The steady near-equalization in patterns of alcohol use and misuse between women and men over the last decade has revealed women’s greater risks for alcohol-related consequences. A 2015 National Institute on Alcohol Abuse and Alcoholism (NIAAA)-led analysis of annual data from the National Survey on Drug Use and Health found that differences in measures such as current drinking, number of drinking days per month, reaching the criteria for alcohol use disorder (AUD), and driving under the influence of alcohol in the past year all narrowed for U.S. females and males between 2002 and 2012. An analysis of six different national surveys between 2000 and 2016 suggests that the number of women ages 18 and older who drink each year increased by 6 percent but the number of men who drink each year decreased by 0.2 percent, and the number of women who binge drink increased by 14 percent but the number of men doing so increased by only 0.5 percent. At the same time, analyses of the adverse effects of alcohol have shown that, compared to men, women are more likely to experience blackouts, liver inflammation, brain atrophy, cognitive deficits, certain cancers, negative affect during withdrawal and stress, and anxiety-induced relapse.
“A consistent finding of epidemiological studies in recent years has been that measures of total alcohol consumption and misuse among women have largely converged with those of men, and women are more likely to suffer harmful consequences of drinking,” says NIAAA Director George F. Koob, Ph.D. “While men still hold a dubious ‘lead’ in these categories, the differences are much smaller now than they were throughout the last century, when measures of alcohol consumption and harmful alcohol use by men exceeded those of women by as much as a 3 to 1 margin.”
Higher Blood Alcohol Concentration (BAC) and More Alcohol Pathology
Studies show that women start to have alcohol-related problems sooner and at lower drinking levels than men do—and for multiple reasons. On average, women weigh less than men. Also, alcohol resides predominantly in body water and, pound for pound, women have less water in their bodies than men. This means that after a woman and a man of the same weight drink the same amount of alcohol, the woman’s blood alcohol concentration (BAC, the amount of alcohol in the blood) will tend to be higher, putting her at greater risk for harm. Reaching the “binge drinking” threshold of 0.08 percent BAC tends to require fewer standard drinks for females than males—roughly 4 drinks in 2 hours instead of 5 drinks in 2 hours. Other biological differences may contribute to women’s alcohol-related problems as well.
Studies also show that women have faster progression of AUD than men and are at greater risk than men for certain alcohol-related consequences. For example, compared with men, women with alcohol-associated liver disease have a more rapid progression to fibrosis that persists after abstinence from alcohol. Studies demonstrate that women who consume about 1 drink per day have a 5 to 9 percent higher chance of developing breast cancer than women who do not drink at all.
Alcohol-related medical emergencies and deaths are increasing among women as well. Although men still account for most emergency department (ED) visits, women are catching up. For instance, between 2006 and 2014, the number of ED visits involving alcohol increased by 58 percent for men and by 70 percent for women. Unfortunately, women are less likely than men to be advised about the risk of binge drinking, and women who report binge drinking are less likely to be advised to reduce their drinking.
And in October 2020, the U.S. Centers for Disease Control and Prevention (CDC) reported that the rate of alcohol-induced deaths among women in rural areas more than doubled between 2000 and 2018, rising 150 percent, compared with a 50 percent increase among males over the same period.
Drinking To Cope
For some time, research suggested that levels of anxiety and depression are increasing among adolescents and young adults, particularly females. CDC recently reported that ED visits for suicide attempts increased 51 percent for adolescent females during the pandemic compared to 4 percent for males. Evidence also suggests that females, in general, are more likely than males to drink to cope. Drinking to cope is associated with a faster progression of alcohol misuse and a higher incidence of alcohol-related harms. The percentage of adolescents who report drinking alone on their last drinking occasion also is increasing, and more so for girls than boys. Drinking alone is predictive of developing problems with alcohol.
It is common for people to consume alcohol in an effort to cope with stress, sleep disturbances, and even boredom. Beginning in adolescence, females are more likely to suffer from anxiety disorders and depression, increasing the motivation to drink alcohol for temporary relief. Unfortunately, this approach tends to make problems worse, not better, and increases the risk for AUD and other adverse consequences. Although alcohol temporarily dampens the body’s response to stress, feelings of stress and anxiety not only return but worsen once the alcohol wears off. Over time, alcohol misuse can cause adaptations in the brain that intensify the stress response. As a result, drinking alcohol to cope amplifies feelings of stress, anxiety, and depression, and one may end up drinking to fix problems caused by the alcohol itself.
Events such as the 9/11 attacks and Hurricane Katrina showed that stressful situations and anxiety about the future can increase people’s drinking and exacerbate symptoms of AUD. Feelings of social isolation and the loss of social support, which are possible side effects of the COVID-19 pandemic, can worsen symptoms of anxiety or depression, and may encourage more alcohol intake. Indeed, the current COVID-19 crisis appears to have fueled increases in retail alcohol sales. For people experiencing stress from unemployment to feelings of isolation during physical distancing, the COVID-19 emergency may be influencing alcohol consumption for many reasons. In several studies, increases in drinking were more likely for women, particularly those reporting increases in stress. Women have been affected more, in a variety of ways, by the pandemic due to increased responsibilities as they care for children and families—often while still working—in addition to the loss of more jobs and income than men, and preexisting differences in pay and in the number of single-parent homes led by women. These stressors are associated with more alcohol use among women.
“It is important that women be aware of these health risks and the 2020–2025 U.S. Dietary Guidelines for Americans. The Guidelines recommend that women of legal drinking age who choose to drink should limit their intake to 1 drink or less in a day, when alcohol is consumed,” says Dr. Koob. “Drinking less is better for health than drinking more. Some individuals should avoid alcohol completely, such as those who are pregnant or might be pregnant, or people taking medications that could interact negatively with alcohol.”
Webinar – Innovations in Treating Stress and Trauma in Women With Alcohol Use Disorder
NIAAA continues to support research to develop improved alcohol interventions for females and to promote greater awareness of the growing impact of alcohol misuse among women. Recently, NIAAA hosted a webinar titled Innovations in Treating Stress and Trauma in Women With Alcohol Use Disorder. The webinar focused on vulnerable populations— such as women living with HIV and female veterans with military sexual trauma—and included discussions about advances in treatments, such as community partnerships and development of medications targeting stress. The webinar featured NIAAA-supported research conducted by Geetanjali Chander, M.D. (Johns Hopkins University School of Medicine); Tracy Simpson, Ph.D. (Veterans Affairs Puget Sound Healthcare System), and Sherry McKee, Ph.D. (Yale School of Medicine).
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This article first appeared in NIAAA Spectrum.
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