Alcohol and Women
National Institute on Alcohol Abuse and Alcoholism
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
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
In addition to these many psychosocial 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
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
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
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
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.
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National Institute on Alcohol Abuse and Alcoholism No. 10 PH 290
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