1. health and fitness
2. disorders

Clinical Psychology Review 24 (2004) 981 – 1010
Gender differences in risk factors and consequences for alcohol
use and problems
Susan Nolen-Hoeksema*
University of Michigan, United States
Received 11 March 2004; received in revised form 27 July 2004; accepted 12 August 2004
Abstract
Women drink less alcohol and have fewer alcohol-related problems than men. Women appear to be less likely
than men to manifest certain risk factors for alcohol use and problems and are more likely to have certain
protective factors against these problems: women perceive greater social sanctions for drinking; women are less
likely to have characteristics associated with excessive drinking including aggressiveness, drinking to reduce
distress, behavioral undercontrol, sensation-seeking and antisociality; and women are more likely to have desirable
feminine traits (e.g., nurturance) protective against excessive drinking. In addition, consequences of heavy alcohol
use, or alcohol use disorders, appear to be more negative for women than men, at least in some domains: women
suffer alcohol-related physical illnesses at lower levels of exposure to alcohol than men, and some studies suggest
women suffer more cognitive and motor impairment due to alcohol than men; women may be more likely than
men to suffer physical harm and sexual assault when they are using alcohol; heavy alcohol use in women is
associated with a range of reproductive problems. Implications of these findings for future research and public
health education campaigns are discussed.
D 2004 Published by Elsevier Ltd.
Keywords: Alcohol; Gender; Women; Risk factors; Consequences
1. Introduction
A robust finding in the mental health literature is that women drink less alcohol than men and have
fewer alcohol-related problems than men (SAMHSA, 2002). In this paper, the epidemiology of gender
* Department of Psychology, Yale University, P.O. Box 208205, New Haven, CT 06520, United States.
0272-7358/$ - see front matter D 2004 Published by Elsevier Ltd.
doi:10.1016/j.cpr.2004.08.003
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differences in alcohol consumption and alcohol-related problems is reviewed. Then, the literature on
the predictors and consequences of women’s and men’s alcohol consumption and alcohol-related
problems is summarized. This literature is vast; the major themes in this literature are highlighted, and
empirical articles that have examined gender differences are reviewed.1 This review suggests that
predictors of heavy drinking and alcohol use disorders are more similar than different in women and
men, but women may be less likely than men to carry certain of these risk factors. Gender differences in
the consequences of drinking alcohol are large and consistent. Specifically, women appear to suffer
serious negative consequences of alcohol consumption earlier and to a greater degree than men. The
proximal consequences (e.g., negative effects on cognitive and motor functioning at low doses of
alcohol) may discourage most women from excessive alcohol intake, and the distal consequences (e.g.,
poor reproductive health) may have created selection pressures against heavy alcohol consumption in
women, resulting in lower rates of alcohol use disorders or alcohol-related problems in women compared
to men.
2. Definitions
Alcohol use disorders are the alcohol-related psychiatric disorders recognized by the DSM-IV-TR
(APA, 2000) and its predecessors. These include alcohol abuse, which involves persistent drinking
behavior in the face of repeated social, interpersonal, and occupational problems that are due to
excessive alcohol consumption. Alcohol dependence includes these psychosocial problems, but can also
involve physiological dependence on alcohol, such as tolerance and withdrawal symptoms. This is the
syndrome that is often referred to as alcoholism. Heavy drinking and binge drinking are operationalized
in different ways across different studies. Indeed, an important debate in recent years has been over the
definition of a binge and whether that definition must be different for women and men because of gender
differences in the absorption of alcohol (e.g., Wechsler, Dowdall, Davenport, & Rimm, 1995). The
guidelines put forward by the National Institute on Alcohol Abuse and Alcoholism define moderate
drinking for women to be no more than 1 drink per day, and at-risk drinking to be more than 7 drinks per
week or more than 3 drinks per drinking occasion. In contrast, moderate drinking for men is defined as
no more than 2 drinks per day, and at-risk drinking is defined as more than 14 drinks per week or more
than 4 drinks per occasion. Except where noted, in the studies reviewed here, heavy or binge drinking is
operationalized for both men and women as having 4 or more, or 5 or more, drinks per occasion.
Alcohol-related problems will be used to refer to scores on (usually continuous) measures of negative
psychosocial consequences of excessive alcohol consumption (e.g., arrests for drunken driving). Finally,
social drinkers is the label for people who drink alcohol at least occasionally, but do not meet the criteria
for alcohol abuse or dependence.
1
For each section of this paper, computerized database searches were conducted using a combination of three types of key search words: (a)
words indexing gender (i.e., gender, sex, women, men), (b) words indexing alcohol (i.e., alcohol, alcoholism, alcohol disorders), and (c) words
indexing the predictor or consequence of concern for that section (e.g., genetics, heritability, alcohol sensitivity, gender roles, violence, physical
health). All articles and chapters generated by these searches were examined for whether results included comparisons of men and women on
mean levels of variables or in the relationships between key variables and alcohol use or problems. In some sections, space limitations
prohibited citing all relevant articles or chapters, so a representative sample was cited.
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An Institute of Medicine Task Force (IOM, 1990) concluded that the majority of problems accruing
to society and to individuals as a result of alcohol were not created by people with alcohol use
disorders, but by people with a range of maladaptive alcohol use patterns. Thus, predictors and
consequences of both alcohol use disorders and the spectrum of alcohol-related problems and
consumption levels will be reviewed. It is possible that the risk factors for alcohol use and the risk
factors for alcohol problems or disorders are different (Zucker, 2000). Thus, type of alcohol-related
dependent variable of concern from one study to the next will be noted. In addition, although alcohol
abuse and dependence are often part of a pattern of multiple substance use, the predictors and
consequences of alcohol use will be the focus of this review because alcohol is the most widely used
legal substance of abuse.
3. Epidemiology of the gender difference in alcohol use and disorders
Women consistently drink less than men and have more alcohol-related problems than men.
Nationwide data show that, at all ages and among Blacks, and Hispanics, and non-Hispanic Whites, men
are more likely than women to drink four or more drinks in one sitting (Jackson, William, & Gomberg,
1998). Large age differences are also apparent, with the greatest consumption occurring in the young
adult years for both men and women, and in all three racial/ethnic groups.
Gender differences are found for symptoms of alcohol use disorders as well. The National
Comorbidity Survey (NCS), which surveyed over 8000 adults under 55 years of age, found that 38.6%
of men versus 19.7% of women reported at least one of the criterion symptoms for alcohol dependence
from the DSM-III-R (Nelson, Heath, & Kessler, 1998). The NCS estimated that, at some time in their
lives, 12.5% of men and 6.4% of women will meet the criteria for alcohol abuse, and that 20.1% of men
and 8.2% of women will meet the full criteria for alcohol dependence (Kessler et al., 1994). Similarly,
the more recent National Longitudinal Alcoholic Epidemiologic Survey (NLAES), which had a
nationally representative sample of 42,862 adults 18 years of age and older, and used DSM-IV criteria to
diagnose alcohol dependence, found a lifetime prevalence for alcohol dependence of 18.6% for men and
8.4% for women (Grant, 1997).
Some studies suggest that, in recent decades, the gender difference in drinking and alcohol-related
problems has decreased. For example, using retrospective data from the National Comorbidity
Survey, Nelson et al., 1998 found that there has been a convergence in recent decades between men
and women in their probabilities of alcohol use and problems, with both genders showing earlier
onset of drinking and symptoms of alcohol use disorders in more recent cohorts than in cohorts born
a few decades ago. Retrospective data from the National Longitudinal Alcohol Epidemiologic Study
(Grant, 1997) also suggest a convergence in men’s and women’s alcohol use, although the author
does not report significant sex by cohort interactions in the prediction of alcohol consumption. Crosssectional data from surveys of high school students from 1975 to 2001 suggest that the gender gap in
the prevalence of binge drinking (five or more drinks in a row) decreased from 22.6% in 1975 to
12.3% in 2001 (significance of change in the gender gap not reported; Johnston, O’Malley,
Hackman, 2002). Although the size of the gender gap in alcohol use and related disorders may be
decreasing, girls and women still consume significantly less alcohol and are less likely to manifest
alcohol-related psychiatric disorders than boys and men (Grant, 1997; Wallace et al., 2003; Nelson et al.,
1998).
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4. Risk factors for women’s and men’s alcohol consumption and problems
A number of biological, psychological, and social risk factors for heavy alcohol consumption and
alcohol-related problems and disorders have been studied. The focus here will be on those risk factors
for which at least some studies have examined gender differences in the prevalence of the risk factor or
in its association to alcohol use and problems. Table 1 summarizes the evidence regarding each of the
factors.
4.1. Biological factors
Two biological factors in which gender differences have been directly examined are genetics and
alcohol reactivity or sensitivity.
4.1.1. Genetics
Family history, adoption, and twin studies all indicate that genetics play a substantial role in at least
some forms of alcohol dependence and heavy drinking (Bierut et al., 1998; Crabbe, 2002; Kendler,
2001; Kendler, Davis, & Kessler, 1997; McGue, 1999; Merikangas, Dierker & Szatmari, 1998). Until
relatively recently, studies often utilized all male samples, or if they had a female subsample, it tended to
be small and gender differences were not analyzed (Wilsnack, 1995). In the last few years, data from
mixed-sex samples have been reanalyzed, and large-scale genetic studies of women have been reported.
Some studies have suggested that genetics play a stronger role in alcohol use disorders among men
than women (Bierut et al., 1998; Cloninger, Bohman, & Sigvardsson, 1981; Jang, Livesley, & Vernan,
1997; Light, Irvine, & Kjerulf, 1996; McGue & Slutske, 1993). For example, some twin studies find no
evidence for a genetic contribution to alcohol dependence in women, or that the genetic contribution for
women is less than that for men (Caldwell & Gottesman, 1991; McGue, 1999; McGue, Pickens, &
Svikis, 1992; Pickens et al., 1991). Similarly, some adoption studies find a lower association between
alcohol dependence in birth parents and alcohol dependence in their adopted-away children in women
adoptees compared to men adoptees (Cloninger, Bohman, Sigvardsson, & Von Knorring, 1985).
In contrast, one large twin study found similar heritability for alcohol dependence in women and men
(Heath, Bucholz, & Madden, 1997), while another study found modestly higher heritability for women
than for men (Prescott & Kendler, 1999; see also Allgulander, Nowak, & Rice, 1992). In addition, at
least one large adoption study found that the relationship between alcohol use disorders in birth parents
and these disorders in adopted-away children was somewhat greater for female adoptees than for male
adoptees (Cadoret et al., 1995).
Heath, Slutske, and Madden (1997) suggest that several of the studies finding that genetics do not
contribute to alcoholism in women lacked statistical power, due to relatively small sample sizes and the
low rate of alcoholism in the female population (see also Wilsnack, 1995). In addition, some genetic
studies rely on records of hospitalization for alcohol use disorders or other social indicators of severe
alcohol problems (e.g., drunk-driving arrests) to bdiagnoseQ alcohol use disorders in study participants.
Such methods detect only the most severe and perhaps antisocial alcoholics, who are more likely to be
men. In addition, women are less likely to seek treatment for alcohol use disorders (Beckman, 1994) and
thus may be excluded from these studies.
Heath (1995) reviewed twin studies of the genetic influences on alcohol consumption patterns (rather
than alcohol use disorders) and concluded that genetic factors are as important in women as in men for
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Table 1
Summary of findings on gender differences in risk factors for alcohol use and problems
Risk factor
Evidence
Genetics
Most studies find genetics contribute to alcoholism and alcohol use in both women and men;
some studies suggest genetics play a stronger role in alcoholism for men than for women.
Studies of men find low alcohol reactivity is associated with a history of familial risk for
alcohol use disorders and the development of alcohol use disorders in men. There are only
a few small studies of women, but these studies also tend to find an association between
familial risk for alcoholism and low alcohol reactivity. It is unknown whether there are gender
differences in alcohol reactivity, but other studies find women may be more cognitively and
motorically impaired at lower doses of alcohol, suggesting they have greater alcohol reactivity.
Social sanctions are perceived to be greater for women drinking than for men drinking. It is
unclear whether or not women actually suffer more negative social consequences as a result
of heavy drinking than men.
Feminine traits (e.g., nurturance and warmth) are associated with less use and fewer alcohol
problems. Undesirable masculine traits (aggressiveness and overcontrol) are associated with
heavy and problematic alcohol use. Socially desirable masculine traits (instrumentality) are
associated with fewer drinking problems. Patterns are generally the same for males and
females. One study found that gender differences in gender role traits mediated gender
differences in alcohol use and problems.
Avoidant coping is more consistently associated with alcohol consumption and drinking
problems in men than in women. It is not clear whether there are gender differences in
avoidant coping.
Drinking to cope with distress and positive expectancies for the outcomes of alcohol
consumption (e.g., that it will reduce distress) are associated with alcohol consumption and
problem drinking; this relationship tends to be stronger for men than for women. Men tend
to be more likely than women to report drinking to cope and positive
expectancies for alcohol use.
Among social drinkers, some studies show a stronger relationship between distress and
drinking for men than women, whereas others show the opposite gender pattern; among
alcoholics, the relationship between distress and alcohol use or problems is stronger for
women than men.
Some evidence suggests that low self-esteem is associated with alcohol-related problems
in women more than men, but this result is inconsistent.
Men score higher than women on measures of behavioral undercontrol, sensation-seeking,
and impulsivity. These variables are consistently associated with alcohol use and problems
in men, less consistently so in women.
Males are more likely to show symptoms of antisociality and delinquency than females.
Antisociality is associated with alcohol use and disorders in both males and females.
There are strong similarities between partners in heterosexual couples in drinking patterns.
It is not clear whether the effects of a partner on the individual’s drinking are stronger for
women or men.
A history of sexual assault is associated with problem drinking and alcohol use disorders in
both women and men. Women are more likely to have a history of sexual assault.
Alcohol reactivity
Social sanctions
Gender roles
Coping styles
Motives and
expectancies
Depression/distress
Self-esteem
Behavioral undercontrol/
sensation-seeking/
impulsivity
Antisociality
Interpersonal
relationships
Sexual assault
measures of frequency and quantity of consumption, typical weekly consumption, and frequency of
excessive drinking. These conclusions come from large-sample epidemiologic twin studies conducted in
Finland (Kaprio et al., 1992; Partanen, Bruun, & Markkanen, 1966), Sweden (Medlund, Cederlof,
Floderus-Myrhed, Friberg, & Sorensen, 1977), Australia (Heath & Martin, 1994), the United Kingdom
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(Clifford, Fulker, Gurling, & Murray, 1984), and the United States (Heath, 1995; see also Prescott et al.,
1994).
In sum, the vast majority of studies indicate that genetic factors play a role in alcoholism and alcohol
use in women as well as men, although there remains controversy as to the relative strength of this role
across the genders.
4.1.2. Alcohol reactivity or sensitivity
Another frequently studied biological predictor of alcohol use disorders is alcohol reactivity (or
alcohol sensitivity; Schuckit, 1998; Schuckit & Smith, 1997). The research on alcohol reactivity has
focused mostly on men. When given moderate doses of alcohol, sons of alcoholics, who are at increased
statistical risk for alcoholism, report a lower subjective sense of intoxication than sons of nonalcoholics
(Pollock, 1992). Experimental studies find that sons of alcoholics also show fewer signs of intoxication
in their cognitive and motor performance and on some physiological indicators than do the sons of
nonalcoholics (Schuckit & Smith, 1996; 1997). This lower reactivity to moderate doses of alcohol
among sons of alcoholics may lead them to drink substantially more before they begin to feel drunk; as a
result, they may not learn to recognize early signs of intoxication or to quit drinking before they become
highly intoxicated. They may develop a high physiological tolerance for alcohol, which leads them to
ingest more and more alcohol to achieve a subjective sense of intoxication. Long-term studies of men
with low reactivity to moderate doses of alcohol suggest they are significantly more likely to become
alcoholics over time than are men with greater reactivity to moderate doses of alcohol (Schuckit, 1998;
Schuckit & Smith, 1997). The low-reactivity men are especially likely to develop alcohol-related
problems if they encounter significant stress, or have a tendency toward poor behavioral control.
There are only a few studies of alcohol sensitivity in women and most have had small sample sizes or
have not directly compared alcohol sensitivity in women and men (Lukas et al., 1989; Lundahl & Lukas,
2001; Nagoshi & Wilson, 1989; Savoie, Emory, & Moody-Thomas, 1988). For example, Lex, Lukas,
Greenwald, and Mendelson (1988) administered a 0.56 g/kg dose of alcohol to 6 women with a positive
family history of alcoholism (FHP) and six women with no family history of alcoholism (FHN). They
found that the FHP women showed lower reactivity to the alcohol on measures of standing steadiness or
body sway, but not on subjective feelings of intoxication, compared to the FHN women. In a larger
study, Schuckit et al. (2000) compared 38 FHP women with 75 FHP men and 68 FHN men. The FHP
women showed a similarly low alcohol reactivity, measured by body sway and subjective feelings of
intoxication, as did the FHP men, and both FHP women and men showed lower alcohol reactivity than
FHN men. This study also assessed a small group of FHN women (n=11) and found that the FHP
women showed lower alcohol reactivity than the FHN women, although the differences were not
statistically significant.
Heath et al. (1999) assessed alcohol sensitivity (body sway and subjective intoxication) in
approximately 200 women and 200 men, some of whom were identical or fraternal twins. They found
that alcohol sensitivity was significantly related to having a genetic risk for alcoholism (as assessed by
twin concordance rates) and having a lifetime history of alcohol use disorders in men but not in women.
Again, Heath et al. suggest that a relatively low rate of alcoholism among the female twins may have
reduced statistical power to find effects. Unfortunately, Heath et al. (1999) did not test for overall gender
differences in alcohol reactivity in their sample. As will be described below, however, other studies have
found that women show more cognitive and motor impairment than men at low doses of alcohol, which
may indicate that women have a higher alcohol sensitivity than men.
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In sum, alcohol sensitivity is associated with a history of, and genetic risk for, alcohol-related
disorders in men, and in most studies in women, although there are few of these studies.
4.2. Psychosocial factors
A large number of psychosocial factors have been studied in relation to alcohol consumption and
alcohol-related problems and disorders in men and women.
4.2.1. Social sanctions against women drinking
It is often argued that the main reason women do not drink more than men is that the social sanctions
against drinking are greater for women than for men (e.g., Blume, 1991; Gomberg, 1988). Women
perceive that these social sanctions exist. In a national survey, women judged that 50% of other people
would strongly disapprove of a woman getting drunk at a party but only 30% of others would strongly
disapprove of a drunken man (Wilsnack, 1996). The women themselves also were more disapproving of
intoxication in women than in men (65% said they strongly disapproved of a woman getting drink,
whereas 58% strongly disapproved of a man getting drunk). Similarly, a study of adolescents found that
girls reported more pressure from their friends against alcohol use than boys (Keefe, 1994). Other
studies presenting participants with vignettes of men or women drinking alcohol or cola in a
heterosexual dating context find that women drinking alcohol are rated by participants as more sexually
available and aggressive than women drinking cola, but similar differences are not consistently found for
men (Corcoran & Thomas, 1991; George, Gournic, & McAfee, 1988; George et al., 1995).
The evidence is mixed as to whether women who drink heavily actually suffer more negative social
consequences than men who drink heavily. Some studies find that heavy drinking in women is
associated with more drinking-related problems, greater social and occupational impairment, and more
problems related to fighting with spouses, friends, or family than heavy drinking in men (Dawson,
Grant, & Hartford, 1995; Knupfer, 1984; Perkins, 1999; Wilsnack, Wilsnack, & Klassen, 1986). Other
studies do not find gender differences in the psychosocial consequences of heavy drinking (Hilton, 1987;
Robbins & Martin, 1993). For example, Room, Bondy, and Ferris (1995) analyzed reports from 11,634
Canadians on a variety of types of harm they experienced due to drinking alcohol (e.g., harm to
friendships, health, homelife, work, finances). Men reported more problems than women at very low
average levels of drinking (less than a third of one drink per month), and, at higher levels of drinking; no
gender differences were found at moderate levels of drinking. Women appear to have a less aggressive
and more controlled style of drinking than men and may be more likely to drink alone (Robbins &
Martin, 1993). This may reduce the number of psychosocial problems they experience as a result of their
drinking, relative to what men would experience at similar levels of intoxication (Vogeltanz & Wilsnack,
1997).
4.2.2. Gender roles
Related to the bsocial sanctionsQ theory is the theory that alcohol consumption is part of the male
gender role, but is discouraged as part of the female gender role (Chassin, Tetzloff, & Hershey, 1985;
Landrine, Bardwell, & Dean, 1988; White & Huselid, 1997). Several studies find that people,
particularly women, who endorse traditionally feminine traits (nurturance, emotional expressivity) report
less quantity and frequency of alcohol use (e.g., Chomak & Collins, 1987; Horwitz & White, 1987;
Huselid & Cooper, 1992; Ricciardelli, Connor, Williams, & Young, 2001; Wilsnack & Wilsnack, 1978).
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Adolescent girls and young women who hold more traditional gender role attitudes are less likely to
drink at all (Parker & Harford, 1992; Zucker, Battistich, & Langer, 1981).
Socially undesirable traits associated with the male gender role, such as aggressiveness and
overcontrol of emotion, have been consistently associated with heavy and problematic alcohol use in
both men and women (Mosher & Sirkin, 1984; Snell, Belk, & Hawkins, 1987; Spence et al., 1979).
Socially desirable traits such as instrumentality have been associated with fewer drinking problems
(Horwitz & White, 1987; Huselid & Cooper, 1992; Koch-Hattem & Denman, 1987), but not with
lower quantity and frequency of alcohol use (Snell et al., 1987). Males who generally hold traditional
bmachoQ beliefs toward male and female roles are more likely to use alcohol and to show heavy
drinking and drinking problems (Huselid & Cooper, 1992; Mosher & Sirkin, 1984; Pleck, Sonenstein,
& Ku, 1994).
Huselid and Cooper (1992) found that gender-role attributes and ideologies substantially mediated the
relationship between gender and measures of alcohol use. Gender roles completely mediated the gender
differences in drinking to intoxication, and partially mediated gender differences in quantity consumed,
frequency of heavy drinking (five or more drinks per occasion), and drinking problems (see also White
& Huselid, 1997). Thus, the theories that differences in gender roles contribute to the gender differences
in drinking behavior have been supported in a variety of studies.
4.2.3. Coping styles
A related theory is that heavy drinking is part of a style of coping with stress that involves denying or
avoiding one’s negative emotions, and that men are more likely than women to engage in denial or
avoidance of emotions (see Cooper et al., 1992). Avoidant coping, measured with responses to stressors
such as bI avoided being with people,Q and bI daydreamed about better timesQ, has been related to greater
alcohol consumption and problems in some studies (Cooper, Russell, & Frone, 1990, 1992; Laurent,
Catanzaro, & Callan, 1992; Moos, Finney, & Gamble, 1982; although, see also Armeli, Carney, Tennen,
Affleck, & O’Neil, 2000; Folkman, Bernstein, & Lazarus, 1987).
Avoidant coping is more strongly and consistently related to alcohol consumption and problems in
men than in women (Cooper et al., 1992; Frone, Russell, & Cooper 1993). However, gender differences
in mean scores on avoidant coping measures are not always found, and some studies show women score
higher on these measures than men (e.g., Cooper et al., 1997). This may be due to the fact that measures
of avoidant coping sometimes simultaneously include items externalizing of emotions (bI took my
feelings out on othersQ) and internalizing of emotions (bI kept my feelings to myselfQ); men may score
higher on externalizing items and women higher on internalizing items.
In sum, avoidant coping is associated with alcohol-related problems in men more than in women, but
the gender differences in the tendency to engage in avoidant coping are not consistent.
4.2.4. Drinking motives and expectancies
Several investigators have examined people’s motives to drink alcohol in order to cope with distress
or depression, or to escape from negative feelings (Cooper, Frone, Russell, & Mudar, 1995). Males
appear more likely than females to report drinking to escape (Ratliff & Burkhart, 1984), drinking to cope
with distress (Nolen-Hoeksema & Harrell, 2002; Park & Levenson, 2002), and drinking to relieve
depression (Olenick & Chalmers, 1991). In addition, Nolen-Hoeksema and Harrell (2002) found that
drinking to cope with distress predicted increases in alcohol-related problems over 1 year in a
community sample of men but not women (see Rutledge & Sher, 2001 for similar results).
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Cognitive–personality theories of alcohol use disorders and alcohol-related problems have focused on
people’s expectations for the effects of alcohol (Abrams & Niara, 1987; Fromme, Kivlahan, & Marlatt,
1986). Several different types of expectancies have been identified such as the expectancy that alcohol
will reduce tension or increase social or physical pleasure, that alcohol will increase sexual enjoyment,
and that it will facilitate social interactions (Brown, Goldman, Inn, & Anderson, 1980; Cooper et al.,
1990, 1992; Fromme, Stroot, & Kaplan, 1993). Sometimes, these subscales of expectancies are
examined separately, but often they are combined into a global positive expectancies scale.
Positive expectancies for the outcome of alcohol consumption are associated with higher average
levels of alcohol consumption, reports of drinking to cope with stress, and problem-drinking (Armeli et
al., 2000; Cooper et al., 1992, 1995; Fromme et al., 1993; Kushner, Abrams, Thuras, & Hanson, 2000;
Kushner, Sher, Wood & Wood, 1994). The relationship between positive expectancies and various
measures of alcohol use or problems has been greater in males than in females in several studies (Armeli
et al., 2000; Cooper et al., 1992; Johnson & Glassman, 1999; Kidorf & Lang, 1999; Kidorf, Sherman,
Johnson, & Bigelow, 1995; Kushner et al., 1994).
Some studies have found that males score higher than females on measures of positive expectancies
for alcohol use, particularly on the expectancy that alcohol will reduce tension or negative affect
(Bartholow, Sher & Strathman, 2000; Berger & Adesso, 1991; Brown et al., 1980; Park & Levenson,
2002; Rauch & Bryant, 2000; Rohsenow, 1983). Other studies have found no gender differences in
positive expectancies (Armeli et al., 2000; Lundahl, Davis, Adesso, & Lukas, 1997; Molina, Pelham, &
Lang, 1997), or that females have stronger expectancies than males for alcohol increasing assertiveness
(Baldwin, Oei, & Young, 1993).
Laboratory studies have found that women expect alcohol to interfere with their ability to cope with
difficult situations, and avoid alcohol when they must deal with stressful situations (Abrams & Wilson,
1979; Sutker, Allain, Brantley, & Randall, 1982). Survey studies have found that heavy drinking is
associated with a greater number and variety of conflicted cognitions about their drinking in women
compared to men (Bailly, Carman, & Forslund, 1991; Ricciardelli et al., 2001; Thombs, 1993; Williams,
Connor, & Ricciardelli, 1998). These cognitions may reflect a conflict between the increased leniency
toward women’s drinking and the continuing negative stereotypes of women’s drinking (Leigh, 1990).
In sum, men consistently report stronger motives to drink to escape from or cope with distress than
women, and these motives are more strongly associated with alcohol-related problems in men than in
women. Positive expectancies for the effects of alcohol are more strongly related to alcohol-related
problems in men than in women, but the gender differences in positive expectancies have been
inconsistent across studies. Laboratory studies suggest women may avoid alcohol more than men when
they must cope with a stressful situation, and survey studies suggest women are more conflicted than
men over alcohol consumption.
4.2.5. Depression/distress
There are two contradictory notions about gender differences in the relationship between alcohol
consumption and depression or general distress. On the one hand, some researchers argue that women’s
drinking is more often the result of an underlying depression than men’s drinking (Fillmore et al., 1997).
On the other hand, it is widely believed that alcohol abuse in men often is a mask for depressive
symptoms, which they feel they cannot express openly because of social sanctions against men
expressing distress and weakness (see Cooper et al., 1997). The relationship between depression or
general distress and alcohol consumption and problems is actually quite complex, and the gender
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differences in this relationship depend on how distress and alcohol use are measured, and whether the
sample being studied is a community sample or a sample of people with alcohol use disorders (Corte &
Nolen-Hoeksema, 2004).
4.2.5.1. Community samples. Some studies of samples from the general community, most of whom
would be social drinkers if they drank at all, have found a stronger association between negative affect
and alcohol use in men compared to women. In a longitudinal study of a community sample of adults,
Aneshensel and Huba (1983) found that depressive symptoms predicted more alcohol consumption 4
months later, and that alcohol consumption predicted a decrease in depressive symptoms 4 months later;
these effects were stronger for males than females. Similarly, cross-sectional studies using self-report
measures have also found that male social drinkers have a stronger relationship between alcohol
consumption and negative affects such as depressed mood (Berger & Adesso, 1991; Nolen-Hoeksema &
Harrell, 2002; Olenick & Chalmers, 1991; Peirce, Frone, Russell, & Cooper, 1994), and anxiety
(Kushner et al., 1994), compared to women social drinkers.
Ecological momentary assessment allows for more detailed examination of the relationship between
distress and drinking than cross-sectional or long-term longitudinal studies. Hussong, Hicks, Levy, and
Curran (2001) followed 74 college students for 28 days, randomly contacting them by pager three times
a day to ask them to rate their moods and to report on their alcohol use. There was a relationship between
depressive affect and later alcohol use for the men, but not for the women, in this study (see also
Swendsen et al., 2000).
Other studies have found no gender difference in the relationship between distress and alcohol use, or
that this relationship is greater in women than in men. In a meta-analysis of eight longitudinal population
based studies, Hartka et al. (1991) found that the relationship between depressive symptoms at baseline
and quantity of later alcohol use was stronger among females than males (see also Chassin, Pitts, &
Prost, 2002; Fillmore et al., 1997). However, the time interval between measurement points ranged from
2 to 10 years across studies—considerably longer than the time intervals in studies using ecological
momentary assessment.
Thus, some studies of community samples show a stronger relationship between measures of
depression or distress and alcohol use in men versus women. These studies are in line with studies of
motives to drink reviewed earlier showed that men were more likely than women to report drinking to
cope with or escape from distress. In contrast, longer-term longitudinal studies suggest that there may be
stronger link between vulnerability to depressive symptoms and vulnerability to heavy alcohol use in
community samples of women than in men.
4.2.5.2. Samples of people with alcohol use disorders. Alcohol use disorders and major depression are
often comorbid with each other, and this comorbidity is consistently greater among women than among
men (Helzer & Pryzbeck, 1988; Kendler, Heath, Neale, Kessler, & Eaves, 1993; Kessler et al., 1997).
This is true even when controlling for the higher base rates of these disorders by gender (Brady &
Randall, 1999). In addition, there is consistent evidence that women are more likely to report having
developed depression before they developed alcoholism, whereas men are more likely to report having
developed alcoholism before they developed depression (Kessler et al., 1997; Sannibale & Hall, 2001).
In a laboratory study of inpatient alcoholics 18–67 years of age, Rubonis et al. (1994) first induced a
negative mood state and then asked participants to hold and smell an alcoholic beverage for several
minutes. In the presence of a negative mood, women reported stronger urges to drink in response to the
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alcoholic beverage cue, whereas men actually reported a reduced urge to drink under the same
conditions. This interaction effect suggests that women alcoholics may be more vulnerable to drinking in
response to negative affect than men alcoholics.
Olenick and Chalmers (1991) compared 104 social drinkers (56% of whom were female) and 102
persons in outpatient treatment for AUD (43% of whom were female) on their self-reported use of
alcohol for the purposes of altering negative mood. The within-gender results showed that more than
four times as many alcoholic females (87%) as social drinking females (18%) acknowledged the use of
alcohol specifically to change negative mood, whereas the difference for males, while still impressive,
was much smaller (77% vs. 43%).
Thus, studies of people with alcohol use disorders consistently show a stronger relationship between
depression and other negative moods and alcohol use in women than in men.
4.2.6. Self-esteem
Theorists have long argued that low self-esteem plays an important role in the development of
alcohol-related problems in women (Gomberg, 1988). Some studies find that women alcoholics have
lower self-esteem than men alcoholics (Beckman, 1978; Marsh & Miller, 1985) and women
nonalcoholics (Schlesinger, Susman, & Koenigsberg, 1990; Sorell, Silvia, & Busch-Rossnagel, 1993).
One study of a community sample of young men and women found that low self-esteem did not predict
future alcohol use in either men or women (Stein, Newcomb, & Bentler, 1987), while another
community sample of young adults found that low self-esteem did predict an alcohol use disorder
diagnosis in women but not in men (Walitzer & Sher, 1996).
4.2.7. Impulsivity, sensation-seeking, and behavioral undercontrol
Three individual difference characteristics that overlap conceptually and cluster together empirically—impulsivity, sensation-seeking, and behavioral undercontrol—are consistently related to heavy
alcohol consumption and alcohol-related problems (Caspi et al., 1997; Cloninger, Sigvardsson, &
Bohman, 1988; Sher, 1991; Sher, Trull, Bartholow, & Vieth, 1999; Waldeck & Miller, 1997; Zuckerman
& Kuhlman, 2000). Men generally score higher on ratings of impulsivity, sensation-seeking, or
behavioral undercontrol than women (Labouvie & McGee, 1986; Miller, 1991; Nagoshi, Wilson, &
Rodriguez, 1991; Petry, Kirby & Kranzler, 2002; Waldeck & Miller, 1997; Zuckerman, Eysenck, &
Eysenck, 1978; Zuckerman & Kuhlman, 2000).
The evidence as to whether this cluster of characteristics is equally correlated with alcohol-related
problems in men and women is mixed. Caspi, Moffitt, Newman, and Silva (1996) found that 3-year-old
boys who were rated as having more problems with behavioral control were more likely to have alcoholrelated problems at age 21, but this association was not found for girls. Rutledge and Sher (2001) found
that behavioral undercontrol was more strongly related to heavy drinking (5+ drinks per occasion) in
college men than in college women. In contrast, in a large twin study, Slutske et al. (2002) found that
behavioral undercontrol was equally correlated with lifetime history of alcohol use disorders in men and
women, and that behavioral undercontrol accounted for significantly more of the genetic risk for alcohol
use disorders in women than in men.
4.2.8. Antisociality
Related, but not identical, to the literature on behavioral undercontrol, sensation-seeking, and
impulsivity is the literature on antisociality and delinquency as predictors of alcohol use and problems
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(Donovan & Jessor, 1985; Jessor & Jessor, 1977). Several studies have found that early alcohol use and
alcohol-related problems are often part of a broader syndrome of adolescent problem behavior that
includes other drug use, sexual activity, and delinquent and aggressive behavior (Hawkins, Catalano, &
Miller, 1992; Zucker, 2000). These adolescents are more likely to come from families in which at least
one parent has an alcohol use disorder, and often has an antisocial personality disorder (Jansen,
Fitzgerald, Ham, & Zucker, 1995; Zucker, Fitzgerald, & Moses, 1995).
Females are much less likely than males to be diagnosed with a conduct disorder, an antisocial
personality disorder, or to show antisocial or delinquent behaviors (Moffitt, Caspi, Rutter, & Silva,
2001). Antisociality is associated with alcohol problems in women as well as in men, however. For
example, the Dunedin study (Moffitt et al., 2001), which followed youth from early childhood through
young adulthood, found that multiinformant ratings of antisociality taken when the participants were
young adolescents predicted symptoms of alcohol dependence at age 21 for both the male and female
participants. Similarly, both males and females who had been diagnosed with conduct disorder between
11 and 18 years of age were more likely than those not diagnosed with a conduct disorder to have
symptoms of alcohol dependence at age 21.
In sum, males are consistently more likely to show antisociality than females, but antisociality and
alcohol-related problems are correlated in both males and females.
4.2.9. Interpersonal relationships
Both clinical studies and general population surveys have found strong similarities between women’s
levels of drinking and their husbands’ or male partners’ levels of drinking (Corbett, Mora & Ames,
1991; Demers, Bisson, & Palluy, 1999; Jacob & Bremer, 1986; Hammer & Vaglum, 1989; Roberts &
Leonard, 1997). Some studies find that men have a stronger influence their women partners’ drinking
(Wilsnack & Wilsnack, 1990), where others find that women have a stronger influence on their men
partners’ drinking (Cronkite & Moos, 1984), and others find men and women influence their partners
equally (Roberts & Leonard, 1997). Women problem-drinkers are more likely to be married to male
problem drinkers than male problem drinkers are to be married to women problem-drinkers (Hall,
Hesselbrock, & Stabenau, 1983; Roberts & Leonard, 1997). This may be because there are more male
problem-drinkers than there are female problem-drinkers. Some researchers have attributed this to
assortative mating: problem-drinkers, especially women problem-drinkers, seek out partners with similar
drinking patterns (Jacob & Bremer, 1986), although the evidence for this has been weak (Roberts &
Leonard, 1997). When a husband’s and wife’s drinking patterns are discrepant, there is more general
discord in the marriage (Mudar, Leonard, & Soltysinski, 2001). A movement toward more similar
drinking patterns in a couple may be reinforced by the resolution of marital discord.
A fascinating twin study provided evidence that marriage does affect how women drink: Heath,
Jardine, and Martin (1989) found that genetic factors were more strongly related to women’s drinking
patterns if they were unmarried than if they were married, suggesting that marriage exerted a significant
effect on women’s drinking patterns over and above the effect of their genetic heritage.
4.2.10. Violence and sexual assault
Numerous epidemiological studies have shown that women with a history of childhood or adult
sexual assault are at increased risk for problem-drinking and alcohol use disorders (Kilpatrick et al.,
2000; Widom, Ireland, & Glynn, 1995; Wilsnack, Vogeltanz, Klassen, & Harriss, 1997). A history of
sexual assault is also associated with increased risk of alcohol-related problems in men in some studies
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(Cutler & Nolen-Hoeksema, 1991; Stein, Golding, Siegel, Burnam, & Sorenson, 1988). Sexual assault
appears to be a risk factor for several psychological disorders in women, however, and not a specific risk
factor for alcohol-related diseases (Bulik, Prescott, & Kendler, 2001; Fergusson & Mullen, 1999). As
will be discussed later, alcohol use may also increase a woman’s risk of assault.
4.3. Summary
Table 1 summarizes the findings on the range of biological and psychosocial factors thought to be risk
factors for alcohol use and alcohol-related problems in men and women. The bulk of the evidence
suggests that relationships between risk factors and alcohol use or problems are more similar than
different in women and men. When gender differences are found, it is most often the case that a given
risk factor is more strongly or consistently related to alcohol use and problems in men than in women.
Most of these risk factors have been associated with alcohol use and problems in women in the majority
of studies, however. In addition, the statistical power to detect relationships between risk factor and
alcohol problems in women was low in some studies due to the low prevalence of alcohol problems in
women and small sample sizes. Men appear to be more likely than women to manifest certain risk
factors for alcohol use and problems including fewer perceived social sanctions for drinking, undesirable
masculine traits (i.e., aggressiveness), lack of desirable feminine traits (e.g., nurturance), drinking to
reduce distress, positive expectancies for alcohol use, behavioral undercontrol, sensation seeking and
antisociality. In contrast, women are more likely to manifest the risk factors of negative mood and
exposure to sexual assault. Data on gender differences in other risk factors are inconsistent or not
available.
5. Gender differences in the consequences of drinking alcohol
Women appear to suffer more negative consequences in a number of domains than men from drinking
a given amount of alcohol, as is summarized in Table 2.
5.1. Blood alcohol concentration
After an equivalent dose of alcohol, women have higher blood ethanol levels than men (Jones &
Jones, 1976; Lieber, 1997). There are multiple explanations for this. First, women are generally smaller
than men so the same dose of alcohol leads to higher blood alcohol levels for women than men. Second,
women’s body water content is smaller than men’s per kilogram of body weight. Thus, a dose of ethanol
will be distributed in a smaller volume of water in women than in men, leading to somewhat higher
concentrations of ethanol in women’s blood (Frezza et al., 1990; Lieber, 1997).
Third, the bfirst passQ metabolism of alcohol in the stomach may lead to higher blood alcohol levels
in women than men. In the stomach, alcohol is metabolized with the enzyme gastric alcohol
dehydrogenase (ADH). The stomach thus acts as a barrier against the penetration of alcohol into the
body, by retaining and breaking down part of the alcohol (Lieber, 1997). Gastric ADH activity is lower
in women than in men; one study found that for a given alcohol dose, men’s ADH levels were two
times higher than women’s, and in turn, women’s blood alcohol levels were higher than those of men
(Frezza et al., 1990).
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Table 2
Summary of findings on gender differences in consequences of alcohol use
Domain
Evidence
Blood alcohol level
Physical illness
Women achieve a higher blood alcohol level than men for a given dose of alcohol.
Women suffer alcohol-related physical illnesses (cirrhosis of liver, cardiac disease,
reduced brain volume) at lower levels of exposure to alcohol than men.
Heavy alcohol use reduces fertility in women, and possibly in men. Heavy drinking
by pregnant women is associated with increased risk for deformities and complications
in the fetus; moderate-to-light maternal drinking during pregnancy is associated with
more subtle, but long-term deficits in children.
Some evidence that women suffer more cognitive and motor impairment due to alcohol
intake than men, or that they suffer impairment at lower levels of alcohol consumption.
Women who abuse alcohol are more likely to be the victims of partner assault than
women who do not. Men are also more likely to be the recipient of partner violence with
both partners are drinking than when they are not, but the degree of harm done to men is
probably less than that done to women.
Several survey studies show links between alcohol use and risky sexual behavior in both
men and women, although some studies, including laboratory-based studies, do not find
this link in women or adolescent girls, or that women become more cautious when they
think they have ingested alcohol.
Reproductive health
Cognitive and motor
performance
Violence
Risky sexual behavior
This gender difference in metabolism of alcohol appears to hold for younger adults but not older
adults. ADH activity decreases with age, particularly for men, leading to similar blood alcohol
concentrations in older men and women, or even higher concentrations in older men than older women
(Seitz, Egerer, & Simanowski, 1990).
5.2. Alcohol-related physical illness
The increased bioavailability of alcohol in women compared to men in young and middleadulthood may lead to gender differences in susceptibility to alcohol-related physical diseases. A
meta-analysis of 38 studies found that women are more likely than men to report health problems
when they have a history of bout of control drinking,Q alcoholism, or alcohol abuse (Fillmore et al.,
1997). Several studies have found that mortality rates for women are significantly higher than for men
among heavy drinkers and those with alcohol dependence (Holman, English, Milne, & Winter, 1996;
Lindberg & Agren, 1988; Smith, Cloninger, & Bradford, 1983). For example, one study found that
heavy drinking (defined as six or more drinks per day) increased women’s risk of death by 160%
compared with light drinking (more than one drink per month but less than one drink per day),
whereas heavy drinking increased men’s mortality risk by only 40% over light-drinking (Klatsky,
Armstrong, & Friedman, 1992).
Evidence concerning specific alcohol-related disorders also suggests drinking women are more
susceptible to these disorders than drinking men. Although men are at least twice as likely as women to
die of alcoholic cirrhosis of the liver, probably because they are more likely to be heavy drinkers (Hallen
& Krook, 1963), the progression to severe liver injury appears to be accelerated in women heavy
drinkers compared to male heavy drinkers (Deal & Gavaler, 1994; Morgan & Sherlock, 1977; Pares,
Caballeria, Bruguera, Torres, & Rodes, 1986). Women’s greater susceptibility to liver disease may have
to do with the negative effects of both endogenous and exogenous female hormones on liver function,
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and gender differences in several other biochemicals (e.g., cytochrome P450, hepatic acid binding
protein, NA+, K+ ATPase; Kappas, 1967; Lieber, 1997; Saleh & Abd-El-Hay, 1977).
Several studies have found that moderate alcohol use is associated with lowered risk of myocardial
infarction or cardiac death in men and in postmenopausal women (e.g., Fuchs et al., 1995; Garg,
Wagener, & Madans, 1993; Gordon & Kannel, 1983; Klatsky, 2001; Stampfer et al., 1988). Among
younger women and those without other risk factors for heart disease, however, low-to-moderate alcohol
use is not consistently associated with cardiac protection. On the other hand, excessive alcohol
consumption is associated with a significantly increased risk of cardiac diseases, including
cardiomyopathy, dysrhythmia, and hypertension (Klatsky et al., 1992; Linn, Carroll, Johnson, Fulwood,
Kalsbeek, & Briefel, 1993; Moushmoush & Mansour, 1991). The level of drinking at which people
move from cardiac benefit to cardiac harm is considerably lower for women than for men (Kupari,
Koskinen, & Suokas, 1991; Urbano-Marquez et al., 1995). For example, Hanna, Chou, and Grant (1997)
analyzed data from a health survey of 43,763 men and women to determine the association between
various levels of alcohol consumption and heart disease. Among women, even moderate drinking
(defined as more than two drinks per day during their heaviest drinking period in the last year) was
associated with a significant increase in risk for heart disease. Among men, heavier drinking (more than
five drinks per day in their heaviest drinking period in the last year) was associated with an increased risk
for heart disease.
Alcohol intake also influences risk for breast cancer in women (Longnecker, 1994; Singletary &
Gapstur, 2001; Smith-Warner et al., 1998; Willett, Stampfer, Colditz, Rosner, Hennekens, & Speizer,
1987). The increase in cancer risk due to alcohol intake may have to do with increases in estrogen and
androgen levels, enhanced mammary gland susceptibility to carcinogens, and greater metastatic potential
of breast cancer cells (Singletary & Gapstur, 2001).
Finally, studies suggest that alcohol has more toxic effects on the brain, or effects at lower doses, for
women compared to men (Ammendola et al., 2000; Schweinsburg et al., 2003). Hommer, Momenan,
Kaiser, and Rawlings (2001) compared the brain volumes of alcoholic and nonalcoholic men and
women. Alcoholic women showed smaller volumes of gray and white matter than nonalcoholic women,
and these differences were greater than those between the alcoholic and nonalcoholic men, indicating
greater sensitivity to alcohol neurotoxicity among women.
5.3. Reproductive health consequences
Women with alcohol use disorders are more likely than women without alcohol use disorders to
experience sexual dysfunctions, amenorrhea, anovulatory cycles, luteal phase dysfunction, and early
menopause (Blume & Russell, 2001; Klassen & Wilsnack, 1986). Several studies have found that
moderate to heavy alcohol use is associated with lower fertility in women, although several studies have
failed to find such an association (see review by Gill, 2000).
Heavy drinking by pregnant women is associated with fetal alcohol syndrome, which is characterized
by growth deficiency, altered structural development, and central nervous system dysfunction due to the
exposure of a fetus to alcohol in the womb (Jones & Smith, 1973). Studies of moderate maternal
drinking on reproductive outcomes such as birth weight, gestational age, rate of miscarriage or stillbirth,
congenital abnormalities, and social and cognitive development, suggest that even low to moderate
levels of drinking during pregnancy are associated with subtle alcohol-related birth defects (Jacobson &
Jacobson, 2000; Kelly, Day, & Streissguth, 2000; Olson, Feldman, Streissguth, Sampson, & Bookstein,
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1998). For example, longitudinal studies of children exposed to alcohol prenatally show negative effects
on growth at 6 years of age, and on learning and memory skills at 10 years of age (Cornelius,
Goldschmidt, Day, & Larkby, 2002). These results held even after controlling for correlates of prenatal
alcohol use, including income, and tobacco and marijuana use.
The results across studies are inconsistent, however, due in part to the fact that moderate drinking is
defined variously across studies, from a few drinks per week to up to four or more per day. Most studies
have focused on average levels of drinking per day or week, but a woman’s pattern of drinking may have
more effects on fetal development than her average amount of drinking (Coles, Kable, Drews-Botsch, &
Falek, 2000; Day, 1992). Timing of alcohol consumption during fetal development may also be a critical
variable, as may the interaction between alcohol consumption and race, socioeconomic status, and
smoking status (Coles & Platzman, 1993; Passaro & Little, 1997).
Alcohol clearly interferes with testicular function in males (Anderson et al., 1989), but whether it
affects reproductive outcomes or infant development is unclear. Some animal studies suggest it does,
while others suggest it does not (Passaro & Little, 1997). Two studies of humans produced conflicting
results, with one finding paternal drinking in the month of conception to be associated with reduced
infant birth weight (Little & Sing, 1987), and another finding no effects of men’s drinking during their
partner’s pregnancy on birth outcomes (Savitz et al., 1992).
5.4. Cognitive and motor performance
Alcohol may have greater negative effects on cognitive and motor functioning in women than in men
(Nixon, 1994). Studies using standardized problem-solving and neuropsychological tests show that
alcoholics perform more poorly than nonalcoholics in both genders, but suggest that women alcoholics
show greater impairment in functioning than men alcoholics (Acker, 1986; Mann, Batra, Gunthner, &
Schroth, 1992; Niaura, Nathan, Frankenstein, Shapiro, & Brick, 1987; Nixon, 1994). Other studies find
no overall differences in neuropsychological functioning in women versus men alcoholics, but the
women alcoholics in these studies typically report shorter or less-severe alcoholic drinking patterns than
the men (Bergman, 1987; Glenn et al., 1993; Parsons, 1998). This may mean that lower severity of
alcoholism leads to significant impairment in women than in men.
Dougherty, Bjork, and Bennett (1998) report evidence that the time course of cognitive and motor
impairment due to alcohol intake may be different in women and men. They recruited 10 male and 10
female social drinkers for a laboratory study in which they first consumed either three placebo beverages
or three beverages laced with alcohol on each of 6 consecutive days. The dosage of alcohol for the
females was titrated to achieve the same breath alcohol content (BAC) levels as the males achieved.
After consumption of the beverages, participants performed a rotary pursuit task in which they were
instructed to maintain the tip of a wand they held over a circling light source shone through a glass top as
long as possible without the tip of the wand contacting the glass top. Alcohol impaired the performance
of the women more than the men on the rotary pursuit task, despite similar BAC levels. Across days in
which they consumed alcohol, men tended to develop some tolerance to the deleterious effect of alcohol
on performance whereas women became more sensitive to the effect of alcohol on performance. There
also was evidence that women were aware of their greater sensitivity to the effects of alcohol over time:
men reported feeling less intoxicated on the second day they consumed alcoholic beverages compared to
the first day they consumed alcohol, but women reported feeling more intoxicated on the second day
compared to the first.
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Mulvhill, Skilling, and Vogel-Sprott (1997) assessed the performance of men and women on a go–
stop task that measured cognitive control of response inhibition. One-third of the men and women were
given moderate doses of alcohol (titrated for women to result in similar BACs to the men’s), one-third
were given a placebo beverage, and one-third were given no beverage. Alcohol impaired inhibitory
control equally in the men and the women.
Results from Dougherty et al. (1998) indicate, however, that greater gender differences in cognitive
impairment may be found with more long-term ingestion of alcohol (e.g., moderate doses on several
subsequent days) than with administration of a single moderate dose of alcohol (see also Schuckit et al.,
2000). This suggests that women may not suffer more than men cognitively from a single dose of
alcohol, but frequent moderate use may lead to more cognitive and motor impairment in women than in
men. In turn, greater cognitive and motor impairment in women due to alcohol intake may account for
recent findings that even low levels of alcohol intake are associated with a greater risk of injury in
women compared to men (Stockwell et al., 2002).
5.5. Violence
Sexual and physical assault may not only be risk factors for problem-drinking in women; heavy
drinking may also increase a woman’s risk of assault. Women who abuse alcohol (or other drugs)
are more likely than nonabusing women to be the victims of sexual and physical violence (Kaufman
Kantor & Asdigian, 1997). More generally, being under the influence of alcohol appears to increase
a woman’s risk of assault (Amaro, Fried, Cabral, & Zuckerman, 1990; Frieze & Schafer, 1984;
Miller, Downs, & Gondoli, 1989). Abbey, Ross, McDuffie, and McAuslan (1996) found that over
half of serious sexual assaults reported by a sample of 1160 women involved alcohol; in almost all
these cases, the man had been drinking; in the majority of cases, both the man and woman had been
drinking. Observational studies show that alcohol consumption by husbands, or by husbands and
wives together, increases negative interactions between the couple, particularly when the husband has
aggressive or antisocial tendencies (Haber & Jacob, 1997; Jacob, Leonard, & Haber, 2001; Leonard
& Roberts, 1998).
5.6. Risky sexual behavior
Both men and women expect alcohol to increase their subjective sexual experience, although heavy
alcohol consumption decreases physiological sexual arousal in both men and women (Klassen &
Wilsnack, 1986; Wilsnack, 1995). General population surveys suggest that adults who use more
alcohol are more likely to report liberal attitudes toward sex (more sexual assertiveness, becoming less
choosy about partners) and to report participating in risky sexual activity (i.e., unprotected sex, sex
with multiple partners, or with partners at high risk for sexually transmitted diseases) (Anderson &
Dahlberg, 1992; Cooper, 1992; Leigh, Temple, & Trocki, 1994; McEwan, McCallum, Bhopal, &
Madhok, 1992; Parker, Harford, & Rosenstock, 1994; Wilsnack et al., 1997). Similarly, survey studies
of adolescents and young adults have linked alcohol use with risky sexual behavior (Biglan, Metzler,
Wirt, & Ary, 1990; Cooper, Peirce, & Huselid, 1994; Hingson, Strunin, Berlin, & Heeren, 1990;
Zucker et al., 1981).
Not all studies find an association between alcohol consumption and risky sexual behavior in women
and adolescent girls, however. In a community study of adolescents, Cooper and Orcutt (1997) found
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that the likelihood of sexual intercourse or heavy petting on a first date increased when the male, but not
his female partner, drank alcohol. Indeed, the likelihood of intercourse on the first date decreased when
the female consumed alcohol, suggesting alcohol inhibits girls’ willingness to engage in sex with male
acquaintances. Cooper and Orcutt argue that this pattern results because girls and boys experience
qualitatively different kinds of conflict over the perceived costs and benefits of sexual activity, so that
alcohol has an inhibitory effect on sexual activity for girls but a disinhibitory effect for boys.
Similarly, experiments using the bbalanced placebo designQ suggest that women may sometimes
become more cautious in heterosexual encounters when they are drinking (Caudill, Wilson, & Abrams,
1987; Crowe & George, 1989; Leigh, 1990; Wilson, 1981). In these experiments, women and men are
told they would receive a placebo or an alcoholic beverage; this manipulation is crossed with the actual
receipt of an alcoholic or placebo beverage, creating four groups. Participants are then asked about their
levels of sexual arousal, or asked to interact with an opposite sex partner or to respond to sexually
explicit materials. These studies generally find that men who believe they have consumed alcohol
become more sexually aroused and forward in their interactions with women, regardless of whether they
have actually consumed alcohol. In contrast, women participants do not show consistent expectancy
effects, and sometimes show suppression of sexual arousal and interactions with male partners.
The relationships between alcohol consumption and risky sexual behavior in men and women found
in survey studies may be due to a third variable of sensation-seeking or a general tendency toward risky
behavior (Cooper, 1992). Moreover, risky sexual behavior may occur primarily after heavy alcohol
consumption. In contrast, low-to-moderate alcohol intake in the context of heterosexual interactions may
actually lead many women to be more cautious and controlled (Robbins & Martin, 1993).
5.7. Summary
Consequences of heavy alcohol use, or alcohol use disorders, appear to be more negative for women
than men, at least in some domains. Women suffer alcohol-related physical illnesses at lower levels of
exposure to alcohol than men, and experience a range of reproductive health problems due to heavy
alcohol use. Some studies suggest women suffer more cognitive and motor impairment due to alcohol
than men. Women may be more likely than men to suffer physical harm and sexual assault when they are
using alcohol. Survey studies suggest that both men and women who use alcohol heavily engage in more
risky sexual behavior, although laboratory studies suggest women may actually become more cautious in
some heterosexual situations when they have consumed low amounts of alcohol.
6. Conclusions
Women may drink less than men and may be less likely to develop alcohol-related problems because
they are less likely to carry several risk factors for these behaviors or these risk factors are less potent for
women than for men. Specifically, a genetic predisposition to alcoholism may have a weaker effect
among women than among men, although studies are not completely consistent. The few existing studies
of alcohol sensitivity suggest that women are less likely than men to manifest low alcohol sensitivity,
which is a risk factor for the development of alcoholism. Women appear less likely than men to manifest
undesirable personality traits associated with heavy drinking (aggressiveness, behavioral undercontrol,
sensation-seeking) and to be less motivated to drink to reduce distress (at least among social drinkers)
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and less likely to expect alcohol consumption to have positive outcomes. On the other hand, women may
carry certain protective factors against the development of alcohol-related problems more than men, such
as perceiving greater social sanctions for drinking and being more nurturant toward others.
Significant inconsistencies exist in the literatures on each of these risk factors, however. Although
some studies have found gender differences in the strength of relationships between risk factors and
alcohol use or problems, other studies of the same risk factors have not found gender differences (e.g., in
the domain of genetics). In addition, significant gender differences in the presence or level of risk factors
are not always found (e.g., positive expectancies for alcohol use). These inconsistencies are probably due
in part to variations in the assessment of alcohol use and problems, small sample sizes of women, and the
relatively low prevalence of drinking problems in women. In addition, predictors of alcohol use and
problems in women versus men may vary by ethnicity or race, but this has not been examined
adequately in any of the literatures reviewed.
More research is needed which specifically focuses on the sources of gender differences in drinking
patterns, and examines more than one risk factor at a time. Many of the risk factors reviewed here are
probably strongly related to each other (e.g., self-esteem and depression, gender role adherence, coping
styles, and marital interaction styles). In addition, some risk factors are likely to be more important than
others in predicting women’s drinking, and in explaining the gender differences in alcohol use, but since
they tend to be studied one at a time, this is currently unknown. It will be important in future research to
include multiple risk factors to determine how they cluster together and to determine the relative amount
of variance in drinking behavior each one explains. Such research will also hold important implications
for the design of gender-specific interventions for women, and men, with problematic alcohol use
behaviors.
Evidence regarding gender differences in the consequences of alcohol consumption suggests that
women suffer alcohol-related physical illnesses at lower levels of exposure to alcohol than men, and
heavy alcohol use is associated with several reproductive problems in women. Women may be more
likely to suffer more cognitive and motor impairment due to alcohol than men may and may be more
likely to suffer physical harm and sexual assault when they are using alcohol. In contrast, the relationship
between risky sexual behavior and alcohol use in women is inconsistent.
Taken together, this pattern of results suggests that women’s lower levels of drinking and fewer
alcohol-related problems compared to men may be due both to the absence of risk factors for alcohol use
and abuse in women and to women’s sensitivity to the negative consequences they will suffer from
alcohol consumption. Women appear less likely to carry many of the risk factors for the initiation of
heavy alcohol use compared to men; when they do use alcohol, women may notice they are becoming
intoxicated at a much earlier stage of intoxication than men, and may be more likely to find these effects
aversive or frightening, leading them to inhibit their alcohol consumption. This, in turn, protects women
from developing tolerance to high doses of alcohol, and alcohol-related social and occupational
problems.
An evolutionary argument can also be made for why women would be more sensitive or averse than
men to the early negative effects of alcohol. If alcohol consumption reduces women’s reproductive
capacity, and leads them to produce offspring that are less likely to survive and to produce their own
offspring, then there would be selection pressures against alcohol consumption in women. Women who
were more sensitive and averse to the early negative effects of alcohol on their functioning might be less
likely to develop alcohol-related physical diseases and more likely to produce healthy offspring than
women who were less sensitive and averse to the effects of alcohol.
1000
S. Nolen-Hoeksema / Clinical Psychology Review 24 (2004) 981–1010
The cultural differences in women’s drinking patterns and in the size of the gender difference in
drinking and alcohol-related problems indicate that social factors also play a role (Gilbert & Collins,
1997). For example, Hispanics and African American women generally drink less than non-Hispanic
White women (Caetano, 1994; Helzer & Canino, 1992; Jackson et al., 1998). In addition, greater
acculturation among Hispanic women is associated with greater alcohol consumption (Caetano, 1994;
Gilbert, 1993). Asian–American women generally have low levels of alcohol consumption, but
substantial variation is found across subgroups (e.g., Korean–Americans, Japanese–Americans,
Chinese–Americans; Gilbert & Collins, 1997). The sources of differences across racial/ethnic groups
may have to do with cultural and religious norms, education, socioeconomic status, group differences in
gender roles and social activities, and a number of other social factors. In addition, these sources may
vary by historical cohort and age (Gilbert & Collins, 1997). Currently, little is known about the
contributors to culture-by-gender interactions in drinking patterns, so this is an important area for future
research.
The increasing evidence that even relatively low levels of alcohol consumption are associated with
elevated risk for some physical illnesses in women suggest that there is a rather narrow window of bsafe
drinkingQ for women. The media’s coverage of studies showing beneficial effects of moderate drinking
on health has failed to note that these effects may be more true for men than for women, and that harmful
effects for women begin to accrue at quite low levels of alcohol intake. This will be an important focus
for health education campaigns in the future. It also points to the importance of developing more
effective interventions for women who are abusing alcohol, to improve both their psychological wellbeing and to protect their physical health.
Acknowledgement
Support for the writing of this review was provided by NIAAA grant R01 AA007065. The author
thanks Robert Zucker for his helpful comments on previous drafts of this paper.
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