution" (E1)."The woman is forced into prostitution because of her drug habit" (E12).
The health professionals thus think that female crack and cocaine addicts are more prone to use their bodies as a means of subsistence and to access income to maintain their drug use: "Women usually have more limited economic needs.It's easier for women to make money.Women work at prostitution" (E3)."The women have a way to access income on the street that's different from the men.We see a lot of cases of prostitution among the female users" (E10).

Gender stereotypes in psychosocial care
The female health professionals treat the women differently, with a different approach, requiring that they take a more sensitive and delicate stance in practicing psychosocial care: "You have to approach [the women] differently, no matter how much women demand equality.After all, we are different.We have to take a more delicate approach to the women" (E2)."I think caring for these women requires a lot of sensitivity" (E15).
When comparing social gender roles, the female health professionals felt that women crack and cocaine users are subject to greater demands in caring for home and family, besides taking the responsibility for raising the children, giving them greater responsibility over the nuclear family: "When the man leaves the home, the women takes on the responsibility [for the house and children]" (E9)."The family reference is rarely a father.The woman carries different weight in the family" (E10).
Women's special role in motherhood and caring for the family is a therapeutic resource used in their psychosocial care, and is used as an element to motivate them to rebuild their social lives: "Controlling their drug addiction is the point of departure for reorganizing their lives, for them to meet modern society's expectations as respectable mothers, as an example of attitude and character for their children, to teach Cad.Saúde Pública 2018; 34(5):e00110317 their children not to use drugs, and to transform their reality by educating their children" (Observation n. 3, women's group).
The sacred institution of motherhood emerged in the group work with the women, as a stimulus for reflection and debate among crack and cocaine users on the importance of their focusing on their healing process to be able to meet the needs of their families and children: "The women were welcomed today with a poetry reading on mothers.The last line of the poem said, 'To speak of mothers is to speak of God'.The poem mentioned a divine force that women receive from God to experience motherhood" (Observation n. 10, women's group).
Despite the group coordinator's intention of motivating treatment adherence, some of the women questioned this idealized maternal role: "'What kind of mother am I going to be?'.'What kind of example am I setting for my children?'" (Observation n. 3, women's group).
Another highlight in the groups was the encouragement for crack and cocaine users to become involved in some kind of work as a means to generate income and rebuild social ties.Learning manual skills was featured as a livelihood, for example, learning to fold and cut artificial flowers for sale.
The health professionals viewed such manual skills as inherently female activities.When one of the female crack users failed to display such skills, the health professional leading the activity comments: "It's simple!Haven't you ever sewn?Not even doll clothes?" (Observation n. 2, socializing space).
When female crack and cocaine users failed to display typically "female" behaviors, like meekness and submission, the health professionals equated them with male behaviors and deviant attitudes: "Whether men or women, the profile [of crack and cocaine users] is one and the same: they're conniving liars.Sometimes we have to be firm, as if talking to a man" (E2)."Today you hear women talking like macho men: 'I'm more macho than a lot of men!'" (E15).

Discussion
The female crack and cocaine users in this study were interpreted by health professionals based on the hegemonic notions of women's social roles and attributes, even though the majority of these health professionals were women.Such concepts mark the social distinctions between womanhood and manhood and reveal the influence of gender stereotypes crystalized in the Brazilian sociocultural order and the mechanisms of reproduction of a patriarchal society's social codes.
These influences shape the way the health professionals view and practice psychosocial care for the clinic's female clientele.Furthermore, these stereotypes also exist in the care for women in situations of violence and psychological distress, both in primary care and in the hospital system 15,16 .
The health professionals in this study (the majority of whom were women) situated the differences between male and female crack and cocaine addicts in the biological sphere.This approach reveals a reductionist view of women, highlighting their reproductive role and their social role with their offspring and family, to the detriment of other health needs and their own human fulfillment, besides relegating the health problems related to gender violence and the symbolic structures of oppression in society.The social mechanisms and dynamics that perpetuate these conceptions pose an obstacle to women's struggle for social equality, impacting access to health services and planning of specific care 4 .
In the health professionals' view, women's constitutional frailty and emotional dependency are related to the women's drug addiction.Thus, the women's substance use is related to their experiences in the social context, which is under the influence of structuring elements in social and power relations in societies organized dichotomously according to male and female roles 17 .
Violence is a complex and serious social issue in Brazil and in the world as a whole, and is more intense in large cities 18 .For women, violence is a public health problem that is also present in the context of drug use.However, due to gender issues, the problem needs to be understood primarily as a human rights violation that affects them simply because they are women 16 .
The phenomenon of violence emerged in the current study as one of the consequences of women's submission to their male partners' wishes, including situations of sexual exploitation.Experiencing an abusive relationship impacts the psychological and social condition of women (like anyone), with feelings of guilt and low self-esteem, undermining their self-determination for dealing with this adverse Cad.Saúde Pública 2018; 34(5):e00110317 and perverse reality, which can lead to substance abuse and the development of other psychiatric morbidities like anxiety disorders and derpesssion 5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 .
The association between prostitution and drug addiction emerged in the interviews with health professionals, who felt that the very fact of being a woman predisposes to situations of prostitution, since the drug use scene is represented as a male (and thus male-dominated) environment.Some segments associate prostitution with the situation of discrimination in society.Still, exchanging sex for money or drugs is relatively common and occurs with both women and men, who distinguish their amorous relations from the fortuitous encounters used for their own subsistence and drug use 3,15 .Thus, this issue is far more complex than perceived by the health professionals interviewed in this study.
The harmful effects of crack and cocaine include socioeconomic breakdown, serious harm to mental health, involvement with crime, marginalization, violence, prostitution, and multiple sex partners, and the resulting increase in the potential for HIV infection 5 .The health risks should not be overlooked and require an understanding of users' daily dynamics in order for the care to include personal and existential specificities, regardless of whether the users are women or men.
Gender inequalities are present in women's lives, such as their habitually taking responsibility for their families 20 .This hierarchical and traditional social organization was also observed among homeless crack users, where the women were depicted as responsible for caring for their children.Still, there were some women in these street scenes that did not adhere to this hegemonic logic, and who viewed motherhood as a matter of their own personal choice 21 .
The health professionals interviewed here did not even glimpse the possibility that some women might not adhere to this traditional social organization.They viewed female crack and cocaine users as typical heterosexual women responsible for caring for traditional families.Self-esteem, selfefficacy, and self-image are important health aspects that contribute to the elaboration of personal identities and influence the way individuals experience social relations.
Female crack and cocaine users, in addition to suffering social prejudice and stigma resulting from addiction, have their unique needs jeopardized by the representations elaborated with a binary gender view that shapes the way health professionals practice care, elaborated on the basis of a traditional definition of the male and female genders 6,8 .
Viewing women as frail has negative effects on their self-image, leading to greater propensity to accepting victimization.The underlying asymmetrical power relations in traditional and stereotypical social roles also negatively impact people's psychological and social conditions and influence the way they live and experience illness 20 .
Understanding these processes and their effects on psychosocial care is necessary to promote the women's self-esteem and their potentialities for a healthier life, to support their personal empowerment, with the possibility of elaborating new meanings in the production of health and improving their quality of life.
The notion of female crack and cocaine users as emotionally dependent and with the primary responsibility of caring for the family aggravates the feeling of guilt and reinforces existing social stereotypes.However, the loss of family ties has been observed in the research on homeless crack users.Users who stay on the streets or have no fixed housing develop other affective ties and organize their lives in this new space 21 .
The psychosocial care expressed by the health professionals in this study centers on the notion of the heterosexual woman's role, subordinate to the man, and for whom motherhood is a restorative element of life and social ties.Therefore, gender relations influence the health professionals' view of the people under their care and the narrow way they conduct such care 22 .
Importantly, these notions emerged in a group of health professionals who are mostly women, who appeared to take gender inequalities for granted, thus highlighting the need for continuing education programs on gender as a determinant of health, and thus on its influences and repercussions for psychosocial care for illegal drug users.The gender issue should also be emphasized in the training curricula for future mental health professionals in order to break with the reproduction of gender inequalities in their practice.

Conclusion
The health professionals reproduced stereotypical notions of the female gender, viewing the women as sensitive, frail, emotionally dependent on men, more attuned to the home environment, household chores, and care for the family.They thus expressed a traditional view of an idealized docile and maternal heterosexual woman.
For these health professionals, women's frailty and meekness play an essential role for female crack and cocaine users, justifying their assumption that these women are more emotionally dependent on their affective ties with their families and male partners.These ties and relations have interfaces with the way psychosocial care is conducted at the CAPSad II, since there is a focus on motherhood in the discourses to motivate abstinence in these women and to reclaim their social role in caring for the children.
The health professionals showed that they need a more refined understanding of gender relations as a social determinant of the mental health-disease process in order to establish more qualified, comprehensive, and equitable psychosocial care, consistent with the women's life stories and individual needs, in order to overcome the stereotypical notions of the female gender and women's condition and the reductionist practices in such care.
Despite the focus on the views of a particular group of health professionals, the study's results provide food for thought on female gender issues in psychosocial care for crack and cocaine users and support for health policies, suggesting the need for continuing education strategies for these professionals and specific measures for the care provided to the female clientele, based on the discussion of gender issues and inequalities.

Resumen
La presente investigación analizó las concepciones de los profesionales de salud sobre las mujeres consumidoras de cocaína y crack en proceso de terapia psicosocial, basándose en la perspectiva de género.Para tal fin, se entrevistaron a diecisiete profesionales de salud y se procedió a realizar observaciones sistemáticas en los espacios de cuidado colectivo en un Centro de Atención Psicosocial para el alcohol y drogas de la Región Metropolitana de Río de Janeiro, Brasil.El análisis de las entrevistas y diarios de campo se realizó mediante el método hermenéutico-dialéctico, que reveló tres categorías: fragilidad como atributo constitutivo de la condición femenina; la dependencia afectiva femenina, relacionada con el uso de cocaína y crack; y los estereotipos de género en el cuidado psicosocial.Los profesionales de salud expresan la visión tradicional de la mujer heterosexual, dócil y maternal, y reproducen concepciones estereotipadas, al considerar a las consumidoras de cocaína y crack como personas sensibles, frágiles, dependientes afectivamente de los hombres y más involucradas en el hogar y la familia.Estos profesionales carecen de una comprensión más sofisticada sobre cuestiones de género en el proceso salud/enfermedad mental, a fin de posibilitar la superación de creencias comunes y de la praxis de Contributors E. B. O. Silva and A. L. F. Pereira contributed to the study conception, data collection and interpretation, writing and critical revision of the content, and approval of the final version for publication.L. H. G. Penna contributed to writing the article, critical revision of the content, and approval of the final version for publication.Cad.Saúde Pública 2018; 34(5):e00110317 cuidados reduccionistas.Coicaína Crack; Consumidores de Drogas; Género y Salud; Salud de la Mujer Submitted on 26/Jun/2017 Final version resubmitted on 22/Oct/2017 Approved on 21/Nov/2017