Alcoholic Women and the Treatment Gap - Increasing Physician Awareness

Janice A. Holbeck, PhD, and Jay Segal, PhD

Disclosures

June 08, 2005

In This Article

Introduction

Since 1966, both the American Medical Association (AMA) and the American Psychiatric Association have recognized alcoholism as a disease. The National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine jointly defined alcoholism as a "primary, chronic disease with genetic, psychosocial and environmental factors influencing its development and manifestations. This disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial."[1] Paradigms of the disease concept of alcoholism, many of which are still in use today, were developed by Jellinek on the basis of results of a 1946 survey of 98 active members of Alcoholics Anonymous.[2] When he reviewed the responses to the survey questionnaire, those from the women differed so dramatically from those of the men that he excluded the data on women from the results of the study.[3] At the time, Jellinek acknowledged the limitations of his study; yet to date, no comprehensive study has been conducted that methodologically explores basic differences between alcoholic men and alcoholic women.

Despite thousands of research studies conducted to explore the causes, risk factors, manifestations, consequences and recovery process of alcoholism, significant gaps in knowledge about sex and gender differences continue to exist. (See Table 1 for a list of recognized gender-specific differences). Research on alcoholism has been conducted primarily using male subjects. A review of 259 studies published in 1984 revealed that out of 64,000 subjects, only 8% were women.[4] In addition, in many studies, the results obtained with women were either combined with the results for men, ignored, assumed to be the opposite of the results for men, or the results were so confusing that they were not interpreted at all.[5] The failure of research to identify, address, and incorporate these differences into treatment services has left an important gap in understanding women's treatment needs.

Alcohol Use Disorders in Primary Care: Summary of Gender-Specific Differences
  • Overall prevalence for alcohol use disorders is greater in men.

  • National Institute on Alcohol Abuse and Alcoholism defines "moderate" and "at-risk" drinking at lower levels for women.

  • Alcohol problems are increasing in adolescent girls and older women.

  • Women are more likely to seek help in health care settings.

  • Women with alcohol problems are lees likely to be identified by their physicians.

  • "Telescoping": Women have a greater sensitivity to the toxic effects of alcohol and have accelerated medical, physiologic, and psychological progression from alcohol use compared to men given the same duration and intensity of drinking careers.

  • Women have higher all-cause mortality at lower levels of alcohol consumption than men.

  • Women who are light -to-moderate drinkers experience decreased risk of cardiovascular mortality compared to abstainers and heavy drinkers. This protection is largely confined to women at greatest risk for coronary artery disease.

  • Women consuming one or more drinks daily are at increased risk for breast cancer.

  • Women are more likely than men to attribute their drinking to a past or current traumatic event/stressor and are more likely to report "self-medicating" with alcohol.

  • Psychiatric co-morbidities (especially depression) are more common in women with alcohol problems than in men and are more likely to precede the alcohol problem in women than in men.

  • Eating disorders frequently co-occur in women with alcohol problems.

  • A past or current history of sexual and/or physical abuse places a woman at increased risk for alcohol problems and relapse.

  • Women with alcohol problems experience greater social stigma than do men with alcohol problems, which may contribute to later presentation at more advanced stages of disease.

  • Women with alcohol problems are more likely to be left by their partner at the time of entry into treatment than men with alcohol problems.

  • Mothers who suffer alcohol problems view potential loss of custody of children as a barrier to presenting for treatment.

  • Women with alcohol problems are more likely cross-addicted to prescription pain or sedative medications.

  • Lesbians may be at higher risk of alcohol problems than heterosexual women.

  • Women with alcohol use disorders are at increased risk for infertility, menstrual abnormalities, and adverse pregnancy outcomes.

Adapted from Brienza and Stein, 2002.[37]

The purpose of this article is to increase physicians' awareness about alcoholism and women -- differences in biologic responses as compared with men, medical consequences, psychiatric comorbidity, and social manifestations of alcoholism. Most needs assessment and diagnostic procedures and programs for prevention, education, and intervention have been designed using the white male as the standard.[5] According to Reed,[5] categorizing everyone other than white males as special populations obviates the necessity of examining and possibly revising basic assumptions that have set the standard for alcoholism treatment services. Yet primary care physicians need to understand sex and gender differences regarding alcoholism in order to intervene more effectively with their female patients. Alcoholic women will sooner go for help to a medical or mental health setting (in which fewer than half are likely to be correctly diagnosed) than to a substance abuse facility.[6]

The prevalence of female alcohol abusers in medical settings is significantly higher than that of the general population (rates of lifetime alcohol abuse in women in primary care settings have been estimated to be as high as 25%).[7] According to statistics from the National Survey of Drug Use and Health, the gender gap for substance abuse is narrowing.[8] In 1993, percentages of lifetime alcohol use among boys aged 12 to17 were 31.2% and, among girls, 23.7%. The percentage rates for boys and girls in 2002 were exactly the same at 43.4%. These numbers not only reflect the increasing use by girls, but the fact that rates of overall substance abuse continue to rise. [9]

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