Very limited research has explored the relationship between gender equality and women's (or men's) alcohol consumption and consequences. Research at the individual level examining the relationship between men's and women's social roles and alcohol has found mixed results (Gmel et al., 2000; Kuntsche et al., 2009; Mansdotter et al., 2008; Murphy et al., 2000). Consideration of men's and women's social roles is one possible way of operationalizing gender equality at an individual level. Less research has explored the relationship of macro-level gender equality and alcohol use and consequences. Two recent multi-country studies are notable exceptions (Bond et al., 2010; Rahav et al., 2006). One study examined the association between macro-level gender equality and current drinking, weekly drinking, heavy drinking, heavy episodic drinking, alcohol dependence, total alcohol-related deaths, deaths due to cirrhosis, deaths due to motor vehicle crashes and alcohol-related physical aggression by a spouse or partner (Rahav et al., 2006). This study included 23 developed and developing countries from five continents. This study found that increased macro-level gender equality was associated with smaller gender ratios in current and weekly drinking as well as each alcohol-related consequence. However, in some cases, the association was no longer significant after controlling for gross domestic product (GDP). The study also found that, with the exception of alcohol dependence and alcohol-related physical aggression, increased gender equality was associated with decreases in consequences for both men and women. Another study examined the association between macro-level gender equality and gender differences in the frequency of drinking in public and private settings in 22 developed and developing countries in six continents (Bond et al., 2010). This study found that increased gender equality was associated with smaller gender differences in the frequency of drinking in public, but not private, settings and that, after controlling for GDP, gender equality in economic participation was the only equality indicator that predicted size of this gender difference. These two studies generally reported findings in the direction predicted by the recent claims, i.e. that increased gender equality predicted smaller gender differences. It is important to note that this varied depending on the gender equality indicator and the specific alcohol measure.

The Rahav et al. (2006) study provides an important first step, identifying possible existing country-level indicators of gender equality/women's status that may be relevant for alcohol research. They used an existing measure, the Gender Empowerment Measure (GEM; United Nations Development Programme, 2009), and created an additional single composite index based on numerous potential indicators of gender equality/women's status. Their single composite index included the ratio of women and men in the labour force, the proportion of women in management positions, the proportion of women in parliament and higher education, the difference between men's and women's earnings as well as indicators of beliefs regarding women's status and gender roles from the World Values Survey. However, they did not specify the theoretical relevance of the selected indicators. Bond et al. (2010) included six country-level equality indicators: the Gender Gap Index (GGI) subindices for economic participation, education and political participation (Hausmann et al., 2007); the GEM; context of VAW; and reproductive autonomy. The first four are existing indices. Bond et al. (2010) presented a theoretical rationale for including economic participation and context of VAW as the gender equality/women's status indicators likely to predict gender differences in drinking in public settings.

In addition to these two studies, there is a larger body of research from which alcohol researchers can draw lessons. One example is the theoretically driven research exploring the relationship between gender equality and VAW. This broad body of research is not specific to alcohol. With the goal of identifying lessons for and conceptual frameworks to guide research relating to macro-level gender equality and alcohol, this paper reviews literature relating to macro-level gender equality and VAW. Reviewing the macro-level gender equality and VAW literature makes sense because the body of research is conceptually driven and because there are strong folk beliefs regarding relationships between macro-level gender equality and both VAW and alcohol. Further, VAW and alcohol may share certain attributes, such as associations with impulsivity/risk taking (Cherpitel, 1999; Schafer et al., 2004); and share certain patterns, i.e. with women tending to be the victims in the violence and tending to drink less than men (Basile et al., 2007; Wilsnack et al., 2000). Also, there may be relationships between VAW and alcohol. Alcohol may exacerbate VAW (Abbey et al., 2009) and violence in general is a component of alcohol-related problems (Midanik and Clark, 1995). This means that findings from research relating to macro-level gender equality and VAW may have direct implications for research relating to gender equality and alcohol. Finally, both VAW and alcohol consumption involve interactions between men and women, whether the actual violent event or the likely mutual influence of male on female and female on male drinking patterns. These interactions could plausibly be influenced by gender equality.

Three conceptually driven hypotheses drive the macro-level gender equality and VAW research. These hypotheses include: amelioration, backlash and convergence (see, for example, (Brewer and Smith, 1995; Eschholz and Vieraitis, 2004; Martin et al., 2006; Pampel, 2001; Whaley and Messner, 2002). Amelioration suggests that increases in gender equality will decrease VAW. Backlash suggests increases in equality will increase VAW, at least in the short term, and then may decrease it over time. Convergence does not focus on whether increases in equality leads to increases or decreases in VAW, but rather suggests that increased equality/status will lead men and women to become more similar in experiencing (and perpetrating) violence. An example of convergence would be domestic/partner violence perpetrated by women against men becoming similar to rates perpetrated by men against women. These hypotheses predict differences in how increases in equality might affect VAW.

The research about the relationship between gender equality and VAW generally includes similar equality measures to those in the limited alcohol research. Importantly, the VAW research also distinguishes measures of gender equality from measures of women's status and suggests that this distinction is conceptually important. A measure of gender equality might compare the proportion of women to men completing secondary education, while a measure of women's status would look only at the proportion of women completing secondary education. While potentially highly correlated, an equality measure could plausibly look very different from a women's status measure. For example, in country A and country B, 40% of women complete secondary education (an indicator of women's status). In country A, 80% of men complete secondary education, while in country B, 40% of men complete. Country A's gender equality measure (2:1) would look very different from country B's measure (1:1). Vieraitis et al. (2007) explain that the gender equality hypothesis is associated with liberal/radical feminist theory and that it suggests that inequality between men and women puts women at a structural disadvantage to men, who then use violence to keep them in their place. Vieraitis et al. explain that the women's status hypothesis is associated with socialist and Marxist feminist theory. This theory suggests that women in lower/working classes have fewer economic resources to keep themselves out of harm's way, specifically from men who are frustrated with their disadvantaged life and economic situations and therefore take their frustrations out on the women in close proximity. When women have more resources, they can more easily extract themselves from these higher crime contexts. To operationalize these distinctions, researchers use relative measures—such as the ratio of employed men to employed women—as indicators of gender equality and absolute measures—such as percentage of all women who are employed—as indicators of women's status. For the remainder of the paper, gender equality will be used to refer to relative measures as well as generically while women's status will be used to refer to absolute measures.

These findings may have direct implications for alcohol research. For example, increased gender equality could lead women to drink more frequently in public settings, a possibility based on the Bond et al. (2010) study. The backlash hypothesis suggests this increase in drinking in public (which may violate existing gender norms as well as create additional opportunities for exposure to violence) could lead to an increase in VAW in the short term and then, possibly, decrease in the long term. Some research supports the first component of this backlash hypothesis, suggesting that increased frequency of drinking in bars is associated with increased risk of sexual assault (Ullman, 2003). This expected relationship could be complicated if the backlash of violence then leads to either increases in or decreases in women's alcohol use. Increases are plausible if women, who experience violence, use alcohol as a coping strategy (Ullman, 2003). Decreases are plausible if women forgo drinking, especially in bars, as a strategy to avoid violence. On the other hand, gender equality could either confound the male alcohol and male violence perpetration relationship (see, for example, Powell et al., 2010) or mediate the gender equality violence relationship, with low levels of gender equality causing men to drink in risky patterns to prove masculinity and possibly also perpetrate violence. However, if increased gender equality does not reduce VAW, these hypothesized relationships are not plausible.

Beyond these direct implications for research into gender equality, violence and alcohol, this review may offer some lessons for alcohol researchers examining the relationship between macro-level gender equality and alcohol. First, distinguish indicators of gender equality from indicators of women's status. Researchers should either have a theoretical rationale for choosing one or the other or include both as distinct measures, especially from the same domain (such as both economic equality and women's economic status). Second, develop and test conceptually and theoretically driven hypotheses about the expected relationships between different indicators of gender equality and different alcohol measures. The three main hypotheses—amelioration, backlash and convergence—may have analogies in alcohol research. For example, increases in women's economic participation could lead to women having more control over resources, which they may decide to spend on alcohol, or to women adopting similar behaviours to men, such as drinking after work (backlash and convergence). More women in the workplace could change workplace cultures that involve regular alcohol consumption and thereby decrease men's drinking (leading to convergence). Conversely, women participating in the workplace cultures that involve regular alcohol consumption could increase women's alcohol consumption and, as feared by temperance activists (Eriksen, 1999), decrease their ‘nagging’ of men about their alcohol use, which could result in both women and men drinking more (backlash, maybe convergence). Additionally, women's increased economic participation could lead to women being more fulfilled by having multiple roles (Mansdotter et al., 2008) and therefore to women drinking less often to cope with stress (amelioration). However, if systems to support women's increased economic participation do not exist, as may happen in early stages of gender equality (Chafetz, 1990), such increases could lead women to drink more heavily to cope with stress and then, over time as systems develop, reduce their drinking to levels lower than where they started (complete backlash). Third, use study designs and analysis methods that allow for explicit testing of these hypotheses. For example, test the complete backlash hypothesis by using both cross-sectional and lagged data and allow for non-linear relationships.

This study should be considered in light of its limitations. First, the sample size of findings is small, which limits the power to detect effects and makes multivariate analyses untenable. Second, some study characteristics such as gender equality indicator and study location may be correlated. Given that the small sample size makes multivariate analyses untenable, it is not possible to determine whether, for example, study location confounds the gender equality and VAW association. Third, the bivariate findings include 28 statistical tests. The choice to use P-values of 0.10 and 0.05 capitalizes on chance, and thus should be interpreted with caution. A conservative interpretation of these findings is that none are statistically significant. However, as this is the first systematic study of this entire body of literature, statistical significance levels are reported so that the reader can draw his or her own conclusions. Fourth, the decision to classify a finding as significant if one or more of the indicators of that domain in the study was significant may capitalize on chance and thus may count too many findings as significant. Fifth, the lack of significant findings in some of the reviewed papers may be due to lack of power to detect small effects and to small samples of macro-level units. Sixth, many of the studies also reported interactions and findings from stratified analyses. By not including findings from these analyses, this review excludes addressing the implications of such findings.

This study also has strengths. To the author's knowledge, this is the first study in the alcohol literature to review existing research about the relationship between macro-level gender equality and health and discuss the implications for alcohol research. Future alcohol studies that incorporate lessons from this review will have the opportunity to determine which, if any, aspects of macro-level gender equality influence alcohol use and problems and for whom. Depending on the significance and direction of the findings, the findings from this research can be used to either counter false claims that impugn gender equality or to develop appropriate interventions to reduce consequences of increased alcohol use for women's health and well being.