The hidden health burden: alcohol-abusing women, misunderstood and mistreated
Advice Desk for Abused Womcn, Department of Criminology Private Bag X54001, University of Durban-Westville,4000, South Africa
That paper commences with the challenge that women's health rights must be seen as part of the human rights movement it' we want to treat such issues effectively and efficiently. The author then goes on to substantiate why this issue has become a major concern, especially with regard to women alcoholics. The paper focuses particularly on South Africa as a democracy, which claims to give all its citizens equal rights through its constitution, yet at service levels, discrimination occurs. The author highlights two important causes of this problem: (a) how women are constituted by health care professionals; and (2) the discriminatory service provision in the health care system. The author emphasizes among other recommendations that priority be given to the two key issues discussed in the paper. She concludes that programmes for implementation of these recommendations be dealt with urgently or else this hidden health burden will escalate with drastic consequences.
The day will come when the progress of nations will be judged not by their military or economic strength, nor by the splendor of their capital cities, but by the well-being of their people~ by the levels of health, nutrition and education; by the provision that is made for those who are vulnerable and disadvantaged; and more importantly by their achievements in progress for women (UNICEF, 1995).
If we were to apply these principles to countries or nations today, how many would qualify as a nation that has made progress'? Very few if any at all. Yet some 117 countries claim to have made progress by signing and ratifying the United Nations Human Rights Convention and the Convention on the Elimination of all forms of Discrimination Against Women (CEDAW) which claims to make the human rights machinery work for women.
Whilst 'paper rights' for women have been in existence for many years in some countries its translation into 'real rights', especially in the area of women's health rights has been selectively interpreted, and discriminatory practices and treatment continue to exist. Chemically dependent women in particular have been and continue to be relegated to the category of 'alcoholics invisible', despite the fact that chemical dependency hasbeen recognized as a disease which may result in disabilities and even premature death.
Women's rights activists (Worcester and Whatley, 1988) claim that where women's human rights are concerned, if the disease is not directly linked to especially their reproductive health, the issue is often ignored. This has been the case particularly with alcohol-abusing women in South Africa. Soutter (1988), in support of the above statement claims that the subject of women's health has received little attention until recently, and the particular question of women and alcohol has been virtually ignored.
Many countries that claim to be committed to the human rights concerns of women and which appear to represent the highest spirituality come under serious indictment for this particular violation of' women's human rights.
The pervasiveness of discrimination against women in health care and health policy settings had increasingly been recognized in the 1990's, both in South Africa, developing and developed countries. Even when women's access to health care is theoretically equal in countries such as South Africa, some women, especially chemically dependent women, appear to be vulnerable to receiving inadequate, insufficient and indifferent treatment. South Africa in particular seems to be in denial about the alcoholic women syndrome. When one examines the studies of \~omen and health in South Africa, the issue of women and alcohol abuse and women and drug abuse seems to be totally ignored. Yet research evidence, media reports and therapists themselves claim that women alcoholics and drug dependents suffer the greatest social, political and sexual violations. As women's rights activists ourselves we tend to prioritize health issues of women indiscriminately, giving very low priority to women alcoholics and drug users. Violations of dignity, misdiagnosis and mistreatment prevail in the field of treating substance-abusing women. Research evidence suggests that this occurs because of stereotypical beliefs, myths and misconceptions that therapists and health care workers harbor about alcoholic women. Research cited in this field exposes this as an international phenomenon. The failure of our health care system to support women, and misconceptions about and mistreatment of substance abusing women is our 'hidden health burden' in South Africa This hidden health disadvantage that women suffer on the grounds of gender alone, must be tackled.
A review of literature. research and interviews conducted by the researcher reveals that substance-abusing women suffer discrimination and mistreatment because of:
1. the way health professionals construct women substance abusers,
2. the way health care systems are constituted, and policy implemented; and
3. societal stigma surrounding alcoholic women.
1. How are women constructed by the health care professionals?
Members of the health professions have done much to mitigate the health consequences of' women's gendered disadvantage.
In my interviews with a sample of substance abusing women (135), 98% of the respondents claimed an appalling lack of' support from especially their doctors, therapists and alcoholism personnel who were charged with diagnosing and treating their 'illness. They discovered, what most alcoholic women it appears are forced to recognize, that contemptuous attitudes and the sheer ignorance about women pervade the health care system as destructively and thoroughly as any other segment of society. What became apparent in my interviews was that their real needs and the very humanity of' alcoholic women remained invisible.
This need to evade and deny the reality of substance abuse amongst women in South Africa is so powerful that it has permeated the treatment field very deeply.
A 29-year-old women alcoholic illustrates her therapist's denial of her condition in her recollection of treatment. She said:
"In all the times (five times in all) I was in hospital, no doctor, social worker, nurse or psychologist said anything to me about mydrinking problem. I was always asked about mycolitis, my ulcers or my 'poor nerves'. Twice I attempted suicide and in all those times all the professionals treating me failed to or just did not want to respond to my alcohol problem. They blamed my childhood, my siblings, my partner, my job situation for my 'nervous condition".
Sandmaeir (1998) supports the above patient's assessment of her therapists' responses when she says that some doctors fail to respond to even clear-cut evidence of alcohol problems in their women patients. She maintains that their failure to respond to women alcoholics sometimes steins from their lack of training in the field but more specifically because they hold notably stereotypical attitudes about appropriate behavior for women. It is this attitude of therapists and health care personnel towards alcoholic women that creates our hidden health burden. Whilst we may believe that we in South Africa have made tremendous strides as far as scientific breakthroughs with regard to treatment of' alcoholism, we still seem to be in a 1960's time warp with respect to attitudes about alcoholic women. If one compares the research findings on attitudes of' therapists Lind health personnel in the 1960's with the findings of attitudes of therapists and health personnel in the 1990's, nothing has really changed.
Johnson (1965), in his study of doctors, revealed that doctors believed that alcoholic women had loose sexual morals, had more psycho-sexual conflicts and were more likely to get into social difficulties than alcoholic men. Almost 15 years later in the 1980's Soutter quotes Lord Ennals, the former Secretary General of Social Services in UK saying, "Let's face it there is nothing manly or heroic about those who drink too much. In men it is crude and embarrassing, and in women it is plain sickening."
Lending support to all the above findings the study of Chesler (1972) on women and madness revealed that the physicians in her study were of the opinion that alcoholism was a sign of 'moral laxity'. They subscribed to the double standard that alcoholism in women was more shameful than alcoholism in men and therefore more discomforting to discuss with a female patient. Alcoholism, according to Walitzer and Connors (1996) is still viewed primarily as a male disorder in the 1990's.
Despite the progress made by women since the high point of feminism in the 1970's, it still remains true that treatment personnel hold the view that a drunken women causes more offense to society than a drunken man. Whilst this attitude is not always overt, the way in which health personnel label and make their primary diagnosis and treatment of the problem indicates their denial of the condition. The research findings internationally serve to illustrate the ways in which traditional, patriarchal values reinforce the desire to silence, narcotize and tranquilize women. The possible negative impact of this denial by health professionals is best illustrated through the words of one women on her journey to recovery:
"Pills. No more tears. Days melt into months. I don't care about anything. I see my therapist on a Friday, the only day I go out. My therapist decides I don't like my mother. Tries to talk to me about my mother. I refuse to talk. He threatens me, it' I don't co-operate I will be put into an institution. I make things up for him, because I'm afraid he will send me to an institution. He nods in his chair, makes notes, writes a new prescription for stronger pills. It's so nice to be stoned. I care about nothing. I can even manage to sleep with my husband. Both of them are pleased with the 'progress' I have made."
When health care professionals treat the 'disease' they often fail to treat the real disease because of the myths they harbor and their traditional views about women.
If treatment is to become effective for women, therapists' attitudes and mindsets about the alcoholic women and their sex role experiences need to be challenged. Myths about alcoholic women need to be exploded, and the knowledge base of the treatment field needs to be evaluated in terms of the feminist approach.
2. The discriminatory service provision in the health care system is also part of the equation of hidden health burden
It is imperative to point out that whilst not every health care professional acts as an obstacle to treatment, some are not only impressively knowledgeable, but will confront any patient, regardless of gender.
In spite of the fact that some health service providers adopt a non-sexist, professional approach with alcoholic women, the first challenge an alcoholic woman confronts is simply finding an alcoholism program that has room for her.
The scarcity of treatment spaces for women in such programs stems largely from the longstanding assumption by the health system that alcoholism is essentially a male illness. Having asserted that women tend to under-utilize alcohol abuse services, we need to examine the issues and realities that fail to bring women into treatment.
A frequently cited barrier to treatment utilization is that alcoholism treatment services frequently have been structured to reflect and meet the needs of male clients, both in terms of services provided and availability of in-patient facilities and treatment groups (Beckman, 1984; Thom, 1994; Collins, 1993).
The Dawn Report (1994) maintains that it is because services have been developed to meet the needs of men that this environment may be intimidating to women.
Several researchers inter alia Beckman (1984), Thom (1994), Collins (1993), and the Dawn Report (1994) note that another significant barrier to access was that the male majority support group setting tended to focus on issues and situations which often did not relate to the issues women considered as priority.
Pressure to stay home and look after children, was one barrier that neither affected nor concerned male alcoholics seeking treatment or remaining in a treatment facility (Badiet, 1975).
Women in rural areas, especially in South Africa, are further prejudiced by having no support system in their home environments. The exaggerated stigmatization of women alcoholics in small isolated towns appears to be stronger, which in turn further victimizes the women and prevents them from seeking assistance.
Sandmaeir (1998) commenting on programs for alcoholic women in the 'first world' specifically the United States, maintains that support for women's programs has been grudging at best. Her study revealed that only 29 out of 500 treatment facilities offered specialized treatment programs for women. Some countries are still without a single women's program or even a co-ed program. Hence the vast majority of women substance abusers continue to be treated in facilities that fail to meet many of' their most pressing needs.
Du Toit (personal communication, 1997), Director of Lularna Treatment Centre, KwaZuluNatal, South Africa raises the concern that the Durban Centre is the only center which provides a gender-specific service for women in South Africa. She quotes the following in-patient statistics for women in the province: 24.6% at Lulamaand, 31'Y,, at Warman House, the majority of whom are white women. Black women, despite the change in the country's policy on race, still experience difficulty and discrimination in accessing treatment. Community stereotypes, financial difficulties, marketing and awareness raising programs in the townships and rural areas are still a problem. In-patient treatment programs for women are almost non-existent for women and Du Toit shows that only 13.3% of women were admitted to an out-patient treatment program in rural KwaZulu-Natal (personal communication, 1997).
Another seriously destructive approach to women alcoholics is the fact that treatment centers and personnel often perceive women's alcoholism as a mental health problem, and prefer to treat them in a mental health facility (Padayachee, 1993).
This approach to the alcoholic woman may contribute to the problem of cross addiction. Even if women are able to avoid the route of the psychiatric ward, women find themselves in treatment programs which are neither prepared not committed to meeting many of their fundamental psychological and practical needs.
It is deeply disturbing that in the 1990's gender still influences the extent to which treatment services are utilized and made available.
It is crucial to acknowledge at this point that apart from the insensitivity of health personnel and health services towards alcoholic women. societal stigma also affects how women seek treatment.
If society is condemning of alcoholism in women, it will obviously affect the significant others in her life, and her own selfesteem and sell' image. It is quite common to find husbands or partners and other family members discouraging women from seeking treatment (Holmstrom, 1990). This obviously affects a woman's access to treatment and the ability of health professionals to see her.
Furthermore, it appears that much of' modern research and drinking behavior of women tends to focus on deviant aspects of drinking. It is clear however that women's alcoholism cannot be understood solely within the framework of deviation. The patterns of alcohol use, function and meaning are enormously influenced by the cultural context in which drinking occurs.
Given the above obstacles. it is not unusual, to find women who resume abusive drinking after leaving treatment and becoming part of the 'revolving door syndrome'.
Several researchers have found that women who fail to obtain proper treatment for alcoholism show pathological coping strategies. The study of Gomberg (1989) indicated that Young alcoholic women show high risk for suicide and attempted suicide. Cross addiction was mother coping skill that was often resorted to and was more commonly found amongst women who were diagnosed as chronically depressed (Padavachee, 1993).
The impact of these negative coping skills leads to, among other disadvantages, job loss because of high absenteeism, sexual abuse, sexual harassment, poor health, disabilities and even premature death.
It is clear from the preceding discussion that alcohol substance abuse in women cannot be looked at in isolation. Society can no longer afford to hide its alcoholic women and evade its consequences. Women make up 54% of the world's population and contribute politically. socially and economically to the upliftment of' their respective countries. Hence their human right and access to equal treatment cannot be denied.
Treatment programs and therapists in particular need to look at the realities of women's lives. Health personnel must he challenged with regard to practice and malpractice. Re-training of' in-service personnel in gender-sensitivity is essential and training pre-service personnel in gender-sensitivity must become a prerequisite for the selection of the health care workers if we are serious about reducing the phenomenon of' alcohol-related harm.
Badict P. Women and Legal Drugs: An Analysis of' the literature MSW thesis Corleton Univesity Ottawa 1975.
Beekman L.I. Analysis of' the suitability of' alcohol treatment resources for women Subst. Alcohol Actions Misuse 1984:5:21 7.
Chesler P. Women and Madness. New York: Avon Books. 1972.
Collins RL. Women's issues in alcohol use and cigarette smoking. In: Baci JS, Marlatt GA. MeMahon RJ, editors. Addictive Behaviours Across the Lifespan: Prevention. Treatment, and Policy Issues. Newbury Park, CA: Sage, 1993:274 306.
Dawn Report, 1994. No.5 cited in Boumanhuis Newsletter 1997:3(1)10.
Gomberg ESI---. Suicide risk among women with alcohol problems. Am J Public Health, October, 1989:79(10):1363 5.
Holmstrom C. Women and Substance Abuse. Psychiatr J. April June, 1990:53:141.
Johnson MW. Physicians' views on alcoholism, with special reference to alcoholism in women. Nebraska State Med J 1965:50:380.
Padayachee A. Substance-abusing spouses, inadequate socio legal advice: A dangerous, mix for abused women in South Africa. Acta Criminol 199316(2):43 51.
Sandmaeir. M. Alcoholics invisible: The ordeal of the female alcoholic. In: Worcester N, Whatley M 11, editors. Women's Health. Kendall 11unt~ 1998:24 80.
Soutter K. Women and alcohol. Challenging the stereotypes. Health Educ .; 1988:47(1)12 4.
Thom. A process approach to women's use of alcohol services. Br J Addict 1994 , 79:377 82
UNICEF In: The Progress of' Nations. United Nations Children's Fund, Part 1, 1995.
Walitzer KS, Connors G.J. Gender and treatment of alcohol problems. Boumanhuis Newsletter, Holland, 3 1996~2j)).
Worcester N, Whatley M11, editors. Women's Health: Readings on Social, Economic and Political Issues. Iowa: Kendall Hunt 1988.