The void of public health policies for women who use alcohol and other drugsABSTRACT
Objective: To reflect critically, from the Marxist perspective of totality, on how the inherent contradictions of social relations in the capitalist mode of production manifest in the scarcity and inadequacy of public policies aimed at women who use alcohol and other drugs. Development: From the critical Marxist approach to the State and public policies, considering that these have their formulation process arising from society itself, the fragility of care in the context of alcohol and other drug consumption by women may seem justified in the capitalist scenario. Negligence cannot be understood merely as an administrative failure, but as a systematic exclusion that reveals the priorities of the State as a form of social organization.
Final considerations: Understanding this logic is fundamental to highlighting the urgency of approaches that include women who use alcohol and other drugs and question the structural foundations of their exclusion.
DESCRIPTORS:
Public Policy; Capitalism; Gender-Specific Needs; Women; Drug Users.
HIGHLIGHTS
1. One must think critically about the exclusion of women users.
2. The State does not fully meet the needs of women users.
3. To constitute a synthesis of evidence to compose coherent public policies.
4. To highlight the urgency of approaches that include women users.
RESUMO
Objetivo: Refletir criticamente, sob a perspectiva marxista da totalidade, sobre como as contradições inerentes às relações sociais do modo de produção capitalista se manifestam na escassez e na inadequação das políticas públicas destinadas às mulheres usuárias de álcool e outras drogas. Desenvolvimento: A partir da abordagem crítica marxista sobre Estado e políticas públicas, considerando que estas têm seu processo de formulação a partir da própria sociedade, a fragilidade do cuidado no âmbito do consumo de álcool e outras drogas por mulheres pode parecer justificada no cenário capitalista. A negligência não pode ser entendida apenas como uma falha administrativa, mas como uma exclusão sistemática que revela as prioridades do Estado enquanto forma de organização social.
Considerações finais: Compreender essa lógica é fundamental para evidenciar a urgência de abordagens que incluam as mulheres usuárias de álcool e outras drogas e questionem os fundamentos estruturais da sua exclusão.
DESCRITORES:
Política Pública; Capitalismo; Necessidades Específicas do Gênero; Mulheres; Usuários de Drogas
HIGHLIGHTS
1. Deve-se pensar criticamente sobre a exclusão de mulheres usuárias.
2. O Estado não atende plenamente às necessidades das mulheres usuárias.
3. Constituir uma síntese de evidências para compor políticas públicas coerentes.
4. Evidenciar a urgência de abordagens que incluam as mulheres usuárias.
RESUMEN
Objetivo: Reflexionar críticamente, desde la perspectiva marxista de la totalidad, sobre cómo las contradicciones inherentes a las relaciones sociales del modo de producción capitalista se manifiestan en la escasez y en la inadecuación de las políticas públicas destinadas a las mujeres usuarias de alcohol y otras drogas. Desarrollo: A partir del enfoque crítico marxista sobre el Estado y las políticas públicas, considerando que estas tienen su proceso de formulación a partir de la propia sociedad, la fragilidad del cuidado en el ámbito del consumo de alcohol y otras drogas por mujeres puede parecer justificada en el escenario capitalista. La negligencia no puede ser entendida solo como una falla administrativa, sino como una exclusión sistemática que revela las prioridades del Estado como forma de organización social.
Consideraciones finales: Comprender esta lógica es fundamental para evidenciar la urgencia de enfoques que incluyan a las mujeres usuarias de alcohol y otras drogas y cuestionen los fundamentos estructurales de su exclusión.
DESCRIPTORES:
Política Pública; Capitalismo; Necesidades Específicas del Género; Mujeres; Consumidores de Drogas.
HIGHLIGHTS
1. Se debe pensar críticamente sobre la exclusión de mujeres usuarias.
2. El Estado no atiende plenamente las necesidades de las mujeres usuarias.
3. Constituir una síntesis de evidencias para componer políticas públicas coherentes.
4. Evidenciar la urgencia de enfoques que incluyan a las mujeres usuarias.
INTRODUCTION
Historically, public policies on alcohol and other drugs have been formulated from a generic perspective and fail to consider the particularities of women. Far from being neutral, they end up reflecting and perpetuating social inequalities, ignoring the structural causes that drive alcohol and other drug consumption among women, as well as the barriers they face in accessing adequate treatment and support1.
Data from the Global Survey on Progress regarding target 3.5 of the Sustainable Development Goals for health indicate that specialized treatment programs and services for women are less available, and that only 31.7% of countries report having services for pregnant women with alcohol use disorders, and only 35.2% of countries have these services for users of illicit drugs2.
International data show that policies on alcohol and other drugs without a gender focus require revisions so that they can, in fact, accommodate the female audience facing particular issues, such as the strong presence of childhood sexual abuse, domestic violence, loss of child custody by the courts, prostitution, and stigmatization in health services2. Despite this, there is a discrepancy in the demand for treatment services between men and women, with many of the interventions and programs developed for women being designed with the male figure at the center.
Studies highlight the urgency of raising awareness about the promotion of gender-sensitive policies and programs at different levels of care, and to bridge the gaps, it emphasizes the need for: research that addresses gender issues and considers them in all aspects of its conception and analysis; policies and practices planned and integrated with a gender perspective; women participating in the planning, formulation, and development of policies and programs; professionals in specialized services with appropriate attitudes, disciplinary domains, knowledge, and skills to work with women3-4.
Starting from these points, this theoretical reflection distanced itself from the narratives that are devoid of the totality that intend to assume that the void in public policies regarding women versus the use of alcohol and other drugs would occur due to isolated failures in management or merely by the choices of state agents. For the discussion, we begin with the following question: What mechanisms or structures exist that perpetuate gender inequality in the formulation and implementation of health policies, and how can they be dismantled or transformed?
The category of totality constitutes a fundamental methodological axis for a critical analysis of social relations in capitalism, and for it to be understood, it requires more than just gathering scattered empirical data; there is also the demand for a rigorous process of logical-material reconstruction that allows for the apprehension of the multiple determinations that articulate contradictorily in concrete reality5.
In this sense, the Marxian method starts from the apparent and chaotic complexity of phenomena to reduce them to their most elementary forms, enabling the identification of their contradictory content and the specific form they assume in their appearance5. After this dialectical abstraction, one returns to the totality, understood not as a chaotic aggregate, but as an organized whole rich in reciprocal determinations.
The conception of totality, far from being a static concept, constitutes an epistemological tool to reveal the essence and historical mediations of social processes, surpassing the limitations of fragmentary and empirical approaches, and presents itself as a fundamental principle for the critical and integrated apprehension of social reality5.
It is emphasized that the term void used here does not refer to the simple absence of public policies or the scarcity of normative and programmatic content. It is understood as an expression of the structural determinations of the capitalist mode of production, which impose concrete limits on the constitution and realization of public policies6. Such restrictions arise from the very nature of the State-Form, whose primary function is to ensure the conditions for the reproduction of capital6. Thus, the void is neither accidental nor the exclusive result of omissions or technical management failures, but an expression of a logic that subordinates public policy to the needs of accumulation.
Given the relevance and complexity of the topic, the objective is to reflect critically, from the Marxist perspective of totality, on how the inherent contradictions of social relations in the capitalist mode of production manifest in the scarcity and inadequacy of public policies directed at women who use alcohol and other drugs.
DEVELOPMENT
For the construction of this theoretical reflection, a strategy of intentional selection of literature was adopted, guided by criteria of theoretical and empirical relevance to the object of study, including: (1) studies on alcohol and other drug consumption among women with a gender focus; (2) productions on public policies and care models in the field of alcohol and other drugs; (3) theoretical literature aligned with the critical Marxist perspective of the State; (4) studies that incorporate social determinants of health and intersectionality. Recent reviews, studies, and institutional documents were prioritized. The analysis was conducted interpretatively, guided by the category of totality, seeking to identify mediations, contradictions, and gaps.
The central proposal of this reflection consists of understanding the State not as an autonomous subject or mere instrument of the dominant class, but as a social form that emerges from the very contradictions of the capitalist mode of production. The theoretical framework of the Marxist critical approach to the State and public policies proposes that these should be understood as processes of trial and error, characterized by limited rationality; that is, the agents who develop them (or even those who set the agenda) do not have absolute control over their process, with their end directed towards the requirements of capitalist reproduction6. This critical perspective opposes the dominant rationalist view in which public policies are formulated and implemented in a linear and efficient manner, where contingencies, improvisations, and structural limitations shape political decisions.
The theme of women and madness is integrally present in classical psychiatry, influencing diagnoses, public policies, and health care. Nevertheless, the narrative of the Brazilian Psychiatric Reform has failed to mention women and their particularities, even amidst a system of bourgeois and patriarchal domination that permeates the logic of asylums7. Furthermore, despite the strong popular participation in the construction of mental health policy, it alone cannot compete with the hegemonic medical model, as other factors intersect in the daily operations of health services (basic care policy, social assistance policies, etc.), necessitating a broader perspective beyond purely technical-administrative issues.
Given that public policies derive their formulation and modification processes from the very society in which they are embedded, the invisibility of mental health care for women may seem justified in the capitalist scenario. Historically, women have been excluded from all that is social, and within the realm of alcohol and other drug use, this is no different, leading to difficulties in recognizing the problem and seeking treatment3. At the moment a woman seeks help, she exposes herself and acknowledges her use of psychoactive substances to society, consequently being questioned about her capacity and integrity in light of patriarchal ideals.
To understand the historical invisibility of the issue by the media and science, and the persistent lack of care policies, one must focus on the central role that female exploitation plays within the capitalist system, where women have been positioned as producers of the most essential commodity, labor power, under the guise of a biological destiny. Capitalism, as an economic-social system, has sexism as one of its sustainers, with the woman’s body being what the factory is to men: the primary site of exploitation. Thus, it becomes impossible to conceive of female liberation - or effective care for them - within this system8.
The same logic of sexism as one of the constitutive bases of capitalism applies to the idea of modern manifestations of the social question, such as mental disorders and problematic use of alcohol and other drugs. In this perspective, sexism, racism, and class inequality appear as different faces of the same coin - the product of the capitalist system - and cannot be explained in isolation9.
The author also points out that the phenomenon of problematic use of alcohol and other drugs involves all its production, commercialization, and consumption9, but here one can make the connection with gender and contemporaneity when analyzing global consumption data, revealing that countries of central capitalism - where there tends to be less stigma surrounding consumption by women - show smaller differences in consumption rates between the sexes.
It is worth noting that in the case of women who use alcohol and other drugs, there is a convergence of vulnerabilities related to gender, race, and class: women, black, and poor4, and the effects of these intersections position their treatment and recognition difficulties at the center of the social problem of capitalism9. Regarding health professionals and their forms of care, it should be understood that both their personal values and their training are not detached from society or immune to its reflections, with both being, in some way, permeated by pejorative and moralizing ideals6,9.
Thus, attention is drawn to the fact that many issues are not even recognized as legitimate problems by the State, and this non-recognition already expresses a fundamental limit of public policies6. In this sense, the neglect of women’s mental health cannot be understood merely as a technical lapse or administrative failure, but as a systematic exclusion that reveals the priorities of the State as a form of social organization.
It is also important to consider that, when confronted with multiple forms of inequality (such as unpaid domestic labor, emotional overload, and gender-based violence), women face psychological suffering whose origin is structural and cannot be fully addressed by fragmented policies or those focused on the individualized management of suffering. Therefore, women’s mental health, especially for those who use alcohol and other drugs, is unlikely to be prioritized on state agendas, precisely because it touches on aspects of life that escape productive logic.
In order to develop health policies that meet the needs of a population, it is necessary to consider the social determinants involved. Health is a right interconnected with others, such as leisure and security; if all are not addressed, health will not be positively affected either.
The relationship with social determinants is not merely a cause-and-effect relationship, nor is it something constant. Housing, income, employment, nutrition, and race are some of the most prominent determinants among the population that uses alcohol and other drugs. In the case of women, gender inequalities are added, which implies a greater need for security and care regarding sexual and reproductive health10.
From this understanding, it becomes necessary to advance from structural analysis to the identification of strategies that operate as concrete mediations between social determinations and the organization of care. In this sense, the integration of women who use alcohol and other drugs into society and within public policies requires the articulation of care models that incorporate, in a transversal manner, the gender perspective and the social determinants of health. This implies the construction of care devices that are not limited to the provision of treatment but that integrate intersectoral actions among health, social assistance, justice, and labor, addressing dimensions such as gender violence, motherhood, economic autonomy, and social inclusion.
Such strategies favor adherence to care by recognizing that the continuity in services does not depend exclusively on individual motivation, but on the concrete living conditions of women. Thus, adherence should be understood as a relational and structural phenomenon, resulting from the capacity of services to respond to the complex needs of this population.
Moreover, gender-sensitive care models should encompass the reduction of institutional stigma, the qualification of professional practices, and the creation of care spaces that promote bonds, trust, and continuity. These dimensions operate as central elements in producing more stable and effective care trajectories.
In this understanding, between the Brazilian Psychiatric Reform, the National Drug Policy, and its decrees and ordinances, there remains a thematic void to be filled. From a critical Marxist perspective, it can be stated that the void in public health policies for women who use alcohol and other drugs relates to the State-Form and the process of public policies that, due to their capitalist nature and their organization aimed at meeting the requirements of capital reproduction, produce voids generated by the State’s inability to fully meet human needs.
Contrary to what occurs in Brazil, where the formulation process of policies is influenced by social pressures, it is observed that other countries already interpret that these should primarily be shaped by evidence at the top. Globally, the use of evidence is considered a priority for formulating well-informed and effective policies, aiming to strengthen institutional capacity and the performance of health systems.
FINAL CONSIDERATIONS
The absence of public policies directed at women who use alcohol and other drugs results not only from stigmas or cultural barriers but from a structure that tends to manage inequality without confronting its roots, manifesting in fragmented and disarticulated interventions that aim more at containing the effects of social exclusion than at transforming its causes.
Understanding this logic is fundamental to critically thinking about the possibilities and limits of public policies in contexts marked by multiple oppressions, as well as highlighting the urgency of approaches that not only include women who use alcohol and other drugs but also question the structural foundations of their exclusion.
In this context, it is evident that women who use alcohol and other drugs constitute a social group whose experience of illness and access to care are strongly determined by sociodemographic and intersectional factors, such as gender, race, class, housing conditions, and labor market insertion. These markers operate articulately in the production of inequalities that directly impact their care trajectories and their adherence to services.
Thus, understanding this logic is fundamental not only to highlight the urgency of approaches that include these women but also to guide the formulation of public policies and care models capable of responding to the complexity of their needs, articulating structural transformation and concrete intervention.
Finally, there is a need for the development of evidence syntheses of public policies, aiming to convince the target audience about the urgency of the current problem and the necessity to adopt options or intervention strategies selected through a systematic and transparent process, a purpose currently being pursued by the authors of this reflection.
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FUNDING
National Council for Scientific and Technological Development (CNPq), Brazil. Process: 304904/2025-2.
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HOW TO REFERENCE THIS ARTICLE:
Fernandes MC, Nóbrega MPSS, Antelo VS. The void of public health policies for women who use alcohol and other drugs. Cogitare Enferm [Internet]. 2026 [cited “insert year, month and day”];31:e101917en. Available from: https://doi.org/10.1590/ce.v31i0.101917en
Data availability:
The authors declare that all data are fully available within the article.
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Edited by
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CAssociate editor:
Dra. Mariana Torreglosa Ruiz
