Women and their special needs regarding addiction was the topic of a recent two-day conference held at New York University (NYU).
Women and their special needs regarding addiction was the topic of a recent two-day conference held at New York University (NYU).
Called "Women Healing: A New Look at Women and Recovery," the conference was presented by the Minnesota-based Hazelden Institute in collaboration with the Betty Ford Center at Eisenhower in California.Together they are presenting a series of similar conferences across the United States, with all conference profits to be used for treatment scholarships for women.
The New York City event-the second in the national series-was cosponsored by Hazelden New York and NYU's Shirley M. Ehrenkranz School of Social Work. It included a Friday seminar for health professionals involved in treating women, and a Saturday meeting for recovering women themselves. Speakers on both days included numerous representatives from the cosponsoring organizations plus other experts in the field, including author Stephanie S. Covington, Ph.D., co-director of the California-based Institute for Relational Development, and Anne Geller, M.D., chief at Smithers Alcoholism Treatment Center in New York and associate professor of clinical medicine at Columbia University's College of Physicians and Surgeons, who presented an overview of gender differences in addiction.
Gender Differences in Addiction
"The most important gender difference in the addictions, as in all medicine, is access to treatment," said Geller. "Women are much less likely to be insured, much more likely to be poor, and much more likely to have children to take care of, all of which prohibits treatment. This is really, for me, a burning political issue, and without our continued advocacy, the state of affairs will not change."
The second issue, said Geller, is the paucity of research on women's health.
"It's a measure of how we accept the status quo that very little is known about women's health," she said. "Until the last decade, all studies were done on men, especially addiction studies. This is because women were not around and it was a nuisance to study people with so many variables-pregnancy and menstruation create a great deal of noise in the system. It wasn't until 1991 that there was an initiative and an Office of Women's Health set up. Now, every time an NIMH grant is submitted, it has to include women or give a good reason why they're omitted."
Geller noted that little is known about coronary heart disease in women, even though it's the number one killer of females.
"Almost all studies have been done with men," she said. "And women are much less likely to be diagnosed and treated than men. Furthermore, the major cancer killer for us is not breast cancer, but lung cancer. So in recognizing these facts, one of the things we've learned as part of the recovery process is to change our habits and lifestyle, not just in relationship to the addiction one came in for, but the entire lifestyle. We must [urge women to] change diet, exercise and quit smoking."
Geller said the strategy in the alcoholism treatment community used to be that "you deal with the alcohol first, then five to 10 years down the road, the cigarettes. But it's the cigarettes that will kill...This is important because you look at breast cancer and say there isn't anything you can do about it, but it's very clear what you can do about the major killers-lung cancer and heart disease."
Stigma of Female Addiction
Another factor in addiction treatment is the attitude of society in general about women and addiction, and the attitude of women themselves about female addiction.
"We hate ourselves for our addictions far more than men do," said Geller, reporting on a study wherein women who were not alcoholic rated mothers who drank heavily much more harshly than fathers who drank heavily. "Women addicts are much more stigmatized by other women, and by themselves. Because we hate ourselves it is hard for us to get into treatment."
Another social factor is the attitude about how women behave when drinking or drunk.
"It's an attitude of 'you're available' [sexually] if intoxicated," Geller said. "In fact, in terms of desire and performance, women who are drinking are less interested in sex. However, they are frequently coerced into unwanted activity if both partners are drinking."
Geller said that another social attitude, one that in fact protected women in her generation, was that women "didn't and shouldn't drink much." She recalled her college days at Oxford, and the time her "moral tutor" there saw her come in drunk.
"She said 'My dear, there are no sights more disgusting in the entire world than a woman who is drunk,'" recalled Geller. "This kind of attitude kept us from manifesting our alcoholism because it just wasn't socially acceptable."
But now "girls are drinking at the same rate as boys and getting drunk as often, so we may see women achieve parity in the expression of the disease, if not the treatment," she said.
Geller reported that today one-third of all alcoholics are women, and that the number of men addicted to illicit drugs is double that of women. But for prescription drug dependence, women exceed men, especially in older populations.
"Women, who live longer than men, tend to have more chronic illnesses during their lives," said Geller. "Those extra seven years are not years of joy and good health. Women are more likely to get medicated with psychoactive drugs to which they can become dependent."
Another important fact, said Geller, is that 17% of women alcoholics in treatment drank less than five drinks a day.
"Most men don't think [drinking that amount] is a big deal, so when they evaluate women, they don't see a problem. But this issue of heavy drinking in women needs medical intervention."
Geller said women's livers are much more sensitive than men's livers.
"No one knows why, because they haven't done the studies," she said. "It may be related to estrogen. But we do know women get liver damage at a much lower threshold than men."
For women, a safe level of alcohol consumption is no more than one drink a day, and not more than three drinks on any one occasion.
"If a woman exceeds that, they do so at risk of end-organ damage," said Geller. "The brain, liver and ovaries can all be damaged at relatively low alcohol levels in women."
Also, for the same amount of alcohol, women have a higher blood alcohol content than men.
"Drink for drink, women will get approximately two times as drunk as men," Geller noted. "We weigh less and have more fat, in which alcohol is insoluble...There's no question that for us, liquor is quicker."
Women also tend to start using substances and come into treatment later than do men. "We tend to have a ton of misery associated with alcohol use, some because of the effects of alcohol itself, but some due to the social environment surrounding addiction," Geller added. "We have more unwanted pregnancies and lots of gynecological mishaps: stillbirths, miscarriages, a variety of pelvic diseases, sterility and more likely difficulty in conceiving than women who don't use."
Geller said that the number of warnings about drinking during pregnancy far exceed the number of warnings about drinking and driving, a "male thing." There is far more mortality from drinking and driving than from drinking during pregnancy, she added. Yet because of the heavy censure of women who drink during pregnancy, pregnant women who are alcoholic fear that censure and don't get treatment.
Also, alcohol and drugs strongly affect hormonal balances in women.
"It's very common in treatment to see women who've not menstruated in a year or two," Geller said. "They also have more irregular cycles, less vaginal lubrication, more susceptibility to STDs [sexually transmitted disease], and many have early menopause. And as if this were not enough, women also have a disproportionate amount of psychiatric comorbidity...They have a greater chance of becoming depressed either as a consequence of addiction or of something that exists alongside addiction."
Geller added that the suicide rate in addicted women is three to four times that of nonaddicted women.
"One of the problems in women giving up cigarettes is depression," she said. "That needs to be addressed."
One way of addressing depression is exercise, said Geller, noting a study which showed exercise is as effective in treating mild depression as medication or psychotherapy.
"And exercise is cheaper," she added.
Socioeconomic Barriers to Treatment
Another area in which addicted women differ from addicted men is what Geller calls "socioeconomic comorbidity." She repeated that women are more likely than men to be poor, unemployed, single or divorced, and responsible for dependent children.
"They are much less likely to recover if those socioeconomic issues are not addressed," she said. "Also, they are much more likely to marry addicted men. They are much more likely to do that than are alcoholic men to marry addicted women. Therefore, the chances of an addicted man still being with his wife is much greater than an addicted woman still being with her husband. So women coming to treatment are much less likely to have the same social support essential to recovery as do men."
In fact, said Geller, the factors that make for good outcome in addiction-a good economic base, lots of social support and lack of serious psychological problems-are the same factors as those involved in outcome of arthritis, asthma or any other chronic disease.
Noting that she also treats addicted physicians, Geller said she is conducting a large national study of 1,500 addicted physicians. Preliminary data indicate that the three-year sobriety rate in physicians treated for addiction is 90%.
"That tells you what you can do when you have the right ingredients," she said. "So very often, it's not the addiction that causes the problem in recovery, it's these other factors."
Another very powerful factor in outcome for addicted women is the prevalence of sexual trauma in women coming into treatment.
"Studies of women coming into treatment indicate they have 60% to 90% rates of sexual trauma or violence, compared to a 30% rate in women not alcoholic or addicted," Geller said. "They are three to four times more likely to have been victims of violence than women not alcoholic or addicted. These traumatic incidents play into the whole recovery process. Socioeconomic and historical differences are what's important, not the medical differences that my male colleagues will stress."
Yet another issue is that of who gets diagnosed for addiction, said Geller, reporting on a large study that was conducted at Johns Hopkins. In that study, an alcoholism diagnostic questionnaire was given to all patients to see what percentage had actually been diagnosed as alcoholic.
Discussing the results, Geller said "Your chances of being diagnosed are really poor if you're a fairly affluent elderly white woman. You're more likely to be diagnosed if you're on the psych unit. But if you're in obstetrics, your chances are remote. Women as a group of all ages are much less likely to be diagnosed than men."
But it's not just diagnosis that matters.
"What about case findings?" said Geller. "How do women get into treatment? Men get in through the criminal justice system, DWI [driving while intoxicated] programs, and employee assistance programs, all of which are very limited for women. So how do women get identified?"
Geller said the major identification source is the medical system.
"But women are underdiagnosed there. We have to lobby to get general physicians to understand that women's best hope is to be diagnosed. If doctors aren't going to do it, other avenues are much less powerful."
If women do get into treatment, they do as well as men, despite their relative disadvantages, Geller said. But still, women are also disadvantaged in treatment itself, she added.
"Hazelden and Betty Ford have separate women's programs, but in the current economic climate, most treatment programs women go to will be mixed. Women will be in the minority, and therefore disadvantaged in treatment."
Continued Geller: "If we didn't have AA [Alcoholics Anonymous], I don't know what we'd do, because in the current economic climate, treatment is less and less and less. Why? There is no lobby. If women were tossed out of the hospital within 24 hours of having a baby or coronary disease, people would be outraged. But if you're an addict and denied inpatient detox, who is going to scream? This is our task-to get a lobby for addicted people. In the meantime, we have AA."
Geller called for more research on women, parity of insurance and access for addiction treatment.
"In recovery, among the behaviors you can change, your health behaviors are the most important to ensure a happy and long life," she said, again encouraging women to quit smoking, exercise and eat well.
For information about future conferences, call Hazelden at (800)257-7800 or e-mail firstname.lastname@example.org.