Do the new UK Government guidelines for alcohol take gender equality too far? Melissa Denker University of Glasgow Total word count: 2,995

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1 Do the new UK Government guidelines for alcohol take gender equality too far? Melissa Denker University of Glasgow Total word count: 2,995 In 2016 the UK government announced new weekly recommended maximum alcohol intake guidelines. The recommendations for males have been lowered so that for the first time they are the same for males and females. In the light of differences between male and female patterns of drinking and physiology, is this a sound recommendation or has gender equality been taken too far?

2 Introduction The UK government began setting guidelines for sensible limits of alcohol consumption in 1987, stating that men should have no more than 21 units per week, and women no more than Research has continued since then, and in the 1995 Sensible Drinking Guidelines the government changed their recommended limits to 3-4 units per day for men, and 2-3 units per day for women due to the new understanding of the harmful effects of binge drinking 1 ; however, since then there has been little evidence that these guidelines have decreased alcohol consumption in the UK 1. Alcohol-related disease (ARD) is still increasing in prevalence in the UK; new interventions are needed to combat this. The new UK guidelines of 14 units per week for both men and women 2 is one such step. While some may argue that this is taking gender equality too far, setting equal limits on alcohol consumption is an important step in decreasing the burden of ARD, and should be viewed in the context of improving public health, rather than gender equality. These recommendations are sound for three main reasons: firstly, ARD is increasingly common, and poses a significant burden on men s health; therefore it is important that men be encouraged to drink less by setting lower guidelines. Secondly, new research since 1995 has shown that the risk for men and women is generally equal, therefore there is no longer adequate justification for setting different alcohol intake guidelines. Thirdly, there remains significant gender inequality in attitudes to ARD; this suggests we need more efforts to achieve greater gender equality, rather than worrying we have taken it too far. The Burden of Alcohol-Related Disease on Men s Health Taking into account male drinking patterns and the severe effects of this on men s health, it is reasonable to suggest that men should decrease their alcohol consumption lowering the recommended intake guidelines would be one way of achieving this. a. Male and Female Patterns of Drinking Men drink more alcohol than women: this fact has been well established 3,4,5. Men drink larger volumes of alcohol 4 ; they are almost twice as likely to binge drink 6 ; they are more likely to suffer from recurrent intoxication, chronic heavy drinking and diagnosable alcohol abuse than women are 3. As a consequence, men suffer from high rates of ARD, for example, alcoholic liver disease, brain damage, or accidental injury due to alcohol intoxication. This has a significant burden on men s health; in 2000, men lost 6.5% of disability adjusted life years due to alcohol, compared to 1.3% in women 3. The high amounts of alcohol consumed by men suggest that they need to drink less; one way of doing so is to further decrease recommended alcohol intake, as done in There have also been several public health campaigns in recent years aimed at decreasing alcohol consumption. However, women are more likely than men to quit drinking alcohol; this may have several different explanations: for example, it may be due to the amount of women who stop drinking during pregnancy and never continue afterwards 4. While it is crucial to continue the public health campaign aimed at decreasing alcohol consumption, for example through agencies such as Drink Aware 7 or Change4Life 8, the fact that these campaigns have not yet been successful in curbing men s drinking habits in the UK suggests that other methods are needed for instance, lowering the recommended alcohol intake guidelines. Historically, alcohol consumption has been an emblem of male superiority 3 ; associated with this is the idea that alcohol is often associated with increased sexual behaviour something which is tied to men s social status, but which women are stigmatised for. Another reason for this gender gap in

3 alcohol consumption is that men are generally more willing to take risks, and to find this an important part in demonstrating their masculinity; as alcohol has been strongly associated with risky behaviour, this may explain why they drink more than women do 3. Furthermore, men are more likely to experience factors encouraging them to drink (such as possessing character traits associated with excessive drinking, including aggression; or the perception that alcohol reduces stress), and less likely to experience factors which would discourage them for drinking (such as social sanctions and increased vulnerability to physical and sexual violence, which predominantly affects women) 9. Consequently, it is sensible to start introducing more factors to discourage them from drinking as much for example, lowering the alcohol consumption guidelines. b. Alcohol-Related Disease and the Burden on Men s Health Men accounted for 65% of alcohol-related hospital admissions in 2014/15, and the total number of admissions has been increasing in recent years 10. There are several health consequences of alcohol consumption, the most well-known of which is alcoholic liver disease; however, alcohol also causes an increased risk of conditions including, but not limited to, accidental injury, psychiatric problems, and cancer. Liver disease is becoming more common this is largely due to the increasing rates of alcohol consumption in the UK. Mortality related specifically to alcoholic liver disease has increased by 450% in the UK over the last 30 years 11. Although this is becoming an increasing problem for women, alcoholic liver disease still disproportionately affects men. Alcoholic liver disease (ALD) has 3 main stages, beginning with alcoholic fatty liver disease, then progressing to alcoholic hepatitis and eventually alcoholic liver cirrhosis. Cirrhosis causes the most morbidity and mortality (with a 50% 5 year survival rate 12 ; in 2014, 63% of all alcohol-related deaths were due to ALD 10 ). Liver transplant is the only curative treatment for liver cirrhosis, and due to limited donor supply, it is not available for everyone; the only other way of managing ALD is by avoiding alcohol this may not reverse ALD, but will slow its progression 12. In the face of the rising incidence of ALD in the UK, it is crucial to decrease the amount of alcohol that the British public (and especially British men) are drinking. This may also decrease the cost of alcohol related disease to the NHS: currently, the cost of alcohol misuse is 2.7 billion per year; treatment for alcohol related conditions costs the NHS over 1 million per day in Scotland alone 11. This suggests again that more measures are desperately needed to decrease alcohol consumption in the UK and reducing the recommended alcohol intake for men may be one way of achieving this. There are also several other types of ARD, the most predominant of which is cardiovascular disease. Others include mental and behavioural disorders, alcohol poisoning, cancer, nervous system disease, and unintentional injuries 10. Many of these affect men disproportionately, especially unintentional injury: for example, men are at greater risk of trauma and accidental injury associated with alcohol intoxication, including head injuries, fractures and facial injuries; they also report higher rates of alcohol poisoning 2. Men are also by far more likely than women to be implicated in fatal road traffic collisions involving alcohol 6. Overall alcohol-related mortality is also more common in men: in 2014, 1% of all deaths were related to alcohol, and of these 65% were men 10. Alcohol consumption also has a significant impact on men s mental health. It has been shown that, statistically, men are more likely to develop psychiatric consequences of alcohol abuse than women 9 for example clinical depression, cognitive impairment, dementia, and delirium tremens; it is also associated with neurological disorders such as Wernicke s encephalopathy or Korsakoff s syndrome 13. Men also report much higher rates of alcohol dependence, with a lifetime incidence of 18.6%, compared to 8.4% in women 9.

4 Alcohol is also frequently implicated in suicide in men 6. Suicide is already more common in men than women, even without the influence of alcohol; why, then, should men have higher alcohol intake recommendations, when it is clearly associated with such significant psychiatric morbidity and mortality? Studies have shown that 39% of men who attempted suicide were chronic drinkers, compared to 8% of women; alcohol was implicated in attempted overdose in 70% of men, but only 40% of women % of alcohol related hospital admissions in 2014 were for mental and behavioural consequences of alcohol consumption 10. These figures strongly support lowering recommended intake guidelines in an attempt to curb the amounts of alcohol consumed by men, thereby reducing the psychiatric consequences. New Research on Alcohol, Gender and Risk of Alcohol-Related Disease While developing the 1995 Sensible Drinking Guidelines, the UK government utilised the most upto-date research on alcohol available at the time; however, in the 22 years since then, there have been rapid advances in research. New research suggests that some of the previous recommendations are now out of date; the 2016 guidelines take into account this updated knowledge, and provide safer guidance for drinking. a. Male and Female Physiological Responses to Alcohol One area of updated knowledge is the difference in physiology between men and women in regards to alcohol consumption. Generally speaking, alcohol has a stronger effect on women: consuming an equal amount of ethanol will create a higher blood alcohol concentration in women than in men 14. This may be due to women having a smaller body water content, and therefore a smaller circulating volume for alcohol to disperse into 14 ; or it may be due to slower metabolism of alcohol in women, leading to longer lasting effects. When the 1995 Sensible Drinking Guidelines were published, it was acknowledged that it was not possible to weigh up definitively [the differences in drinking patterns and drinking physiology] and produce an authoritative statement about women and alcohol. 13 Since then, more evidence has arisen to suggest that women develop alcohol dependence more quickly than men 15 ; and that women, individually, are more likely to develop chronic alcohol-related disease 2. Individually speaking, therefore, it is true that a woman is at greater risk of ARD than a man is. However, as discussed earlier, men still drink significantly more than women. Consequently, overall rates of ARD are still greater in men: thus, looking at this from a public health perspective, it can be seen that men have higher rates of ARD. Indeed, it has been shown that men are twice as likely to die due to ARD than women are 3. This would suggest that men do indeed need lower alcohol intake recommendations, in order to decrease the overall prevalence of ARD in men. Furthermore, as previously discussed, men are at a higher risk of accidental injury due to alcohol consumption than women are so even though women have a higher risk of long term ARD, the overall risk balances out so that it is broadly similar for men and women 2. With such similar levels of risk, it stands to reason that recommended intake levels should be equal, too. c. Beneficial Effects of Alcohol Prior to the 1995 Sensible Drinking Guidelines, research had concluded that moderate alcohol consumption was associated with a decreased rate of all-cause mortality 13 ; this was seen especially in the apparent relationship between alcohol and coronary heart disease. The Sensible Drinking Guidelines quoted that drinking in the range of 7 units to 40 units a week lowers the risk of CHD by between 30% and 50% 13. This protective effect of alcohol was one of the reasons why the 1995

5 guidelines set a higher limit for men; the same guidelines also recommended that non-drinkers started drinking to reduce their risk of cardiovascular disease 13. Of course, it is now recognised that any level of drinking even if within the safe limits may lead to alcohol-related disease 2 ; indeed, cardiovascular disease now makes up almost half of alcohol-related hospital admissions 10. It is clear, then, that the 1995 guidelines needed to be revised. New research since 1995 has shown that the net benefits of drinking alcohol are not as significant as previously thought 2,16. Higher levels of drinking do not have any advantage for men, and may instead be harmful; it would be irresponsible of the UK government to continue advocating higher alcohol consumption for men in the face of this new research. c. New Research Affecting Previous Guidelines New research has also brought to light stronger associations between alcohol and negative health consequences, especially cancer. In 1995, the Sensible Drinking Guidelines concluded that it can be safely stated, based on current evidence, that alcoholic beverages do not cause genetic changes in body cells which might lead to cancers or other diseases 13. This conclusion contributed to the higher limits set for men (and the suggestion that non-drinkers start drinking). However, alcohol is now known to increase the risk of several types of cancer, for examples oral, laryngeal, oesophageal, colon and liver cancer 2,16. One study has suggested that 4% of all cancers are related to alcohol consumption 16. It has also been shown that these risks increase with relatively low levels of alcohol consumption (as little as 1-2 units per day 17 ), providing further evidence that reducing men s alcohol intake guidelines is a sensible strategy. Persisting Gender Inequality Related to Alcohol Consumption By looking at male and female drinking patterns and the risk of ARD, then, we can conclude that men s recommended drinking guidelines should be lowered to help reduce the burden of disease of alcohol on men s health. The question remains: does this have anything to do with gender equality, and has equality gone too far? As will be discussed in this section, it is impossible to say that gender equality has gone too far in this case because there remain several areas of gender-based inequality in regards to alcohol, addiction and treatment. a. Access to Alcohol Abuse Support Services Although alcohol abuse is an increasing problem for both men and women, the fact remains that more men than women receive treatment for alcohol abuse 15. Alcohol abuse may often be overlooked in women due to assumptions that drinking alcohol is a male behaviour 3 ; this is probably due to the fact that men have always consumed more alcohol. If women aren t recognised as suffering from alcohol dependence, then they cannot receive adequate support. Other obstacles to support which women face include the inability to find childcare while undergoing treatment, family responsibilities, or the fear that admitting to alcohol abuse will lead to losing their children to social care authorities 18 (these problems may also affect men, but affect women disproportionately). One feature to note here is that gender inequality may also impact men in receiving support for alcohol abuse: this stems from the culture associated with drinking. Drinking alcohol is frequently associated with displays of masculinity this may encourage male drinkers to deny or minimise problems or to regard drunken behaviour as normal or permissible 3 ; this may lead to many men refusing to access support services, or even refusing to recognise that excessive levels of alcohol consumption are a problem. Attitudes like this will firstly prevent men from seeking support for

6 addiction problems, but will secondly prevent them from decreasing their alcohol consumption, leading to continuing problems with alcohol-related disease; this may be part of the reason why alcohol-related disease is such a significant problem for men. How, then, could these attitudes be changed, to encourage more men to adopt healthier drinking habits? By assumptions about gender roles and what these say about drinking alcohol, more men might be encouraged to cut down on their alcohol consumption. In this way, achieving more gender equality may improve access to support services for women and men, thereby helping to reduce the negative consequences of alcohol consumption in the population as a whole. c. Female Addicts and Stigma As well as the inequality issues discussed so far, women also face significant stigma associated with drinking alcohol, and especially with alcohol abuse. This particularly effects older women 19. There has been evidence reported to suggest that women are often discouraged from seeking treatment by family and friends, due to the stigma faced by women suffering from alcohol abuse; traditionally, substance abuse problems have been more socially acceptable for men than for women 18. This stigma may not only prevent women from seeking treatment for their alcohol abuse issues, but may also drive them to drink more in order to cope with the social stigma therefore it becomes doubly important to remove this stigma through creating greater gender equality. One other concept suggesting we need more gender equality is the fact that many risk factors contributing to alcohol dependence disproportionately affect women; this often has a lot to do with gender inequality and gender based violence. Women are disproportionately affected by child abuse 9,19 or gender based violence, such as rape or intimate partner violence; more than 1 in 3 women have experienced physical violence at the hands of an intimate partner 15. All of these are significant risk factors which may drive women to consume more alcohol, and increase risk of alcohol abuse; an important aspect of improving women s health is by removing all these risk factors, which can only be achieved through more gender equality. Conclusion In conclusion, then, research has shown that women are individually more likely to develop chronic alcohol-related problems due to the relatively greater effects of alcohol on their physiology, caused by higher alcohol blood levels and decreased rates of alcohol metabolism; however, men have consistently been shown to drink more alcohol than women. Consequently, the overall rates of alcohol-related morbidity and mortality are higher in men; looking at the issue from a public health perspective, it is clear that men need lower recommended alcohol limits to decrease the burden of alcohol-related disease on men s health. The 2016 UK government guidelines are therefore justified in doing this. Moreover, although women have a higher risk of chronic alcohol-related problems, men have a higher risk of accidental injury and death related to alcohol consumption, so that the overall risk of alcohol-related disease is similar for both men and women. This indicates that having equal guidelines for both genders is fitting. Furthermore, it is inappropriate to state that the 2016 UK government guidelines take gender equality too far by giving men the same recommendations as women, as this ignores the many areas of gender inequality which still exist in the field of alcohol, dependence and support services. Given that so many areas of inequality still exist, it would be more appropriate to say that more gender equality is needed to improve the UK s drinking habits and rates of alcohol-related disease.

7 Alcohol-related disease is an ongoing problem, and must be tackled soon in order to curb the significant levels of mortality and morbidity that it presents. The 2016 UK government alcohol intake guidelines are one way of doing this, and represent an important step in the right direction for tackling the UK s current alcohol problem. Reference List 1. Science and Technology Committee, Alcohol guidelines: Eleventh Report of Session , House of Commons. Report no.: 1536, Department of Health, UK Chief Medical Officers Low Risk Drinking Guidelines, Available through: < CMOs report.pdf> [Accessed on: 27 th March 2017] 3. Obot, I; Room, R (eds.) Alcohol, Gender and Drinking Problems: Perspectives from Low and Middle Income Countries [e-book], Switzerland, World Health Organisation Available through: < [Accessed on: 27 th March 2017] 4. Wilsnack, R; Wilsnack, S; Kirstjjanson, A; Vogeltanz-Holm, N; Gmel, G. Gender and Alcohol Consumption: Patterns from the Multinational GENACIS Project, Addiction Vol. 104(9): Available through: < [Accessed on: 27 th March 2017] 5. Wilsnack, R; Vogeltanz, N; Wilsnack, S; Harris, T; Ahlstrom, S; et al. Gender differences in alcohol consumption and adverse drinking consequences: cross-cultural patterns, Addiction Vol. 95(2): Available through: < [Accessed on: 27 th March 2017] 6. Centers for Disease Control and Prevention, Fact Sheets Excessive Alcohol Use and Risks to Men s Health. Available through: < [Accessed on: 27 th March 2017] 7. Drink Aware, About Us. Available through: < [Accessed on: 27 th March 2017] 8. NHS, Change4Life: Cutting down on alcohol. Available through: < [Accessed on: 28 th March 2017] 9. Nolen-Hoeksema, S. Gender differences in risk factors and consequences for alcohol use and problems, Clinical Psychology Review Vol. 24(8): Available through: < 10. NHS, Statistics on Alcohol. Available through: < [Accessed on: 27 th March 2017] 11. British Liver Trust, Facts About Liver Disease. Available through: < [Accessed on: 27 th March 2017] 12. NHS, Alcohol-related liver disease. Available through: < 13. Department of Health, Sensible Drinking: The Report of an Inter-Departmental Working Group [e-book], Wetherby, Department of Health Available through: < nsum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_ pdf>

8 14. Institute of Alcohol Studies, The effects of alcohol on women. Available through: < 15. National Institute on Drug Abuse, Sex and Gender Differences in Substance Use. Available through: < 16. Drink Aware, Alcohol and Cancer. Available through: < 17. Patient UK, Alcohol and Liver Disease. Available through: < 18. DARA, Gender and Substance Abuse. Available through: < 19. National Institute on Alcohol Abuse and Alcoholism, Alcohol: A Women s Health Issue. Available through: <