Women, Alcohol, and Sexuality

2015

Alcohol consumption increases subjective sexual desire, arousal, and pleasure for many women, although it lowers physiological arousal. Despite the general belief that alcohol disinhibits female sexual behaviors, alcohol leads to changes in sexual behavior only for a minority of women. Expectancies about the effects of alcohol on sexual behavior may be important mediators of the alcohol–sexual behavior linkage. There also is a relationship between overall alcohol consumption and risky sexual behavior for women, but when alcohol use at or preceding individual instances of sexual activity is examined, there is no association in the majority of studies. Alcohol use by both perpetrators and victims has been implicated in instances of sexual victimization. Heavy alcohol consumption and alcohol problems in women are associated with heightened risk of childhood incest, sexual assault, and sexual dysfunction.

The last ten years have witnessed a dramatic increase in some areas of research involving alcohol and sexual behavior in women, while other areas have remained dormant. Most notably, the devastating scourge of AIDS since the early 1980s and the recent rise in the United States in the percentage of AIDS cases involving heterosexual transmission have led to a focus on the role of alcohol in promoting risky sexual behavior. Second, an increasing awareness of the high incidence of violence against women and the frequent presence of alcohol consumption among both perpetrators and victims of sexual assault have resulted in a burgeoning series of studies that attempt to better understand the role of alcohol in incidents of rape and incest. Finally, research on alcohol-related expectancies, beliefs, and attributions that grew rapidly in the early to middle 1980s has continued to grow, albeit at a reduced rate. In contrast, the study of alcohol and female sexual arousal, responsiveness, and dysfunction and of sexual behavior in specific subgroups of women, with the exception of those at high risk for HIV, has remained sparse.

The purpose of this chapter is to review and critique recent research on women, sexuality, and alcohol from all of the above areas. In this review we emphasize research that has been published since Wilsnacks excellent 1984 review. Sexuality is one area in which women are not expected to be like men. Although to some extent women have been ignored in research in this area, it is widely accepted that gender differences in sexuality and sexual behavior exist. For instance, a recent meta-analysis of gender differences in sexuality reported that men and women show differences in both the incidence of specific types of sexual behavior (e.g., masturbation), with men reporting higher levels, and sexual attitudes, with men having more permissive attitudes toward casual sex. Similarly, with regard to sexual violence, it is widely recognized that women are more often the victims of abuse rather than the perpetrators. While at times differences between women and men will be discussed, it is not our purpose to examine gender differences in alcohol consumption and sexual behavior. Rather, this chapter reviews the empirical literature and clinical research on alcohol consumption and sexuality for women, a group whose alcohol consumption and sexuality have (separately and jointly) too frequently been ignored in the research literature.

The research on women, alcohol, and sexuality presents a series of conflicting views, unanswered questions, and methodological problems. Definitions of alcohol abuse and alcohol consumption vary in different studies and almost all studies of alcoholism in women are studies of women in treatment and/or recovery. Few studies of nonalcoholic and nonproblem drinking in women have examined dose–response relationships in a systematic way. Definitions that attempted to discern problem drinking and alcoholism for men sometimes have been poorly adapted to measure the patterns of drinking exhibited by women. Definitions of sexual dysfunction, sexual assault, rape, and incest have fluctuated across studies, making cross-study comparisons problematic. In many earlier studies only these terms (e.g., have you even been raped?) were presented to participants. Only in more recent studies have definitions been more precise, focusing on specific situations and behaviors.

Sexuality is a multidimensional concept. When examining alcohol use and female sexuality, we find the following dimensions most appropriate: (1) physiological sexual responsiveness; (2) subjective feelings of sexuality, that is, subjective arousal, desire, and enjoyment; (3) expectancies about alcohol and sexuality; sexual behaviors, that is, types and frequency of sexual acts including coerced sex and sexual behaviors that heighten risks of AIDS and other sexually transmitted diseases (STDs); and (4) sexual partners, including the number and type of partners. Each dimension interacts with other dimensions and more than one dimension may have a specific effect; for instance, number of sexual partners is itself a risk factor for sexually transmitted diseases and AIDS.

Alcohol Use, Physiological Sexual Arousal, and Sexual Feelings

For women a discrepancy exists between the reported effects of alcohol use on sexual responsiveness and physiological indices of these effects. Generally women report that alcohol at least in moderate amounts has positive effects on sexual feelings, yet laboratory studies suggest that alcohol suppresses physiological sexual responsiveness in women. Level of alcohol consumption has been found to be negatively associated with vaginal blood flow and positively associated with the time to achieve orgasm during masturbation. As consumption increased, women in the Malatesta et al. study also reported increased difficulty in having an orgasm and decreased organismic intensity. What is surprising is that in all of these studies, womens self-reports reveal greater sexual arousal and sexual pleasure with increasing blood alcohol levels.

The reputed aphrodisiac effects of alcohol for women have been widely accepted for thousands of years in Western society. The results of many survey studies, as well as the laboratory studies discussed above, suggest that women have internalized such views. Many contemporary women without alcohol problems report in surveys and other nonlaboratory studies that they experience increased sexual desire, feelings, and arousal and decreased sexual inhibitions when drinking., For instance, Beckman found that for women without a history of alcoholism or other psychiatric disorder, 29% reported they desired intercourse more after alcohol consumption and 32% reported they enjoyed intercourse more after drinking. In a recent national survey of womens drinking in the United States, Wilsnack et al. found that 59% of light- and moderate-drinking women and 68% of heavy-drinking women stated that alcohol sometimes or usually resulted in less sexual inhibition.

Method of data collection may have an effect on results. In a study of 69 female volunteers aged 18 to 34, the retrospective questionnaire data indicated that alcohol enhanced female sexuality, while results from daily diaries kept over two to three menstrual cycles suggested that drinking had little effect on sexuality. Apparently, women expect alcohol to affect sexuality. Therefore, they report these effects when retrospectively reporting on frequency or presence of behavior over a considerable time period, whereas daily reports, which are less subject to distortion due to beliefs about alcohol and sexuality, show no association.

And what of the effects of alcohol on sexuality among women who are alcohol abusers? Do the expected effects of alcohol serve as a reason for drinking for these women? Beckman found that alcoholic women were more likely to report increased sexual desire, enjoyment, and activity after drinking compared with both women without drinking problems and women with other psychiatric problems. Other studies of alcoholic women suggest that responses to alcohol may be bimodal, with approximately equal proportions indicating that drinking has positive and negative effects on sexual arousal and performance. Interestingly, Jenson found that 50% of alcoholic women believed that alcohol relieved their sexual problems, usually problems of lack of sexual desire, even though 25% of these women identified as having sexual dysfunctions. Klassen and Wilsnack report that heavier-drinking women in their national survey were more likely to indicate that alcohol consumption sometimes or usually made them feel less inhibited sexually. They interpret these findings as suggesting that expectations of disinhibition of sexuality might serve as a motive for drinking for some women.

Several explanations have been put forth to explain the discrepancy between reported and actual effects of alcohol on female sexual responsiveness and desire including: (1) both pharmacological (through effects on cognitive functioning) and psychological disinhibition; (2) the presence of a generalized state of physiological arousal that women interpret as sexual arousal; (3) social learning theory; and (4) expectations about how alcohol will affect sexual feelings and behavior that lead to psychological disinhibition.

Alcohol Use and Sexual Behavior

Expectancies about Alcohol Consumption and Sexual Behavior in Women

The psychological disinhibitory effects of alcohol on sexual functioning at least for a subgroup of women may be due to socially learned expectations. Crowne and George define alcohol expectancies as beliefs regarding alcohols influence on behavior as well as beliefs regarding its effect as a mediating variable on social judgments. As Cooper et al. have pointed out, if alcohol provides an anticipatory excusefor engaging in risky sexual behaviors, individuals who engage in such behaviors should show a combination of specific beliefs about its excuse-giving properties. The belief that alcohol has been consumed appears to have had no effect on sexual arousal for women. However, more specific social expectancies about the effects of alcohol on sexuality, sexual desire, and sexual behavior may play a significant causal role in the association between alcohol consumption and risky sex.

A key question is does the expectancy that drinking leads to less inhibition influence womens drinking in a sexual or potentially sexual situation. The literature suggests that expectancies about the effects of alcohol on sexual feelings and behavior motivate drinking for some women. Klassen and Wilsnack interpret their findings as suggesting that this expectation may serve as a motive for drinking, and women in our sexually repressed society may use alcohol to counteract the sexual suppression that they experience. Kline found no evidence of gender differences in expectancies for sexual enhancement; but for women the belief that alcohol enhances sexuality was associated with social rather than solitary drinking, which is to be expected if drinking disinhibits sexual behavior since sex is a social act.

Leigh recently studied sexual-related alcohol expectancies in a community sample of adults aged 18 to 50 in San Francisco. Heavier drinkers more strongly endorsed positive beliefs about the effects of alcohol on sexual responsiveness (e. g., enhances sexual experience, decreases nervousness). She found an interaction between negative sexual attitudes (i.e., more guilt about sex, nervousness, etc.) and alcohol expectancies among heterosexual women. Women with negative sexual attitudes and strong expectancies drank the most during their last sexual encounter. Also, women with stronger alcohol expectancies were twice as likely to initiate sexual activity as women with weaker expectancies. Her results suggest that expectancies are most likely to motivate drinking in women in need of an excuse for sexual disinhibition.

More research is needed on identification of individual differences that moderate the association between expectancies and sexual feelings and behaviors for women. It is possible that negative sexual attitudes, nervousness about sexual encounters, poor interpersonal communication skills, certain types of sexual dysfunction, past sexual experiences, and heavy alcohol consumption may help explain the association or lack of association between alcohol expectancies and the disinhibitionof sexual behavior.

Alcohol Use and Sexual Dysfunction

Sexual Orientation

Among variation in sexuality involves sex of partner. The percentage of women alcoholics who report having had one or more homosexual experience varies widely, ranging from 4 to 45%. The figures vary by sample characteristics and year of data collection, with more recent studies generally reporting higher levels of homosexual experience. This reported change may be due to changing attitudes about the provision of sensitive information involving sexual behavior rather than to an actual increase in homosexual experience. The above figures include women who describe themselves as bisexual or as having had one or more same-sex experience as well as those who self-define as lesbian. For instance, although 20% of the women alcoholics in Beckmans study reported at least one same-sex sexual experience, only 6% considered themselves homosexual and 3% identified as bisexual. Beckmans study was one of the few with multiple control groups of women. In this study the alcoholic women were more likely to have had a homosexual experience than the normalnontreatment controls, but they did not differ significantly from the psychiatric treatment control group.

In the few studies of women alcoholics in which the percentage of women who self-identify as lesbians as differentiated from bisexual is calculated, the range is from 2 to 29%, a figure higher than the 2–3% of women estimated to be lesbian in the general population.

When a complementary approach is adopted and the rate of alcohol abuse among homosexuals is examined, clinical studies and community surveys both suggest high rates of alcohol problems in female and male homo-sexuals. In community surveys the rates of alcohol problems among lesbians and gay men have been estimated at as much as 30%, a rate much higher than that of the general population. Additionally, the percentage of abstainers in the homosexual community is half that found in the general population, 14% versus 29%; respectively.

A criticism of research looking at homosexual populations and alcohol use is that samples are selected mainly from bars and drinking establishments. Thus the rates of reported alcohol use and abuse may be overestimated. In a large study (N = 3400) in an urban setting, McKirnan and Peter-son distributed surveys through a large homosexual-oriented newspaper, advertisements in mainstream publications, groups serving the homosexual community, and large events within the homosexual community. Only 5% of their respondents learned about the survey in a bar setting. Responses from this homosexual sample were compared with results from a 1979 national general population survey, but apparently comparisons were not adjusted for demographic and other differences between the two samples. Usage of alcohol by the homosexual sample was higher than in the general population and homosexual women and men were much more similar in drinking patterns and rates of alcohol problems than were women and men in the general population sample. Heavy drinking, defined as over 60 drinks a month, was not found to be higher in homosexuals, but they reported a higher rate of alcohol-related problems. What is most interesting is that lesbians had identical rates of alcohol problems as men homosexuals and there was a large difference in problem prevalence between lesbians and general population women (23% vs. 8%). At every age group, lesbians reported alcohol-related problems that exceeded those of heterosexual women, although differences were greatest at ages 26 to 40. The authors concluded that these differences in alcohol-problem prevalence may be due to psychosocial and cultural factors related to lower role responsibilities of lesbian women compared with their heterosexual counterparts in more traditional social environments. The levels of reported alcohol problems remain relatively stable with age for lesbian women but decrease dramatically for heterosexual women. It is assumed that as they get older many heterosexual women have increased role responsibilities associated with marriage and children which leads to a decrease in their alcohol consumption and as a consequence a lower rate of alcohol-related problems.

Lesbians may drink for different reasons and develop alcohol problems through different pathways than heterosexual women. They may drink as a way of coping with the stigma and discrimination that they experience as lesbians or, for some, the stress of attempting to appear straight to family or co-workers. There is evidence suggesting that lesbians receive less support from families than do heterosexual women. Mays et al. found that African-American alcoholic women who are lesbian or bisexual received less social support for treatment entry from family and from male sources than did heterosexual black women alcoholics. Lesbians also may drink for social and cultural reasons that reflect the lifestyle of certain groups of lesbians. Heavy-drinking norms exist in many lesbian communities and lesbians may congregate in occupations in which drinking is part of the lifestyle, expected of those who wish to attain success. Important issues for future research include the effects, if any, of the recent national emphasis on health and curtailment of consumption in some environments (e.g., if you intend to drive) on the lesbian community; drinking patterns of subgroups of lesbians who maintain different lifestyles; and the interactions of environmental stress (including stigma and discrimination), quality of social support, and coping strategies on the consumption and alcohol problems of lesbian women.

Sexual Violence against Women

Women, Alcohol, and Sexuality: Conclusions

The 1980s and 1990s have produced new information about women, alcohol, and sexuality, partially answering some questions and raising others. We know that alcohol use and abuse by women and their partners are associated with heightened risk of sexual dysfunction, childhood incest, and sexual assault. At the same time alcohol use may increase subjective sexual desire, arousal, and pleasure and in certain cases may “disinhibit” female sexual behavior. The research literature would benefit from: (1) studies that disentangle the causal pathways involved in the association of alcohol and sexuality and examine varying causal explanations for the relationships that exist; (2) studies based on theory, including theories of adolescent and adult development; (3) a focus on subgroups of women diverse in cultural values, racial/ethnic group, social class and socioeconomic status, age, and sexual orientation; (4) behaviorally based definitions of sexual behavior and instruments that use these definitions which are employed in multiple studies and with different populations so that findings are comparable across studies; and (5) new modes of data collection such as daily diaries that may be provide more reliable and valid measures of sexual feelings and behaviors. Only through continued, careful investigation that is both rigorous and creative will we further develop a knowledge base, valuable for enhancing the sexual functioning of women and their partners, preventing sexual abuse and assault, and perhaps limiting drinking problems in women.

 

Selections from the book: “Recent Developments in Alcoholism. Volume 12: Alcoholism and Women.” Edited by Marc Galanter. An Official Publication of the American Medical Society on Alcoholism, the Research Society on Alcoholism, and the National Council on Alcoholism. 1995.