Journal of Addiction Research & Therapy
Open Access

Female alcoholism; Alcoholics anonymous; Gender; Treatment; Alcoholic women

Introduction

In Brazil, drinking is a typically male act and alcoholic women suffer gender discrimination [1]. The mean alcohol consumption in the country of 8.7 liters per person per year (>13 liters for men; 4 liters for women) is above the global average [2]. About 3.63% of the female population is alcohol dependent, according to the DSM-IV criteria [3]. The abusive use of alcohol (≥ 4 doses for women or ≥ 5 doses for men on the same occasion in the last 30 days prior to the survey date) among women increased to 11% in 2018 to 13.3% in 2019.

Alcoholics Anonymous (AA) is the largest support group for the treatment of alcoholism in the world [4] and allows the construction of new possible meanings about alcoholism and new social support networks. In Brazil, since 1947, AA is accessible to the majority of the population, including those of low socioeconomic status, and is recognized and promoted in health service by healthcare professionals. Currently, 4,598 groups hold 9,780 weekly meetings placing Brazil (Alcoholics Anonymous), behind only the United States and Canada, which share the same service infrastructure, and then Mexico.

The support group works on the one hand through participation in the AA group meetings and on the other hand through practice of the 12 Step Programs, a set of principles aimed at achieving sobriety. Women who have been AA members for a longer period of time say that the 12 Steps gave them the reassurance they required to remain sober within a new lifestyle, helping them recognize that they are mothers and workers who suffer from alcoholism and that this is no cause for embarrassment [5].

The rehab meetings occur in premises that are rented or provided by churches, schools, correctional detention centers or healthcare units, as is also the case in other countries. Meetings can either be “closed” when the encounters consist exclusively of individuals who consider themselves alcoholics, or “open” when the meeting is accessible to anyone wanting to know more about the organization. The meeting room and the AA celebrations in Brazil, particularly those aimed at groups of individuals with limited socioeconomic status, are similar to those held in Mexico with the rooms being decorated with framed posters illustrating the 12 Steps and the 12 Traditions, as well as phrases aimed at encouraging compliance with treatment: “Avoid the first Sip”, “Keep Calm”, “You are the Most Important Person in the Room”, etc. Celebrations held to commemorate the time an individual has remained sober, and anniversaries of the groups consist of get-togethers involving typical Brazilian food and non-alcoholic drinks at which everyone socializes, including family members of the individuals in the group.

Despite being important in supporting the alcoholic, AA in Brazil remains a predominantly male association, with only 13% of members being women and little is known regarding how these women view and experience the treatment of alcoholism offered by the AA (Alcoholics Anonymous). If the AA is recognized as a means of treating alcoholism, there would appear to be a discrepancy between men and women in the group. This fact relates to the very history of the association, with most of the literature having been written by men and by the founding fathers, Bill Wilson and Dr. Bob Smith, who valued traditional family and conservative gender roles [6].

Gender-based relationships and AA have been the focus of some studies [7-10] which emphasizes how gender asymmetries impair the treatment of AA women. Because retained clear patriarchal traits and is based on very traditional gender roles, the AA groups in Brazil tend to reproduce within themselves the gender-related social relationships of a setting in which sociability is much like that experienced in bars with informal conversation, sexists joke and situations of sexual harassment that end up discouraging women from participating in mixed-sex meetings that include the presence of men, leading them to discontinue treatment [11-12].

Based on this, the objective of this present investigation is to understand how gender asymmetries shape and interfere in the treatment of alcoholic women within AA.

Methods

A qualitative study was conducted between August 2019 and February 2021 with 30 alcoholic women attending AA meetings in the city of São Paulo, Brazil. It´s interest to say that in 2021, São Paulo had a population of 12.33 million inhabitants and 119 AA groups, mostly in peripheral neighborhoods (Alcoholics Anonymous).

Purposeful sampling was used to select participants. The inclusion criteria were women who recognized themselves as alcoholics and who participated in AA rehab meetings in the city. Thirty women with different times of sobriety were included using the criterion of data saturation, i.e., recruitment ceased when the data became redundant and new data failed to supply any additional elements for analysis of the phenomenon under investigation.

With the pandemic and the need for social distancing, the AA groups suspended their rehab meetings, which went on to be held virtually. AA members who had participated in the face-to-face interviews were then contacted so that they could message to other women in the AA asking them to participate in the study.

The qualitative data collection was carried out through semistructured interviews were held face-to-face or, following the onset of the Covid-19 pandemic, by Google Meet/telephone, from March 2020 until February 2021.

The questionnaire included an informed consent form in which the study objectives were explained, the women’s anonymity was guaranteed and their consent to the publication of their data was requested. The questionnaire was used to collect data such as the woman’s name, age, marital status, education level, profession and time in the AA. The questions about gender-based relationships and AA addressed alcoholism female, rehab meetings and the AA female meeting.

An in-depth analysis was conducted of the meanings of the phenomenon gender asymmetry and its specificity and singularity. Data analysis aimed to progress from what was explicit in the content to what was implicit. This process was carried out to obtain a comprehensive, interpretative and inclusive synthesis that would allow the way in which gender-related social relationships affect the treatment of women alcoholics within the AA to be understood. The categories of analysis were drawn up based on a rigorous interpretative and comprehensive synthesis with the objective of explaining how gender asymmetries affect the treatment of alcoholism in female AA members.

The University Ethics Committee review board approved the study protocol, and all the participants signed an informed consent form that guaranteed their autonomy, anonymity, and confidentiality.

Results

Characteristics of participants

The 30 study participants are referred in Table 1. The age ranged from 31 to 77 years. Some had recently begun in AA, with only 1 or 2 months of abstinence, while others had been attending meetings for many years, with 31 and 38 years of abstinence. Most were married to other AA members. Education level varied from high school to PhD. Most worked in the service sector and all were in charge of household chores.

Categories of analysis

Three categories were identified: “Alcoholism is a single disease, but for women it is much worse”; “Women cannot air their intimate feeling in AA mixed meetings”; “In AA women's meeting I share the exact nature of my pain and feel stronger”. Each one reflects gender asymmetries in the treatment of alcoholic women within AA.

“Alcoholism is a single disease, but for women it is much worse”

This category indicates the perceptions of women about the differences between female and male alcoholism and how the alcoholic woman is frustrated by not fulfilling the women roles. These following statements illustrated this perception:

It is so much more painful, because society does not accept alcoholism in women (Miriam, 55 years old, single, 3 years in AA).

In society, men have always had more freedom and for them there appears to be a greater degree of permissiveness in relation to alcohol (Janaina, 45 years old, divorced, 2 years in AA).

Men are freer. It’s always more embarrassing for women. A man drinking is ugly, but in a woman, it is even uglier. Because the woman is labeled a slut, and we’re not sluts […] But to me the way of drinking is the same, the disease, where it leads you, it leads us all down the same path (Berenice, 44 years old, divorced, 3 years at AA).

A man drinking is horrible but a drunken woman in a bar is very sad, really horrible. Because you are treated like a prostitute; if you’re in a bar, to them you’re a prostitute. So, yes, it’s very different. (Francisca, 61 years old, widowed, 4 years at AA).

Alcoholism is a single disease, but there are differences because it is much easier for a man to drink in a bar; it’s permitted to a much greater extent for men. For women it's much worse, so, yes, there is a difference (Marina, 61 years old, divorced, 15 years at AA).

I liked a certain brand of rum […] but I was too ashamed to buy it. And the more embarrassed I was, the more I wanted it […] I was not brave enough to buy it, so I stole it. Because I’m female, because I’m a woman, I was ashamed to buy it. (Norma, 34 years old, single, 6 months at AA).

Men drink outside the home. Women drink alone at home. Men drink and that’s fine. Women drink and it’s not fine. That’s because of society. For that reason, I think that there is a greater percentage of women drinkers but because of that, they hide themselves away. (Juliana, 33 years old, single, 10 months at AA).

Women are all mad. That’s a way of underestimating women […] of course there is [a difference]. Men are always “the guy” and women are always “mad” (Leticia, 34 years old, married, 6 years at AA).

Marcia (58 years old, divorced, 9 years at AA) also highlights the shame she used to feel when she drank:

One similarity I have seen among women is that they hide their drinking […] I remember, for example, at my daughter’s party […] I drank a full bottle, or almost that, of vodka during the party. However, that bottle of vodka was in my bathroom and the house was large.

However, even when drinking in their own homes, women used strategies to conceal it from their families and hide the alcohol away:

The problem is that I would get home and start drinking […] my drink of choice was always whisky. I had other bottles hidden away in other places, on the veranda, at the pool, in the bathroom. They were strong drinks, whisky and vodka, spirits. (Eunice, 54 years old, married, 2 years at AA).

I was drinking continuously. Every day. Ten cans of beer. I would hide it in my closet, under the sink, in the bathroom. Everything was hidden. (Fatima, 61 years old, widowed, 25 years at AA).

Women highlight how alcoholism is linked to the moral degradation causing them to lose auto respect, including the mother role:

I thought I needed to stop drinking because I could see that I was not a good mother. I didn’t take care of my children. I didn’t like chastising my children […] And I began to notice that I was shouting. By good luck I came to AA, because I had not yet become an aggressive mother, but I was heading in that direction. (Telma, 61 years old, married, 25 years at AA).

A drunken woman loses all respect. If we don’t even respect ourselves, imagine how others see us, particularly our children. The children are those most affected. […] But I never hit my two children, ever; I never raised my hand to them Catarina (58 years old, married, 24 years at AA).

I was the kind of mother who would leave her daughter with others so I could go out at night and party. So, I was a dreadful mother (Agnes, 64 years old, widowed, 31 years at AA).

“Women cannot air their intimate feeling in AA mixed meetings”

The perceptions of the women regarding the difficulties of exposing their intimates feeling in AA meetings with the presence of men, as well as situations of harassment are indicating in this category.

Despite being an important source of support for alcoholdependent women, there are things that aren´t said in AA room with the presence of men. This is clear in the reports on the difficulties the women have faced in the AA, particularly in relation to men:

You are not going to go into a mixed-sex room and say that you had an abortion, that you were raped. There is no way you are going to do that (Regina, 49 years old, married, 2 years at AA).

If the women don’t open up, am I going to open up? I think they just don’t open up. Because it’s not possible that they have only experienced minor problems. There are things you don’t talk about in a mixed-sex meeting (Norma, 34 years old, single, 6 months at AA).

There are things you can talk about in the chair, things you can tell your sponsor. You avoid talking about certain intimate things. Women can’t expose their feelings in the chair when there are men present. At the beginning, I ended up saying a lot of things that I shouldn’t have said (Alicia, 31 years old, married, 1 year at AA).

The most difficult thing was speaking about the peculiarities of my behavior when I’m drunk, in a place where most of the people are male (Natali, 34 years old, single, 9 years at AA).

It’s difficult to put myself out there in front of other members who are men (Paula, 55 years old, divorced, 6 years at AA).

I started in a mixed-sex room, with men and women; however, for many years I was the only woman. Many others came and went, and I had to learn to deal with certain issues regarding sex, feelings and deprivations, because not everything could be said at the table (Sara, 57 years, married, 19 years at AA).

Harassment is defined as behavior that is unwanted and unconsented, and which often intimidates, embarrasses, and humiliates. For some of the participants in this study, it is clear how such situations significantly impact on the treatment of alcoholism, even causing them to stop attending recovery meetings:

I stopped attending [mixed sex] meetings years ago because of the lack of respect from male members. I felt abused and impotent (Fernanda, married, 1 month at AA).

I would stop going whenever I felt that one of the members was becoming interested in me as a woman, like he wanted to have a relationship with me. When I was able to rid myself of the feeling, I would go back to the meetings (Aline, 55 years old, widowed, 5 years at AA).

Harassment is common; there used to be more. Precisely because before there were fewer women and the women were not as united. You had nowhere to go. Some men think that alcoholism in women is not as bad as alcoholism in men (Nair, 77 years old, married, 38 years at AA).

The difficulties are the same as those we see throughout society: machismo! Women in AA have to defend themselves against the lack of respect, often committed by the veteran members (Aurora, 58 years old, married, 16 years at AA).

“At an AA women's meeting, we share the nature of pain, and it makes us stronger”

This category indicates that AA women's value the female AA meeting for the treatment and strengthening of alcoholic women:

In women-only meeting is where I talk to my peers, the other women, about many things that a woman needs to externalize […] Even if you find a partner, marry one of the other members, you are experiencing difficulties you’re. If you have a women-only meeting, you’ll pour it all out and there it will stay (Marina, 61 years old, divorced, 15 years at AA).

The men sometimes talk about things to do with sexuality, not in any depth, do you understand? […] The part involving sexuality I would say more [in a women-only meeting], definitely (Fabia, 43 years old, divorced, 6 months at AA).

There have always been women in my base group, but when I started there were few, two or three, older than me. So, we soon started a women-only meeting, which helped me a lot and which continues to this day (Tereza, 61 years old, single, 26 years at AA).

Andreia (31 years old, married, 6 years at AA) also emphasizes the importance of identifying with what the other women share and that this is a crucial aspect of the women-only meetings:

On a score of 1 to 10, my rating for the women-only AA meetings would be 10 because I feel extremely at ease with the other women. Identification is complete and I now have the opportunity to talk about many issues that I had never before voiced, since we are all equal here, and certainly together I feel stronger […] It’s in a women-only meeting that I share the EXACT (the interviewee emphasizes the word) nature of my pain, for me to go on receiving the gift of recovery in sobriety.

In general, women-only groups are seen as territories where there is freedom to discuss subjects such as romantic and sexual relationships for which gender stigma is greater, and also the specificities of female alcoholism that often include situations of abortion, rape, abuse and harassment.

Women-only meetings are essential because it is with other women that we feel free to talk about things like sex, relationships, about these things. We feel more at ease (Rosa, 63 years old, widowed, 5 years at AA).

The amazing advantage of this group is that we are free to expose our intimate thoughts, particularly with regards to sex. In a mixed-sex group, because of questions of ethics and respect, we would not feel at ease to do so. The women in my group are extremely united (Elza, 52 years old, divorced, 1 month at AA).

I believe it is very important to have the option of women-only meetings. I was feeling very lost and not at all at ease in the mixed-sex meetings. Finding a women-only group stimulated me more to attend the meetings (Cassia, 35 years old, divorced, 2 months at AA).

Discussion

This qualitative study analyzes how gender asymmetries shape and interfere in the treatment of alcoholic women within AA. The three categories identified in the women´s statements reflect the way in which gender relationships involves the entire experience of the alcoholic woman and her treatment in AA.

The gender asymmetry between men and women in relation to alcohol consumption is evident in the women´s reports of this study, which highlights the idea of moral degradation in alcoholic women. Campos [13] showed the strength of the social stigma associated with “women who drink”, who are seen as “shameless”, the opposite of “honest” women.

That is why the women interviewed reveal a feeling of shame about drinking in public. This feeling increases when the limits of socially acceptable drinking are exceeded, leading the woman to drink alone, often in the solitude of her own home. Silva & Lyra [14] also pointed out that, among alcoholics, women suffer greater prejudice and are much more likely to experience loneliness and isolation.

This feeling of shame also highlights the moralities involving gender relations in Brazilian society, defining the significance of alcohol consumption and alcoholism to women in AA. This substantiates findings that emphasize how gender-related social relationships morally disqualify alcoholic women.

In this sense, Basnyat [15] reported how customers sexually harassed alcoholic women who worked in bars. This reinforces how gender inequalities affect health, with women being disqualified due to the work they do. Bogren [16] further reinforces this relationship between alcohol use and gender by showing that some women are seen as available for sex because they do not follow female moral codes in relation to alcohol. Hanpatchaiyakul et al. [17] described how alcoholic women feel inferior, guilty, ashamed, and unappreciated for drinking in public. Visser & McDonnell [18] showed that even the most egalitarian men are more critical of female alcoholism, which causes women to change their lifestyle to maintain a desired or acceptable gender identity by society.

Brazilian women consider motherhood an important moral value. Campos [13] studied an AA group in the outskirts of the city of São Paulo and also showed that being a mother who responsibly takes care of her children is an important moral value that is shaken by alcoholism. Hanpatchaiyakus et al. [17] founded that alcohol-dependent Thai women also felt inferior and guilty at not having succeeded in fulfilling their role as women, and considered themselves bad mothers.

The women showed how they felt devalued within the family and in their social life. This finding is supported by a study conducted by Raine who found that alcohol consumption by women is considered immoral because such women are neglecting their social role of wife and mother. Thurang & Bengtsson Tops [19] also showed that alcoholdependent women are more introspective and consider themselves culpable because of their alcoholism.

In a study on gender and controlling alcoholism, McPherson and Martin [20] reported that, whereas men trusted more to luck and to doctors to control their alcohol addiction, women were found to have greater self-control and believed more in other methods, including AA meetings. The importance of these groups in controlling alcoholism for women was also confirmed by Krentzman et al. [8] who reported that the chances of remaining sober in AA were four times greater for women than for men.

Despite being an important source of support for alcohol-dependent women, AA groups are also affected by gender relationships. This is clear in the reports on the difficulties the women have faced in the AA, particularly in relation to men. Author emphasized those situations of sexual harassment and sexist jokes made by men show how gender asymmetries keep women away from AA groups, aggravating their alcoholism. Women tend to share more intimate issues at AA meetings than men, making rehabilitation in mixed-sex meetings difficult.

The importance of women-only meetings in the AA is clearly emphasized in the women’s statements. However, in the city of São Paulo, there are only two groups that currently hold women-only meetings. This finding corroborates the reports of author revealing that only in the United States there are, at the time of the study, a significant number of women-only meetings.

Therefore, the women-only AA meetings show how genderrelated social relationships occur within AA, making it essential for alcoholic women to have some women-only meetings at which to share their experiences and intimacies, their experiences from when they were active alcoholics and from their recovery [7,12,21]. Womenonly meetings resolve the discomfort experienced by women who feel harassed by men for sexual encounters and those they enable the women to discuss intimate topics such as affective relationships, menstruation, menopause, abortion, incest, sexuality and child neglect.

Conclusions

In Brazil, the number of women with alcohol-related problems has increased in recent decades. Nevertheless, because Brazilian society is defined by a patriarchy that establishes gender asymmetry, women who consume alcohol and have drink-related problems are victims of prejudice and social stigma, which makes it difficult for them to seek treatment.

In this regard, the three categories of the present study showed how the participants emphasized that female alcoholism is the target of gender prejudice, considered worse than male alcoholism, and that alcoholic women also face gender prejudice in AA, having difficulties in share their intimate thoughts at mixed-sex meetings. Situations involving sexual harassment and sexist jokes made by men show how gender asymmetries drive women away from AA groups, making their alcoholism worse.

Since the objective of this research was to analyze how gender asymmetries influence the treatment of alcoholic women in AA, the qualitative findings cannot be generalized for all alcoholic women, which is an important limitation of the study. More studies are required to understand the experiences of alcohol addiction in women in different settings, as well as their interpersonal relationships. In this respect, Mänsson and Bogren and Nolen-Hoeksema & Hilt [22] highlighted the importance of conducting further researchers on gender differences and the problems resulting from alcoholism in women, as well as on the associated differences between women and men.

In this sense, meetings for women only represent an antidote to the gender inequality that defines the experience of alcoholic women, allowing them to strengthen themselves and participate in support group meetings, without the pressures of stigma and social prejudice. In this sense, the organizers of the meetings of the support groups must also be attentive to create opportunities for the realization of some exclusively female meetings.

Acknowledgement

The authors are grateful to the São Paulo State Foundation for the Support of Research (FAPESP) for the financial support received for this study under reference number: 2017/18535-9.

Funding Sources

São Paulo State Research Support Foundation (FAPESP) – number: 2017/18535-9 and This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

Disclosure Statement

The authors declare no conflicts of interest.

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