What a bloody mess!

This post is about periods. It is personal and somewhat more visceral than the things I usually write, so if you don’t like descriptions of blood and gynaecological issues, you might want to skip it. It does feel a bit uncomfortable to share something that feels quite private, so I have waited a while to click post. But I want the information to be out there for other people to find, and to encourage research about the impacts of hormonal contraceptives on women’s wellbeing, so I wanted to share my personal experience. And I figured that I wanted to support other people who have spoken out, like Caitlin Moran and Naga Munchetty.

I’ve never had easy periods. Since being a teenager I’ve had marked PMS the day before, with aching belly and back, tearfulness, labile mood, moments of anxiety and irritability, as well as an increased risk of migraine. Over the decade since having children (which my Mum had always told me was the end of her period pains) they got worse. I would often experiencing clusters of sharp “spike” pains as my period approached, which seemed as if they sent needles from womb to bowel and could double me over in pain, and make it impossible to get comfortable, but were thankfully intermittent and would rarely stick around for more than a few hours. During the actual period days I would get disconcerting numbness in my upper legs, as well as abdominal pains which were almost disabling on the first day of my period, and would often transmit through my lower back. They were also associated with changes to my energy level, appetite and mood. Doctors didn’t seem to think this was a medical issue, and the only medication I tried led to cramps so severe I was curled foetal on the floor for an hour, so I never took a second dose. By trial and error I learnt that heat around my midriff seems to help, so at times I would need to retreat to bed, or my last resort of sitting in a hot bath for hours on end. When it comes to medication Ibuprofen helps the most, but I often need to combine it with prescription strength co-codamol to manage the first day.

I never really thought about how my periods compared to other women, or whether my experience was normal or a condition like dysmenorrhea or menorrhagia. I guess I just accepted that I would always have period pains, and tried to schedule my life so I didn’t put anything important on the day my period was due or anything that might need a level head the day beforehand. I’d been brought up that periods were something private, that you didn’t talk about with others, so I generally tried not to complain about it. This was reinforced by a head of year that would make me run around the school field if I asked to be excused from class in secondary school when my legs went numb and the level of discomfort prohibited me from being able to sit in the classroom. She said exercise was good for period pains, which may be true, but I suspect she just wanted the overweight girl to stop complaining and get extra exercise.

After having twins I had heavier periods with more marked blood clots, so I joked to my husband about bleeding for two. I become anaemic a few times, perhaps because I’m vegetarian and my iron stores were depleted by the twin pregnancy and never fully restored. I don’t know for sure, but I was told to take vitamins with iron every day, and have done so reliably for several years now. On the good side my periods were always as predictable as clockwork, and using a menstrual cup has helped a lot with the discomfort and length of my periods, as well as reducing the risk of embarrassing leaks (and being more ecologically sound). As a result the pain rarely lasts after the first day or two, and the period itself is short and usually tails off after three days. That gives me 24 good days per month, and only two days that seriously interfere with my functioning. I can normally manage to do some work even on the worst days if I take painkillers and wear soft warm clothing around my abdomen, but my functioning is definitely reduced and given the choice a warm bath, or a duvet day is better.

However, in 2017 I mentioned my heavy periods and the fact I get marked period pain to my GP, who suggested I try a hormonal IUD, telling me these much reduce bleeding and stop it altogether for a large proportion of women. I had previously tried the Mirena in 2002, long before having children, but had found it uncomfortable and asked for it to be removed after a few weeks. However this time the GP said it would be much more comfortable since I had carried twins and delivered them naturally (albeit prematurely) so I agreed to give it another go. After a ridiculous delay of nearly a year to find an appointment when it could be fitted at my GP practice, I found a sexual health clinic and booked an appointment during June 2018. My GP had prescribed a Mirena and a Jaydess, and I had collected both and took them to be fitted. There was no mention of potential side-effects in any of the conversations I had with the GP or the clinic where it was fitted, although I was told to take a painkiller just before it was fitted, as they said “for some people it isn’t a comfortable process”. I think I had also read that there might be some cramps whilst my body adjusted to it.

The first problem was the fitting. It hurt. Enough to make me considerably uncomfortable. It was a right-to-the-nerves-at-the-core-of-my-being-do-not-pass-go pain that was different to ordinary pain, of which I’m normally pretty tolerant. The nurse and care assistant tried to make conversation to distract me, but the pain meant I kept losing concentration and wasn’t really able to talk properly, and I felt like I was going to faint at several points. It hurt being dilated. It hurt being measured. It hurt when the nurse tried to fit the Mirena and removed it when it didn’t fit correctly, and then it hurt when he inserted the Jaydess. He said my cervix spasmed, and that the whole area is very near the vasovagal nerve and can be very sensitive. But once he had finished and removed the speculum I had high hopes that I’d done the hardest part. As I drove home the painkillers kicked in and the pain settled to much like the level of period pains.

However, that period pain feeling stuck around in variable intensity for much of the time I had the Jaydess in, which ended up being nearly four months. I also had aches and spike pains throughout the month, to the point I needed painkillers on more days than not. There were times it felt painful to stand, or that I couldn’t sleep for the pain. I got hot flushes. My boobs ached for three weeks out of every four, to the point they were tender to the touch and hurt if I took my bra off. There was severe bloating and intermittent nausea, and a feeling like having a perpetual bug of some kind. I had loose bowels and painful stomach cramps after eating that meant I couldn’t enjoy food. I had lots of headaches, and a kind of aching in my bones and joints (particularly my hip joints) that made me feel old and unwell. My hair became really greasy, to the point it was visible by the end of the day, and looked awful on day two, when previously it was fine for two or three days and I never had to think about it between the times I went swimming. I got painful cystic acne on my face, shoulders, back and bum. Not in huge numbers, but there was always a new zit or two visible in the mirror each day, they took several days to rise to the surface of my skin, and it increasingly felt uncomfortable (when prior to the IUD I’d only get a couple of visible spots per month, and they were never painful).

It also changed my mood. Like the worst examples of how I had been on the day before my period before, I found myself on the verge of tears about anything sentimental or sad, and my feelings felt less rational and less within my control. I had patches of acute anxiety, and generally lower mood, with greater irritability. That may have been compounded by the fact I had weird dreams and disrupted sleep, and would often wake in the night with stomach pains, cramps or aching and find it hard to get back to sleep. And to cap it all my periods were longer and heavier than before, with a shorter gap in between, leaving me only one week of feeling relatively good, and even that was characterised with lots of low level aches and pains. A minor additional problem was I couldn’t reach the coil’s strings to check it. I don’t know if that is my short fingers or inflexibility, my slightly retroverted cervix, or whether they were clipped a bit short. But it was a bit unnerving to be told to check it and not to be able to.

Weirdly, I was prepared to tolerate all that for month after month on the basis that it might get better over time and reach a point where the side effects disappeared and the promised effects appeared. They had told me to stick with it, and that things would get better, and I was determined to do so. But the symptoms seemed to get worse month by month, rather than reduce or resolve. The final straw was that my vision started to blur. I noticed that I couldn’t see the TV properly from the sofa, and was moving forwards to sit on the floor closer to the screen. I couldn’t see the road signs or number plates when driving until much closer to them than usual. And anything at a distance seemed fuzzy and indistinct. That made no sense, given I’d just had an eye test that said my vision was fine only a couple of weeks before I got the IUD. In fact, my prescription had not changed for over a decade, and I’d been wearing the same contact lenses and glasses for as long as I could remember. My eyes started to feel dry in the evening, and my contact lenses also started to feel uncomfortable, after being almost unaware of wearing them for most of the last thirty years. I read online that levonorgestrel can affect your eyes. So I went back to the optician. He said there was nothing overt wrong that he could measure, except that my astigmatism, which had previously been below the level at which they correct it, had markedly increased and I now needed toric lenses to compensate for this. He didn’t think it was related to the Jaydess, but the sudden change seemed very strange.

Looking up the side effects of Jaydess/Mirena made me realise quite how many I was experiencing, and how this wasn’t typical of the official reported level of side effects, or the miraculously lighter and easier periods I had been promised. So I phoned the GP, who tried to get me to persist, promising it would settle, and really didn’t seem to listen to or appreciate the level of discomfort it was causing. After nearly four months I insisted it was removed. That actually went pretty smoothly. I managed to get an appointment with the one female GP with an interest in contraception. She listened and said it didn’t seem to suit me and agreed to remove it on the spot as I had not had unprotected sex in the prior seven days (to be honest, it had been a pretty effective contraceptive in that it put me off sex altogether for the entire time that sharp anchor of metal was inside me). The removal was equivalent to having a smear test. The awkwardness and discomfort of the speculum, then one second of that direct-to-the-vagus-nerve pain and it was done. Afterwards mild aching that was relieved by analgesics. So I figured it had gone pretty well. Again, there was no warning from the GP or in anything I was given to read of any symptoms likely to appear because of the artificial hormones disappearing from my body.

However, that mild aching came and went for the next few days, and then I started to get cramps and traces of dark brown blood as my period approached. That developed into a fairly typical PMS level of discomfort, but the volume of blood was still very small and much darker than usual. Typically my periods arrive quite quickly after the PMS and cramps, with two days of moderately heavy flow (about 40-60ml per 24 hours) and the bleeding then tapers off during the third day (making a total volume of about 80-120ml shed during the whole period). Hence the use of a femmecup, which can normally see me through the night, or through a working day, without any problems. However this time around my period started slowly, but then on day three there was suddenly large volumes of thin bright red liquid blood like the stuff they squirt around for a horror b-movie. At times it filled the 30ml of my menstrual cup in under an hour and if I didn’t catch it, this unusually liquid blood then leaked out onto my clothing or bedding spreading obvious bright red stains. No form of sanitary protection helped. I had more leaks and mess in that two days than in the last decade of periods combined, and had to change enough clothing and launder enough bedding to run the washing machine twice (both times having to interrupt it to add more items after the wash cycle had started). I’d estimate I bled 250ml of this thin bright red blood over 48 hours – that’s seven times the volume of an average woman’s period, and more than double my usual total in a very short period of time. It was incapacitating because of the need to empty the cup so often and the risk of embarrassing leaks, but it didn’t hurt at all. I just felt a little nauseous and faint, which might just have been a reaction to seeing so much blood. And no matter how careful I was it kept creating crime scenes for a low budget horror movie.

It would have utterly freaked me out, and perhaps even sent me running to A&E, except that I found other reports of similar bleeding after the removal of Mirena on the internet. Thankfully after the second day of flooding it petered out. I’d guess I bled near 300ml in total, which is ten times a typical period and nearly the amount I donate from my veins when I give blood as a donor. I really think they should warn women about that, as that much blood without warning has the potential to be pretty traumatic.

By then I had read about the “Mirena crash” and was prepared for massive emotional symptoms that might spiral me into a depression, but thankfully they were not too bad compared to what others report – perhaps because (like any review site) it is only the more extreme experiences that motivate people to write about them, or perhaps I’m normalised to some hormonal symptoms, or because the Jaydess uses lower doses of hormone, or because it had only been in for three months. I did have increased emotional lability, to an extent that was very out of character for me and created a couple of protracted emotional confrontations with family members about minor things I would normally have let pass without comment. Plus for a week or two I was in a generally more negative headspace. Possibly the most disconcerting element was patches of free-floating anxiety; I’d get a sudden sense of having remembered something I should have done, or had done really badly, or that had made someone else react really negatively to me, or foreboding about something terrible happening, but without anything to pin it to. And then, gradually, it settled back down to more or less how things had been before. The breast ache, abdominal pain and cystic acne dispersed and I went back to the prior level of period pain I had been having for the decades before.

About 18 months ago I finally saw an endocrinologist who tested lots of things and didn’t find anything he needed to treat, but referred me on to a gynecologist. Whilst I hadn’t had symptoms I’d associate with menopause, like hot flushes or cessation of periods, loss of libido or vaginal dryness, she seemed particularly swayed by the fact I was 45, had missed one period (albeit with timing that seemed related to other stress/health issues) and had experienced anxiety, and joint stiffness (though the latter has been present since an RTA in 2015), and concluded the underlying cause of all my symptoms was probably perimenopause. She recommended I try HRT – even though most of the symptoms I reported had been the same throughout the prior decade, and many had been fairly consistent since I was about 15 years old. I was cautious, given the one ingredient in the HRT is the same as the hormone used in the coil, but I didn’t have any better options and decided to give it a go.

I went onto HRT just as the nation went into lockdown for the coronavirus pandemic, so it was hard to pick out what was the result of the acute anxiety I felt at that point and what was side effects of starting the meds. Subsequently it has been hard to unpick the impact of the HRT from the impact of pandemic lifestyle changes. When I weigh up the positive and negative changes I have observed, it is a fairly close-run contest, but overall I think it has more benefits than costs, particularly in my mental state. On the good side, I have less marked emotional swings prior to my period, and my anxiety has reduced. My periods are slightly less heavy, and there has been a small reduction in pain. On the down side, my skin is now very dry (which has exacerbated the eczema I get on my feet) and I seem much more prone to heat rash in my armpits and groin, and thrush-like discomfort. I’ve also put on some extra (and very much unwanted) weight – but I’ve been much less physically active as I haven’t been swimming or to the gym. Given the risk of stroke, I’d rather be on patches than tablets, but I’m now closed to gynecology and none of the GPs feel able to review my HRT since the female partner left.

Whilst clearly everyone’s experiences of health conditions and treatments are different (and I’ve known several colleagues who raved about Mirena) there are some wider themes that I think are more universal. I’d say my experience of putting up and shutting up is probably quite typical, in that lots of women just get on with things. We are taught not to moan. Women’s reports of pain are taken less seriously, and conditions like PCOS and endometriosis are massively underserved. Medical research treats men as the default, and sees women as innately skewed by our hormones. The funders setting priorities and the people leading the research are more often male, so they don’t give women’s health issues the same level of priority. Contraception is seen as a problem women must shoulder the burden of, and menopause something shameful we must hide and suffer in silence (Davina McCall’s TV program on this topic captured it well). These issues really aren’t things men would be expected to tolerate. I was really struck by the furore about the few awful cases in which people had blood clots after receiving their covid vaccination, and how the probability was a fraction of that caused by the contraceptive pills millions of women take without the same level of public or professional concern. Women’s health is too often forgotten and devalued. No wonder periods and contraception are so poorly addressed, and so many women suffer in silence.

Our relationship with alcohol

Today an article from WHO about reducing the harm caused by alcohol around the world has got people all fired up on social media. The article has slightly clumsy wording about prevention of harm to unborn babies from alcohol, that some people have interpreted as a recommendation to prevent women of child bearing age from being allowed to drink. In response people have jumped in as much to defend/normalise drinking as to stick up for women’s rights (and to rightly criticise the way certain other types of risks from alcohol are only mentioned by reference to other documents, such as the risk of interpersonal violence, or not mentioned at all, such as the risk of perpetrating or becoming a victim of sexual assault). Having tried to reply on twitter but ended up with a mega-thread, I thought it might be preferable to respond fully in a blog post about our relationship to alcohol, including some links to relevant psychological theory.

Before I begin, I should note that I’m not an unbiased observer on this topic. For the last 30 years or so, I have chosen to drink very little alcohol (typically about 5 units per year) as I don’t particularly like the taste of most alcoholic drinks, or the way I feel after the effects have worn off. I also had a very negative experience of being drunk early in my life (see this blog entry, which comes with a trigger warning about sexual assault). That led me to often choose to be the driver or the person who stayed sober on nights out, which also gave me a rather atypical perspective on alcohol – as I was often the person who was looking after the person who had puked up or passed out, or was vulnerable to sexual assault. Speaking of which, I have previously expressed some strong opinions about whether alcohol is an excuse for behaviour (it isn’t; blog also deals with sexual assualt).

So, I am fully on board with the criticism that any global policy about alcohol needs to mention its association with interpersonal violence and sexual assault. We know that drugs and alcohol are often the source of disinhibition for abusers (and can be a step used in overcoming inhibitions for those who feel guilt or social pressure, such as in Finkelhor’s model of factors neceesary for child sexual abuse to occur). We also know that they are often used to create vulnerability in victims (eg with use of drugs in alcoholic drinks by rapists like John Warboys and Reynhard Sinaga) and that the vulnerability of intoxication is frequently exploited as an opportunity for sexual assault. As BPAS say in their response to the document “In the UK alone, more than a third of sexual assaults, more than 39% of all violent crimes, and nearly 1 in 5 incidents of domestic abuse are committed under the influence of alcohol” and this clearly needs to be mentioned in a document about reducing the harm caused by alcohol around the world, more than by passing references to other WHO documents about violence.

However, I’m also someone that believes in preventative and health promotion interventions like schemes to provide healthy food for pregnant women and young children, or the tax on sugary drinks. So it should come as no surprise that I’m broadly in support of measures to reduce problem/excessive drinking and tackle the culture of binge drinking amongst young people. I think a minimum price per unit of alcohol, and more education about alcohol (and drugs) and their risks and benefits would be a good starting point. This should ideally be part of the national curriculum for children, and something that is revisited at developmentally appropriate levels.

So, with my general opinions laid out, let us return to today’s publication. The WHO document is called “Global alcohol action plan 2022-2030 to strengthen implementation of the Global Strategy to Reduce the Harmful Use of Alcohol” and is clearly marked as a first draft. The statement that has been perceived as controversial is that they recommend we “raise awareness among decision-makers and the general public about the risks and harms associated with alcohol consumption. Appropriate attention should be given to… prevention of drinking among pregnant women and women of childbearing age”.

To state something I hope would be obvious: Taking a literal interpretation of this sentence to mean that all women of fertile age should be prevented from drinking alcohol would be ridiculous and awful. I strongly agree with the critics that women are more than just breeding vessels, and that it would be massively disproportionate and set back women’s rights to prevent all women of fertile age from drinking on the basis of potential harm to a foetus. There are many complex and interwoven issues here, the way that gender and fertility have been conflated ignores the presence of anyone trans, intersex or with any of numerous medical conditions that can create infertility. It also assumes that all women are sexually active and none are using contraception or taking any control over their ability to conceive. Taken literally this therefore extends guidance that is perfectly logical for sexually active women who are fertile and not using contraception to every person identifying as female under the age of 50. However, I hope is a thoughtless omission in their wording rather than the intended meaning. It also assumes that any consumption of alcohol at any stage of the pregnancy is potentially harmful to a foetus, which does not appear to be entirely supported by science (where to the best of my current knowledge it would appear that low consumptions of alcohol have not been associated with harm and there are particular windows during pregnancy in which harm to the developing foetus is more or less likely to occur). Thus advice to avoid excessive or chronic consumption of alcohol during pregnancy appears to have been extrapolated into advice for all women of fertile age to consume no alcohol at all. And that clearly needs to be clarified as this first draft is developed into the final published document.

However, I genuinely don’t think that is the intended meaning here. The document doesn’t mention the rights of the foetus being more important than those of the mother as some critics have inferred (in fact it doesn’t even use the word foetus). Nor does it call for bans on the sale of alcohol to women (in fact it doesn’t even expand on the topic of female alcohol use at all). It only uses the word “women” four times, twice in that sentence, once in relation to mortality and once when talking about the incidence of alcohol use disorders. It literally just says the one sentence I quoted above.

I can see that the wording of the relevant sentence is slightly clumsy, perhaps because of international authors, but It is my belief having read the full guidance that this document is not advocating an unreasonable curtailment of the freedoms of women. Whilst it mentions “prevention” of women drinking, this is in a section entitled “Advocacy, awareness and commitment”. It is written in the context of preventing harm by reducing the social pressures encouraging excessive drinking and providing information about risks that would lead to informational campaigns discouraging children and pregnant women from drinking. It is not an assault on feminism or suggesting that states increase authoritarianism.

And importantly, this isn’t a personal message to individual female readers. It isn’t some jumped up know-it-all judging you for having glass of wine or two in the evening to unwind. It is a draft policy statement proposing educating people around the world about the risks of drinking whilst pregnant in the hope that more women choose to abstain. If you are past menopause, or not sexually active, or use contraception, or drink little/no alcohol, or for any of a myriad of other reasons aren’t going to end up binge drinking before realising you are pregnant, this message to reduce or cease alcohol consumption is not for you. You can let go the anticipated reproach and stand down.

Whilst the tabloids are trying to make this into a big deal, this fits with their xenophobic British exceptionalism agenda, whereby they are dismissive of international bodies, experts and science and try to frame them as limiting personal freedom and autonomy. So when they use stories like this to fuel the “nanny state curtails our rights, its political correctness gone mad” narrative, remember that each of these little fires is built to distract from the way the government are slowly attacking our rights and the safeguards over their power like the right to call for judicial review of government actions, GDPR and the protection of our data from commercial exploitation. Like the fantasy that conservative voices are being cancelled/silenced by an oversensitive generation of woke snowflakes rather than that market forces mean racists and sexists are increasingly feeling the rightful consequences of their repugnant views, or the way that taking the knee to acknowledge racism exists and needs to be tackled has become some unpatriotic politicising of football, this is just a distraction technique. These stories distract from the unlawful crony contracts that have funnelled public funds to friends of cabinet members, the way politicians no longer resign when they are found to have been dishonest, the failure of Brexit, growing inequality, the mess they have made of the pandemic and all the other ways the Overton window has shifted right and the current pack of corrupt incompetents are making a mess of governing the nation.

I think the best way to look objectively at the issue here is to let go of the wording and look at the overall tone of the message. WHO advisors are trying to reduce rates of death, disability and children harmed by foetal alcohol exposure. Surely that is a good thing? It is directly parallel to trying to prevent cancers/disease and harm to others from smoking (including during pregnancy or around young children) – something that was socially acceptable until surprisingly recently. Smoking is (or at least was) another choice that some people find enjoyable, but scientific studies associated with excess mortality. If we saw a publication warning women about smoking harming an unborn child it would probably not immediately make people want to post “oh just reading this makes me want to smoke a whole box of cigarettes”. So I wonder, objectively, why a twitter post replying to the report saying “I’m not sure where to start with this. Maybe by opening a bottle of wine?” has received so many likes?

For context: Alcohol causes 3 million premature deaths a year – that is more than tuberculosis, HIV/AIDS and diabetes. This includes 13.5% of all deaths among 20 to 39-year-olds in the world. In Russia and eastern Europe, nearly a third of people’s lives are shortened by alcohol use, though the rate in the UK is about 3.4%. In the USA research shows that alcohol contributes to about 18.5 percent of emergency room visits and 22.1 percent of overdose deaths related to prescription opioids. Around the world about 1.4% of people are considered to have an alcohol use disorder, with the highest prevalence in Russia and neighbouring states, where it is about 5%, and Brazil and Greenland, where it is about 3%. In America the diagnostic rate is higher (at about 5%), but it is unclear whether the prevalence is higher or the thresholds for diagnosis are lower. Globally, alcohol use disorders lead to 185,000 deaths per year, with around 2300 in the UK. This number has increased considerably since the 1990s, but has been fairly steady for the past 15 years. Few of these people receive formal treatment, with only 5-6% getting treatment in the UK. The incidence of alcohol use disorders increases significantly for those with mental health problems, showing that either the same stressors can lead to both outcomes, or that mental health problems can increase the risk of alcoholism or vice versa.

Problematic alcohol use can either take the form of binge drinking – where the drinking is excessive in quantity, but happens intermittently, perhaps once or twice a week, or on particular occasions or where the individual gets together with a particular social group – or chronic and excessive consumption (where the individual drinks every or almost every day over a protracted period of time). Both patterns are surprisingly common.

About 25% of the population meet the criteria for binge drinking on surveys about alcohol consumption, whilst around 7% report heavy drinking (5 or more units per day on 5 or more days during the last month). Even within geographic regions, there is a high level of variation between countries: in Italy, only 6 percent of drinkers had a heavy episode of drinking during the past month in contrast to nearly half in Ireland; 42 percent in Belgium one-third in the UK and France; and 20 percent in Spain. Binge drinking is particularly common amongst students and young adults, with around 50% of those who have ever drunk alcohol reporting in surveys they had drunk to the point of blacking out at least once, and 10% reporting a blackout associated with drinking in the prior two weeks. If some of those young women are becoming pregnant (perhaps due to sexual encounters when intoxicated), that level of drinking could potentially be a significant risk factor for the unborn babies.

Drinking alcohol to excess can also lead to other additional risks for the drinker. Whilst the immediate effects of alcohol are usually perceived as pleasant, and resolve fairly quickly when drinking stops, they can lead to memory lapses, poor judgements and an increased risk of accident and injury (as well an increased risk of sexual assault). Blackouts can involve potentially dangerous behaviour and loss of consciousness. Binge drinking is known to increase the risk of medical crises, and is a significant contributor to the number of people who present at A&E. Studies show that compared with people who did not binge drink, people who drank alcohol at twice the recommended thresholds were 70 times more likely to have an alcohol-related A&E visit, and those who drank three times as much as the recommended limit were 93 times more likely to present there.

Alcohol also presents other less acute risks of harm. The effects of alcohol on the body become more severe with larger volumes consumed over extended periods of time – with particular risk to the liver, heart and brain. Changes to the brain can eventually disrupt memory and lead to Korsakoff’s syndrome. Alcohol is also physically addictive, with greater risks associated with sudden withdrawal than most drugs.

There are no hard and fast rules, but chronic excessive use appears to follow a different pattern to binge drinking, which is typically social – perhaps because the cost of alcohol in quantity soon prohibits this being consumed at pubs and clubs, or because of the pattern of drinking, or the impact of the level of intoxication on social functioning. The reality of problem drinking is, like most things in life, a bit more complicated than simply being the upper section of a spectrum of consumption. It seems to have some biological components, marked social components (eg when alcohol is used to cope with social situations or fit with peers) and is often cumulative over time. As with most addictions serious alcohol issues are often rooted in combinations of learnt behaviour and exposure to trauma. Impoverished or abusive relationships in childhood set a harmful template that can lead to dysfunctional coping strategies and relationships later on. These can create patterns that reinforce problem drinking, and masking the drinking can disrupt supportive relationships.

However, it is not just in the context of alcohol misuse disorders that alcohol causes harm and excess mortality. Alcohol also increases mortality via road traffic accidents. In South Africa and Papua New Guinea more than half of all traffic deaths are attributable to alcohol consumption. In the US, Canada, Australia, New Zealand, Argentina, and many European countries alcohol is responsible for around a third of all traffic deaths. Alcohol is also implicated in more than half of all crimes in the UK – either because the crime involves alcohol (eg drink driving, drunk and disorderly, theft of alcohol) or because the person committing the crime had consumed alcohol (eg in violent crime, assault or criminal damage). This is higher than elsewhere in the world where this has been studied.

Alcohol also causes Foetal Alcohol conditions that can have a lifelong impact on the brain. NICE say the exact incidence is unknown, but it was thought that about 7.7 people per 1,000 worldwide are affected, and 32.4 per 1,000 population in the UK. A study following up a cohort of births looking at possible symptoms suggested the prevalence could be as much as 6 to 17% of the population. The official UK advice is that the safest approach for women who are pregnant is not to drink alcohol to minimise risks to a baby. However, multiple sources suggest that 41% of pregnant women in the UK consume alcohol, and research shows women are not universally given information about the risks of alcohol during pregnancy (with 30% of those who drank before pregnancy reporting getting no information on this topic from maternity services, and only 29% of midwives saying they routinely share this information). The messages about how much alcohol is safe are unclear. There is a consensus from the stakeholders that NICE consulted that education and raising awareness of the risks of drinking alcohol in pregnancy is necessary, and 91% of alcohol bottles sold in the UK now warn against drinking during pregnancy. So it should be no surprise that the WHO also feel that women around the world who are pregnant or who may become pregnant (because they are of fertile age and are having sex without contraception) need to be aware of the risk posed to a baby by excessive alcohol consumption. Reducing alcohol consumption in these groups will reduce harm.

Yet as soon as reduced consumption of alcohol is mentioned, it brings out an almost reflexive response. I think some of that is “anticipated reproach” – the defensive (but often antagonistic) response people have to anyone they feel may judge them negatively, which can sometimes be combined with “do-gooder derogation” the feeling that anyone taking the higher moral ground about an issue personally, or taking action to resolve it, must be pompous and judgemental. Anticipated reproach has been studied by Benoit Monin, who has shown the effect in relation to everything from vegans to racism. We can see that playing out in the response to this WHO report. People want to speak out for their right to consume alcohol, and don’t perceive it as harmful (except in others with obviously excessive drinking).

The pandemic has also conflated unrestricted access to alcohol with the idea of personal freedom and agency. Closing pubs has been seen as more of an imposition on our rights than closing schools – particularly for the vocal anti-mask/anti-vax brigade (I wonder if there is some overlap between views about pub-drinking and a rejection of broader progressive values? It certainly seems to be associated with covid denial, Brexit-voting, and dismissal of expert advice, which I associate with a kind of disenchanted malaise that comes from underachievement and a feeling of being cheated by the changing social contract that makes people vulnerable to alt-right propaganda).

But I think this positive and normalising view of alcohol long predates the more recent changes to the socio-political environment, and the increasing polarisation of society. Alcohol has been embedded in our culture for thousands of years, and it holds an important role in social engagement and special occasions. So for most people it has positive associations. It is also an example of something where many people use the substance, yet comparatively few are harmed by it (the same could be said of illegal drugs like cannabis). So (as with the “just say no” campaigns that portrayed illegal drugs in entirely negative terms) dramatic warnings about potential harms don’t tend to chime with personal experience, which may be another reason for the defensive response.

The annual global average alcohol consumption is equivalent to 6.4 litres of 100% proof alcohol per adult per year. This is equivalent to 53 bottles of wine or 225 pints of beer (a bottle of wine or 4.5 pints of beer per week). In the Middle East and north Africa (which contain many Muslim nations where alcohol is frequently prohibited for religious reasons), consumption is much lower than average and often close to zero. In eastern Europe (and Nigeria) consumption is typically double the global average, and western Europe is not far behind. The UK, Russia and Australia are also well above the global average. However the type of alcohol, age and gender of drinkers, and the patterns of consumption vary from place to place. Broadly beer is quite widely consumed outside of the middle east, wine is most popular in Europe, Australia and southern South American nations, whilst spirits are most popular in Asia and Russia. In the UK the consumption of wine has increased steadily over the past three decades, whilst consumption of beer has reduced. The highest percentage of income is spent on alcohol in Europe and Australia – with Ireland being an outlier where around 7% of income is spent on alcohol. In general wealthier individuals drink more, although there is not a higher incidence of problem drinking.

For most people alcohol is a pleasurable mild intoxicant. And most people consume alcohol in moderation, where the impacts on health are more debatable (and in some cases even suggested to be positive – especially when it comes to wine as a component of a Mediterranean diet). So we do have to set the concerns about harm in context with the fact that many people derive pleasure and little or no harm from their alcohol consumption.

However, even when it comes to foods, consumers are increasingly given a warning of the fat, salt and sugar content, so that they can make informed decisions about their health. This balancing of benefits and risks is also something we are familiar with when it comes to the leaflets enclosed with prescribed medications, and has been in the spotlight in relation to the coronavirus vaccinations – where potential harms, like the tiny proportion of people who have had blot clot related complications, have dominated the discourse, despite the fact that for the vast majority of people it is protective and side effects are relatively trivial. Perhaps it is a good precedent that the benefits and risks of something have to be clearly explained even when there is widespread consumption?

After all, alcohol gets lots of positive messages to the public every day. There are numerous adverts showing beautiful, healthy, happy people engaging in social drinking. But on top of this, alcohol gets advertised from peer to peer. I see lots of social media posts about drinking, and almost all have a positive or light-hearted tone. Research corroborates this – surveys of social media show that posts which picture or talk about alcohol use show happy social occasions, groups of people interacting, romantic settings and chilled nights in. They talk about fun and exciting experiences, celebrating, dancing, dating. Posts rarely show risks or consequences. There are numerous memes like “wine o’clock” or “just a little glass” with a picture of an enormous glass of wine, as well as many references to alcohol as a survival strategy or a means to cope with parenting. Comedians joke about binge drinking and Irish weddings. I’m not sure people think about the impact before sharing posts or memes that feature alcohol, but studies show that exposure to alcohol posts on social media leads to increased alcohol consumption (why else would alcohol companies spend billions on advertising?). This means that seemingly harmless posts can potentially have negative impacts on others. This might particularly be an issue for those who have a problematic relationship with alcohol. Studies have also shown that people who post about alcohol consume more of it.

Yet it seems we each normalise our own consumption. Alcohol consumption and related risk is influenced by how the person perceives they compare to others in the population (if they believe others drink as much/more than they do, they believe their drinking is less risky). This is compounded by overestimating norms. So the more we drink, the more we assume others drink to subconsciously justify our own drinking (the same pattern also appears to be true of drug use, or sexual behaviours). The influence of social norms is a whole field of psychological research.

But I think that this can also happen at the societal as well as the interpersonal level. There has long been a tendency to encourage/normalise drinking in the UK that leads to people not recognising excessive/harmful use. Perception of alcohol use varies by drink, context, time and characteristics of the drinker. Adults typically regard themselves as moderate drinkers and disapprove of excessive drinking by others. We are not very good at judging the threshold at which alcohol use can be harmful, particularly when we are amongst others who consume alcohol in large quantities. I’ve met many who normalise drinking vast amounts (eg >40 units in a day). So maybe, like smoking and sugar consumption, and out lack of physical activity and increasing obesity, we do need to think more about harm minimisation?

Alcohol causes 24,000 deaths and over 1.1m hospital admissions each year in England, at a cost of £3.5bn to the NHS. Yet at the moment, the only labelling of alcohol to indicate risks is voluntary, as is the industry funded Drink Aware campaign (which sprung from the Campaign for Smarter Drinking instigated by my business mentor and NED Richard Evans before he left the drinks industry). Like the similar Gamble Aware campaign, the aim springs from corporate social responsibility and is intended to maintain profits and consumption whilst reducing harm – which could be considered to be competing interests. Experts say that the drinks industry would lose 38% of their income if drinkers kept to recommended guidelines, losing £13 billion per year of sales, which is why they are so reluctant to promote accurate information about the risks involved. So once again, there is a weighing up of corporate profits against public health. A minimum price per unit of alcohol and increased duty to subsidise costs to the NHS and the impact of alcohol-fuelled crime (eg police, services for sexual assault, refuges for survivors escaping domestic violence) might seem to be appropriate steps towards getting that balance right, but the public really don’t seem to like the idea of raising the cost of their simple pleasures….