The 2002 MTF survey, involving 43,700 students in 394 schools throughout the United States, found that over half the students had taken at least one illicit drug by the time they completed high school. The survey brought some good news evidenced by a modest decline in the use of some drugs compared to the previous year, particularly of MDMA (“ecstasy”) and, to a lesser degree, of cannabis. Other drugs, including cocaine and heroin, held steady, while tranquilizers and barbiturates showed some increase. By twelfth grade 57% of students had already tried cigarettes, 27% were current smokers, and 62% reported having been drunk at least once in their lifetime. Although prevalence estimates of substance use in this survey tend to be higher for male students than for female students, the magnitude of gender differences has become smaller over time. Rates of cigarette smoking are now the same for boys and girls (1,2). In view of adolescent girls’ increased difficulty in quitting smoking compared to boys (3), this is a cause for concern. It is also estimated that 26% of high school girls binge drink (defined as consuming five or more drinks at one sitting), 20% currently use marijuana, 4% use cocaine, and another 4% use inhalants (4).

The National Household Survey on Drug Abuse (NHSDA), conducted annually in the United States, also provides evidence for gender convergence regarding alcohol use initiation among adolescents, showing that from the 1950s to the 1990s the male:female ratio (MFR) of starting to drink among adolescents aged 10-14 slowly decreased from 4:1 to 1:1. It is not surprising, then, that a MFR of 1:1 was found for alcohol dependence in the 12-year-old to 17-year-old group in 1999. Even more disturbing is the predominance of early cocaine use among girls. MFRs for lifetime cocaine and crack use in the 12-17 age bracket were 0.7:1 and 0.5:1, respectively, in 1996 (5).

These trends, also observed in other parts of the world (6), imply that the previously identified pattern of women starting substance use later in life than men (a protective factor in terms of progression to substance dependence) is no longer the case. Added to this concern is the fact that, partly due to gender differences in drug metabolism, women develop substance-related medical complications more rapidly than men do, including, in some cases, substance dependence.

Substance use is starting at progressively younger ages in recent generations, and this drop in age of onset is more marked for girls, particularly for alcohol (the most consumed substance in adolescence) and tobacco. Physically, girls tend to have smaller body sizes and lower tolerances compared to boys, putting them at greater risk for alcohol-related problems even at lower levels of consumption. Similarly, smoking is now as frequent in girls as in boys, but girls are more likely to carry over nicotine addiction into adulthood. Also, girls who begin to smoke are likelier than boys to develop nicotine dependence and do this more rapidly. Substance use differs between girls and boys in many ways, including reasons for
use. Girls most often initiate substance use as a coping mechanism, whereas boys usually are motivated by curiosity. Boys who are risk takers and crave excitement are therefore the most likely to become early substance users. While girls who fit this description also use substances, many are quite the opposite—shy, anxious, depressed, troubled girls who find that alcohol, in particular, helps them cope with the stresses of teenage life.

A matter of current debate is the “gateway theory,” postulating that particular substances (usually tobacco and alcohol) act as introductory drugs that pave the way to further substance use. This theory was first applied to cannabis use in adolescents. Opponents argue that the association is an artifact of the higher prevalence of alcohol and tobacco use at earlier ages. Although not all persons who smoke, drink, or use cannabis will progress to harder drug use, evidence suggests that the risk for progression is increased for those who start before age 15 (4).

Girls commonly prefer wine or spirits, whereas boys more often drink beer. Adolescents in general are more likely to be intermittent or binge drinkers and users than to drink or use drugs in a pattern of consuming small amounts throughout the day.

Rebellious adolescents, some of whom have a history of attention deficit or hyperactivity disorder and/or conduct disorder, often drink and use drugs in groups that openly defy adult norms. They have a high prevalence of associated behaviors such as early and risky sexual activity, shoplifting, truancy, and unplanned pregnancy. However, girls who use substances to cope with internal mood states or social discomfort may carefully conceal their drinking or use of illegally obtained prescription medications or other illicit drugs.

Girls with substance-related problems seldom reach the attention of medical or mental health professionals for the substance use alone, except in cases of alcohol poisoning or other toxic states such as hyperthermia related to the use of MDMA. They are more often seen because of menstrual irregularities, injuries or vague physical complaints, failing school performance, or family problems, so that it is up to the clinician to maintain a high index of suspicion and inquire carefully about substance use. Adolescent girls often minimize their use of alcohol and drugs, as well as rationalizing that “everybody does it.” Those who are focused on body image and the desire to be thin rationalize the use of cigarettes or stimulant drugs as helping them lose weight. Those who use alcohol or prescription drugs to cope with depression are at increased risk for suicide, so that it is particularly important to evaluate substance use in depressed teens.

Sexual assault, including date rape, is a hazard to which adolescent girls are exposed. Alcohol and other drug use (particularly sedative drugs) by both rapist and victim increase the risk of this traumatic event.

Alcohol-impaired driving is also a concern for adolescent girls in the United States given that motor vehicle crashes are currently the most frequent cause of death in the U.S. for persons aged 15 to 20. Because of their inexperience behind the wheel and sensitivity to alcohol, alcohol-involved teen drivers have a rate of crashes that is more than twice as high as that for alcohol-involved drivers aged 21 or older (7).