DECREASED RISK OF ALCOHOL DEPENDENCE AND/OR MISUSE IN WOMEN WITH HIGH SELF-ASSERTIVENESS AND LEADERSHIP ABILITIES

G. Hensing*, F. Spak, K. L. Thundal and A. Östlund

Department of Social Medicine, Sahlgrenska Academy, Göteborg University, Box 453, SE-405 30 Göteborg, Sweden

Received 15 April 2002; in revised form 18 November 2002; accepted 9 December 2002


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Aims: To analyse dimensions of gender identity and its association to psychiatric disorders and alcohol consumption. Methods: The study was performed in two stages: an initial screening (n = 8335) for alcohol consumption, followed by a structured psychiatric interview (n = 1054). The Masculinity/Femininity-Questionnaire was used as an indicator of gender identity. The final study group included 836 women. Results: Leadership, caring, self-assertiveness and emotionality were dimensions of gender identity found in a factor analysis. Low self-assertiveness, high emotionality and to some extent low leadership were associated with increased odds for having bipolar disorders, severe anxiety disorders and alcohol dependence and misuse. Low self-assertiveness and high emotionality were not only associated with alcohol dependence and misuse, but also with high episodic drinking. Conclusions: There was an association between some of the dimensions of gender identity and psychiatric disorders and alcohol consumption. Further attention is needed in both clinical work and research.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Recent psychological research has described gender identity as consisting of multiple components, such as personality attributes, attitudes, relationships, behaviour and abilities (Ashmore, 1990Go; Blanchard-Fields et al., 1994Go). The development of gender identity is probably influenced by genes, sex assignment at birth and socialization (Ashmore, 1990Go). It would be extremely difficult to disentangle the relative contribution of each of these determinants in order to explain whether biological, social and cultural factors are the most influential in the development of a certain gender identity.

Instruments, for example the Bem’s Sex Role Inventory (BSRI) or the Personal Attributes Questionnaire (PAQ), include self-assessment of masculinity and femininity as a way to operationalize gender identity (Bem, 1975Go; Spence et al., 1975Go). In her earliest studies, Bem found that an androgynous sex-role orientation was associated with higher self-esteem and psychological well being (Bem, 1975Go; Ashmore, 1990Go; Sorell et al., 1993Go). Androgynous persons scored highly on both the masculinity and the femininity scale, which was interpreted as being associated with a broad repertoire of behavioural and psychological coping strategies and personality traits. However, later studies have shown that the masculinity scale mainly can explain these positive effects on self-esteem and psychological well being (Sorell et al., 1993Go). The role of femininity for psychological well being has been discussed. In a comprehensive review of 69 studies, Murnen and Smolak (1997)Go found a small, but positive, relation between femininity and eating problems, especially anorexia nervosa.

In a review of earlier studies, Sorell et al. (1993)Go concluded that the results on the relation between alcoholism and sex-role orientation were contradictory. It was shown that women with alcoholism were ultra-feminine, overly masculine, con-fused about sex-role identity or had a masculine approach to life. Beckman (1978)Go found in a study with BSRI that women with alcoholism were undifferentiated, i.e. they were low on both the masculinity and the femininity scale. Wilsnack et al.(1985)Go found that androgynous sex-role orientation (according to PAQ) was associated with lower levels of alcohol consumption and of drinking-related problems. Finally, Sorell et al. (1993)Go found that psychological masculinity (PAQ) was the most important factor in differentiating women with alcoholism from those without. In a study on a European sample, and using a different but related concept, Neve et al. (1997)Go found that traditional gender role attitudes were associated with lower alcohol consumption and a higher proportion of abstainers among women.

Several authors have pointed to the need for further elaboration of the association between gender roles, gender identity and alcoholism (Sorell et al., 1993Go; Neve et al., 1997Go). Room (1996)Go concluded that ‘Because gender roles and interactions are so often steeped in drinking and drug use, such studies can teach us something more general about the interaction of social forces and norms with mundane and private behavior. But the studies also offer the promise of finding ways forward in the practical task of reducing harm associated with alcohol and drug use’ (p. 237).

The aim of the present study was to analyse gender identity among women and its association to psychiatric disorders and alcohol consumption in a country that has undergone important changes in gender relations.


    SUBJECTS AND METHODS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Study population
The study is part of the project ‘Women and Alcohol in Göteborg’ (WAG) conducted in two districts in the second largest city of Sweden (Spak and Hällström, 1996Go). These two districts are urban and suburban areas with 93 157 and 105 683 inhabitants (1995), respectively.

Overall study design
The overall study design of the screening phase is presented in Table 1Go. Three different cohorts were included in the project: (1) all women born in 1925, -35, -45, -55, -65, and registered for census purposes in the District West of Göteborg on 31 December 1985; (2) a sample of consecutive female visitors to clinical settings such as maternity units, GP units, acute wards and psychiatric clinics, between March and May 1986; (3) all women born in 1970 and 1975 and registered for census purposes in District West or the Central District of Göteborg on 1 January 1995.


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Table 1. Study design and participation in the screening phase of the ‘Women and Alcohol in Göteborg study’
 
Study group
In order to minimize the effect of the attrition, a randomly selected quarter of the attrition from the screening phase 1986 was included in the interview phase in 1990. Likewise, women from the attrition in the interview study 1990 were included in the interview in 1995.

Out of 1252 interviewed women, 836 fully completed the Masculinity/Femininity-Questionnaire (henceforth M/F-Q) (Bergman et al., 1988Go), and were thus included in the study.

Screening instrument and stratification procedure
A screening instrument, ‘Screening — Women and Alcohol in Göteborg’ (SWAG), was mailed to the home addresses of the population-based sample and handed out to consecutive arrivals in the clinical sample. SWAG has 13 items and is based on the Short-MAST, ML-MAST and the CAGE (Spak and Hällstöm, 1996Go). Since the prevalence of alcohol problems is low among women, the stratification method was designed to over-sample women with probable alcohol problems (Spak and Hällström, 1996Go).

Interviews
The interviews were conducted after informed consent was obtained. The Ethics Committee of the Medical Faculty of the University of Göteborg has approved the study. Interviews were performed by seven clinicians (six women and one man), all with several years of clinical experience. They were all trained in DSM-III-R, and clinical examinations were performed until sufficient inter-rater reliability was achieved. One of the authors (F.S.) has been a consultant in diagnostic procedures. The interviews focused on socio-demographic characteristics, childhood conditions, family relations, work situation, physical and mental health, alcohol consumption and its adverse consequences, and personality factors (Wilsnack et al., 1991Go; Spak and Hällström, 1996Go). Clinical psychiatric diagnoses were made according to DSM-III-R (axis I, IV and V) (American Psychiatric Association, 1987Go). For diagnosis of alcohol dependence and abuse (ADA), the structured diagnostic instrument CIDI-SAM (Robins et al., 1986Go) was also included in the protocol.

Masculinity and femininity questionnaire
As an indicator of gender identity in this study, the masculinity and femininity questionnaire was chosen. M/F-Q is based on BSRI and adapted for use in Sweden (Bergman et al., 1988Go).

The M/F-Q used in this study included 43 statements with four response alternatives: ‘disagree completely’, ‘partly disagree’, ‘partly agree’ and ‘agree completely’, which are quantified to 1, 2, 3 and 4 points, respectively. Of the 43 statements, 17 items are considered to represent masculine dimensions and 17 items represent feminine dimensions, while nine items are seen as neutral.

All neutral questions were excluded from our analyses, since they are included in the questionnaire only to disturb the response pattern. Furthermore, the items ‘I am masculine’ and ‘I am feminine’ were excluded as recommended in earlier studies (Blanchard-Fields et al., 1994Go) and also because there was almost no variation over the response categories. Finally, a question on the use of swearing was excluded due to its strong correlation to age in this cohort. The final number of statements analysed was 31.

Psychometric analyses
Initially, we were interested in determining whether any effects of ageing were in evidence. Mean and P-values of paired differences (Wilcoxon matched-pairs signed-ranks test), item-specific and at the individual level, were therefore used in order to test for systematic changes between the two measurements (Table 2Go). All women who had answered the M/F-Q twice were included (n = 302). There were statistically significant changes in four of the 31 items (3, 16, 36 and 39), all related to the masculinity dimension. No statistically significant changes were found for any other item. Thus, there was considerable stability over time.


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Table 2. Paired differences in means between 1990 and 1995: significance, proportion of identical answers on each item at two measurements and a factor analysis with the Masculinity/Femininity-Questionnaire
 
As an estimate of the reliability, we calculated the proportion of women answering identically at measurement points one and two (Table 2Go). The proportion of identical answers was on average 60% (range 49–68%). The proportion of women who changed their answers more than one step on the scale, irrespective of direction, was on average 3% per question. We consider that these results indicate adequate reliability.

Face validity was discussed among the authors and we concluded that the items included in the M/F-Q represent aspects of identity and personality related to gender. A comparison has also been made between the items used in M/F-Q and a recent Dutch study (Visser, 1996Go) on contemporary notions on masculinity and femininity, and close resemblance was found.

Factor analysis
A factor analysis with varimax rotation was conducted in order to analyse the properties of the questionnaire in this cohort. Different solutions were tested. If no restriction was introduced, eight factors with an Eigen value above 1 were computed. In some of these, there were few items and the content was similar to other factors. A restriction was therefore introduced and a solution consisting of four factors was computed (Table 2Go), labelled ‘leadership’, ‘caring’, ‘self-assertiveness’ and ‘emotionality’. The factors represent four dimensions of gender identity and, based on these dimensions, indices were created for the subsequent analyses. These indices were scored by summing the ratings (range 1–4) of the items included in each factor and for each person.

Psychiatric disorders and alcohol consumption
The study population was grouped into four categories with regard to psychiatric disorders (Table 3Go). Women with an alcohol diagnosis, irrespective of which one, were all included in the group ‘Alcohol dependence and abuse’. These women could also have other psychiatric disorders. However, in the other three groups, no women with alcohol diagnoses were included. Of the total number included in the study (n = 836), 445 (53%) had never met the criteria for a DSM diagnosis. The distribution of psychiatric disorders is based on a stratified sample and does not represent the distribution in the general population.


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Table 3. Categorization of psychiatric disorders based on interviews according to DSM-III-Ra
 
A separate analysis was performed on different aspects of alcohol-related behaviour. High episodic drinking (HED) was defined as consumption of at least 60 g of ethanol on at least one day in the last 12 months. High alcohol consumption (HAC) was defined as consumption of at least >=600 g ethanol per month during the last 12 months. These cut-off limits were chosen in accordance with international literature (Knibbe, 1999Go).

Logistic regression
Logistic regression was used to calculate odds ratios with 95% confidence intervals and to adjust for age in the analysis of the relation between gender identity and psychiatric disorder.

Attrition
Four types of attrition were noted. One external attrition consisted of those selected for screening who declined participation or did not answer the screening questionnaire. Another external attrition involved those selected for interview who declined further participation or were impossible to reach. The internal attrition consisted of those interviewed by telephone (the M/F-Q was not used) and those interviewed who did not fill in the M/F-Q.

Earlier studies on external attrition have not shown significantly higher proportions of women with ADA in the attrition (Midanik, 1982Go; Hasin et al., 1990Go; Spak and Hällström, 1995Go). Furthermore, telephone interviews conducted with women who were reluctant to participate indicated low alcohol consumption and shortage of time as the most common reasons for not participating. These findings do not indicate that the external attrition should differ substantially from the sample that filled in the M/F-Q. A medical record study of the women born in 1925, -35, -45, -55 and -65 did not show a higher proportion of ADA in the attrition group (Spak, 1996Go). Thus, we believe our sample to be representative for an analysis of the association between gender identity, operationalized through the M/F-Q, and ADA and psychiatric disorders. We also believe that our findings are possible to generalize to the general population. No analyses were performed to test for differences in gender identity profiles between the study and attrition groups; however, we do not assume that gender identity influenced participation in this study.


    RESULTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
As mentioned earlier, four dimensions of gender identity were identified, namely leadership, caring, self-assertiveness and emotionality (Table 2Go). We analysed the relation between gender identity and psychiatric disorders (Table 4Go) and found that women low on self-assertiveness and/or high on emotionality had a high probability of belonging to the groups of women with severe anxiety disorders or ADA. Being low on leadership was associated with increased odds of belonging to the group of women with ADA. No statistically significant associations were found between caring and psychiatric disorders including ADA. Of the four diagnostic groups, it seemed that minor anxiety or depressive disorders was least associated with gender identity.


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Table 4. Dimensions of gender identity, measured with the Masculinity/Femininity-Questionnaire (based on Bem’s Sex-Role Inventory), and psychiatric disorders, according to DSM-III-R (logistic regression, adjusted for age)a
 
A separate analysis was performed for alcohol consumption, ADA and gender identity (Table 5Go). Two definitions of alcohol consumption were used, namely HED and HAC. The same pattern emerged as that found between gender identity and ADA, although, with lower odds, since this comparison was made between those with ADA and all others (including women with or without other psychiatric disorders). Furthermore, we found that women who were low on self-assertiveness and high on emotionality had increased odds for belonging to the group of women with HED. High emotionality was associated with HAC. No specific pattern emerged related to the caring dimension.


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Table 5. Dimensions of gender identity, measured with the Masculinity/Femininity-questionnaire (based on Bem’s Sex-Role Inventory), and alcohol dependence/abuse (according to DSM-III-R), high episodic drinking and high alcohol consumption (logistic regression, adjusted for age)a
 

    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
In this sample of Swedish women, we found that those who scored low on leadership and self-assertiveness, and high on emotionality, had increased odds for having ADA. Those who scored low on self-assertiveness and high on emotionality had increased odds for being high episodic drinkers. These findings are in accordance with the studies of Wilsnack et al. (1985)Go and Sorell et al. (1993)Go, who found that women who were androgynous or masculine had lower alcohol consumption and less alcohol-related problems, and were seldom alcoholics. Lara-Cantú et al. (1990)Go found, in a study of Mexican women based on BSRI, that drinking (as compared to not drinking) was associated with aggressive masculinity. The number of drinks consumed per month was negatively associated with affective femininity. The concept of affective femininity employed in the Mexican study is very similar to the caring dimension in our study. However, in our study, we found no statistically significant associations between caring and ADA or any of the two alcohol consumption measures used.

Comparisons between studies are difficult, since different concepts of gender identity were used, different instruments employed, alcohol outcomes were measured in different ways, and the associations probably also varied between time periods and cultures. For example, the study by Lara-Cantú et al. (1990)Go was performed in a country and time period when, according to the authors, there were double standards regarding drinking for women and men. There were strong restrictions against women drinking and a highly liberal attitude towards drinking by men. In contrast, our study was performed in a country that has undergone great changes in attitudes towards drinking in women, with a much more liberal attitude in recent decades. Such cultural differences influence gender identity according to recent theories and accordingly complicate comparisons over time and cultures (Ashmore, 1990Go).

We found an association between bipolar disorders and severe anxiety disorders and low self-assertiveness, low leadership and high emotionality. These were the same dimensions of gender identity as those associated with ADA and, apart from low leadership, with HED. Earlier studies based on BSRI found an association between masculinity and better mental health (Spence et al., 1974Go; Bem, 1975Go; Ashmore, 1990Go; Blanchard-Fields et al., 1994Go). Our findings are in line with these studies, since most items of the factors self-assertiveness and leadership come from the masculinity dimension of the M/F-Q. However, none of these indices, or the emotionality index, included items solely from the masculinity dimension. These findings speak in favour of using more descriptive components of the different gender dimensions than masculinity and femininity. Based on M/F-Q, factor analysis and theoretical considerations, we found that gender identity consisted of four dimensions, which we labelled leadership, caring, self-assertiveness and emotionality.

When gender identity is analysed in relation to psychiatric disorders, ADA and alcohol consumption, we suggest that a division into different diagnostic groups should be made and that several alcohol outcomes are used. As an example of more detailed information, we did not find any obvious pattern or association regarding gender identity and minor anxiety and depressive disorders, contrary to what we had expected. Neither did we find an association between any of the gender identity dimensions and high alcohol consumption.

As alcohol consumption measures often are used as the outcome variables in studies of alcohol problems, it is important to study the relation of gender identity to HED and HAC as well as to diagnostic concepts, e.g. ADA. Of the two alcohol consumption measures, the associations between HED and the different dimensions of gender identity showed the strongest similarities with those found for gender identity and ADA. HED may thus be a better predictor of risky outcome than HAC. However, women with HED had less extreme values on the different dimensions of gender identity, compared to women with ADA. We believe that these findings provide support for the use of strictly defined diagnoses such as ADA, rather than consumption measures, when trying to understand alcoholism clinically.

Methodological considerations
Construction of a mixed study sample. There are three main concerns over the inclusions of various samples in this study base, as well as collecting interviews from different occasions of the respondent’s participation. First, there was an over-sampling of women with alcohol problems in all three samples, and thus also of women with somatic illnesses or various other reasons for attending treatment settings. The effect of this over-sampling was somewhat reduced as the largest participant groups were recruited at the GP units and the maternity units, in connection with the observation that both of these groups contained comparatively few persons with ADA. Secondly, there is the problem of time of entry, i.e. at which state of participation the women were included in this study. They could be entered either from the first interview occasion or from the follow-up interview 5 years later. It is possible that the answers to the M/F-Q change with increasing age, albeit this hypothesis was not supported by our reliability test. Thus, it appears plausible to include subjects from various stages of the study. Thirdly, we feel that it was justified to include subjects from the different samples, as we studied associations, and not rates, in a certain population.

Self-reported data. Our results are based on self-perceived gender identity which might lead to a bias, since the role of social desirability might be stronger among women who were healthy, compared to those with psychiatric disorders. On the other hand, the majority of the women with psychiatric disorders had good social functioning and were well adapted to society (Hensing et al., 1997Go). Apart from the previously discussed possible differences between the age groups (for example, younger women might be more eager to present themselves as having leadership abilities), we do not believe that the effect of social desirability in answering the M/F-Q was different across the different stratification groups.

Discussion on causal directions is limited in a cross-sectional study. This study is cross-sectional and thus we do not know anything about the causal directions. For example, the analysis cannot tell us whether, say, lacking self-assertiveness leads to mental health problems/alcohol problems or vice versa. It might be assumed that women with psychiatric disorders become, as a consequence of their disorder, less gifted for leadership, low in self-assertiveness and become more emotional. However, more empirical research with a prospective and longitudinal design is needed regarding gender identity development and the course of alcoholism and psychiatric disorders respectively, as well as in combination.

In conclusion, we found that different dimensions of gender identity were associated with psychiatric disorders, ADA, HED and HAC in different ways. More effort should be made to study the concept of gender identity, preferably broken up in more detailed indices. Our findings need to be tested also in longitudinal studies to gain further knowledge on causal directions.


    ACKNOWLEDGEMENTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
This work was supported by the Swedish Fund for Health Care and Allergy Research, grant no. 96/8 V96 203.


    FOOTNOTES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
* Author to whom correspondence should be addressed. Back


    REFERENCES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
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