Gender Differences in Addiction: Clinical Implications
Dependence on alcohol and tobacco or illicit drugs is generally higher in men, but the gender gap is narrowing at an alarming rate, especially in adolescents.
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KEY POINTS
FIGURE 1. Gender differences for drinking and tobacco use
FIGURE 2. Worldwide prevalence of substance use
Dependence on or harmful use of alcohol and tobacco or illicit drugs is generally higher in men. Epidemiological studies, however, indicate an alarming narrowing in this gender gap especially in adolescents, which may reflect changes in sociocultural patterns rather than biology. Yet, health consequences significantly differ according to gender. In addition, women’s consumption of psychoactive substances during pregnancy may be associated with serious birth and developmental consequences in newborns.
The World Health Organization has defined different risks for occasional and chronic alcohol use in women, which are significantly lower in women: low risk (<20 g/d); moderate risk (>20-40 g/d); high risk (>40 g/d). There is no safe level for tobacco or illicit drug use.
Epidemiologic differences
Slade and colleagues1 stratified 68 studies by 5-year birth cohorts from 1891 to 2001. In cohorts born in the early 1900s, males were 3.0 times more likely to drink alcohol (problematic use) and 3.6 times more likely to experience alcohol-related harm. In contrast, among cohorts born in the late 1900s, males were 1.2 times more likely to drink alcohol (problematic use) and 1.3 times more likely to experience alcohol-related harm.
Worldwide, the total alcohol per capita consumption in 2010 was on average 21.2 L and 8.9 L of pure alcohol in male and female drinkers respectively. Europeans and Americans had the highest prevalence of female current drinkers and heavy episodic drinkers-defined as drinking at least 60 g or more of pure alcohol on at least one occasion in the past 30 days (Figure 1). In the US, 10% to 11% of women were using alcohol during pregnancy in 2010.2 In France, findings indicate that on average 15.8% of women use alcohol during pregnancy.3 The prevalence of reported binge drinking (defined as four or more standard drinks on one occasion) was 3.1% in pregnant women compared with 18.2% in women of childbearing age. Higher rates of substance and alcohol abuse were found among minorities and adolescent LGBT populations.4,5
The highest prevalence of tobacco use was reported in Europe (19.3% of women) followed by the Americas (13.5% of women, 17.5% of men in the US). The prevalence of tobacco use (cigarettes) was very similar among boys and girls in Europe and even higher in girls in the Americas. In the US, 14.9% of pregnant women reported tobacco use in the past month.2
The worldwide prevalence of cannabis, amphetamine, cocaine, and opioid use was 0.14%, 0.18%, 0.06%, and 0.14%, respectively in females compared with 0.23, 0.31, 0.14 and 0.31% in males (Figure 2). In the US, 12.8% of males and 7.3% of females aged 12 years and older used an illicit drug during the past month in 2015. More men than women aged 12 and up reported using marijuana (10.9% vs 6%), cocaine (0.8% vs 0.4%), and hallucinogens (0.6% vs 0.3%). A notable
exception, however, is the non-medical use of tranquillizers and sedatives.6
Considering behavioral addictions, the prevalence of food binging (especially chocolate) was higher in women. For sexual addiction, gambling, or internet addiction the prevalence was generally higher in men. For exercise, the results were mixed.7,8
Health consequences
There are important gender differences in terms of pharmacokinetics and pharmacodynamics. The small number of studies on gender differences in addictions is surprising when considering the modulatory role of estradiol in decision making and its interplay with dopamine in modulating reward, motivation, and cognitive processes. Using the same amount of alcohol as men, women usually have greater alcohol blood concentrations, which increases the risk for health problems. Morphine has both a slower onset and offset at μ-opioid receptors in women, thus women usually require higher dosages of morphine.9 Nicotine metabolism is faster in women (especially in those who are using oral contraceptives at the same time).10 In addition, heavy drinking puts women at risk of injuries and death from accidents, as well as unsafe sex, sexual assaults, and violence.
Worldwide, alcohol-attributable mortality is higher in men. Cardiovascular diseases are the most important cause of alcohol-attributable mortality in women. In men, injuries are the most common cause of alcohol-attributable mortality. Health consequences are more frequent in males, which reflects sex differences in the prevalence of alcohol use disoders (AUDs), except for a higher percentage of disability-adjusted life years (DALYs) for cancers and cardiovascular diseases in women.11 The risk of breast cancer increases according to the daily dose of alcohol used with a relative risk (RR) of 5 to 9 with one standard drink daily and of 41 with three to six standard drinks daily.12
The protective effect of alcohol at low dose is less clear in women than in men, in whom a clear decrease in RR of ischemic heart disease is observed at doses lower than two to three standard drinks daily. Similarly, the RR of liver cirrhosis increases by 13 with four standard drinks of alcohol in women compared with six standard drinks daily for men.
The worldwide proportion of all deaths attributable to tobacco is 12% among adults aged 30 years and older. Cigarette smoking is the leading cause of preventable disease and death in the US, accounting for more than 1 in 5 deaths. Jemal and colleagues13 found a decrease of annual age-adjusted death rates from almost all cancers among women (including breast cancer) except for lung and bronchus cancer, which has dramatically increased since the 1930s. These findings were confirmed by Pirie and colleagues14 in a cohort of 1.2 million women followed for 12 years in the United Kingdom with an RR of 21 for lung cancer in women who smoked.
The total burden (DALYs) of drug dependence remained about half in women, the highest number was seen with opioids.15
Pregnancy and psychoactive substance use
Despite the international consensus recommending total abstinence of psychoactive drug use during pregnancy, prenatal alcohol, tobacco, or illicit drug exposure remains a major public health issue. In particular, alcohol consumption during pregnancy is associated with a large range of adverse effects including spontaneous abortion, stillbirth, weight and growth deficiencies, birth defects, prematurity and fetal alcohol spectrum disorder.
Based on data obtained in seven countries (Australia, Canada, Croatia, France, Italy, South Korea, and the US) on the prevalence of both alcohol use during pregnancy and resulting fetal alcohol syndrome (FAS), Popova and colleagues16 estimated that 1 in every 67 mothers who consumed alcohol during pregnancy had a child with FAS. Prematurity and low birth weight are also frequently associated with tobacco exposure during pregnancy (smoking or second-hand smoke). The World Federation of Societies of Biological Psychiatry and the International Association for Women’s Mental Health have recently published guidelines for the treatment of alcohol use disorders in pregnant women.17
Vulnerability and environmental triggers
In general, women with addictive behaviors exhibit higher comorbid neuropsychiatric disorders than men (eg, anxiety, depression, stress-related disorders) which are, in turn, more likely to trigger craving and relapse in women. Women are also more likely to have a lower socioeconomic status (eg, lack of education, lower job status, worse financial situation, violent partners, history of sexual violence).
Weight control also plays an important role in women who use tobacco. Women may be using alcohol or tobacco to better fit the societal norm.
Other factors underlying sex differences in tobacco use were identified in several studies: pleasure/rewarding, compulsion, and gesture are important in both men and women. In contrast, transgression as well as psychostimulant effects of tobacco might play a greater role in women who smoke. In women, restrictions, lack of availability of a drug on the legal market, or the price may reduce tobacco smoking or drug intake.18
Men and women are also differentially affected by environmental triggers for relapse to drug taking. Potenza and colleagues19 reported sex differences in neural correlates of cocaine-induced craving. Corticostriatal-limbic hyperactivity was linked to stress cues in women but to drug cues in men. In the same way, women are also less sensitive to the reinforcing effects of nicotine but more sensitive to social cues.
Gender differences in treatment
Women are more likely than men to encounter barriers that prevent them from seeking or continuing treatment (eg, economic barriers, family responsibilities, comorbid psychiatric disorders, feeling shame). Worldwide, female outpatients are still underrepresented in specialized treatment settings. Often, women seek substance abuse treatment in primary care and mental health settings. In the US, many women now appear at least as likely as men to engage in and complete treatment. Nevertheless, African American women as well as women with lower incomes or who have psychological problems or greater severity of addictive disorders are less likely to continue with treatment. Yet, addiction treatment is at least as effective in women as in men.
Conclusion
Despite a higher prevalence of substance use observed in men, women begin using drugs at younger ages. They develop addiction more quickly with a stronger motivation to take drugs and have different propensities to relapse. Despite this, female outpatients are still underrepresented in specialized treatment settings. Training care providers in primary care and mental health settings may help to identify and refer women to specialty addiction services. Providing services such as child care, also helps keep women in treatment. Finally, raising public awareness about the risks of alcohol, tobacco, and illicit drug use during pregnancy is crucial, especially in all women of childbearing age.
Resources
The National Center on Substance Abuse and Child Welfare
Women and Smoking: A Report of the Surgeon General
Disclosures:
Dr Thibaut is Professor of Psychiatry, University Hospital Cochin (site Tarnier), Faculty of Medicine Paris Descartes, INSERM U 894, Centre Psychiatry Neurosciences, Paris, France.
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