Gender differences

Summary

Gender and Health

Men have a lower life expectancy than women: 75.1 years compared with 80.0 years (D0H, 2001 b). Men are more likely to die from cancer, heart disease, HIV, accidents and suicide than women (D0H, 1998). Men are more likely to take risks with their health than women — on average they drink more alcohol, smoke more cigarettes, and take more drugs (c). They use less sun cream and are involved in more accidents (D0H, 2001 a). Men also have less contact with the health services than women. In response to the question ‘Have you consulted your GP in the last two weeks?’ 19 per cent of women and only 13 per cent of men said yes. The gender difference was even more pronounced for men under the age of 45 (10 per cent of men compared to 20 per cent of women) (ONS, 1998). Interestingly, other issues of inequality are more pronounced in men than women. In men, social class based on employment is the most important influence on early death. To put it brutally, the less you earn, the sooner you die. For women however, although there is still an effect of income on early death, it is much weaker (Sacker et aI., 2000).

The puzzle for health workers is to understand why men have worse health and die younger, and why they make less use of the health services. Recent initiatives by the UK government (Yamey, 2000) have acknowledged that the biggest health inequality is between men and women. They are attempting to increase men’s involvement in general health promotion such as smoking cessation, and also to deal with specific problems such as prostate cancer. It might be that the problem with men’s health is that the area is far less defined than women’ health which is focused around reproduction.

According to a medical textbook from the 19th century: ‘childbearing is essentially necessary to the physical health and long life, the mental happiness, the development of the affections and whole character of women. Woman exists for the sake of the womb’ (Holbrook, 1871, pp. 13—14; cited in Gallant et al., 1997). Attitudes have changed and, supported by policy and legislation, women s health is near the top of the health researcher’s agenda.

In industrialized societies today men die earlier than women but women have poorer health than men (Macintyre and Hunt, 1997). In 1996 in the UK boys had a life expectancy of 74.4 years compared with 79.7 years for girls. This excess mortality of 5.3 years in males in 1996 increased over the course of the twentieth century from only 3.9 years in 1900—1910. However, the evidence suggests that from the Paleolithic period to the industrial revolution men lived longer than women, 40 years as compared to 35. Also, in less developed countries (e.g. India, Bangladesh, Nepal and Afghanistan) women still live longer than men (WHO, 1989). Thus, there are significant historical and cultural differences in gender-related health. To complicate the picture further, the SES—mortality gradient appears to be steeper for men than for women while illness rates, treatment rates, absenteeism and prescription drug use are generally higher for women (Macintyre and Hunt, 1997).

Women have higher morbidity rates but lower mortality rates. (See recent world data from New Scientist). Women suffer more non-fatal chronic illnesses and more acute illnesses. They also make more visits to their family physicians and spend more time in hospital. Women suffer more from hypertension, kidney disease and autoimmune diseases such as rheumatoid arthritis and lupus (Litt, 1993). They also suffer twice the rate of depression. Men, on the other hand, have a shorter life expectancy, suffer more injuries, suicides, homicides and heart disease.

Psychosocial and lifestyle differences are likely to play a major role in mediating gender-related health differences. In industrialized societies women suffer more from poverty, stress from relationships, childbirth, rape, domestic violence, sexual discrimination, lower status work, concern about weight and the strain of dividing attention between competing roles of parent and worker. Financial barriers may prevent women, more than men, from engaging in healthier lifestyles and desirable behaviour change (O’Leary and Helgeson, 1997).

Social support derived from friendships, intimate relationships and marriage, although significant, appears to be of less positive value to women than to men. Although physical and mental well-being generally benefit from social support, women often provide more emotional support to their families than they receive. Thus, the loss of a spouse has a longer and more devastating effect on the health of men than on that of women (Stroebe and Stroebe, 1983). The burden of caring for an elderly, infirm or dementing family member also tends to be greater for females in the family than for males, especially daughters (Grafstrom, 1994). While the health of women is a focus for renewed efforts in health care, the health of men cannot be taken for granted. Men are more likely to suffer diseases of the cardiovascular system, more often suffer a violent death and die younger.

Biological explanations for the difference between men and women for CHD point to the role of Oestrogen, that reduces blood clotting and cholesterol levels, whereas testosterone increases clotting (McGill and Stern 1979). Men respond to stresses in a way that is biologically more dangerous than it is for women. They show, under laboratory conditions, greater stress hormone levels, blood pressure and cholesterol levels, than women. However, these differences are in part due to cultural factors. Women who take on traditionally male stressful jobs tend to exhibit similar biological responses as men (Lundberg et al, 1981). Men are more likely to be overweight, smoke more frequently cigarettes containing higher levels of nicotine and tar, eat less healthily and drink more heavily than women (Reddy et al. 1992). They are more likely to work in unhealthy environments and be subjected to a greater risk of accidents.

This study explored the extent to which college men and women of various racial and ethnic groups differ in their health beliefs and behaviors. Exploratory factor analyses of survey responses from a diverse sample of 1,816 undergraduate students (60% women, aged 18-72 yrs) identified 21 items in six cohesive domains: Diet; Anger and Stress; Preventive Care; Medical Compliance; Substance Use; and Beliefs about Masculinity. Analyses of variance explored group differences across these domains. Findings revealed consistent gender differences, with men engaging in riskier behaviours and holding riskier beliefs than women. Main effects for ethnicity were also observed, but only for the diet domain was a gender by ethnicity interaction found. Courtenay,-Will-H; McCreary,-Donald-R; Merighi,-Joseph-R Journal-of-Health-Psychology. 2002 May; Vol 7(3): 219-231

Use of health services

The graph depicts how physician contacts vary with age and with another important factor, the patient’s gender. Women have a higher rate of physician contacts than men (USDHHS, 1987, 1991). This gender difference does not exist in childhood, but begins to appear during adolescence. Much of the gender difference in physician contacts in early adulthood certainly results from the medical care women require when they become pregnant. But even when physician visits for pregnancy and childbirth are not counted, women still use medical services more than men (Cleary, Mechanic, & Greenley, 1982; Verbrugge, 1985). The reasons for this difference in use of medical care are unclear, but researchers have offered several possible explanations (Verbrugge, 1980, 1985). One obvious explanation is that women may simply develop more illnesses that require medical attention. Although men are more likely than women to develop fatal chronic diseases, women show higher rates of medical drug use and illness from both acute conditions, such as respiratory infections, and from nonfatal chronic diseases, such as arthritis and migraine headache. Another explanation is that men are more hesitant than women to admit having symptoms and to seek medical care for the symptoms they experience. This difference in responding to symptoms probably reflects sex-role stereotypes; that is, American society encourages men more than women to ignore pain and to be tough and independent. However Basbaum et al (2002) has found that males are better at tolerating pain than females because of a key difference in how the sexes transmit pain messages. A protein called GIRK2 plays a major role in pain sensation and drug sensitivity in males, but is not as important in females. Removing GIRK2 means the sexes become equal in their ability to withstand pain, experiments on mice showed.

Gender differences in health from early to mid adolescence
(Sweeting and West)
This analysis used self-report health measures obtained at 11, 13 and 15 in
order to test the hypothesis that there is an emerging or increasing female
excess in general ill-health and physical symptoms, as well as psychological
distress, during early to mid adolescence. Generally high levels of health
problems at age 11 tended to increase with age, these increases being
greater for females than males, not only in respect of psychological
distress and 'malaise' symptoms, but also limiting illness, 'poor'
self-rated health, headaches, stomach problems and dizziness. The result, by
age 15, was the emergence of a female excess in general ill-health and
'malaise', and a substantial strengthening of a sex differential in
'physical' symptoms and psychological distress already apparent at 11 years.

Diet

Robinson and Killen (1995) found that adolescent boys of all ethnic groups (Hispanics, Asian Americans, African Americans, and Whites) ate significantly more high-fat foods than did adolescent girls. A number of environmental factors may differentially influence male and female eating behaviors, such as gender role stereotypes and their relationship to dietary behaviors. For example, Perry et al. (1987) found that a program design that emphasized weight and physical appearance as secondary benefits of healthy eating was more relevant for adolescent girls (compared with boys). They suggested that involvement of boys might be enhanced by incorporating male sports role models and increasing emphasis on improved strength, endurance, and performance as a result of healthy eating habits. Similarly, Kumanyika and Charleston (1992) found that females were much more likely to volunteer for their church-based weight-loss program than males. These studies suggest that additional research is needed to better understand how genetic and environmental factors may differentially affect male versus female adolescent eating behaviors.

Cancer

Blaxter (1990) found women were more likely to define health in terms of personal relationships. In their study of working-class women’s views of cancer, Murray and McMillan (1988) also found that the women made repeated reference to their families when describing the disease. For them, health and illness were not simply characteristics of their individual body but rather involved their relationships with others.

Condom use

Campbell et al. (1992) investigated attitudes towards condom use. Participants were 393 unmarried, heterosexual American undergraduates. The questionnaire consisted of twenty items, which assessed comfort and convenience, protective effectiveness, interpersonal aspects and sexual sensation. The results showed that women had more positive attitudes towards condoms. Men were concerned about the effects of condoms on sexual sensation. Women worried more about getting a sexually transmitted disease from a new partner. For women, past condom use was best predicted by positive general attitudes towards condoms as well as less negative attitudes towards the effects of condom use on sexual sensation. For men, feeling positive about the interpersonal aspects of condom use as well as having positive general attitudes towards condoms were significant predictors of past condom use. For both women and men, intended condom use in the future was best predicted by positive general attitudes towards condoms and positive views about the interpersonal aspects of condom use. In addition, those students who had had fewer sexual partners were more likely to say that they would use a condom in the future. For women only, increased worry about contracting a sexually transmitted disease also predicted intention to use condoms in the future.

Exercise

Murray and Jarrett (1985) examined gender differences in perceptions of health and health maintenance. They conducted detailed interviews with a sample of young people and found that young men were more likely to define health in terms of fitness and health maintenance in terms of physical activity, which improved their ability to perform. Young women preferred diet and weight control which improved their physical image. Other studies (e.g. Hayes and Ross, 1987) have found that concern for bodily appearance is the most important reason for physical activity among females. However, this concern with bodily image is closely linked with social position.

In their survey Oygard and Anderssen found that level of education was positively associated with extent of participation in physical activity among females but not among males. In reviewing this finding, they refer to the suggestion that concern with the body is more common among those belonging to the cultural elite who are more anxious about their appearance and their ‘body for others’ (Bourdieu, 1984, p. 213). Oygard and Anderssen concluded: ‘For females in higher social positions, it may be of importance to show others who they are by developing healthy and “delicate” bodies, i.e. they are more concerned with the inner (being healthy) and outer body (being attractive) than females in lower social positions’ (1998, p. 65). However, they also added that the lesser involvement of less educated females may be due to them having limited access to leisure facilities. They found little relationship between education and physical activity among males and suggest that this may reflect the greater promotion of male sporting activities and the greater integration of physical activity into male culture.

Lewinsohn et al (2002) Identified problematic eating behaviours and attitudes in young men and compared them with those of young women. A community sample of 1,056 14-18 yr olds completed a questionnaire that contained the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the Eating Disorder inventory, as well as probes for inappropriate compensatory behaviours, excessive exercise, and episodes of binge eating. Results show a 5-factor structure fit both male and female samples. Women had substantially elevated scores on all of the factors except excessive exercise, for which men had significantly higher scores. The absolute proportion of men and women wanting or having sought treatment was very low. However, at comparable levels of problematic eating behaviours, women were more likely to have sought treatment than men. Lewinsohn,-Peter-M; Seeley,-John-R; Moerk,-Kirstin-C; Striegel-Moore,-Ruth-H International-Journal-of-Eating-Disorders. 2002 Dec; Vol 32(4): 426-440

Smoking

Graham (1996) considered the sex differences in the prevalence of smoking across Europe between 1950 and 1990. During this period there was a consistent decline in the prevalence of smoking among men from about 70—90% to about 30—50%. However, among women the same period saw a rise in the prevalence of smoking followed by a slow decline reaching 20—40% in 1990. Women from professional backgrounds led the initial rise in prevalence, but they have also led the decline such that today smoking in Britain is more common among women from poorer backgrounds.

In a detailed qualitative and sociometric study of friendship patterns of a sample of Scottish schoolchildren, Michell and Amos (1997) found evidence that gender differences in the meaning of smoking and how it was intertwined with issues of style and social identity. Girls identified at the top of the pecking order and who projected an image of high self-esteem were more likely to smoke. These girls were more often described as ‘good-looking’ and being attractive to boys. They often hung out in the park after school rather than participating in organized activities. These girls did not feel under pressure to smoke. Rather they adopted smoking as part of the image of being cool, rebellious and sophisticated. It was seen as part of the ‘top’ girl package. One 11-year-old girl said: ‘You don’t want to be seen as a wee sad people.’ To avoid this image she would wear her short skirt, jewellery and makeup and would smoke.

Admittedly in this study there was a small minority of girls who were low in the pecking order and who smoked. These girls did admit that they had felt bullied or coerced into smoking or that they smoked in order to be like the ‘top’ girls. These girls had poor social skills and low self-esteem. They felt they were not responsible for smoking themselves. For ‘top’ boys the desire to smoke was less clear-cut. Michell and Amos (1997) suggested that they occupied an ambivalent position since smoking conflicted with their desire to be fit. Smoking was less important because they had other means, especially sports, of claiming a top position.

An important although neglected aspect of this study is the broader socio-cultural context within which the young people lived. The two schools investigated in this study had a varied catchment area, which included private and public housing. However, the fact that 50% of the students were receiving free school meals, the Glasgow average, would suggest that a large proportion came from lower SES backgrounds. It is not simply that all ‘top’ girls smoked but rather those within a particular subculture did.

Wearing et al. (1994) in their review have drawn attention to the importance of the socio-cultural context. They refer to an American study by Lesko (1988), which identified two subcultures in a school she studied. There were the ‘rich and popular’ girls who were fashionably and expensively dressed and fitted with the classic ‘good girl’ image. Conversely, there were the ‘burn outs’ who challenged school discipline and enjoyed ‘hanging out’. This latter group of girls smoked. In commenting on this study Wearing et al. (1994) note: ‘Smoking . . . for the “burn outs” is a leisure activity which symbolizes resistance to the passive, sweet tempered, modest, restrained, domestic identity associated with traditional female identity and which for the “rich and popular” girls is being constructed in adolescence through school and leisure’ (p. 632).

Smoking in girls has also been explained in terms of controlling weight. Adolescence is the period when girls become particularly aware of society’s emphasis on body size. Teenage girls are particularly concerned about being overweight. Smoking would seem to be one strategy used to control weight gain.

Charlton (1984) in a large survey of British teenagers found that girls were much more likely to agree that smoking controlled weight. In a survey of a large sample of US students in seven to ten grades (11—15 years old), French et al. (1994) found a strong association between various measures of dieting and smoking among girls but not among boys. Girls who reported symptoms of eating disorder, had tried to lose weight, feared weight gain or reported a strong desire to remain thin were more likely to report smoking. In the USA there is evidence that this belief is particularly pronounced among white girls. Heckler (1985) found that obesity is more acceptable in black culture and Camp et al. (1993) found in a survey of teenagers that white girls more frequently agreed that smoking helps control body weight. (Most women feel too fat).

The character of social activities enjoyed by teenage boys and girls needs also to be considered. While boys often remain involved in sport and other organized activities, girls become more involved in less organized activities. In a survey of English teenagers (Murray et al., 1983; Swan et al., 1990) it was found that smoking was more common among girls who got involved in such activities. Smoking for these girls had a variety of positive social meanings including affirming social bonds with their peers, asserting their adult status and regulating time.

Etter et al (2002) compared the distributions of smoking-related variables and the size of associations between these variables in men and women. 2,934 daily smokers who volunteered for a smoking cessation trial were surveyed. Follow-up occurred after 7 mo in 2,456 people (84%). Women smoked less than men (18 vs 22 cigarettes per day), had lower confidence in their ability to refrain from smoking, used more frequently the strategy defined as coping with the temptation to smoke and reported more drawbacks of smoking. There was no gender difference in the distribution of smokers by stage of change. At follow-up, smoking cessation rates were similar in men and women. Intention to quit, quit attempts in the previous year and a more frequent use of self-change strategies predicted smoking cessation and were associated with tobacco dependence in both sexes. A more frequent use by women of coping strategies suggests that some women are self-restrained smokers who control their smoking permanently. This could explain lower smoking rates in women. The size of associations between smoking-related variables was similar in men and women. Even though there were gender differences in the distributions of some smoking-related variables, associations between these variables were similar in men and women. Etter,-Jean-Francois; Prokhorov,-Alexander-V; Perneger,-Thomas-V Addiction. 2002 Jun; Vol 97(6): 733-743