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WOMEN AND SUBSTANCE ABUSE

There are gender differences in the prevalence of substance abuse.

ALCOHOL AND TOBACCO USE

General population studies indicate that fewer women drink than men, and women who do drink consume less alcohol than men. Of the estimated 15 million alcohol-abusing or alcohol-dependent individuals in the United States, fewer than one-third are women. In the 1993 National Household Survey on Drug Abuse (NHSDA), 57 percent of men reported they drank alcoholic beverages in the previous month, compared with 43 percent of women. The NHSDA defines heavy alcohol use as 5 or more drinks per day on each of 5 or more days in the past 30 days. By this definition, in 1993 men were much more likely than women to be heavy drinkers (10 and 2 percent, respectively).

It has been suggested that male and female sex roles, and therefore drinking norms, have become more similar in recent years. Some sex-role changes that could increase opportunities for, and acceptability of, female drinking include greater female labor force participation, delayed marriage and childbearing, and more equitable sex-role attitudes. According to this convergence thesis, greater sex-role equality may cause Problem Drinking and Alcoholism to increase among women. However, recent epidemiological data reveal little evidence of increased female alcoholism or problem drinking. Changing female drinking patterns have resulted more in a reduction in female abstainers than an increase in problem drinkers. Nevertheless, there is some evidence for convergence in the youngest cohorts, with the smallest sex differences in heavy drinking being for youths aged twelve to seventeen (2 percent of boys and 1 percent of girls in 1993). Among adults aged thirty-five and older, men are eight times as likely as women to be heavy drinkers (8 percent compared with 1 percent).

There is greater evidence of sex-role convergence in Tobacco use. In 1955, 52 percent of adult men smoked, compared with 25 percent of adult women. Since then, the proportion of men who smoke has decreased markedly while rates among women have held fairly steady. Among adults aged 35 and older in 1993, 27 percent of men and 21 percent of women were current smokers. Among youths aged twelve to seventeen, girls have surpassed boys in their rates of current cigarette use (10 percent of girls compared with 9 percent of boys in 1993). Because boys are more likely than girls to use smokeless tobacco products, however, their overall rates of nicotine addiction still exceed girls' rates.

Biener (1987) reviews factors that have contributed to the convergence in male and female smoking. Product developments such as filtered and low-tar cigarettes have made smoking easier for women to tolerate physically. Tobacco companies have targeted Advertising to make smoking attractive to young women. Once tobacco use is initiated, women are less likely than men to quit smoking and, compared with men who have quit smoking, women quitters are more likely to relapse.

The convergence in male and female smoking rates has been accompanied by a convergence in smoking-related health problems. For example, lung cancer deaths among women have increased markedly since the 1970s, and lung cancer now surpasses breast cancer as the leading cause of Cancer deaths among women.

ILLICIT DRUG USE

Males are far more likely than females to be arrested for possessing or selling illicit drugs. In 1992, for example, the Federal Bureau of Investigation reported that only 16 percent of those arrested for drug-abuse violations were female. At all ages, males are more likely than females to use illicit drugs. Gender differences are smallest among adolescents aged twelve to seventeen and among adults aged thirty-five and older, and largest among young adults aged eighteen to thirty-four, the age range in which illicit-drug use is most prevalent. In the 1993 NHSDA, 11 percent of men, compared with 6 percent of women, aged twenty-six to thirty-four reported they had used some illicit drug in the previous month. Nineteen percent of men and 8 percent of women reported current (i.e., past month) illicit-drug use in 1993. Among both men and women, marijuana is the most frequently used illicit substance, with 16 percent of men and 6 percent of women aged eighteen to twenty-five reporting current use.

Cocaine use has decreased since the mid-1980s, and is rare compared with marijuana use. Sex differences in regular cocaine use are small. In the young adult age group, where use is most common, 1.7 percent of men and 1.4 percent of women reported cocaine use in the past month. In 1993, among youths aged twelve to seventeen, boys and girls were equally liken to report cocaine use in the past month (0.4 percent).

Prior to the Harrison Narcotics Act of 1914, the typical Opiate addict in the United States was a white, middle-aged, middle-class housewife who had become addicted to medically prescribed drugs or nonprescription Patent Medicines. Following criminalization of most opiate use through the Harrison Act and subsequent legislation and court interpretations, overall levels of opiate use declined dramatically. When Heroin addiction reemerged as a social problem in the 1950s and 1960s, the typical opiate addict was a nonwhite urban male from a lower socioeconomic class. Although the Vietnam war exposed a broader spectrum of young American men to heroin use, and although many servicemen tried opiates and even became addicted in Vietnam, most were able to discontinue use when they returned to the United States.

In the 1970s and 1980s, heroin use decreased and became quite rare in the United States. In 1993, only about one in 1,000 Americans aged twelve and older reported use of heroin in the past year, and the majority of users were men. An increase in drug seizures, arrests, and heroin-related emergency room episodes in the early 1990s led to assertions that heroin was making a comeback and that women would be especially vulnerable to addiction. Although these trends merited watching, such speculation was premature, given current evidence.

MEDICAL DRUG USE

In the 1970s feminist scholars drew attention to possible overmedication of women with Psychoactive Drugs. These early critiques derived from content analyses of sex-stereotyped advertisements in medical publications. Most of the ads depicted woman patients, and survey research on representative populations confirmed that women were using more prescription psychoactive drugs than were men.

Critics of these patterns are concerned that drugs are being used beyond traditional medical psychiatric concepts of disease. For example, medical ads suggested prescribing Tranquilizers and Antidepressants to alleviate normal life transitions, such as menopause, starting college, or a woman's adult children moving out. It has been suggested that prescribing psychoactive drugs is a subtle form of social control that diffuses or channels women's discontent with limiting and inequitable sex roles.

Some of the prescription psychoactives have dangerous side effects and a high potential for producing dependency. Further, since women also use more Overthe-Counter medications and women's alcohol problems are often undetected by physicians, use of prescription psychoactive drugs may make women especially vulnerable to adverse drug interactions. Alcohol in combination with other substances is the most frequent cause of emergency-room episodes in the Drug Abuse Warning Network (DAWN) system. Although women drink less and are less likely to use illicit drugs, they have equaled or exceeded men in drugrelated emergency room episodes since the mid-1980s. This is because more women needed emergency treatment related to tranquilizer, sedative, and nonnarcotic analgesic use.

GENDER DIFFERENCES IN THE ETIOLOGY OF SUBSTANCE ABUSE

Studies of Adolescents generally find similar correlates of substance abuse among both boys and girls. The strongest predictor of adolescent alcohol, tobacco, and illicit-drug use is having friends who use alcohol, tobacco, and drugs. Other factors that predict substance abuse by boys and girls include parental substance abuse, poor academic performance, and low commitment to educational pursuits.

Researchers, however, have identified some gender differences in the development of alcohol and drug problems. Relationship issues are particularly salient in the etiology of female substance abuse. For example, alcoholism in women is more strongly correlated with a family history of drinking problems than is alcoholism in men. Girls and women are likely to be introduced to alcohol or illicit drugs by a boyfriend or spouse, and female alcohol or drug dependence frequently develops in a relationship with an alcohol- or drug-dependent male partner.

Alcohol and drug abuse are more often associated with Depression in girls and women compared with males, but it is not clear whether depression is more likely to cause female substance abuse or is a more typical consequence of substance abuse among girls and women. Women in treatment for substance abuse are more likely than men to say their problem drinking or drug abuse developed after a life crisis or tragedy, such as the death of a family member. Also, a sizable proportion of women in treatment report histories of sexual abuse. Men are more likely to say their problem drinking or drug abuse developed out of social or recreational use.

Some believe these different attributions and recollections reflect genuine sex differences in the etiology of substance abuse. Others caution, however, that the greater stigma attached to female substance abuse may motivate women to develop an explanation for their problem drinking or drug use, and that personal crises and emotional difficulties serve as socially acceptable reasons.

The course of problem drinking and drug addiction varies by gender. Women entering treatment for alcoholism or drug abuse tend to have begun heavy drinking or drug use at a later age, on average, compared with men entering treatment. The term "telescoping" has been used to describe a more rapid progression from controlled alcohol or drug use to alcohol and drug dependency in women, compared with men.

GENDER DIFFERENCES IN THE CONSEQUENCES OF SUBSTANCE ABUSE

It is generally presumed that alcohol and drug abuse will produce more deleterious consequences among women than among men. This expectation is grounded both in biological differences and in social-role expectations.

From a biological standpoint, it is frequently noted that the lower ratio of water to total body weight in women causes them to metabolize alcohol and drugs differently than men. Even when body weight is controlled, given equivalent alcohol consumed, women pass more alcohol into the bloodstream and reach higher peak Blood Alcohol Concentrations than men, in part because of differences in enzyme activity in the intestinal wall. Drugs such as marijuana that are deposited in body fat may be slower to clear in women than in men. Slow clearance rates create a potential for cumulative toxicity and adverse drug and alcohol interactions.

The behavioral telescoping of women's uncontrolled drinking and drug use is paralleled by a telescoping of some physical health consequences of alcohol and drug use. Alcoholic liver disease progresses more rapidly in women compared with men. Women also seem to be more prone to alcohol-related brain damage. They show physical brain abnormalities after a shorter drinking history and at lower peak alcohol consumption. Women also exhibit cognitive deficits on psychological tests of memory, speech, and perceptual accuracy with a shorter drinking history than that of men.

Women diagnosed as alcoholic have very high mortality rates relative to both the general population of women and to alcoholic men. A follow-up study of alcoholic women in St. Louis, found that, 11 years after treatment, they had lost an average of 15 years from their expected life span. Another study of 1,000 female and 4,000 male alcoholics in Sweden found the excess mortality was higher for the women (5.2 times the expected rate) than for the men (3 times the expected rate).

Deaths due to drugs other than alcohol and tobacco are relatively uncommon among women. Men are far more likely than women to die from drug use. The higher male death rates are largely explained by males' greater drug use rather than by sex differences in vulnerability among drug users. In 1990, medical examiners in twenty-seven U.S. metropolitan areas reported 5,830 deaths involving illicit and/or legally obtained drugs. Of those who died from drug-related causes (e.g., Overdose, accidental injury), 71 percent were male.

The HIV virus that causes AIDS is transmitted primarily via infected blood and semen. Sharing needles and having sexual relations with intravenous (IV) drug users places both men and women at risk for contracting that incurable disease. Although most AIDS cases have resulted from transmission of HIV during intimate sexual contact between men, about 12,000 of the 43,000 people reported to have AIDS in 1990 were IV drug users. Most of these AIDS cases involving IV drug use were male. When women contract AIDS, the most common route of transmission is through their own IV drug use or sexual contact with a partner who is an IV drug user.

Women's reproductive function increases alcohol- and drug-related health risks to themselves and to their unborn children. Alcohol and drug abuse are associated with numerous disorders of the female reproductive system, including breast cancer, amenorrhea, failure to ovulate, atrophy of the ovaries, miscarriage, and early menopause. Men also experience reproductive and sexual difficulties as a result of alcohol and drug abuse, including impotence, low testosterone levels, testicular atrophy, breast enlargement, and diminished sexual interest.

Infants born to women who used alcohol, tobacco, or other drugs during Pregnancy can experience numerous health problems, including low birth weight, major congenital malformations, neurological problems, mental retardation, and withdrawal symptoms. Although substance abuse at any time during pregnancy can cause birth defects, the very rapid cell division in the first weeks of embryonic development means the teratogenic effects of alcohol and drugs are generally greatest early in pregnancy, before a woman even realizes she is pregnant.

As the medical and social costs of prenatal alcohol and drug exposure become more apparent, so does public pressure for action. Many advocate termination of parental rights in cases where a newborn tests positive for drug or alcohol exposure. In some jurisdictions, mothers who used alcohol or drugs during pregnancy have been charged with child abuse or delivering a controlled substance to a minor. Critics of these policies charge that alcohol and drug screening will discourage substance-abusing women from obtaining necessary prenatal care. Legally, it may be difficult to establish criminal intent if substance abuse occurred early in an unintended and unrecognized pregnancy. Further, it is often difficult to causally disentangle alcohol or drug effects from other adverse conditions the mother may have experienced, such as poor nutrition, acute or chronic illness, and inadequate prenatal care. As currently practiced, prenatal drug-use detection procedures raise important questions of fairness. Hospitals and clinics serving largely poor and minority patient populations are more likely to detect prenatal substance abuse despite evidence that substance abuse occurs in all socioeconomic categories.

The tendency of female problem drinking and drug abuse to develop in a relationship with a substance-abusing male partner may shield women from some consequences of their substance abuse. For example, women alcoholics and addicts are less vulnerable to arrest if their partner procures drugs for the couple or drives when they are intoxicated. On the other hand, substance-abusing partners increase some other risks for alcohol- and drug-dependent women compared with men. Women with substance-abusing partners are vulnerable to domestic Violence. Also, a substance-abusing partner can be an impediment to women's seeking or complying with alcohol and drug treatment.

Despite women's biophysical vulnerability and the stigma associated with female alcohol and drug abuse, men are more likely than women to experience some problems related to heavy drinking and illicit drug use. Substance abuse is more strongly related to intrapsychic problems among women, and to problems in social functioning (employment difficulties, financial problems, unsafe driving, arrest) among men.

These gender differences may be related to sex-role differences in drinking and drug use. Male substance use is less socially controlledoccurring more often in recreational contexts, public places, and all-male settingswhereas female substance use is more likely to occur in the home, with a male partner, and under medical auspices. Sex roles may also allow males to exercise less personal control while drinking or using drugs. For example, male episodes of intoxication are more often associated with rapid ingestion, blackouts, and Aggression.

GENDER AND SUBSTANCE ABUSE TREATMENT

Men outnumber women in drug and alcoholism treatment units. The 1991 National Drug and Alcoholism Treatment Unit Survey (NDATUS) found 213,681 women in some type of treatment, compared with 562,388 men (U.S. Department of Health and Human Services, 1992). Self-reports of treatment experience indicate a somewhat smaller sex difference. In the 1991 NHSDA, 1.8 percent of males aged twelve and older reported they were treated for substance abuse in the previous year, compared with 0.9 percent of females. The discrepancy may occur because women are less likely to report informal help, such as pastoral counseling or Self-Help groups, as Treatment.

Among alcoholics and addicts, a greater percentage of women are parents, and among substance-abusing parents, more women have child custody. Parenting considerations are a major barrier to women seeking substance-abuse treatment. Few residential treatment programs make provisions for pregnant women or mothers. Many women are unable to find caregivers for their children if they enter residential treatment, and fear permanent loss of custody if their children enter the foster care system.

Substance-abuse treatment programs have been geared more to the problems and needs of male clients. Some contend that only sex-segregated treatment can meet the unique needs of female clients. Even those advocating integrated programs acknowledge the need for greater attention to women's issues. In addition to parenting responsibilities, it is urged that treatment programs address women's histories of physical and sexual abuse, domestic violence, and relationships with substance-abusing partners. Burman (1994) also suggests that treatment programs for women should emphasize skills such as problem solving, assertiveness, self-advocacy, and Life Skills (including parenting and job seeking).

(See also: Addicted Babies ; Complications: Endocrine and Reproductive Systems ; Family Violence and Substance Abuse ; Gender and Complications of Substance Abuse ; Injecting Drug Users and HIV ; Stress ; Treatment ; Vulnerability As Cause of Substance Abuse )

BIBLIOGRAPHY

Beers, M. H., & Berkow, R. (Eds.) (1999). The Merck Manual of Diagnosis and Therapy, 17th ed. Whitehouse Station, NJ: Merck Research Laboratories.

Boyd, M. R., & Mackey, M. C. (2000). Alienation from self and others: The psychosocial problem of rural alcoholic women. Archives of Psychiatric Nursing, 14, 134-141.

Center for Substance Abuse Prevention. (2000). Alcohol, Tobacco and Other Drugs (ATOD) Resource Guide for Lesbians, Gay Men, and Bisexuals. Rockville, MD: National Clearinghouse for Alcohol and Drug Information.

Ford, J. A. (1999). Substance Abuse: A Strong Risk, Often Overlooked. Window on Wellness, 3, Summer 1999. Dayton, OH: Substance Abuse and Disability Issues, Wright State University School of Medicine.

Gay, Lesbian, Bisexual, and Transgendered (GLBT) Health. (2000). Substance Abuse. New York: GLBT Health.

National Council on Alcoholism and Drug Dependence (NCADD). (2000). Use of Alcohol and Other Drugs Among Women. New York: NCADD.

Rigotti, N. A., Lee, J. E., & Wechsler, H. (2000). US college students' use of tobacco products: Results of a national survey. Journal of the American Medical Association, 284, 699-705.

Smith, W. B., & Weisner, C. (2000). Women and alcohol problems: A critical analysis of the literature and unanswered questions. Alcohol in Clinical Experimental Research, 24, 1320-1321.

Cynthia Robbins

Revised by Rebecca J. Frey

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