National Institute on Alcohol Abuse and Alcoholism
No. 10 PH 290 October 1990
Alcohol and Women
Much of our knowledge of alcoholism has been gathered from studies
conducted with a predominance of male subjects. Recent studies involving
more female subjects reveal that drinking differs between men and
women.
Studies in the general population indicate that fewer women than men
drink. It is estimated that of the 15.1 million alcohol-abusing or
alcohol-dependent individuals in the United States, approximately 4.6
million (nearly one-third) are women (1). On the whole, women who drink
consume less alcohol and have fewer alcohol-related problems and
dependence symptoms than men (2,3), yet among the heaviest drinkers,
women equal or surpass men in the number of problems that result from
their drinking (3).
Drinking behavior differs with the age, life role, and marital status
of women. In general, a woman’s drinking resembles that of her husband,
siblings, or close friends (3). Whereas younger women (aged 18-34) report
higher rates of drinking-related problems than do older women (3,4), the
incidence of alcohol dependence is greater among middle-aged women (aged
35-49) (5).
Contrary to popular belief, women who have multiple roles (e.g.,
married women who work outside the home) may have lower rates of alcohol
problems than women who do not have multiple roles (6). In fact, role
deprivation (e.g., loss of role as wife, mother, or worker) may increase
a woman’s risk for abusing alcohol (7). Women who have never married or
who are divorced or separated are more likely to drink heavily and
experience alcohol-related problems than women who are married or
widowed. Unmarried women living with a partner are more likely still to
engage in heavy drinking and to develop drinking problems.
Heath and colleagues (8) studied drinking behavior among a select
sample of female twins to identify possible environmental factors that
may modulate drinking behavior. They reported that, among women, marital
status appears to modify the effects of genetic factors that influence
drinking habits. Marriage or a marriage-like relationship lessens the
effect of an inherited liability for drinking.
Several researchers have explored whether drinking patterns and
alcohol-related problems vary among women of different racial or ethnic
groups. Black women (46 percent) are more likely to abstain from alcohol
than white women (34 percent) (9,10). Further, although it is commonly
assumed that a larger proportion of black women drink heavily,
researchers have disproved this assumption: Equal proportions of black
and white women drink heavily (3,9). Black women report fewer
alcohol-related personal and social problems than white women, yet a
greater proportion of black women experience alcohol-related health
problems (11).
Data from self-report surveys suggest that Hispanic women are
infrequent drinkers or abstainers (12,13), but this may change as they
enter new social and work arenas. Gilbert (14) found that reports of
abstention are greater among Hispanic women who have immigrated to the
United States; reports of moderate or heavy drinking are greater among
younger, American-born Hispanic women.
The interval between onset of drinking-related problems and entry into
treatment appears to be shorter for women than for men (15,16). Moreover,
studies of women alcoholics in treatment suggest that they often
experience greater physiological impairment earlier in their drinking
careers, despite having consumed less alcohol than men (17,18). These
findings suggest that the development of consequences associated with
heavy drinking may be accelerated or “telescoped” in women.
In addition to these many psych osocial and epidemiological
differences, the sexes also experience different physiological effects of
alcohol. Women become intoxicated after drinking smaller quantities of
alcohol than are needed to produce intoxication in men (19). Three
possible mechanisms may explain this response.
First, women have lower total body water content than men of
comparable size. After alcohol is consumed, it diffuses uniformly into
all body water, both inside and outside cells. Because of their smaller
quantity of body water, women achieve higher concentrations of alcohol in
their blood than men after drinking equivalent amounts of alcohol. More
simply, blood alcohol concentration in women may be likened to the result
of dropping the same quantity of alcohol into a smaller pail of
water.
Second, diminished activity of alcohol dehydrogenase (the primary
enzyme involved in the metabolism of alcohol) in the stomach also may
contribute to the gender-related differences in blood alcohol
concentrations and a woman’s heightened vulnerability to the
physiological consequences of drinking. Julkunen and colleagues (20)
demonstrated in rats that a substantial amount of alcohol is metabolized
by gastric alcohol dehydrogenase in the stomach before it enters the
systemic circulation. This “first-pass metabolism” of alcohol decreases
the availability of alcohol to the system. Frezza and colleagues (21)
reported that, because of diminished activity of gastric alcohol
dehydrogenase, first-pass metabolism was decreased in women compared with
men and was virtually nonexistent in alcoholic women.
Third, fluctuations in gonadal hormone levels during the menstrual
cycle may affect the rate of alcohol metabolism, making a woman more
susceptible to elevated blood alcohol concentrations at different points
in the cycle. Research findings to date, however, have been inconsistent
(22,23,24).
Chronic alcohol abuse exacts a greater physical toll on women than on
men. Female alcoholics have death rates 50 to 100 percent higher than
those of male alcoholics. Further, a greater percentage of female
alcoholics die from suicides, alcohol-related accidents, circulatory
disorders, and cirrhosis of the liver (25).
Increasing evidence suggests that the detrimental effects of alcohol
on the liver are more severe for women than for men. Women develop
alcoholic liver disease, particularly alcoholic cirrhosis and hepatitis,
after a comparatively shorter period of heavy drinking and at a lower
level of daily drinking than men (26,27). Proportionately more alcoholic
women die from cirrhosis than do alcoholic men (28).
The exact mechanisms that underlie women’s heightened vulnerability to
alcohol-induced liver damage are unclear. Differences in body weight and
fluid content between men and women may be contributing factors (29). In
addition, Johnson and Williams (30) suggested that the combined effect of
estrogens and alcohol may augment liver damage. Finally, alcoholic women
may be more susceptible to liver damage because of the diminished
activity of gastric alcohol dehydrogenase in first-pass metabolism
(21).
Drinking also may be associated with an increased risk for breast
cancer. After reviewing epidemiological data on alcohol consumption and
the incidence of breast cancer, Longnecker and colleagues (31) reported
that risk increases when a woman consumes 1 ounce or more of absolute
alcohol daily. Increased risk appears to be related directly to the
effects of alcohol (32). Moreover, risk for breast cancer and lower
levels of alcohol consumption are weakly associated. Data from other
studies (33), however, do not concur with these findings, suggesting that
more research is needed to explore the relationship between drinking and
breast cancer.
Menstrual disorders (e.g., painful menstruation, heavy flow,
premenstrual discomfort, and irregular or absent cycles) have been
associated with chronic heavy drinking (34,35) . These disorders can have
adverse effects on fertility (36). Further, continued drinking may lead
to early menopause (37,38).
Animal studies have provided data that replicate the findings of
studies in humans to determine the effects of chronic alcohol consumption
on female reproductive function. Studies in rodents and monkeys
demonstrated that prolonged alcohol exposure disrupts estrus regularity
and increases the incidence of ovulatory failure (39,40,41).
Researchers have begun to examine whether women and men require
distinct treatment approaches. It has been suggested that women
alcoholics may encounter different conditions that facilitate or
discourage their entry into treatment.
Women represent 25.4 percent of alcoholism clients in traditional
treatment centers in the United States (42). Although it appears that
they comprise a small proportion of the treatment population (25 percent
women compared with 75 percent men), the proportion of female alcoholics
to male alcoholics in treatment is similar to the proportion of all
female alcoholics to male alcoholics (30 percent women to 70 percent
men). In addition, women drinkers pursue avenues other than traditional
alcoholism programs, such as psychiatric services or personal physicians,
for treatment (43).
Women alcoholics may encounter motivators and barriers to seeking
treatment that differ from those encountered by men. Women are more
likely to seek treatment because of family problems (44), and they often
are encouraged by parents or children to pursue therapy. Men usually are
encouraged to pursue therapy by their wives. Fewer women than men reach
treatment through the criminal justice system or through employee
assistance programs (45). Lack of child care is one of the most
frequently reported barriers to treatment for alcoholic women (46).
Sokolow and colleagues (47) attempted to compare treatment outcome
between men and women and reported that, among those who completed
treatment, abstinence was slightly higher among women than among men.
Women had a higher abstinence rate if treated in a medically oriented
alcoholism facility, whereas the abstinence rate was higher for men
treated in a peer group-oriented facility. Treatment outcome was better
for women treated in a facility with a smaller proportion of female
clients and better for men in a facility with a larger proportion of
female clients. This study provided preliminary data on gender-specific
treatment outcome; however, the trials were not controlled. Although the
question of whether women should have separate treatment opportunities is
an important one, the supporting evidence still has not been found.
Alcohol and Women–A Commentary by
NIAAA Director Enoch Gordis, M.D.
The extent of women’s participation in alcoholism treatment appears to
equal roughly the prevalence of alcohol-related problems among women.
Even so, some women may face barriers that limit access to treatment.
Limited financial resources may be one barrier. For example, many women
do not have access to the employer-paid alcoholism treatment provided by
larger industries, where men tend to predominate in the work force.
Child-care concerns and the fear that an identified alcohol problem will
cause the loss of dependent children also may create barriers to
treatment. With regard to treatment, many questions remain to be answered
by research, including whether specialized treatment in a women-only
program is more effective than treatment in a mixed-gender setting.
Previous concerns about a lack of women as research subjects in
alcohol studies are beginning to be addressed. However, there have been
recent charges that alcohol research on women is discriminatory (48,49).
Research on fetal alcohol and drug effects and the fear of discriminatory
actions, such as imprisoning pregnant women solely because of their
addiction, is central to this controversy. The issue of fetal effects and
how to prevent and treat them will not go away simply because
discriminatory policies have been suggested. The challenge for alcohol
research will be how both sexes can benefit from the fruits of
science.
All material contained in the Alcohol Alert is in the public domain
and may be used or reproduced without permission from NIAAA. Citation of
the source is appreciated.
Copies of the Alcohol Alert are available free of charge from the
Scientific Communications Branch, Office of Scientific Affairs, NIAAA,
Willco Building, Suite 409, 6000 Executive Boulevard, Bethesda, MD
20892-7003. Telephone: 301-443-3860
Go to NIAAA
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service * National Institutes of Health
