Over a past few decades, there have been major advances in our understanding of gender differences in behavioral addictions especially alcohol consumption. Usually, females have lesser tendency to consume alcohol but their intake most of the times is heavy and is linked with more deleterious effects than males. But recently an increase in female alcohol consumption is observed in most societies and cultures. It is essential to clarify the distinction between “gender” and “sex” used interchangeably in most of the researches so far. “Sex” is a biological characteristic while “gender” refers to the adaptation of social, cultural and behavioral attributes by an individual and we will refer “female gender” unanimously throughout this text. In this review, we have tried to analyze reasons for gender disparity in alcohol consumption from a socialist point of view enlightening the historical background and development of Ladette culture in Europe. In the later half an attempt was made to analyse the global scenario of female alcohol consumption by comparing its contrasting trends between developed nations; UK, Scotland, European Union nations, Australia, New Zealand, Canada, Russia, USA and the developing countries such as Asia, South America and India. Thus, it is empirical from a public health point of view to analyze the female drinking pattern globally, unveil its etiology and suggest measures for harm minimization.

Alcohol has played a central role in almost all human cultures since Neolithic times and all societies make use of this intoxicating substance. There has been a distinction between alcohol consumption and feminism since Roman era when drinking installations were in close proximity with the sex industry. There is ample evidence that the development of agriculture - regarded as the foundation of civilisation - was based on the cultivation of grain for beer, as much as for bread. The grocery license to sell alcohol in 1861 (UK) increased its accessibility to women and imposed a challenge for male dominant pub culture which portrayed female drinking as inferior and laughable. Alcohol industry in collaboration with the media tried to establish a strong coalition between professionalization and independence of women. High liquor consumption and Ladette culture (assertive behaviour and heavy drinking) slowly became popular amongst women in Europe [1-4]. Literature analysis of some famous youth magazines such as Cosmopolitan, Marie Claire and FHM Magazine, etc. elicited that alcohol was promoted immensely through articles, letters, jokes and health advises clearly neglecting medical and ethical guidelines. Also cost effectiveness of alcohol and variety of available drinks were cited innumerable times using explicit and abusive content to allure readers [5]. The idea throughout was to promote female drinking a part of normal life and associating hazardous behavior to all types of drinking is cynical citing with its constant description in poems, songs, advertisements, books on etiquette etc. It surely has an empirical impact on behavior with its intake undoubtedly rewarded socially and reinforced [3].

Healthcare for alcohol related problems is provided by hospitals, social care organisations and rehabilitation centers in collaboration with each other. Women were more inclined “to use non-alcoholspecific health care settings, particularly mental health treatment services, and to report greater symptom severity” than men despite the social stigma attached to it. Although the primary aim of the research was to investigate alcoholic women’s access to healthcare set ups yet the particular issue wasn’t clearly addressed and only cited as a future recommendation at the end. There wasn’t much literature available supporting this argument and it was need to conduct this study in different populations to know the authenticity of finding as the concept lacked consistency on repetition as well [6].

A study by McCreary et al. [7] on alcohol and gender argued about the ‘sex role conflict’ which primarily concentrated on women drinking heavily, portraying masculinity and emphasised that researchers always accept male alcohol consumption normal and consider deviance from femininity when women enter into this arena. They suggested that both the genders with communal personality drink less whilst “men and women with stronger feminist attitudes (i.e., attitudes that stress gender egalitarianism) tend to drink more”. So at the end perhaps it was the personality trait not the gender which determines drinking behaviour. Thus, for high risk alcohol consumption, distinct implications are required for both men and women [7]. Typically masculinity was linked with aggression with bio medics explaining it on the basis of ‘testosterone’ levels while female violence was treated as mental illness. But a study analysing working women challenged this whole perception and cited that women pugnacity is a direct consequence of female entry into the workforce, economically making them more stable and their resultant desire to challenge male hedonism and hierarchy. They have cited evidences as cat fight in pubs, night club brawls, etc. and recorded conversations as part of their study data [8].

Trend of heavy drinking has been widely accepted amongst teenagers; young British women off late became the worst binge drinkers in the world [8]. In Scotland, teenage boys were 54% more likely to present in hospitals than girls due to alcohol intoxication [9]. They all perceive drinking worthwhile for socializing. A psychoanalytical study conducted on four college students (18-21) in UK scrutinised unconscious male desires and their perception of hegemonic masculinity under the influence of alcohol. The findings revealed that heterosexual males consider themselves paramount to women, gay men and men from other ethnic origin. Their attitude towards feminism was derogatory and they love female disparaging humour most of the time although it is quite difficult to generalise the analysis from a few conversations [10].

In Britain, Richard et al. analysed the psyche of young men (18-21 years) who consume alcohol profusely. Through numerous conversations they identified aspiration of masculine identity as the prime force behind high alcohol intake. They correlated hegemonic masculinity’ which is “characterised by physical and emotional toughness, risk taking, predatory heterosexuality, being a breadwinner” to alcohol consumption. Drinking, drug abuse, casual sex and fights were considered as key domains of masculinity although a fit girl friend or exemplary soccer skills might occasionally compensate for alcohol. Other cited factors affecting booze frequency include ethnicity, culture religion, etc. as white Britishers drink more than their black or Asian counterparts. Religious norms abstain Muslim youth from alcohol intake as compared to their peers of other religions most of the time [11]. However, in this study method of interviewing may result in interviewer and response bias.

The last few decades in Scotland witnessed a steady rise in alcohol consumption, and as a consequence many epidemiological cohort researches were performed to assess female drinking pattern. Emslie et al. collected data from three different age group cohorts through a questionnaire and compared alcohol consumption trend between 1990 and 2000. The results for heavy and binge drinking revealed “30.8% vs. 11.3% in the youngest cohort, 30.7% vs. 7.3% in the middle cohort and 20.8% vs. 3.1% in the oldest cohort” between men and women respectively. Although males were drinking more than female amongst all cohorts yet the latter was catching quickly. The quantity of alcohol intake too increased with time in both the genders. But, these results can only be generalized once adjusted for inter observer bias and bias due to loss of follow up [12]. However, these notions help Scottish government to devise anti-alcohol policies prioritising youth. They started planning in 2002 by setting up standard measures for the management of alcohol intoxication; this was subsequently followed by the foundation of SEDAA (Scottish Emergency Department Alcohol Audit) in 2005. Surveillance and monitoring was initially carried to identify the extent of problem and later on target groups were identified. In 2008 strategic policies were designed with suggestions such as the collection of social responsibility fee from retailers, increasing the minimum age limit for alcohol purchase, new legislations for media advertising of alcoholic beverages posted to keep Scotland healthy [9,13].

Kuntschea et al. [14] analysed heavy drinking and gender variance across European nations found an overall increase in female alcohol consumption and this rise was particularly evident in teenagers. Their overall results although showed some discrepancy across nations yet few findings can be generalised. For example, living with two parents, healthy communication within the family, high level of education and employment found to be protective against alcohol consumption. On the contrary depression, stress and company of problematic peers almost always indulge people in heavy drinking [14]. A similar survey of 13 EU (European Union) and 2 non-EU countries by Kim et al. investigated trend of binge drinking in context of socio economic status (SES) measured by the level of education. They found a lot of gender variance as women acquiring higher education in Netherland, France, Germany and Austria drink more than men while lower education was hitched with high alcohol consumption amongst men at most places. Thus, higher SES in developed nations is linked with frequent consumption of small quantities of alcohol. In contrast, low SES drinkers consume alcohol in hazardous quantities despite financial constrain [15]. Richard et al., in his report perhaps summarises findings of many studies on gender and alcohol with its evidence based on 16 population surveys from 10 countries (including US, Canada, Australia, Russia, Israel and some EU countries). He concluded that despite a growing narrow gender difference in alcohol consumption men still outnumber women in quantity, frequency, rate of risk drinking and were less likely to abstain [16].

In USA, a community based study by Laura et al. compared cohort effect on gender difference in prevalence and severity of alcohol dependence in two cohorts of men and women born between 1941 and 1960 respectively. Younger cohort born in the sixties showed higher alcohol dependency in both genders (40% men and 13% women) in contrast to the older cohort of forties (33% and 6%). Women were found more susceptible to physical effects of alcohol intoxication than men. Factors cited for this difference include wide cultural shift, relative reduction in price of alcohol and an increased availability [17].

Moscow and Toronto were expected to exhibit more diversity in masculinity, feminism and alcohol prevalence due to their versatile cultural and political atmosphere. The socialist political system in Russia emphasises collectiveness in contrast to the individualistic society of Canada which provokes freedom. But findings were not in support of this presumed notion as feminism showed no significant impact on gender narrowing in terms of heavy drinking. Both Russian and Canadian women drink less than men but possessed high femininity levels. However, citation of the abovementioned facts as relative risk and proportion from a critical perspective makes facts dubious. Selfreported data in this study had response bias which is common in alcohol surveys [18].

In Australia, a questionnaire based cross sectional survey was conducted among New South Wales University students to assess characteristics such as restrained drinking and self-efficacy for alcohol denial. Heavy and risk drinkers scored high on govern subscale (restrained drinking measurement) and low on social pressure sub-scale measuring refusal capacity. Overall risk drinking was higher in women than men (88.1% vs. 66.8%) while men scored heavily in moderate drinking (31.4% vs. 16.6%). Drinking cognition and stereotyping delineate between moderate and heavy drinking in women but not in men [19].

The pub culture of New Zealand was dominated by men since colonial times. But, there was a steady rise in female alcohol consumption and binge drinking pattern after the 2^nd world war, much in accordance with Europe. Young Kiwi working professionals accepted heavy drinking leisurely and consider alcohol absenteeism unusual [20]. However, interviewer and response bias exists for the above study as both parties were aware about the conversation objective. McPherson et al. [21] described female drinking “a narrowing of the gender gap” arguing that this trend may be either biological or cultural but high alcohol consumption definitely showed significant gender convergence. Between 1995 and 2000, the prevalence of absolute heavy drinking increased from 47–53% for men vs. 31–42% in women. A rise of 11% in 5 years although looks convincing yet a population size, 4232 (1995) and 5113 (2000) somewhat diminishes its significance [21].

In developing nations of Asia females from India, Pakistan and Afghanistan consumed least amount of alcohol closely followed by Indonesia and Malaysia. On the contrary, Korean women ingest the largest volume of alcohol followed by Japan. Between 1980 and 2000, Asian countries experienced a hike of 50% in per capita alcohol consumption. Huu Bich et al. discussed alcohol consumption pattern in context of socio demographic and cultural factors across nine different sites in five Asian countries using Health and Demographic Surveillance System (HDSS). They found alcohol intake almost negligible at all four locations in Bangladesh (less than 2% drinkers vs. more than 98% nondrinkers) pertaining to religious and cultural norms. On the contrary in Vietnam, male and female drinking were estimated as 85.8% and 84.7% respectively, whilst in Thailand the overall % was around 29.4% (Chililab) and 28.4% (Kanchanaburi) [22]. Low education level was prevalent among alcoholics in both genders in accordance to previous findings [14]. However, hitches are expected in the available evidence due to limited coverage and authenticity of the aforementioned data.

India acknowledged 115% increase in per capital alcohol consumption since 1980. Researchers investigated the socio economic variables behind this rise and the impact of governmental policies on alcohol cessation. Both genders of low socioeconomic status (SES) were 1.92 times more likely to consume alcohol than high SES individuals. Men from abstain educational background consumed alcoholic drinks 2.28 times more than the educated ones. These results simulate previous findings [14,22] and both men and women from scheduled castes of Hindus, backwards castes of other religions and rural tribal population presumed to be ingesting alcohol in larger quantities. But limited data availability forced researchers to demand better surveillance system. But, from a critical perspective towards this study a small sample size lacked power, and precision aimed at confidence interval width was missing too, perhaps showed limited statistical power of the study [23]. Heterogeneous pattern of alcohol consumption was present across different states; 1 year alcohol prevalence across northern states of India 25-40%; it was 33-50% in southern part. Sikkim, a small eastern state has 35% population of chronic alcoholics which was momentous as compared to rest of India. A lot of local and illegal alcohol was consumed throughout the country in the form of Arrack, palm wine along with the imported duo of whisky and brandy [24].

A generalised trend of less alcohol consumption in females across some Asian countries can be owed to traditional culture of alcohol abstain. Not many women can access liquor freely at wine shops and bars in most of the rural areas. With joint family system pertaining in the majority of rural areas consumption at home too is prohibited. However, gradual urbanisation is making female alcohol consumption more acceptable. Education, higher SES, entrance of women into the workforce is responsible for a prevalence of Ladette kind of culture everywhere.

Despite an overall rise in the female alcohol consumption worldwide, women drink less and are more lifetime abstainers than men. However, they are potential candidates suffering from deleterious effects of alcohol than men because of the effect of sex hormones on alcohol pharmacokinetics. Their higher grade of intoxication is due to three major reasons. Firstly, in men a higher concentration of gastric alcohol dehydrogenase enzyme metabolizes more alcohol in stomach decreasing its availability for absorption in small intestine. Secondly, men have increase muscle mass allowing greater blood flow thus diluting alcohol more than females. And finally, with a blood volume of 45% to 50% water females are again more likely to concentrate alcohol available for absorption [25].

To conclude, overall alcohol consumption throughout the world is on a rise with a consistent narrowing gender gap although discrepancy is present within nations and societies. The striking difference between the trends in Europe and Asia is perhaps the inferior surveillance system, a difference in culture and tradition, variable SES, education, and female entry into the workforce. Women by far are more likely to be affected from alcohol abuse owing to the aforementioned biological and sociocultural factors. Hence, a conscientiousness task is necessary from multiple disciplines to combat this emerging female alcohol epidemic.