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Substance abuse by women: A review of the epidemiologic literature
J Chron Dia Vol 33. pp 383 10 394 0 Pergamon Precs Ltd 19x0 Pnn~ed I” Great Bntam
SUBSTANCE A REVIEW
ABUSE
BY WOMEN:
OF THE EPIDEMIOLOGIC
DAVID D. CELENTANO,
DAVID V. MCQUEEN
LITERATURE and ELSBETH CHEE
Department of Behavioral Sciences, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, MD 21205, U.S.A.
(Rewired
in recised,form
28 August 1979)
IN THIS literature review, the generic term ‘substance abuse’ is used to refer to alcoholism, licit drug abuse and the combined use of alcohol and licit drugs. That is, our stress is upon the use and abuse of legally obtainable substances which alter mood. The review’s focus on substance abuse by females reflects a growing concern with the status and roles of women in contemporary society. While in the past, alcohol and drug abuse research has centered primarily on men, there has been increasing awareness that these problems also affect the female population. One area which has not been adequately explored is the effect of changes in female sex-role orientation (expected behavior or interaction style) on the prevalence of substance abuse. The scope of this review includes: (1) general methodological and definitional issues in population studies; (2) reviews of the prevalence literature on alcoholism, drug abuse and combined use and abuse by women; and (3) a brief discussion of research directions emerging from the recent sex-roles literature. Alcoholism and drug abuse present similar methodological and interpretative problems in research, have similar populations at risk and similar individual characteristics of users. Yet, little attention is paid to these similarities. It is apparent that there is a lack of awareness in the field of alcoholism of work being conducted in the drug abuse area and vice versa. This lack of cross-fertilization is demonstrated by the fact that little has been written about ‘substance abuse’ or the ‘substance abuser’ per se. In the past, persons abusing licit (alcohol and psychotherapeutic drugs) or illicit substances have been studied by separate, and often competing, researchers. Rather than reflecting a rational approach to the problem of substance abuse, this situation has emerged as a consequence of federal funding procedures (i.e. two separate Institutes in HEW), resulting in separate domains of research. Although efforts have been made by HEW to combine the alcoholism and drug abuse Institutes, vocal alcoholism and drug constituencies have thwarted any such move. Hence, female substance abuse, an increasingly important public-health problem with chronic-disease implications, has essentially remained unaddressed at the level which it merits, In the past, separate journals were the primary means used to disseminate research findings; recently, joint journals have evolved (e.g. American Journal of Drug and Alcohol Abuse, International Journal of the Addictions). Yet, the dichotomy still prevails; often in one article on substance abuse the author will separately discuss alcohol and drug problems without discussing the problem in toto [l]. Historically. this separation stems from the divergent developmental paths of the two research areas; i.e. in alcohol research, studies commenced in the 1940s with the promulgation of Jellinek’s disease concept, while a major impetus for drug abuse research arose only with the heroin ‘epidemic’ of the 1960s. Female drinking patterns have received increasing attention in the literature in the past several years as part of a renewed interest in population studies of alcohol consump-
DAVID D. CELENTANO, DAVID V. MCQUEEN and ELSBETH CHEE
384
tion. However, while the volume of articles is growing rapidly, the majority of such studies contain few substantive research findings. In the relatively few review articles [24], basic epidemiologic parameters are not emphasized. In the drug ‘abuse’ area, it is even more difficult to locate literature directly discussing the epidemiology of licit (psychotherapeutic) drug abuse. This may reflect a definitional problem (see below) as well as the different focus on the two fields: the drug abuse area has historically been more oriented towards the development of policy in response to perceived crisis stituations (e.g. Domestic Council [7], National Commission on Marihuana and Drug Abuse [8]) than toward conducting basic epidemiologic research. Given the popular perceptions of what constitutes the ‘real’ problem of drug abuse-that is, illicit drug use, and not the abuse of licit drugs which are obtained from physicians or are available ‘over the counter’-funding priorities and research interests have not promulgated studies focused on determining a basic descriptive epidemiology of licit drug problems. Finally, the literature on concomitant problems of drug and alcohol abuse is scant. This weakness in the general literature is also found in the literature on women, which, in addition, has its own deficiencies. DEFINITIONAL
PROBLEMS
One of the fundamental problems in substance abuse research is the lack of consensus as to definitions and measurement strategies used to ascertain basic epidemiologic information. This lack of consensus within the research community is reflected in much of the field research which has been undertaken in past decades. Comparative and replication studies are virtually non-existent, leading researchers to continually develop new instruments and methods which have questionable reliability and lack substantive validity. The literature has become swamped with untested assumptions, and with definitions and measures which have not been adequately verified [9-lo]. Alcoholism
One of the predominant difficulties cited in the alcohol literature is that no standardized procedure exists for distinguishing an ‘alcoholic’ case; there are nearly as many definitions as there are definers [ll]. There is no systematically used diagnostic nosology; without a clear definition of a ‘case’, it becomes nearly impossible to establish what is not a case, or for that matter, what is a control. Thus, one is unable to determine what will be included and excluded in any study concerning alcohol use. Some of the accepted definitions of ‘alcoholism’ found in the medical literature are: It is possible to view alcoholism as a medical problem without regarding it as a specific disease. The alcohol pattern ol the patients described are beyond doubt symptomatic. Alcoholism is a symptom [12]. Alcoholism is an illness characterized by preoccupation with alcohol and loss of control over its consumption such as to lead usually to intoxication if drinking is begun; to chronicity; by progression; and by tendency toward relapse [ 131. Those excessive drinkers whose dependence upon alcohol has attained such a degree that it shows a noticeable mental disturbance, or an interference with their bodily or mental health, their interpersonal relations and their smooth social and economic functioning; or who show prodromal signs of such developments [ 141.
This definition is similar to that of the World Health Organization [15]. Plaut prefers the term ‘problem drinking’ which is defined as the ‘repetitive use of beverage alcohol causing physical, psychological, or social harm to the drinker or to others’ [16]. By taking such an approach, one can gain etiological information and develop typologies of drinking behaviors [ 173. Siegler et al. analyze various models of ‘alcoholism’ which have been extensively used in the alcohol literature. They describe eight models: the ‘skid row impairment’ model. the ‘moral’ model (based on temperance feelings), the deviancy paradigm (based upon labelling and stigma which are conceived of as departures from social norms), the Alcoholics Anonymous model, psychiatric models and medical models [ll]. This variety of ideas illustrates an overall lack of consensus which has important practical ramifications. for each theoretical orientation prescibes the method and measures to be used in research, and this ultimately leads to non-comparability of research findings.
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Abuse by Women
385
While there is no concensus for the delineation of a disease entity called ‘alcoholism’, it appears that during the past 30 yr there has been a progressive move away from moralistic, non-medical models of alcoholism to the point where, in recent years, the Criteria Committee of the National Council of Alcoholism, composed predominantly of physicians, established ‘criteria for the diagnosis of alcoholism’. The Criteria Committee assumed alcoholism to be a ‘disease’ and a ‘pathological dependency on ethanol’ [18]. Cahalan explores the rationale of the concept of ‘problem drinking’ [17] ; such a concept is considered to be an encouragement for research. The term ‘drinking problem’ places “emphasis upon the behavior, rather than on the person (and thus serves less readily as a permanent label for the person with drinking problems)“. Further, it allows an inquiry into the possibility that there is a range of drinking problems associated with a spectrum of problem drinkers [17]. Drug abuse
In drug abuse research, the definitional problem is as salient as in the alcohol field; moreover, there is even less agreement in studies of drug abuse. The National Commission on Marihuana and Drug Abuse identified four major definitions of drug ‘abuse’: (1) any ‘use’ of drugs; (2) any ‘non-medical’ use of drugs; (3) using drugs to ‘excess’; and (4) anything that is ‘addictive’. The National Commission noted this disparity in public definitions of ‘drug abuse’ and pointed out that over the last several years “The public and press often employ drug ‘abuse’ interchangeably with drug ‘use’. Indeed many ‘drug experts’, including government officials, do so as well” [S]. Josephson [19] states that problems in definition are in part due to differences in conceptualization and measurement, and to the interrelationships between the variety of drugs used in different ways with different pharmacological effects (and concomitant symptoms and sequellae). Smart [20] addresses this problem by noting that an holistic measure of ‘drug abuse’ is difficult to use in epidemiologic studies since clear indicators of pathological consumption are difficult to delineate and only rarely have been tied to use. Only for narcotics has this relationship been documented (in alcohol studies, one measure often used has been liver cirrhosis). Finally, within the field of drug abuse there has been considerable argument over several other terms: ‘addiction’, ‘habituation’, ‘dependence’ and ‘abuse’ [8,20]. Another dimension of the definitional problem is the context in which the term is used. The National Commission noted that the term ‘drug’, when used in the context of ‘abuse’, has a social (not scientific) meaning. The National Commission defined drugs as encompassing only psychoactive drugs, ‘those which have the capacity to influence behavior by altering feeling, mood perception or other mental states’ [8]. Balter’s [21] definition of ‘drug abuse’ emphasized immediate consequences of use rather than secondary social implications (i.e. arrest, social disapproval etc.): Use of a drug or other substance with central nervous system activity in excessive amounts, or in a fashion, whether on one occasion or repeatedly, so as to produce: 1. Significant physical or psychological dependency. 2. Serious mental or personality disturbances, psychoses or serious and/or prolonged states of disoricntation. 3. Serious impairment or personal and/or social functioning, including significant toxicity of behavior, e.g.. impulsivity, poor judgement and psychomotor instability. 4. Death or behavior endangering the life of oneself or others. 5. Serious interference with growth of personality and/or social development. particularly among younger persons. 6. Physical damage or debility-physiological, biochemical, genetic, neurological etc.
Smart [20] prefers the term ‘drug use and problems arising from drug use’ to ‘drug abuse’. Noticeably, Smart is one of the few drug abuse researchers with broad experience in alcohol studies; this may account for his preference for drug ‘problems’ rather than ‘abuse’. Smart explained his rationale: “Drug use, and not ‘drug abuse’, should be studied because prevention is the most important ‘use’ of epidemiology” [20]; this function, according to Smart, should be the prevention of drug ‘problems’. not drug ‘abuse’. He further argues that few studies are designed to locate the causes of drug ‘use‘; the reason
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DAVID D. CELENTANO, DAVID V. MCQUEEN and ELSBETH CHEE
for the non-utility of most epidemiologic studies of drug ‘use’ has been the lack of attention paid to drug problems while studying drug use. In essence, his criticism is that most studies erroneously equate drug ‘use’ with drug ‘problem’. Thus, it becomes immediately clear that definitional (and consequently, measurement) problems are rampant in the substance abuse field. This lack of consensus results in duplication and unreliability in research findings. Hence, prevalence estimates and concomitant factors of ‘abuse’ cannot be ascertained with confidence. Basic epidemiologic
dejinitions
An analysis of studies reporting on the prevalence of drug and alcohol abuse requires attention to the definitions of traditionally used epidemiologic measures. Most indicators are reported as rates which occur in given populations; in substance abuse research, rates are usually specified for an adult population. Most often, the population includes all individuals over age 21; however, in some instances, studies include persons of lower ages (15 yr is generally the minimum age specified for an adult population). Often researchers use a base rate consisting of the population of users as opposed to non-users of the total population at risk. Prevalence rates are traditionally given as either point, period or lifetime figures. Point prevalence (the frequency of a disorder at a designated point in time) and period prevalence (total number of cases existing during some specified time period, i.e. sum of point prevalence and incidence) are commonly used measures. Substance abuse studies often fail to distinguish which rate is being used. In alcohol and drug research, another type of measure is encountered-‘lifetime’ prevalence. Lifetime prevalence is seldom reported in most epidemiologic literature; this measure exists in alcoholism studies because of the inclusion of persons who possess what may be called ‘alcoholism in remission’, persons who have been previously classified as being alcoholic. Lifetime prevalence makes evaluation and comparison of studies exceptionally difficult; it appears in the literature because of the failure of researchers to specify a time period for the ‘abusive’ behavior. Thus, staggering prevalence numbers may be found by counting all individuals who at some period in their lifetime had a problem with drinking or drugs [9]. Incidence is infrequently cited in the alcohol literature, but is common in studies of illicit drug use. Incidence (the number of new cases of a disease in a specific population during a given interval of time, usually 1 yr) is especially tied to a fairly exacting definition of what constitutes a case. In addition, one must distinguish genuine new cases from those which may ‘re-occur’ during the incidence measure interval. Generally, incidence figures for substance abuse are obtained from statistics on admission or readmission to psychiatric or treatment facilities [22]. THE
PREVALENCE
OF
SUBSTANCE
ABUSE
AMONG
WOMEN
Alcohol problems among women is an area in which there is little present knowledge. ‘Hidden drinking’, asserted changes in prevalence rates and the development of new roles for women are all factors of interest. The drug abuse literature, too, has recently focused upon women due to a high rate of psychotherapeutic drug use and suspected abuse among women. Few studies have observed the effect or estimated the prevalence of alcohol and drug problems which exist simultaneously. Problem
drinking among women
The population survey would appear to be the most direct way of measuring the prevalence of problem drinking. However, a review of population surveys conducted during the past 30 yr has yielded highly variable estimates of the prevalence of problem drinking in women [23]. This is due, at least in part, to the aforementioned measurement and definitional problems rampant in the area of substance abuse, as well as to difficulties in population selection and sampling. As will become apparent in the following discussion of selected population studies, the major focus of these surveys has been in no way uniform; some have looked at actual drinking patterns and practices while others
SubstanceAbuse by Women
387
have emphasized the consequences of drinking which are used as proxy measures (or ‘indirect’ retrospective inferences) of drinking behavior. There has been little comparability either in terms of the methods used or the types of populations surveyed. One of the first large-scale population surveys was conducted by Marconi et al. [24]. In a household survey in Santiago, Chile, the authors asked respondents about the level of their alcohol intake (a measure of quantity) and about ‘loss of control’. They projected an annual period prevalence rate of 6/1000 for females for ‘severe problems’ (alcoholism) and S/l000 for ‘alcohol abuse’. The study of Bailey et al. [25] was one of the first urban American population surveys. The authors interviewed respondents randomly selected from a household survey sampling frame of upper Manhattan. They were primarily interested in assessing ‘problems with living’ associated with ‘excessive alcohol abuse’ and related health problems. The authors reported a prevalence rate of ‘alcoholism’ of 4.13/1000 for females. Zax [26], in 1967, utilized records and reports from the city court, county penitentiary, the Salvation Army, the Alcoholism Center and all psychiatric treatment agencies of Monroe County, New York, to establish a prevalence rate of 0.56/1000 for white females and 4.78/1000 for non-white females. An alcoholic was defined as a person who had a medical diagnosis of alcoholism, one who had applied for services for an alcohol problem or one who had been arrested for public intoxication. Knupfer [27] interviewed a population sample in San Francisco and estimated the lifetime prevalence of ‘troubles due to drinking’. Various types of problems were categorized in terms of intensity and time period. Rates of 1.7% for problems with ‘serious consequences’ and 3.4% for problems with ‘moderate or severe consequences’ were obtained. Cahalan et al. [28] conducted the first national probability sample survey concerned with describing drinking patterns. From a random probability..sample 6f the entire contiguous United States, the group reported a rate of ‘severe’ problems of 4% for females. This category included persons who were ‘heavy’ drinkers with high ‘escape’ reasons (a psychological measure) for drinking. Alcohol ‘abuse’ rates (defined as moderate and severe problems with alcohol) were 21% for women. Celentano and McQueen [9] studied prevalence rates obtained by five methods: (1) index of uncontrolled drinking; (2) heavy intake, a measure of quantity-frequency; (3) heavy-escape drinking; (4) loss of control; and (5) escape-drinking, and found great discrepancies among the estimates. In Maryland, within the same population, the estimates of problem drinking for women ranged from 0.6 to 14% Many studies have been conducted which have attempted to develop summary measures for use in predicting the rate of alcoholism in various populations [29-361. Most of these studies have utilized different types of populations and indicators which are often not comparable. Some of the evidence does appear to be consistent despite the numerous methodological problems and disparities. Yet, one must not fail to notice that the prevalence rates often vary widely from study to study, which may result partially from differences in the indicators themselves. In-depth reviews of the prevalence literature may be found in Cahalan et al. [28]. Celentano [23], and Celentano and McQueen [IS,lo]. Generally what emerges is a variety of rates dependent upon the estimator used, each with its own reliability and validity, the population and its cultural context, and type of prevalence measure used. However, it is believed that all of these rates are understated for one reason--‘hidden’ (secretive) female drinking. Female hidden drinking
Badiet [l], Greenblatt and Schuckit [37], Gomberg [2], Rubington [38], Curlee [39] and Lisansky [40] have reviewed the literature on female drinking, and all mention the presence of ‘hidden’ drinking. The assumed cause underlying hidden drinking is the stigma of the drunken female [38-511. Drunkenness among women is considered tantamount to breaking taboos, for it runs counter to the American idealized norm of selfcontrolled ‘lady-like’ behavior [40]. Drinking and heavy drinking are often tolerated in
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DAVID D. CELENTANO, DAVID V. MCQUEEN and ELSBETH CHEE
men [17], but women are viewed as guardians of social values in the preliberation context, and those who abuse alcohol are seen as a threat to family stability. Thus, their deviation from the expected role is viewed as more serious than that of their male counterparts [40]. The drunken female can be viewed as a threat, for: “No one likes to believe that the hand that rocks the cradle might be a shaky one.” The traditional female role requires constant vigilance over others; for men, business functions can be put off for a day, while the care of children (the domain of women) cannot [39]. Badiet [l] states that: “Such social pressures do not prevent addiction, but they discourage females from admitting their problem and seeking help.” Female drinking patterns are said to differ from men’s in that women tend to drink at home and alone far more than men [2,52,53]. Cartwright et al. [54], in a 1974 replication of a 1965 survey, found an increased tendency among women, but not among men, to consume at home. Rubington [38] estimates that 70% of female alcoholics are hidden drinkers, a phenomenon arising from numerous factors. Friends, law enforcement personnel and judges ‘protect’ female problem drinkers [48,50,53,55] ; as social class increases the amount of protection also increases [56]. The role of the housewife is an inducement for concealment, for there is increased time, opportunity and pressure (all ostensibly leading to boredom) for drinking alone or secretly, behaviour which can last undetected for years [4,39,57]. Lindbeck [4] also states that husbands of problem drinkers use denial themselves when they realize their wives’ problems, for the social stigma reflects upon them as well; their cover-up hinders referral and treatment [39,40,43], and most female problem drinkers remain hidden. There are a host of theories on why women become problem drinkers (cf. Gomberg [2] for a review of many psychological and physiological theories). Johnson et al. [49] and Johnson et al. [SO] believe that women, and particularly housewives, tend to drink heavily to escape routine (boredom), to improve self-image (challenges) and to attain self-confidence. Curlee [47] believes that the onset of problem drinking lies in a crisis situation. The archetypal crisis here is the middle-age identity crisis or the ‘empty-nest’ syndrome, which occurs after the children leave home or following divorce or death of a spouse, leaving the women with a loss of sense of identity, purpose and worth. Heavy alcohol use is often employed to cope with those situations setting into motion a ‘vicious circle’. Despite these differing theories, no research data exist to select any one with confidence. Many of the problems with past prevalence studies have been the result of a remarkable lack of attention paid to the problem of hidden drinking. While Cahalan er al. [28] devised the ‘escape’ drinking scale to account for psychological motivations for alcohol use, escape drinking alone is not synonymous with problem drinking. Numerous prevalence measures focusing on consequences of alcohol consumption (alcohol-related problems) include questions which do not appear to be overly relevant to areas of concern for female problem drinking [30,31]. In essence, it can be argued that most alcoholism prevalence estimators were developed and used primarily to obtain rates of problem drinking for men, as they were the population most often observed (clinically and anecdotally) to be alcoholics. What is needed, then is a prevalence estimator for women which is free of contamination by the traditionally male-oriented measures of alcohol-related problems or consequences of abusive drinking, e.g. employment and law enforcement problems. It is the contention here that the previous focus on males has led to a bias in prevalence rates for women. One piece of evidence verifying the above assumption is some data based on liver cirrhosis mortality. Keller [SS] reviewed the studies to 1960 and found a sex ratio of between 4 and 5 males to each female problem drinker, the generally accepted sex difference [59]. However, Ledermann [60] reported a sex ratio of 2:l; Celentano and McQueen [lo] found a ratio of only 2 : 1 in Maryland using a virtually complete enumeration of all deaths for one county over a period of 7 yr, while survey results showed a difference of 4: 1. This difference, then. may be due to the ‘hiding’ of female problem drinking.
Substance
Abuse by Women
389
Drug abuse among women
It is quite difficult to summarize the literature on the prevalence of licit drug abuse, due to the proliferation of types of drugs abused which has resulted in a very large number of published studies. Yet, this body of literature can be quickly reduced by focusing interest upon women; the majority of drug abuse studies has been conducted on adolescent psychotropic drug use (and most of that on illicit drug ‘use’, cf. Smart and Fejer [61], Bakal et al. [62], Russell and Hollander [63], Hughes et al. [64], Savada [65]), veteran (male) heroin use [66] or narcotic abusers in treatment [67]. One of the most famous studies focusing on psychotropic drug use was that reported by the National Commission [8] who supported Abelson et al. [68] in conducting a national probability sample survey. Approximately twice as many females as males ‘used psychotropic drugs in the 6 months preceding the interview. Manheimer et al. [69] reported that, in 1970, approx. one third of U.S. adults had taken a psychotherapeutic drug on one or more occasions, and 6% used these drugs on a regular daily basis for 6 months or longer during 1970. Forty per cent of females and 20% of males had used one or more psychotherapeutic drugs in the past year. Female use was generally constant across all ages. In a survey of 1200 adults in metropolitan Toronto, Fejer and Smart [70] found almost three times as many women as men among persons with prescriptions, and that women reported approx. 75% of all prescriptions. Borgatta [71] reported that 27.6% of females and 16.8% of males in a probability sample used psychoactive drugs, while 10.9% of women and 5.6% of men used two or more. The problem with all of these studies (generally held to be indicative of the state of the art) is that ‘use’ and ‘number of drugs’ are not measures of quantity and frequency (Q-F) and are, thusnot equivalent to those terms used in alcohol studies. Further, these studies do not address the questions of ‘problems’, the endpoint of all substance abuse epidemiologic studies. Mellinger et al. [72] developed a drug abuse measure (frequency-duration) which approaches the concept of a Q-F measure used in alcohol studies. They found that the 2: 1 female-to-male ratio reported in other studies held for all levels of use in the general population. Yet, among ‘users’ of psychotherapeutic drugs, men were slightly more likely to be ‘high’-level users (abusers). Among users, there was also a preponderance of heavy users among the lower socio-economic groups. Parry et al. [73] reported approximately equal proportions of high users of psychotropic drugs across social classes, yet there was a negative association with social status when observing the proportion of heavy users among all users. For housewives, this negative association held for both the total population and among users. Thus, there is some evidence that lower-class women are high users (and abusers) of licit psychoactive drugs. Many prescription studies have been conducted in the past 10 yr to document sex differentials in drug abuse. Cooperstock [74] found that 69% of all psychotherapeutic drugs are prescribed for women, a proportion also reported by others [I, 39,75,76]. Brahen [77] analyzed ‘habitual frequent users’ by type of drug-54% of barbiturate and 58% of major tranquilizer abusers were women. Further, 73% of regular barbiturate users and 850/, who used ‘powerful sedatives’ were middle- or upper-class women. Chambers et al. [78] stated that the 2:l ratio in the prevalence rate of psychotherapeutic drug use found was due to the use of minor tranquilizers by women, not to differences in the rates of barbiturate use. Dunnell and Cartwright [79] reported that in a study conducted in England, 31% of women and 20% of men were ‘abusing’ a drug (defined as using a drug prescribed more than 1 yr previously). Others have reported similar findings [SO-821. Being knowledgeable of these prevalence data, many authors have attempted to explain why more women than men use psychotropic drugs. Cooperstock [83] has recently reviewed the evidence; she contends that physician responses to female roles contribute to the high level of prescribing. She states that physicians expect women to bring feelings to the doctor; thus, women are assumed to require more mood-altering drugs [74]. Linn reported that social and psychological ‘problems in living’ have been redefined as medical problems, causing high rates of prescriptions to be ordered for
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DAVID D. CELENTANO. DAVID V. MCQUEEN and ELSBETH CHEE
women [84]. Lennard et nl. [85] discussed the role of the drug industry this change in definition. Individual reasons for drug abuse are varied. The National Commission the extent of the problem:
in developing [S] discussed
reported that they take a pill to calm down The National Survey shows that 15”” of the adult population or cheer up when they feel out of sorts, _. not really sick. but nervous. or depressed or under stress. Eighteen per cent of the public reported that they used alcohol for similar purposes. The use of a variety of new mood altering drugs to cope with stress is undoubtedly a significant social development, particultrrl~ amongwmen [68] (emphasis added).
Chambers et al. [78] reported that regular users of psychotropic drugs are white females 35 yr or older who are middle or upper class; the majority are housewives or women not participating in the labor force. Parry et al. [73], however, stated that their findings “suggest rather strongly that long-time daily use of presciption sedatives and minor tranquilizers is more prevalent not among well-to-do and well-educated women, whether working or full-time housewives, but among the housewives who are poor and ill-educated”. Despite the lack of agreement between these two studies relating social class and frequent drug use, both studies substantiate Nathanson’s [86] observation that ‘*employment has, perhaps, the most clearly positive effects upon women’s health of any variable investigated to date”. She presents data showing fewer symptoms and less anxiety (both characteristics of imputed motivations for drug use) as compared to similarly aged non-working women. The problem with most drug abuse studies presented here has been the limited attention paid to ‘problems’ and the majority of interest paid to ‘use’. As with alcohol studies, little (if any) attention is paid to other forms of substance abuse. Again, the role of employment and the role status of ‘housewife’ emerge as important for substance abuse.
Prevalence of alcohol and drug abuse The major finding to be reported in terms of combinative alcohol and drug use and abuse is that there is little definitive data. The data that exist deal with special groups, and the focus there is upon use (Wechsler and Thum reported on adolescents 1871; Robins discussed Vietnam veterans [66]). Despite a paucity of studies, the literature which does exist, and which purports to address questions of the commonalities of alcohol and drug abusers, demonstrates either gross methodological flaws or displays a lack of knowledge concerning the field in which the researchers are not recognized as experts. For example, the National Commission [S] stated: “Only a marginal relationship exists between consumption of alcohol beverages and recent use of ethical or proprietary psychoactive drugs.” Unfortunately, the questions which yielded these data were not of the same time parameter-drug use was asked for the past year while alcohol use was asked for the past 7 days. Further, when discussing multiple drug use, concomitant use is usually not ascertainable. Most of the data that do exist deal with alcohol and drug ‘use’. The National Commission [8] reported concurrent (past 6 months) use of alcohol and use of sedatives (1%). tranquilizers (7x), stimulants (20%) and proprietary drugs (6yh). Crowley et al. [88] reported high rates of both alcohol and drug abuse among psychiatric admissions, and Mellinger et al. [72] stated that 15% of the respondents used both alcohol and drugs during the past year, but not necessarily concomitantly. They stated that the “use of alcohol is most prevalent among groups of people who are least likely to use medically prescribed mood-changing drugs, and vice-versa”. It has been well documented that the rate of self-reported alcohol abuse is higher in males than females [9,28], while the rate of abuse of prescribed psychoactive drugs is higher among women [83]. For alcohol abuse, prevalence decreases with age, while for drug abuse (in general) there is a slight increase. Abelson et al. [68] reported that 2496 of men and loo/;; of women used alcohol to cope with moodiness or stress ‘a lot’ or ‘sometimes’, while only 13O:, of men and some 18”,, of women used pills for these reasons.
Substance
Cooperstock
[74] explained
Abuse by Women
this set of conflicting
391
data as follows:
It would be an oversimplification to attribute all of the sex differences found in the use of mood-modifying drugs to the higher prevalence of escape drinking by men as some have suggested. While this is undoubtedly a partial explanation, it begs the question of the role of the physician writing such a disproportionate number of prescriptions for women patients. However, one cannot account for this difference in sex ratio differentials by the proportion of the population utilizing physician services. Rather, one again confronts differences in the manner in which drugs are prescribed for women. CONCLUSIONS
It has been shown that, for a number epidemiology of substance abuse among the problem: That seems double others
literature evident.. standards. (husband,
of reasons, little substantive knowledge of the women exists. Badiet [l] has aptly summarized
in the addictions field has tended to ignore women in terms of use and misuse of drugs the literature which does exist abounds with myths, sexism. patriarchal notions, and Women have received great attention mainly when there is concern about their effect on children, doctors. etc.).
The outlook reflects traditional sex roles in the U.S.A. which have centered around the familial division of labor. “These roles prescribe behavior regardless of marital status and age, but they are most centrally concerned with the gender-based bread-winner-versushomemaker specialization” [89]. Support for such a view was widespread in the past. However, since 1940, this sex-role division has declined, in part due to increasing female wage-levels [90], the increasing proportion of married women in the labor force [91], the growing proportion of women comprising the labor force (up from 20% in 1920 to 407; in 1975) [92], rising divorce rates and the increasing number of female-headed households [93]. The results of these changes, along with concomitant orientations of attitudes towards appropriate roles [89], has led to a greater equality between the sexes. Mason et al. [89] showed how attitudes towards women’s sex-roles represent clues to the relative statuses of the sexes; and national polls have demonstrated shifts in women’s outlooks towards their rights and obligations [94]. One logical outgrowth of such an evolutionary process in sex-role orientations is that women’s behavior may become more like that currently attributed to men. Indeed, they may develop similar social and cultural risk factors for many problems and illnesses, not the least of which is substance abuse. Some have argued [2,4] that a decrease in the sex ratio of alcoholism may be a result of changing sex-roles and the relative status of women. Although Kilty [95] found sex differences in terms of attitudes and normative expectations related to drinking, no differences in terms of actual drinking behavior were found in a student sample. Bowker [96] has dealt with the sociological aspects of sexual differentiation in substance abuse, and examined drug and alcohol problems among specific groups of women. Wilsnack [97] has reviewed the literature on sex-role orientations and their role in female drinking from a psychological perspective. She believes that the liberation movement has been responsible for many sociocultural changes in female behavior; changing behavior in the use of alcohol as well as alterations in ‘predisposing’ factors for the effects of alcohol may be counted amongst these shifts. In accounting for factors which are viewed as important in explaining differential rates of substance abuse among women, and as a rationale for speculations concerning the apparent increase in alcohol and drug use, sex-role orientations appear to offer a basis for these associations. However, as with most of the female substance abuse literature reviewed, few empirical data exist [98]. In sum, a new epidemiology of substance abuse is needed, one which recognizes the problems surrounding a very complex issue. Only when these many substantive and methodological problems are confronted will a realistic assessment of the extent of the problem of substance abuse be ascertained. AcLnowle&emenrs--The authors wish to thank George during
the preparation
of this manuscript,
J. Vlasak
and Linda
A. LeResche
for their assistance
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Badiet P: Women and legal drugs; a review. In: Women: Their Use of Alcohol and Other Legal Drugs. Maclennan A (Ed.). Toronto: Addiction Research Foundation, 1976 2. Gomberg ES: Alcoholism in women. In: The Biology of Alcoholism, Vol. 4. Kissen B, Begleiter R (Eds.). New York: Plenum Press. 1976 3. Beckman LJ: Women alcoholics; a review of social and psychological studies. Q J Stud Ale 36: 797-824. 1975 4. Lindbeck VL: The woman alcoholic, a review of the literature: lnternat J Addict 7: 567-580, 1972 5. Schuckit M: The alcoholic woman: a literature review. Psychiat Med 3: 3743, 1972 6. Curlee J: Alcoholic women; some considerations for future research. Bull Menninger Clin 31: 154163, 1967 7. Domestic Council Drug Abuse Task Force: White paper on drug abuse, a report to the President. Washington, DC.: U.S. Government Printing Office, 1975 8. National Commission on Marihuana and Drug Abuse: Drug use in America: problems in perspective. Second report of the National Commission on Marihuana and Drug Abuse. Washington. D.C.: U.S. Government Printing Office, 1973 9. Celentano DD. McQueen DV: Comparison of alcoholism prevalence rates obtained by survey and indirect estimators. Q J Stud Ale 39: 420434, 1978 10. Celentano DD. McOueen DV: Reliabilitv and validitv of estimators of alcoholism mevalence. 0 J Stud Ale 39: 869-878. 1978 11. Siegler M, Osmond H,‘Newell S: Models of alcoholism. Q J Stud Ale 29: 571-591. 1968 1969 12. Eaton MT. Peterson MH: Psychiatry, 2nd ed. Flushing. New York: Medical Examination. 13. American Medical Association: Manual on Alcoholism. Chicago: American Medical Association. 1968 14. Jellinek EM. Keller M: Rates of alcoholism in the United States of America. 194G-1948. Q J Stud Ale 13: 49-59. 1952 15. World Health Organization, Expert Committee on Mental Health, Alcoholism Subcommittee: Second report. WHO Tech Rep Ser. No. 48, 1952 16. Plaut TFA: Alcohol Problems-A Report to the Nation by the Cooperative Commission of the Study of Alcoholism. New York: Oxford Univ&sity Press, 1967 _ I I. Cahalan D: Problem Drinkers. San Francisco: Jossev-Bass. 1970 18. Criteria Committee of the National Council on Alcdholism: Criteria for the diagnosis of alcoholism. Ann Int Med 77: 249-258, 1972 19. Josephson E: Introduction. In: Drug Use: Epidemiological and Sociological Approaches. Josephson E. Carroll EE (Eds.). New York: John Wiley, 1974 20. Smart RG: Addiction, dependency, abuse or use: which are we studying with epidemiology. In: Drug Use: Epidemiological and Sociological Approaches Josephson E. Carroll EE (Eds.). New York: John Wiley. 1974 21. Balter MB: Drug abuse: a conceptual analysis and over-view of the current situation. In: Drug Use: Epidemiological and Sociological Approaches. Josephson E, Carroll EE (Eds.). New York: John Wiley, 1974 72. McQueen DV: Client change measures utilized in federally funded programs: an evaluation. Paper prepared for NIAAA. Baltimore. Maryland: Johns Hopkins University, 1974 23. Celentano DD: An evaluation of alcoholism prevalence estimators. Doctoral dissertation presented to the Department of Behavioural Sciences, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, 1976 24. Marconi J, Varela A, Rosenblat E et al.: A survey of the prevalence of alcoholism among the adult population of the suburb of Santiago. Q J Stud Ale 16: 438-446, 1955 2.5. Bailey MB, Haberman PW. Alksne H: The epidemiology of alcoholism in an urban residential area. Q J Stud Ale 26: 1940. 1965 26. Zax M, Gardner EA. Hart W: A survey of the prevalence of alcoholism in Monroe County. N.Y.. 1961. Q J Stud Ale 28: 316-327, 1967 27. Knupfer G: The epidemiology of problem drinking. Am J Pub Hlth 57: 973-986, 1967 28. Cahalan D, Cisin IH, Crossley HM: American drinking practices: a national study of drinking behavior and attitudes. Monograph of the Rutgers Center of Alcohol Studies. No. 6. New Brunswick, New Jersey: Rutgers Center of Alcohol Studies. 1969 29. Essen-Mtiller E. Larson E, Uddenberg CE et t/l.: Individual traits and morbidity in a Swedish population. Acta Psychiat Khn Suppl. 100, 1956 30. Mulford HA, Miller DE: Drinking in Iowa-II. The extent of drinking and selected sociocultural categories. Q J Stud Ale 21: 26-39, 1960 31. Mulford HA, Miller DE: Drinking in Iowa-III. A scale of definitions of alcohol related to drinking behavior. Q J Stud Ale 21: 267-278, 1960 32. Helagson T: Epidemiology of mental disorder in Iceland. Acta Psychiat Stand Suppl. 173, 1964 data on alcoholism in Maryland: based on 33. Gorwitz K. Bahn A. Warthen J er al.: Some epidemiological admissions to psychiatric facilities. Q J Stud Ale 31 : 423-443, 1970 34. Blaney R. Radford IS: The prevalence of alcoholism in an Irish town. Q J Stud Ale 34: 1255-1269. 1973 35. Secretary of Health, Education, and Welfare: Extent and patterns of use and abuse of alcohol. In: The First Special Report to the U.S. Congress on Alcohol and Health. Keller M (Ed.). Washington, D.C.: National Institute of Alcohol Abuse and Alcoholism, 1971 36. Wechsler H. Demone HW, Gottlieb N: Drinking patterns of greater Boston adults: subgroup differences on the QFV Index. Q J Stud Ale 39: 1151-I 165, 1978 37. Greenblatt M. Schuckit. MA: Alcoholism Problems in Women and Children. New York: Grune & Stratton. 1976 38. Rubington E: The hidden alcoholic. Q J Stud Ale 33: 667-683, 1972
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Curlee J: A comparison of male and female patients at an alcoholism treatement centre. J Psych 74: 239-247, 1970 40. Lisansky ES: The woman alcoholic. Ann Am Acad Polit Sot Sci 315: 73-81, 1958 41. Beckman LJ: Alcoholism problems and women: an overview. In: Alcoholism Problems In Women and Children. Greenblatt M, Schuckit MA (Eds.). New York: Grune & Stratton, 1976 by the bottle. Addict 20: 3-19, 1973 42. Wilsnack S: Femininity 43. Chalfant HP: The alcoholic in magazines for women. Social Focus 6: 14-26, 1973 IG: Women alcoholics: a clinical study. Q J Stnd Ale 32: 45-52, 1971 44. Rathod NH, Thomson 45. Sclare G: The female alcoholic. Br J Addict 65: 99-107, 1970 46. Curlee J: Women alcoholics. Fed Probation 32: 16-20, 1968 and the empty nest. Bull Menninger Clin 33: 165-171, 1969 47. Curlee J: Alcoholism 48. Senseman LA: The housewife’s secret illness: how to recognize the female alcoholic. R I Med J 49: 4G42, 1966 MI: The female alcoholic. Nur Res 15: 343-347, 1966 49. Johnson MW, DeVries JC, Houghton MW, DeVries JC, Houghton MI: Physicians’ views on alcoholism: with special references to 50. Johnson alcoholism in women. Nebr St Med J 50: 378-384, 1965 in women: social and psychological concomitants. Q J Stud Ale 18: 588423, 51. Lisansky ES: Alcoholism 1957 and behavior of men and women alcoholics. 52. Wanberg KW, Knapp J: Differences in drinking symptoms Br J Addict 8: 347-355, 1970 factors in alcoholic women. Am J Psychiat 123: 341-345, 1966 53. Wood H, DutTy EL: Psychological AKJ, Shaw SJ, Spratley TA: The relationships between per capita consumption, drinking 54. Cartwright patterns and alcohol related problems in a population sample 1965-1974. Part I: increased consumption and changes in drinking patterns. Br J Addict 73: 237-246, 1978 55. Fraser J: The female alcoholic. Addict 20: 64-80, 1973 of female drunkedness offenders. J Hlth 56. Cramer MJ, Blacker E: Social class and drinking experiences Hum Beh 7: 276-283, 1966 57. Corrigan EM: Women and problem drinking: notes on beliefs and facts. Addict Dis 1: 215-222, 1974 and the estimation of its prevalence. In: Society, Culture and 58. Keller M: The definition of alcoholism Drinking Patterns Pittman DJ, Snyder CR (Eds.). Carbondale, Illinois: Southern Illinois University Press. 1962 Q J Stud Ale 33: 1147-l 148, 1972 59. Keller M: The oddities of alcoholics. S: Measures of the degree of alcoholization of a population. Q J Stud Ale 21: 170, 1960 60. Ledermann surveys of student diug use in Toronto. Bull Narcot 27: 61. Smart G, Fejer D: Six years of cross-sectional 1 l-22, 1975 62. Bakal DA, Milstein SL, Rootman I: Trends in drug use among rural students in Alberta: 1971-1974. Can Mental Hlth 23: 8-9, 1975 63. Russell JS, Hollander MJ: Drug Use Among Vancouver Secondary School Students: Summary of Findings 1970-1974. Vancouver: Narcotic Addiction Foundation. 1974 64. Hughes PH, Schaps E, Snader CR: A methodology for monitoring adolescent drug abuse trends. Intemat J Addict 8: 403419, 1973 65. Sadava SW: Patterns of college students drug use: a longitudinal social learning study. Psych Rep 33: 75-86, 1973 66. Robins LN: The Vietnam Drug User Returns. Washington, D.C.: U.S. Government Printing Office, 1973 of drug use and its consequences. Thematic plenary session presentation made 67. Rootman I: Epidemiology at the Eleventh Annual Conference of the Canadian Foundation of Alcohol and Drug Dependence (InformAction). Tororito, 20 June 1976 68. Abelson H, Cohen R, Schrayer D et a/.: Drug Experience, Attitudes and Related Behavior Among Adoles cents and Adults, Part I. Princeton, New Jersey: Response Analysis, 1973 DI, Kleman MT, Balter MB et al.: Use of mood-changing drugs among American adults. In: 69. Manheimer SocioIogicaI Aspects of Drug Dependence. Winick C (Ed.). Cleveland, Ohio: CRC Press, 1974 70. Fejer D, Smart R: The use of psychoactive drugs by adults. Can Psychiat Ass J 18: 313-320, 1973 drug use in American families. In: Sociological Aspects of Drug Dependence. 71. Borgatta EF: Psychotropic Winick C (Ed.). Cleveland, Ohio: CRC Press, 1974 drug use in the United 72. Mellinger GD, Baiter MD, Parry HJ et al.: An overview of psychotherapeutic States. In: Dmg Use: EuidemioloGcal and Socioloeical Aouroaches Josephson E. Carroll EE (Eds.). New .York: John Wiley, 1976 patterns of psychotherapeutic drug use. Arch Gen 73. Parry HJ, Balter MV, Mellinger GD et al.: National Psychiat 28: 769-783, 1973 R: Sex differences in the use of mood-modifying drugs: an explanatory model. J Hlth Sot 74. Cooperstock Beh 12: 238-244, 1971 drugs by U.S. adults. Pub Hlth Rep 83: 799-810. 1968 75. Parry HJ: Use of psychotropic 76. Rogers JM: Drug abuse: just what the doctor ordered. Psycho1 Tod 4: 16-24, 1971 77. Brahen SL: Housewife drug abuse. J Drug Educ 3: 13-24, 1973 CD, Inciardi JA, Siegel HA: Chemical Coping: A Report on Legal Drug Use in the United 78. Chambers States. New York: Spectrum, 1975 A: Medicine Takers, Prescribers, and Hoarders. London: Routledge & Kegan Paul. 79. Dunnell K, Cartwright 1972 SN, Berenson LB, Kavaler F er al.: Prescribing patterns in the New York City Medicaid 80. Rosenberg Program. Med Care 12: 138-151, 1974 and use in an American community. Ann 81. Stolley PD, Becker MH, McEvilla JD et al.: Drug prescribing Int Med 76: 537-544, 1972 39.
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DAVID D. CELENTANO. DAVID V. MCQUEEN and ELSBETH CHEE Shapiro S, Baron SH: Prescriptions for psychotropic drugs in a non-institutional population. Pub Hlth Rep 76: 481488, 1961 Cooperstock R: Women and psychotherapeutic drugs. In: Women: Their Use of Alcohol and Other Legal Drugs. MacLennan A (Ed.). Toronto: Addiction Research Foundation, 1976 Linn L: Physician characteristics and attitudes toward legitimate use of psychotherapeutic drugs. J Hith Sot Beh 12: 1322140, 1971 Lennard H. Epstein L, Bernstein A er 111.:Hazards implicit in prescribing psychoactive drugs. Science 169: 438441, 1970 Nathanson CA: Illness and the feminine role: a theoretical review. Sot Sci Med 9: 57-62. 1975 Wechsler H. Thum D: Drug use among teenagers: patterns of present and anticipated use. lnternat J Addict 8: 9099921, 1973 Crowley T, Chesluk H, Dilts S et al.: Drug and alcohol abuse among psychiatric admissions, Arch Gen Psychiat 30: 13-20. 1974 Mason K, Czajka JL. Arber S: Change in U.S. women’s sex role attitudes. 19641974. Am Sot Rev 41: 573-596. 1976 Mincer J: Labor force participation of married women: a study of labor supply. In: Aspects of Labor Economics. Universities’ National Bureau Committee for Economic Research (Eds.). Princeton, New Jersey: Princeton University Press, 1962 U.S. Department of Labor: Women Workers Today. Washington D.C.: Women’s Bureau. Employment Standards Administration, U.S. Department of Labor. 1976 _ U.S. Denartment of Labor: 1975 Handbook of Women Workers. Washington D.C.: Women’s Bureau, Employment Standards Administration, U.S. Department of Labor, 1975 Ross HL, Macintosh A: The emergence of households headed by women, Working paper. Washington. D.C.: The Urban Institute, 1973 Roper Organization, Inc: The Virginia Slims American Women’s Opinion Poll. Vol. 3: A Survey of Attitudes of Women on Marriage, Divorce, the Family and America’s Changing Sexual Morality. New York: The Roper Organization, 1974 Kilty KM: Attitudinal and normative variables as predictors of drinking behavior. Q J Stud Ale 39: 1178-l 194. 1978 Bowker LH: Drug Use Among American Women, Old and Young: Sexual Oppression and Other Themes. San Francisco: Rand E. Research Associates, 1977 Wilsnack SC: The impact of sex roles and women’s alcohol use and abuse. In: Alcoholism Problems In Women and Children. Greenblatt M, Schuckit MA (Eds.). New York: Grune & Stratton. 1976 McQueen DV, Celentano DD: The Extent of Problem Drinking: A Community Based Validation and Assessment of Measurement Strategies. Baltimore: The Johns Hopkins University School of Hygiene and Public Health. 1978
SUBSTANCE A REVIEW
ABUSE
BY WOMEN:
OF THE EPIDEMIOLOGIC
DAVID D. CELENTANO,
DAVID V. MCQUEEN
LITERATURE and ELSBETH CHEE
Department of Behavioral Sciences, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, MD 21205, U.S.A.
(Rewired
in recised,form
28 August 1979)
IN THIS literature review, the generic term ‘substance abuse’ is used to refer to alcoholism, licit drug abuse and the combined use of alcohol and licit drugs. That is, our stress is upon the use and abuse of legally obtainable substances which alter mood. The review’s focus on substance abuse by females reflects a growing concern with the status and roles of women in contemporary society. While in the past, alcohol and drug abuse research has centered primarily on men, there has been increasing awareness that these problems also affect the female population. One area which has not been adequately explored is the effect of changes in female sex-role orientation (expected behavior or interaction style) on the prevalence of substance abuse. The scope of this review includes: (1) general methodological and definitional issues in population studies; (2) reviews of the prevalence literature on alcoholism, drug abuse and combined use and abuse by women; and (3) a brief discussion of research directions emerging from the recent sex-roles literature. Alcoholism and drug abuse present similar methodological and interpretative problems in research, have similar populations at risk and similar individual characteristics of users. Yet, little attention is paid to these similarities. It is apparent that there is a lack of awareness in the field of alcoholism of work being conducted in the drug abuse area and vice versa. This lack of cross-fertilization is demonstrated by the fact that little has been written about ‘substance abuse’ or the ‘substance abuser’ per se. In the past, persons abusing licit (alcohol and psychotherapeutic drugs) or illicit substances have been studied by separate, and often competing, researchers. Rather than reflecting a rational approach to the problem of substance abuse, this situation has emerged as a consequence of federal funding procedures (i.e. two separate Institutes in HEW), resulting in separate domains of research. Although efforts have been made by HEW to combine the alcoholism and drug abuse Institutes, vocal alcoholism and drug constituencies have thwarted any such move. Hence, female substance abuse, an increasingly important public-health problem with chronic-disease implications, has essentially remained unaddressed at the level which it merits, In the past, separate journals were the primary means used to disseminate research findings; recently, joint journals have evolved (e.g. American Journal of Drug and Alcohol Abuse, International Journal of the Addictions). Yet, the dichotomy still prevails; often in one article on substance abuse the author will separately discuss alcohol and drug problems without discussing the problem in toto [l]. Historically. this separation stems from the divergent developmental paths of the two research areas; i.e. in alcohol research, studies commenced in the 1940s with the promulgation of Jellinek’s disease concept, while a major impetus for drug abuse research arose only with the heroin ‘epidemic’ of the 1960s. Female drinking patterns have received increasing attention in the literature in the past several years as part of a renewed interest in population studies of alcohol consump-
DAVID D. CELENTANO, DAVID V. MCQUEEN and ELSBETH CHEE
384
tion. However, while the volume of articles is growing rapidly, the majority of such studies contain few substantive research findings. In the relatively few review articles [24], basic epidemiologic parameters are not emphasized. In the drug ‘abuse’ area, it is even more difficult to locate literature directly discussing the epidemiology of licit (psychotherapeutic) drug abuse. This may reflect a definitional problem (see below) as well as the different focus on the two fields: the drug abuse area has historically been more oriented towards the development of policy in response to perceived crisis stituations (e.g. Domestic Council [7], National Commission on Marihuana and Drug Abuse [8]) than toward conducting basic epidemiologic research. Given the popular perceptions of what constitutes the ‘real’ problem of drug abuse-that is, illicit drug use, and not the abuse of licit drugs which are obtained from physicians or are available ‘over the counter’-funding priorities and research interests have not promulgated studies focused on determining a basic descriptive epidemiology of licit drug problems. Finally, the literature on concomitant problems of drug and alcohol abuse is scant. This weakness in the general literature is also found in the literature on women, which, in addition, has its own deficiencies. DEFINITIONAL
PROBLEMS
One of the fundamental problems in substance abuse research is the lack of consensus as to definitions and measurement strategies used to ascertain basic epidemiologic information. This lack of consensus within the research community is reflected in much of the field research which has been undertaken in past decades. Comparative and replication studies are virtually non-existent, leading researchers to continually develop new instruments and methods which have questionable reliability and lack substantive validity. The literature has become swamped with untested assumptions, and with definitions and measures which have not been adequately verified [9-lo]. Alcoholism
One of the predominant difficulties cited in the alcohol literature is that no standardized procedure exists for distinguishing an ‘alcoholic’ case; there are nearly as many definitions as there are definers [ll]. There is no systematically used diagnostic nosology; without a clear definition of a ‘case’, it becomes nearly impossible to establish what is not a case, or for that matter, what is a control. Thus, one is unable to determine what will be included and excluded in any study concerning alcohol use. Some of the accepted definitions of ‘alcoholism’ found in the medical literature are: It is possible to view alcoholism as a medical problem without regarding it as a specific disease. The alcohol pattern ol the patients described are beyond doubt symptomatic. Alcoholism is a symptom [12]. Alcoholism is an illness characterized by preoccupation with alcohol and loss of control over its consumption such as to lead usually to intoxication if drinking is begun; to chronicity; by progression; and by tendency toward relapse [ 131. Those excessive drinkers whose dependence upon alcohol has attained such a degree that it shows a noticeable mental disturbance, or an interference with their bodily or mental health, their interpersonal relations and their smooth social and economic functioning; or who show prodromal signs of such developments [ 141.
This definition is similar to that of the World Health Organization [15]. Plaut prefers the term ‘problem drinking’ which is defined as the ‘repetitive use of beverage alcohol causing physical, psychological, or social harm to the drinker or to others’ [16]. By taking such an approach, one can gain etiological information and develop typologies of drinking behaviors [ 173. Siegler et al. analyze various models of ‘alcoholism’ which have been extensively used in the alcohol literature. They describe eight models: the ‘skid row impairment’ model. the ‘moral’ model (based on temperance feelings), the deviancy paradigm (based upon labelling and stigma which are conceived of as departures from social norms), the Alcoholics Anonymous model, psychiatric models and medical models [ll]. This variety of ideas illustrates an overall lack of consensus which has important practical ramifications. for each theoretical orientation prescibes the method and measures to be used in research, and this ultimately leads to non-comparability of research findings.
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While there is no concensus for the delineation of a disease entity called ‘alcoholism’, it appears that during the past 30 yr there has been a progressive move away from moralistic, non-medical models of alcoholism to the point where, in recent years, the Criteria Committee of the National Council of Alcoholism, composed predominantly of physicians, established ‘criteria for the diagnosis of alcoholism’. The Criteria Committee assumed alcoholism to be a ‘disease’ and a ‘pathological dependency on ethanol’ [18]. Cahalan explores the rationale of the concept of ‘problem drinking’ [17] ; such a concept is considered to be an encouragement for research. The term ‘drinking problem’ places “emphasis upon the behavior, rather than on the person (and thus serves less readily as a permanent label for the person with drinking problems)“. Further, it allows an inquiry into the possibility that there is a range of drinking problems associated with a spectrum of problem drinkers [17]. Drug abuse
In drug abuse research, the definitional problem is as salient as in the alcohol field; moreover, there is even less agreement in studies of drug abuse. The National Commission on Marihuana and Drug Abuse identified four major definitions of drug ‘abuse’: (1) any ‘use’ of drugs; (2) any ‘non-medical’ use of drugs; (3) using drugs to ‘excess’; and (4) anything that is ‘addictive’. The National Commission noted this disparity in public definitions of ‘drug abuse’ and pointed out that over the last several years “The public and press often employ drug ‘abuse’ interchangeably with drug ‘use’. Indeed many ‘drug experts’, including government officials, do so as well” [S]. Josephson [19] states that problems in definition are in part due to differences in conceptualization and measurement, and to the interrelationships between the variety of drugs used in different ways with different pharmacological effects (and concomitant symptoms and sequellae). Smart [20] addresses this problem by noting that an holistic measure of ‘drug abuse’ is difficult to use in epidemiologic studies since clear indicators of pathological consumption are difficult to delineate and only rarely have been tied to use. Only for narcotics has this relationship been documented (in alcohol studies, one measure often used has been liver cirrhosis). Finally, within the field of drug abuse there has been considerable argument over several other terms: ‘addiction’, ‘habituation’, ‘dependence’ and ‘abuse’ [8,20]. Another dimension of the definitional problem is the context in which the term is used. The National Commission noted that the term ‘drug’, when used in the context of ‘abuse’, has a social (not scientific) meaning. The National Commission defined drugs as encompassing only psychoactive drugs, ‘those which have the capacity to influence behavior by altering feeling, mood perception or other mental states’ [8]. Balter’s [21] definition of ‘drug abuse’ emphasized immediate consequences of use rather than secondary social implications (i.e. arrest, social disapproval etc.): Use of a drug or other substance with central nervous system activity in excessive amounts, or in a fashion, whether on one occasion or repeatedly, so as to produce: 1. Significant physical or psychological dependency. 2. Serious mental or personality disturbances, psychoses or serious and/or prolonged states of disoricntation. 3. Serious impairment or personal and/or social functioning, including significant toxicity of behavior, e.g.. impulsivity, poor judgement and psychomotor instability. 4. Death or behavior endangering the life of oneself or others. 5. Serious interference with growth of personality and/or social development. particularly among younger persons. 6. Physical damage or debility-physiological, biochemical, genetic, neurological etc.
Smart [20] prefers the term ‘drug use and problems arising from drug use’ to ‘drug abuse’. Noticeably, Smart is one of the few drug abuse researchers with broad experience in alcohol studies; this may account for his preference for drug ‘problems’ rather than ‘abuse’. Smart explained his rationale: “Drug use, and not ‘drug abuse’, should be studied because prevention is the most important ‘use’ of epidemiology” [20]; this function, according to Smart, should be the prevention of drug ‘problems’. not drug ‘abuse’. He further argues that few studies are designed to locate the causes of drug ‘use‘; the reason
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DAVID D. CELENTANO, DAVID V. MCQUEEN and ELSBETH CHEE
for the non-utility of most epidemiologic studies of drug ‘use’ has been the lack of attention paid to drug problems while studying drug use. In essence, his criticism is that most studies erroneously equate drug ‘use’ with drug ‘problem’. Thus, it becomes immediately clear that definitional (and consequently, measurement) problems are rampant in the substance abuse field. This lack of consensus results in duplication and unreliability in research findings. Hence, prevalence estimates and concomitant factors of ‘abuse’ cannot be ascertained with confidence. Basic epidemiologic
dejinitions
An analysis of studies reporting on the prevalence of drug and alcohol abuse requires attention to the definitions of traditionally used epidemiologic measures. Most indicators are reported as rates which occur in given populations; in substance abuse research, rates are usually specified for an adult population. Most often, the population includes all individuals over age 21; however, in some instances, studies include persons of lower ages (15 yr is generally the minimum age specified for an adult population). Often researchers use a base rate consisting of the population of users as opposed to non-users of the total population at risk. Prevalence rates are traditionally given as either point, period or lifetime figures. Point prevalence (the frequency of a disorder at a designated point in time) and period prevalence (total number of cases existing during some specified time period, i.e. sum of point prevalence and incidence) are commonly used measures. Substance abuse studies often fail to distinguish which rate is being used. In alcohol and drug research, another type of measure is encountered-‘lifetime’ prevalence. Lifetime prevalence is seldom reported in most epidemiologic literature; this measure exists in alcoholism studies because of the inclusion of persons who possess what may be called ‘alcoholism in remission’, persons who have been previously classified as being alcoholic. Lifetime prevalence makes evaluation and comparison of studies exceptionally difficult; it appears in the literature because of the failure of researchers to specify a time period for the ‘abusive’ behavior. Thus, staggering prevalence numbers may be found by counting all individuals who at some period in their lifetime had a problem with drinking or drugs [9]. Incidence is infrequently cited in the alcohol literature, but is common in studies of illicit drug use. Incidence (the number of new cases of a disease in a specific population during a given interval of time, usually 1 yr) is especially tied to a fairly exacting definition of what constitutes a case. In addition, one must distinguish genuine new cases from those which may ‘re-occur’ during the incidence measure interval. Generally, incidence figures for substance abuse are obtained from statistics on admission or readmission to psychiatric or treatment facilities [22]. THE
PREVALENCE
OF
SUBSTANCE
ABUSE
AMONG
WOMEN
Alcohol problems among women is an area in which there is little present knowledge. ‘Hidden drinking’, asserted changes in prevalence rates and the development of new roles for women are all factors of interest. The drug abuse literature, too, has recently focused upon women due to a high rate of psychotherapeutic drug use and suspected abuse among women. Few studies have observed the effect or estimated the prevalence of alcohol and drug problems which exist simultaneously. Problem
drinking among women
The population survey would appear to be the most direct way of measuring the prevalence of problem drinking. However, a review of population surveys conducted during the past 30 yr has yielded highly variable estimates of the prevalence of problem drinking in women [23]. This is due, at least in part, to the aforementioned measurement and definitional problems rampant in the area of substance abuse, as well as to difficulties in population selection and sampling. As will become apparent in the following discussion of selected population studies, the major focus of these surveys has been in no way uniform; some have looked at actual drinking patterns and practices while others
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have emphasized the consequences of drinking which are used as proxy measures (or ‘indirect’ retrospective inferences) of drinking behavior. There has been little comparability either in terms of the methods used or the types of populations surveyed. One of the first large-scale population surveys was conducted by Marconi et al. [24]. In a household survey in Santiago, Chile, the authors asked respondents about the level of their alcohol intake (a measure of quantity) and about ‘loss of control’. They projected an annual period prevalence rate of 6/1000 for females for ‘severe problems’ (alcoholism) and S/l000 for ‘alcohol abuse’. The study of Bailey et al. [25] was one of the first urban American population surveys. The authors interviewed respondents randomly selected from a household survey sampling frame of upper Manhattan. They were primarily interested in assessing ‘problems with living’ associated with ‘excessive alcohol abuse’ and related health problems. The authors reported a prevalence rate of ‘alcoholism’ of 4.13/1000 for females. Zax [26], in 1967, utilized records and reports from the city court, county penitentiary, the Salvation Army, the Alcoholism Center and all psychiatric treatment agencies of Monroe County, New York, to establish a prevalence rate of 0.56/1000 for white females and 4.78/1000 for non-white females. An alcoholic was defined as a person who had a medical diagnosis of alcoholism, one who had applied for services for an alcohol problem or one who had been arrested for public intoxication. Knupfer [27] interviewed a population sample in San Francisco and estimated the lifetime prevalence of ‘troubles due to drinking’. Various types of problems were categorized in terms of intensity and time period. Rates of 1.7% for problems with ‘serious consequences’ and 3.4% for problems with ‘moderate or severe consequences’ were obtained. Cahalan et al. [28] conducted the first national probability sample survey concerned with describing drinking patterns. From a random probability..sample 6f the entire contiguous United States, the group reported a rate of ‘severe’ problems of 4% for females. This category included persons who were ‘heavy’ drinkers with high ‘escape’ reasons (a psychological measure) for drinking. Alcohol ‘abuse’ rates (defined as moderate and severe problems with alcohol) were 21% for women. Celentano and McQueen [9] studied prevalence rates obtained by five methods: (1) index of uncontrolled drinking; (2) heavy intake, a measure of quantity-frequency; (3) heavy-escape drinking; (4) loss of control; and (5) escape-drinking, and found great discrepancies among the estimates. In Maryland, within the same population, the estimates of problem drinking for women ranged from 0.6 to 14% Many studies have been conducted which have attempted to develop summary measures for use in predicting the rate of alcoholism in various populations [29-361. Most of these studies have utilized different types of populations and indicators which are often not comparable. Some of the evidence does appear to be consistent despite the numerous methodological problems and disparities. Yet, one must not fail to notice that the prevalence rates often vary widely from study to study, which may result partially from differences in the indicators themselves. In-depth reviews of the prevalence literature may be found in Cahalan et al. [28]. Celentano [23], and Celentano and McQueen [IS,lo]. Generally what emerges is a variety of rates dependent upon the estimator used, each with its own reliability and validity, the population and its cultural context, and type of prevalence measure used. However, it is believed that all of these rates are understated for one reason--‘hidden’ (secretive) female drinking. Female hidden drinking
Badiet [l], Greenblatt and Schuckit [37], Gomberg [2], Rubington [38], Curlee [39] and Lisansky [40] have reviewed the literature on female drinking, and all mention the presence of ‘hidden’ drinking. The assumed cause underlying hidden drinking is the stigma of the drunken female [38-511. Drunkenness among women is considered tantamount to breaking taboos, for it runs counter to the American idealized norm of selfcontrolled ‘lady-like’ behavior [40]. Drinking and heavy drinking are often tolerated in
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men [17], but women are viewed as guardians of social values in the preliberation context, and those who abuse alcohol are seen as a threat to family stability. Thus, their deviation from the expected role is viewed as more serious than that of their male counterparts [40]. The drunken female can be viewed as a threat, for: “No one likes to believe that the hand that rocks the cradle might be a shaky one.” The traditional female role requires constant vigilance over others; for men, business functions can be put off for a day, while the care of children (the domain of women) cannot [39]. Badiet [l] states that: “Such social pressures do not prevent addiction, but they discourage females from admitting their problem and seeking help.” Female drinking patterns are said to differ from men’s in that women tend to drink at home and alone far more than men [2,52,53]. Cartwright et al. [54], in a 1974 replication of a 1965 survey, found an increased tendency among women, but not among men, to consume at home. Rubington [38] estimates that 70% of female alcoholics are hidden drinkers, a phenomenon arising from numerous factors. Friends, law enforcement personnel and judges ‘protect’ female problem drinkers [48,50,53,55] ; as social class increases the amount of protection also increases [56]. The role of the housewife is an inducement for concealment, for there is increased time, opportunity and pressure (all ostensibly leading to boredom) for drinking alone or secretly, behaviour which can last undetected for years [4,39,57]. Lindbeck [4] also states that husbands of problem drinkers use denial themselves when they realize their wives’ problems, for the social stigma reflects upon them as well; their cover-up hinders referral and treatment [39,40,43], and most female problem drinkers remain hidden. There are a host of theories on why women become problem drinkers (cf. Gomberg [2] for a review of many psychological and physiological theories). Johnson et al. [49] and Johnson et al. [SO] believe that women, and particularly housewives, tend to drink heavily to escape routine (boredom), to improve self-image (challenges) and to attain self-confidence. Curlee [47] believes that the onset of problem drinking lies in a crisis situation. The archetypal crisis here is the middle-age identity crisis or the ‘empty-nest’ syndrome, which occurs after the children leave home or following divorce or death of a spouse, leaving the women with a loss of sense of identity, purpose and worth. Heavy alcohol use is often employed to cope with those situations setting into motion a ‘vicious circle’. Despite these differing theories, no research data exist to select any one with confidence. Many of the problems with past prevalence studies have been the result of a remarkable lack of attention paid to the problem of hidden drinking. While Cahalan er al. [28] devised the ‘escape’ drinking scale to account for psychological motivations for alcohol use, escape drinking alone is not synonymous with problem drinking. Numerous prevalence measures focusing on consequences of alcohol consumption (alcohol-related problems) include questions which do not appear to be overly relevant to areas of concern for female problem drinking [30,31]. In essence, it can be argued that most alcoholism prevalence estimators were developed and used primarily to obtain rates of problem drinking for men, as they were the population most often observed (clinically and anecdotally) to be alcoholics. What is needed, then is a prevalence estimator for women which is free of contamination by the traditionally male-oriented measures of alcohol-related problems or consequences of abusive drinking, e.g. employment and law enforcement problems. It is the contention here that the previous focus on males has led to a bias in prevalence rates for women. One piece of evidence verifying the above assumption is some data based on liver cirrhosis mortality. Keller [SS] reviewed the studies to 1960 and found a sex ratio of between 4 and 5 males to each female problem drinker, the generally accepted sex difference [59]. However, Ledermann [60] reported a sex ratio of 2:l; Celentano and McQueen [lo] found a ratio of only 2 : 1 in Maryland using a virtually complete enumeration of all deaths for one county over a period of 7 yr, while survey results showed a difference of 4: 1. This difference, then. may be due to the ‘hiding’ of female problem drinking.
Substance
Abuse by Women
389
Drug abuse among women
It is quite difficult to summarize the literature on the prevalence of licit drug abuse, due to the proliferation of types of drugs abused which has resulted in a very large number of published studies. Yet, this body of literature can be quickly reduced by focusing interest upon women; the majority of drug abuse studies has been conducted on adolescent psychotropic drug use (and most of that on illicit drug ‘use’, cf. Smart and Fejer [61], Bakal et al. [62], Russell and Hollander [63], Hughes et al. [64], Savada [65]), veteran (male) heroin use [66] or narcotic abusers in treatment [67]. One of the most famous studies focusing on psychotropic drug use was that reported by the National Commission [8] who supported Abelson et al. [68] in conducting a national probability sample survey. Approximately twice as many females as males ‘used psychotropic drugs in the 6 months preceding the interview. Manheimer et al. [69] reported that, in 1970, approx. one third of U.S. adults had taken a psychotherapeutic drug on one or more occasions, and 6% used these drugs on a regular daily basis for 6 months or longer during 1970. Forty per cent of females and 20% of males had used one or more psychotherapeutic drugs in the past year. Female use was generally constant across all ages. In a survey of 1200 adults in metropolitan Toronto, Fejer and Smart [70] found almost three times as many women as men among persons with prescriptions, and that women reported approx. 75% of all prescriptions. Borgatta [71] reported that 27.6% of females and 16.8% of males in a probability sample used psychoactive drugs, while 10.9% of women and 5.6% of men used two or more. The problem with all of these studies (generally held to be indicative of the state of the art) is that ‘use’ and ‘number of drugs’ are not measures of quantity and frequency (Q-F) and are, thusnot equivalent to those terms used in alcohol studies. Further, these studies do not address the questions of ‘problems’, the endpoint of all substance abuse epidemiologic studies. Mellinger et al. [72] developed a drug abuse measure (frequency-duration) which approaches the concept of a Q-F measure used in alcohol studies. They found that the 2: 1 female-to-male ratio reported in other studies held for all levels of use in the general population. Yet, among ‘users’ of psychotherapeutic drugs, men were slightly more likely to be ‘high’-level users (abusers). Among users, there was also a preponderance of heavy users among the lower socio-economic groups. Parry et al. [73] reported approximately equal proportions of high users of psychotropic drugs across social classes, yet there was a negative association with social status when observing the proportion of heavy users among all users. For housewives, this negative association held for both the total population and among users. Thus, there is some evidence that lower-class women are high users (and abusers) of licit psychoactive drugs. Many prescription studies have been conducted in the past 10 yr to document sex differentials in drug abuse. Cooperstock [74] found that 69% of all psychotherapeutic drugs are prescribed for women, a proportion also reported by others [I, 39,75,76]. Brahen [77] analyzed ‘habitual frequent users’ by type of drug-54% of barbiturate and 58% of major tranquilizer abusers were women. Further, 73% of regular barbiturate users and 850/, who used ‘powerful sedatives’ were middle- or upper-class women. Chambers et al. [78] stated that the 2:l ratio in the prevalence rate of psychotherapeutic drug use found was due to the use of minor tranquilizers by women, not to differences in the rates of barbiturate use. Dunnell and Cartwright [79] reported that in a study conducted in England, 31% of women and 20% of men were ‘abusing’ a drug (defined as using a drug prescribed more than 1 yr previously). Others have reported similar findings [SO-821. Being knowledgeable of these prevalence data, many authors have attempted to explain why more women than men use psychotropic drugs. Cooperstock [83] has recently reviewed the evidence; she contends that physician responses to female roles contribute to the high level of prescribing. She states that physicians expect women to bring feelings to the doctor; thus, women are assumed to require more mood-altering drugs [74]. Linn reported that social and psychological ‘problems in living’ have been redefined as medical problems, causing high rates of prescriptions to be ordered for
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DAVID D. CELENTANO. DAVID V. MCQUEEN and ELSBETH CHEE
women [84]. Lennard et nl. [85] discussed the role of the drug industry this change in definition. Individual reasons for drug abuse are varied. The National Commission the extent of the problem:
in developing [S] discussed
reported that they take a pill to calm down The National Survey shows that 15”” of the adult population or cheer up when they feel out of sorts, _. not really sick. but nervous. or depressed or under stress. Eighteen per cent of the public reported that they used alcohol for similar purposes. The use of a variety of new mood altering drugs to cope with stress is undoubtedly a significant social development, particultrrl~ amongwmen [68] (emphasis added).
Chambers et al. [78] reported that regular users of psychotropic drugs are white females 35 yr or older who are middle or upper class; the majority are housewives or women not participating in the labor force. Parry et al. [73], however, stated that their findings “suggest rather strongly that long-time daily use of presciption sedatives and minor tranquilizers is more prevalent not among well-to-do and well-educated women, whether working or full-time housewives, but among the housewives who are poor and ill-educated”. Despite the lack of agreement between these two studies relating social class and frequent drug use, both studies substantiate Nathanson’s [86] observation that ‘*employment has, perhaps, the most clearly positive effects upon women’s health of any variable investigated to date”. She presents data showing fewer symptoms and less anxiety (both characteristics of imputed motivations for drug use) as compared to similarly aged non-working women. The problem with most drug abuse studies presented here has been the limited attention paid to ‘problems’ and the majority of interest paid to ‘use’. As with alcohol studies, little (if any) attention is paid to other forms of substance abuse. Again, the role of employment and the role status of ‘housewife’ emerge as important for substance abuse.
Prevalence of alcohol and drug abuse The major finding to be reported in terms of combinative alcohol and drug use and abuse is that there is little definitive data. The data that exist deal with special groups, and the focus there is upon use (Wechsler and Thum reported on adolescents 1871; Robins discussed Vietnam veterans [66]). Despite a paucity of studies, the literature which does exist, and which purports to address questions of the commonalities of alcohol and drug abusers, demonstrates either gross methodological flaws or displays a lack of knowledge concerning the field in which the researchers are not recognized as experts. For example, the National Commission [S] stated: “Only a marginal relationship exists between consumption of alcohol beverages and recent use of ethical or proprietary psychoactive drugs.” Unfortunately, the questions which yielded these data were not of the same time parameter-drug use was asked for the past year while alcohol use was asked for the past 7 days. Further, when discussing multiple drug use, concomitant use is usually not ascertainable. Most of the data that do exist deal with alcohol and drug ‘use’. The National Commission [8] reported concurrent (past 6 months) use of alcohol and use of sedatives (1%). tranquilizers (7x), stimulants (20%) and proprietary drugs (6yh). Crowley et al. [88] reported high rates of both alcohol and drug abuse among psychiatric admissions, and Mellinger et al. [72] stated that 15% of the respondents used both alcohol and drugs during the past year, but not necessarily concomitantly. They stated that the “use of alcohol is most prevalent among groups of people who are least likely to use medically prescribed mood-changing drugs, and vice-versa”. It has been well documented that the rate of self-reported alcohol abuse is higher in males than females [9,28], while the rate of abuse of prescribed psychoactive drugs is higher among women [83]. For alcohol abuse, prevalence decreases with age, while for drug abuse (in general) there is a slight increase. Abelson et al. [68] reported that 2496 of men and loo/;; of women used alcohol to cope with moodiness or stress ‘a lot’ or ‘sometimes’, while only 13O:, of men and some 18”,, of women used pills for these reasons.
Substance
Cooperstock
[74] explained
Abuse by Women
this set of conflicting
391
data as follows:
It would be an oversimplification to attribute all of the sex differences found in the use of mood-modifying drugs to the higher prevalence of escape drinking by men as some have suggested. While this is undoubtedly a partial explanation, it begs the question of the role of the physician writing such a disproportionate number of prescriptions for women patients. However, one cannot account for this difference in sex ratio differentials by the proportion of the population utilizing physician services. Rather, one again confronts differences in the manner in which drugs are prescribed for women. CONCLUSIONS
It has been shown that, for a number epidemiology of substance abuse among the problem: That seems double others
literature evident.. standards. (husband,
of reasons, little substantive knowledge of the women exists. Badiet [l] has aptly summarized
in the addictions field has tended to ignore women in terms of use and misuse of drugs the literature which does exist abounds with myths, sexism. patriarchal notions, and Women have received great attention mainly when there is concern about their effect on children, doctors. etc.).
The outlook reflects traditional sex roles in the U.S.A. which have centered around the familial division of labor. “These roles prescribe behavior regardless of marital status and age, but they are most centrally concerned with the gender-based bread-winner-versushomemaker specialization” [89]. Support for such a view was widespread in the past. However, since 1940, this sex-role division has declined, in part due to increasing female wage-levels [90], the increasing proportion of married women in the labor force [91], the growing proportion of women comprising the labor force (up from 20% in 1920 to 407; in 1975) [92], rising divorce rates and the increasing number of female-headed households [93]. The results of these changes, along with concomitant orientations of attitudes towards appropriate roles [89], has led to a greater equality between the sexes. Mason et al. [89] showed how attitudes towards women’s sex-roles represent clues to the relative statuses of the sexes; and national polls have demonstrated shifts in women’s outlooks towards their rights and obligations [94]. One logical outgrowth of such an evolutionary process in sex-role orientations is that women’s behavior may become more like that currently attributed to men. Indeed, they may develop similar social and cultural risk factors for many problems and illnesses, not the least of which is substance abuse. Some have argued [2,4] that a decrease in the sex ratio of alcoholism may be a result of changing sex-roles and the relative status of women. Although Kilty [95] found sex differences in terms of attitudes and normative expectations related to drinking, no differences in terms of actual drinking behavior were found in a student sample. Bowker [96] has dealt with the sociological aspects of sexual differentiation in substance abuse, and examined drug and alcohol problems among specific groups of women. Wilsnack [97] has reviewed the literature on sex-role orientations and their role in female drinking from a psychological perspective. She believes that the liberation movement has been responsible for many sociocultural changes in female behavior; changing behavior in the use of alcohol as well as alterations in ‘predisposing’ factors for the effects of alcohol may be counted amongst these shifts. In accounting for factors which are viewed as important in explaining differential rates of substance abuse among women, and as a rationale for speculations concerning the apparent increase in alcohol and drug use, sex-role orientations appear to offer a basis for these associations. However, as with most of the female substance abuse literature reviewed, few empirical data exist [98]. In sum, a new epidemiology of substance abuse is needed, one which recognizes the problems surrounding a very complex issue. Only when these many substantive and methodological problems are confronted will a realistic assessment of the extent of the problem of substance abuse be ascertained. AcLnowle&emenrs--The authors wish to thank George during
the preparation
of this manuscript,
J. Vlasak
and Linda
A. LeResche
for their assistance
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