Findings from this review suggest that neither the existence of nor the direction of relationships between gender equality and VAW can be assumed. In relation to alcohol, these findings suggest that the relationship between macro-level gender equality and alcohol should not be assumed, but rather tested through research. This review identified both some content-related factors that may influence these relationships as well as study design characteristics that may influence significance and direction of study findings. Composite indices of equality may be more likely than measures of education to predict VAW, but the direction of the relationships is not yet clear. While not significant in the bivariate analyses, the qualitative review of studies that included distinct measures of both gender equality and women's status in the same study suggests whether predictors measure gender equality or women's status matters. Therefore, the choice of whether to use an absolute (measure of status) or relative (measure of equality) indicator may influence findings. Finally, bivariate analyses suggest that findings may vary depending on characteristics of the outcome, including the specific type of violence.
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.
This project was supported by National Institute for Alcohol Abuse and Alcoholism Graduate Training on Alcohol Problems (T32 AA07240).