**1. Introduction**

Fifty years ago, in 1972, feminist icon Phyllis Chesler published Women and Madness, a definitive work on women's psychology that addressed critical questions around women's mental health. Chesler's foundational work cited studies highlighting a predominantly male psychiatric population, or 90% male compared to 10% female counterparts, who had been diagnosing, hospitalizing, and researching a predominantly female population of patients [1]. Furthermore, Chesler argued that research at that time showed that female clinicians, having studied under male teachers and professionals, were echoing the professional biases of their male colleagues when diagnosing women with mental health issues [1].

During the 1990s and early 2000s, Chesler (2005) pointed out that gender-biased diagnosis within psychiatry persisted, with many textbooks failing to include mention of sex or gender bias or the feminist critique [2]. In 1999, Brady and Randall's summary of research on mental health issues such as substance use disorder (SUD) highlighted gender differences related to psychological and biological factors, indicating that men had a statistically higher rate of dependence on, and use of substances compared to women [3]. However, it is critical to note that research focused on addiction during the 1980s and 1990s particularly about alcohol use disorder (Blume, 1986) and treatment (Weisner and Schmidt, 1992), shows that women were almost entirely excluded [4]. Certainly, we must consider the significance gender biases have had on diagnoses, treatment, and research related to SUD, which have contributed in part to associated gender disparity. Brady and Randall (1999) proposed that

**Citation:** Perham-Lippman, K. Gender Disparity in the Wake of the Pandemic: Examining the Increased Mental Health Risks of Substance Use Disorder and Interpersonal Violence for Women. *Merits* **2022**, *2*, 445–456. https://doi.org/10.3390/ merits2040031

Academic Editor: Wendy M. Purcell

Received: 15 November 2022 Accepted: 29 November 2022 Published: 2 December 2022

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**Copyright:** © 2022 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

the increase in women entering traditionally male dominated professions and workplaces might also impact these gender differences through changes in the drinking culture and societal influence that would potentially increase women's participation in drinking and drug use in the future [3].

Despite Chesler signaling the urgent need for gender discrimination to be addressed in the field of mental health, over the decade's most mental health and addiction research continued to be skewed in terms of gender. Within the United States, however, female psychologists in education, as well as females in professional roles in the field of psychology and within the American Psychiatric Association are currently experiencing greater representation compared to males [5]. This has undoubtedly created the potential for increased focus on gender differences in diagnosis and treatment related to mental health. However, despite these advances, for the past two decades there have still been broad inequities in salary, training, and job opportunities related to gender in the field of psychiatry. According to Clay (2017), there are even greater disparities for women with disabilities as well as women of color [5].

Notwithstanding, there are examples that have provided valuable insights regarding the relationship between gender differences and mental health disorders. For instance, a longitudinal study of more than three decades (Fillmore et al., 1979) found that predictors for future alcohol dependencies were significantly differentiated by gender [6]. Furthermore, Jones' (1968, 1971) research showed that coping difficulties and reduced self-concept clarity serve as predictors for future alcohol dependencies. Additionally, Walitzer and Sher (1996) found that sense of self played a more significant role in the etiology of alcohol use disorder in women than it does in men [7]. Also, a 1997 study of more than 1000 women found that those with sexual experiences before age 18, specifically sexual abuse, were at risk for later substance use, as they reported significantly more symptoms associated with alcohol dependence and misuse of drugs [6]. We are, therefore, seeing the prior gender gap associated with mental health illnesses like SUD narrowing worldwide. This is especially true given the rise of prescription drug abuse, which is creating gender parity among adolescents engaged in misuse [8]. In 2013, the CDC reported a 400% increase in prescription opioid overdoses in women compared to the 265% in men [8]. Efforts by the National Institutes of Health (2015) requiring that sex be considered as a biological variable within research has helped to advance understanding regarding how gender plays a role in disease processes and to inform development of interventions [9]. However, there is still more progress needed, particularly in terms of intersectional identities. In 2022, the National Institutes of Health reported that intentional prescription drug overdose deaths occur more consistently among women than men with an even greater increase among non-Hispanic Black women [10]. Furthermore, recent research on gender convergence for prevalence of substance use suggests an increase in vulnerability to alcohol and prescription drugs due to the biological and social challenges women face at different stages in life, including changes in mobility, menopause, osteoporosis, empty nest, and career [6].

Given these inequities, there is a long way to go in terms of female-gendered power and status that can impact institutions, governance, and organizations in terms of addressing gender-differentiated mental health needs. Now, three years into a global pandemic, the need to focus on mental health issues and experiences of women as well as gender-diverse individuals in workplaces across all industries and sectors around the world is inescapable. The prevalence of COVID-19 and its global impact seems to have subsided with the elimination of restrictions like mandatory masking, quarantining and social distancing in most public and communal spaces. However, while the collective perception may be that the pandemic has ended, Shmerling (2022) points out that we are merely shifting from the panic we experienced in the pandemic to "endemic acceptance" [11]. This is extraordinarily true as there is still a significant number of deaths and daily cases being recorded worldwide.

#### **2. The COVID-19 Pandemic Exacerbated Mental Health Issues for Women**

The global pandemic has had a profound impact on women compared to men in the workplace, and principally negative impacts include increased workload and mental health issues. Women were more likely to be exposed to the virus as frontline healthcare workers where they represented more than 70% of the workforce, increasing the severity of occupationally associated depression and anxiety [12,13]. Research during the pandemic found that healthcare workers, especially women, experienced a greater risk of developing mental health symptoms such as depression, insomnia, and psychological distress [12]. Huang et al.'s (2020) survey of medical staff in a tertiary infectious disease hospital in China found that female medical staff working on the frontlines of the pandemic early in the outbreak experienced a higher incidence of symptoms associated with anxiety and post-traumatic stress disorder comparative to their male counterparts [14].

The worsening mental health effects for women related to the COVID-19 pandemic were not limited to the frontlines of healthcare. For example, women in academic STEM fields experienced burnout or chronic workplace stress, extreme disruptions to work-life boundaries, and the exacerbation of existing gender-based inequalities in role advancement and workload compared to male counterparts [15]. Borrescio-Higa & Valenzuela (2021) found that across sectors with higher female employment, the pandemic profoundly affected gender inequality [16]. Women experienced disconcerting rates of mental health problems and an increase in health-related socioeconomic vulnerabilities such as interpersonal and intimate partner violence and increase in substance use [17,18]. The relationship of health-related socioeconomic risk factors and mental health disorders must be considered concomitant risk factors for developing substance use disorder, shifting to an increase or relapse if already recovered, especially given the high comorbidity of SUD and other psychiatric illnesses [14,18,19]. Furthermore, women have been found to have "a significantly higher prevalence of comorbid psychiatric disorders, such as depression and anxiety than men, which typically predate the onset of substance-abuse problems" [16] (p. 249). Women are also more likely to report the existence of trauma prior to the onset of SUD as well as more frequent use of substances to manage associated negative effects [8]. Lindau et al. (2021) found in their U.S. based cross-sectional study of 3200 women aged 18–90, those with pre-existing mental health symptoms and health-related socioeconomic risk factors were subject to two- and three-times greater risk for worsening circumstances during the pandemic, many of which are addressable with mitigation strategies [18].

#### *2.1. Substance Use Disorder (SUD)*

The COVID-19 pandemic profoundly disrupted humanity. No one has been immune to some level of stress induced by the myriad of economic and societal effects. Moreover, it has elicited a global mental health crisis; individuals with pre-existing mental disorders are experiencing a worsening of their conditions, and new mental health issues are surfacing as well [12,17]. Amid the pandemic, there was an exponential rise in substance use associated with mental health issues. In the first year of the pandemic, alcohol sales rose nationally in the U.S. by 262% compared to the prior year [20]. In 2020, the American Medical Association (AMA) reported that nearly 75,000 deaths were caused by drug-related overdoses, with increased concerns for individuals with mental health issues and SUD across 40 U.S. states [21]. Despite these alarming statistics, the pandemic overburdened both health care and social services, such that in many cases addressing the economic impact included diversion of resources for SUD-related resources [22]. The combination of reduced support and resources and the stigma and discrimination experienced by people with mental health challenges created serious implications at a time when interventions for SUD were needed most. Pfeffer and Williams' (2020) study of more than 36,000 respondents found that 81% of those with SUD did not receive treatment due to the continued stigma and negative perceptions of mental health conditions and substance abuse. More recent data found that nearly 110,000 drug overdose deaths occurred in 2021, with the AMA urging action for increased "access to evidence-based care for substance use disorders" [23]. Women in treatment for SUD consistently report increased barriers associated with perceived stigma and greater negative outcomes associated with employment, social, family, medical, and psychiatric functioning, which may be related to the disproportionate percentage of women who seek treatment [8].

Stigmatizing views of people with SUD are commonly associated with perceptions of questionable personal responsibility and an inaccurate belief that addiction is a moral failing rather than a persistent treatable disease. Descriptive terminology often associated with such discriminatory beliefs about addiction and substance use has included user, junkie, drug abuser, addict, drunk, and substance abuser. Our earliest understanding of the word addiction is the Latin compound, addicere from the 5th to mid-3rd century BCE, a verb that translated as 'to speak to', assent or agree, whereas the noun addictio described someone indebted or enslaved by a judge or creditor [24]. In the first century BCE, the use of the verb addicere transitioned from a legal or technical term into a term to represent self-destructive behavior, particularly in descriptions of women who gave themselves to their ruinous desires, whereas in contrast it was often perceived as positive or honorable when applied to a male [24]. In the 16th and 17th centuries, the word addict represented attachment, commitment, or devotion to king, religion, or God. Many Protestant Evangelical reformers (e.g., Calvinists, Anglicans and Catholics) utilized the term to describe attachments to objects of sin [24]. In this context, the word was depicted positively if the attachment was considered appropriate, and negatively if it was connected to something identified as sinful. Rosenthal and Faris (2019) point out that throughout the historical evolution of addiction terminology there is "tension between the active and passive meanings, suggesting that both obligation/compulsion and active choice may be built into the original meaning of the word" [24] (p. 14).

Notably, advances in both the clinical and psychiatric study of addiction have helped to reduce attitudes of blame that foster discrimination and the misconception of choice in relation to compulsion which has aided in providing deeper understanding of its characteristics as a disease. Discernment of various facets of substance use disorder—"reinforcement and reward, tolerance, withdrawal, negative affect, craving, and stress sensitization"—have expanded our knowledge [25] (p. 1015). Prior criteria and classifications associated with substance use disorder found in the DSM-IV defined substance abuse as "continued use despite physical or psychological problems caused or exacerbated by the substance" with a focus on negative consequences, but still "limited to physical or psychological problems and not extended to social or interpersonal problems" [26] (p. 60). Since 2007, a Substance-Related Disorders Work Group has worked with a DSM-5 Task Force to formulate new criteria for diagnosing substance use and dependence, removing the earlier distinction between excessive use and dependence as separate disorders, and making recommendations for analysis to examine potential biases related to gender, age, and ethnicity in diagnostic criteria [26].

As a result, when the DSM-5 was published in 2013, substance abuse, addiction, and alcoholism were changed to encompass both drugs and alcohol with new definitions: Substance Use Disorder (SUD), which includes both, and Alcohol Use Disorder (AUD), which includes only alcohol [27]. In 2017, the Office of National Drug Control Policy issued a federal memorandum addressing the stigma of terminology associated with substance use disorder. This aligned with the updated DSM-5 which required the use of person-first language like "person with a substance use disorder," removing negative connotations and distinguishing the person from their diagnosis [28]. Despite the more inclusive language, expanded research, advances in diagnostics, and increase in therapeutic treatments and pharmacological agents, substance use disorders remain vastly undertreated [29]. Inequities in healthcare largely contribute to many of the existing barriers that prevent treatment, including "the lack of resources at the individual level, a dearth of trained providers and appropriate treatment facilities, racial biases, and the marked stigmatization that is focused on individuals with addictions" [19] (p. 1015). In addition to studies highlighting

the disparity of negative impacts related to mental health and increased risk factors for substance use during the COVID-19 pandemic for women, research has also shown an increase in intimate partner violence and sexual abuse.
