Only recently have social work professionals recognized that too little is known about treatment effectiveness for women's alcohol abuse and dependence, and that empirically based interventions designed around women's issues, concerns, and lifestyles need to be developed. For example, the origin of alcohol problems is highly correlated with experiences of sexual abuse, rape, intimate partner violence, chronic pain, anxiety disorders, and depression. These issues are not addressed by many traditional services, thereby making the services less effective and less relevant to the women being served. Integrating alcohol treatment research into women-centered programming is a critical step in planning for mainstream adoption of women-centered intervention and prevention efforts.
Men and women have both similarities and marked differences in alcohol use, abuse, and dependence. Practitioners must understand that research knowledge based on males can explain, or fail to explain, the experiences of women. This understanding of discrepancies applies to all topics covered in this curriculum. Social workers need to develop a working knowledge of this content to affect appropriate changes in social policy, program planning, evaluation research, social work practice, community norms, and basic science research.
This module is concerned with developing an empirically based understanding of the relationships between women and alcohol. Its bio-psycho-social perspective recognizes ways in which women's biology, psychology, and social worlds interact to affect their reactions to alcohol and to alcohol-related interventions. This module also recognizes that women are not just a homogeneous population, distinct from men. Women are a diverse population, based on their ethnic and national origins, spirituality, sexual orientation, health/mental health, abilities/disabilities, life structures/circumstances, and ages.
By the end of this module, learners should be able to:
A. Describe the biological differences in the effects of alcohol and in alcohol dependence between women and men.
B. Discuss the psychosocial and environmental issues that affect alcohol dependent women.
C. Identify screening questions that can solicit alcohol-related information from women.
D. Discuss the special treatment needs of women with alcohol problem
Alcohol use among women represents an ever-increasing area of concern in social work practice and research. On one hand, findings from large-scale community studies indicate that alcohol abuse and/or dependence rates are much greater for men than women (Grant, 1994; Kessler, McGonagle, Zhao, Nelson, Hughes, Eshleman, et al., 1994; Lewis, Bucholz, Spitznagel, & Shayka, 1996; Regier, Farmer, Rae, Locke, Keith, Judd, et al., 1990). On the other hand, the unfortunate message interpreted through such prevalence reports is that alcoholism is a man's disease. Despite this misperception, women's alcohol use problems have great impact upon our society, not only because of the numbers of women involved but also because of the roles and positions these women occupy in their social contexts.
Epidemiological statistics do not reflect the gender specific differences in male and female drinking or its consequences. In a U.S. telephone survey of childbearing aged women, 50.6% reported any drinking and 12.6% reported frequent heavy drinking-defined as consumption of an average of 7 or more drinks per week or 5 or more drinks on at least one occasion (Centers for Disease Control, 1997). While these criteria may seem to reflect relatively low levels of alcohol consumption, the levels are in excess of those defining moderate or low risk drinking for women, established by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services (National Institute on Alcohol Abuse and Alcoholism, 1992). It is also important to note that there are wide variations in the drinking rates among women from various ethnic and racial groups. For example, Caucasian women have higher rates of drinking and of alcohol problems than women from other racial backgrounds (Grant, 1994).
Women of childbearing age:
- 50.6% reported ANY drinking
- 12.5% reported heavy
Among white women, the frequency of reported heavy drinking (defined as 5 or more drinks on 5 or more occasions per month) diminished during the decade between 1984 and 1995-in all age groups. The highest levels of drinking are still among the 30-39 year olds, and this is true of both time periods. Hence, it is not a cohort effect, but a true age group effect. It is also possible that those women who drink heavily during this stage of life have a much higher rate of attrition from the study groups, and therefore heavy drinkers are less likely to show up among the older age groups. In 1984, the pattern for black women was not dramatically different than that of white women. However, the "improvements" seen among white women by 1995 were not replicated among black women at that point in time. This suggests that racial or ethnic discrepancies in services to screen, diagnose, prevent and treat women with alcohol problems existed by that time. However, noting the period of history, it is also a time when the advertising companies began "targeted ad campaigns" at the black communities-the prevention effort advantages may have been countered by the advertising efforts.
The increasing rates of heavy episodic drinking by younger women are of particular concern (Wilsnack, 1996). Female drinking during early adulthood has attracted attention primarily due to concerns about its effect on both childbearing and parenting responsibilities in our society (Smyth & Miller, 1997). While the consequences of heavy drinking in women over the age of sixty have received minimal attention and research, the reality is that the aging of younger, heavy drinking women may present serious alcohol-related issues in the future.
Between 2.7 and 4.5 million women over age 12 in U.S. are alcohol abusers or alcoholics (Blumenthal, 1998; Straussner & Attia, 2002). NIH's Office of Research on Women's Health (ORWH) addresses and coordinates research efforts related to sex and gender differences in biomedical and behavioral aspects of health, as well as promoting multidisciplinary approaches to a wide array of women's health issues (Pinn, 1998). One of the key initiatives has been women and substance use. This is, in part, because of the many direct effects on women's health and well-being associated with use and abuse of substances, but also because of the many less direct consequences (e.g., exposure to HIV/AIDS and violence, as well as child maltreatment outcomes).
Heavy alcohol consumption affects:
- Brain, CNS, mental functions
- Heart health
- Liver (cirrhosis), GI system (ulcers, pancreatitis)
- Risk of some cancers (e.g., throat, bladder, breast?)
- Weight, nutrition, absorption
- Reproductive health
- Injury (falls, accidents)
For women in particular, the health related aspects of alcohol consumption include:
- Different degree of impact on organ systems (e.g., liver, cognitive function)
- Risks to fetal development
- Compromised parenting capabilities
- HIV/AIDS risk
There is some evidence that women are more likely to engage in or experience risky sexual behavior when intoxicated (Testa & Collins, 1997). This is in part because alcohol may affect a woman's perceptions of risk from a sexual partner (Murphy, Monahan, & Miller, 1998; Testa, Livingston, & Collins, 2000). It is also attributable to the observation that sexual coercion and unwanted sexual activity are statistically related to women's alcohol abuse (Corbin et al, 2001; Felton, Gumm & Pittenger, 2001; Molitor, Ruiz, Lausner & McFarland, 2000; Testa & Livingston, 1999, 2000). Women who drink in bars report numerous encounters of aggression, physical violence, rape, and other forms of assault (Parks, Miller, Collins, & Zetes-Zanatta, 1998); 48.1% of women interviewed had experienced physical violence/assault related to bar drinking; 32.6% had experienced attempted or completed rape (Parks & Miller, 1997).
Comparisons of Men and Women With Respect to Alcohol
Both biological and environmental issues impact women's consumption of alcohol. Alcohol dependence progresses more quickly in women than in men, a process called the "telescoping effect." This results in women developing more physical problems within fewer years of drinking onset (Blume, 1988).
Men and women metabolize alcohol differently. The most noteworthy difference is that smaller concentrations of alcohol produce intoxication in women compared to men, even when body sizes are comparable.
A number of physiological explanations exist for this gendered alcohol phenomenon, including:
- differential weight/body mass
- chemical absorption rates
- stomach enzymes
- ratios of body fat to water (Plant, 1997).
The literature suggests that one explanation for disproportionate gender intoxication (based on equal intake) is that, even when equal body weight is similar, men have more body water content than women. This results in women having higher concentration levels of alcohol circulating in the blood (Mumenthaler, Taylor, O'Hara, & Yesavage, 1999).
Frezza , di Padova, Pozzato, Terpin, Baraona, and Lieber (1990) have reported that the initial process of biochemically breaking down alcohol in the system may be hampered among women. This is due to lower levels among women (as compared to men) of the primary enzyme, alcohol dehydrogenase, found in the stomach and small intestine. This gastric activity, often referred to as the 'first-pass metabolism' has been found to be notably reduced in alcoholic women (Frezza et al., 1990).
The study of biological differences between male and female drinking has focused not only on the metabolic processes involved in alcohol use, but also on the biological consequences. For example, women demonstrate an increased vulnerability to liver damage from alcohol consumption (Lieber, 1997). A recent review of the literature on gender differences reported some evidence that women, compared to men, may present with increased alcohol-related problems relative to cognitive performance (Mumenthaler et al., 1999). Another area of significant concern is the potentially damaging effect of alcohol use related to childbearing potential. Alcohol consumption during pregnancy has been linked with an increased risk of birth defects, low birth weight, and cognitive and motor deficits in children (Straussner, 1994). Children with birth defects from fetal alcohol syndrome or fetal alcohol effects may present with behaviors that require considerably enhanced parenting skills. This specialized parenting may be exceedingly difficult for women who are already struggling with problems associated with alcohol use, abuse, or dependence.
Other research endeavors have examined the environmental factors that place women at a greater risk for alcohol-related difficulties. Alcoholic women are more likely than their male counterparts to come from alcoholic families and to have a greater history of loss experiences (Gomberg, 1976; Gobmerg, 1980). In addition, addicted women have high rates of childhood physical and sexual abuse, as well as other forms of victimization experiences (Clayson, Berkowitz, & Brindis, 1995; Miller, Downs, & Testa, 1993). In one study, 66% of women in alcohol treatment reported a history of childhood sexual abuse compared with 35% of women in a general population sample (Miller et al., 1993). Alcoholic women also report higher rates of partner violence (87% vs. 28%) than other women (Downs, Miller, & Patek, 1993).
Women with alcohol problems have fewer social and economic resources as compared to alcoholic men (Beckman & Amaro, 1986; Gomberg & Nirenberg, 1993). Problem drinking women are also more likely to be divorced single parents, and to have lower income than men (Beckman & Amaro, 1984; Beckman & Amaro, 1986; Gomberg & Nirenberg, 1993). Alcohol-related fatal crashes increased since 1982 for girls aged 15-20, while dropping for boys (Center for Behavioral Health, 2002). Women's alcohol problems are significant because of the numbers of women involved, and their social roles and contexts which are affected (Smyth & Miller, 1997).
Sources of Treatment Discrepancy
Women are more likely than men to be admitted to treatment for "harder drugs" like cocaine, stimulants, and heroin/opiates, and are also less likely than men to be admitted for alcohol and marijuana-63% of men are admitted for alcohol/marijuana compared to 47% of women admitted for alcohol/marijuana (DASIS, 2001).
Alcoholic women, compared to men, may experience less social support from friends and family for entering addiction treatment programs (Beckman & Amaro, 1986). In particular, childcare issues become exceedingly challenging barriers to treatment if women do not have the necessary support and must choose between meeting parental responsibilities and achieving recovery (Finkelstein & Derman, 1991). Furthermore, married alcoholic women are more likely to be married to an alcoholic partner than non-alcoholic married women (Miller, Smyth, & Mudar, 1996). These complex factors affect engagement in treatment programs and suggest clues as to why women have been underrepresented in addiction treatment programs. While there is some indication that more women are now entering addiction treatment (Schmidt & Weisner, 1995), there is still great variation among specific treatment programs.
- Marriage to alcoholic partner
- Co-morbid problems from past victimization
- Low self esteem
- Social withdrawal
- Social policy
Research has revealed that past victimization places alcohol-abusing women at an increased risk of experiencing other, co-morbid psychiatric problems (Finkelhor & Browne, 1986). In general, community women with alcohol problems are at a greater risk for psychiatric disorders (19% vs. 7%) than are women who report no alcohol problems (Helzer & Pryzbeck, 1988). The most common disorders reported in this research were depression and anxiety. Rates of dual disorders-mental health and addiction-are generally higher in treatment settings (20-50%) compared to community-based settings (Zimberg, 1993). In addition, younger alcoholic women under age 40 were found to attempt suicide almost five times more frequently than nonalcoholic women (Gomberg, 1989).
Other risk factors for alcoholic women, as compared to nonalcoholic women, are low self-esteem and guilt (Colton 1979; Reed, 1985), stigmatization (Bepko, 1991), and social withdrawal (Turnbull & Gomberg, 1991). These compounding problems contribute to both women's avoidance of treatment services and the lack of an "appropriate fit" between women's treatment needs and treatment program characteristics.
Another barrier to possible treatment options for addicted women is inconsistent and fluctuating social policy. Child protection laws and regional child welfare practices may place women at risk for prosecution (Hawk, 1994). Whether reality or perception, this vulnerability deters many woman from utilizing addiction treatment programs and from seeking prenatal health care (Hawk, 1994; Merrick, 1993).
Screening and Assessment Issues
The lack of social support for women with alcohol problems, possible legal repercussions, and the increased likelihood of mental health problems make the recognition and identification of alcohol disorders problematic. The use of screening instruments is a first-level attempt to identify potential alcohol problems in women. Their use is viewed as a process that leads to early diagnosis of, and intervention with, alcohol-related issues (Substance Abuse and Mental Health Services Administration, 1993). The Addiction Severity Index (ASI) currently has a form specific to women (ASI-F).
Another of the few screening instruments validated on women is the TWEAK (Russell, 1994):
T. Tolerance: How many drinks can you "hold"? (Number = _____)
W. Have close friends or relatives Worried or Complained about your drinking in the past year?
E. Eye-Opener: Do you sometimes take a drink in the morning when you first get up?
A. Amnesia (blackouts): Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
K. Do you sometimes feel the need to Kut Down on your drinking?
The TWEAK is scored with a seven-point scale. Two points are attributed to a woman who reports that she can "hold" more than five drinks without passing out (Tolerance), and a positive response to the "worry" question scores two points. The last three questions score one point for each positive response. A total score of three or more points indicates a woman who is likely to be a "heavy/problem drinker" (Allen & Columbus, 1995).
A positive screen for alcohol use problems should lead to further screening and assessment related to current partner violence, child maltreatment, and possible current and past sexual and physical abuse. Research suggests that multiple, specific questions are more effective in establishing reports of childhood sexual abuse than are single, general questions (Peters, Wyatt, & Finkelhor, 1986). It has also been suggested that women are more likely to respond positively to female interviewers, given the sensitive nature of sexual abuse issues (Miller et al., 1993) and the gendered nature of intimate partner violence experiences.
It is important for clinicians consistently to assess for past and present psychiatric disorders, and the part they play in alcohol use problems and women's role functioning (Brown et al., 1995; Davidson, 1995; Sederer, 1990). Women with alcohol problems should also be evaluated for issues involving poor self-esteem, family relationships, and parenting concerns that may present significant barriers to successful treatment outcomes.
Personalized psychoeducational interventions concerning the negative and harmful aspects of alcohol abuse and dependence can be helpful to motivate women to reduce their alcohol intake or to become abstinent. In particular, women appear to have better outcomes than men to moderate drinking treatment programs and programs that provide choice of treatment goals (Sanchez-Craig,, Leigh, Spivak, & Lei, 1989; Sanchez-Craig, Spivak, & Davila, 1991).
Couples and family system counseling may be beneficial for the family. It may be vital to treat individual family members or family subsystems, particularly the children (Logue & Rivinus, 1991). Among adult children of problem drinking mothers, one study found that 40% of daughters and 36% of sons reported a history of childhood sexual abuse. Rates of alcohol and other drug problems were 40% and 68%, respectively (Miller et al., 1996). Varied treatment approaches can address issues specific to alcoholic women. Counseling that deals with low self-esteem, such as assertiveness training and coping skills development, has been promising (Reed 1985). Given the high rate of physical and sexual abuse among problem drinking women, it would be beneficial to incorporate specialized treatment for trauma survivors into any program that serves addicted women (Evans & Sullivan, 1995).
Working through problems related to having an alcoholic partner is an especially important intervention (Zelvin, 1997). Addressing these problems within support groups may provide additional strength through positive feedback and the reduction of personal stigmatization. Specialized self-help groups for women, like Women for Sobriety, can be especially useful (Kaskatus, 1996). Women only meetings of Alcoholics Anonymous can also fulfill many of these needs. Parenting groups are also recommended to increase parental self-concepts and effective parenting skills (VanBremen and Chasnoff, 1994). Due to issues of guilt and shame, special parenting programs targeting addicted mothers should be considered.
Whether women should be in women-specific vs. mixed gender groups is an issue of debate (McCrady and Raytek, 1993, Vannicelli, 1984). An evaluation of women-only vs. mixed gender addiction groups found that women identified several issues that they would discuss only in women's groups, including guilt regarding being an inadequate mother (Kauffman, Dore, & Nelson-Zlupko, 1995). Two studies found superior outcomes for women treated in specialized women's programs vs. mixed gender programs (Dalhgren & Willander, 1989; UCLA Study, 2000). While two others found no differences (Copeland, Hall, Didcott, & Briggs, 1993; Dodge & Potocky-Tripodi, 2001), the Copeland team noted that the treatment program content had not been altered significantly to accommodate the specialized needs of women, only that it had female staff and women group members.
It is important that social workers be ever mindful that many addicted women struggle with additional guilt, shame and inadequacy as women and particularly, as mothers. Empathy, compassion, sensitivity, and respect are the cornerstones of any intervention practices involving women battling with addictions. Clinical work must include focused attention on women's self-perceptions and their past and present life experiences. It is also important to recall that women face difficulties in participating in treatment: child care, basic access, and other gendered issues (DASIS, 2001).
Empowerment to change is derived from a strengths approach to assessment and treatment. Treatment of women experiencing problems related to alcohol abuse and dependence is a complicated task. It is important to recognize that women have unique aspects to their alcohol problems and to understand the complex interplay of biological, psychological, social, and environmental factors.
Only through effective recognition and treatment of gender concerns can we hope to interrupt the cycle of addiction, violence, and mental health problems facing a significant number of women in our society.
RECOMMENDED CLASSROOM ACTIVITIES
- Read the following and report on its significance for social work practice with individuals who experience alcohol use problems:
a. Straussner, L.A. and Straussner, S.L.A. (eds.) Gender and Addictions: Men and Women in Treatment. Northvale, NJ: Jason Aronson, 1997.
b. Lieber, C.S. Gender differences in alcohol metabolism and susceptibility. In R. W. Wilsnack, S. C. and Wilsnack (Eds.) Gender and Alcohol: Individual and Social Perspectives (pp. 77-89). New Brunswick, N. J.: Rutgers Center of Alcohol Studies, 1997.
- Read the following and report on its significance to understanding alcohol use problems:
a. Evans, K. and Sullivan, J.M. Treating Addicted Survivors of Trauma. New York: Guilford Press, 1995.
- Read the following and report on its implications for social work practice with women of reproductive age:
a. National Institute on Alcohol Abuse and Alcoholism. Special Focus: Alcohol-related birth defects. Alcohol Health and Research World. 18(1), 1994.
- Visit the following website and report on its contents:
a. Women for Sobriety: [Online] http://www.womenforsobriety.org Women For Sobriety, Inc. (They can also be reached at: P.O. Box 618, Quakertown, PA 18951-0618, or (215) 536-8026).
DISCUSSION TOPIC1. Discuss the implications of the information presented here and in a source such as the book, Women's Ways of Knowing, in reference to the suggestion that women-only treatment contexts should be made available. Discuss what a male social worker could/should consider when working with women who have alcohol use problems. (Belenkey, M. F., Clinchy, B.M., Goldberger, N.R., & Tarkle, J. M. (1986). Women's Ways of Knowing: The Development of Self, Voice, and Mind. New York: Basic Books.
Allen, J. P., & Columbus, M. (Eds.) (1995). Assessing alcohol problems: A guide for clinicians and researchers. NIAAA Treatment Handbook, Series 4 (no. 95-3745-1995). Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism.
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Beckman, L. J., & Amaro, H. (1986). Personal and social difficulties faced by women and men entering alcoholism treatment. Journal of Studies on Alcohol, 47, 135-145.
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Logue, M. E. & Rivinus, T. M. (1991). Young children of substance-abusing parents: A developmental view of risk and resiliency. In T. M. Rivinus (Ed.) Children of chemically dependent parents: Multiperspectives from the cutting edge (pp. 55-73). New York: Brunner/Mazel.
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Updated: March 2005