This study adds to the growing literature on gender differences in CUD and incorporate information on sociodemographic, medical, psychopathological and cocaine consumption variables. Moreover, it adds a new point of view that investigates how educational achievements can affect the onset of use, the development of dependence and the duration of cocaine addiction in a different way among men and women. In addition, this study shows a comprehensive analysis of gender profiles based on models from patients attending treatment for cocaine use.

There is high prevalence of psychiatric comorbidities associated with CUD, which may coexist with other substance use disorders or other psychiatric disorders^31–34. Regarding its association with gender-based differences, in our study the most prevalent disorders in women were anxiety disorders, with generalised anxiety disorder and post-traumatic stress disorder being highly common, as also described in other findings^15,20,32. In the women population, traumatic experiences such as having suffered child abuse and sexual abuse are factors that have been considered predictive for the development of CUD^32,35. Thus, these women are more likely to have post-traumatic stress disorder, and more likely to have any anxiety disorders in comparison to men⁹. On the other hand, we observed that the women also showed high prevalence of eating disorders and exhibited more depressive disorders of both, induced and primary nature, throughout their lives in comparison to men, as has also been described in other studies^8,14,20.

Concerning men population, we found a frequency of antisocial personality disorders that were similar to by other authors^15,20. Similarly, we observed that the coexistence of another substance use disorders throughout life was 64.3%, with alcohol use disorders and cannabis use disorders being more common, as reported by other authors^14,33. Men are more likely to develop polydrug use of most substances except anxiolytics³. There is a biological and social basis for understanding the comorbidity between alcohol use disorder and CUD, since pathological alcohol use enhances cocaine use and vice versa³⁶. It is worth noting that the processes of gender violence are more evident in individuals who have concomitant pathological use of these two substances³⁷.

Thus, if the pathological use of other substances of abuse (especially alcohol), as well as evident lack of effective pharmacological therapies are added to those psychiatric comorbidities, the evolution of these patients consequently worsens, being more vulnerable to relapse and distancing them from primary health resources and deepening their social stigmatisation^38,39.

Related to the variables associated with cocaine consumption, we observed that women developed cocaine dependence two years later than men (28 vs. 26 years), as other authors have also indicated^5,15. However, we did not find a faster process in women from the first use of cocaine to the development of CUD (telescoping effect), nor did we observe greater severity of addiction in comparison to men, as described in other studies^40,41. In addition, we did not find gender-based differences in other variables such as the age at onset of use, duration of abstinence, number of abstinences, or the duration of the disorders, as reported by other authors^9,15.

Despite the several gender-based differences related to drug use have been described, healthcare services do not consider the need for a different medical approach for women and men, in spite of demonstrating deserving characteristics of special attention¹⁸. Our model showed that women and men had different clinical characteristics that should be reflected when designing therapeutic policies. Therefore, it is important to take into account the results of the logistic regression analysis carried out in which appear as predictors the variables: “alcohol use disorder”, “anxiety disorders”, and “eating disorders”. We believe that this class of models—based on sociodemographic variables, patterns of cocaine use, and associated psychiatric comorbidities—could provide information about the aetiology and the progression of the addiction, individually and specifically. They could be useful guides for professionals both at preventive and clinical levels. In this way, preventive measures could be determined and better therapeutic strategies will be developed to improve the quality of treatment.

Furthermore, our results indicated that the profiles of women who sought treatment were different and more complex. The most repeated male profile was that of unemployed men, whereas the most frequent female profile was that of unemployed women who consumed psychotropic medication and had anxiety disorders. This fact means that they had come to the centres in worse psychiatric state than men. In addition, they were at risk of social exclusion and vulnerability. In other words, a triple stigma was observed: being a woman, addiction, and mental disorder.

This characteristic profile in women could indicate a delay in entering the treatment circuits, and we consider that this could be motivated by social, cultural, and medical reasons. Women consume in a less exposed way, since addictions continue to be poorly accepted socially, thus constituting a reason for stigma and implying less family and social support in the female^6,42. Requests for treatment decreases due to the legal or social repercussions that the consumption of substances could cause to women during the periods of motherhood and education of their children. It is also important to emphasise the pressure exerted by the family members so that the treatments are as brief as possible and the woman can return to perform the household chores, often sacrificing treatment⁴³. These aspects explain the low rate of women’s admissions to treatments, since they only represented 15% of the total sample of our study, like other studies^20,44.

In addition, the three most frequent profiles of women seeking treatment for cocaine use had the use of psychotropic medication as a common factor, even though two of the profiles did not exhibit any correlation with a specific psychiatric symptom, which could reflect the medical tendency to prescribe this type of psychotropic drugs to women in great proportion²¹.

Finally, there are very few studies that relate educational levels to the use of cocaine and much less with its interaction with gender. We observed the protective effect that the educational level exerts on the development of cocaine addiction: the onset and development of CUD occurred earlier when patients had a lower educational level and these had a longer duration of CUD, whereas patients with university studies started use and developed CUD later. This has also been observed in alcohol, since young people who had dropped out of secondary education or university studies were at higher risk of developing abuse in adult life, compared to those who had completed secondary school or university⁴⁵.

The CUD has also been related to executive dysfunctions that compromise efforts to initiate or maintain abstinence and affects the functionality and therapeutic effectiveness of patients^46,47. Regarding the relationship between gender and educational level, women and men with low educational level started cocaine use much earlier than those with secondary studies. This is particularly important to women with primary education, since they could have a higher risk of gender discrimination and illicit drug use²⁷. However, the age at onset of cocaine use and the development of CUD is still earlier in men compared to women who have a low educational attainment.

All this evidence places the educational level as a risk factor or a protective factor depending on the academic achievements, occupying a fundamental role in the appearance and course of addictive disorders. Low educational level can predispose to the emergence of earlier and more severe CUD. While high educational level can prevent or delay the onset of consumption and the subsequent development of CUD, as well as provide better cognitive skills that can promote therapeutic success. Therefore, prolonging the years of compulsory education, as well as implementing cognitive rehabilitation programmes in treatment centres could be extremely useful both for the prevention and for the evolution of patients⁴⁸.

In conclusion, women and men have different clinical characteristics that should be considered when designing therapeutic policies for patients with CUD. The educational level plays a fundamental role in the onset and progression of CUD, which is why it is essential to focus attention on it. Therefore, the progressive equality between women and men in the consumption of addictive substances leads us to be even more rigorous in the development of gender-based therapies.