Section II: Results

5. Women's Substance Use and Misuse: Overview

5.1 Historical Background

Historically, substance use patterns among women have varied and the societal interpretation of these patterns has had impacts on attitudes toward women's use of substances as well as on treatment responses. In the 17th and 18th centuries, Cooper (1991) noted that alcohol was consumed by men, women and children and was not considered morally "wrong" or dangerous. In the 50-year period from 1776 to 1826, North American society's view of drinking changed; alcohol came to be considered "demonic" and unsafe. By the end of the 19th century, drinking was deemed a "lower class" activity and, among women, was associated with prostitution or "loose morals." However, alcohol and certain drugs were still included in commonly-used medications well into the 20th century (Hewitt et al., 1995).

Until the mid-1970s, the extent of heavy drinking among women in general was considered to be minimal, and there was a paucity of research exploring substance misuse. For example, "between 1970 and 1984, women represented only 8% of subjects in alcoholism studies" (Cooper, 1991:1). Though, in comparison with men, women are less likely to report heavy drinking occasions and alcohol-related problems (36% of those reporting alcohol-related problems are women) (Canadian Centre on Substance Abuse and Centre for Addiction and Mental Health, 1999), there are still concerns that women are under-represented in substance abuse treatment settings. In the 1980s, women made up only 20% of clients in treatment.

The emphasis on male substance use patterns and treatment for men has resulted in a "male as norm bias," which has judged women who require treatment more harshly, and has limited the exploration of gender-specific treatment approaches (Finkelstein et al., 1997).

5.2 Use Patterns

Recent Canadian research (Health Canada, 1995; Health Canada, 1997, Canadian Centre on Substance Abuse and Centre for Addiction and Mental Health, 1999) identifies the following patterns of substance use among women.

• Alcohol is the most common substance used and misused by women.
• Women, in comparison with men, are less likely to be current drinkers, and more likely to be former drinkers or lifetime abstainers.
• Women who are current drinkers drink less frequently and consume smaller amounts than men who are current drinkers.
• The proportion of women who completely abstain from alcohol is decreasing.
• Among women who are current drinkers, 6.2% report the occurrence of an alcohol-related problem in the past year.
• The most common problem women associate with "problem" alcohol use is related to impacts on physical health.
• Women most frequently drink with a spouse or partner.
• Women who drink a higher number of drinks per occasion tend to:
  - be younger;
  - have lower educational attainment;
  - have lower incomes;
  - be single or divorced;
  - be unemployed, a student or in a blue collar job.
• Women who report drinking more frequently tend to:
  - be older;
  - have higher educational attainment;
  - have higher incomes;
  - be single or divorced;
  - hold blue collar or managerial positions.
• In any age group, women are more likely than men to report the use of medications, especially psychoactive medications such as sleeping pills, tranquillizers and anti-depressants. The age categories reporting the heaviest use are 45 to 54 and 65+.
• Marijuana and hashish are the most common drugs used illegally by women.
• Except for marijuana, lifetime illegal use of drugs is relatively rare among Canadian women. Illegal use of drugs decreases with age and is almost non-existent after age 45.
• Cocaine, crack, LSD, amphetamines and heroin are used primarily by sub-group populations (e.g. street involved women). Because general population surveys usually miss these groups, the overall use of these drugs may be under-reported.
• In 1995, there were 804 deaths in Canada attributable to illicit drugs. One hundred and eight (13%) were women.

5.3 Impacts of Substance Use on Women

Substance use impacts on women in a variety of ways, many unique to gender. A review of the literature suggests the following general themes:

• The physical health of women is affected more severely and in a shorter period of time by intensive substance use (in comparison to men). Women reach higher peak blood alcohol levels than men from equal doses per pound of body weight. Hill (as cited in Schliebner, 1994) reported that "the average duration of excessive drinking before first signs of liver disorders, hypertension, obesity, anemia, malnutrition, gastrointestinal hemorrhage and ulcers requiring surgery is much shorter for women than for men (1994:513). Other health effects include risk of HIV, osteoporosis and coronary disease (Finkelstein et al., 1997). Physiological differences between men and women also make women more vulnerable to health effects of other drugs such as tobacco and benzodiazepines (Addiction Research Foundation, 1996).
• Women's reproductive physiology is uniquely affected by substance misuse. Excessive drinking can affect the menstrual cycle, fetal development, child birth, menopause and sexual responsiveness (Finkelstein et al.,1997).
• Among women, mental health disorders are commonly associated with and exacerbated by intensive substance use. Almost two thirds of women alcoholics have mental health problems (Halzer and Pryabech as cited in Beckman, 1994b). The most common disorders are anxiety, depression, phobias and panic disorders. Women alcoholics also report experiencing more depressive symptoms than male alcoholics physiologically (although alcohol itself has a depressant effect). However, depressive symptoms may persist after sobriety (Turnbull and Gomberg as cited in McCrady and Raytek, 1993).
• Women who misuse substances are at high risk for suicide ideation and completion
  (Finkelstein, 1997).
• Women who misuse substances commonly experience sexual dysfunction. Prevalence estimates of sexual dysfunction range from 20% to 100% depending on research (Acherman as cited in Beckman, 1994b). According to Wilsnack et al. (as cited in Finkelstein et al.,1997), sexual dysfunction in women is one of the strongest predictors of continued problem drinking. Impacts of substances on sexual functioning may vary according to the substances used.
• Women who misuse substances typically experience low self-esteem (Gomberg as cited in Drabble, 1996).
• Other health disorders are associated with women who misuse substances. Eating disorders, particularly bulimia, frequently occur concurrently with alcohol problems (Peverler and Fairburn as cited in McCrady and Raytek, 1993).

Specific characteristics appear to be associated with women who misuse alcohol or drugs. These are causative, rather than associated factors:

• High rate of childhood sexual abuse. The rate of historic sexual abuse is higher in women with drinking problems than in the general population. Estimates of the prevalence of incest, for example, range from 12% to 31% (Young, 1990; Beckman and Acherman as cited in Beckman, 1994b).
• High rate of victimization. Women who misuse alcohol are likely to have had a history of victimization in general (including physical violence) (Thom, 1986 and Smith, 1992 as cited in Schober and Annis, 1996). In a study of 472 women (ages 18 - 45), Miller et al. (1993) concluded that there is a strong linkage between victimization and the development of adult alcohol problems.
  

One of the most important differences between men and women is that they identify different reasons for using drugs or alcohol. Women typically see drugs/alcohol use as a method of coping with specific crises or personal problems. This perception determines their definition of "problem," identification of needs and their approach to seeking help.