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Issue 1, January 1998, pp.8-9.

Gender and health
Kate Hunt

Men die quicker
It is well-known that in most developed countries women outlive men. In 1996 in the UK a girl's life expectancy at birth was 79.6 years and a boy's was 74.4 years. Although the ratio of male to female births (1:1.05 in 1991) might seem to give males an advantage, males in fact have higher rates of foetal death, stillbirth and neonatal mortality. Male death rates continue to be higher than female death rates through adulthood. The difference in male and female mortality reaches a peak in late adolescence and early adulthood, owing much to an excess of accidental deaths amongst men.

These differences between male and female mortality might signal some important biological differences between men and women, but it would be a mistake to assume that they were an unchangeable feature of the human condition. Indeed, greater female longevity appears to be a relatively recent phenomenon. It seems that from the Palaeolithic period until the Industrial Revolution it was men that had a longer life expectancy (at around 40 years, as compared with around 35 years for women). During the nineteenth century, women's life expectancy became more similar to men's. In 1841, life expectancy at birth was 41 years for men and 43 for women. Since that time, life expectancy has improved dramatically, particularly for women.

Most of the improvement has occurred in the twentieth century and is attributable to the dramatic decline in infectious disease mortality. It is important to remember that men stil1live longer than women in some (less developed) countries (e.g. India, Pakistan, Nepal, Afghanistan), where infectious disease remains an important threat to health, where potentially harmful environmental and occupational exposures are unregulated, and where women have more children at younger ages in the face of poorer nutrition.

But women are sicker?
In north America and western and northern Europe, men's higher mortality is often contrasted with women's greater morbidity. In adulthood, women are often said to rate their health less positively, to report more physical and psycho-social symptoms, to consult health professionals more frequently, to report more days of disability or sickness absence from work, and to have a higher level of conditions which are not life-threatening than do men. It was sometimes suggested that this presented a paradox: why should women seem to be sicker yet live for longer? More recently, people have argued that this picture has become over-generalised, and that we have drifted too far towards a blanket expectation of difference.

Gender specific symptoms of ill-health
Plenty of studies have shown differences in some aspects of health. Certain symptoms (such as headaches, tiredness) are more often reported by women, and as a group, women have a higher prevalence for some kinds of mental distress. The British Health and Lifestyle Survey showed an excess in women of depression and problems with nerves, of varicose veins, of migraine, and haemorrhoids at most ages, and of arthritis and rheumatism at older ages; but it also suggested a male excess of digestive disorders, asthma and back trouble in younger adulthood, and (as expected) a male excess in heart disease at older ages. The proportion reporting that they have a chronic illness is very similar for men and women up until the age of 74 years. However, women between 65 and 74 have more musculoskeletal problems than men, and a higher proportion of women in the oldest age group (75+ ) report having a chronic illness. This is partly because of the difference in the age distribution in this oldest age group by sex. It also bears witness to the fact that many women may survive longer than men, but that at these later ages their healthy life expectancy may not be that different from men's.

Perhaps it is not surprising that the evidence should be so mixed. There is no doubt that men and women differ biologically in some ways, but any biological differences that do exist are mediated by a complex interplay of exposures which are socially determined. Gender, as well as socio-economic status, continues to structure opportunities and life chances. For example, although the difference between men's and women's participation in the formal labour market has narrowed in the last two decades, men are still more likely to work full-time in different types of jobs (see Figure 1).

Figure 1


Source: Census and Labour Force Survey, Office for National Statistics

Explaining the difference
A number of possible explanations for differences in men's and women's health have been put forward. These include biological risks, acquired risks relating to different behaviours or exposures (broadly defined), differences in the propensity to recognise illness and to report symptoms of ill-health, and different access to, and use of, health care. Some of these are premised on the different social roles that men and women experience, others are based on assumed differences between the sexes.

Challenging assumptions
There are plenty of widespread assumptions about men's and women's health and health behaviour which are based on surprisingly little evidence. For example, not many studies have examined directly whether women really are more ready to recognise and act on symptoms of illness, and those that have, provide little support. Of the few that have compared men and women with the same illnesses or conditions, some suggest that women may be more reluctant to go to their doctors or that they may underestimate their symptoms. An American study interviewed men and women with clear evidence of osteoarthritis on x-ray and found that men were more likely than women to report pain. A more recent British study found that male volunteers at a research unit studying the common cold were more likely than female volunteers to 'over-report' cold symptoms. These studies certainly do not suggest a consistent tendency for women to over-report compared to men, yet the 'myth' of women's lower threshold for reporting illness and their greater willingness to consult is still very widespread.

Research in the Health Variations Programme
There are a number of other projects funded under the ESRC's Health Variation Programme which are giving special consideration to gender as a factor which may help us to understand the link between our social world and health.

Until the last decade or so, research on health inequalities has primarily focused on men and relied heavily on a measure of social class which is occupationally based (namely the Registrar General's classification of occupations). This schema has been less useful when used to study class inequalities in women because fewer women are in full-time paid employment, (see Figure 1) and the nature of their employment differs from that of men. The 'solution' of classifying women according to their husband's occupation has been heavily criticised. Mel Bartley (University College London) is using two alternative indicators of social position, one based on employment conditions and the other based on a measure of lifestyle advantage, to study the socio-economic variations in health-related behaviour, ill-health and mortality among women.

Gender is a central focus of a study being conducted by Graham Watt (Department of General Practice, Glasgow University) and colleagues on how perceptions of having a family history of heart disease might influence health-related behaviours (such as smoking, diet and consumption of alcohol). Women have lower rates of coronary disease than men, and they are often assumed to be the guardians of their families' health. This study will compare the experience of family history of heart disease in men and women of different social classes in relation to individual perceptions of familial susceptibility to major chronic illness and how each effects current coronary health promotion.

Chris Power and colleagues (see Health Variations Programme Newsletter, Issue 1, pp. 14-15) are using Britain's 1958 birth cohort to examine how home and workplace environments differ for men and women (especially in relation to social support, job strain and insecurity), and whether home and workplace factors can account for socio-economic differences in health among men and women.
James Nazroo (Policy Studies Institute, London) and colleagues are using the Fourth National Survey of Ethnic Minorities to assess the importance of socio-economic status, gender and geography in ethnic variations in health.

Although there may have been many changes in men's and women's lives in Britain over the last few decades, it is still the case that our gender is of fundamental importance in determining the course of our lives. Understanding how our gendered biographies may protect us from some aspects of ill-health but predispose us to others is not only important for understanding the relationship between gender and health. It can also point to ways that we can better understand how social inequalities in health by other dimensions, such as socio-economic status and ethnicity, are produced and maintained through the life span.

Kate Hunt is Senior Research Scientist at the MRC Medical Sociology Unit, Glasgow