A Modest Proposal: All men of impregnating age should be prevented from drinking alcohol to improve pregnancy outcomes

My submission to the WHO Global Strategy to Reduce the Harmful Use of Alcohol

Intimate partner violence is a serious concern during pregnancy and the postpartum period, which are heightened times for violence. Medical consequences of pregnancy-related intimate partner violence include unplanned pregnancies, maternal injury and death, and fetal injury and death. Women who experience intimate partner violence during pregnancy are more likely to have a miscarriage or a premature delivery. In the United States alone 324,000 pregnant women are abused by an intimate partner each year. Alcohol is a significant co-factor in intimate partner violence, so as part of the WHO’s Global Strategy to Reduce the Harmful Use of Alcohol appropriate attention should be given to prevention of drinking among men of impregnating age.

As we can never depend on a man to understand the medical consequences of alcohol, be truthful about his risk of impregnating someone, or otherwise keep his sperm to himself this problem requires the broadest of brushes. Prevention of alcohol use among all men of impregnating age is the only solution.

Do I have your attention? Does this sound extreme and invasive? Can you imagine judgmental signs in all establishments where alcohol is sold warning men not to drink? Bartenders that ask men if they “Really want to have another in case there is a baby in their future?” Warning labels on every bottle telling men they must consider the future destination of their sperm?

I hope so. Because this is exactly how some of the language regarding women and alcohol reads in the WHO’s Global Alcohol Action Plan 2022-2030 to strengthen implementation of the Global Strategy to Reduce the Harmful Use of Alcohol and the kind of tactics that could be employed to enact that plan. You can read the draft here (thank goodness it’s a draft). 

I want to be clear. Alcohol is a major contributor to disease and death. According to the WHO it kills about 3 million people a year, which is 5.3% of all deaths. Alcohol causes liver failure, heart failure, it is a carcinogen, leads to motor vehicle fatalities, as well as homicides and suicides just to name a few of the medical consequences. More people die from alcohol than from tuberculosis, HIV/AIDS or diabetes. Alcohol also kills many more men than women—2.3 million of those annual alcohol related deaths are among men and 0.7 million are women. When it comes to disability related to alcohol use, men also face a much higher disease burden. 

And yet, the WHO document, which I just reconfirmed was in fact published in the 21st century, states the following  (bold type for emphasis is mine):

Appropriate attention should be given to prevention of the initiation of drinking among children and adolescents, prevention of drinking among pregnant women and women of childbearing age, and protection of people from pressures to drink, especially in societies with high levels of alcohol consumption where heavy drinkers are encouraged to drink even more.

Yes, pregnant women and women of childbearing age should be prevented from drinking alcohol.

This language clearly exists because of fetal alcohol spectrum disorders or FASDs which are very serious, but the assumption here is that all women are simply potential pregnancy vessels. That’s why my modest proposal applies to all men, because the WHO didn’t see the need to clarify that not all women of childbearing age have sex with men, are capable of getting pregnant (for example, some have had hysterectomies), or that many are on highly reliable contraception. Also, some men and non binary people can get pregnant, a fact also omitted by the WHO. 

There is also this nugget:

One of the most dramatic manifestations of harm to persons other than drinkers is prenatal alcohol exposure and the development of fetal alcohol spectrum disorders (FASD). 

Yes, while it is true that a child affected with FASD is a person, a fetus is not. Given the unprotected status of abortion in many countries, including most of the United States, and the personhood movement, conflating a fetus with a person is indeed an unfortunate choice. The line above works just as well by removing “to persons other than drinkers.”

This misogyny is only further emphasized when you take into account there is another dramatic manifestation of harm to persons other than drinkers during pregnancy that is not even mentioned in the document, but the basis of my modest proposal - being beaten to the point of miscarriage, injury, premature delivery, or death by an intimate partner under the influence of alcohol. Why was this magically left out when the WHO had previously made it clear in other documents that alcohol is a cofactor in intimate partner violence? If the goal is to protect all people and fetuses from the effects of alcohol, shouldn’t we also care about the maternal deaths and pregnancy complications that are the direct result of men drinking alcohol? 

In fact, I couldn’t find the term “intimate partner violence” in the document at all, double checking with a word search for both “intimate” and “violence.” There is just a generic mention of violence several times, such as the following:

The harmful use of alcohol can also result in harm to others, such as family members, friends, co-workers and strangers.  

The language in the WHO about preventing alcohol use among women of childbearing age is even more appalling given the document begins by noting the fact that alcohol negatively affects men more than women. Given this fact, isn’t it even more important that we “prevent” men from drinking alcohol altogether? Not only can we save the lives of pregnant women and prevent pregnancy loss from beatings during pregnancy due to alcohol fueled violence, we could save the lives of men! Why just focus on pregnancy and children, don’t the men who are alive right now matter? My modest proposal could save a lot of lives. Men, I’m looking out for you because Lord knows you can’t do it yourselves. 

The way to tackle the very real and serious problem of fetal alcohol spectrum disorders is not patriarchal messaging. If you want to bring ~50% of the population to the table on an important issue, you cannot reduce them to the diminished status of potential breeders. Most messaging about alcohol and FASDs will simply be dismissed as patriarchal because that is how it is being delivered.

Rewriting the section of the WHO document that pertains to FASDs: 

While my earlier comments about preventing men from drinking were written to make a satirical point, the following is a serious attempt to help the WHO out with language that is both factual and more inclusive:

Alcohol is a teratogen, meaning it causes birth defects. The general population typically underestimates the frequency and significance of fetal alcohol spectrum disorders. FASDs are believed to affect 1.1-5% of children, but this is a conservative estimate. The first step in reducing FASDs is to get all people to buy into the magnitude and severity of the issue, and that it is a preventable condition. 

There has been an unfortunate false narrative that “some” level of alcohol (although what “some” means is rarely spelled out) is safe in pregnancy and often the corollary is the equally false narrative that doctors are lying about alcohol safety in pregnancy. While the more alcohol consumed, the greater the risk, predicting a safe amount of alcohol under which threshold FASDs won’t occur is not possible. Given this fact, the safest medical position is to recommend no alcohol for the duration of a pregnancy. The second step in preventing FASDs is to correct the disinformation about alcohol and pregnancy that is perpetuated online, in some popular books on pregnancy and parenting, and by some medical professionals. This must be done in a way that does not single out women of childbearing age and position them as breeders. It is also important to note that many women of childbearing age are at no or minimal risk of pregnancy and not all people who get pregnant are women. In addition, singling out women of childbearing age opens the door for laws that might target and further disenfranchise this population, so this language must be avoided.

Unplanned pregnancies are common and many people do not realize they are pregnant in their first few weeks or even months. If they are drinking alcohol they are at risk for a pregnancy affected by a FASD. As binge drinking among women is increasing, this only further compounds the risk. The answer here is not to prevent those who can get pregnant from drinking, rather it is education about FASDs and other alcohol related conditions (see steps 1 and 2 above), and to enact step 3 of the plan, which is implementation of universal and accessible health care that includes education and treatment if desired for binge drinking for all people regardless of gender or ability to conceive, as well as free contraception, abortion, and prenatal care (the latter so access to prenatal care starts early and can involve counseling about alcohol use in pregnancy if necessary). It is important to remember that the medical ramifications of binge drinking are not unique to those who can get pregnant or who are pregnant and this should be reflected in potential programs. It is equally important to remember that access to contraception, abortion, and prenatal care will reduce FASDs.

As minimizing alcohol-related harm to pregnancies is part of the Global Strategy to Reduce the Harmful Use of Alcohol it is essential to address the fact that alcohol use can seriously impact pregnancy even when it is not consumed by the pregnant individual as alcohol fuels intimate partner violence, and pregnancy and the postpartum period are a heightened time for this violence. The risk of homicide among pregnant/postpartum women is increased 1.84 times when compared with non pregnant/non postpartum women. Step 4 of the plan involves education regarding this serious health concern as well as implementing community resources and laws that actually protect victims of intimate partner violence and prevent or reduce the risk of a perpetrator committing further acts of violence.

Fetal alcohol spectrum disorders are serious and preventable, but the current WHO language focuses on fetal outcomes and ignores the pregnant person. It is patriarchal, divisive, and condescending and as a result is likely to be ignored by those it is trying to help. It also sets up people who can get pregnant and their fetuses as a class that needs special protection, and there are many concerning social and political ramifications inherent in that messaging. The emphasis on FASDs and absence of discussion about injury and death caused by alcohol-fueled attacks by male intimate partners only reinforces the breeder language in the document. 

The answer here is not to reduce women of childbearing age to broodmares and to prevent them from drinking as if they are a lower class of citizenry needing special protection from themselves, rather, it is to improve messaging about all the harms of alcohol and effective and accessible tools of prevention, including those specific to pregnancy as outlined above.

The good thing is this is a draft document and hopefully the WHO will take all these concerns under consideration. Messaging about the risks of alcohol in pregnancy won’t be received if they are patriarchal or hypocritical. In fact, it may even backfire and make people more resistant to factual messaging about FASDs. We have a lot of disinformation about FASDs specifically because of patriarchal messaging, so this is an area where the language matters as much, or perhaps even more, than the message.

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