Gender differences in adolescent anxiolytic, hypnotic and sedative use across 32 European countries: a multilevel analysis of the influence of country-level gender inequality and economic factors

Despite consistent evidence of higher anxiolytic, hypnotic, and sedative (AHS) use among adolescent girls, influence of country-level context in shaping gendered patterns remains unexplored. This study examines how national gender inequality and economic factors affect adolescent AHS use and its gender differences in Europe. We analysed cross-sectional data from 96 954 adolescents aged 15-16 across 32 European countries using the 2019 European School Survey Project on Alcohol and Other Drugs (ESPAD). Countries were grouped into tertiles according to the Gender Inequality Index (GII), GDP per capita and Gini index. We calculated lifetime AHS use prevalence and gender prevalence ratios (PRs). Multilevel logistic regressions estimated the contribution of country-level context to consumption variability, and the association of national inequalities and wealth with boys' and girls' consumption, adjusting for individual sociodemographic variables and AHS accessibility. Most countries showed significantly higher AHS use among girls. Countries with higher gender and income inequality and lower GDP per capita reported overall lower consumption and wider gender gaps (e.g. PRGII-Low = 1.18 [1.12-1.25], PRGII-High = 1.49 [1.40-1.59]). Country-level context accounted for 6.7% of between-country consumption variance. Significant interactions between country level context and gender were found, such that gender gaps were wider in countries with greater gender inequality (ORGII-Med*Girls = 1.16 [1.05-1.28], ORGII-High*Girls = 1.33 [1.19-1.48]), lower GDP per capita (ORGDP-Low*Girls = 1.25 [1.12-1.38]), and higher income inequality (ORGini-High*Girls = 1.19 [1.07-1.32]). Structural inequalities in gender and wealth were associated with adolescent AHS use across Europe. Focusing on cultural factors, medicalisation processes and their gendered impact could provide a meaningful framework for mental health interventions.