As an emergency room doctor, I’ve long observed how gendered health and disease are. One classic example is a particular subpopulation that presents to emergency care with high frequency: the individual whose daily, heavy drinking means that it is rare to see them sober. For mysterious reasons, this population used to be overwhelmingly male. When I graduated from medical school, in fact, I had never met a woman who fit this description.
Over time, this has changed in my personal practice, and recent research suggests the gender imbalance in all alcohol-related ER visits is changing across the nation.
In a recent study in the journal Alcoholism: Clinical and Experimental Research, researchers looked at millions of emergency room visits nationally between 2006 and 2014. They showed that ER visits related to alcohol are increasing markedly—particularly in women. The trend brings women’s visits closer to those of men, who have had the dubious distinction of dominating in terms of prevalence of alcohol-related problems.
In my work studying substance use disorders and women’s health, I’ve been watching this gap close for many years across all types and metrics of risky drinking, including binge drinking, alcohol abuse, and physiologic dependence.
However, this study was especially concerning for a few reasons.
First is the magnitude of the change. In this national hospital sample, over nine years, the number of alcohol-related ER visits rose 61.6 percent—even though per capita alcohol consumption increased by less than 2 percent and total ER visits increased by just 8 percent during that time. Looking just at women, the total number of alcohol-related ER visits increased from 947,173 visits in 2006 to 1,609,320 visits in 2014; for men, the total of number of alcohol-related ER visits increased from 2,132,645 visits in 2006 to 3,366,477 visits in 2014.
The rates of alcohol-related ER visits increased in almost all age groups for both men and women, but the annual percentage increase was significantly larger for women (5.3 percent) than it was for men (4 percent). The steepest increase for women was seen in the 25-34 age group and the 55-64 age group. While the increase in acute alcohol-related ER visits was similar for both genders, the increase in chronic alcohol-related ER visits was significantly higher for women (6.9 percent) than for men (4.5 percent).
Aaron White, Ph.D., the study’s lead author, tells SELF that this was a surprise to his research team as well. “We suspected alcohol-related ER visits might be increasing more for women than men, but we had no idea the increases for women were so big.”
The types of visits were an additional surprise: Many of the additional visits were by young women who required medical attention for problems related to chronic drinking (i.e., long-term, heavy alcohol use), for example, alcohol withdrawal or alcohol-related liver damage or heart damage. “These are not the types of visits one expects to see among young women in this age range,” he said.
While the closing gap is not completely understood, there are hypotheses among certain specialists who deal with this in their careers.
One is that equality in the workplace has led to shifting social norms and greater exposure of women to the drivers of heavy alcohol use, such as career-related stress and workplace functions that virtually require the consumption of alcohol. In other words, women may have lost the relatively protective environment of being at home.
But White warns that it’s not just as simple as women acting socially more like men: “It is far more complicated than that,” he states. He points out data from the Monitoring the Future study (a longstanding national study of the attitudes and behaviors of 8th through 12th graders), which demonstrates that among high schoolers, a long-standing gender gap in alcohol use has disappeared because males declined faster than females, not because drinking by females increased.
The ER often serves as a bellwether for significant shifts in the health of the population. In this case, visit patterns are a strong indicator that we need to pay more attention to what is happening with women’s drinking, and the deficits in understanding, awareness, dialogue, screening, education, prevention, and treatment that may be responsible.
When it comes to helping someone cut back on their drinking (or treat another substance use issue), gender needs to be a consideration.
The fact is, whenever we dig a little, we find that many things related to drug and alcohol use differ between men and women: the influences that lead to first-time use, whether someone continues to use them, how and when they use drugs or alcohol, whether they progress to dependence or addiction, etc.
Women may be more likely to progress from initiation to dependence, a phenomenon called “telescoping.” We also know that some negative health effects are sex-specific: For example, the risk of breast cancer appears to be elevated even at only moderately increased levels of consumption. And, unfortunately, research shows an association between problem drinking in women and being abused by a partner.
Women can also face multiple barriers to stopping drinking. Consider all of the women-focused social events (e.g., book clubs, “painting and drinking” events) that revolve around the consumption of alcohol. At the same time, women face significant stigma around heavy drinking, which can make it tougher when it comes to seeking care. For mothers, being the primary caretakers of children may also make stepping out to attend a substance use treatment program less possible for them; and they may have a greater fear of the repercussions of openly discussing substance use, including judgmental attitudes or even reports to child protective services.
Even when women finally do seek care, it’s possible that the procedures and practices we typically employ to address substance use just aren’t as accessible to them. One of my own studies examining drug-related visits to the emergency department found that women were much less likely than men to receive appropriate referrals to treatment services upon discharge, whether because providers were less likely to take their problems seriously and refer them, or because the women themselves were less likely to accept offered services. (It’s possible that these women didn’t have access to childcare that would allow them to use these services, or they may have been in abusive relationships where they didn’t have the agency, resources, or social support to allow them to attend treatment programs.)
Another study showed that the kinds of brief counseling sessions we commonly administer in the emergency department likely work for men, but not for women, likely for similar reasons.
Overall, it seems that recognition, stereotypes, and resources are trailing behind the reality of women’s alcohol use, problem drinking, and treatment needs.
We need substantive change, starting with an acknowledgement that women are far from immune from serious and frequent alcohol problems.
We also need a shift in our cultural treatment of alcohol as a benign, friendly social lubricant or coping mechanism (re: wine mom memes)—instead acknowledging that it is a potentially harmful substance that should be limited for a variety of health reasons. Finally we need additional science to fill in the gaps of knowledge so that we understand the issues specific to women’s alcohol use disorders, and their solutions.
These are all long-term goals. In the meantime, here are a few thing women can do for themselves and for others they love:
– Recognize that the thresholds for safe alcohol use are different for women.
White emphasized that NIAAA guidelines for safe drinking are different for women than for men: For men, up to two servings of alcohol per day can be part of a healthy lifestyle, whereas the recommendation is only one serving per day for women (a serving would be a 12 oz. 5 percent beer, a 5 oz. pour of 12 percent wine, or 1.5 oz. of 40 percent/80 proof spirits). Beyond these levels, people face an increased risk of negative health effects, such as certain cancers, liver disease, and brain damage.
– Know that treatment for alcohol and drug use disorders work best hand-in-hand with care for co-occurring problems, such as seeking healing from a past trauma, or safety from a current abusive relationship.
Christina Girgis, M.D., a physician and assistant professor of psychiatry at Loyola University Medical Center and Edward Hines Jr. VA Hospital, says addressing underlying factors linked to substance use is key for women.
“Women who are stressed, or in difficult relationships, or who are being subjected to domestic violence, tend to drink more. Physicians need to know the risk factors and we need to be screening for these problems at every step of the way.”
It’s also important to keep in mind that physical and emotional partner abuse can get worse during efforts to enter recovery, so having contact with domestic violence counselors and a safety plan is important for those who have made a decision to get help for a substance use problem.
– Look for women-centered treatment options.
Women tend to stay in recovery programs longer, and have greater success in them, if they are women-centered. When I lived in Rhode Island a number of years ago, one of the popular addiction treatment programs in the state, Anchor Recovery Community Center, had a main site and a unofficial “women’s site.” A peer counselor at the facility told me, “We didn’t intend for that to be the women’s site. But there was something about it that attracted women—maybe that it was more discreet of a location, and felt particularly private and intimate, and over time, the women gravitated there. And then women would come and see that there were a lot of other women there, and now it’s virtually all women.”
Find a woman-centered program or group, if one is available in your area, or ask if there are enough women engaged in the program to form one.
This isn’t the first time that researchers and clinicians have disregarded gender differences in a major health issue.
Across all kinds of health topics, women have been historically underrepresented and understudied. Thankfully, there has been more and more recognition that disease of all kinds can manifest differently based on sex and gender, and greater interest in understanding the biological underpinnings that determine these differences. Moving forward, this still-emerging science may allow us to develop more effective treatments for women who have substance use problems and—better yet—effective approaches to preventing women from developing these problems to begin with.
If you’re concerned about your drinking or a loved one’s visit the NIAAA’s new Treatment Navigator, which can help you decide on and locate the right type of treatment for your unique situation.
Esther Choo, M.D., M.P.H, is currently an associate professor in the Department of Emergency Medicine at Oregon Health and Science University.