Commentary on Steingrimsson <i>et al</i>. (2012): An equal right to addiction

The gender convergence hypothesis, proposed originally in the early 1980s 1, has always been tinged with irony. There is a now a reasonably sized literature supporting its claim that, as populations move towards greater gender equity, women come to drink more like men 2-5. I believe this is partly because drinking and intoxication are symbolic acts—acts that manifest deeper divisions and inequities within societies. Those allowed to drink freely—traditionally, men of high economic standing—tend also to be among those at the top of the status hierarchy. One symbol of their privilege, power and independence is the freedom to drink and to drink to intoxication 6. When women become more economically equal to men, they are allowed to join the gentlemen's club and to drink with less restraint. Among the many privileges afforded the modern working woman is the right to a three-martini lunch. The irony is that along with the equal right to drink may come a more equal burden of alcohol-attributable health harms, abuse and dependence. In a novel analysis of the gender convergence hypothesis, Steingrimsson et al. 7 take this hint of irony to its logical conclusion. Drawing on data from patient registries in all of Iceland's psychiatric hospitals over the past quarter-century, they measure secular changes in the gender gap among patients treated for addictive disorders. They show that, between 1983 and 2007, the gender gap for alcohol use disorders (AUDs) narrowed significantly—from a 4.2 to 1.5 male-to-female ratio. Meanwhile, they find no statistically significant changes in the gender gap for substance use disorders (SUDs, defined as drug disorders that may or may not be accompanied by an AUD), which only travels from a male/female ratio of 1.7 to 1.2 during this time span. My main objection to Steingrimsson et al.'s paper is that it underplays the broader significance of the changes observed. The authors, for example, argue that a ‘limitation’ of their analysis is that the narrowing gender gap in AUDs could be attributable to changes in treatment seeking by women; but this seems precisely the point. From a broad societal standpoint, gender convergence in drinking is a manifestation of changing norms as women begin to shed their traditional status as subordinates to men. A probable consequence is some lifting of the veil of stigma for those women who experience alcohol problems, allowing more to admit they have a problem and seek help 8, 9. Indeed, American feminists are not at all inhibited about asserting the woman addict's ‘equal right’ to substance abuse treatment 9. Using trends data, researchers have shown that gendered drinking norms in the United States began to fade with the rise of feminism 10. Normative shifts of this kind have also been linked to changes in social pressuring and the willingness to seek help in general population studies 11, 12. Steingrimsson et al. also underplay a rather striking increase in the number of Icelandic women in treatment for SUDS, noting conservatively that the gender gap in SUDs, unlike AUDs, is ‘not statistically significant’. Their focus on tracking the gender gap—the ratio of men to women in treatment—tends to obscure a substantial increase in the absolute number of women treated for an SUD. My rendering of their data in Fig. 1 shows the crude numbers of women and men treated for SUDs over time. (Numbers, rather than proportions, are adequate for this demonstration because base rates of men and women are fairly similar and stable over time.) The figure shows that for both genders, numbers treated for an SUD have been rising since 1983. By 2007, there were 2.58 times more women treated for an SUD compared to the 1983 baseline; there was a more modest 1.87 increase among men. Number of patients admitted annually to psychiatric hospitals for a substance use disorder. Source: Steingrimsson et al., 2012, Table 1 I suspect that Steingrimsson et al. hesitate to assert more forcefully the convergence hypothesis for a couple of reasons. There is, of course, the need to present one's findings with appropriate caveats and cautions if authors want to make their way through the rigorous peer reviews required by a major science journal such as Addiction. At a deeper level, however, it is simply difficult to offer up evidence that more equal rights for women, where this has occurred, has not necessarily been an unmitigated success. Evidence of gender convergence in addictive disorders is what Max Weber would have called ‘an inconvenient fact’. It exposes the reality that the record on equal rights for women is not completely unblemished. With the rising fortunes and freedoms brought by upward mobility also tend to come increases in alcohol consumption and problems—for both men and women alike 13, 14. At the end of the day, Steingrimsson et al. should be commended for bringing this inconvenient fact to light, even if they do so with a little guardedness and hesitation. None.

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