Editor’s Note: Laura Schmidt is Professor of Health Policy in the School of Medicine at the University of California, San Francisco and the Co-Director of UCSF’s Clinical and Translational Research Institute’s (CTSI) Community Engagement and Health Policy Program. A Phd in Sociology, she also holds Master’s degrees in Public Health and Social Welfare. She is the author of dozens of articles on the complicated interrelationships among gender, race, poverty, addiction, and women’s and family well-being, including (with Constance Weisner) the ground-breaking “The Emergence of Problem-Drinking Women as a Special Population in Need of Treatment,” which tracked the efforts of the Women’s Alcoholism Movement (WAM) to de-stigmatize and fund treatment for female problem drinking (Recent Developments in Alcoholism, Vol 12: Women and Alcoholism, 1995). As part of her project on feminism and addiction, Points editor Trysh Travis talked with Laura Schmidt about the legacies of WAM.
Your article charts the development of women-centered alcoholism treatment within the “special populations” paradigm that emerged with the founding of NIAAA in 1970 (311). Briefly, what’s happened to the notion of “special populations” within the policy and treatment communities?
I think the special populations paradigm is still very much alive and well. In fact, it has expanded into new areas, most notably, the debates around racial/ethnic disparities in addiction treatment, attention to which has actually outpaced that paid to women since early 2000.
The discourse around racial/ethnic disparities has many resonances with the one around women addicts. First, it derives from an equal rights frame, with all the accompanying tensions around defining a socially disadvantaged group as uniquely prone to addiction while attempting to medicalize the problem in an effort to neutralize the stigma. “The Emergence of Problem Drinking Women” argued that two assumptions define a special population: 1) it is ”underserved” in the sense that the need for treatment exceeds the supply, and 2) it has “special needs” for culturally tailored treatments that are currently unmet. Both of these assumptions fundamentally frame the current debate around ethnic disparities in treatment just as they did the Women’s Alcoholism Movement. And as with the special population of women addicts, the data on ethnic disparities in treatment don’t support many of the assumptions underpinning this debate. I have written a couple of reviews of the literature on disparities, and found that there is very little evidence that minorities receive addiction treatment at substantially lower rates than whites. Instead some studies suggest that minorities are actually over-represented in treatment programs, most likely due to higher rates of coercion, although the evidence is mixed. The one exception to this may be Native Americans who experience both a greater likelihood of addiction and a diminished likelihood of receiving treatment. There have also been studies of treatment outcomes suggesting that minorities do just as well as whites in standard treatment, even though they tend to enter care with more negative prognosticators than whites. As with women, there is no evidence that specialized, culturally tailored treatments make a huge difference in recovery, although they may marginally increase the likelihood of entry to care. As with the WAM, advocacy around minorities as a special population continues despite much evidence to the contrary. I was at an NIH meeting last year on disparities in addiction treatment—how minorities need more treatment, and more culturally competent treatment, and just aren’t getting it. I spent two days listening to people talk about a problem that the evidence suggests does not exist.
One of the key achievements of WAM, you argue, and a place where it shows its debt to feminism more broadly, was the creation of “a more sympathetic view of problem-drinking women…one that emphasized her unenviable place in patriarchal society” (315). Twenty years later, how would you evaluate that achievement? Has connecting women’s addiction to patriarchy meant a net gain for women, in practical terms? A loss? A break-even?
This, I think, very much depends on which population of women you are talking about. Perhaps the biggest losers of the post-Second Wave feminist era have been low-income women. I spent a lot of the last half of the 1990s doing research on welfare mothers and the problems of addiction for this group. The first thing I learned was that welfare mothers, on the whole, drink less than their wealthier counterparts, which shouldn’t really be news for anybody who understands the social epidemiology of alcohol use. The second thing I learned was that drinking and drug use are not related to how long people stay on aid.
Nevertheless, addiction among welfare mothers was a major preoccupation in the mid-1990s debates around welfare reform. One of the most powerful tools in the arsenal of welfare reformers was the image of a welfare mom addicted to drugs and paying for her habit with the public dole. The imagery started with the crack baby epidemic in late 80s and came to its logical conclusion in welfare reform’s Gramm Amendment that ends all aid (even Food Stamps) for the families of female drug felons on a lifetime basis.
I do not think that the welfare reform debate or its imagery would have been possible without feminism. Liberal feminists won many economic benefits and freedoms. In the process, they reshaped the image of the mother into that of a working woman. Somewhere along the way, as a culture we seemed to forget that poor women don’t have the same wherewithal to purchase the services of a wife on the open market—daycare, housekeeping, food preparation, etc. Fast forward to the 1990s, when 65% of women are working outside the home. Where does this leave the welfare mother? Basically, looking like a loser—“why can’t she make ends meet like the rest of the women? Maybe it’s because she’s too busy getting high.”
So, I think with feminism we wound up with two cultural scripts about women and substance use. There’s the “wet feminist” script that applies to women of means and power. These women, it seems, have earned the right to a three-martini lunch. Then there are different standards for women who have not experienced the economic mobility promised by feminism –standards that are more prohibitive, more punitive, and drier than ever before.
You posit that one of the reasons mainline feminists were not interested in addiction issues was the strong pro-natalism of the women’s alcoholism movement—an attitude articulated most strongly in the concern about Fetal Alcohol Syndrome, which then became a panic over “crack babies” in the late ‘80s (328). How has that pro-natalist sentiment evolved in the intervening years, and have the implications for women been as bad as feminists suspected?
Since the 1960s, we have witnessed the ascendancy of the political right in US, and this has shifted the whole political-cultural discourse rightwards as well. One consequence has been a renaissance for the moral categories of “disreputable” or “unworthy” poverty, and a shift whereby poor women have landed closer to the “unworthy” end of the spectrum. In the 1960s, it actually used to be illegal to ask a woman applying for aid if she even drank or used drugs—aid was her “entitlement,” so any blame casting was considered “welfare discrimination.” Since, then, the welfare mother has traveled from the category of the worthy to the unworthy poor, leaving her children behind.
I think WAM helped this along by offering up the images of the “hidden” woman alcoholic, by promoting expansion in the categories of fetal alcohol disorders (from Fetal Alcohol Syndrome to Fetal Alcohol Spectrum Disorders) and by building on the image of the crack babies in an effort to promote treatment expansions for women. But the evolution was not so much towards pro-natalist sentiment as it was against women in poverty, an offensive capped off by the 1996 welfare reform law that transformed aid from an entitlement to a benefit. To get the benefit, poor women must now prove their worthiness by signing abstinence pledges, showing evidence that they are trying to get a job and increasingly, by submitting to urine drug tests. [Editor’s note: the relationship between these reforms and recent changes in state laws that make women’s drug use/ abuse during pregnancy punishable as child abuse or “feticide” remain to be explored.]
Among the key reforms championed by WAM activists and discussed in “Problem Drinking Women” was woman-specific and women-only treatment that “involved some aspect of ‘feminist consciousness-raising’” (316). But you note that, at the time of your writing, “studies of specialized women’s therapies are virtually non-existent” (318). Have those studies been done in the intervening years and, if so, what have they shown?
There is a wonderfully thorough review of this literature published by a team of women scientists recently. They conclude that there remains little evidence that specialized treatment for women measurably impacts recovery outcomes. So the story has not substantially changed, even after 15 more years of research on the topic.