Keywords

1 Gambling Disorder in Women

Gambling disorder (GD) is a maladaptive pattern of gambling behaviour that persists despite negative consequences. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [1] (DSM-5) includes nine diagnostic criteria, four being required for diagnosis: (1) tolerance; (2) withdrawal; (3) loss of control; (4) gambling preoccupation; (5) gambling in response to negative affect; (6) chasing losses; (7) lying to conceal gambling extent; (8) jeopardising relationships, work, career or educational opportunities; and (9) relying on others for bailouts. Problem gambling (PG) is a general term used in research where screening measures identify problem gamblers without clinical interview confirmation.

1.1 Definitions and Diagnostic Criteria

Technology has changed how games are played, from socially to alone; they are more available and globalised (local and cultural differences have reduced). The British Gambling Prevalence Survey (BGPS) series showed statistically significant increases in female gambling from 65% in 2007 to 71% in 2010 (disproportionally greater among older women). Gambling rates in the United Kingdom are now similar among males and females. Women prefer lotteries, slot machines, scratch cards and bingo compared to male preference for poker, sports betting, fixed odds betting terminals (FOBT) and casino games. Female PG has doubled from 0.1% to 0.2% in the same period [53].

Targeted advertising has increased female vulnerability to gambling. In France, following the legalisation of online gambling in 2010, studies to 2014 show a significant increase in gambling prevalence among women in the previous 12 months (44.4% in 2010 vs. 54.8% in 2014) and a doubling in female problem gambling in the year (1.4% vs. 2.8%): the proportion of women to men remaining the same (25% vs. 75%) [6, 7].

Gambling preferences may be socially determined, so liable to change with changes in society. British records demonstrate that in the mid-twentieth century, most women (66%) bet in some form, often through illegal street betting. Two out of five women bet on horses in 1951 compared to one out of ten in 2010. The 1960s Betting and Gaming Act legalised and regulated betting shops, introducing austere interiors designed to prevent loitering, which almost certainly discouraged women from using them. By the mid-1970s, less than 2% of women bet at least monthly on horses or dogs. Bingo, popular among male servicemen in the late nineteenth century, expanded into public spaces women were familiar with and was promoted as glamorous and aspirational. Legislators had created an environment attractive to women, contrary to that seen with bookmakers [52]. That some women are engaging more in gambling, as barriers to entry and social contexts change, could be seen to represent a resurgent interest in gambling among women – part of a cyclic pattern rather than a new phenomenon.

PG rates among interactive gamblers are three times higher than overall rates (2.7% vs. 0.9%) in Australia. In these gamblers, electronic gaming machines (EGM), interactive poker, casino games and sports betting were associated with increased severity of PG. Interactive gambling may not cause GD but is likely to exacerbate it. Policymakers could focus on gambling most associated with harm [16].

1.2 Gender Differences in Development and Course of Illness

International gender-focused research finds differences between male and female problem gamblers in terms of reasons and preferences for gambling, progression, mental health and treatment seeking.

Women gamble to escape loneliness, dysfunctional relationships, violence, isolation and childcare and to self-medicate perceived intolerable levels of stress, anxiety and depression. They engage in a narrower range of gambling activities offered by low-skill, high-absorption games [22]. Men gamble more widely, on fast-moving activities, for excitement and to outperform others [8].

Pathological and problem gambling is seen in a range of sociodemographic groups. The risk of PG for women increases with decreasing socio-economic status [20]. In an Australian cross-sectional study [5], men and women were found to be equally susceptible to the addictive potential of gambling, the strongest independent risk factor for both genders being positive gambling expectancies (of enjoyment or financial gain) [27]. Other risk factors associated with PG in women include deprivation, marginalisation (in Māori women), violent partners and/or childhood [31] and the interaction of dysphoric moods and ‘avoidance’ coping [47]. Gender-sensitive public health initiatives are needed, and for female problem gamblers, prevention/intervention should focus on coping skills. Measures targeting positive gambling expectancies may also improve intervention outcomes for both genders.

Women consistently start gambling at a later age than men, progress more quickly to PG or gamble for shorter durations before seeking treatment [40]. This ‘telescoping’ is also found in women substance abusers [57]. Theories exist as to why, none of which satisfactorily explain the phenomenon. Female preference for more addictive games (slot machines, electronic bingo) does not account substantially for the telescoping effect. Links between psychopathology and gambling disorders, appearing strongly in women with anxiety and depression and in men with alcohol dependence, do not explain gambling progression: studies have not yet proved a causal relationship. In relation to neurocognitive measures, male gamblers score higher on risk-taking measures than female gamblers, although no gender differences are found on impulsivity measures. A few neuroimaging studies have begun to investigate neural mechanisms – women with GD showed increased dorsomedial prefrontal, posterior insula and caudate activation when viewing gambling-related videos, compared to men with GD, but the extent to which these relate to telescoping is unknown [55].

Using data from the BGPS 2010, investigating differences in age of first gambling experience among cohorts of women in the United Kingdom, two patterns are evident. Younger cohorts started gambling at a younger age than older cohorts, and among younger cohorts, age 16 marked a pivotal point in starting to gamble, reflecting the legal milestone for engagement in the national lottery, scratch cards and football pools. There appears to be a further cohort effect in operation: fewer of those aged 25–31 had gambled by age 16 (40%) than those aged 16–24 (50%). Within this cohort, the youngest are gambling earlier still, implicating the Gambling Act 2005, which permitted applications for land-based gambling venues, increased gambling opportunities and vastly expanded advertising [52].

Recent subgroup analysis shows younger women aged 16–34 gamble more frequently, across multiple products, and demonstrate more PG. EGM use is most common among women overall, whilst younger women are more likely to bet on sports and gamble at casinos. There are significant differences in the perception of harm associated with horse and sports betting, young women perceiving these as less harmful than older women and non-gamblers [29].

1.3 Comorbidities and Suicide

GD is frequently associated with comorbid psychiatric disorder, including depression, anxiety disorders, bipolar affective disorder, personality disorders and SUDs. Its presence is associated with greater severity of gambling problems and related consequences, including suicide – the leading cause of death in GD (31%), followed by neoplasia (16%) and cardiovascular disease (12%) [21].

A recent Spanish study demonstrates that female problem gamblers with a criminal history were younger, had greater GD severity and dysfunctional personality traits and showed higher levels of comorbid psychopathology than those without. This population is especially vulnerable and could benefit from public policies that target their mental health needs [30].

The same authors clustered women with GD into subtypes based on clinical and sociodemographic variables, finding those with the most severe GD confirmed novelty seeking as well as impaired self-direction, and psychiatric comorbidity, all of which can interfere with treatment. These findings concurred with studies of males with GD [17].

1.4 Treatment Seeking (Including Barriers to Treatment)

Female pathological gamblers, underrepresented in treatment, perceive barriers to seeking professional help more than males. Research identifies lack of social support, poverty, lack of childcare, guilt and shame due to stigmatisation and difficulties in finding appropriate treatment. Women using gambling helplines are more likely to have mental health problems, gambling-related financial problems and prior treatment for mental health than men [26]. Higher levels of comorbid psychiatric disorders, difficult biographical backgrounds (significantly higher rates of childhood neglect, abuse and trauma) [3], ‘avoidance’ coping strategies [13] and increased feelings of guilt or shame and/or fear of being stigmatised discourage women from seeking treatment [19].

Women earn less than men and thus gamble with a higher percentage of their income in comparison, especially older women (on average, 249% more than men of their income in the month prior to treatment) [33].

Non-gendered Australian research has found that help-seeking for PG is crisis driven, prompted by suicide attempts, court charges, arrests, financial ruin or relationship conflicts [8]. Qualitative research further supports this finding in females. Despite low help-seeking rates, women are at least as likely as men to seek professional and non-professional help for PG. Other research indicates barriers that may differ by gender [42]. [43] found men were discouraged by stigma and attitudes to treatment seeking from calling a helpline. In contrast, others found women more likely to feel guilt or shame [18] and to fear consequences of treatment entry (removal of children or injury from abusive husbands) [48].

Women made up 12.5% of a population in treatment in Austria and Germany, were 10 years older than their male counterparts, had greater GD severity and were more likely to live alone or alone with at least one child (50% of the women vs. 28% of the men), suggesting relative social isolation [28]. Just 10–15% of patients in gambling treatment institutions are women [56].

There is a lack of suitable treatment approaches and settings for women, who may feel greater discomfort in a male environment, especially if suffering from traumatic experiences. Available treatment may be incompatible with financial and time constraints for women, who may also fear losing custody of their children.

2 Treatment

Individual CBT results in greater improvements (96% recovered or improved) than self-directed workbooks with Gamblers Anonymous (GA) referral (81%) or GA referral alone (77%) [34]. Men were more likely to be abstinent from gambling than women at the end of an eight-week program, but these differences dissipated by the 12-month follow-up.

In a randomised trial of brief interventions, one short advice session was more effective than single-session motivational enhancement therapy (MET) or MET followed by three CBT sessions. It was the only intervention associated with clinically significant improvements in gambling habits after 9 months. Gender was not associated with response to these treatments [35].

Female gambling addicts need a group setting, not associated with addictions, where they feel heard. Donne in Gioco, an Italian female-only therapy group focusing on relationships, narration and metaphor in systemic therapy, places emphasis on the ‘here and now’, with reference to relationship networks [37].

A Swiss study of the effectiveness of self-exclusion found that the incidence of PG was lower among those who had self-excluded previously than in those who do so for the first time [46]. This finding may motivate Swiss casinos to promote voluntary exclusions.

At the National Problem Gambling Clinic in Britain, where females comprise just 7–8% of all referrals, women have high attrition rates. In addition to practical barriers, cost, distance and waiting times, research demonstrated internal barriers: fear, denial, stigma, feeling misunderstood and a sense of ambivalence – a fear of success of treatment – gambling having offered a temporary sense of control. CBT may not be the optimum model to facilitate emotional processing for those displaying high avoidance of their difficulties, for whom psychodynamic treatment may work better [38].

Women often prefer online therapy, helplines and forums, overcoming practical accessibility issues and concurring with other recent research in the field [23].

Sagris and Wentzel [45] reported that feminist cognitive behavioural strategies, such as challenging beliefs, exploration of roles and myths, using mutual aid to encourage self-help and lobbying for policy change, reduced stigma, shame and loneliness. Women can carry high levels of guilt; provision of anonymous online and telephone treatment and development of self-help resources and tools may be more effective still than stigma-reduction campaigns.

Preventative measures such as public health messages and the promotion of self-regulatory strategies (e.g. to contain EGM gambling) need to be assessed for their relevance and resonance with women problem gamblers. The implementation of responsible gambling features on EGMs (the ability to set precommitment limits, receive personalised gambling feedback and access gambling expenditure records) as well as reforms to EGM design, such as lower maximum bet sizes, would also help to reduce gambling-related harm among women. Screening older women presenting with comorbid mental disorders could detect those with GD, expediting therapy.

2.1 Pharmacotherapy

Drug treatments for GD in men and women are in their infancy. The efficacy and utility of a number of drugs have been tested, but currently, no drug is approved for GD. In a recent case series, 50 mg a day of the opioid antagonist naltrexone led to marked reduction in cravings to gamble in all 10 patients (20% women), as tested by pre-and post-commencement Gambling Craving Scale (GCS) at 6-week follow-up. The study provides evidence for the efficacy of naltrexone in PGs who have failed to respond to psychological therapies, although care should be taken when prescribing to those with concurrent alcohol use disorder who show evidence of treatment resistance for PG associated with relapse of gambling [51]. Opioid antagonists are advocated as a treatment modality for PG, and there is scope for a randomised controlled trial to ascertain long-term outcomes and tolerability once cessation has occurred.

3 Gaming Disorder in Women

Internet addiction has been proposed as a diagnostic entity and studied for over 20 years [especially in light of work by Kimberly Young (e.g. [54])]. However, there has been debate and disagreement regarding a standardised definition. Prevalence of addictive internet use worldwide varies, and comparability of available studies has been limited by variable diagnostic criteria and assessment tools and differing populations screened.

Increasingly, specific online activities are recognised for their addictive potential: online gambling, gaming, use of pornography, shopping, chatting, repeated email checking and use of instant messaging and social media. Definitions for such addictions are heterogeneous: they vary, and many are not yet determined. Diagnostic instruments are not sufficiently standardised, aetiological models and preventive and therapeutic concepts are not sufficiently evaluated and long-term randomised controlled trials (RCT) are lacking.

Problematic gaming is most commonly conceived of as a behavioural addiction rather than a disorder of impulse control [10, 25]. Important similarities between behavioural addictions and substance use disorders (SUD) include initial pleasure, progressing to increased use with diminished enjoyment. Shared neurobiological features include activation and neuroadaptation in the reward pathways [15].

3.1 Definitions and Diagnostic Criteria

Although recreational for most, gaming becomes excessive for others, leading to various negative consequences: dropping out of or doing badly at school, being repeatedly fired from jobs, impaired personal relationships or neglected personal hygiene.

In 2013, internet gaming disorder (IGD) was included in Sect. III of the DSM-5 [1] in a list of conditions requiring future study. This addition suggested that IGD may be identified by the presence of five or more of nine criteria within a 12-month period. These criteria include:

(1) tolerance; (2) withdrawal; (3) loss of control; (4) gaming preoccupation; (5) gaming to escape negative affect; (6) loss of interest in offline relationships, social interaction and entertainment; (7) deception to conceal gaming extent; (8) jeopardising relationships, work, career or educational opportunities; and (9) continued excessive gaming despite knowledge of these consequences.

Gaming disorder (GmD) is to be classified as a disease in the eleventh revision of the International Classification of Diseases (ICD-11) [41], under ‘disorders due to addictive behaviours’. GmD is defined as:

A pattern of gaming behaviour (‘digital-gaming’ or ‘video-gaming’) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities and continuing or escalating gaming despite negative consequences.

It is differentiated from non-pathological gaming by significant distress or impairment in personal, family, social, educational, occupational or other important areas of functioning and must have been evident for at least 12 months.

Given this recent change in the ICD-11, we will refer to addictive internet gaming or pathological online gaming as gaming disorder (GmD) unless otherwise specified.

3.2 Gaming Prevalence and Patterns

Gender differences in specific problematic online activities have attracted attention.

A German study of problematic online behaviours showed more females than males using social networking sites (77.1% vs. 64.8%), whereas the reverse was true for online video games (7.2% vs. 33.6%) [44].

Mirroring this, in [2], researchers found that gender was significantly associated with individual’s social media addiction screening scores, with females tending to score higher on measures of social media addiction than males. Conversely, male participants tended to score higher on measures of addiction to video games than females. Similarly, in [9], researchers found that male adolescents were more likely to report gaming. Furthermore, among gamers, males were more likely to report gaming problems than their female counterparts. However, by contrast, in [36], researchers analysed problematic internet activities in a representative sample of Swiss adolescent females. Results were unable to show that problematic internet use was associated differently with levels of either online gaming or social networking. Further work is necessary to determine the extent to which problematic gaming occurs among males and females when the relative prevalence of these activities among genders is taken into account.

The prevalence of problematic gaming is unclear. According to one recent systematic review of publications from 1991 to 2016, 5.5% of the population met criteria for IGD [32]. However, a recent study of large-scale national cohort sample suggests that only a very small proportion of the general population (between 0.3% and 1.0%) might meet these criteria [39]. This demonstrates the variance in the scientific literature. Prevalence rates of IGD are widely derived from rates observed for internet addiction, so may be inaccurate at best. Finally, no reliable gender-specific prevalence rates exist.

3.3 Gender Differences in Risk, Aetiology and Comorbidity of GmD

Despite an interest in GmD by researchers, few studies have focused on gender differences, and conclusions are vague. In females, risk factors may include having had below secondary school education and high anxiety and depression scores [4]. Being alexithymic may almost double the risk of IGD (odds ratio = 1.88, p = 0.030). However, significant replication work is required to confirm the robustness of these results. Furthermore, whether alexithymia contributes to the development and/or maintenance of IGD or results from prolonged, repeated, problematic online gaming is not known.

In a recent study of both genders, females with IGD were found to have reduced cortical thickness in the left and right rostral middle frontal gyri (MFG), the left superior frontal gyrus, the left supramarginal gyrus, the right posterior cingulate cortex and the right superior parietal lobule, compared with female recreational game users (RGU). These are small, statistically significant differences in cortical thickness. Low craving scores in female IGD subjects were associated with thick right (r = −0.290, p = 0.018) and left (r = −0.359, p = 0.003; Bonferroni corrected) rostral MFG. The authors suggest that females may therefore be more vulnerable to IGD, though causation cannot be demonstrated without longitudinal studies, and further preregistered replication work is necessary to confirm the robustness of these findings [50].

Cravings are an important feature of addiction and constitute a diagnostic criterion for substance use disorders though not for GD or GmD. In a recent functional magnetic resonance imaging study, Dong et al. [11] found that gaming-related cues elicited greater cravings in males with RGU than females with RGU and that related cortico-striatal-limbic brain activations correlated more consistently with craving responses in males than females, suggesting potential biological mechanisms for male vulnerability in developing IGD [11].

In a related study, Dong et al. [12] made two distinct and significant observations. First, both male and female IGD subjects showed reduced left dorsolateral prefrontal cortex (DLPFC) activation compared with RGU subjects. Left DLPFC activation (which contributes to executive control) may therefore be a target for treatment (e.g. transcranial magnetic stimulation or transcranial direct current stimulation) in IGD as it is in other addictions [12]. Second, IGD status was associated with increased activation of the caudate in both males and females, post gaming, but RGU males showed higher caudate activation than females. The caudate (being a component of reward circuitry and may promote motivations to pursue rewards) findings led the authors to speculate that this difference may relate to female resilience to developing IGD (compared to males) but that once they develop IGD, gaming may impair executive control and make it harder to stop. However, these notions are speculative and warrant specific examination in future preregistered longitudinal studies [12].

In a population of 472 students aged 13–21, emotional dysregulation was associated with substance and non-substance addictions (GmD, GD, alcohol and drug abuse), but no significant gender differences were found. In the same study, IGD was associated with poor parental and peer attachment in both genders, females scoring significantly higher on maternal and peer attachment problems. The authors conclude that ‘IGD may be related to the need for relational satisfaction in adolescence’ [14].

Young people with IGD may have a high level of comorbid symptoms from underlying autism spectrum disorder, ADHD, anxiety and depression, though studies examining gender patterns are lacking [49].

4 Screening and Treatment

Various assessment tools have been developed to measure IGD: all are self-report questionnaires with no clinician-administered interviews, many derived from existing internet addiction scales [24]. If internet addiction and IGD are to be regarded as distinct clinical phenomena, then tools for each need to be assessed separately. More research is needed, using the new ICD-11 (GmD) criteria in combination with the DSM-5 (IGD), to produce diagnostic and screening tools which will then need to be validated for a range of clinical populations.

A systematic search for keywords related to gaming disorder in Medline, PsycInfo, and Embase found no published randomized controlled trials for treatments of GmD at the time of writing. There is a dearth of research on treatments for GmD altogether, and no studies have yet looked at gender-specific needs in treatment of GmD. More research is needed into the prevalence of GmD, and clinical tools and parameters need validating. Brain-based biology, socio-economic/health impact, empirically justified intervention and policy approaches all need to be investigated with gender-focused longitudinal studies and controlled trials in cross-cultural populations. Preregistration and the application of open science principles are essential in order to build confidence in the robustness of this work. The way in which gender moderates problematic internet activities, including GmD, warrants specific research.

Key Points

  • The prevalence of gambling has increased among women in recent years and is likely to represent a cyclic resurgence in gambling among women, linked to societal change and targeted advertising, rather than a new phenomenon.

  • Women consistently start gambling at a later age than men, progress more quickly to PG or gamble for shorter durations before seeking treatment.

  • Gender differences in gambling preferences are evident: women prefer lotteries, slot machines, scratch cards and bingo while men prefer poker, sports betting, FOBT and casino games. However, younger women (aged 16–34) are increasingly using EGM.

  • Motivations for gambling among women include escape from loneliness, dysfunctional relationships, violence, isolation and childcare and to self-medicate perceived intolerable levels of stress, anxiety and depression.

  • The incidence of problem gambling among women has risen in recent years, and is linked to lower socio-economic status, deprivation, marginalisation, violent partners and/or childhood and the interaction of dysphoric mood and ‘avoidance’ coping.

  • Comorbid psychiatric disorders often associated with GD include depression, anxiety disorders, bipolar affective disorder, personality disorders and SUDs – suicide being the leading cause of death in GD (31%).

  • Barriers to seeking professional help faced more predominantly by women than men include lack of social support, poverty, lack of childcare, guilt and shame due to stigmatisation and difficulties in finding appropriate treatment.

  • There is a lack of suitable treatment approaches and settings for problem gambling among women, who may feel greater discomfort in a male environment, especially if suffering from traumatic experiences.

  • Available treatment for problem gambling may be incompatible with financial and time constraints for women, who may also fear losing custody of their children.

  • When it comes to treatment, individual CBT results in greater improvements (96% recovered or improved) than self-directed workbooks with Gamblers Anonymous (GA) referral (81%) or GA referral alone (77%). However, CBT may not be the optimum model to facilitate emotional processing for those displaying high avoidance of their difficulties, for whom psychodynamic treatment may work better.

  • Women with GD need a group setting, not associated with addictions, where they feel heard. Women often prefer online therapy, helplines and forums, overcoming practical accessibility issues.

  • Preferences for treatment may be partly due to the observation that women can carry high levels of guilt; provision of anonymous online and telephone treatment and development of self-help resources and tools may be effective in this regard.

  • Drug treatments for GD in men and women are in their infancy. In a recent case series, 50mg a day of the opioid antagonist naltrexone led to marked reduction in cravings to gamble in ten patients (20% women). However, care should be taken when prescribing to those with concurrent alcohol use disorder.

  • Online gambling, gaming, use of pornography, shopping, chatting, repeated email checking and use of instant messaging and social media have been recognised for their addictive potential. However, definitions for such disorders are heterogenous, diagnostic instruments are unstandardised, aetiological models and therapeutic concepts are not sufficiently evaluated and RCTs are lacking. There is a dearth of research into gender differences in gaming disorder.

  • Gaming is more prevalent among males than among females, and studies have suggested that males may be more likely to suffer from problematic gaming even when these increases in prevalence are taken into account. However, the overall prevalence of problematic gaming behaviours is unclear. Furthermore, no gender-specific prevalence rates exist.

  • Various neurobiological explanations for gendered differences in problematic gaming have been proffered. However, significant preregistered replication work is necessary to confirm the robustness of these explanations.

  • There are no published randomised controlled trials for treatments of GmD at the time of writing. There is a dearth of research on treatments for GmD altogether, and no studies have yet looked at gender-specific needs in treatment of GmD. More research is needed into the prevalence of GmD, and clinical tools and parameters need validation.