Editorial Virtual Special Issue: Gender & Health
Ellen Annandale, University of Leicester
Social Science & Medicine often has led the way in publishing landmark articles in the area of gender and health. Many have become 'defining moments' in debate by identifying theoretical and empirical lacunae in existing research and taking research in new directions. The sheer breadth of papers that have been published over several decades presents an 'embarrassment of riches', which has made it very difficult to select which to include and which, regrettably, to leave out. The object of this Virtual Special Issue is to show how the field of gender and health has developed as new topics and new ways of thinking about gender and health have emerged, mainly covering the period from the early 1990s to the present. In doing this I have endeavoured to select both theoretical and empirical papers, papers which use a variety of research methods, and papers concerning research in a range of different countries. It is hoped that this showcase selection will be an aid to research and teaching and that it will encourage readers to delve deeper into the Journal where they will find a wealth of research on gender in the offing.
Robin Saltonstall (1993:12) makes clear that 'doing health is a form of doing gender'. As she remarks, 'this is not because there is an essential difference between male and female body healthiness, but because of the social and cultural interpretations of masculine and feminine selves – selves which are attached to biological male and female bodies'. The relationship between gender and health therefore works two ways: gender influences health and health influences gender. Although there is growing recognition that this implicates both the social and the biological body (Bird and Rieker 1999), the prevailing argument is that, more often than not, it is social factors that matter the most because they often manifest in brute inequalities between men and women. This was first highlighted by feminists and others back in the early1970s as they drew attention to the social oppression of women and its impact on their health status and their experience of health care. Over the ensuing decades research has shown that where women are disempowered their health suffers and their lives can be placed at risk. Research by Rachel Jewkes and colleagues (2005) in Namibia and South Africa, for example, has found that dominant patriarchal ideologies render girl children highly vulnerable to rape which is often used by men as a way of demonstrating their own masculinity and powerfulness to themselves as well to exert their power over females. A large and important body of research published in Social Science & Medicine and elsewhere has highlighted women's vulnerability to infection to sexually transmitted infections and HIV worldwide due to male power over both their bodies and their selves. Thus Joanne Mantell and colleagues (2005) draw on examples from around the world to show how gender relations in local contexts shape and inhibit the acceptance and use of 'female-controlled' preventative methods (such as female condoms and microbicides) which have been developed for use by women who are disempowered vis a vis their male partners.
At issue here is the capacity for negative attitudes towards women to undermine women's potential to protect themselves. Perceptions of the male and female body and expectations about how women and men behave can also have a powerful impact on how they relate to symptoms, and whether they see themselves, and are seen by others, as candidates for particular health problems and the kind of treatment that they receive. The gendering of illness operates at many levels. One of the most powerful actors in this regard has been the pharmaceutical industry and the particular way medications are marketed. Two illustrations of this are included in the virtual special issue. Joanna Kempner (2006) has found that direct-to-consumer advertising targets mainly women, creating the impression that migraine is a female disorder. She explains that, in targeting migraine as a purely "women's health issue", drug companies may be actually constructing their market as much as representing it. Focusing on Irish medical journals, Phillip Curry and Marita O'Brien (2006) found that advertisements not only have depicted but strengthened the stereotypical image of the 'male' heart patient and the depressed 'female' patient.
Images such as these are highly potent and likely to filter into the health care arena. Research in the US and UK by Sara Arber and colleagues (2006), using a video-simulation experiment found that, while the social class, age and ethnicity of patients had no significant impact on doctors' diagnostic and management decisions about coronary heart disease (CHD), women were asked fewer questions than men, received fewer examinations than men, and had fewer diagnostic tests ordered. It is likely that this 'gender bias' in treatment is influenced at least in part by perceptions of heart disease as a male disease. This is supported by a large scale study in England by Mary Shaw and collaborators (2004) which found that women have been far less likely to receive coronary revascularisation procedures than men. Given that revascularisation rates are also lower for older people, and women tend to present with CHD at older ages, the authors conclude that women seem to be suffering from a "double whammy". As Lesley Doyal (2000) explains, although the issue of equity in health and health care is being promoted as a goal by many governments worldwide, there is a fair amount of confusion as to what it means and how to achieve it.
'Gender equity' can only be discerned with any confidence when research attends to the experiences of both men and women (recognising, of course, there are some aspects of health and health care that concern only men or only women). This has involved making men's health gender transparent. Until recently, the term 'gender and health' was synonymous with women's health. Any health problems that men might experience were hidden by assumptions of their privilege. There has been a recent swell of research on men's health as gendered experience since the mid to late 1990s. Thus Aki Tsuchiya and Alan Williams (2005) discuss the current 'longevity advantage of women' in western nations raising what they term the 'fair innings argument.' Hegemonic masculinity is often identified as the reason why men tend to die at younger ages than women in western societies. Will Courtenay's (2000) article discussing constructions of masculinity and their implications for men's health was seminal in developing this line of argument. As Carol Emslie and colleagues (2006) discuss in relation to men's experience of depression, it has been suggested that men find it difficult to seek help due to culturally dominant forms of masculinity which emphasise emotional control and lack of vulnerability, while depression often is associated with the opposite; that is, lack of control and vulnerability. Their research in the UK found that, for many men, recuperation rested on recovering a sense of their masculinity, but that a minority found ways of being masculine outside of hegemonic discourse. This study highlights that, while gender differences between men and women are often important, we need also to appreciate that men and women are not homogenous groups. As Maria Lohan (2007) discusses, it is important that research on men's health takes a critical approach which both appreciates that masculinity can promote health damaging behaviours and is critically aware that health status is a result of the complex interplay of a wide range of factors associated with peoples' lives. When attempts are made to 'turn the tables' and construe men as the 'really disadvantaged' this pits 'men's health' and 'women's health' against each other in ways that are often unhelpful.
Research on gender inequalities in health status originated mainly in feminist work of the 1970s which showed that, despite their greater longevity compared to men, women were more likely to live their lives in poor health. As Sally Macintyre, Kate Hunt and Helen Sweeting (1996) discuss, as in many other areas of research, there is a tendency for common assumptions to be replicated rather than problematized. Their research in the UK suggested that assumptions of a universal 'female excess' in morbidity are questionable. This does not mean to say that women do not experience health disadvantage or that men cannot not be disadvantaged too, but rather that the 'gendering of health' is highly complex and sensitive to the changing contexts of men's and women's lives. Sweeping generalisations about men and women are less useful than detailed explorations of the social contexts of their lives. This is made clear in Jen'nan Ghazal Read and Bridget Gorman's (2006) research on how 'race' and ethnicity condition gender difference in various measures of morbidity in the US. They found that the magnitude of the gender difference varied considerably by racial/ethnic group and health outcome measure. It is also important to appreciate that gender differences in health status vary across the lifecourse. Helen Sweeting (1995) summarises research showing the gradual emergence of a female excess in general ill-health over the age period 7 to 15. This is supported in a cross-national exploration of variation in adolescent (ages 11 to 15) subjective health across 29 European and North American countries by Torgjørn Torsheim and colleagues (2006), although they found that the magnitude varied considerably across countries.
It often is assumed that greater gender equality in society generally will lead to a convergence in men's and women's health status. An interesting seam of research is developing on this theme. This typically involves measures of gender equity at the area level. Research by Mona Backhans, Michael Lundberg and Anna Månsdotter (2007) comparing Swedish municipalities on several indicators of gender inequality found some support for the association of greater gender equality at the municipal level and a convergence of health outcomes (life expectancy and sickness absence). An unexpected finding, however, was that gender equality was generally correlated with poorer health for both men and women. Although they excerise caution by pointing to some methodological limitations in their study, the authors advance that Sweden may have reached a critical point where further one-sided expansion by women into traditionally male roles, spheres and activities will not lead to positive health effects unless men also change. Women, they report, may have become more burdened as men have lost many of their old privileges. By comparison the research by Torgjørn Torsheim and colleagues (2006) found that, in countries where the gender distribution of political power and work was comparatively egalitarian, both girls and boys had lower levels of self-reported health complaints.
This research on gender inequality in health status highlights the importance of context. It is not necessarily the case that findings from one study are transferable to other countries, locales, age groups, ethnicities, social classes and so on. As Tina Sideris' (2003) article on the psychological sequelae of war-related violence amongst women Mozambican women refuges in South Africa demonstrates, it is also important that research does not unreflectively transfer theoretical frameworks and concepts developed in research on men to women (and vice versa), and that it attends equally to the specificity and commonality of women's and men's experiences. Drawing us back to Saltonstall's (1993) conclusion that 'doing health is a form of doing gender', the Virtual Issue concludes with two qualitative studies of normative expectations of masculinity and femininity and young people's management of chronic illness. In her interview study of teenagers' management of diabetes and asthma , Claire Williams (2000) found that meanings of masculinity and femininity as they influenced girls and boys through identity construction had significant implications for successful management. Evan Willis, Rosemary Miller and Johanna Wyn (2001) found that the lack of fit between expectations of normative femininity and the medical regimen for the effective treatment of cystic fibrosis was so marked that it may be key to explaining the gender gap in survival amongst young people with the condition.