September 2022

Interrogating the Gender Gap in Overdose Deaths

We examine alleged causes of the higher overdose death toll among men — and explain why it may mask a more complex story about gender and drugs.

When the US opioid epidemic first struck over two decades ago, it confounded the widely held stereotype that heroin was only a problem for people of colour living in poor, urban communities. The phrase “addiction does not discriminate,” though not new, became a popular catchphrase and common coin within drug treatment and advocacy circles.

It’s true that anyone can become dependent on drugs, but like so many headlines, this one lacks crucial context. There is ample evidence that problematic drug use affects some populations more than others, and in different ways. A notable example is the disparity between men and women in fatal overdose statistics.

Australia’s Annual Overdose Report 2022 found that men accounted for 71.3 per cent of unintentional drug-induced deaths (UDIDs) in 2020, and they reliably make up around two-thirds of UDIDs.

The report also found that, while the incidence of UDIDs is increasing for both men and women, it is increasing more rapidly for men. Since 2012 the number of unintentional deaths among men increased by 45 per cent, while deaths among women increased by 12 per cent.

The ratio of approximately two male deaths for every one female death is borne out with striking consistency around the world, with comparable figures observed in the US (70.2 per cent male), Canada (74), England and Wales (67.4), and Europe (79). This is not a recent development, nor is it news to those on the frontlines of drug-related issues. That men outnumber women for UDIDs is widely acknowledged, but perplexingly, it is rarely interrogated.

Canadian psychologist and men’s mental-health specialist Dr. Dan Bilsker has spoken about his field’s apparent blind spot for gender. He has lamented that men’s disproportionately high mortality rates in suicide and overdose (the two closely mirror each other) are simply accepted, chalked up to an inherently male impulse towards self-destruction. Such a discrepancy, he argues, “needs explanation, it needs understanding, it needs response. It is not to be taken for granted.”

Unfortunately, a straightforward explanation is not readily forthcoming. That more men die from unintentional overdose is clear, but beyond that the data are much less definitive, more varied, and often seemingly contradictory. Behind these numbers, we can begin to discern a more nuanced story about drugs and gender.

The most popular theory is that men are more likely to engage in risk-taking behaviour, and high-risk drug use leads to overdose deaths. Ask almost anyone what they think is behind the gender disparity in UDIDs and they are likely to give some version of this argument. While not flatly wrong, it is not as clear-cut as is often assumed, as risk-taking behaviour is difficult to define and quantify.

Even if we accept the answer as true, it only replaces our initial question with a new one: what drives men to take more risks? Is it an intrinsically, even genetically male characteristic, or are sociocultural factors to blame?

Various explanations have been advanced to explain the gender disparity in unintentional overdose deaths. These include:

  • Men engage in more risk-taking behaviour
  • Men use more illicit drugs
  • Men have fewer emotional resources
  • Men are experiencing a crisis of masculinity
  • Women are motivated by pregnancy and child raising to reduce drug consumption
  • Women are more likely to come into contact with the healthcare sector
  • Women may avoid illicit drug-use settings due to the risk of violence
  • Women use more pharmaceutical drugs
  • Women have better support networks

A 2020 study looking at patterns of gender convergence and divergence in US overdose deaths might shed light on the issue. Central to this study was the fact that the ratio of male-to-female UDIDs is not static but fluid. The total number of UDIDs has always been higher for men, but there have been times when the rate of increase in UDIDs was higher for women.

These include the late 1800s and mid-1990s, two periods during which prescription opioids were much more freely prescribed, and in each case, the rate of increase was significant. In the late 1800s, when laudanum was widely used as a painkiller and sleeping aid, women actually surpassed men for incidence of drug dependence, if not mortality. This suggests that the gender gap is heavily influenced by external factors.

Healthcare data further complicate the picture. Australian hospital records from 2019-2020 reveal that most people who presented at emergency departments for drug-related poisoning were women, but those poisonings were less likely to result in death. This is partly explained by the types of substances consumed by each group: pharmaceutical opioids and illicit drugs were more prevalent in male drug poisonings, and women were more likely to overdose on non-opioid pharmaceutical drugs.

Alexandra Collins

People haven't really focused on how overdose varies across genders, why it varies across genders, and the experiences of women and trans and gender-diverse folks in particular.

A US study, meanwhile, found that women were more likely to be prescribed an opioid, were more likely to report using drugs to cope with emotional or physical pain, and progressed more quickly to substance use disorders following exposure to an addictive substance. There is strong evidence that women – as well as trans and non-binary people – experience greater stigma relating to their drug use and encounter more barriers than men when attempting to access treatment. Given these compounding factors, we might wonder why the number of female UDIDs does not at least match that of men.

In other settings, the differences are less pronounced. A spokesperson for the Melbourne Supervised Injecting Room in Richmond said there are only slight differences in overdose rates between men (2%) and women (1.5%) who attend the facility, and that gender was not a major consideration when delivering services.

There is no single cause for the gender disparity in UDIDs, but a web of probable contributing factors that interact in often surprising ways: studies show that men are more likely to seek treatment for drug use, but women tend to have better outcomes when they do enter treatment; women are far more likely to experience sexual violence that compels them to self-medicate, but they are also better able to identify how their trauma influences their drug use, behaviours they are then able to address.

When gender and overdose do appear together in public discourse, these shadings are often absent, overshadowed by the less ambiguous male-to-female mortality rate. It is a dynamic familiar to US-based researcher Alexandra Collins. She doesn’t dispute the disparity in UDIDs or downplay its significance, but she cautions that women and gender-diverse people risk being sidelined if overdose is framed as a men’s health issue.

“We know that drug use is very much gendered, and we know that women and gender-diverse folks experience a lot of inequities that impact their drug use and that impact their overdose risk and their health outcomes. But it’s not a huge focus.

Data that resist a satisfyingly straightforward interpretation may be one reason researchers have been slow to address the gender gap in UDIDs. Another may well be the polarising nature of gender issues. Focusing too heavily on male mortality carries risks; a high-impact statistic with no single cause, it has sometimes been co-opted by men’s rights groups eager to dismiss issues that disproportionately burden women, trans, and gender-diverse people.

For Alexandra, the lack of attention given to marginalised groups and the reticence to address gender in drug use are especially dangerous in the context of the ongoing COVID-19 pandemic and the explosion of synthetic psychoactive drugs like fentanyl.

It is all changing right now. In the US and Canada, we saw the highest rates of overdose deaths we’ve recorded. It’s hard to say who’s being impacted more because everyone’s being impacted.

“[I’m] not saying men aren’t impacted or men aren’t dying at greater rates,” she asserts, “it’s just that we can’t focus only on men, and we can’t just develop interventions that are supposed to be addressing overdose in a gender-neutral way, because more than just men use drugs.”

Achieving a greater understanding of the drivers of the overdose-death gender gap remains a worthwhile goal. Whatever weight we attribute to the individual drivers, the fact remains that men are dying in disproportionately high numbers, and it would seem counterintuitive not to incorporate this knowledge into our interventions. The data tells us that this issue is not gender-neutral, and yet most of our interventions proceed as if gender bears no consideration.

If we hope to accurately explain the source of the gender-overdose gap, we will need to acknowledge that our assumptions about causes – like male risk tolerance – are themselves loaded with gendered assumptions. Clearing away these preconceptions will help us move toward both an explanation of the gap and a conversation in which all identities and experiences are treated as valuable.