The Psychology of Sex and Gender - Jennifer Katherine Bosson, Joseph Alan Vandello, Camille E. Buckner 2022
Gender and Physical Health
Health and Well-Being
Susannah Mushatt Jones on her 113th birthday, with her 72-year-old niece, Lois Judge.
Source: Getty Images / New York Daily News / Contributor
Test Your Knowledge: True or False?
· 12.1 Women tend to live longer than men in wealthier countries, but men live longer than women in poorer countries.
· 12.2 In surveys, men generally report being in better health than women.
· 12.3 The global tendency for women to experience disproportionate rates of poverty is linked to early motherhood.
· 12.4 The most frequent cause of death for women in the United States is heart disease, but physicians less often test and prescribe medicine for heart disease in women than in men.
· 12.5 In health care surveys, most transgender adults say that it is not necessarily important for their doctor to know their gender identity status.
How Have Understandings of Health and Longevity Changed Over Time?
· Changes in Life Expectancy
· Mortality (Death) and Morbidity (Sickness)
· Debate: Do Women or Men Experience Better Physical Health?
How Do Biological Factors Shape Sex Differences in Health?
· Genetic Factors
· Hormonal Influences
· An Evolutionary Theory of Health and Longevity
How Do Social Factors Contribute to Sex Disparities in Health?
· Health-Relevant Behavior: Things That People Do
o Accidents and Risky Sex
o Smoking, Alcohol Use, and Diet
o Physical Activity and Exercise
· Health-Relevant Traits: Ways That People Are
· Accessing Health Care
o Seeking Health Care
o Receiving Health Care
· Gender-Egalitarian Communities and Health
How Do Multiple Systems of Discrimination Shape Health and Health Care?
· Sex, Race/Ethnicity, Socioeconomic Status, and Culture
· Sexual Orientation and Gender Identity
What Do We Know About Sex-Specific Health Issues?
· Sex-Specific Medical Conditions
· The Medicalization of Reproductive Health
· Journey of Research: Pregnancy and Childbirth Advice Through the Centuries
Students who read this chapter should be able to do the following:
· 12.1 Describe the major causes of mortality for men and women and how they have changed over time.
· 12.2 Explain biological and social causes for sex differences in health and longevity.
· 12.3 Analyze the roles of race, social class, culture, sexual orientation, gender identity, and intersectionality in physical health.
· 12.4 Explain sex-specific health conditions and describe some of the consequences of medicalizing reproductive health.
GENDER AND PHYSICAL HEALTH
Before New Yorker Susannah Mushatt Jones died in 2016 just shy of her 117th birthday, she was the oldest living American. Born in Alabama into a low-income family of sharecroppers, Jones moved to Harlem as a young woman. Asked about the key to a long life, she claimed that abstaining from alcohol and tobacco kept her going. This may be true to a degree, but a more important factor likely contributed to Jones’s longevity. Topping the list of the oldest people who have ever lived are Jeanne Calment (age 122), Sarah Knauss (age 119), and Kane Tanaka (age 117). Notice anything similar about these people? They’re all women. In fact, 96% of the 50 oldest people alive in 2016 were women (Margolis, 2016).
Women swell the ranks of the elderly. Among all people in the United States, women constitute 55% of those who are in their 70s, 62% of those in their 80s, 72% of those in their 90s, and 83% of those over the age of 100 (U.S. Census Bureau, 2010). Moreover, women outlive men in every country in the world, by an average of 4.4 years worldwide (World Health Organization, 2019). This is not a new phenomenon, as we have known that women outlive men for as long as there have been reliable death records. Data from 1751 to 1790 in Sweden, the first country to collect national death records, show that the average life expectancy for women was 36.6, compared with 33.7 for men (Perls & Fretts, 1998).
It may not surprise anyone who has visited a nursing facility that women tend to live longer than men. But have you ever wondered why this is so? Are women just “naturally” likely to outlive men? Are the sex differences in longevity due to something biological or are there social factors in play? As is the case with many questions about sex and gender, both types of factors interact to influence sex differences in longevity.
But longevity tells only part of the story of health. That women outlive men does not necessarily mean that they experience better health than men do. In fact, women tend to report higher rates of illness compared with men. And sex interacts with structural inequalities and discrimination based on race, ethnicity, socioeconomic status, gender identity, and sexual orientation to shape health outcomes. Health, illness, wellness, and longevity are all complicated, and our understandings of them continually evolve. In this and the next chapter, we attempt to shed some light on the roles that sex and gender—along with other important identities—play in health. We focus on physical health in this chapter and on mental health and well-being in the next chapter. Of course, physical and mental health do not operate independently of each other. Not only does physical health influence mental health, but the reverse is true as well. At the end of this chapter, we will consider the connection between the two.
HOW HAVE UNDERSTANDINGS OF HEALTH AND LONGEVITY CHANGED OVER TIME?
From a health perspective, you live at the best possible time in human history. Our understandings of disease and medicine, along with improved safety standards, have radically transformed humanity in a relatively short time period. If you lived at the turn of the 20th century, you would likely die much younger and from a different cause, as compared with today.
Changes in Life Expectancy
Figure 12.1 shows the average life expectancy, or length of time a person is expected to live, based on year of birth over the past century. Note that life expectancy in the United States was 46.3 for men and 48.3 for women in 1900, and this increased to 76.1 for men and 81.1 for women by 2016 (World Health Organization, 2019). This 30-year increase in average life span in just over a century is a remarkable achievement. That said, in addition to sex differences in longevity, there are differences based on race, ethnicity, and sexual orientation as well. Due to unique stressors (e.g., discrimination, poverty, inadequate or no health insurance), members of marginalized groups tend to have lower life expectancies than dominant group members. In the United States, White people tend to outlive Black people by about 3.6 years, and lesbian, gay, and bisexual people have lower life expectancies than heterosexual people (Cochran, Bjorkenstam, & Mays, 2016). Inconsistent with this pattern, however, Latinx people tend to outlive White people by an average of 3 years (National Center for Health Statistics, 2015). For more on this topic, see Sidebar 12.1.
Life expectancy The average length of time a person is expected to live, based on year of birth.
Figure 12.1 Estimated U.S. Life Expectancy at Birth
Source: E. Arias (2015).
SIDEBAR 12.1 THE LATINO PARADOX
Since the mid-1980s, health researchers have been interested in the Latino paradox, which refers to the tendency for Latinx Americans in the United States to have health outcomes as good as, if not better than, those of non-Latinx White people in the United States, despite tending to have a lower average income and less education. This is considered a paradox because lower income and education generally correlate with worse health outcomes worldwide. While several hypotheses (regarding diet, smoking, exercise, and family ties) have been offered to explain this paradox, researchers still do not fully understand it. Of note, the Latinx health advantage correlates negatively with degree of acculturation, meaning that the health advantage decreases as Latinx people become more acculturated to the U.S. lifestyle (Gonzalez, 2015).
STOP AND THINK
LGB individuals who live in high-prejudice communities have a shorter life expectancy than those who live in low-prejudice communities (Hatzenbuehler, Slopen, & McLaughlin, 2014). This link is correlational, which does not allow for a determination of cause and effect. What factors might account for this link? Do you think that experiencing prejudice causes early mortality? If so, how? Could this association be caused by a third variable? If so, what third variable(s) might be operating here?
SIDEBAR 12.2 LIFE EXPECTANCY IN THE TRANSGENDER COMMUNITY
Do transgender individuals have a shorter life expectancy than their cisgender counterparts? As a highly vulnerable population, transgender individuals face many stressors and health risks that can shorten life expectancy, including discrimination, violence, lack of adequate health care, and reliance on smoking, drugs, and alcohol as coping tools (Hughto, Reisner, & Pachankis, 2015). And yet, the systematic research needed to determine the average life expectancy of transgender people has not yet been conducted. Although some popular media cite a statistic that transgender women in the United States have an average life expectancy of 35 years, this statistic appears to reflect a misinterpretation. It stems from these findings: Out of nearly 600 LGBT homicides in South, Central, and North America, 80% of murdered transgender people were 35 or younger, and transwomen sex workers were murdered at particularly high rates (Inter-American Commission on Human Rights, 2015). It is inaccurate, however, to extrapolate from these findings that transgender people in general have an average life expectancy of 35 years (Herzog, 2019).
Mortality (Death) and Morbidity (Sickness)
Table 12.1 lists the leading causes of death in the United States in 1900 and in 2010. Take a minute to examine these two lists and note their differences. In 1900, infectious diseases such as pneumonia and tuberculosis topped the list. Over the decades, discoveries and developments like vaccines, antibiotics, refrigeration (which slows the growth of bacteria in food), and mosquito control (mosquitos transmit many fatal diseases), along with improved understandings of health and health care, led people to become healthier and live longer. As longevity increased, “diseases of old age” replaced infectious diseases among the top causes of death. For instance, people die of heart disease, cancer, and Alzheimer’s disease more frequently now than they did a century ago.
Latino paradox A phenomenon in which Latinx Americans in the United States have health outcomes as good as, if not better than, those of non-Latinx White people in the United States, despite tending to have a lower average income and less education.
Morbidity-mortality paradox A phenomenon in which women tend to have higher rates of morbidity (sickness and disability) than men, while men tend to experience mortality (death) earlier than women.
Compare the top-10 leading causes of death in the United States in 1900 and 2015 (note that number of deaths is per 100,000 people). What differences do you notice?
Source: Centers for Disease Control and Prevention (2017a) and National Office of Vital Statistics (1947).
For every one of the top causes of death in 2015, except Alzheimer’s disease, men die at higher rates than women (Xu, Murphy, Kochanek, Bastian, & Arias, 2018). So, men suffer from life-threatening conditions more often than women. Women across cultures, however, tend to suffer from chronic, nonfatal, debilitating conditions—such as arthritis, osteoporosis, and autoimmune disorders—more often than men (Needham & Hill, 2010; Wheaton & Crimmins, 2016). These sex differences underlie the morbidity-mortality paradox, the phenomenon in which women tend to have higher rates of morbidity (sickness) than men, but men tend to experience mortality (death) earlier than women.
Specifically, compared to men, women more frequently suffer from musculoskeletal disorders (such as arthritis and neck or back pain) and chronic pain conditions such as headaches (Malmusi, Artazcoz, Benach, & Borrell, 2012). Women also self-report having poorer health than men do at all ages and in all world regions, although the sex difference in self-reported health is smaller in European and sub-Saharan African countries and larger in Latin American and South Asian countries (Boerma, Hosseinpoor, Verdes, & Chatterji, 2016). But why would sex differences in chronic, painful disorders occur? Some propose that women’s traditional role of caretaker contributes to their poorer health because being a caretaker can increase stress and make people vulnerable to various debilitating conditions. In addition, taking care of others may reduce the likelihood of taking care of oneself (Helgeson, 2012). For more on the topic of mortality versus morbidity, turn to the debate titled “Do Women or Men Experience Better Physical Health?”
DEBATE: DO WOMEN OR MEN EXPERIENCE BETTER PHYSICAL HEALTH?
Who is generally healthier: women or men? Women live longer than men in almost every culture, often by several years. Although living a long life is one way to measure health, it is not the only way. What if a person lives a long life but suffers a painful debilitating condition for a large portion of it? Some argue that while men tend to experience mortality (death) earlier than women, women tend to have higher rates of morbidity (sickness) than men. Let’s consider both sides of the debate.
MEN ARE HEALTHIER
If we use self-reported health as a guide, men are healthier. Despite women living longer, men report better health than women do. Women report poorer health than men do at all ages and in all world regions (Boerma et al., 2016). Asking people to report their own health status might not seem like a very valid indicator of health, but in fact, self-reported health strongly predicted mortality over a 28-year period (Schnittker & Bacak, 2014).
Women’s health-related behaviors are consistent with these self-reports. Women use more health-related services, make more doctor visits, and spend more out-of-pocket money on health care and prescriptions than men do. Women also take more sick days from work than men do (Jenkins, 2014; National Center for Health Statistics, 2015).
Similarly, women suffer more than men from several chronic, debilitating conditions, such as irritable bowel syndrome, headaches and migraines, widespread body pain, fibromyalgia, and joint, abdominal, and chest pain (LeResche, 2011). Women are also more likely than men to develop autoimmune diseases (when the immune system attacks healthy cells by mistake), such as multiple sclerosis, rheumatoid arthritis, and lupus (Lockshin, 2005). Thus, women’s advantage in longevity does not necessarily mean an advantage in overall health.
WOMEN ARE HEALTHIER
Women’s greater life expectancies across cultures suggest that women are, in fact, healthier than men. In developed nations, men’s rates of death from nearly all major causes exceed women’s (Kruger & Nesse, 2006). Although women self-report worse health than men, this may be due to gender role norms that pressure men to suppress any signs of weakness while allowing women to express their vulnerabilities and seek help. Thus, if women appear sicker than men, this may be because they go to the doctor more often and admit to their illnesses.
Stereotypes portray women as the physically weaker sex, but girls and women are actually heartier and more robust biologically than boys and men. Although slightly more baby boys than girls are born each year, boys die at higher rates than girls at every age (T. J. Mathews & Hamilton, 2005). By their first birthday, baby boys are about 24% more likely to die than girls (Drevenstedt, Crimmins, Vasunilashorn, & Finch, 2008). The higher male mortality rate may reflect the fact of a stronger female immune system: Compared with girls and women, boys and men get more infections and have more difficulty clearing them (Zuk, 2009).
Now that you have read both sides of the debate, which evidence seems more compelling? Do you think it makes more sense to conceptualize health in terms of mortality or morbidity? Why?
HOW DO BIOLOGICAL FACTORS SHAPE SEX DIFFERENCES IN HEALTH?
Humans are not the only species in which females outlive males. In many nonhuman animal species, including pilot whales, African lions, prairie dogs, and some primates, females have a longer average lifespan than males (Austad & Fischer, 2016). The cross-species generality of female animals’ longer lifespan suggests biological bases for this sex difference. In this section, we examine how various biological factors shape health and contribute to sex differences in health and longevity.
From nonhuman animals (e.g., pilot whales, African lions, and prairie dogs) to humans, female members of the species tend to outlive male members.
Source: © iStockphoto.com/eco2drew; iStockphoto.com/elmvilla; iStockphoto.com/aMikeK; iStockphoto.com/hadynyah
As we discussed in Chapter 3 (“The Nature and Nurture of Sex and Gender”), genetic sex is determined by the sex chromosomes, termed X and Y. Individuals who carry an X and a Y chromosome usually become boys, whereas those who carry two X chromosomes usually become girls. Interestingly, having two X chromosomes may provide a health advantage to girls and women. How so? The sex chromosomes can sometimes carry genetic mutations that code for diseases, such as certain types of muscular dystrophy or hemophilia (Del Vecchio, Verrilli, Glielmo, & Corless, 2017). Most sex-linked diseases are passed down through the X chromosome, which contains far more genes than the much smaller Y chromosome. Among people who have two X chromosomes, if they carry an abnormal, disease-producing gene on one X chromosome, the normal gene on the other X chromosome can override the abnormal gene and prevent the expression of the disease. In this case, individuals are carriers of the defective gene, but they do not experience the disease. In contrast, among people who have only one X chromosome, if they carry an abnormal, disease-producing gene on the X chromosome, they do not have another X chromosome to overcome the abnormality, thus making them more likely to develop the disease (Migeon, 2006). In this way, boys and men are more vulnerable to X-linked diseases than girls and women.
Muscular dystrophy A set of sex-linked disorders characterized by increasing muscle loss and weakness.
Hemophilia A sex-linked, genetic blood clotting disorder, which can cause excessive bleeding.
Telomeres Disposable DNA sequences at the ends of chromosome strands that protect the remaining genes on the chromosomes during cell division.
The discovery of telomeres represents an exciting breakthrough in the genetics of aging. Telomeres are deoxyribonucleic acid (DNA) sequences at the ends of chromosome strands that protect genetic data and allow for cells to divide. Think of them as the caps at the tips of shoelaces that keep the laces from fraying. The telomeres get shorter each time a cell divides, until eventually the cell dies when it can no longer divide. Although the telomeres of male and female chromosomes are the same length at birth, male telomeres shorten faster than female telomeres, suggesting that male cells age faster (Barrett & Richardson, 2011; Brown, Needham, & Ailshire, 2017). Thus, sex differences in telomeres appear linked to sex differences in aging and longevity. Much remains unknown, but research on telomeres may one day unlock the secrets of sex differences in aging and life expectancy.
Sex hormones, including testosterone and estrogen, play well-documented roles in health and longevity. Testosterone, which is on average much higher in men than women, boosts male fertility by increasing aggression and risk-taking, as well as by contributing to sex drive and regulating sperm production. However, testosterone may also have negative consequences for long-term health. For instance, high doses of experimentally administered testosterone decrease “good” cholesterol (high-density lipoprotein, or HDL) and increase “bad” cholesterol (low-density lipoprotein, or LDL), thereby increasing the risk of cardiovascular disease (Herbst, Amory, Brunzell, Chansky, & Bremner, 2003). Testosterone also suppresses the body’s immune system, which can help to explain why women have more robust immune responses than men (Furman et al., 2014). In fact, male members of most species, including humans, generally show greater susceptibility to infections from parasites, bacteria, viruses, and fungi than their female counterparts (Ingersoll, 2017). This may reflect the suppressing effects of testosterone on male animals’ immune system.
Conversely, estrogen, which is typically much higher in women than men, provides health benefits. Premenopausal women, who have higher levels of estrogen than menopausal women, have less cardiovascular disease and lower blood pressure compared with age-matched men, and this may be due, in part, to their higher estrogen levels (Xue, Johnson, & Hay, 2013). Estrogen also increases cardiac output during the menstrual cycle, which some liken to a “jogging female heart” because it mimics the effects of exercise (Eskes & Haanen, 2007). Finally, estrogen increases the expression of longevity-associated genes (Viña, Borrás, Gambini, Sastre, & Pallardó, 2005). However, it also can increase the risk of certain forms of cancer, such as breast, uterine, and ovarian cancers, which will be discussed further later in the chapter.
Telomeres are structures at the ends of chromosomes that protect chromosomes from deterioration. They shorten over time, which is associated with aging and mortality.
Source: © iStockphoto.com/wildpixel
An Evolutionary Theory of Health and Longevity
Stepping back a bit, we can ask why female and male members of species even differ at all in ways that contribute to health and longevity. To answer this question, evolutionary theorists point to the different mating challenges that men and women faced in their ancestral past. Recall from our discussion of sexual selection in Chapter 3 (“The Nature and Nurture of Sex and Gender”) that traits and behaviors that increase the likelihood of reproduction more frequently get passed on genetically. Because male and female members of many species presumably faced different mating challenges in their ancestral past, they should have evolved different features (e.g., hormone levels, traits, and behaviors) that allowed them to adapt to these challenges. Since gestation occurs internally in the female in most mammalian species, females invest more in each offspring than males do and tend to be more discriminating than males in choosing mates. In contrast, male animals of many species, including humans, typically compete for access to female mates by performing aggressive and risky behavior. At the same time that risky and aggressive tendencies give some males a reproductive advantage over others, they also increase the likelihood of death. Thus, evolutionary theorists propose that men evolved to pursue a “live hard, die young” strategy because this strategy results in more offspring, even if it means an earlier average age of death for men than women (Zuk, 2009).
Sex differences in testosterone may play a role in men’s “live hard, die young” strategy. That is, men’s (compared to women’s) higher concentrations of testosterone may reflect evolutionary pressures on men to compete aggressively for mates, because such aggressive competition increases men’s reproductive success. However, while high testosterone levels may increase men’s reproductive success, they also suppress men’s immune systems and increase their vulnerability to infection. In other words, testosterone is good for reproduction but bad for long-term health and survival. According to the evolutionary perspective, men’s bodies evolved to prioritize procreation over immunity (Zuk, 2009).
In contrast to men’s bodies, women’s bodies contribute more directly to healthy fetal growth and infant nourishment. Thus, evolutionary theorists propose that women’s bodies evolved to invest more energy into fighting disease (e.g., immune functioning) and repairing damaged cells (Kirkwood, 2010). People age because the body’s cells naturally produce tiny damaging mistakes that accumulate over time, but female bodies are better than male bodies at repairing damaged cells and thus slowing the aging process. This may reflect an adaptation to evolutionary pressures on women to gestate and bear healthy and viable offspring. In short, evolutionary theorists argue that sex differences in immunity and longevity reflect evolved adaptations to the problems of attracting mates and reproducing.
STOP AND THINK
People tend to perceive aging differently in men versus women, typically perceiving older women more negatively than older men. Why do you think this double standard in perceptions of aging exists? How might evolutionary psychologists explain it?
HOW DO SOCIAL FACTORS CONTRIBUTE TO SEX DISPARITIES IN HEALTH?
As the preceding section illustrates, biological factors contribute to sex differences in health and longevity. However, behavior matters as well. To illustrate, turn back to Table 12.1 and look at the leading causes of death in 2015. All of these causes of death are influenced, to some extent, by people’s behaviors. Things like diet, exercise, alcohol, smoking, and drug use can influence rates of heart disease, cancers, diabetes, and kidney disease. Accidents, suicides, and homicides have obvious behavioral influences. In fact, the more that behavior contributes to a given cause of death, the larger the sex difference in rates of death from that cause (Kruger & Nesse, 2006). In this section, we will consider social factors that contribute to sex disparities in health. These include behaviors that can improve health and those that can impair health. What kinds of things do individuals do—and not do—that influence their health in positive and negative ways?
Health-Relevant Behavior: Things That People Do
Accidents and Risky Sex
One of the most promising explanations for sex differences in physical health is men’s proclivity toward risky behavior, which undoubtedly contributes to their lower survival rates. In the United States, accidental deaths are the fourth leading cause of death for men but only the seventh for women. In the workplace, men account for an astonishing 92% of fatal injuries (U.S. Bureau of Labor Statistics, 2019). At home, men account for 83% of accidental deaths, likely due to engaging in riskier tasks, such as electrical repairs, climbing on roofs, and so on (Driscoll et al., 2003). Men also tend to engage in more risky and accident-prone leisure activities and sports than women, such as rock climbing, whitewater rafting, cliff diving, skydiving, scuba diving, motorcycle racing, and bungee jumping (Schrader & Wann, 1999). In the United States, men are three times more likely to own a personal firearm (Pew Research Center, 2013a) and six times more likely to die from an unintentional firearm injury (Centers for Disease Control and Prevention, 2015b) compared with women.
Men tend to take more physical risks than women, on average.
Source: © iStockphoto.com/Grigorev_Vladimir
On the road, men tend to drive more recklessly than women. In the United States, men account for about 71% of motor vehicle fatalities, including 92% of motorcycle deaths (Insurance Institute for Highway Safety, 2016), and European men are three times more likely than women to die in road traffic accidents (White et al., 2011). This holds true when controlling for how much people drive, indicating that the way men drive—and not merely how much they drive—plays a role in their vehicle accident deaths. Compared with women, men less frequently wear seat belts and more frequently speed and drive under the influence of alcohol or other drugs (Insurance Institute for Highway Safety, 2016).
Another form of risky behavior, sexual activity, reveals a somewhat different pattern. Some kinds of sexual activity, such as unprotected sex, sex with a stranger, and sex while intoxicated or under the influence of drugs, are considered risky because they can increase the chances of sexually transmitted diseases, pregnancy, and violence. One meta-analysis of 47 studies found almost no sex differences in risky sexual behavior overall (d = 0.07), but some sex differences emerged as a function of age. While male teenagers tend to engage in riskier sex than female teenagers, women are slightly more likely than men to engage in risky sexual activity during post-college years (d = −0.11; Byrnes, Miller, & Schafer, 1999). Not surprisingly, some kinds of risky sex (e.g., intoxicated sex) go hand in hand with other kinds of risky sex (e.g., unprotected sex). One study of college students found that for both women and men, alcohol consumption during their most recent episode of sex with a nonregular partner correlated with a lower likelihood of condom use (Connor, Psutka, Cousins, Gray, & Kypri, 2013).
One of the most devastating consequences of risky sex—for cisgender, transgender, and nonbinary individuals—is infection by the human immunodeficiency virus (HIV). In the United States, 81% of new HIV cases each year occur among men (Centers for Disease Control and Prevention, 2017b), but globally, women account for about half of all HIV cases among adults (United Nations Entity for Gender Equality and the Empowerment of Women, 2016). As shown in Figure 12.2, the types of sexual activity associated with HIV infection show large sex differences: Among men, most cases of HIV transmission (77%) occur during same-sex sexual activity; among women, most cases (86%) occur during heterosexual activity. When estimating HIV prevalence, researchers have historically grouped transwomen with men who have sex with men, which leads to misleading statistics. Given this problem, Sara Gianella and her colleagues call for HIV research that specifically focuses on transgender and gender-nonbinary populations (Gianella, Haw, Blumenthal, Sullivan, & Smith, 2018). They report that, from 2009 to 2014, approximately 2,300 transgender individuals in the United States were diagnosed with HIV, 84% of whom were transwomen. In addition, approximately 25% of transwomen in the United States are HIV positive, and transwomen in the United States are 50 times more likely to be HIV positive than are adults of reproductive age in general. Since the transgender population experiences disproportionate rates of HIV infection and relatively poor access to clinical care, it is important to include them more intentionally in HIV research and clinical care outreach.
Human immunodeficiency virus (HIV) A virus that attacks the body’s immune system and makes it difficult for the body to fight diseases.
Figure 12.2 Transmission of HIV
Source: National Institute on Drug Abuse (2010).
HIV/AIDS also disproportionately affects Black and Latinx people in the United States. While Black and Latinx people represent about 12% and 17% of the U.S. population, respectively, they account for 45% and 25% of new HIV diagnoses (Centers for Disease Control and Prevention, 2017b). These race and ethnicity disparities in HIV infection rates are not well understood. They do not appear to reflect differences in risky behaviors, such as numbers of sexual partners, frequency of risky sexual practices, or tendency to use substances during sex. However, some researchers have made headway by analyzing risk networks, which are extended networks of individuals with whom people have sexual contact or engage in other risky practices, such as intravenous drug use. According to the logic of risk networks, the likelihood of HIV infection increases as a function of both individual risks (e.g., having unprotected sex) and the proportion of infected sexual partners in a person’s risk network. Thus, even if Black and Latinx people do not take more individual risks than White people, they may still exhibit higher rates of HIV infection than White people if they have relatively high concentrations of HIV-infected sexual partners in their risk networks (Mustanski, Birkett, Kuhns, Latkin, & Muth, 2015).
Risk networks Extended networks of individuals with whom people have sexual contact or engage in other risky practices (e.g., intravenous drug use) that can transmit disease.
Despite advances in new highly active antiretroviral therapies (HAARTs) that greatly reduce the risk of dying from HIV-related causes, only about 41% of those living with HIV across the world can afford these therapies (Avert.org, 2016). Moreover, at the same time that HAARTs can offer hope in fighting HIV/AIDS to those who can afford them, they can also have the unintended and ironic effect of increasing people’s tendencies to engage in risky sex. One study tracked a sample of HIV-negative gay men over 3 years and measured both their concerns about contracting HIV and their tendency to engage in unprotected receptive anal intercourse (URAI), the sex act that carries the single highest probability of HIV transmission (Beyrer et al., 2012). While most men in the sample remained highly concerned about the possibility of contracting HIV, those who reported that the availability of HAARTs made them less concerned about HIV were also more likely to have URAI with casual sex partners (Stolte, Dukers, Geskus, Coutinho, & de Wit, 2004). This suggests that the availability of HAARTs may give some people a false sense of security that can increase their sexual risk-taking.
Highly active antiretroviral therapies (HAARTs) Drug treatments, usually consisting of a combination of at least three drugs, that suppress HIV replication.
Smoking, Alcohol Use, and Diet
Globally, nearly five times as many men as women smoke (Guindon & Boisclair, 2003). There are also about 8.5 times more men than women around the world who are hardcore smokers, defined as smoking more than 10 cigarettes per day, smoking within 30 minutes of waking up, and having no intentions to quit smoking (Sreeramareddy, Hon, Abdulla, & Harper, 2018). In the United States, 18.8% of men versus 14.8% of women smoke daily (Jamal et al., 2015). Smoking is now widely recognized as one of the riskiest health habits, but this was not always the case. In the United States, smoking rates rose steadily between 1900 and the mid-1960s, at which point the rates leveled off and then slowly declined. The decrease likely stemmed from research published in the 1940s and 1950s that convincingly linked smoking to lung cancer, which then spawned several decades of antismoking health campaigns in the United States (U.S. Department of Health and Human Services, 2000). These health campaigns paid off: Whereas nearly half of Americans smoked at the middle of the 20th century, only about 17% of American adults smoke today.
Table 12.2 shows not only the declining rates of smoking in the United States over the past several decades but also the shrinking sex difference in smoking rates. In 1955, men were about twice as likely as women to smoke, but today, men are only 1.27 times as likely as women to smoke. This declining sex difference in smoking likely helps explain why the size of the sex difference in longevity has decreased in the United States since the 1970s. If you look back at Figure 12.1, you can see that the sex difference in longevity was largest in 1970 (when women outlived men by 7.6 years), but by 2015, the sex difference was only 4.7 years. This likely occurred because deaths from smoking-related diseases, such as lung cancer, chronic obstructive pulmonary disease (COPD), and heart disease, have become more evenly distributed across men and women. However, despite smoking less than men, women often have more difficulty quitting than men do (P. H. Smith et al., 2015). This may be because women are more likely than men to use smoking to control their weight based on the belief that smoking suppresses the appetite (Pomerleau & Snedecor, 2008).
Both men and women have decreased their smoking rates since 1955. Men have always smoked at higher rates than women, but the sex difference has gotten much smaller over the decades.
Source: Centers for Disease Control and Prevention (2015a) and Jamal et al. (2015).
Like smoking, alcohol abuse used to be mainly a male problem, but the sex difference narrowed in recent years. In the United States, 60% of men, compared with 44% of women, drink alcohol regularly (Blackwell, Lucas, & Clark, 2014), and globally, 39% of men and 25% of women drink regularly (Griswold et al., 2018). Drinking moderate amounts of alcohol (two drinks per day for men and one per day for women) does not seem to have negative effects, but drinking more than that can increase risks of hypertension, heart disease, liver disease, and various cancers, not to mention increasing risks for violence and accidents. When it comes to excessive, dangerous drinking, men outnumber women. For instance, men are more likely than women to binge drink, which is defined as consuming four or more alcoholic drinks in 1—2 hours for women and five or more drinks in 1—2 hours for men. In one large, representative sample of U.S. adults, nearly twice as many more men (24.6%) than women (12.5%) reported binge drinking over the past month (Kanny, Liu, Brewer, & Lu, 2013).
Binge drinking Consuming four or more alcoholic drinks within 1—2 hours for women and five or more drinks within 1—2 hours for men.
Men also become dependent on alcohol more frequently than women do. In one survey of people in the United States, nearly twice as many men (4.5%) met diagnostic criteria for alcohol dependence compared with women (2.5%) (Esser et al., 2014), a psychological disorder in which alcohol use becomes habitual and difficult to control and interferes with normal functioning (for more on this, see Chapter 13, “Gender and Psychological Health”). Not surprisingly, given their more risky and excessive use of alcohol, men in the United States account for about 77% of all deaths from alcohol-related causes (Mejia de Grubb, Salemi, Gonzalez, Zoorob, & Levine, 2016). Moreover, the sex difference in deaths from alcohol-related causes is larger among White than Latinx people: Whereas White and Latino men die from alcohol-related causes at similar rates, White women experience more alcohol-related deaths than Latina women.
In addition to drinking more alcohol than women, on average, men generally eat less healthy diets than women. Women tend to eat more fruits, vegetables, and fiber and limit their salt intake, whereas men tend to eat more meat, high-fat foods, and salty foods (Vandello, Bosson, & Lawler, 2019). Most major health organizations propose that the risks of chronic diseases, including diabetes, cancer, and cardiovascular disease, can be reduced by adopting a diet high in fruits, vegetables, and whole grains, moderate in lean proteins and dairy products, and low in saturated fatty acids, fried foods, sodium, and sugar (World Heart Federation, 2017). While most people could likely benefit from an improved diet, men in particular often resist adopting such changes. This may partly be due to the existence of powerful, cross-cultural gender stereotypes about food and diets. For example, men and masculinity are associated with red meat and alcohol, while women and femininity are associated with fruits, vegetables, and fish (O’Doherty & Holm, 1999; Rozin, Hormes, Faith, & Wansink, 2012). More generally, stereotypes associate healthy diets with femininity and unhealthy diets with masculinity (Oakes & Slotterback, 2004). Thus, eating healthy and low-fat foods can be threatening for men because it may lead others to view them as feminine or insufficiently masculine. Conversely, going out of their way to eat unhealthy foods can signal men’s masculinity to others. Consider the appeal of the Heart Attack Grill in Las Vegas, Nevada, which markets itself as a manly restaurant for thrill-seekers. Its menu advertises such options as a 9,000-calorie Quadruple Bypass Burger and Flatliner Fries cooked in pure lard. The restaurant gained notoriety when at least two male customers suffered heart attacks while eating there (Jaslow, 2012).
As we have discussed in these sections, boys and men are much more likely than girls and women to take certain health risks. In fact, some theorists propose that risk-taking is a core element of the male gender role. Men often learn to use risky behavior as a means of demonstrating masculine competence, knowing full well the associated perils. As you read in Chapter 4 (“Gender Development”), many cultures around the world subject adolescent boys to physically demanding rituals in which they earn the status of “real men” through public performance of risky, painful acts. Thus, there may be a powerful cultural incentive for men to take risks with their health: Should they survive, they prove their manhood—at least until the next time.
Men are more likely than women to make a show of eating high-calorie, fatty foods.
Source: © iStockphoto.com/Stormcab
Physical Activity and Exercise
In contrast to the trends discussed so far, boys and men demonstrate somewhat healthier habits than girls and women in the domains of physical activity and exercise. A sedentary, nonactive lifestyle increases the likelihood of developing noncommunicable diseases, whereas regular activity and exercise contribute to good physical and mental health and quality of life. To meet recommended guidelines for physical activity, adults should engage in at least 30 minutes of moderate-intensity physical activity at least 5 days per week, or 20 minutes of vigorous activity at least 3 days per week. Healthy physical activity can take many forms in addition to exercise, including leisure activities, work/housework, and transportation (e.g., biking to work). In most countries around the world, including the United States, girls and women are less physically active, on average, than boys and men (Hallal et al., 2012). One large-scale study tracked the physical activity of 9- and 15-year-old European children over 4 days and found that boys showed higher levels of physical activity than girls at both ages (Riddoch et al., 2004). Similarly, women across the globe are slightly more likely than men (27% vs. 20%) to be classified as physically inactive by not meeting minimum activity guidelines. Across all ages, girls and women walk less and engage in less vigorous physical activity, on average, than do boys and men (Mielke, da Silva, Kolbe-Alexander, & Brown, 2018).
Percentages of physical inactivity differ by world region as well, ranging from 17.0% in Southeast Asia to 27.5% in Africa, 34.8% in Europe, and 43.3% in North and South America (Hallal et al., 2012). Interestingly, inactivity increases with the income of a country, likely because wealthier countries tend to be more industrialized and technologically advanced, which means that people’s jobs typically entail less physical labor, and public transportation is more widely available. Thus, while wealth obviously improves quality of life in many ways, it can also discourage healthy levels of physical activity. In one study that tracked physical activity among U.S. residents of various ages throughout the day, fewer than 12% of men and 6% of women over the age of 12 met minimum guidelines for sufficient daily activity (Troiano et al., 2007).
Physical activity also declines with age, both in the United States and worldwide (Hallal et al., 2012). While about 42% of children (ages 6—11) in the United States meet minimum guidelines for physical activity, activity generally declines across adolescence. The 20s and 30s tend to be somewhat more active than other ages for both women and men, but physical activity then declines steadily from the 40s to the 70s and beyond (Troiano et al., 2007). One study found that the most sedentary U.S. adults—specifically, older adolescents and adults aged 60 and older—spent about 60% of their waking hours in sedentary pursuits (C. E. Mathews et al., 2008). Not only does a sedentary lifestyle increase people’s likelihood of developing chronic illnesses and medical conditions, it also contributes to obesity.
Body mass index (BMI) A person’s weight in kilograms divided by the square of height in meters.
Overweight Having a body mass index between 25 and 30.
Obese Having a body mass index over 30.
SIDEBAR 12.3 A GLOBAL OBESITY EPIDEMIC?
Changes in diet and physical activity over the past several decades led to increases in the prevalence of overweight and obesity. According to some health officials, we are in the midst of an obesity epidemic. Since 1975, worldwide obesity rates nearly tripled. Whereas about 13% of adults in the world are obese, the rate is 36% in the United States (World Health Organization, 2018). Physicians typically identify people as overweight or obese based on the body mass index (BMI), which is a person’s weight in kilograms divided by the square of his or her height in meters. In wealthy, developed countries, more men than women meet criteria for being overweight—defined as a BMI between 25 and 30—but in many countries, more women than men are obese, defined as a BMI over 30 (Kanter & Caballero, 2012). Although there is debate about the validity of the BMI, obesity will likely remain a major public health issue in the years to come.
STOP AND THINK
Imagine that you are in charge of developing a public health campaign to increase Americans’ physical activity levels. What strategies would you use? Would your health campaign use different strategies to appeal to people of different sexes? Why or why not? People often cite a lack of time as a primary impediment to exercise. How would you convince people to work more regular activity into their daily routine? Keep in mind that activity can include transportation (e.g., walking or bicycling instead of driving) and housework.
Health-Relevant Traits: Ways That People Are
Aside from the things people do that contribute to or impair physical health, the ways that people are, such as their levels of agency and communion, may also enhance or impair physical health. For instance, regardless of sex or gender identity, people higher in agentic traits, such as competitiveness, assertiveness, and leadership, tend to have fewer physical symptoms and better adjustment to illnesses than those lower in agency (Helgeson, 2012). At the same time, people who display stronger preferences for male-typical occupations are also more likely to die at any given age (Lippa, Martin, & Friedman, 2000). In contrast, no consistent links emerge between physical health and communal traits, such as warmth, cooperativeness, and nurturance.
According to Vicki Helgeson (2012), more extreme and dysfunctional versions of agentic and communal traits—known as unmitigated agency and unmitigated communion—play a central role in physical health. While unmitigated agency is a singular focus on the self to the neglect of others, unmitigated communion is a singular focus on others to the neglect of the self. Both of these tendencies are bad for physical health but for different reasons. Consider unmitigated agency. People high in unmitigated agency often behave inappropriately with others—they are arrogant, boastful, dominating, vindictive, and self-absorbed. They also have a mistrusting, negative view of others. These qualities can lead to interpersonal conflict and make it difficult for people to rely on others for social support. People high in unmitigated agency also engage more often in negative health behaviors, such as smoking, drinking, and drug use, and they tend to disregard the advice of doctors. For example, Helgeson writes about a cardiac patient, high in unmitigated agency, whose doctor told him to limit his intake of eggs; instead, the man increased the number of eggs he ate, perhaps out of a sense of invulnerability or a need to feel in control. Finally, people high in unmitigated agency lack healthy social skills, which means that they have difficulty seeking social support from others or accepting it when offered. Via these four paths—poor health behaviors, interpersonal behavior that leads to conflict, negative views of others, and poor social skills—unmitigated agency correlates with negative physical health outcomes as well as increased depression, hostility, and tension.
Unmitigated agency A tendency to focus on the self to the neglect of other people.
Unmitigated communion A tendency to focus on others to the neglect of the self.
Similarly, unmitigated communion predicts increases not only in physical symptoms but in psychological symptoms (anxiety and depression) as well (Helgeson, 2012). This occurs via several paths. First, people high in unmitigated communion chronically overnurture, exerting a great deal of energy to support others. Intensive support provision often becomes stressful and taxing, which then compromises the immune system and increases the likelihood of illness. Moreover, those high in unmitigated communion tend to take on the problems of others as their own, which compounds their stress and worry. Next, they tend to behave inappropriately with others by being intrusive, overly concerned, and controlling, which leads to relationship conflict. Finally, people high in unmitigated communion avoid focusing on themselves and ignore their own health, often failing to seek and accept social support from others. Through these three paths—overnurturance of others that causes stress and worry, inappropriate behavior that creates conflict, and failure to benefit from social support—people high in unmitigated communion suffer poorer health outcomes.
Keep in mind that while unmitigated agency and unmitigated communion are associated with sex, the correlation is not perfect. That is, both women and men can be high in either unmitigated agency or unmitigated communion, and these tendencies sometimes override sex in predicting health problems. For example, in one study, Helgeson and Fritz (1996) found that sex differences in depression were fully explained by people’s levels of unmitigated communion. Therefore, although gender socialization processes likely encourage more men than women to exhibit unmitigated agency and more women than men to exhibit unmitigated communion, these tendencies are bad for people’s health regardless of their sex.
People high in unmitigated communion tend to take on other people’s problems as their own, which has implications for their physical and psychological health.
Source: © iStockphoto.com/KatarzynaBialasiewicz
Accessing Health Care
Maintaining good health requires being proactive, which means not just treating illnesses when they arise but also scheduling regular visits to monitor health and prevent problems from arising in the first place. Perhaps not surprisingly, men do not attend to these routine health care needs as conscientiously as women. In addition to this sex difference in the tendency to seek health care, sex and gender also influence the quality of health care that people receive from doctors. In this section, we will consider both of these patterns.
Seeking Health Care
In the United States, women are more likely than men to visit doctors, they visit doctors more frequently, and they are also more likely to have a personal physician or a regular place where they receive health care (Blackwell et al., 2014). How should we interpret these findings? It could be an indicator that women are sicker, which aligns with women’s tendency to self-report worse health than men. However, women are more likely than men to schedule regular checkups even when they are well. Sex differences in health care use could also reflect women’s use of routine doctor visits to address reproductive health needs, such as Pap smears, mammograms, contraception, and prenatal care. In fact, these types of visits account for a sizeable proportion of women’s health care use (Owens, 2008).
Sex differences in health care use may also reflect gender role norms that discourage men from seeking help, even if they experience pain or illness symptoms (Samulowitz, Gremyr, Eriksson, & Hensing, 2018). People tend to expect men to be self-reliant, tough, and stoic, and these qualities can discourage men from seeking help for health-related reasons (Addis & Mahalik, 2003). Moreover, men who endorse more traditional beliefs about masculinity are more likely to postpone seeking medical help for physical problems (Himmelstein & Sanchez, 2016). These men are also more likely to choose male doctors, even though they communicate less openly with male than female doctors. This can have important consequences for men because disclosures to doctors about emotional problems during routine health visits serve as a primary route through which individuals receive effective help for mental illness (for more on this topic, see Chapter 13, “Gender and Psychological Health”).
Men’s underutilization of health care also differs by race, with Black and Latino men in the United States being less likely than White men to have a regular doctor or health care provider. While 23% of White men have no regular doctor, 30% of Black men and 49% of Latino men have no regular doctor (McFarlane & Nikora, 2014). For Black men, mistrust of the health care industry may pose a barrier to routine doctor visits that goes beyond male gender role norms (Hammond, Matthews, Mohottige, Agyemang, & Corbie-Smith, 2010). Relative to White Americans, Black Americans tend to view medical doctors as more distant and uncaring and as less trustworthy. These views may stem, in part, from historical events such as the Tuskegee Syphilis Study that took place from 1932 to 1972 in Alabama (Gamble, 1997). As part of this study, researchers gave hundreds of low-income illiterate Black men with syphilis a placebo drug instead of penicillin, a known treatment for the disease, so that they could study the natural progression of untreated syphilis. While the Tuskegee study was eventually shut down for ethical reasons, and a class action lawsuit awarded $9 million to the families of the men who participated, this significant malpractice left lingering feelings of medical mistrust among many Black men.
As a participant in the Tuskegee Syphilis Study, Herman Shaw believed that he was receiving treatment for syphilis when he was not. Here, at age 94, Shaw embraces President Bill Clinton after receiving a public apology at the White House on May 16, 1997.
Source: Getty Images / STEPHEN JAFFE / AFP
Unfortunately, men’s lower rates of health care use may become self-reinforcing. Conversely, establishing a routine with a regular doctor can increase comfort levels and make future visits more likely. Routine visits can also increase the likelihood that doctors detect problematic health issues early. During a routine doctor visit, a physician might ask about a range of health issues, which can prompt a patient to disclose a condition that might otherwise go untreated. Thus, by seeking routine health care more frequently, women have more opportunities for health problems to be detected and treated.
Receiving Health Care
Of course, while deciding to visit a doctor may be under people’s control, the treatment that they receive from the doctor is less so. Sex and gender influence the health care that people receive in a couple of ways. First, the sex of the physician may play a role in how patients are treated. Female, as compared with male, primary care physicians tend to have longer visits with their patients, and they engage in more patient-centered communication, such as positive talk and psychosocial counseling (Roter, Hall, & Aoki, 2002). As mentioned earlier, men who hold more traditional beliefs about gender tend to prefer male over female doctors, which means that they are less likely to benefit from the increased time and attention that female doctors tend to provide.
Second, doctors may (likely unknowingly) treat their male and female patients differently, even when they present with similar symptoms. Implicit physician biases refer to automatic, nonconscious judgments and behaviors exhibited by doctors that are elicited by features such as patients’ sex, race, age, sexual orientation, and social class. Essentially, these biases occur when doctors rely on stereotypes to make judgments or decisions about specific individuals under their care. Once activated, implicit physician biases can perpetuate health disparities between groups (E. N. Chapman, Kaatz, & Carnes, 2013). For example, imagine a man who visits a doctor complaining of stress, lack of appetite, and fatigue. Now, imagine a woman presenting with the same symptoms. Doctors may be more likely to diagnose the woman as suffering from depression because stereotypes link depression to women more than to men. In some cases, this may result in men’s depression going untreated because of the influence of stereotypes on doctors’ judgments. In contrast, women’s reports of chronic physical pain are sometimes met with skepticism from doctors, who assume that the underlying cause of women’s pain is psychological rather than somatic. Compared with men, women struggle to have their chronic pain experiences taken seriously, and as a result are given less—and less effective—pain relief medication (Samulowitz et al., 2018).
Implicit physician biases Automatic, nonconscious judgments and behaviors, based on stereotypes, that influence how physicians evaluate or treat patients.
To measure implicit physician biases, researchers present physicians with hypothetical cases of either female or male patients who display identical sets of symptoms. The findings reveal that physicians more often diagnose COPD in a “middle-aged former smoker with a persistent cough” when the patient is described as male compared with female (K. R. Chapman, Tashkin, & Pye, 2001). Similarly, when orthopedic surgeons read about either a male or a female patient with moderate knee pain and osteoarthritis, they more frequently referred the male than the female patient for a total knee replacement (Borkhoff et al., 2008). In addition to sex, implicit physician biases occur with regard to race, age, and obesity status. For example, medical students recommend breast reconstruction following mastectomy more often for younger than older female patients (Madan, Cooper, Gratzer, & Beech, 2006). Moreover, physicians with greater implicit race bias recommend appropriate treatments less often for a Black than for a White patient who presents with heart attack symptoms (Green et al., 2007). In each of these cases, some groups of people systematically receive lower-quality health care than others due to physician biases.
These biases can have major consequences. For example, because stereotypes link heart disease with men, physicians tend to test women for heart disease less often than they test men (McKinlay, 1996), even though the most frequent cause of death for women in the United States is heart disease. Moreover, when women present with symptoms of heart disease, physicians are less likely to prescribe them essential cardiovascular drugs (Koopman et al., 2013). Factors such as these that reduce the quality of health care that women receive for heart disease symptoms can mean the difference between life and death.
Gender-Egalitarian Communities and Health
Summarizing over the past several sections, we see that many aspects of the male gender role work against men’s physical health. Men, relative to women, more frequently engage in unhealthy behaviors (smoking and excessive drinking) and take unnecessary risks (reckless driving and dangerous hobbies), they show less concern for their health and diet, and they tend to avoid routine health services and delay seeking help when sick. All of this suggests that the male gender role can be bad for physical health and may help explain the shorter life expectancies of men. At the same time, women’s expected roles as caregivers may account for their overall higher levels of chronic pain conditions and poorer self-reported health. If these aspects of male and female gender roles account for sex differences in mortality and morbidity, then the sex differences should decrease or disappear in cultures with less traditional gender role norms. What happens in places that do not enforce strict gender roles?
Israeli kibbutz societies tend to assign similar roles to women and men. Kibbutzim are collective agricultural communities in Israel that base work and social life on socialist principles, and community members commit to gender-egalitarian lifestyles. Men and women engage in similar daily activities and social roles, and everyone contributes equally to decision-making. Studies of gender and health among kibbutz members find no sex differences in health status or illness behaviors, such as doctor visits and medications (Anson, Levenson, & Bonneh, 1990). Also, the sex differences in life expectancy found in most cultures around the world are much smaller on kibbutzim (Leviatan & Cohen, 1985).
Kibbutzim Collective agricultural communities in Israel in which work and social roles reflect socialist principles, and community members pursue gender-egalitarian lifestyles.
Some groups of Catholic nuns and monks also live in environments that minimize sex differences in behavior. Women and men in these religious groups have similar diets, stressors, and lifestyles. They take a vow to live in poverty and chastity and have the same daily routine of sleeping, working, and recreation. One study of nuns and monks in Germany compared this group with age-matched samples from the general population and found much smaller sex differences in mortality between nuns and monks (Luy, 2003). Finally, studies of Seventh-day Adventists in the United States and the Netherlands suggest a similar relationship between gender roles and health. Seventh-day Adventists are a religious community that advocates a number of specific healthy behaviors, including vegetarian diets, no tobacco or alcohol, and regular exercise. The environmental conditions and lifestyles of Seventh-day Adventist men and women are fairly similar, although they do engage in some different occupational and gender roles. Seventh-day Adventists have an average life expectancy of 86 years (Fraser & Shavlik, 2001) and show smaller sex differences in mortality than the general population (Berkel & de Waard, 1983).
These studies of different communities suggest that social behaviors and lifestyles can influence the size of sex differences in health and longevity. At the same time, the fact that women outlive men even among these populations indicates that biological differences also play a role. This brings us back to a recurring theme in this book: that nature and nurture interact in complex ways to shape the attributes and outcomes of women and men.
STOP AND THINK
Consider the notion that the male gender role is “bad for physical health.” Do you believe this proposition? If male-typed behaviors and norms undermine men’s physical health, why do you think men continue to behave this way? We mentioned one domain in which men exhibit healthier behavior than women: physical activity. This illustrates one positive health behavior associated with the male gender role. What are some others?
HOW DO MULTIPLE SYSTEMS OF DISCRIMINATION SHAPE HEALTH AND HEALTH CARE?
Thus far, we have focused primarily on how sex and gender contribute to health, but what about the intersections of sex, class, race and ethnicity, culture, sexual orientation, and gender identity? Do sex differences in mortality rates also differ by race, ethnicity, and class? What unique reproductive health challenges do low-income women around the world face? How does LGBT status increase people’s vulnerability to illness and poor health? In this section, we consider these and other similar questions.
Sex, Race/Ethnicity, Socioeconomic Status, and Culture
Race/ethnicity and socioeconomic status (SES)—an index of class and wealth—interact with sex to impact health and longevity in unique ways. SES and race/ethnicity are tightly linked in the United States, with Latinx, Native American, and Black people typically having lower SES compared with White and Asian people (D. R. Williams, Priest, & Anderson, 2016). Given this, Bowleg (2008) argues that clear understandings of physical health will emerge only when researchers look beyond individuals’ health-related behaviors to the larger social inequalities (e.g., racism, sexism, classism) and related social structures (e.g., educational systems, neighborhoods, and health care) that they experience.
Socioeconomic status (SES) A measure of the income, education level, and occupational status of an individual or household.
Even though life expectancy in the United States increased since 1970 by 17% for Black people, compared with 10% for White people, Black Americans still die nearly 4 years earlier, on average, than White Americans. Black men, in particular, have a relatively short life expectancy of about 72.3 years, compared with the life expectancy of White men (76.5), Black women (78.4), and White women (81.3; Kochanek, Arias, & Anderson, 2015). Homicide plays a role in the lower life expectancy rates of Black men compared to White men, accounting for a loss of 0.87 years in Black men’s life expectancy. For instance, 46% of all U.S. homicide victims in 2018 were Black men, compared to White men (32%), White women (14%), and Black women (8%) (Federal Bureau of Investigation, 2018a). Other factors that shorten Black men’s life expectancy include heart disease (a loss of 1.12 years), cancer (a loss of 0.80 years), and HIV/AIDS. Black men are over six times more likely than White men to die from HIV/AIDS (Centers for Disease Control and Prevention, 2017b). In contrast, illustrating the Latino paradox, Latinx Americans live about 3 years longer, on average, than White Americans (Kochanek et al., 2015).
The factors that shape race differences in life expectancy begin before birth and, as noted, interact with SES. Because they are more likely to be born at low birth weights, Black babies are twice as likely as White babies to die in infancy. Black, Latinx, Asian, and Native American children have less regular access to health care than White children (Blackwell et al., 2014), and Black children tend to have less access to nutritious foods compared with White children (Kann et al., 2014). Studies in Los Angeles, New York City, and New Orleans find that neighborhoods with higher proportions of Black residents also tend to have a higher density of fast-food restaurants and convenience stores that stock canned and processed foods, and there are fewer opportunities to obtain healthy, fresh foods (Hilmers, Hilmers, & Dave, 2012). In fact, people of color in the United States often live in food deserts, or neighborhoods in which the lack of nearby grocery stores and easy public transportation limits residents’ regular access to fresh, healthy food, especially fruits and vegetables.
Race and ethnicity differences in access to healthy diets may help explain race and ethnicity differences in obesity rates. Table 12.3 shows the percentage of overweight (BMI between 25 and 30) and obese (BMI over 30) adult Americans, broken down by sex and race. As you can see, Latinx and Black people are both more likely to be categorized as obese than Asian and White people, and they are also more likely to reside in food deserts. The story gets a bit more complicated, however, when we examine race differences by sex. As we mentioned in Sidebar 12.3, while men around the world are more likely to be classified as overweight, women are more likely to be classified as obese. Although this overall pattern emerges in the United States as well, the size and direction of sex differences in overweight and obesity rates differ by race. For example, the tendency for men to be overweight more often than women is more prevalent among Asian and White people, and the tendency for women to be obese more often than men emerges more among Latinx and Black people. Some argue, however, that using the BMI to classify people’s weight shows sex and race bias because the BMI classification system was originally developed in the 19th century using data from a sample of mostly White men. Since health and weight are far from perfectly correlated, critics of the BMI argue that using White standards to make judgments about the health of people of color overlooks natural and healthy body diversity. Medical professionals should thus not make assessments of an individual’s health solely based on the BMI (Byrne, 2020).
For 30 years, this Pathmark on the Lower East Side of New York City was the only affordable source of fresh food and groceries for low-income families. It was closed in 2012 to make way for a luxury condo tower, leaving local residents in a food desert.
Source: Richard Levine/Alamy Stock Photo
Food deserts Neighborhoods in which the lack of nearby grocery stores and easy public transportation limits residents’ regular access to fresh, healthy food.
Although race/ethnicity and SES work together to impact health outcomes, SES cannot fully explain race/ethnicity differences in physical health. While Black men who lack a high school degree are more than 5 times more likely to die from homicide compared with Black men who attend at least some college, college-educated Black men are still 11 times more likely to die from homicide compared with similarly educated White men. Furthermore, when comparing Black and White Americans at the same levels of SES, Black Americans at all SES levels have higher rates of diabetes, cardiovascular disease, and hypertension and higher mortality rates from coronary heart disease and cancer (D. R. Williams & Jackson, 2005; D. R. Williams, Mohammed, Leavell, & Collins, 2010). This suggests that the health benefits associated with higher SES in the United States are not as apparent for groups that face institutional racism. In fact, according to minority stress theory, belonging to a stigmatized group creates unique stressors, such as harassment, abuse, and employment discrimination, that combine to increase minority individuals’ vulnerability to all types of health problems, regardless of their SES (I. H. Meyer, 2003). For example, self-reported experiences with discrimination predict increases in weight gain and visceral fat (Lewis, Kravitz, Janssen, & Powell, 2011; Reid et al., 2016). This may occur because cortisol, a hormone released during stress, can motivate overeating. Over time, large weight gains can increase the risk of diabetes, high blood pressure, and heart disease.
In general, men are more likely than women to be classified as overweight and less likely than women to be classified as obese. But these sex differences differ by race and ethnicity. Sex differences in overweight status are larger for Asian and White people, and sex differences in obesity are larger for Latinx and Black people. What do you think accounts for these interactions of sex with race and ethnicity?
Source: National Center for Health Statistics (2016).
Minority stress theory A theory that proposes that belonging to a stigmatized group can create stressors that are unique to the minority experience.
Visceral fat A type of body fat stored near vital organs inside the abdominal cavity that is associated with an increased risk for type 2 diabetes and heart disease.
Feminization of poverty The global tendency for women to experience disproportionate rates of poverty.
These patterns in physical health outcomes emerge globally as well. Across the world, people lower in SES have poorer health and die younger than those higher in SES. Several factors likely account for this. People around the globe who lack economic resources are less likely to have health insurance and reliable access to quality medical care. Just as with marginalized communities in the United States, poorer people across the world often live in food deserts, making it difficult to access fresh, healthy food. Across developed countries, people lower in SES tend to become overweight or obese more often than those higher in SES (Devaux & Sassi, 2013), making them more vulnerable to weight-related physical health problems.
Girls and women who live in poverty often face acute reproductive health obstacles that can perpetuate their low SES. Across cultures, compared with those higher in SES, girls and women lower in SES use contraception less often, receive less education about preventing sexually transmitted diseases, and have less access to maternal health services. As a result, they more frequently have children before the age of 18 (Rani & Lule, 2004), and early motherhood reduces the likelihood that young women will get an education, gain financial autonomy, and move out of poverty. This self-perpetuating cycle likely contributes to the feminization of poverty, which is the global tendency for women to experience disproportionate rates of poverty (McLanahan & Kelly, 2006). One factor that might help disrupt this pattern for young girls is more open communication with parental figures about sexual and reproductive health. In world regions characterized by high poverty and teenage pregnancy rates, including many sub-Saharan African nations, young adolescents on average exhibit very little knowledge about pregnancy prevention (Bankole, Biddlecom, Guiella, Singh, & Zulu, 2007). Moreover, it is not always normative for African parents to discuss puberty, pregnancy risks, and sexual and reproductive health with their adolescent children. This may be changing, however. In an interview study of mothers of young adolescents in low-income urban areas in Nigeria and Kenya, mothers reported receiving insufficient information about pubertal development from their own parents, which motivated them to talk more openly with their daughters about how to avoid pregnancy (Bello et al., 2017).
Sexual Orientation and Gender Identity
On average, lesbian, gay, and bisexual individuals experience higher rates of cardiovascular disease and obesity (lesbian and bisexual women), higher rates of diabetes (bisexual men), and poorer overall health (gay and bisexual men) compared with heterosexual individuals (Fredriksen-Goldsen, Kim, Barkan, Muraco, & Hoy-Ellis, 2013). Moreover, compared to their cisgender counterparts, transgender adults experience poorer physical health, higher rates of physical disability (Downing & Przedworski, 2018; Fredriksen-Goldsen et al., 2014), and over twice the rate of heart attacks (Alzahrani et al., 2019). Minority stress theory is relevant here. As discussed in the previous section, the chronic stress associated with being in a stigmatized minority group can impact health via two routes. First, it increases people’s reliance on unhealthy coping behaviors (such as overeating or drinking alcohol to cope with anxiety), and second, it overburdens the body’s stress response and immune systems, thereby weakening the ability to fight illness (I. H. Meyer, 2003).
Both of these routes can impact the health of sexual and gender identity minority individuals. Compared with heterosexual individuals, LGB individuals report more chronic worry and tension, and they tend to exhibit more risky health behaviors, such as smoking, drug use, physical inactivity, and risky sex (Conron, Mimiaga, & Landers, 2010; Saewyc et al., 2006). Furthermore, LGB people who experience more extremely stressful events during childhood and adolescence (such as sexual or physical abuse, homelessness, or witnessing violence) also exhibit more biological markers of cardiovascular risk, while this link between stressful events and cardiovascular risk markers is not evident in heterosexual individuals (Hatzenbuehler et al., 2014). Transgender individuals also frequently encounter social stressors, such as discrimination, violence, and sexual abuse, that predict poorer health outcomes (Hughto et al., 2015). They also report more risky health behaviors, including smoking and physical inactivity, in comparison with LGB individuals (Fredriksen-Goldsen et al., 2014). Consistent with minority stress theory, these findings show that belonging to a stigmatized group can increase the body’s vulnerability to health problems.
In addition to facing stigma-related social stressors that can lead to impaired health, LGBT individuals often experience barriers to quality health care. For one thing, relative to heterosexual individuals, sexual minority individuals are less likely to have health insurance (Dahlhamer, Galinsky, Joestl, & Ward, 2016). Several factors may explain this. Historically, nonrecognition of same-sex partnerships kept many sexual minority individuals from obtaining employer-sponsored insurance coverage through their partners. Even though same-sex marriage is now legally recognized throughout the United States, it will likely take years to close the gaps in health care coverage based on sexual orientation. Furthermore, not all states have protected workers against employment discrimination based on sexual orientation or gender identity. Given that many people in the United States get health care coverage through their employers, the vulnerability of unprotected LGBT individuals to job loss has put them at risk of losing insurance coverage. Going forward, this will change due to the recent Supreme Court ruling that interprets Title VII of the 1964 Civil Rights Act to cover sexual orientation and gender identity (Sponzilli, 2020). And yet, prior to this decision, only 20 U.S. states and the District of Columbia legally protected against employment discrimination based on sexual orientation and gender identity. More time is needed for the remaining states to implement these protections and close any gaps in health care coverage that resulted from employment discrimination against LGBT individuals.
Even when LGBT individuals do have insurance and access to health care, other barriers may prevent them from receiving the same quality of health care that heterosexual and cisgender people enjoy (see Figure 12.3; Hafeez, Zeshan, Tahir, Jahan, & Naveed, 2017). For example, doctors may lack an understanding of the unique health needs of sexual and gender identity minority individuals. Consider the health needs of transgender men who identify and present as men but have developed breasts or female genitalia. Like cisgender women, such individuals benefit from standard gynecological care, including cancer screenings, mammograms, and Pap smears. And yet, many transmen forgo routine gynecological care due to the perception that doctors lack either the competence or the sensitivity to offer them adequate care (Dutton, Koenig, & Fennie, 2008).
Figure 12.3 Barriers to Health Care Faced by LGBT Individuals
Source: Adapted from Albuquerque et al. (2016).
Due to poverty, lack of insurance, and doctors’ inadequate training in LGBT health needs, many LGBT individuals rely on specialized, low-income clinics for their health care needs. Here, several transgender clients chat with Dr. Maya Tri Siswati, an expert in HIV/AIDS treatment, at a clinic in Jakarta, Indonesia, in 2009.
Source: Getty Images / ADEK BERRY / Stringer
When transgender individuals choose to undergo hormone therapy to bring their physical appearance into greater alignment with their gender identity, they need ongoing treatment from a doctor who can prescribe and monitor the therapy (C. A. Unger, 2014). However, the educational training of doctors, which occurs within a heteronormative and cisnormative academic culture, leaves many doctors unprepared to meet the unique health needs of transgender individuals. In fact, one study of transgender adults found that 20% of them had to educate their doctors about their health needs, and more than 25% of them reported needing—but not having access to—at least one transgender-specific service, such as hormone treatment, gynecological care, or psychotherapy (Bradford, Reisner, Honnold, & Xavier, 2013). On a more positive note, Guy T’Sjoen, a Belgian endocrinologist and transgender health specialist, has been making strides to improve and normalize gender-affirming treatments for transgender individuals (see Sidebar 12.4 for a discussion of T’Sjoen’s work). This work is important because transgender individuals who choose to undergo hormone treatments show significant decreases in anxiety and depression after beginning these treatments (Heylens, Verroken, De Cock, T’Sjoen, & De Cuypere, 2014), a topic that will be discussed further in Chapter 13 (“Gender and Psychological Health”).
LGBT individuals and their doctors alike may feel uncomfortable discussing sexual orientation or gender identity status (see Figure 12.3). On the one hand, internalized homophobia or transphobia may make some LGBT individuals anxious about disclosing their sexual orientation or gender identity to their doctor. On the other hand, doctors may prefer not to ask patients about their LGBT status because they assume that such questions will make patients uncomfortable (Haider et al., 2017). And yet, most transgender individuals believe that it is important for their primary care provider to know about their gender identity status (Maragh-Bass et al., 2017). When doctors know the sexual orientation and gender identity status of patients, it can increase the likelihood of open doctor—patient communication about risk factors, health screenings, and treatments that can improve health outcomes.
SIDEBAR 12.4 ADVOCATING FOR TRANS-POSITIVE MEDICAL RESEARCH
Although the transgender population tends to be overlooked in medical research, a Belgian endocrinologist, Guy T’Sjoen, seeks to remedy this. Dr. T’Sjoen dedicates his career to improving transgender health care, regularly doing research and making media appearances to bring visibility to the transgender community. In 2010, T’Sjoen founded the European Network for the Investigation of Gender Incongruence (ENIGI) to assess the long-term health consequences and effectiveness of gender-affirming hormone treatments (Reardon, 2019). By 2019, the study had grown to over 2,600 transgender participants across four European clinics (in Belgium, the Netherlands, Germany, and Norway). This study is unique not only because of its large sample size, but because it tracks the physiology and psychology of transgender individuals from before, to several years after, they undergo gender-affirming procedures. In contrast, most research on the effects of gender-affirming procedures uses small samples and studies transgender people only after they complete treatments. To date, the ENIGI study finds that hormone treatments are safe and have relatively few side effects (Dekker et al., 2016).
The fear of discrimination still discourages many transgender individuals from seeking medical care when needed (Grant et al., 2010). These fears may be well founded. One study of transgender people found that 41% experienced health care—related discrimination (Bradford et al., 2013). Another study found that 19% of transgender and gender-nonconforming adults were denied service by a doctor or other provider (due to their identity), 28% were verbally harassed in a doctor’s office, and 2% were physically attacked in a doctor’s office (Grant et al., 2010). Perhaps unsurprisingly, then, transgender and gender-nonconforming individuals are less likely to have preventative health care checkups (Rider, McMorris, Gower, Coleman, & Eisenberg, 2018). In extreme cases, medical discrimination can result in death, as you may recall from Chapter 1 when we discussed the case of Tyra Hunter. Hunter, a 24-year-old transgender woman, was injured in a car accident and died because paramedics stopped treating her when they discovered that she had male genitals.
STOP AND THINK
Most transgender people want their doctors to know about their transgender status, but they may experience discrimination and mistreatment if they reveal their status. How can we solve this problem? What sorts of changes might have to occur—at the level of societal attitudes, medical training practices, education, and so on—in order for transgender people to be able to disclose their gender identity status to doctors without fear of discrimination?
Of course, there is a great deal of variety among LGBT people regarding their physical health outcomes, health risk behaviors, and utilization of health care services. Some sexual and gender identity minority individuals thrive despite adversity and stigma. What factors might protect the health of LGBT individuals? Having social resources in the form of an accepting family, extended social networks, and a strong, supportive community can all help insulate sexual and gender identity minority individuals from the negative effects of stigma (Fredriksen-Goldsen, Kim, Shiu, Goldsen, & Emlet, 2015; Hatzenbuehler, 2014). To illustrate, a study (conducted before marriage equality laws passed in the United States) found that same-sex couples who lived in states that legally recognized their relationships experienced better health than those who did not (M. E. Williams & Fredriksen-Goldsen, 2014). We will consider these protective factors for LGBT individuals in the next chapter.
WHAT DO WE KNOW ABOUT SEX-SPECIFIC HEALTH ISSUES?
As noted earlier in the chapter, living today (as opposed to 100 years ago) has its health benefits. Thanks to advances in our understanding of biology, chemistry, and technology, we can now safely and effectively treat hundreds of physical health conditions that, in former days, were likely to incapacitate or kill us. Some of these conditions are sex specific, such as hemophilia, which affects men more than women, and fibroids, which affect women more than men. In this section, we examine several of these sex-specific medical conditions. We then consider some of the complications that arise when advances in the fields of health and medicine lead to unnecessary diagnoses and treatments.
Fibroids Noncancerous tumors that form in the uterus, often leading to heavy menstrual bleeding and pelvic pain.
Sex-Specific Medical Conditions
Gynecology and andrology are separate branches of medicine that address the sex-specific medical issues facing women and men, respectively. These two branches of medicine tend to focus on sexual and reproductive health, but our focus here will be broader. Note that gynecology and andrology still largely operate within a binary sex system that tends to exclude transgender and gender-nonbinary individuals, although change is occurring slowly (as you read about in Sidebar 12.4).
Gynecology The branch of medicine that studies female health, with a particular focus on reproductive health.
Andrology The branch of medicine that studies male health, with a particular focus on the sexual/reproductive organs and the urinary system.
How do sex-specific medical conditions develop? Many factors—including genes, hormones, anatomy, and life experiences—are at play. For example, consider diseases linked to the X chromosome. As explained earlier, X-linked recessive diseases—such as certain types of hemophilia, muscular dystrophy, and color blindness—impact males and females differently. With only one X chromosome, boys and men are more likely to develop X-linked diseases, whereas having two X chromosomes can protect girls and women from either developing X-linked diseases in the first place or experiencing extreme forms of them. Recall that having two X chromosomes means that a normal gene on one X chromosome can override a disease-producing gene on the other X chromosome and prevent the disease from being expressed or reduce its severity. Furthermore, females typically receive one X chromosome from each parent, but not all genes on each X chromosome are activated and expressed. Their cells thus become a random mosaic of expressed genes from the mother and expressed genes from the father, offering them further protection from relatively rare X-linked diseases. Interestingly, some genetic disorders that appear to be female specific, such as Rett syndrome, actually affect both female and male embryos. However, male embryos that carry this syndrome typically die in utero, while female embryos survive and are born with a less severe form of the disease (Migeon, 2006).
Rett syndrome A neurological disorder linked to a mutation on the X chromosome and characterized by seizures, language impairments, and difficulty breathing, using the hands, and walking.
Cancer diagnoses, treatment effectiveness, and mortality rates also tend to show consistent sex differences. In the United States, men are more likely than women to be diagnosed with and die from cancer (Siegel, Miller, & Jemal, 2019). Certain cancers (e.g., testicular and prostate) tend to be male specific, whereas others (e.g., uterine and ovarian) tend to be female specific. However, transmen who have female reproductive organs continue to be at risk for cervical, uterine, and ovarian cancers, while transwomen remain at risk for prostate cancer (Braun et al., 2017). In terms of cancer treatments, the efficacy and toxicity of several commonly used chemotherapy drugs can differ by sex, and doctors who consider these sex differences when developing treatment plans may improve outcomes for their patients (Kim, Lim, & Moon, 2018).
What about breast cancer? While both men and women can develop breast cancer, rates are significantly higher for women, affecting approximately 1 out of every 8 women (versus 1 out of every 1,000 men) in the United States (Shapiro, 2017). Interestingly, rates of breast cancer differ somewhat among transgender people undergoing hormone therapies, suggesting a possible influence of hormones in breast cancer risk. In a study of over 3,400 transgender adults in the Netherlands, the rates of breast cancer among transwomen receiving hormone therapy (estrogens and antiandrogens) were higher than those of cisgender men but lower than those of cisgender women. In addition, transmen receiving hormone therapy (testosterone) had lower rates of breast cancer than cisgender women (de Blok et al., 2019).
Researchers have also examined the genetic causes of breast cancer, with a focus on two genetic mutations (BRCA1 and BRCA2) that significantly increase the risk of breast cancer in women and men (Hesse-Biber & An, 2017). Fortunately, genetic testing can identify whether individuals are BRCA positive, which allows them to manage their risk of developing breast cancer with increased screenings, medications, and/or surgical procedures. However, given that breast cancer is perceived as a female disease, men often feel heightened pressure to be strong and avoid seeking help when facing a BRCA or breast cancer diagnosis. Health care professionals may benefit their male patients with breast cancer by recognizing these stressors associated with the male gender role.
The Medicalization of Reproductive Health
Beyond these sex-specific diseases, several natural aspects of reproduction are treated within Western cultures as if they are diseases requiring medical intervention. Medicalization refers to the process whereby normal, natural conditions—such as menstruation, pregnancy, and childbirth—come to be viewed as medical conditions that require diagnoses and treatments. You may recall our discussion of the medicalization of sexuality from Chapter 9 (“Sexual Orientation and Sexuality”). Here, we will examine the medicalization of reproductive health and its consequences, which are summarized for you in Table 12.4.
Researchers identify several natural aspects of reproductive health that are medicalized, or viewed as medical conditions that require treatments. Each kind of medicalization brings potential negative consequences.
Source: Adapted from C. Fisher, Hauck, and Fenwick (2006); J. Roberts, Griffiths, Verran, and Ayre (2015); and Tone (2012).
The medicalization of natural physical conditions can change how people think about these conditions, making them seem abnormal and negative. As an example, consider premenstrual syndrome (PMS), which is a diagnosable illness consisting of aches and pains, bloating, anxiety, anger, depressed mood, and moodiness that occurs monthly before the onset of menstruation (Ussher & Perz, 2013). And yet, it is normal for healthy women to experience these and other changes across the menstrual cycle, corresponding with natural fluctuations in hormone levels. In fact, some estimate that as many as 75% of women in Western cultures would meet diagnostic criteria for PMS if they sought such a diagnosis (Steiner & Born, 2000). As feminist scholars note, the labeling of women’s normal reproductive cycle as an illness encourages a view of women’s bodies as regularly sick and unable to function. This can then fuel stereotypes of premenstrual women as dysfunctional, incapable of logic, and not to be taken seriously as leaders. Moreover, the medicalization of PMS drives a focus on the negative aspects of women’s reproductive cycle, drawing attention away from the positive aspects. In fact, many women notice positive bodily cues and changes that accompany menstruation, such as feelings of elation, energy and creativity, peaks of efficiency, positive body image, and increased sexual interest (King & Ussher, 2012). However, these positive changes are routinely ignored in cultural understandings of PMS.
Premenstrual syndrome A diagnosable illness that some women experience before the onset of menstruation, characterized by aches and pains, bloating, anxiety, anger, and moodiness.
One of the most controversial consequences of medicalization is the overuse of unnecessary (and sometimes unadvised) interventions and treatments. As one example, doctors in some countries have been performing Cesarean section (C-section) procedures—the use of surgery to deliver a baby through the mother’s lower abdomen—at ever-increasing rates. In 1970, the rate of C-section births in the United States, Canada, and Australia was about 6%; today, it falls between 25% and 30% in these same countries (Malacrida & Boulton, 2014). Worldwide, C-section rates range from below 2% among the least developed nations to highs of 50% in China and Taiwan (M. C. Klein et al., 2006; Machizawa & Hayashi, 2012). When performed appropriately in emergency situations, C-sections can and do save the lives of mothers and babies. And yet, the World Health Organization recommends that C-section rates should not exceed 15% in any world region. This suggests that doctors perform a substantial proportion of these procedures unnecessarily, especially in more developed and wealthier nations. As major surgeries, C-sections carry all of the risks of any major surgery and often involve a painful recovery. Moreover, women who have Cesarean births (compared with those who have vaginal births) report less satisfaction with the birth experience, take longer to bond with their infants, are less likely to breastfeed, and interact with their infants less after returning home (DiMatteo et al., 1996).
Cesarean section (C-section) procedure The use of surgery to deliver a baby through the mother’s lower abdomen.
SIDEBAR 12.5 REACTIONS TO MENSTRUATION AROUND THE WORLD
Cultures differ widely in how they view and respond to women’s menstruation. For instance, PMS (premenstrual syndrome) is little known outside of Western cultures (Chrisler & Caplan, 2002). This does not mean that premenstrual symptoms (e.g., bloating, cramps, and anxiety) do not exist in non-Western cultures; rather, people in non-Western cultures do not necessarily view these symptoms as an illness that requires professional help. In fact, women’s own interpretation of their premenstrual symptoms may differ as a function of the surrounding cultural beliefs. One study found that the longer immigrant women lived in the United States, the more likely they were to experience depressed mood and mood swings in the week before their period (Pilver, Kasl, Desai, & Levy, 2011). While some non-Western cultures view menstruation quite positively (Bures, 2016), others, such as Nepal, still practice chaupadi, the banned custom of isolating menstruating girls and women for 4 days per month (Nirola, 2017). Why do you think cultures differ so widely in their views of menstruation?
Labor induction, fetal heart monitoring, ultrasound exams, epidural analgesia (local anesthesia in the lower spine for pain relief), and episiotomies (surgical incisions to increase the vaginal opening during childbirth) are now conducted routinely during pregnancy and childbirth, even when medically unnecessary (M. C. Klein et al., 2006). In addition to being costly, these procedures may increase the risks of harm and medical complications. Such procedures can also alienate women from their bodies by turning pregnancy and childbirth into one long medical procedure, and the overuse of obstetric interventions can heighten women’s sense of danger and uncertainty. For more on how societal views of pregnancy and childbirth have evolved over time, see “Journey of Research: Pregnancy and Childbirth Advice Through the Centuries.”
Contemporary Western pregnancies are highly medicalized.
Source: © iStockphoto.com/FatCamera
JOURNEY OF RESEARCH: PREGNANCY AND CHILDBIRTH ADVICE THROUGH THE CENTURIES
How a society views pregnancy and childbirth offers a window into its views about women and about health more generally. For centuries, from ancient Greece to the Middle Ages, Western medical advice to pregnant women changed very little because doctors (who were mostly men) played little role in pregnancies and childbirth. Before the 20th century, nearly everyone delivered at home (Feder, 2014), and most advice given to pregnant women derived largely from intuition, superstition, and casual observation.
Probably the most influential early medical voice was Soranus, a famous second-century Greek physician who wrote a text on gynecology that was consulted for centuries. However, the science behind his advice was lacking. For instance, Soranus advocated against heavy drinking during pregnancy because drunken fantasies (such as thinking about monkeys) could make a baby hairy. He also warned against sex during pregnancy, reasoning that it drained women of vital energies that should flow to the child. Following Soranus, early books about women’s health were mostly written by monks, who had the advantage of being literate but the disadvantage of being celibate and having little contact with women, making their advice questionable (Hutter Epstein, 2010).
For the most part, science and medicine had little to say on pregnancy and childbirth for centuries. It was not until the 17th century that the medicalization of pregnancy and childbirth began (Feder, 2014). Medical doctors began replacing midwives as the primary caretakers of pregnant women, and the medical community began to take an interest in prenatal development, though with questionable science that reflected insulting stereotypes about women. For instance, people during the 19th century Victorian era viewed women as weak, fragile, passive, and highly emotional. Doctors often placed pregnant women, particularly middle-class pregnant women, in near confinement to keep them from anything strenuous or emotional (Malone, 2000). Since society viewed sex and pregnancy as shameful at the time, pregnant women dressed in a manner that hid the pregnancy for as long as possible. Although anesthetics were discovered in the 19th century, religious views of the era dictated that pain and suffering were natural, dutiful parts of childbirth (Hutter Epstein, 2010). Pain relief medicine did not become common for women during childbirth until the 20th century.
By the turn of the century, medical advice still reflected conservative views about women and sexuality. Some doctors, such as John Harvey Kellogg (the inventor of Corn Flakes), advised against sex during pregnancy for fear that the mother’s enjoyment would get transmitted to her child, turning it into a lustful pervert. Dubious medical advice to pregnant women persisted throughout much of the 20th century. For example, doctors advised pregnant women to avoid exercise and to calm their nerves by smoking cigarettes. As late as the 1970s, some medical professionals still doubted the link between mothers’ smoking and health risks (such as low birth weight) for babies (Lumley & Astbury, 1982).
What about today? Medical advice is much more scientifically grounded, although women often do receive questionable advice from friends and family. Most experts now recognize that smoking harms both the mother and fetus. Many people, however, still do not understand that excessive weight gain during pregnancy can be harmful, and some advise pregnant women to put on a lot of weight (Verna et al., 2016). Furthermore, people increasingly realize that pregnancy and childbirth are overmedicalized. While medical technologies can reduce infant and mother mortality, the increasing medicalization of childbirth (e.g., epidurals and C-sections) can increase the risks of complications and medical problems.
STOP AND THINK
What do you think about the medicalization of reproductive health? Do you think increases in C-sections, ultrasounds, and epidurals are signs of a society that benefits wisely from advances in health knowledge and technology? Or are they signs that the field of medicine has too much control over a natural and nonmedical process? What about PMS? Do you think that this should be treated as a diagnosable medical condition? Why or why not?
Having explored the sex-related dimensions of physical health in this chapter, we will turn our attention to mental health in the next chapter. Though we cover mental and physical health in separate chapters (due to the large amount of material), note that there is a fundamental interconnectedness between mental and physical health. For example, depression, anxiety disorders, and alcoholism correlate with a greater risk of physical disorders such as cardiovascular disease, diabetes, and chronic pain (Culpepper, 2009; D. L. Evans & Charney, 2003). This relates to sex and gender because common psychological disorders—such as depression, anxiety, and substance use disorder—show clear and persistent sex differences. In fact, sex differences in psychological disorders may help to explain why women experience more chronic physical health conditions than men, and why men experience more life-threatening health conditions than women (Needham & Hill, 2010). Although researchers do not fully understand the complex links between psychological and physical health, they have made significant progress in understanding this interconnection in a relatively short period of time. Ultimately, well-being is a product of a healthy mind and body. It will be interesting to see where the next research developments in this area take us.
· 12.1 Describe the major causes of mortality for men and women and how they have changed over time.
A century ago, the average life expectancy was much shorter, and the most common causes of death were from infectious diseases (pneumonia, influenza, tuberculosis, and gastrointestinal infections). As people have lived longer, the most common types of death today are diseases of old age (heart disease and cancer). Women, on average, outlive men across time and place, but the longevity gap between men and women in the United States has decreased since the mid-20th century. Today, women outlive men by slightly less than 5 years, on average.
· 12.2 Explain biological and social causes for sex differences in health and longevity.
Female members of many animal species tend to outlive males. Sex differences in both genes and hormones may contribute to health and longevity. The presence of two X chromosomes may provide a female advantage when recessive disease-producing abnormalities appear on the X chromosome. In these cases, the disorder will not be expressed if the genes carrying abnormalities appear only on one X chromosome. In addition, protective DNA sequences called telomeres at the ends of chromosome strands degrade faster in men than women, suggesting that men may age faster at the genetic level. At the hormonal level, women’s higher levels of estrogen (at least premenopause) may protect them against heart disease, and men’s elevated testosterone levels may increase their mortality risks.
Men engage in more risky health behaviors, and women engage in more health-promoting behaviors. Smoking and alcohol consumption kill more men than women. Heart disease and cancer are the biggest killers in developed countries, and men die more frequently than women from these diseases. Men’s relative reluctance to visit doctors also means that they less frequently identify and treat dangerous health conditions in a timely manner. Given that men’s relatively risky behaviors often negatively affect health, some argue that the male gender role is bad for health. Also bad for health are unmitigated agency (high levels of negative male-typed traits) and unmitigated communion (high levels of negative female-typed traits). While unmitigated agency reduces help-seeking, unmitigated communion fosters prioritizing others’ needs over one’s own. Studies of subcultures with more egalitarian gender roles find that the usual sex differences in health and longevity are minimized, largely because men tend to live longer.
· 12.3 Analyze the roles of race, social class, culture, sexual orientation, gender identity, and intersectionality in physical health.
On average, members of marginalized groups (in terms of race, SES, and sexual orientation) experience worse health outcomes than members of dominant groups. Factors shaping these negative health outcomes include increased stress associated with prejudice and stigmatization, poorer nutrition, decreased access to health insurance and health care, and fewer positive experiences with health care. For members of marginalized groups, real or perceived stigma can lead to mistrust of the medical establishment and avoidance of preventative health care visits. These patterns emerge in the United States and across the globe. Girls and women who live in poverty may get stuck in a cycle, where early pregnancy decreases their educational and work opportunities, which in turn perpetuates their poverty.
· 12.4 Explain sex-specific health conditions and describe some of the consequences of medicalizing reproductive health.
Sex differences in genes, hormones, anatomy, and life experiences can produce sex-specific medical conditions. Examples include X-linked diseases such as hemophilia and muscular dystrophy, which tend to be male specific, and fibroids, which tend to be female specific. The sexes also experience differences in cancer rates and chemotherapy treatment outcomes. Differences in cancer rates among transgender adults undergoing gender-affirming procedures point to a possible role of hormones in breast cancer risk. Men faced with breast cancer diagnoses may experience unique concerns due to the stereotypical association of breast cancer with women.
A side effect of the rapid advancement of medicine and medical knowledge is the tendency to see natural variations in life experiences through the lens of illness or disease. Common and natural processes such as physical and emotional changes associated with women’s monthly menstrual cycle are considered medical problems to be solved. Medical interventions, such as those that often accompany pregnancy and childbirth, may be overused and unnecessary. And complex phenomena are reduced to biological processes, which ignores important social, emotional, and cultural influences. In this way, we would do well to consider and more fully understand the psychological and sociocultural dimensions of physical health.
Test Your Knowledge: True or False?
· 12.1. Women tend to live longer than men in wealthier countries, but men live longer than women in poorer countries. (False: Women outlive men, on average, in every country.) [p. 430]
· 12.2. In surveys, men generally report being in better health than women. (True: Around the globe, women consistently report poorer physical health than men do.) [p. 434]
· 12.3. The global tendency for women to experience disproportionate rates of poverty is linked to early motherhood. (True: Girls and young women who have children before the age of 18 are less likely to get an education, become financially independent, and escape poverty). [p. 453]
· 12.4. The most frequent cause of death for women in the United States is heart disease, but physicians less often test and prescribe medicine for heart disease in women than in men. (True: This may reflect implicit physician biases, in which stereotypes subtly influence physicians’ decisions.) [p. 449]
· 12.5. In health care surveys, most transgender adults say that it is not necessarily important for their doctor to know their gender identity status. (False: Most transgender adults say that it is important for their doctor to know their gender identity status.) [p. 456]
Descriptions of Images and Figures
Back to Figure
The graph is described as follows:
The horizontal axis shows the timeline from 1900 to 2015 in increments of 10 years up to 2010.
The vertical axis shows the average life expectancy from 0 to 90 in increments of 10.
The approximate trend is:
1. Male: 48
2. Female: 49
1. Male: 49
2. Female: 52
1. Male: 51
2. Female: 52
1. Male: 55
2. Female: 60
1. Male: 58
2. Female: 65
1. Male: 62
2. Female: 70
1. Male: 63
2. Female: 70
1. Male: 65
2. Female: 72
1. Male: 67
2. Female: 75
1. Male: 70
2. Female: 78
1. Male: 72
2. Female: 78
1. Male: 72
2. Female: 80
1. Male: 73
2. Female: 80
Back to Figure
The pie charts are described as follows:
The chart on the left shows the means of transmitting HIV in men:
1. Male-to-male sexual contact: 77%
2. Heterosexual contact: 12%
3. Injection drug use: 7%
4. Male-to-male sexual contact and injection drug use: 4%
5. Other: Lesser than 1%
The chart on the right shows the means of transmitting HIV in women:
1. Heterosexual contact: 86%
2. Injection drug use: 14%
3. Other: Lesser than 1%
Back to Figure
The model is as follows:
Linear arrows point:
1. From Lack of Professional Training in Health:
1. to Heteronormative, Cisnormative Academic culture;
2. to Difficulties of Translating Training to Sexual and Gender Minority Populations;
3. to Reduced Use of Health Services.
2. From Homophobia and Transphobia:
1. To Lack of Professional Training in Health and Health Services;
2. To Internalized Homophobia and Transphobia;
3. To Fear of revealing sexual orientation or gender identity;
4. to Reduced Use of Health Services and Unmet Health Demands.
3. From Health Services:
1. To Implicit Physician Biases and Presumed Cisgender, Heterosexuality
2. To Humiliation, Ridicule, Rejection;
3. To Unmet Health Demands.