Elsevier

Social Science & Medicine

Volume 52, Issue 4, February 2001, Pages 547-559
Social Science & Medicine

Gender and health: reassessing patterns and explanations

https://doi.org/10.1016/S0277-9536(00)00159-3Get rights and content

Abstract

Recent research on gender and health challenges the prevailing notion of women’s generalized health disadvantage by revealing a more variable pattern of gender differences in health. As such differences come to be comprehended as more complex than previously thought, there is a need to reassess the pathways linking gender and health. Using data from a Canadian national probability sample, we examine: (1) gender differences in distress, self-rated health, chronic conditions, restricted activity and heavy drinking; and (2) the role of gender-based differential exposure and vulnerability to chronic stress and life events in explaining observed differences. We find that women report more distress and chronic conditions than men, but gender differences are reversed for heavy drinking, and negligible for self-rated health and restricted activity. Although women reported more chronic stress and life events, their greater exposure accounted for only some of the gender disparity in health, and only for distress. Differential vulnerability to stressors played no role in explaining gender differences in health. These findings raise questions about a gendered, generalized health response to the vicissitudes of life and suggest the need for further theoretical and empirical exploration of “gendered” experiences and their pathways to health.

Introduction

It is commonly believed that women are “sicker” than men. This view is sustained by considerable empirical research pointing to a female excess morbidity that effectively reduces the quality of life that women experience over their longer lifetimes. In the search for social mechanisms that might account for these observations, the stress process as it relates to gendered social roles and resource distribution is often investigated (Barnett et al., 1987, Simon, 1998, Gore and Colten, 1991, Turner and Avison, 1989, Newman, 1986, Thoits, 1987). Key here is the notion that the division of labour by gender results in differential exposure and vulnerability to stress among women and men; women are in poorer health because their lives are more stressful than men’s and they are more vulnerable to the health consequences of life stressors because of their relative lack of material, personal, and social resources.

While this work has provided valuable insight into how health is structured by gender and what this “gendering” means, recent research underscores the need for further exploration of these links. Importantly, emerging evidence of a variable pattern of gender disparity in health status leads us to question the conventional assumption that women experience more ill-health than men, and points to the importance of using several measures of health status (Macintyre, Hunt & Sweeting, 1996). Challenging the view of a gendered, generalized health response to the vicissitudes of life, researchers argue that the health effects of stress may be experienced and embodied by women and men in different ways (Aneshensel et al., 1991, Horowitz et al., 1996; Umberson, Chen, House, Hopkins & Slater, 1996) — another argument for diverse measures of health status.

In addition to the need for periodic re-examinations of gender patterns in health status (Macintyre et al., 1996), there is a need to clarify the pathways that account for the differences that are observed. The weight of evidence suggests that, compared with differential vulnerability, differential exposure to stressful living conditions plays a negligible role in accounting for gender differences in health. However, much of this work examines life events as sources of stress, rather than long term, chronic stressors (for reviews, see Thoits, 1995, Turner et al., 1995). In this regard, the failure of the exposure hypothesis to account for women’s apparent greater morbidity is not surprising since there is little reason to think that women would experience more life events than men, especially those of a “random” nature that are commonly included in life event inventories (Aneshensel, 1992). If stress emerges from the gendered division of labour and its associated costs and rewards (Emslie, Hunt & Macintyre, 1999), then the more enduring or “chronic” stressors are worth examining.

The research reported here was prompted by these unresolved issues in the literature. After elaborating upon them in the next two sections, we describe our database, the 1994 Canadian National Population Health Survey, and the measures used in our analysis. We then examine gender differences in five different measures of health and assess whether the differences that are observed can be accounted for by differential exposure and vulnerability to life events and chronic stress. In conclusion, we suggest that although the gendered basis of structural inequality continues to be a crucial avenue for exploring health experiences, it is important to devote greater attention to the similarity of women’s and men’s experiences.

Empirical research buttresses the belief that women experience more ill health than men, and social theory locates its origin in women’s reduced access, on average, to the material and social conditions of life that foster health. However, it has been suggested that one of the reasons for women’s greater morbidity is researchers’ tendency to focus on health conditions more commonly reported by women. In direct challenge to the view of women’s higher levels of ill health across all indicators, Aneshensel et al. (1991) argue that gender differences in the health effects of stress may depend on the specific health outcome of interest. Men appear to embody stress-related angst in substance abuse disorders that express anger and hostility, while women do so in affective or anxiety disorders indicative of depression (but see Umberson et al., 1996). Behind these gendered responses to stress may lie sex-role socialization patterns that channel frustration of desires and aspirations in different ways for men and women (Mirowsky & Ross 1995).

Support for a more varied pattern of gender differences in health also comes from a recent, detailed tabulation of a variety of physical and mental health indicators stratified by sex. Using data from a British regional, longitudinal study and a national cross-sectional investigation, Macintyre et al. (1996) found female excess in ill health for depression, high blood pressure, varicose veins, “malaise symptoms”, such as worrying, nerves, difficulty concentrating, tiredness, and sleep problems, as well as selected “physical symptoms”, such as headaches, fainting, or dizziness. A host of other health measures displayed no gender differences in their distribution while others, like rheumatism, arthritis, asthma, digestive disorders, and back troubles, revealed a variable pattern. Interestingly, none displayed a consistent male excess throughout the life span.

The idea that gender differences in health may be not as simple as they seem was recently addressed in a special issue of Social Science and Medicine (1999) that re-examined the generalization of women’s greater morbidity. The studies yielded considerable variability in gender differences in health. For example, some reported that women’s poorer health was marked for mental and somatic symptoms, but less so for long-term illness and self-rated health (Lahelma, Martikainen, Rahkonen & Liventoinen, 1999). Others observed a weak female excess for malaise symptoms and minor psychiatric morbidity and no gender differences in physical symptoms (Emslie et al., 1999). Still others found that, despite the greater prevalence of long-term illness, physical symptoms, and psychological distress among women, the magnitude of the differences was often small (Matthews, Manor & Power, 1999). Differences in health outcomes, national jurisdictions, samples, and time periods across the studies make it difficult to draw overall conclusions, but the observed variable pattern of the relationship between gender and health urges caution in accepting women’s excess morbidity as all-pervasive. As gender differences in health come to be comprehended as more complex than previously thought, similar questions can be raised about explanations of such differences. One of the most commonly-used is that invoking the stress model of disease and illness.

Fundamental to the stress model of illness is susceptibility to psychological or physical breakdown that is shaped largely by inequalities in life chances emerging from the organization of gender, class, race, age and other social statuses (Gerhardt, 1989). Counterbalancing susceptibility are factors that help resist noxious environmental stimuli. Examples of forces of resistance include economic resources, social relationships, and personality factors that shape the meaning and impact of life experiences. Not surprisingly, they reflect the very social arrangements that give rise to susceptibility factors. Disease or illness results when the balance between susceptibility and resistance is tipped in favor of susceptibility because the counteracting forces do not work, are not strong enough, or become overwhelmed by additional aggravating experiences (Gerhardt, 1989).

In examining susceptibility to stress as a basis for gender differences in health, research centres on two hypotheses: differential exposure and differential vulnerability. The differential exposure hypothesis suggests that women report more ill health than men because of higher levels of demands and obligations in their social roles. By implication, equal allocation of social role conditions ought to eliminate gender differences in health. The differential vulnerability hypothesis makes reference to women’s greater reactivity or responsiveness to life events and ongoing strains that are experienced in equal measure by men. It is argued that gendered reactivity is located in a generalized female disadvantage in social roles and coping resources that affects the nature and meaning of stressors and, ultimately, harms health.

As research on gender, stress, and health accumulates, three issues remind us of the complexity of people’s lives. First, the view that gender differences in health emerge because women experience more stress and react with greater intensity is challenged by studies demonstrating the contextual dependency of exposure and vulnerability to stress. For example, it appears that women report more network-related events (i.e., stressors experienced by members of one’s social network) than men. They are also more vulnerable to the misfortunes of those in their social sphere. In contrast, men are more likely to mention economic stressors, such as financial loss, and suffer more from them than women (Wheaton, 1990, Turner and Avison, 1989, Kessler and McLeod, 1984, Wethington et al., 1987, Bolger et al., 1990; but see Aneshensel et al., 1991, Thoits, 1987).

A second issue concerning gender, stress, and health is the conceptualization and measurement of stress. It is usually assessed as life events, such as marital breakdown, death, financial loss, and residential moves, that occur to the respondent or his/her significant others. However, the patterning of exposure to life events by gender is inconsistent (Thoits, 1982) and many researchers find that differential exposure to life events is considerably less important than differential vulnerability in accounting for gender differences in health (Thoits, 1987, Kessler, 1979, Kessler and McLeod, 1984, Turner and Avison, 1989). Some argue that this latter conclusion is premature because stress is inadequately conceptualized and measured (Turner et al., 1995). They call for greater attention to the role of chronic stress or “the relatively enduring problems, conflicts, and threats that many people face in their daily lives” (Pearlin, 1989, p. 245), such as barriers to achieving life goals, inequity in rewards, excessive or inadequate environmental demand, frustration of role expectations, and resource deprivation (Wheaton, 1983).

A third issue that is relevant to our discussion is the current research emphasis on interpersonal relationships in studies of gender differences in stress and health. Indicative of the tendency to restrict the search for understanding such differences to the realm of the family-based roles, other important life domains, such as paid work, have received less attention. Considerable research on work stress among men documents the deleterious health consequences of jobs that limit individuals’ opportunities for learning and control over job tasks (Johnson et al., 1996, Theorell et al., 1998, Landsbergis et al., 1992, Everson et al., 1997, Siegrist et al., 1990). However, we know very little about the health effects of the social organization of paid work for women, and even less about whether differential exposure and vulnerability to work stressors account for sex differences in health. Women appear to experience greater exposure to jobs with low levels of substantive complexity and control over tasks, but sex-based vulnerability to paid work conditions has not been demonstrated consistently (Roxburgh, 1996, Pugliesi, 1995, Lennon, 1987, Hall, 1992).

While stress research contributes to our understanding of gender differences in health by exploring exposure and vulnerability pathways, unresolved issues in the literature prompted our research questions. First, if we broaden our gaze and include other measures of health, in addition to distress, do we still observe gender differences in health? Second, moving beyond a focus on life events, does exposure to chronic stresses, including those emerging from paid work, explain gender differences in health? Third, exposure appears to be less important than vulnerability in studies of life events, but is this so if chronic strain is taken into account? Specifying this pathway more explicitly has theoretical significance for understanding relationships between social processes and health insofar as stress experiences arise from the “gendered division of labour and the rewards and costs associated with that labour” (Emslie et al., 1999, p. 34). Such inquiry also has implications for policy and social change efforts. If differential exposure to stressors is more important in the stress–health relationship than differential vulnerability, then policy and other social initiatives ought to focus on the forces that differentially expose men and women to health risk. If vulnerability is more critical, then such efforts should be directed to building resistance resources. The following analysis uses data from the 1994 Canadian National Population Health Survey (NPHS) to investigate these questions. Before presenting our results, the data base, measures, and analytic model are outlined.

Section snippets

Data

The NPHS is a longitudinal study of a representative sample of household residents in Canada. Initiated in 1994, data collection is scheduled to occur every second year for six years. In each of just over 20,000 households, limited information was collected from all household members and one individual, aged 12 years and older, was selected for a more in-depth interview. The initial household response rate was 88.7%, while the selected person response rate was 96.1%. The present analysis uses

Gender and health

Means for the health outcomes of interest are presented for women and men in Table 1. Women had higher distress scores (23% higher), were more likely to report chronic diseases than men (30% more likely), and rated their health slightly lower (2% lower) than men. In contrast, men were more than five times as likely to consume more than 14 servings of alcoholic beverages on a weekly basis, but there were no gender differences in activity restrictions. Hence, although limited to selected health

Discussion

This analysis set out to re-examine gender differences in health. One aim was to extend consideration of this issue beyond commonly-used mental health outcomes, such as distress or depression, to other measures, including a more “typical” representation of male angst, alcoholic drinking. In accounting for any gender differences that were observed, we also wanted to broaden our conception of stress beyond recent life events to encompass chronic or enduring stress, particularly as it emerges from

Acknowledgements

This study was supported by a grant from the National Network on Environments and Women’s Health. We thank Lisa Strohschein for her assistance with data analysis.

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