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SER MULHER EM RELACIONAMENTO COM HOMENS QUE VIVENCIAM O ADOECIMENTO PELO USO DE ÁLCOOL: REVISÃO INTEGRATIVA
BEING WOMEN IN RELATIONSHIP WITH MEN WHO EXPERIENCE ILLNESS DUE TO THE USE OF ALCOHOL: INTEGRATIVE REVIEW

Laiza Carvalho Costa, Federal University of Bahia, Multidisciplinary Health Institute, Anísio Teixeira Campus, laiza.ccosta@hotmail.com, https://orcid.org/0000-0001-5500-8737
Maria Lidiany Tributino de Sousa, Federal University of Western Bahia, https://orcid.org/0000-0002-2332-8821
George Gonçalves Machado, Federal University of Bahia, george.goncalves.m@gmail.com, https://orcid.org/0009-0009-6313-0041

ABSTRACT
Objective: to investigate how women are affected by marital life with people sickened by alcohol use. Methodology: integrative review, carried out between February and April 2024, in the databases: LILACS, Scielo, Google Scholar, Pubmed, PsyINFO, Web of Science, Scopus and ScienceDirect. The inclusion criteria were complete, available articles, published from 2001 to 2024, with a target population of non-alcoholic women in a relationship with a person sickened by alcohol use, and the outcome analyzed was the effects of this coexistence on women. The exclusion criteria were studies with marital relationships in which only women suffered from illness due to alcohol use, outcomes related to the marital relationship itself, the family and/or other family members, and/or women with other degrees of relationship, and master\'s and/or doctoral dissertations. Twenty-seven articles were selected for this study. Results: they were organized into two thematic categories: 1) Life experiences of wives of men sickened by alcohol use 2) Women and the repercussions on mental and physical health. Final considerations: Women in marital relationships with men sickened by alcohol are exposed to suffering, violence, and an increased risk of developing mental and physical problems.
KEYWORDS: Women; Alcoholism; Spouses; Family Relations

ABSTRACT
Objetivo: investigar como as mulheres são afetadas pelo convívio conjugal com pessoas adoecidas pelo uso álcool. Metodologia: revisão integrativa, realizada entre fevereiro e abril de 2024, nas bases de dados: LILACS, Scielo, Google Scholar, Pubmed, PsyINFO, Web of Science, Scopus e SienceDirect. Os critérios de inclusão foram artigos completos, disponíveis, publicados de 2001 a 2024, com população alvo de mulheres não alcoolistas em relacionamento com pessoa adoecida pelo uso de álcool, e o desfecho analisado foram os efeitos dessa convivência para as mulheres. Os critérios de exclusão foram estudos com relações conjugais em que apenas as mulheres apresentavam adoecimento pelo uso de álcool, desfechos relacionados à relação conjugal em si, à família e/ou a outros entes familiares, e/ou a mulheres com outros graus de relação, e dissertações de mestrado e/ou doutorado. Foram selecionados vinte e sete artigos para esse estudo. Resultados: foram organizados em duas categorias temáticas: 1) Experiências de vida de esposas de homens adoecidos pelo uso de álcool 2) Mulheres e as repercussões na saúde mental e física. Considerações finais: Mulheres em relações conjugais com homens adoecidos pelo álcool são expostas a sofrimentos, violência, e risco aumentado para desenvolvimento de agravos mentais e físicos.
KEYWORDS: Women; Alcoholism; Spouses; Family relations;

INTRODUCTION
Studying women means studying the different ways of being a woman within the sociocultural context. The different ways of experiencing relationships, forms of discrimination and exclusion, attribute to women conditions and vulnerabilities that will affect access to health and its determinants(1). In this sense, knowing the plurality of being a woman allows us to promote comprehensive and equitable collective health.
In parallel, the presence of individuals sickened by alcohol consumption is relevant in the field of individual and collective health(2). This illness reflects on family relationships constituted by disharmony, conflicts, with experiences of suffering for the ill individual and their family members(3–5), such as children who report memories of ambiguous feelings in relation to parents who became ill due to alcohol use(6). These families need to restructure themselves as the use of alcohol affects the living conditions of the sick person(4). Thus, it is understood that illness caused by alcohol use goes beyond the body, reflecting affective, social and cultural implications for the individual and the family.
Regarding conjugal relationships, it is understood that these are established maintaining the patriarchal social structure in which women are constantly subjugated, needing to meet the social demands of the roles of mother, wife and woman, which attributes unequal conditions in affective relationships and can contribute for suffering and vulnerabilities of women in different realities(7).
There are, therefore, three paths that meet: being a woman, families that become ill with the individual who consumes alcohol and marital relationships in patriarchal ways. This intersection results in experiences that can change the living conditions and health of women.
In this context, understanding the subjectivity of these women becomes relevant, and it is desirable to understand the factors that come together in these relationships, locating these women in the sociocultural field to which they are subjected and how the alcohol marker of illness interferes with marital dynamics. Thus, the question arises what are the effects of marital relationships permeated by illness due to alcohol consumption for female partners?
Therefore, this study aims to investigate how women are affected by marital life with people sickened by alcohol use through an integrative literature review.

MATERIALS AND METHODS
This is an integrative literature review carried out from February to April 2024.

ELECTION CRITERIA
To define which studies were eligible for this review, the criteria used were to have a target population: non-alcoholic women whose intervention analyzed was having a relationship with a person sickened by alcohol use, and the outcome analyzed was the effects of this coexistence on women. Regarding the spouses\' illness, the following were considered: having alcohol abuse with repercussions on their health, having a diagnosis of alcohol dependence, having been hospitalized for causes related to alcohol use, being or having been undergoing treatment for alcohol consumption, or being an illness reported by women. Furthermore, studies that called women wives were included.
Finally, the review was restricted to studies published between 2001 and 2024, in the format of full published articles, available for reading, without language restrictions. The year 2001 was considered the starting point due to the creation of Law No. 10,216, of April 6, 2001, the Mental Health Law in Brazil. From which it begins changes in conduct related to mental health in Brazil, aiming to cover a greater number of national articles.
Studies that evaluated marital relationships in which only women suffered from illness due to alcohol use, studies that presented outcomes related to the marital relationship itself, the family and/or other family members, and/or women with other degrees of illness were not included. relationship other than marital, making it impossible to stratify the exclusive effects on female spouses, nor master\'s and/or doctoral dissertations.

SOURCES OF INFORMATION
The searches were carried out from February to April 2024, in the databases: Latin American and Caribbean Literature in Health Sciences (LILACS), Scientific Electronic Library Online - Scielo, Google Scholar, Pubmed, PsyINFO, Web of Science, Scopus and ScienceDirect.

RESEARCH STRATEGY
The following Health Sciences Descriptors – DECS, and their respective pairs were used Medical Subject Headings – MESH: women/women; wives/wife/spouse; alcoólicos/alcoolistas/alcoholic; alcoholism/Alcoholism; marriage/marital relationship//Marriage; minorities/homoaffective relationships/ Sexual and Gender Minorities, associated with the Boolean operator AND. Search terms were identified by observing words in the titles, abstracts and subject indexing of these studies.
Thus, the following search expressions were applied to each database: (mulheres) AND (casamento) AND (alcoólicos); (mulheres) AND (casamento) AND (alcoolistas); (mulheres) AND (relacionamento conjugal) AND (alcoolistas); (mulheres) AND (relacionamento conjugal) AND (alcoólicos); (esposas) AND (alcoolistas); (esposas) AND (alcoólicos); (mulheres) AND (Minorias Sexuais e de Gênero) AND (relacionamento conjugal) AND (álcool); (mulheres) AND (casamento) AND (alcoolismo) AND (Minorias Sexuais e de Gênero); (mulheres) AND (Minorias Sexuais e de Gênero) AND (alcoolistas); (esposas) AND (Minorias Sexuais e de Gênero) AND (alcoolistas); (Women) AND (Marriage) AND (Alcoholics); (wife) AND (alcoholics); (spouse) AND (alcoholics); (Women) AND (Sexual and Gender Minorities) AND (marriage) AND (alcoholics); (Women) AND (Sexual and Gender Minorities) AND (alcoholics); (wife) AND (Sexual and Gender Minorities) AND (alcoholics) .
Afterwards, the research was subjected to the application of filters: 2001 to 2024, full text available. For articles in non-Portuguese languages, a free translation was carried out.

SELECTION PROCESS
The selection process was carried out by two reviewers separately. After applying the filters, the title and abstract were read, from which studies that were compatible with the eligibility criteria described above were selected for reading the full text. Articles that presented inconsistency in the criteria by reading the title and abstract were included for reading the full text.
Finally, the articles were fully read and those that met the eligibility criteria were included as a sample for this study. Articles in other languages were translated using simultaneous translation available online and/or free translation. After carrying out the selection process, a meeting was held between reviewers to analyze the articles included in full text that presented doubts. Thus, 27 articles participated in the sample composition. The data extracted from this review are deposited in the repository Scielo, accessible on the page https://doi.org/10.48331/SCIELODATA.0HGZDE .
The selection process scheme is structured in Figure 1 – Research Scheme.

DATA COLLECTION PROCESS
Data collection was carried out by a reviewer, who extracted data from eligible articles. These were organized according to the categorization of results, presenting authorship, year, title, country, study objectives and methodological design, and according to the effects of marital relationships with people sickened by alcohol use in women. Finally, these results were associated with the scientific literature present through discussion.
Figure 1

RESULTS AND DISCUSSIONS
Twenty-seven articles were selected for analysis. South Korea (25%; n=7) was the country with the highest number of publications, followed by Brazil (21.43%; n=6) and India (17.86%; n=5). Nine articles (32.14%) were published in the last five years (2019-2024), and fifteen (53.57%) used a quantitative approach (Table 1 – Categorization of studies).
The first point observed is that all studies were carried out with cis women in heterosexual relationships. At this point, we draw attention to the maintenance of research that focuses on studies with normative marital configurations and is supported by epidemiological data where illness due to alcohol use, in all regions of the world, is mostly male.(2), despite national indicators pointing to a growing rate of consumption by women(8). Furthermore, in none of the studies found was there an analytical discussion about class and race/color intersecting with discussions of gender.
To better present the results, they were divided into two thematic categories: 1) Life experiences of wives of men sickened by alcohol use; 2) Women and the repercussions on mental and physical health.

1) Life experiences of wives of men sickened by alcohol use
Nine articles analyzed life experiences through perceptions, life history, daily life and/or memories of women from the perspective of being wives/ex-wives of a man sickened by alcohol use. Thus, these studies focused on analyzing from the point of view of these women.
Life experiences were reported, prior to romantic relationships, with the presence of parents and/or family members sickened by alcohol consumption(9,10). Furthermore, women\'s difficulty in perceiving their husbands\' abusive drinking, not being able to determine when this drinking becomes a dependency(10–12).
Living with a father figure who is ill due to alcohol use interferes with the emotional formation of children(5), in addition, there may be a transgenerational aspect that naturalizes events experienced previously with parents, and now with spouses(13). Thus, women who had parents who became ill due to alcohol use may have more fragile emotional resources(5). This naturalization can make it difficult to perceive the moment when spouses start to develop an illness due to alcohol use.
Women, however, notice the persistence of consumption and/or their husbands\' difficulty in controlling the amount they drink(11,14). Furthermore, they live with the ambiguity of their husband\'s behavior when sober and drunk, contrasting moments of affection, when sober, with moments of emotional distance when drunk.(11).
As the illness due to alcohol use sets in, the spouses begin to: distance themselves from emotional and paternal responsibilities(12); lose their job(9,11,15) and spend the family\'s finances on alcoholic beverages(14); on the other hand, women experience: concern about health and money(15); increased family responsibilities(11), including financial responsibility(9,15); social and family isolation(10,15); the attempt to fulfill the social role of father, and willingness to sacrifice oneself for the benefit of children(15). Thus, when their husbands become ill, women are exposed to financial vulnerabilities and emotional overload.
Illness caused by alcohol consumption affects the social relationships of individuals through functional incapacity, reduced or non-existent productivity at work, involvement in accidents, urban and family violence, in addition to physical and mental illness.(16). Furthermore, how a complex health condition affects people and their emotional relationships(17,18) in the life experiences and health conditions of their family members(3).
Falling ill as a result of spouses\' alcohol use also exposes women to experiences of violence. In some families, violence against women was associated with the pattern of alcohol consumption by husbands, with an increase in violent behavior when drunk(10–12,14).
Women report being victims of aggression and marital conflicts(9), experiencing situations of domestic violence(10) with episodes of verbal violence(10,14), physical and/or sexual(10,15). In the latter, conditions of inability to negotiate safe sexual behaviors due to fear of physical abuse are reported(19), in addition to sexual conflicts related to women\'s refusal to have sexual relations, repulsion to contact or sexual attempts by their husbands(15). Furthermore, situations of violence against their children are still reported(10,11,14).
In this way, it is understood that, gradually or simultaneously, violence against women is experienced alongside the illness of men. However, these realities were not analyzed, in the articles found, from an intersectional perspective. This gap feeds a distorted view that all women whose husbands become ill due to alcohol use experience these experiences in a similar way.
The use of violence as a demarcation of power by men is understood as a reaffirmation of control and domination in relation to their wives. There is, therefore, a need to elucidate the existence of a reality shaped by the cohabitation of race, gender and social class that acquire qualitative factors in these experiences(7). It is not about the perspective of those who suffer most, but about how intersections intersect in these realities.
These inferences are necessary when we look at national data on violence against women, which show that the majority (45%) of victims of violence are black women(20). Furthermore, there is also evidence that black women are more vulnerable when compared to brown women, and that there is a higher prevalence of physical violence against black women when compared to white women(20). These data expose the need for studies that analyze these experiences under the intersectional theory, making it possible to highlight which aspects these experiences distance or meet.
Table 1

The women\'s family environment is therefore dysfunctional. In addition to financial issues, emotional overload, and situations of violence, family disharmony with conflicts between sick spouses and children(10,12). In this way, women experience concerns about their children, such as the fear that their parents\' behaviors will be considered models for their children to follow(14), in addition to insecurities related to the repercussions of the family context of illness caused by alcohol use experienced by children(9,14).
Therefore, the family environment presents itself as a social and behavioral modulator. The structuring of norms tends to follow what is socially and culturally accepted within the spaces where they cohabit. This translates into the norms of when you drink, who drinks, how much you can drink and what you drink(21). Thus, the development of these individuals, as social agents, is formed by memories of their generational predecessors in relationships with alcohol, with this behavior being learned and often expected for new generations(22).
It is evident that the complexity of events resulting from the illness of spouses exposes women to the deterioration of their marital relationships. Thus, they understand them as conflicting, stressful, perceived as unloving(9). It is also linked to the disconnection in communication between couples with difficulties in emotional communication on the part of women resulting from anger and resentment(15) nurtured in the illness of this relationship. In this experience, the need to maintain relationships, even with the behavior of companions(12), which happens for economic reasons(14) or because they understand that divorce is harmful to their children(15).
In this sense, the attempt at solidarity in the face of the couple\'s failure(23), moral and religious guidelines(10), the lack of resources to face(12), expectations related to the treatment of spouses(11) encourage the maintenance of the relationship. In this way, the obligation falls on them to endure this context until they need to decide between: running away from home, seeking a divorce or maintaining relationships for fear of their children\'s future.(15).
Women are therefore overcome by feelings of fear(11,14), blame for lack of control over drinking(9,11) and shame due to social situations of husband\'s drunkenness, impotence(10,11), manifestations of anger, anxiety and horror derived from fear of violence and behaviors of spouses during drunkenness(15). There is, therefore, a collection of factors that result in lower self-esteem(15) and that subjugates women to conditions of suffering.
However, a well-founded mode of relationship was established in the patriarchal system, which constructed stylized acts repeated over time that are performed daily by the individual and collective, taking them as natural beliefs(24). Thus, these women, even though they understand disconnected aspects of the relationship, find themselves obliged to maintain the family system, guaranteeing their children the experience of this patriarchal dynamic.
Therefore, having relationships with ill men exposes women to joint illness, which is perceived by them as an inability to control the effects of alcohol in the family(12). These women face a severe level of stress associated with exposure to domestic violence and signs of mental illness(10).
Thus, through studies on women\'s life experiences from the perspective of women-wives, it is possible to understand that the illness of men-partners acquires changes in the social and family field, with fragility in the marital relationship, establishing a place of suffering and continuous stressors that contribute to women\'s greater vulnerability. Finally, the question is how these experiences are being experienced by women in other marital configurations, and in what ways these conditions can present themselves in different ways of being a woman.

2) Women-wives and the repercussions on mental and physical health
Eighteen studies analyzed health-related conditions. Problems or risk of problems in the physical and mental field were highlighted, and the development of therapeutic strategies for women-centered care.
When analyzing studies with a central focus on the health of women who live with men sickened by alcohol use, greater psychological distress is attributed to lower marital satisfaction, the presence of violence, less perceived social support from the family and greater frequency of attempts to deal with partner\'s consumption(25), greater chances of systemic arterial hypertension and are more likely to suffer from food insecurity, violence and develop a smoking habit(26). In addition, they may present anxiety, sleep disorders, symptoms of depression and physical symptoms.(27).
In this sense, these relationships end up exposing these women to a greater propensity to develop psychological suffering(28). The majority (93.53%) of wives of husbands with alcohol use disorder experienced stress, with 67.70% of women in the resistance phase. Sources of stress include responsibility for everything and anger at the spouse\'s alcoholism, among others(29).
In this field, anxiety and depression stand out. In the study by Lopes and Franco Júnior (2018): 55% of women presented with anxiety and 43.3% with depression(30). Accordingly, being the wife of a man sickened by alcohol consumption increases the prevalence of Major Depression Disorder (MDD)(31). Furthermore, exposure to intimate partner violence (IPV) increases the chance of wives suffering from moderate/severe depression by 37.5 times and the chance of moderate/severe anxiety by 8.15 times, when in relationships with men who are addicted to alcohol(32).
Related to sexual health, it highlights that the assessment of risk perceptions of acquiring the Human Immunodeficiency Virus - HIV highlights a mistake in the mode of transmission and the recognition of the potential risk for HIV associated with the husband\'s alcohol consumption and possible activities extramarital sexual activity carried out by them(19), reflecting power relations and violence in the health of these women.
The complex conditions associated with marital relationships and their consequences give these women less adaptive coping skills compared to women in the general public(33). Furthermore, these coping strategies may vary depending on the family atmosphere, the husband\'s behavior and the wives\' genetic and personality factors(34), which may use avoidance, adjustment of expectations, competition or the search for support to maintain the relationship(34). Finally, these women also have low scores on the resilience scales(35) reinforcing support needs to deal with the complexity of these experiences.
In this sense, Korean studies were significant in the different evaluations of therapeutic methods to support and cope with these women. Studies that worked with forgiveness therapy proved to be effective in improving resilience, self-esteem, spirituality and codependency(36,37), in addition to enabling these women to experience recovery through this therapy(38).
In women undergoing the enneagram program, an improvement in codependency and anger was observed through forgiveness(39). Furthermore, the use of the autobiographical method showed that women submitted to this method showed an improvement in the meaning of life, in somatization, depression, hostility and severity index scores(40). While, the use of the logo-autobiography method showed that women can acquire a meaning in life through suffering(41).
It is emphasized that in Korean studies(36,37,40,41) there is an indication of the use of these therapies by nursing professionals, showing a tendency for these studies to value and encourage the role of this professional class in the mental care of these women. Furthermore, Margasinski (2022) presents the development and validation of the Emotional Dependence Questionnaire for individual and group research on wives of people sickened by alcohol, presenting itself as a useful tool for defining therapeutic goals for this group(42).
Thus, the experiences described above raise questions about the absence of studies, in this review, that address the care of women in family support groups such as Al-Anon, and in institutions of the Unified Health System (SUS) such as CAPS- ad, which may indicate a weakness in care in terms of social and institutional support, or operational aspects that made it difficult to find research focused on this topic.
Coexistence with social demands related to gender is linked to situations of violence and overload of care for spouses sickened by alcohol use. In this sense, it is understood that the experience of violence, regardless of the type, results in mental illness in women(43). Furthermore, this illness also needs to be understood from a racial perspective, as, throughout history, the intersection of gender and race was constructed in circumstances of oppression and exclusion that exacerbate the mental illness of black women.(44).
Therefore, this panorama allows us to understand that being in this social place as the wife of a man sickened by alcohol use infers unique aspects that intervene in these relationships and in the health of these women.
This study is limited by not evaluating the degree of evidence of the research found, and by presenting a limited research process, which may have relevant articles that were not found, or were “lost”.
Finally, it is understood that the analyzed results allowed us to identify gaps in knowledge, mainly in relation to other forms of marital relationships and intersectional studies.

FINAL CONSIDERATIONS
The present study points out that the scientific evidence regarding the marital life of women with people with alcohol dependence elucidates an illness concomitant with that of the husbands, with indications of a correlation between this process of becoming ill and conflicting, stressful life experiences and episodes of violence, in which women presented an increased risk of mental and physical problems.
Despite the complexity in which these experiences are established, it is noted that these women report a lack of necessary family and/or social support, and there are no reports on therapeutic care in Brazil, suggesting care centered on the man-partner, not encompassing the other family members. The absence of national studies that address women\'s care at the level of institutional support is also highlighted. This can contribute to the maintenance of marital relationships permeated by alcohol despite its implications for the physical and mental health of these women.
Understanding Public Health as a set of knowledge that seeks the promotion, protection and recovery of health in line with the particularities of each subject and based on the Korean experiences found, the importance of studies that allow life-centered care can be elucidated of women affected by their spouse\'s alcohol consumption.
Finally, the lack of studies that evaluate the living and health conditions of these women from an intersectional perspective, and of women in other marital configurations, is highlighted, contributing to the invisibility of conditions in the racial, affective, economic, cultural and similar fields, constituting an important knowledge gap.

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