GENDER DIFFERENCES IN SUBSTANCE USE DISORDERS

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The notion of meaningful differences between men and women in many aspects of substance use disorders is a topic that has received increasing attention over the past decade. Before this recent era of investigation, substance use was considered to be primarily a male problem, and many of the studies of both alcoholism and drug abuse were conducted with a predominance of male subjects. The recent focus on substance use disorders in women has brought attention to important gender differences in the biology of substances of abuse, epidemiology of substance-use disorders, etiologic considerations, and psychiatric comorbidity. All of these differences have important treatment implications. In this article, the findings concerning gender differences in key areas related to development, diagnosis, and national trends in substance-use disorders are reviewed.

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EPIDEMIOLOGY

Epidemiologic data concerning gender differences in substance-use disorders can be derived from several sources. The Epidemiologic Catchment Area (ECA) study,43 a large survey study conducted in the early 1980s with a representative sample from throughout the United States, showed a number of interesting gender differences. For 1-month prevalence rates of substance-use disorders, men were more than five times as likely to have an alcohol-use disorder and two or three times more likely to have a

SOCIAL ISSUES

A number of social factors differentiating women from men with regard to substance use have been identified. Of major importance is the societal response to women with substance-use disorders. Although substance-use disorders in general are stigmatized, women experience more social disapproval of substance use, and substance use is more stigmatized in women than men.4 Alcoholic women are more likely than men to have alcoholic role models in their nuclear families and to have alcoholic spouses.33

PSYCHIATRIC COMORBIDITY

One area in which many important differences between male and female substance abusers have been found is psychiatric comorbidity. Hesselbrock and co-workers21 reported more depression, panic disorder, and phobia among hospitalized female alcoholics compared with male alcoholics. Similarly, Cornelius and colleagues11 found significantly more major depression and anxiety disorders in female alcoholics and more antisocial personality disorder in male alcoholics. Data from the ECA study20 indicate

DIFFERENCES IN BIOLOGIC RESPONSE

Important gender differences exist in the physiologic effects of alcohol. Women become intoxicated after drinking smaller quantities of alcohol than do men. This may be related to the fact that women have less total body water than men of comparable size, meaning that they achieve higher blood-alcohol concentrations than do men after drinking equivalent amounts of alcohol.35 Frezza et al16 have also demonstrated that women have a lower concentration of gastric alcohol dehydrogenase than do men.

MEDICAL CONSEQUENCES

Long-term alcohol use has more severe medical consequences in women compared with men. Women develop alcoholic liver disease (i.e., cirrhosis and hepatitis) after comparatively shorter and less-intense drinking than do men, and proportionately, more alcoholic women die from cirrhosis than do alcoholic men.17 This may be because of gender differences in body weight and fluid content, or it may be related to an additive effect of estrogen in augmenting alcohol-related liver damage. Some have also

PATTERNS OF HEREDITY

In men, twin and adoption studies have suggested that genetic factors play an important role in the cause of alcoholism, but not until recently were these factors explored in women. In an epidemiologic-based twin study in women, Kendler et al25 found that the concordance for alcoholism was consistently higher in monozygotic compared with dizygotic twin pairs, suggesting a heritability of liability toward alcoholism in women (range, 50% to 60%). Patterns of heritability of drug-use disorders are

COURSE OF ILLNESS

The course of substance-use disorders, particularly alcohol-use disorder, seems to be different for women than for men. The interval between the age of first drinking and treatment-seeking seems to be shorter for women than for men.40 As previously mentioned, studies also suggest that women experience greater medical, physiologic, and psychological impairment earlier in their drinking careers. In addition, women seem to progress between landmarks associated with the developmental course of

TREATMENT

Although a great deal has been written abut the treatment of women with substance-use disorders, little systematic research on gender-specific treatment has been performed. Although some studies have indicated that women are under-represented in alcoholism-treatment programs,2 in recent surveys of treatment programs,7 the ratio of women to men in substance-use treatment programs was consistent with the gender ratios of addictive disorders in the general population. Weisner and Schmidt50 found

SUMMARY

Despite the fact that the rate of substance abuse and dependence is higher among men than it is among women, the prevalence rates, especially the more recent ones, indicate that a diagnosis of substance abuse is not gender specific. From the emerging literature on gender differences over the past 25 years, male and female substance abusers are clearly not the same. Women typically begin using substances later than do men, are strongly influenced by spouses or boyfriends to use, report different

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    Address reprint requests to Kathleen T. Brady, MD, PhD, Medical University of South Carolina, Department of Psychiatry, 171 Ashley Avenue, Charleston, SC 29425, e-mail: [email protected]

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    Center for Drug and Alcohol Programs, Department of Psychiatry, Medical University of South Carolina, Charleston, South Carolina

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