Gender and Substance Abuse

Does gender have an influence on whether abuse of a drug causes complications? Because many early studies of substance abuse were only of male subjects, this question long went unanswered. Later researchers, prompted by the concerns raised by the women's movement of the 1970s regarding the lack of attention given to women's health issues, began to study female substance abusers as a separate group as well as to compare them with male substance abusers.

This research has yielded interesting results. First of all, the physical effects of drugs are relatively similar for men and women. For example, mortality (death) rates are about the same for men and women in a sample population of heavy drinkers and heavy smokers. However, men and women have different patterns of alcohol and drug use. In general, women drink less often and in smaller amounts than men do, and they suffer from fewer alcohol-related problems. Women also use illegal drugs less often than men do, although women have a higher rate of use of prescription tranquilizers, sleeping pills, and over-the-counter drugs. The differences between the genders in complications largely reflect the differences in the patterns of their alcohol and drug use.

The sexes are also different in their social patterns of drug use. For example, alcohol- and drug-using women are more likely to have partners who are alcohol and drug users. Such women are often victims of violence: 53 percent of reported rapes involve the use of alcohol by the victim, the rapist, or both. Women who use illegal drugs frequently support their drug habits by prostitution, putting themselves at risk for sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) and hepatitis B, even if they are not needle users. Accidents and trauma related to substance abuse are more common in men, as is substance-related homelessness. Men report drinking and driving more often than women do.

Researchers in the late 1990s were moving beyond these generalizations to study more specific subgroups of men and women. Health professionals need to distinguish more precisely between the effects of gender roles on substance abuse and the effects of other social categories such as race, religion, sexual orientation, age, income, occupation, and educational level. It is now widely recognized that gender is difficult to separate from other aspects of a person's self-image, lifestyle, and environment. Researchers are also devoting more attention to special populations, such as bisexuals or women with disabilities.

Specific Substances of Abuse

Research has shown that the alcohol, tobacco, and illegal drug use of women and girls differs in significant ways from that of men and boys. However, research also suggests that in some respects women's substance use is becoming more like men's.

Alcohol. On average, women drink alcohol less frequently than men do, and they also tend to drink less per occasion. Moreover, women are more likely than men to drink no alcohol at all. These same sex differences occur for the adolescent and young adult population, but they are smaller than the differences observed in the overall adult population. In a 2000 survey of high school seniors, 24 percent of girls and 37 percent of boys reported occasions of drinking five or more drinks in a row in the past two weeks. Sex differences are much smaller, however, for reports of ever drinking alcohol. For example, 44 percent of eighth-grade girls compared to 42 percent of eighth- grade boys reported ever drinking in the previous year, and among high school seniors, 72 percent of girls compared to 74 percent of boys reported drinking in the past year.

The smaller sex differences in drinking patterns observed over time and among younger teens has led many observers to suggest that differences between male and female alcohol abuse patterns will disappear in the coming decades. This equality in drinking behavior could be problematic, because mounting evidence suggests that alcohol may be more damaging to the health of girls and women.

Evidence suggests that it takes far less alcohol consumption to produce liver damage in women than in men. For women, cirrhosis of the liver may develop with drinking only 20 grams of alcohol (one or two drinks) per day, as compared to 80 grams (6 drinks) per day for men. Women alcoholics have death rates 50 to 100 percent higher than their male counterparts. Women develop hypertension (high blood pressure), obesity, anemia, malnutrition , and bleeding in the gastrointestinal tract at lower alcohol consumption levels and over a shorter period of drinking. Women become intoxicated after drinking smaller quantities of alcohol than do men. For an equivalent dose of alcohol corrected for body weight, women absorb alcohol faster and reach a higher peak blood alcohol concentration compared to men. These differences can be explained in part by the lower total body water of women compared to men. With a higher percentage of fat and lower water content, there is less volume in which to dilute the alcohol, and its concentration is therefore increased. Women also produce less stomach alcohol dehydrogenase, the enzyme responsible for breaking down alcohol. The effects of some hormones or the immune system in women may account for the increased liver damage.

Tobacco. Historically in the United States, men have had higher death rates from lung cancer, emphysema, and heart disease related to tobacco use. This was due to their higher rates of smoking. As with alcohol use, however, recent trends suggest that women and men are becoming more similar in their patterns of tobacco use despite the possibility that smoking takes a greater toll on women's health. In the 2000 "Monitoring the Future" survey, 8 percent of eighth-grade and 20 percent of twelfth-grade girls reported they smoked cigarettes every day compared to 7 percent of eighth-grade and 21 percent of twelfth-grade boys. Although rates of daily cigarette smoking are almost identical for girls and boys, boys still exceed girls in their use of smokeless tobacco. For example, more than 6 percent of male high school seniors reported daily smokeless tobacco use in 2000 compared to less than 1 percent of senior girls.

Women are at risk for all the same health complications of smoking as are men. The differences seen until the 1990s largely reflect the lower number of women smokers in previous generations. For example, as smoking rates have increased in women, lung cancer rates have also risen. Lung cancer now surpasses breast cancer as the leading type of cancer death among women. Due to their higher rates of smokeless tobacco use, men still far surpass women in their rates of tobacco-related oral cancers.

Illegal Drugs. Among older adolescents and young adults, males are more likely to use most illegal drugs, and the differences tend to be largest for frequent illicit drug use. For example, among high school seniors in 2000, 8 percent of males versus 4 percent of females reported daily marijuana use. Among adults aged 19 to 32 years, 5 percent of males compared to slightly less than 3 percent of females used marijuana daily. Similar patterns are observed for illegal drugs other than marijuana. In the twelfth-grade survey, 11 percent of males compared to 9 percent of females reported using an illegal drug other than marijuana in the previous month. Among eighthand tenth- grade students, however, there are few gender differences in the use of illegal drugs, perhaps because girls tend to date and follow the lead of older boys who are more likely to use and provide drugs.

Reproductive Health

A woman's drinking pattern may be influenced by the mood changes associated with the phases of the menstrual cycle. A woman's blood alcohol level actually measures higher during the premenstrual period for any given amount of alcohol. This may make it difficult for a woman to predict the effects of her drinking. Use of oral contraceptives (birth control pills) by women who smoke cigarettes increases their chance of coronary heart disease. Cigarette smoking is also correlated with a younger age of menopause (the end of menstruation). Alcohol, tobacco, and illegal drugs like cocaine and heroin all contribute to a decrease in fertility, an increased rate of spontaneous abortion (miscarriage), and decreased birth weight in the newborn. A woman who is severely dependent may stop menstruating altogether. The menstrual period resumes if the woman stops using drugs or, in the case of a heroin addict, becomes stabilized on methadone maintenance treatment.

Infants born to women who used alcohol, tobacco, or other drugs during pregnancy can suffer from numerous health problems, including low birth weight, major congenital malformations (birth defects), neurological problems including cerebral palsy, mental retardation, and withdrawal symptoms. Women who drink too much alcohol during pregnancy risk giving birth to a baby with fetal alcohol syndrome, a set of problems that includes facial deformities, abnormal coordination, and behavior and learning problems. Although substance abuse at any time during pregnancy can cause birth defects, the very rapid cell division in the first weeks of the embryo's development means the harmful effects of alcohol and drugs are generally greatest early in pregnancy before a woman may even realize 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 call for removing an infant from the mother's custody in cases where the newborn tests positive for drug and alcohol exposure. In some regions of the United States, mothers who used alcohol or drugs during pregnancy have been charged with crimes such as child abuse or delivering a controlled substance to a minor. Critics of these policies argue that alcohol and drug screening will discourage substance- abusing women from getting the prenatal care they need, because they fear being caught by legal authorities.

Legally, it may be difficult to prove that a woman committed an intentional crime against her unborn child if the substance abuse occurred early in an unintended and unrecognized pregnancy. Further, it is often difficult to disentangle alcohol or drug effects from other harmful conditions the mother may have experienced such as poor nutrition, serious or chronic illness, and inadequate prenatal care. Currently, prenatal drug 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 even though evidence shows that substance abuse occurs in all social and economic categories.

Addiction, Treatment, and Recovery

Women are less likely to become addicted to alcohol or illegal drugs than are men because they use these substances less often than men do. However, when women do use alcohol and drugs, they may be more vulnerable to addiction and face greater obstacles to treatment and recovery compared to men who are addicted to alcohol or drugs. This greater vulnerability of women is due to a combination of factors: physical differences, sex differences in the causes and course of addiction, and social barriers to treatment and recovery.

Telescoping. Research on such varied substances as alcohol, tobacco, and heroin suggest that girls and women move more quickly along the path from experimentation to addiction than do boys or men. In other words, they progress from controlled to uncontrolled use of a substance in a shorter time. This progression is termed "telescoping." It is unclear whether biological or social factors cause the telescoping. Research on adolescents reveals that boys and girls have very similar risk factors for developing a substance abuse problem: friends who use substances, difficulties in school, low academic goals, paid employment, and lack of closeness with and supervision by parents. However, among male and female alcoholics and drug addicts, there are gender differences in the experiences leading to addiction. Girls and women are more likely to report that their alcoholism or drug addiction developed in the course of a relationship with a substance-abusing boyfriend or husband. More female alcoholics and addicts report histories of physical and sexual abuse. Also, more women alcoholics or

addicts attribute their alcohol or drug dependence to a significant loss or trauma , while males more often report their alcohol and drug dependence developed gradually from their recreational drug use .

Obstacles to Treatment. Compared to male alcoholics and drug addicts, female substance abusers face obstacles in seeking treatment and recovering from alcohol and drug dependence. Their lower rates of employment and greater likelihood of working in jobs without healthcare benefits reduce women's access to employee assistance plans and health insurance to pay for substance abuse treatment. Women substance abusers are more likely to be solely responsible for infants and young children who would be forced into foster care if their mothers sought residential treatment. More substance-abusing men receive treatment through drug courts and the prison system. Most substance abuse treatment programs were developed for male clients, and therefore may not meet the unique treatment needs of female clients. Recently, treatment programs for girls and women have made greater efforts to address such issues as childcare, parenting skills, codependence with substance-abusing partners, sexual and physical abuse, and eating disorders.

Gender Issues and Substance Abuse in Special Populations

Within the general categories of male and female are many subgroups. Three of these groups have particular issues related to substance abuse.

Gays, Lesbians, Bisexuals, and Transsexuals. As of 2000, more research was needed to uncover the relationship between discrimination against gays, lesbians, bisexuals, and transsexuals and substance abuse. A common belief since the early 1990s is that lesbians, gay men, and bisexuals are more likely to abuse drugs because of discrimination they experience, as well as the cultural importance of gay bars as meeting places. People in these groups have substance abuse rates about three times that of the general population. The rate of smoking among lesbians increases with age, while the rate for women in the general population declines with age. While gay people in general often do not receive substance abuse treatment at rates equal to other groups, lesbians face barriers beyond those of gay men because of their gender as well as sexual orientation.

Women with Disabilities. Research done since 1996 indicates that women with disabilities have higher rates of illegal drug use than women without disabilities, but lower rates of illegal drug use than their male counterparts. Women with disabilities are at higher risk of substance abuse for several reasons: the early signs of substance abuse are often overlooked because caregivers focus on the disability; the woman is likely to be taking two or more prescription drugs that interact with alcohol; she is often socially isolated; and friends or family may excuse her substance abuse as a way to compensate or make up for the disability.

Women with Eating Disorders. It has been known since the mid- 1980s that women with eating disorders, particularly bulimia nervosa , are at a higher risk of abusing alcohol and other drugs. One study done in the mid-1990s indicates that one in every four bulimic women abuses alcohol. However, the reasons for this overlap are not clear. It has been suggested that bulimics are more likely than women with anorexia nervosa to be impulsive, and that this character trait encourages substance abuse.

Recent Changes in Male Gender Stereotypes

Substance abuse has increased among males born after 1975. A 1998 report explains this increase by noting the growing confusion about male roles. It also points to long-standing explanations of substance abuse (the importance of drugs in joining a male peer group; seeing risk-taking, aggression, and violence as masculine behaviors; and the high rate of drug use among athletes and similar role models). The report observes that young men in the late 1990s are caught between traditional models of masculinity and newer images of "sensitive" men. In addition, the rising rate of eating disorders among men, related to increased media emphasis on male physical appearance, has been linked to an increased risk of substance abuse. Among adolescents and young adults, males are more likely than females to report using anabolic steroids to increase muscle mass. The largely unregulated market of herbal supplements to enhance bodybuilding and sports performance targets male consumers.

Another new substance abuse risk to males is the explosion in the diagnosis and medical treatment of attention-deficit/hyperactivity disorder (ADHD). In the 1990s prescriptions for stimulant drugs to treat ADHD increased over 1,000 percent. Boys are far more likely than girls to be diagnosed with this condition and prescribed drugs to treat it. Little is known about the long-term effects of these drugs, but they are very similar to other stimulants such as amphetamines, which are known to be highly addictive. Substantial increases in nonprescription use of these drugs have already been witnessed, as they have made their way onto the street for recreational use and self-medication (for example, to stay awake to cram for tests). According to the Monitoring the Future survey, for 12th graders the nonmedical use of one such drug, Ritalin, grew from 0.1 percent in 1992 to 2.2 percent in 2000. Since newer ADHD drugs are not specifically included in the Monitoring the Future survey, this figure probably underestimates the extent of nonmedical prescription stimulant use.

see also Attention-Deficit/Hyperactivity Disorder; Babies, Addicted and Drug-Exposed; Eating Disorders; Fetal Alcohol Syndrome (FAS); Substance Abuse and AIDS.