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Section 8
Precursors to FASD: Alcohol Abuse in Women

Question 8 | Answer Booklet | Table of Contents

Alcohol is the most common socially accepted psychoactive substance in use today. In 1998, 45% of women and 59% of men reported alcohol use in the prior month. Although alcohol use is greater among adult men than women, among adolescents, use is approximately equal between genders. In primary care, 10% of female patients and 15% to 20% of male patients are either experiencing or at risk for experiencing alcohol-related problems.

In a general practice, alcoholism prevalence rates approach 20%, similar to rates of other chronic diseases; however, alcoholism continues to be underdiagnosed. Historically, clinicians have identified alcoholism-associated symptoms such as heart disease, cancer, traumatic injury, and depression, but have failed to identify the disease itself. Underdiagnosis persists regardless of ethnicity, race, gender, or socioeconomic status, but the pattern of underdiagnosis is particularly notable in women.

The standard diagnostic definition of alcoholism is the American Psychiatric Association's Diagnostic and Statistical Manual-IV (DSM-IV) criteria (see Table 1). Alcoholism may be characterized as a persistent inability to control drinking coupled with significant negative consequences. Negative consequences include but are not limited to disruptions in interpersonal relationships and economic and legal complications. In 1997, more than 4 million adult women met the diagnostic criteria for alcohol abuse or alcohol dependence compared to approximately 11 million men.

The National Institutes of Alcohol Abuse and Alcoholism defined low-risk drinking for women as no more than one drink per day, two drinks per occasion, seven drinks per week, and no use in risky situations. Women who are considered at-risk drinkers may occasionally exceed the recommended guidelines, but they do not generally experience negative consequences from alcohol use. These women may have a personal or family history of alcohol-related problems but negative results to the CAGE questionnaire.

Women who drink more than recommended (more than seven drinks per week or more than three drinks per occasion), have one to two positive responses to the CAGE questionnaire within a year, and show evidence of alcohol-related medical or behavioral problems are considered problem drinkers. These women meet the DSM-IV criteria for alcohol abuse and often have drinking-related problems such as driving under the influence, job loss, and family disruptions; however, these women do not meet the diagnostic criteria for alcohol dependence.

This distinction is critical because brief interventions with women who are at risk or problem drinkers can result in a reduction in drinking patterns to moderate levels. A metaanalysis of 32 brief intervention studies found that 27% of patients who received brief interventions reported positive changes in their drinking habits.

Gender-based Differences
Much of the literature on alcoholism has focused on men. In the 1970s, researchers recognized that gender-based differences existed in alcohol absorption and in the natural history of alcoholism. Generally, women have approximately 14% less body water content than do men. Because ethanol is a water-soluble molecule that diffuses uniformly, women reach higher blood-alcohol concentration (BAC) levels than do men after drinking equivalent amounts of alcohol.

Physiological differences in the metabolism of alcohol have important implications. Research suggests that women exhibit a "telescoped" or more rapid development of alcoholism with fewer drinking years than do men.  Women generally begin to become intoxicated at a later average age than men (26.5 versus 22.7), experience their first drinking problems later than men (27.5 versus 25), and exhibit loss of control over their drinking at a later average age (29.8 versus 27.2).

Women progress faster than do men between first getting intoxicated regularly and first encountering drinking problems (0.9 years versus 2.3 years) and between first losing control of drinking and onset of drinking problems (5.5 years versus 7.8 years). Researchers conclude that the phenomena of telescoping are robust and consistent with other studies.

The morbidity and mortality data on alcoholism reflect this phenomena. Female alcoholics have death rates 50% to 100% higher than those of male alcoholics. Female alcoholics develop alcoholic liver disease at lower levels of intake and over shorter periods of time when compared with men (P ≤ .001).[ 10] In women, liver disease progresses from alcoholic hepatitis to cirrhosis at a faster rate than it does in men. A greater percentage of female alcoholics die from suicide, alcohol-related accidents, circulatory disorders, and cirrhosis of the liver than do men.

Fetal Alcohol Syndrome
Fetal alcohol syndrome is a devastating potential effect of alcohol use in women. Fetal alcohol syndrome, which is the leading preventable cause of intellectual disability, occurs in 0.3 to 20 cases per 1,000 live births (4,000 to 12,000 infants annually). Alcohol's effect on the fetus depends on the fetal developmental stage, biologic and environmental variables, and the amount and timing of alcohol consumption. One drink daily appears to increase the risk of congenital malformations, particularly in the first trimester. Two to three drinks a day may also increase the incidence of spontaneous abortion, preterm labor and birth, low birth weight, and stillbirth.

According to a national survey, 18.8% of pregnant women reported drinking alcohol during pregnancy. Unfortunately, the incidence of pregnant women drinking alcohol has increased over the past several years. In 1995, 3.5% of pregnant women reported drinking seven or more alcoholic drinks per week or five or more drinks on at least one occasion compared with 0.8% in 1991.

Other Risk Factors
A woman's drinking behavior differs with age, role, and marital status. Younger women tend to engage in binge drinking; older women tend to drink moderately. The highest risk group for drinking to intoxication is ages 21 to 30; however, the incidence of alcohol dependence is greatest among women ages 35 to 49.

In adolescence, differences in substance abuse between genders appear to be lessening. In a 1996 Massachusetts school survey, 54% of young women in grades 9 to 12 were using alcohol compared with 50% in 1993. Current alcohol use among female 7th and 8th graders rose slightly in 1996 to 28%, nearly equal the rate of use among young men (29%).

Women who are single, divorced, separated, or cohabitating are more likely to have alcohol-related problems than married or widowed women. Women are more likely than men to be influenced by their partner's, sibling's, or close friend's drinking habits. Clinically, an association exists between a partner's drinking behavior and the drinking behavior in women. Men, however, are more likely to have partners who do not abuse alcohol.
Reasons for using alcohol differ between men and women. Although men more often use alcohol to socialize, women more often use alcohol to cope with negative moods. Women are also more likely than men to attribute use of alcohol to specific events or stressors.

Women who have multiple roles have a lower incidence of alcohol problems than do women who experience role deprivation. For example, married women who work outside the home have fewer alcohol-related problems than women who have experienced a role loss, such as women whose children have left home.

Caucasian women are more likely to abuse alcohol followed by Hispanic and then African-American women. Lesbian women appear to have higher rates of alcoholism than do heterosexual women. Women suffering from prescription drug abuse are also more likely to have alcohol-related problems when compared with women who are not abusing prescription drugs.
- Backer, Kathleen Lent, Walton-Moss, Benita; Detecting and Addressing Alcohol Abuse in Women; Nurse Practitioner; Oct2001; Vol. 26, Issue 10.

Fetal Alcohol Spectrum Disorders

- Ford-Jones P. C. (2015). Misdiagnosis of attention deficit hyperactivity disorder: 'Normal behaviour' and relative maturity. Paediatrics & child health, 20(4), 200–202.

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 150 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information regarding alcohol abuse in women.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Effectiveness of a practice change intervention in reducing
alcohol consumption in pregnant women attending public maternity services

- Tsang, T. W., Kingsland, M., Doherty, E., Wiggers, J., Attia, J., Wolfenden, L., Dunlop, A., Tully, B., Symonds, I., Rissel, C., Lecathelinais, C., & Elliott, E. J. (2022). Effectiveness of a practice change intervention in reducing alcohol consumption in pregnant women attending public maternity services. Substance abuse treatment, prevention, and policy, 17(1), 63. https://doi.org/10.1186/s13011-022-00490-2

Peer-Reviewed Journal Article References:
Acuff, S. F., Soltis, K. E., Dennhardt, A. A., Borsari, B., Martens, M. P., Witkiewitz, K., & Murphy, J. G. (2019). Temporal precedence of self-regulation over depression and alcohol problems: Support for a model of self-regulatory failure. Psychology of Addictive Behaviors, 33(7), 603–615.

Key, K. D., Ceremony, H. N., & Vaughn, A. A. (2019). Testing two models of stigma for birth mothers of a child with fetal alcohol spectrum disorder. Stigma and Health, 4(2), 196–203.

Marceau, K., Rolan, E., Leve, L. D., Ganiban, J. M., Reiss, D., Shaw, D. S., Natsuaki, M. N., Egger, H. L., & Neiderhiser, J. M. (2019). Parenting and prenatal risk as moderators of genetic influences on conduct problems during middle childhood. Developmental Psychology, 55(6), 1164–1181.

QUESTION 8
What are three factors that affect a female’s alcohol consumption? To select and enter your answer go to Answer Booklet.