Louisa McGillicuddy reports on the silent epidemic of sleep deficits in women, and why we pay a greater emotional sleep tax than men.
How did you sleep last night? For one in every two women sitting around the breakfast table reading the newspaper this morning, the answer will be: badly. In a groundbreaking survey commissioned by The Sunday Times Style, our study of 1,162 women reveals that more than half (52%) of women rate their sleep quality as bad or very bad. For those between the ages of 55-64, this jumps to 65%, nearly two in every three.
About a third of people in developed nations are getting the eight hours recommended by the World Health Organisation. Yet we found that only 12% of women manage that amount, which suggests a worrying gender sleep gap. Many experts agree that women are sleeping consistently worse than men, yet few people are talking about it.
So what does the average night look like for this silent majority? According to our findings, a poor female sleeper averages 5 hours 18 minutes a night — well below the recommended seven to nine hours. Three in five bad sleepers experience poor sleep every night, and in many cases are chronically exhausted. More than a quarter (28%) have had sleep issues for more than a decade.
More troublingly, 29% have taken sleeping pills in an attempt to remedy the situation. Not all have been as a short-term fix. "I'm working hard to stop taking them every night," said one respondent in her late fifties. One woman, in the 55-64 age range, said she had taken sleeping pills "for several periods over the past 40 years".
The sleep-loss epidemic has been called the greatest public health challenge facing developed nations in the 21st century. But scrutiny of how this affects women in particular is woefully lacking. We know that lack of sleep has links to heart disease and diabetes, and may be a factor in breast cancer and dementia — all of which are leading causes of death for women.
"Women are not studied as much as men when it comes to sleep. There's an attempt to address it, but definitely we're behind," says Katherine Sharkey, professor of psychiatry and human behaviour at the Alpert Medical School at Brown University, Rhode Island, and one of few academics specialising in sleep patterns in women. For instance, sleep apnoea (one of the most common sleep disorders, in which a sleeper has pauses in their breathing during the night) goes "90% undiagnosed in women", Sharkey says. "There's no other disorder that you would be OK about diagnosing only 1 out of 10 women suffering from it. Men will say, 'I'm falling asleep behind the wheel. My wife doesn't want to sleep with me.' Whereas women will say, 'I'm a wreck, I'm crying all the time, I can't get my work done.' For too many clinicians the response is 'There, there, darling'."
Our survey provided revelatory new insights into the issues that are keeping women up at night. The biggest culprit is work stress (30%), with younger women hustling at the beginning of their careers especially affected: nearly half (46%) of those aged 18-24 cited this as the biggest factor affecting their sleep, versus 26% of those aged 45-54.
The usual lifestyle stressors we all know to avoid — screens, caffeine, alcohol — are still having an impact, of course, but the women in our study opened up about the emotional sleep tax they pay from worries over their career, family, friends and relationships — 16% said relationship stress kept them up at night.
"I often wake during the night because of stress and anxiety in both my work and personal life, and I struggle to get back to sleep," said one woman aged 54. Another woman, aged 25, said that fear of losing her job kept her up, while one 50-year-old said: "Stress and anxiety about work and family are the main contributors to bad sleep. While I generally enjoy what I do, I can't wait to have the financial capacity to retire."
Among the other stressors our respondents mentioned were "financial stress, problems with business" (a 55-year-old woman) and "grief after the sudden death of my husband that remains with me" (a woman aged 70).
In fact, our survey revealed that the quality of women's day-to-day lives affects their sleep more than the conditions set in the bedroom: sleeping solo versus sharing with a partner or having a child in the bed made little difference to the quality of sleep.
Professor Matthew Walker, author of the 2017 international bestseller Why We Sleep and a leading expert on the topic, agrees. "Insomnia in the general population is about 12%-13%. However, when you break it down into males and females, women suffer twice as much." And insomnia isn't just poor sleep — it can be short-term (disrupted sleep for a few nights or weeks, which often goes away) or chronic (disrupted sleep at least three nights a week for at least three months). "I think part of the reason is that anxiety is more impactful on and for women than it is for men," Walker says.
So what is the waking effect of this sleep deficit among women? When it comes to their personal lives, one in four said that poor sleep has affected their relationships. "It's easy to become resentful when one is sleeping and the other one cannot," said a 65-year-old woman. Another woman, aged 45, echoed this: "Not willing to talk about lack of sleep and angry at husband for being asleep!" One in 10 women — presumably at their wits' end — have broken up with a partner due to snoring.
This matches with what Sharkey finds in her sleep clinic. "The number-one issue I see among couples is when partners come in together and say they're not sleeping in the same bed any more. That's across the board — from twentysomethings to eightysomethings," she says. "The bedroom is a place of intimacy and the toll of the symbolic separation of that loss of intimacy is real."
More than one in five (22%) of women said it has affected their sex lives: "Lack of sleep makes me tired and irritable, so I don't want to engage in sexual activities," said one young respondent, aged 18. A 45-year-old woman said: "At times I've needed to sleep, or fallen asleep, when my partner wanted to have sex, or foreplay had begun." Another woman, in the 65-74 age group, said: "I always fall asleep very easily in bed while my partner doesn't. I enjoy sex better when I am fully awake and have lots of energy, while my partner prefers sex when we go to bed."
The ripple effect on our emotional wellbeing goes even deeper: 40% of women say that their sleep quality has affected their mental health. "My sleep deprivation led to burnout and depression," said one 51-year-old respondent. A further 16% said it had affected their career: "Disturbed sleep patterns at night caused fatigue and mental health problems at work," said one 45-year-old woman.
"Across the board, sleep essentially provides a form of emotional first aid," Walker explains. "It's a soothing nocturnal balm that takes the sharp edges off the painful sting of emotional experiences during the day. It also recalibrates the brain systems that control our emotions so that we come back the next day and we're a little more stable. It sort of resets the magnetic north of our emotional compass."
So how can we stop it getting to this point? Our study found that women begin complaining of bad or very bad sleep in their mid-thirties to early forties. Young women aged 18-24 start off with an even balance of good and bad sleepers. Average sleep quality improves slightly after that up to the age of 34, before getting progressively worse: 52% of those aged 35-44 report bad or very bad sleep, rising to 60% aged 45-54, and 65% aged 55-64.
Of course, the big bump in a woman's sleep life comes when children enter the picture, which appears to be one of the main factors driving the gender sleep gap. One woman in our survey admitted: "I don't think I've had a really good night's sleep since having children." Even long after children grow up, the sleepless nights have left their mark. "My problems really started after they left home," said another.
This is an all-too-common complaint, says Sharkey: the lingering effect of "on-call" sleep. "Sleep disruption starts during pregnancy and I see women in their forties saying they've had insomnia for 20 years after having their first child. Data suggests that it never goes back to normal," she says. "And that does get sort of hand-waved over. You have a kid, now you're a parent, this is what you signed up for. But there's a continuum of what is expected versus when it is something that needs treatment."
So what's the solution? Tailored treatments for women, for a start. According to the somnologist Helen Driver, who leads a sleep lab at Kingston General Hospital and Queen's University in Canada and has examined women's sleep specifically, sleep disorders present differently in men and women. "Women are more vulnerable to some, and typically need 15 to 20 minutes more than men. We go to bed a little earlier — women are more larks than owls — and we have a higher recovery time after poor sleep than men."
Second, reconsider relying on sleeping pills — these are a short-term fix. "There is the worry of people building up a tolerance or becoming dependent or addicted to these meds," Sharkey says. "The biggest risk with sleeping pills is that it perpetuates the other things that people are doing wrong." Both Driver and Sharkey agree that the best long-term solution is cognitive behavioural therapy for insomnia (CBTi). "It's easier to give someone a pill and say get out of my office, move along," says Sharkey. "But CBTi is excellent at changing some key behaviours that will make a huge difference. If you do the work that it asks you to do, and there are some excellent online programmes, you can make real strides, especially in young people."
One other glimmer of hope: our survey shows that there's good news ahead. Sleep finally improves — in fact is the best of your life — from your mid-sixties to early seventies. More than half (59%) the women in that age bracket describe themselves as good or very good sleepers, or at least neither good nor bad. The advice from those who have come out the other side: "Don't put unnecessary stress on yourself. It will run its course in time."
Additional reporting by Scarlett Russell and Jenna Davies
Writers and experts share their sleep diaries
Pandora Sykes, age 32
Sleep issues run in my family (five out of six members of my immediate family suffer from insomnia), though they never affected me until two years ago, during the second trimester of my pregnancy. It's a real chicken-and-egg situation: lack of sleep impacts my anxiety, and an increase in anxiety prevents sleep. Similarly, it turns out that I only want to sleep when my daughter doesn't want to sleep; and when she does sleep, I wake up an awful lot during the night and have come to pre-empt cries, like many other mothers I know. I will take sleeping pills when sleep won't come. Since I started to get insomnia, I have tried to be much more respectful of my sleep — I don't watch TV in the evenings, I turn off my phone when I finish work, and I don't drink much on weekdays.
• Night one 6½ hours
I go to bed at 9.30pm and read until 10.15pm. I haven't drunk any alcohol and I'm well rested after a long weekend away with my husband, sans infant. But it's a Sunday night and I rarely sleep on Sunday nights: a combination of Sunday blues (a boarding school hangover, which continues even though I am now freelance) and post-holiday comedown. After an hour and a half of tossing and turning, I take a Zopiclone tablet to help me sleep. After three pre-emptive wees, I fall asleep at 12.30am. I'm up at 7am, when my daughter wakes up.
• Night two 8½ hours (including doze)
I lie on my bed reading from 8.30pm after an early dinner (with no alcohol), which I will always do unless I have to work late or have evening plans, and I drift off at about 11pm. The baby wakes up twice in the night and goes back to sleep relatively easily. But I toss and turn, partly because I am very hot and partly because I am troubled by a strange dream. Baby wakes up at 6.50am, but my husband is on morning duty, so I get up at 7.30am and feel rested.
• Night three 5 hours
The first of three dark nights of the soul. My husband is working until past midnight and I struggle to go to sleep before he comes to bed if I know he is still in the house (I know, it's annoying for both of us). I fall asleep at 10.30pm, wake up an hour later when I realise all the lights are on downstairs, and I don't get back to sleep until 1am. The baby wakes up at 3am and stays awake until 5am, during which time my husband has showered and left to go skiing for a long weekend. I hear her crying at 6am, but I literally cannot move with tiredness and she eventually stops and we both sleep until 8am, when the nanny comes and wakes us up. I thank the lord that I don't have to commute to work — I'm feeling the kind of fragile that someone just jostling you might make tears leak from your eyes.
• Night four 5½ hours
I return to my computer after the baby's bedtime and work until 9pm, with a glass of wine. I turn my light off at 10.30pm, but it's another night of going in and out of the baby's room. She has a cold, a cough and a terrible rash from teething, and even Calpol doesn't work. I get into her cot at 4am — a risky move that even my husband is not above, but she won't sleep in bed with us — and she falls asleep at some point. After two nights of this, I feel like I did when she was a newborn: functioning, but like I'm high on drugs.
• Night five about 4 hours
I'm chairing a panel tonight, and I get back to our exhausted babysitter, who spent two hours trying to get Zadie to sleep. Sure enough, she wakes pretty much every hour, although, thankfully, she goes back to sleep almost instantly each time, until she wakes up at 5.45am with a dirty nappy. I pull her into my bed and pretend to sleep while she pats me on the face and squeaks in my ear. I have so much respect for single parents. I am truly on my knees. I drive home to my parents, as I have to work on Friday and Saturday, but don't have childcare those days.
• Night six 11 hours
My mum is kindly on night and morning duty. I fall asleep at 10pm and wake up at 7am, but slumber until 9am, which is glorious. I heard the baby in the night, but just being able to stay put is a game-changer. I feel human again.
What the expert says
There needs to be a degree of acceptance that her sleep will be disrupted due to the child, moving the focus onto improving the quality of the sleep that she does get. This would involve leaving a solid two hours between screen time and bed, and definitely not reading in bed: a bedroom is for sleep or sex. Pandora would benefit from minimising her concerns about other issues — ie her husband not coming to bed. Perhaps there is another bed he could sleep in when it becomes distracting to her.
The following steps would improve the quality of sleep Pandora does achieve.
• An established bedtime ritual, which might include ambient light reduction, such as using an eye mask.
• Keeping to set bedtimes and wake times.
• Acceptance that there will be fragmentation — the key to this is to accept that for what it is and to not look for potential triggers or to pre-empt "insomnia", and to keep focused on the fact that once the child is settled into a solid routine and can self-soothe, then her sleep will naturally improve.
• Reduce anxieties around disruptions to sleep through mechanisms such as mindfulness, meditation etc.
• A cool bedroom is necessary, while ensuring that hands and feet are warm. This could improve sleep initiation and perceived overall sleep quality.
- Dr Ari Manuel, sleep and ventilation consultant, Aintree University Hospital, Liverpool
Fleur Britten, age 45
I have always been a hideously light sleeper. These days, my many sleep saboteurs stem from either the nocturnal activities of city life or the nightmares/sickness/sundry other of my two small children, aged four and seven (and, yes, I sleep-trained them from the second it was legal).
Over the years, I've invested in all manner of sleep aids and props. Through my thirties, I took over-the-counter sleeping pills when herbal remedies and melatonin didn't touch the sides, but I quit them after having children because it didn't seem healthy, and have slept badly ever since. Now I follow almost every guideline for better sleep: I exercise regularly, I've given up alcohol and caffeine. I've installed acoustic double glazing to shut out the noise and shutters to banish the light. I wear eye masks and ear plugs, I have Casper pillows and a Vispring mattress. Yet, most days, I find myself contending with a sleep deficit: I either wake up hours before I need to or in the middle of the night and unable to return to sleep for two or three hours. An average of five hours a night is a frustrating reality for me. On mornings when I'm feeling really broken, I will take a Boost pill by Form — a supplement containing caffeine and the calming amino acid L-theanine, so it doesn't give me the jitters or keep me awake at night. Mainly, it pulls me up from my misery and enables me to function as if I've had eight hours. Most days, though, I'm exhausted, firing on cortisol and unable to find the off switch.
• Night one 5 hours
I go to bed at 11.30pm and wake up at 3am, filled with thoughts of my undone to-do list. This twilight wakefulness can be the most painful. I used to suffer the darkest thoughts at this time, but I've learnt to block them out by listening to Radio 4 or, more recently, podcasts and Audible. I fall asleep at 5.30am, half an hour before my alarm rings.
• Night two 5½ hours
Totally overrevving after school quiz night (pathetic, really). I drift off at 11pm but wake at 3am and do two 10-minute Headspace sleep meditations. After the second fail, I give up trying to sleep and read the next day's paper — a bad habit, as it's on the mobile app, though my blue-light filter is switched on.
• Night three 6½ hours
Spend the day promising myself I'll be in bed by 9pm, but the usual life admin (and denial about self-care?) conspire to keep me away. In bed by 10.30pm and read — it usually takes me an hour to wind down. Eyes close involuntarily at 11.30pm. It's a solid, deep sleep. Woken at 6am by a hungry four-year-old boy. Straight into action — no room for self-pity with kids around.
• Night four 5 hours
To bed late (midnight) after a birthday party — it always takes me a long time to wind down after going out. I wake up at 5am — there didn't seem to be any reason why — maybe it was a noise, maybe it was the sticky toffee pudding. Or, most likely, maybe all of this is simply the effect of life stress on a neurotic person. Now how do I fix that?
What the expert says
Fleur's form of insomnia may benefit from professional counselling such as cognitive behaviour therapy for insomnia (CBTi). This will help her to deal with her waking worries and stresses beyond the insomnia, such as the undone to-do lists she mentions. At the moment Fleur is simply focusing on sleep alone near bedtime, which is unlikely to markedly improve her quality of life. CBTi can target these related anxieties and sleep-interfering behaviours, as well as the disorganised sleep itself. It also includes various techniques known as "stimulus controls", designed first to undo those ingrained negative associations with persistent unsuccessful attempts at sleep, and then to substitute more appropriate behaviours. All of which is designed to associate bed with good sleep and pleasurable activities rather than as a site of misery and ordeal.
- Jim Horne, professor of psychophysiology and sleep researcher, Loughborough University
Gail Rolfe, age 60
My lifelong pattern for sleeping, or not sleeping, was established in my teenage years. As an introspective, insecure child I lay in bed rerunning every action or conversation. Going to bed became my time for reflection and analysis rather than sleeping. The catalyst for my insomnia has always been stress — whether it was caused by romantic, financial, work or health issues. If I am lucky, a bout of insomnia will last three or four weeks, but at critical points in my life it has endured for many months. It often feels as though I get no sleep at all, but I have learnt that, even during the worst episodes, I do snatch hours here and there.
My first, brief foray into drug-induced sleep was when I was 26, after the breakdown of a long-term relationship. Many years later, in 2008, when I was going through an excessively traumatic period that caused me to seek counselling, my GP prescribed sleeping tablets to help deal with the crisis. I've relied on pills on and off ever since, depending on my mental wellbeing and the level of insomnia. However, at the time of writing I have weaned myself off and am now six weeks clear.
• Night one 6½ hours (plus nap)
Off to bed at 10.20pm. Read for 20 minutes. It takes me almost an hour to fall asleep. Woken by the need to pee at about 3am, but fall asleep quickly, though woken again by my dogs at 7.10am. Feed them and return to bed for a 30-minute nap. That extra time seems to make all the difference.
• Night two 7½ broken hours
Set off for bed at 10pm. Decide not to have a cup of my normal "sleepy" tea and see if I can sleep through the night. Do some deep-breathing exercises. Probably takes me about the usual 40 minutes-plus to fall asleep. Wake at 3.10am and find my mind racing with thoughts. Doesn't help that I look at my phone to check the time and see messages from my daughter, who is travelling in Indonesia. Decide not to stress and eventually fall asleep again, waking at 7.10am.
• Night three 10 hours
In bed by 10pm. Utterly exhausted after a long day of work. Stay at a friend's house and sleep in her teenage daughter's bedroom. Oversleep and wake at 8am, panic, throw on clothes, no breakfast and drive to work rather sleepily. But I had slept so well in a strange bed — no need even for breathing exercises
What the expert says
When I review sleep diaries such as this with my patients, the main things I look for are the regularity of bedtime and wake time, overall time spent in bed, and napping. For adults, we recommend a sleep duration of 7-8 hours, and that really is all the sleep the brain can produce in one day. Therefore, trying to battle your insomnia by spending more than 8 hours in bed to get more sleep may actually be sabotaging your efforts; the same amount of sleep will just be spread over a longer time period, resulting in longer time to fall asleep and difficulty staying asleep. The pattern recorded here is pretty common — two or three nights of shortened and disrupted sleep followed by a catch-up night. It is better to try to keep a regular sleep schedule and wake up at the same time each day, regardless of how much sleep you get the night before. Sleeping in can throw off the biological clock and contribute to insomnia. I also recommend that people with insomnia avoid stimulating activities at night. If you find yourself wide awake at 3am, it is best to get out of bed and do a quiet (typically non-electronic) activity until you feel sleepy again.
- Katherine Sharkey, professor of psychiatry and human behaviour, Alpert Medical School, Brown University, Rhode Island
Alice Kemp-Habib, age 23
As a teenager I used to lie in bed for hours on end before sheer exhaustion lulled me into a light, often disturbed slumber. No matter how much sleep I eventually got, I would always be exhausted the next day. I was later diagnosed with anaemia and have taken iron tablets ever since — though I often forget to do so. Since starting full-time work in 2017, my sleep has become much less fractured and I fall asleep much faster. Most of my friends also work full time — we don't tend to go "out out" on weekdays and we go to bed at midnight, latest. A straw poll of WhatsApp groups found that we all get between seven and nine hours of sleep a night (I need a solid eight to feel well rested). When I asked if they look at their phones before bed, the overwhelming answer was: "I try to avoid it, but inevitably do."
• Night one 6 hours
Went to the gym straight after work and overdid it. Have been given a Zeeq Smart Pillow that has speakers built in and analyses your sleep — it's much more comfortable than wearing headphones. Went to bed at 11.30pm, asleep by 1am. Have a lot going on at work at the moment so could be that. Woke up at 7am because the alarm didn't go off. Oops. Feel lethargic today.
• Night two 7½ hours
Friday night, slept over at my friend's house for her birthday. Ate loads of pizza and chocolate and drank lots of Coke before going to sleep at 1.30am. Was woken up at about 9am by my friends, and lay in till 11am.
• Night three 9½ hours
Decided not to drink coffee this weekend as I had a withdrawal headache in the morning. Went to sleep at 12.30am after dinner and watching The OA on Netflix for hours. Though I've tried to break the habit, I usually spend 10-20 minutes on my phone before bed. Woke up at 10am. Still very tired.
What the expert says
The bed should only be used for sleep and/or sex, so don't lie in it waiting for sleep. If sleep hasn't come within 20 minutes, get out of bed and do non-stimulating activities (no phones or laptops), and then, when you feel tired again, get back into bed. Alice could also benefit from being a bit more disciplined with her phone usage — she should leave it outside the bedroom, switched off to resist temptation, and use a separate alarm clock. She should also consider what she is doing before attempting to sleep; for example, try not to sleep on a full or empty stomach, and drinking highly caffeinated soft drinks such as Coke prior to bedtime is unwise. She should try to do her exercise in the morning or afternoon instead of the evening, as hormonal and metabolic stimulation post-exertion will likely increase the amount of time it takes her to get to sleep. When it comes to screen time, be it a phone, computer or TV, two hours prior to bedtime is the non-negotiable cut off for usage, irrespective of blue-light filters.
- Dr Ari Manuel, sleep and ventilation consultant, Aintree University Hospital, Liverpool
Your guide to better sleep
by Matthew Walker, author of Why We Sleep
Give yourself enough time to sleep
You have to give yourself what I call "opportunity time". I give myself a non-negotiable eight-hour sleep opportunity every night.
Stick to a sleep schedule
Sleep at the same time and wake up at the same time, whether it's the weekend or a weekday.
Don't stay in bed too long
If you lie in bed awake, your brain quickly learns to associate bed with being wide awake, not fast asleep.
Sleep in darkness
Our bodies use the signal of darkness at night to release a hormone called melatonin. When it's released, it helps time the healthy onset of sleep.
Drop your core body temperature
Open a window or lower your thermostat to keep your bedroom at a cool 17C-17.5C
Limit your caffeine intake
Caffeine has a half-life of about six hours and a quarter-life of 12 hours, which means if you have a cup of coffee at midday, a quarter of that caffeine is still swilling around in your brain at midnight.
Forgo the nightcap
Alcohol knocks your cortex out, meaning you're not going to have natural sleep. It will also fragment your sleep throughout the night, so you will wake up many more times. Limit the bed to sleep and intimacy
Additional reporting Roisin Kelly
Written by: Louisa McGillicuddy
© The Times of London
