FAS, which is preventable, is now considered a leading cause
mental retardation in the United States. 107 Not until 1991 was comprehen-
sive data published concerning adolescent girls and adults with FAS, in
spite of the increasing prevalence of FAS. In their report on 61 adolescent
girls and adult women, Streissguth, et al., found that:

...although mental retardation is not necessarily predictable from the diagnoses alone, major psychosocial problems and life-long adjustment problems were characteristic ....The development and cognitive handicaps persist as long in life as these patients have been studied. None of these patients were known to be independent in terms of both housing and income ....Attentional deficits and problems with judgment, comprehension, and abstraction were the most frequently reported behavior problems ....Conduct problems, such as lying and defiance, also characterized a number of these patients. Data on trouble with the law and substance abuse were not systematically obtained .... 101

In another study of 92 adolescent girls and adult women with FAS, 36 percent of the patients reported having current or past experience with alcohol abuse, and 25 percent reported past abuse of other drugs. 10, While no specific data are provided in the paper reporting this study, the authors indicate that "males abused alcohol at a higher rate than females." It is important for treatment program personnel to recognize that when adolescent girls and adult women with FAS present for treatment, they have particular issues that must be addressed by both medical and mental health personnel.

Use of cocaine, heroin, methadone, and other drugs during pregnancy is widespread, but experts know less about this type of abuse. However, some direct data are available concerning cocaine use during pregnancy. According to Clark and Weinstein, "reported prevalence of use [of cocaine] rates among pregnant women in large urban teaching hospitals
40 Women and Alcohol and Other Drugs: An Overview

range from 8 to 15 percent, although frequency of use during pregnancy
varies considerably." "° In 1992, according to the SAMHSA Household
Survey, an estimated 329,000 women 18 to 34 (the age group with the
highest birth rates) or 1 percent of respondents in this age group, had used
cocaine in the previous month, and 87,000 had used crack."' Data regard
ing women's use of heroin are not available by age group.
Only one national survey of prenatal exposure to illicit drugs has
been conducted. According to that survey of 50 hospitals, an average of 11
percent of pregnant women were abusing illegal substances, with cocaine or
crack as the drug of choice in 75 percent of the cases. "2 Using these data,
researchers estimate that each year 375,000 newborns are exposed
perinatally to at least one illegal drug,' 13 with significant consequences. For
example, low birthweight has been repeatedly associated with the use of
heroin and methadone.I " Heroin has also been shown to produce severe ill
effects in prenatally exposed children.

In an investigation of cocaine, Chasnoff, et al., found that the infants of cocaine-abusing mothers (with or without other drugs) had significantly lower birthweights, increased prematurity, and increased incidence of introuterine growth retardation (IUGR) and abruptio placentae than infants of non-drug using mothers. "6 The findings of increased IUGR, prematurity, and low birthweight have been supported by other studies. ' 11 ' "

Although more studies of the epidemiology of drug abuse among pregnant women are clearly warranted, the growing evidence on adverse birth outcomes strongly suggests that illicit drug use contributes to high rates of infant mortality, Sudden Infant Death Syndrome (SIDS), and mental retardation. Anecdotal reports indicate that the problem may be getting worse, at least in some areas. In the District of Columbia, a sharp rise in infant mortality between 1987 and 1988-from 19.6 to 23.2-has been attributed to increased crack use among pregnant women.' 19

Women and Alcohol and Other Drugs: An Overview 41

2.4.3 Women in the Criminal Justice System

In the past, women in the criminal justice system who had substance abuse problems received very little attention because their numbers were few and they typically served short sentences. In the last decade, however, the increased incarceration of women has shifted the focus to, at a minimum, understanding why more women are in the criminal justice system. Overall, the U.S. prison population has increased 250 percent since 1980 (from 329,821 in 1980 to 823,414 in 1991).'2° As of the end of 1991, 47,691 of the total federal and state prisoners were women. '2' The growth in the rate of women in the prison population exceeded that of men in the prison population at the state level in the 1980s, increasing 202 percent for women as compared to 112 percent for men. '22

The major reasons for the increase in incarceration of women have
been the national crisis regarding alcohol and other drug problems and the
advent of mandatory minimum sentences for most drug offenses. In 1981,
approximately 8 percent of state prisoners were serving sentences for drug
offenses. By 1989, that number had increased to almost 30 percent.
Drug offenses at the federal level showed a similar increase during the
1980s, from 22 percent of all admissions to 55 percent."'

The Bureau of Justice Statistics, in a 1989 survey of inmates in local jails, collected data from interviews in a nationally representative sample of 5,675 inmates in 424 jails, updating data from a similar survey conducted in 1983.'25 These data provide this profile of incarcerated women: In 1989, more than one in three female inmates were in jail for a drug offense, an increase from one in eight in 1983. Among all convicted female inmates, nearly 40 percent reported that they had committed their offense under the influence of drugs. More than half of convicted female inmates had used drugs in the month prior to the current offense, and approximately 40 percent had used drugs daily. These drugs included

heroin, cocaine, or crack cocaine, LSD, PCP, and methadone. The
percentage of women in jail who had used cocaine or crack cocaine in the
month before their current offense more than doubled, from 15 percent in
1983 to 39 percent in 1989. The survey also found that about one in every
three convicted women in jail reported they had committed their current
offense for money to buy drugs. About one-fifth of all convicted women
reported being under the influence of alcohol at the time of the offense,
compared to more than 44 percent of convicted men.
Nearly two-thirds of the women in this study had grown up in a
household with no parents or only one parent present. 40 percent in a
single-parent household and 17 percent in a household without either
parent. Almost one-third of all women in jail had a parent or guardian
who had abused alcohol or other drugs. About 44 percent of the women
reported that they had been either physically or sexually abused at some
time in their lives before their current imprisonment.
In a 1992 study of major cities, the Sentencing Project showed that
women's drug use is escalating, the severity of women's criminal activity is
rising, and their recidivism rates are increasing. Women are being arrested
at a much higher rate, and urinalysis testing indicates that their use of
chemicals is increasing rapidly. Yet a very limited number of resources and
comprehensive treatment efforts within the criminal justice system focus on
women, most of whom are mothers, and their children. 121

Homeless Women

Homeless women represent a highly vulnerable group who engage
in at-risk behaviors and develop health-related disorders at a rate greater
than that of women in the general population. Their children often suffer
from a wide range of medical problems, do poorly in school, manifest

delays in cognitive and other development, and display behavioral or emotional problems.''-'

Markers of the lifetime prevalence rates of alcohol abuse-related disorders among homeless women have ranged from 10 to 37 percent, with the most recent research indicating a 30 percent lifetime prevalence rate, compared with 5 percent for women in the general population. While alcohol problems are more common among homeless men than homeless women, this gender difference is far less than among men and women who are not homeless. '2g

In contrast to homeless women who are not mothers, homeless mothers are much less likely to suffer from alcohol disorders (40 percent of homeless women without children versus 23 percent of homeless mothers). Homeless mothers are also less likely to be told that they have a drinking problem (31 percent versus 5 percent) than homeless women without children. Three studies have documented an approximate 8 to 10 percent lifetime prevalence rate of alcohol problems in homeless mothers, but the numbers are likely underestimated as are any estimates of health and other problems of the homeless. 129 Reports of lifetime prevalence of problems with drugs other than alcohol among homeless women have varied from 9 to 32 percent as compared to the lifetime rate of 5 percent in the general female population. By contrast, homeless mothers have an estimated lifetime 9 to 12 percent prevalence rate of substance abuse. Anecdotal reports from service providers suggest that growing numbers of homeless mothers are abusing not only alcohol but crack cocaine."'

Adverse pregnancy outcomes (miscarriages, low birthweight, and infant mortality) are more likely in homeless women with substance abuse problems because they are usually poorly nourished and have limited access to prenatal health care and substance abuse treatment services. In
one comparative study of homeless women in New York City, 39 percent of pregnant homeless women were found to have received no prenatal care, compared to only 14 percent of low-income women living in public housing communities, and 9 percent of the general population.''

While women who abuse alcohol and other drugs frequently experience depression and anxiety, homeless women are likely to exhibit more profound levels of these disorders. Unfortunately there are no recent data available on this subject.

2.4.5 Lesbian Women

According to Underhill's review of the limited research data available, an estimated 25 to 35 percent of lesbians have "serious problems with alcohol." 112 A 1987 national survey of lesbians found that 16 percent of lesbians believed that they had a problem with alcohol, 14 percent used marijuana several times a week (33 percent used it several times a month), and 8 percent used stimulants in the past year."' These rates are much higher than for women as a whole. The results of the 1988 NIDA Household Survey found that 2 percent of female respondents used marijuana once a week or more, and 2.2 percent of female respondents engaged in nonmedical use of stimulants in the past year. 114 Lesbians also engage in polydrug use at high rates. Although the data are relatively old, a 1978 study found that 60 percent of lesbians used alcohol in combination with marijuana or amphetamines, hallucinogens, and barbiturates. '35 In spite of these relatively high rates of substance abuse, few treatment programs target lesbians or even have services that address their particular needs.

Lesbians experience most risk factors common to other women but also must cope with the effects of stigma, denial, alienation, self-doubt, guilt, and discrimination. These factors can take a heavy toll on the selfesteem of lesbians and make it difficult for them to meet their needs for
affiliation. 116 The relative lack of treatment services responsive to the needs of lesbians and women in general is also a factor in the relatively high rates of alcoholism in this population. Not only are there few programs that conduct outreach to lesbians, few hold meetings or therapy sessions designed to meet their needs, and few have staff trained to address the needs of lesbians. '3'

Although epidemiologic data are not available regarding substance abuse by adolescent lesbians, the recent report of the Department of Health and Human Services Secretary's Task Force on Youth Suicide indicates that lesbian adolescents begin to use drugs to reduce anxiety and pain when they become aware of their sexual orientation. Therefore, outreach, early intervention, and treatment are critical. '3g

2.4.6 Women with Disabilities

The Americans with Disabilities Act (ADA), the landmark civil rights act for people with disabilities, notes that 43 million Americans have some type of disability. '39 These include persons with physical health, sensory, learning, intellectual, or mental disabilities.

While data on the prevalence of alcohol and other drug problems among women with disabilities are lacking, the small body of research on disability and substance abuse suggests that people with disabilities use substances at the same or higher rates than those without disabilities."° Women with disabilities face a similar set of risk factors as non-disabled women, including issues regarding body image, self-esteem, dependence, and sexual abuse, which in some instances are exacerbated by their disability status. '4' Another risk factor for women with disabilities is easy access to substances prescribed for pain or other aspects of the disability, as well as the compounding, often dangerous effects of prescription medication used in combination with alcohol and other drugs. 142

2.4.7 African American Women

In 1991, there were 15.8 million African American women in the
United States: 6 percent of the total population. 143 As with other popula
tions, alcohol is the most commonly abused substance among African
American women and represents a health problem of significant propor-
tions. According to a 1987 NIAAA report, African American women
suffer disproportionately from the health consequences of alcoholism,
obstruetine, including cancer, obstructive pulmonary disease, severe malnutrition,
malnutri- hypertension, and birth defects.'
tion, Alcoholism was cited as a factor in the declining health status of
African Americans in the 1991 report on the Health Status of Minority and
Low Income Populations. "' Death rates from chronic liver disease and
cirrhosis are twice as high for African Americans of both sexes as for
Caucasians. Among women aged 15 to 34, cirrhosis rates for African
American women are six times higher than those for Caucasian women, 146
and the risk of FAS is seven times higher for African American infants than
for Caucasian infants.''
The available data suggest that, while alcohol use begins later
among African Americans than among Caucasians, the onset of alcohol
related problems appears earlier among African Americans. '4$ However,
there are few differences in reported heavy alcohol use by African Ameri
can and Caucasian women. In 1985, both groups of women were equally
likely to be heavy drinkers (9 percent of respondents). In 1988, 7 percent
of Caucasian women and 6 percent of African American women reported
being heavy drinkers. 141
Patterns of drug use (other than alcohol) among African American
women, as reflected in studies of women in treatment, indicate that they are
more likely than other women in treatment to use opiates. A survey of
treatment program data in 1980 showed that 70 percent of African Ameri
cans in treatment used opiates compared with 65 percent of Hispanics and
35 percent of Caucasians. African American women who use opiates enter
treatment earlier than African American men and are more motivated by
specific health problems. '5° In the past, African American women were
less likely to engage in nonmedical use of psychotropic drugs than Cauca
sian or Hispanic women, but in 1992, according to the SAMHSA Survey,
they were as likely to do so. African American women's reported use of
cocaine in the previous month increased slightly between 1988 and 1992
(.5 percent to .6 percent of respondents), in contrast with Caucasian and
Hispanic women whose reported use decreased (see Figure 6).

2.4.8 American Indian Women
According to the 1990 census, there were 992,000 American
Indian women in the United States. '5' Alcoholism is the predominant
health problem for American Indian women in what has been described as
a "triad" that includes violence and depression. The rates of these prob-
lems have increased significantly for this population since 1970.
Fleming has reported that American Indian youth (including girls) "become Indian
involved with alcohol at an earlier age, consume alcohol more frequently
and in greater quantities, and suffer greater negative consequences" than
Caucasian women.'"' Fleming also noted that, as of 1985, alcoholism was
the fifth most frequent cause of death among American Indian women. '54
In all age groups, the alcohol-related mortality rates were signifi
cantly higher for American Indian women than for other women; for
example, for the age group 45 to 54, the rate for American Indian women
was 48.3/1,000,000, while for women of all other races it was 8.4, and for
all other races other than Caucasian it was 14.9.'55 The FAS rate among
American Indian populations is reportedly as high as 1 in 50, significantly
higher than that of the general population of women. 156 As with Asian American women, data concerning use and abuse of other drugs are scarce, in part because the SAMHSA Survey and the NIDA-sponsored High School Survey do not present disaggregated data for this population. There is minimal data available on Alaskan Native women.

2.4.9 Asian and Pacific Islander Women

The term "Asian and Pacific Islanders" is often misunderstood as describing a homogeneous ethnic group. In reality, this label represents more than 60 different Asian and Pacific Islander groups, each with distinct cultural, language, and ethnic identities. Asian Americans have emigrated from countries and cultures as diverse as Japan, China, Vietnam, Cambodia, Thailand, Korea, India, and the Philippines. As of 1990, 3.7 million American women of Asian or Pacific Island origin-a 108 percent increase over the 1980 census-were American citizens."'

There have been only a few studies of alcohol and other drug use among Asian Americans and these studies have focused on Asian Americans in California and Hawaii."g However, the prevalence of alcohol and drug use among Asian American women is believed to be relatively low, '59 and to vary considerably by acculturation status. For example, the Institute of Medicine study of alcohol use found a strong influence of traditional cultures:

There is a significantly lower prevalence of alcohol use and abuse by females [among Asian American populations] until they acculturate over several generations. Even then, the prevalence rates may be lower than those found among Caucasian females. 160

The low prevalence of alcohol and other drug use by Asian American women is related to strong cultural traditions, several of which were described by Sun in 1990: