Title: Structural Sexism in the United States and Patterns of Women's Alcohol Use in Recent Decades
Description: Alcohol consumption is a leading cause of morbidity and premature mortality. In the United States, consumption remains highly prevalent, and certain subgroups have been increasing alcohol risks in recent decades. Among these are women in the mid-life, who have increased rates of both alcohol consumption (vs. abstention) and binge drinking (i.e., multiple drinks in a setting). Women’s alcohol use has increased concurrent with social and economic gains. These gains in women’s social and economic status are indicative of broader declines in structural sexism, a macro-level, systematic source of gender inequality. The objective of this dissertation is to examine the associations between state-level structural sexism (e.g.., social, political, and economic gender inequality) and patterns of women’s alcohol consumption. This dissertation is presented in five chapters: first, an introduction; second, a narrative historical review of the relationship between structural sexism in the United States and women’s health outcomes, with a lens towards understanding the theoretical and epidemiologic sources of conflicting study findings; third, an empirical study of the relationship between state-level structural sexism and both alcohol consumption and binge drinking among women in the mid-life in recent cohorts; fourth, an empirical study examining structural sexism as a source of heterogeneity for relationships between women’s social positions—namely, their occupational characteristics—and both alcohol consumption and binge drinking; fifth, a discussion of findings and implications for future research.

Materials and methods The narrative literature review drew from empirical studies in public health, criminology, and sociology (N=43 studies). The two empirical aims used longitudinal data from Monitoring the Future (MTF), a national survey examining substance use throughout young adulthood, using data from cohorts who were high school seniors between 1988-2006. For both empirical aims, I measured structural sexism using a factor-analytically derived score based on state-level social and economic indicators of gender inequality, and assessed occasions of alcohol consumption and probability of binge drinking as study outcomes. Both studies used three-level multilevel models to estimate associations between structural sexism and each alcohol outcome. The first empirical aim included a sample of 23,862 women surveyed between 1988-2016, and beyond the marginal association also tested the role of three mediators: depressive symptoms, college completion, and restrictive alcohol norms. The second empirical aim included a sample of 16,571 women in the MTF follow-up surveys between 1989-2016, and examined whether associations among work status, high-status careers, occupational gender composition, and both alcohol outcomes varied across levels of structural sexism using interaction models between occupational characteristics and state structural sexism.

Results The review identified the divergent theoretical frameworks and measurement invariance as the most pressing threats to reconciling competing findings. In the review I also observed a dearth of empirical studies relating structural sexism to any behavioral health outcomes, including alcohol use. In the first empirical study, I demonstrated that women living in states with lower levels of structural sexism evidenced increases in both occasions of alcohol consumption (RR: 0.974, 95% CI: 0.971, 0.976) and probability of binge drinking (OR: 0.917, 95% CI: 0.909, 0.926); I showed that this relationship was specific to women (i.e., it was less pronounced among men) and that mediators of this relationship included increases in college completion and decreases in restrictive alcohol norms. In the second empirical study, I found that working women evidenced higher frequencies of alcohol consumption and higher probabilities of binge drinking than non-working women, and that these differences were most pronounced among women in low-sexism environments.

At the lowest level of structural sexism, employed women reported higher occasions of consumption (2.61, 95% CI 2.57, 2.64) then unemployed women (2.32, 95% CI 2.27, 2.37). I also found that women in high-status occupations reported more occasions of alcohol consumption than those in low-status occupations, but only in low-sexism environments. Conclusions Lower levels of structural sexism are related to increases in both alcohol consumption and binge drinking among women. In low-sexism environments, working and belonging to a high-status career increases women’s alcohol use. Increases in women’s equality are positive and important social forces, but have conferred new acceptability of alcohol use that has implications for women’s health.