[gender-aids] Sex, Gender, and Health: Need for New Approach

[gender-aids@healthdev.net]

Sex, Gender, and Health: Need for New Approach
By Lesley Doyal 
BMJ November 3, 2001
********************

The past two decades have seen considerable activism by women to improve
the quality of their health and health care. Recently men too have begun
to draw attention to the negative implications of "maleness" for their
health. There is an increasing danger that these campaigns could be
drawn into conflict with each other as they compete for public sympathy
and scarce resources. If conflict is to be avoided there needs to be a
much clearer understanding of the impact of both sex and gender on
health. This can then provide the foundation for gender sensitive
policies that take seriously the needs of both women and men. 

Sex and health: the biology of risk 

The differences between male and female reproductive systems have always
been an important consideration in healthcare delivery. This reflects
the crucial role of high quality family planning and obstetric services
in enabling women to realise their potential for health. Despite recent
progress, around half a million women continue to die each year as a
direct consequence of pregnancy and childbirth, and more than 10 times
that number are seriously disabled.1 It is the centrality of these
issues in women's lives that has led many to adopt the concept of sexual
and reproductive rights as a major campaigning issue. 

Many countries have developed new services in response to the "platform
of action" devised at the 1994 International Population and Development
Conference in Cairo. Given the greater vulnerability of women to
reproductive health hazards it is not surprising that these programmes
have concentrated mostly on their needs. However, more attention is now
being focused on men as the HIV/AIDS epidemic has highlighted the risks
of sexually transmitted diseases for both partners. This has made it
possible to help men to promote their own health but has also offered
important opportunities for educating them to take more responsibility
for the health of their partners. 2 3 

There has also been a growing recognition that the biological
differences between the sexes extend beyond the reproductive. A wide
range of genetic, hormonal, and metabolic influences play a part in
shaping distinctive male and female patterns of morbidity and mortality.
Sex specific diseases such as cancers of the cervix and prostate are the
most obvious examples. However, there is also growing evidence of sex
differences in the incidence, symptoms, and prognosis of many other
health problems including HIV/AIDS, tropical infectious diseases,
tuberculosis, autoimmune problems, and coronary heart disease. 4 5 One
of the most important of these sex differences is the greater biological
propensity of men to develop heart disease early in life.  

If health services are to meet the needs of both women and men then all
these sex differences need to be taken seriously in the planning and
delivery of care. But biological influences are only part of the complex
of factors shaping the health of women and men. Socially constructed
gender differences are also important in determining whether individuals
can realise their potential for a long and healthy life.6 

Hazards of female gender 

An extensive literature documents the relation between gender divisions
and women's health.7 Researchers have explored a wide range of social,
economic, and cultural factors, showing their links with physical and
mental wellbeing. This analysis has focused mainly on the gender
inequalities that continue to characterise so many of the relationships
between women and men. As a recent report has documented, there are no
societies in which women are treated as equals with men, and this
inevitably affects women's health.8 

Gender inequalities in income and wealth make women especially
vulnerable to poverty. In some parts of the world this makes it
difficult for them to acquire the necessities for health, especially
during the reproductive years when family needs are greatest. Social
norms about the divisions of responsibility mean that many women have
very heavy burdens of work, especially those who combine employment with
domestic duties, pregnancy, and childrearing. Within the household women
often receive little support, and too many are abused by other family
members. A recent study has estimated that 19% of the total disease
burden carried by women aged 15-44 in developed countries is the result
of domestic violence and rape.9 Anxiety and depression are reported more
often by women than by men in most parts of the world, yet there is no
evidence that women are constitutionally more susceptible to such
problems. 10 11 

As well as affecting their health, gender inequalities may also limit
women's access to services. Around the world many millions of women
continue to be deprived of basic health care as a result of poverty and
discrimination. In Britain the removal of these financial obstacles was
one of the main achievements of the NHS. However, there is still
evidence that women are treated by some doctors as less valuable than
men. This can lead to demeaning attitudes as well as the unequal
allocation of clinical resources. 12 13 This gender bias is especially
evident in the context of medical research, where studies have shown
that women have too often been excluded from studies for inappropriate
reasons.14  

Male gender: a mixed blessing? 

Until recently very little attention had been paid to the impact of
gender on men's health. This is now changing as the links between
masculinity and wellbeing begin to emerge. 15 16 At first glance
maleness might seem to be straightforwardly health promoting since it
offers privileged access to a range of valuable resources. However,
closer examination reveals a more complex picture. Though the shape of
masculinity may vary between communities, the development and
maintenance of a heterosexual male identity usually requires the taking
of risks that are seriously hazardous to health.17-19 

The most obvious examples of such risks come from the world of paid
work. In most societies the traditional role of provider has put men at
greater risk of dying prematurely from occupational accidents.20 Though
the gender distribution of the labour force is now changing, men from
the poorest communities still do the most dangerous jobs. Alongside
these potential risks in the workplace, many men also feel compelled to
engage in risky behaviour in order to "prove" their masculinity. As a
result, they are more likely than women to be murdered or to die in a
car crash or dangerous sporting activities.21 In most societies they are
also more likely than women to drink to excess and smoke, which in turn
increases their biological predisposition to early heart disease and
related problems. They also seem to be more likely than women to desire
unsafe sex. Again, many of these hazards are likely to be more common
among men in the poorest communities.16 

The implications of masculinity for mental health are also receiving
increasing attention. It has been argued that "growing up male" renders
many men unable to realise what might be their emotional potential.15
The need to be seen as "hard," for example, may prevent them from
exploring the caring side of their nature. An unwillingness to admit
weakness may prevent many men from taking health promotion messages
seriously and from consulting a doctor when problems arise. 22 23
Indeed, illness itself may be especially feared because of its capacity
to reduce men to what one recent study has called "marginalised
masculinity."24 Thus many men have to grapple with internal constraints
to get optimal value from the health services available to them. 

Putting sex and gender on the health care agenda

This brief analysis has highlighted the complex links between biological
sex, social gender, and health. In one sense it is clearly an
oversimplification since there are marked similarities in the healthcare
needs of women and men as well as major differences between different
groups of women and different groups of men. However, this does not mean
that issues of maleness and femaleness are not important. If health
services are to be equitable and efficient greater sensitivity will be
needed to sex and gender concerns. This will need to be reflected in
research, in patterns of service delivery, and in wider social and
economic policies. 

If the gender bias in medical research is to be eliminated measures will
need to be taken to ensure that study designs include sex and gender as
key variables whenever appropriate. In the short term this would promote
equity through filling the gaps that currently exist in our knowledge of
women's health. In the longer term it would improve the overall quality
of medical science and would therefore benefit men too. 

To improve access to services women may need to have better transport
and child care arrangements. For men (and many women) there may be a
need to provide more services in the workplace or in community
locations. Across the range of healthcare settings it is essential that
women and men are both treated with respect. Women should not be
humiliated by sexist behaviour, for example, or be damaged by
discriminatory practices. 12 13 Men, on the other hand, should not be
expected to live up to stereotypical conceptions of heterosexuality and
masculinity. Clinicians need to recognise the psychological difficulties
that male patients may bring to the medical encounter and the challenges
that illness may pose to their sense of their own identity. 

Health promotion policies in particular need to be gender sensitive if
their messages are to be heard. Too many campaigns are addressed to
women in their role as the carers of others while ignoring their own
wellbeing.25 Men too often feel that health is women's business and that
health promotion messages are not addressed to them. HIV/AIDS campaigns
have simultaneously exhorted women and men to "use a condom" without
recognising the very real differences in power and status that structure
most sexual encounters. If this is to change, campaigns need to be
designed in ways that encourage both women and men to look after
themselves and each other.

Finally, we need to examine the potential of wider social and economic
policies for promoting gender equity in health, and here the issues are
especially complex. On the one hand, the further development of
antidiscriminatory policies could clearly be valuable in tackling the
economic and social inequalities that continue to affect women's health.
On the other hand, changes in patterns of social security provision or
employment conditions would make it easier for men to develop the
"female" side of themselves. Greater flexibility of working hours, for
example, as well as more generous provision of parental leave could make
it easier for men to bridge the gap between work and home. Carefully
designed educational initiatives could also be used to reshape the
gender relations of the next generation. 

These changes in public policy could play a part in promoting gender
equity in health.26 However, they would still leave some of the most
fundamental problems untouched. So long as masculinity continues to be
defined in ways that are hazardous to health too many men will continue
to experience preventable diseases and even death. At the same time, too
many women will continue to be damaged by the actions of male partners
who are following the scripts of masculinity. Changes of this kind will
not be easy to achieve since they will involve a redefinition of some of
the most intimate areas of human life. But unless they are tackled,
gender inequalities will continue to be one of the factors limiting the
capacity of both women and men to realise their potential for health.  

Lesley Doyal
Professor in health and social care
School for Policy Studies,
University of Bristol, Bristol BS8 1TZ
Email: l.doyal@bristol.ac.uk

Source: BMJ 2001;323:1061-1063  November 3, 2001 
References available on http://www.bmj.com


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