A qualitative study conducted by researchers at the University of São Paulo's School of Arts, Sciences and Humanities (EACH-USP) in Brazil suggests that gender influences how people suffering from alcohol use disorder cope with their condition.

The principal investigator was Professor Edemilson de Campos, who was supported by FAPESP and collaborated with Nadia Narchi, also a professor at EACH-USP. The results are reported in an article published in the journal Drug and Alcohol Review.

Campos obtained permission to sit in on strictly women-only meetings of an Alcoholics Anonymous group (AA) in São Paulo City, interviewed the participants, and took notes on the testimonials delivered at the meetings.

"Women-only AA meetings are frequent in the United States but not in Brazil," he said. "AA discourages this format on the grounds that alcoholism is a single phenomenon and affects men and women alike. But the women I interviewed disagreed, and told me they felt intimidated in mixed meetings. Some even said they had been harassed and targeted by sexist jokes at such meetings."

According to Campos, the city has 120 AA groups, but only two hold women-only meetings, one in the north of the city and the other in the downtown district of Santa Cecília. "AA doesn't have a hierarchical structure. The groups have considerable autonomy, and the moderators serve on a rotating basis. I asked to be allowed to sit in on women-only meetings of both groups, but only the group in the northern part of São Paulo agreed," he said.

About 15 women in this group met every Saturday. Some had joined only two months ago, while others had been going to AA meetings for more than 30 years. Generally speaking, they were from low-income households and had little formal education. Some were married to men who were also in the AA program.

It should be noted, Campos explained, that AA members consider alcoholism a "chronic incurable disease" due to a physical predisposition combined with a mental obsession to drink, and believe that the disease cannot be fought by individual willpower alone. The support network formed by the group is indispensable for alcoholics to learn to remain sober while living with the disease. AA defines itself as a "fellowship of men and women", he noted, and is not "linked to any sect, religion, political movement, organization or institution". Membership is entirely free. However, financial self-sufficiency is assured by means of voluntary donations.

"We'd already studied groups with mixed meetings. In the women-only meetings we attended, with great respect we conducted an ethnographic study involving participants' accounts of their family, work and other relationships, as well as other parts of their lives. The phrase 'wounded soul' was how the women themselves referred to their condition, and to the rejection and loneliness they experienced owing to social stigma," Campos said.

He went on to note that whereas in mixed meetings the men focused in their testimonials on work relations and other impersonal aspects of their day-to-day lives, the participants in women-only meetings spoke mainly about their inner lives and feelings. "Hence the importance of women-only meetings," he said. "They provide a safe space for self-expression and enable the participants to reclaim a sense of dignity."

Socially conditioned thinking is typically lenient with fathers who neglect their paternal obligations but implacable with women who are seen as bad mothers. "The sense that alcoholism may have stopped them from doing what society expected of them weighed heavily on these women," Campos said.

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), published by the American Psychiatric Association but also used in many other countries, defines substance dependence as a condition matching three or more of the following criteria: spending a great deal of time in activities necessary to obtain the substance, use it or recover from its effects; taking the substance in larger amounts or for a longer period than intended; needing markedly increased amounts to achieve intoxication; wanting but failing to cut down or control substance use; continuing to use the substance despite becoming aware that it causes or exacerbates physical or mental health problems; and giving up or reducing important social, occupational or recreational activities because of substance use.

In the case of alcohol and other substances that cause chemical dependence, such as tranquilizers (benzodiazepines), stimulants (amphetamines), cocaine and crack, a seventh condition is added: manifesting the characteristic withdrawal syndrome for the substance, in which case subjects are considered dependent if they meet three out of the seven criteria.

These criteria apply equally to men and women, but the study led by Campos found that, beyond this general classification, the experience of alcoholism and its treatment were strongly influenced by gender. "Contrary to the idea prevalent in AA, we found that women do need a safe space in which to express their pain and treat their 'wounded soul'," he said.

A survey on substance use by the Brazilian population conducted in 2017 by Oswaldo Cruz Foundation (Fiocruz, subordinated to the Health Ministry), found that some 2.3 million people aged between 12 and 65 had experienced alcohol dependence in the previous 12 months. The proportion was 3.4 times greater among males (2.4% of the male population) than females (0.7%), but scholars in the field believe the latter may have been an underestimate due to the strong social stigma attached to female alcoholism. Many women may have concealed their alcohol dependence for fear of what "others" might think, say or do.

--José Tadeu Arantes , FAPESP