ALCOHOL & WOMEN’S HEALTH

The following information is to be used as a guide to and at the discretion of the end-user and should not replace a doctor’s opinion.

OVERVIEW

Alcohol – more specifically drinking alcohol or ethanol – is a colourless, volatile, and intoxicating liquid produced through the fermentation of sugars. Primarily consumed in beer, wine, and spirits, it acts as a central nervous system depressant and is one of the most commonly consumed psychoactive drugs on earth. Despite its addictive and carcinogenic properties, it is readily available and legal for sale in many countries.

Many people can’t imagine their lives without alcohol. Drinking alcohol is deeply ingrained in human history and social rituals; for thousands of years it has been embraced as a symbol of celebration. In fact, drinking is so common in many cultures that it is considered as the norm, and in some situations, peer pressure—intentional or subtle—leads individuals to drink to fit in.

For some, it’s a coping mechanism, a way to reduce stress and relax after a long day’s work. For others, it’s a useful social lubricant, used to boost confidence and ease social anxiety. This is because alcohol acts on the brain’s reward circuits, inducing sensations of euphoria, pleasure, and relaxation.

However, in January 2023, the World Health Organisation issued a landmark statement: “No level of alcohol consumption is safe for our health.” Excessive drinking can reduce significantly lifespan: every year, three million people around the world die due to the harmful use of alcohol. One study found that a person who has more than 25 drinks per week will lose four to five years of their life expectancy.

For South African women, this message carries particular weight: our country’s relationship with alcohol is among the most complex and consequential on the continent.

DRINKING IN SOUTH AFRICA

South Africa has a severe, well-documented alcohol abuse problem, ranking among the top alcohol-consuming nations globally. While not every South African drinks, those who do tend to drink heavily — a pattern with serious consequences for individuals, families, and the broader healthcare system. It is considered a national crisis, with high rates of binge drinking contributing significantly to roughly 62 000 annual deaths, violent crime, gender-based violence, and road fatalities. Binge drinking is defined by the WHO as consuming 60 or more grams of pure alcohol (roughly four 340ml beers or 600ml of wine) on a single occasion at least once per month.

31% of South Africans currently drink alcohol
59% of those who drink engage in heavy episodic (binge) drinking
17% of South African women report current alcohol use
10-12% of GDP: estimated total economic cost of harmful alcohol use

Among South African women who drink, the rates of alcohol dependence and binge drinking are alarmingly high. A nationally representative study found that 28% of women who had ever drunk alcohol were alcohol dependent, and 56.6% were binge drinkers.

WHY ALCOHOL AFFECTS WOMEN DIFFERENTLY

Biological differences mean that alcohol causes more damage to the female body, more quickly, even at lower quantities of consumption. The WHO Global Burden of Disease study confirmed that in 2019, alcohol was responsible for 2.4% of all deaths among women globally. This figure rises substantially in countries with high rates of binge drinking, like South Africa.

Body composition and metabolism

Women generally have a higher proportion of body fat and less body water than men of similar weight. Since alcohol distributes through body water, the same number of drinks results in a higher blood alcohol concentration in a woman than in a man.

Women also produce lower levels of alcohol dehydrogenase (the enzyme that breaks down alcohol in the stomach) meaning more alcohol enters the bloodstream unmetabolised. The result: women become more intoxicated faster, on less alcohol, and suffer organ damage sooner than men who drink equivalent amounts.
Hormonal interactions

Alcohol interacts with female sex hormones in ways that elevate health risks specific to women. Research published in peer-reviewed journals shows that alcohol increases circulating oestrogen levels, which raises the risk of oestrogen-sensitive cancers, most notably breast cancer. This effect occurs in both premenopausal and postmenopausal women.
Faster progression to alcohol dependence

Because of these biological differences, women develop alcohol use disorder more rapidly than men. They progress from first drink to alcohol dependence more quickly, experience health consequences at lower consumption levels, and are more likely to suffer liver damage, heart problems, and mental health effects at shorter durations of heavy drinking compared to men.

THE HEALTH EFFECTS OF ALCOHOL ON WOMEN

Cancer risk
The International Agency for Research on Cancer (IARC) classified alcohol as a Group 1 carcinogen, the highest category, meaning there is sufficient evidence that it causes cancer in humans. Alcohol is causally linked to at least seven types of cancer: breast cancer, colorectal cancer, liver cancer, oesophageal cancer, oral cancer, pharyngeal cancer, and laryngeal cancer.

For women, the breast cancer connection is especially important and frequently under-appreciated. Breast cancer is the most common cancer among South African women. Research drawing on data from over 100 studies confirms a dose-dependent relationship — the more you drink, the higher your risk:

Women who have one drink per day have a meaningfully higher breast cancer risk than those who drink less than one drink per week.

Each additional 10 grams of alcohol per day (roughly one standard drink) increases breast cancer risk by approximately 7%.

Women consuming 35–44 grams per day face a risk ratio of 1.32 compared to non-drinkers; above 45g/day, the risk ratio rises to 1.46.

Drinking during adolescence and early adulthood also increases lifetime breast cancer risk, making early awareness essential for young women.
Liver disease

The liver is the primary site of alcohol metabolism, and it bears the greatest burden of chronic alcohol exposure. Women develop alcohol-associated liver disease at lower levels of consumption and after shorter periods of drinking than men. Early liver damage (fatty liver) is reversible with abstinence, but progression to alcoholic hepatitis and cirrhosis can be irreversible.

Research on sex disparities in liver disease confirms that biological sex hormones play a central role: oestrogen affects immune responses, inflammation, and fibrosis (scarring) in the liver, making premenopausal women particularly vulnerable to rapid progression.
Cardiovascular disease

Contrary to widely held beliefs about alcohol protecting the heart, recent large-scale analyses from the WHO’s Global Burden of Disease studies confirm that the risk of all-cause mortality — including from cardiovascular disease — increases with alcohol consumption, with the lowest risk level at zero drinks. The World Heart Federation has confirmed that even low-volume alcohol use increases the risk of certain cardiac events. Alcohol raises blood pressure, can cause cardiomyopathy (weakening of the heart muscle), and contributes to arrhythmias and stroke.
Mental health

Women are more likely than men to develop anxiety and depression as a consequence of alcohol use. Alcohol is a central nervous system depressant, and while it may seem to temporarily relieve stress, regular use disrupts sleep, depletes serotonin, and worsens mood over time.

South African women face particular mental health pressures, including poverty, gender-based violence, unemployment, and caregiving burdens, and alcohol is sometimes used as a coping mechanism, creating a harmful cycle in which alcohol worsens the very conditions it is used to manage.
Reproductive health and pregnancy

There is no known safe level of alcohol consumption during pregnancy. Women who are pregnant or planning to become pregnant should avoid alcohol entirely. Alcohol crosses the placenta and directly affects the developing foetus, causing Foetal Alcohol Spectrum Disorders (FASD), a range of permanent physical, cognitive, and behavioural disabilities.

South Africa’s FASD crisis

South Africa has one of the highest reported rates of FASD in the world.

A multi-year, multi-site study across four provinces (2015–2022) found a pooled Foetal Alcohol Syndrome (FAS) prevalence of 80.2 per 1 000 children. In the Northern Cape, rates reached 199 per 1 000. In some Western Cape communities, prevalence has been reported as high as 310 per 1 000 live births.

FAS is one of the leading causes of non-genetic intellectual and developmental disabilities globally.

Key drivers in South Africa include intimate partner violence, unplanned pregnancies, mental health challenges, poverty, and social norms that normalise drinking during pregnancy.
Sexual health and personal safety

Research using nationally representative data from South African women found that alcohol dependence was associated with more than double the likelihood of engaging in transactional sex, and binge drinkers were more than three times as likely: findings with direct implications for HIV risk. Women also black out more easily than men under the influence of alcohol, increasing vulnerability to sexual assault and unsafe situations.

HOW ALCOHOL AFFECTS US ALL – EVEN IF WE DON’T DRINK

Alcohol’s harms extend well beyond personal physical health. In South Africa, the social and economic consequences of alcohol misuse are deeply intertwined with gender inequality, poverty, and violence.

Gender-Based Violence (GBV)

The link between alcohol and gender-based violence in South Africa is well documented. According to Statistics South Africa, either the perpetrator or victim was under the influence of alcohol or drugs in 72% of sexual violence incidents occurring outdoors and in 23.3% of incidents at home.

Binge drinking is recognised as the single strongest proximate risk factor for violence against women and children in the country. This does not excuse perpetrators — alcohol does not cause violence — but it significantly amplifies existing risk in contexts of gender inequality and social marginalisation.

The economic cost of gender-based violence in South Africa is staggering. KPMG estimates a conservative cost of between R28.4 billion and R42.4 billion per year (0.9%–1.3% of GDP), accounting for healthcare, legal costs, lost productivity, and services. When alcohol’s broader economic impact is included, estimates reach 10–12% of GDP — a figure that far exceeds the revenue generated by the alcohol industry.
Family and child wellbeing

Women bear a disproportionate share of caregiving responsibilities in South Africa. A mother or female caregiver’s alcohol use affects children’s nutrition, school attendance, emotional safety, and long-term development. Households affected by heavy drinking are more likely to experience food insecurity, financial instability, and cycles of poverty that pass across generations.
Workplace and economic participation

Alcohol misuse reduces productivity through absenteeism, impaired performance, and health-related job loss. For women already navigating unequal pay, caregiving demands, and limited economic opportunities, alcohol-related health problems further constrain financial independence and upward mobility.

The wife of an alcoholic often experiences a severely diminished capacity to earn an income due to chronic physical and mental exhaustion, overwhelming unpaid caregiving duties, and career-limiting workplace distractions. The cumulative stress frequently causes depression, which makes it incredibly difficult to maintain focus and advance professionally.
Healthcare system burden

South Africa’s public health system carries a disproportionate burden from alcohol-related trauma (including road accidents, falls, drownings, and burns), liver disease, and chronic illness. Over 62 000 alcohol-attributable deaths were recorded in 2015 alone. Every rand spent treating preventable alcohol-related illness is a rand unavailable for maternal health, HIV treatment, and cancer care, areas where South African women already face significant gaps in access.

IF YOU CHOOSE TO DRINK: REDUCING YOUR RISK

No level of alcohol consumption is completely safe. However, if you do choose to drink, there are steps you can take to reduce your risk as much as possible:

Understand what is meant by a ‘standard drink’ in South Africa
One standard drink in South Africa contains approximately 12–14 grams of pure alcohol. This is equivalent to:

One 340ml can of beer or cider (5% alcohol)

One 150ml glass of wine (12% alcohol)

One 25ml tot of spirits (40% alcohol)
Guidelines for lower-risk drinking
Leading health authorities define the following thresholds as lower-risk for women:

No more than 1 standard drink per day

No more than 7 standard drinks per week

At least 2–3 alcohol-free days per week

Eat before and while drinking

Alternate alcoholic drinks with water

Never drink during pregnancy or when trying to conceive

Know your personal risk factors (family history of cancer, liver conditions, medication interactions)
High-risk patterns to avoid
Binge drinking (4+ drinks on one occasion for women)

Drinking to cope with stress, trauma, or low mood

Drinking during pregnancy or breastfeeding

Drinking before driving or operating machinery

Mixing alcohol with prescription medications without medical advice

Drinking in unsafe environments where you are vulnerable
Certain women should not drink at all
The following groups are advised to avoid alcohol entirely:

Women who are pregnant or breastfeeding

Women trying to conceive

Women with a personal or family history of alcohol dependence

Women diagnosed with liver disease, certain heart conditions, or hormone-sensitive cancers

Women taking medications that interact with alcohol (including many common antidepressants, anticoagulants, and antiretrovirals)

Women who have experienced alcohol-related blackouts
Practical harm reduction tips
Set a limit before you go out and let a trusted friend know.

Pace yourself: no more than one standard drink per hour gives your liver time to process alcohol.

Drink water between drinks: this slows consumption and reduces dehydration.

Avoid rounds and topping-up: it becomes difficult to track your intake.

Plan your safe transport home before you start drinking.

Keep a drinking diary for two weeks: many people are surprised to discover how much they actually drink.

Talk to your doctor if you’re concerned about your drinking or find it difficult to cut back.

Consider Dry January or similar breaks: even short periods of abstinence improve liver health, sleep quality, skin, and mood.

RECOGNISING THE WARNING SIGNS OF ALCOHOL DEPENDENCE

It’s not possible to tell if and when someone will become dependent on alcohol, as everyone’s situation is different. And not everyone who drinks a lot is dependent on alcohol. But drinking too much can affect your health and relationships.

Signs that you or someone you love may be developing a dependence on alcohol:
not being able to function without alcohol – for example, do your job or carry out daily tasks

drinking has become an important, or the most important, thing in life

you spend a lot of time thinking and planning what and when you will drink

continuing to drink despite the negative effects for you or your loved ones

finding it hard to control how much, or when, you drink

finding it hard to stop drinking when you want to

not being able to plan how much you are going to drink on an occasion

becoming tolerant of alcohol so you need to drink more to feel its effect

craving alcohol or having withdrawal symptoms and drinking to avoid these symptoms

not seeming to be drunk after drinking large amounts

you feel physically unwell until you have a drink

if you are unable to drink, you feel anxious, unhappy or tense until you have a drink
Signs that someone may be an alcoholic:
Not all alcoholics have the same symptoms, but many – at different stages in the illness – show these signs:

bloodshot eyes, pupils larger or smaller than usual

changes in appetite or sleep patterns

deterioration of physical appearance, personal grooming habits

runny nose or sniffling

sudden weight loss or weight gain

tremors, slurred speech, or impaired coordination

often want “just one more” at the end of a party.

trying to control their drinking by changing types of liquor, going on the wagon, or taking pledges

sneak drinks, lie about their drinking, and hide bottles

drink at work (or in school) or drink alone

have blackouts (cannot remember what they said or did the night before)

drink in the morning to relieve hangovers, guilty feelings, and fears

fail to eat and become malnourished

get cirrhosis of the liver.

shake violently, hallucinate, or have convulsions when withdrawn from alcohol

Beating alcoholism can be challenging for a number of reasons. Alcohol affects the brain in multiple ways, one of which involves both producing pleasurable feelings and dulling negative ones. Not surprisingly then, people may continue to drink despite its various risks. Additionally, long-term alcohol consumption can change the structure and function of the brain and compromise brain function, making it more difficult to quit drinking and maintain abstinence.

In addition, alcohol withdrawal—whose symptoms can range from mild effects (e.g. anxiety, headache, stomach upset, palpitations, etc.) to hallucinations, seizures, delirium tremens, and more—can be unpleasant and intense. In fact, given the potential severity of withdrawal symptoms, experts recommend medical supervision during alcohol withdrawal.

RESOURCES FOR SUPPORT

You do not have to navigate this alone. The following organisations provide support across South Africa:

ALCOHOL & WOMEN’S HEALTH

ALCOHOL & WOMEN’S HEALTH

The following information is to be used as a guide to and at the discretion of the end-user and should not replace a doctor’s opinion.

OVERVIEW

DRINKING IN SOUTH AFRICA

WHY ALCOHOL AFFECTS WOMEN DIFFERENTLY

THE HEALTH EFFECTS OF ALCOHOL ON WOMEN

HOW ALCOHOL AFFECTS US ALL – EVEN IF WE DON’T DRINK

IF YOU CHOOSE TO DRINK: REDUCING YOUR RISK

RECOGNISING THE WARNING SIGNS OF ALCOHOL DEPENDENCE

RESOURCES FOR SUPPORT

FURTHER READING