The big three of social stratification – class, race, and gender – underlie much of the contemporary work on social determinants of health. But in population health discourse and research around “social inequalities in health” or “health disparities,” gender often seems to recede from the analytic gaze. This may be less a matter of indifference than one of conceptual limitations or confusion and counterintuitive empirical patterns: There is a lack of clear correspondence between gender-based social inequalities and gender differences in health. In other words, male privilege (vs. white or class privilege) does not neatly translate into unambiguous health benefits for men, to the extent one might expect, at least in terms of health outcomes applicable to both men and women. Does this ostensible paradox mean, then, that gender doesn’t really “matter” for population health, especially for those who anchor their research around health disparities?
With this two week seminar I would like us to interrogate the meaning of gender for population health and, more specifically, the role of gender inequalities in generating population health distributions. I propose we anchor our exploration of these issues around two broad questions: 1) what are the reasons for and implications of this apparent lack of correspondence between gender social and health inequalities? (week 1); and 2) what are other, potentially more profitable ways of conceptualizing gender as a social determinant of health – e.g., how gender and patriarchy shape constraints and opportunities for both men and women – (that do not in effect obscure the role of gender in generating and maintaining social inequalities vs. mere “differences”)? (week 2).
Week 1: Why don’t gender inequalities = health inequalities?
One point of entry to the first question is to explore how the two dominant mechanisms hypothesized to explain social inequalities in health – material deprivation and psychosocial stress – perform when it comes to gender or, more specifically, women’s health. Readings for the first week (described below) will hopefully provide fodder for this discussion. Much of the literature that tries to explain women’s relatively good health focuses on the role of social buffers. These readings suggest the possibility of other mechanisms by which deleterious social exposures may not necessarily translate into poor health for women.
A few caveats:
- In these readings and the framing of the questions, I am deliberately restricting the universe of inquiry to the “industrialized” world. This is a somewhat regrettable, but I think necessary, attempt to impose a degree of uniformity in the patterns and processes we consider. It’s messy enough as it is. This does not mean we can’t discuss contrasts with other contexts, but at the outset I’ve decided to organize around this restriction in the interest of relative simplicity.
- The readings are, of course, not exhaustive of the terrain. They are just meant to provoke some thought and discussion. I do not expect, nor want, us to be limited to their content.
- By omission or explicit focus, these readings will, like much scholarship and discourse around gender, be guilty in varying degrees of heteronormative, white, middle class biases. (We are also with this first week’s readings and discussion questions adhering to a very binary construction of gender.) Again, the readings were not meant to be comprehensive, and hopefully during the discussion we can fill in the picture a bit more. Also, during week 2 these issues will be tackled much more directly in readings and discussion.
Readings for Week 1: Why don’t gender inequalities = health inequalities?
Either:
McDonough P and Walters V. 2001. Gender and health: reassessing patterns and explanations. Social Science & Medicine. 52:547-559.
Or, if you’d like something a bit shorter:
Macintyre S, Hunt K, and Sweeting H. 1996. Gender differences in health: are things really as simple as they seem? Social Science & Medicine. 42(4):617-624.
And:
Taylor SE, et al. 2000. Biobehavioral responses to stress in females: tend-and-befriend, not fight or flight. Psychological Review. 107(3):411-429.
Lennon MC and Rosenfield S. 1994. Relative fairness and the division of housework: the importance of options. American Journal of Sociology. 100(2): 506-531.
Optional:
Hall EJ. 2000. Developing the gender relations perspective: the emergence of a new conceptualization of gender in the 1990s. Current Perspectives in Social Theory. 20:91-123.
Notes on the readings
1. McDonough et al and Macintyre et al both debunk some of the long-standing received wisdom that women are sicker but live longer than men. McDonough et al go a little farther into consideration of the stress pathway and in doing so review some of the debates about differential exposure vs. vulnerability to stress. Each of these articles provide an adequate overview of some of the key patterns and debates around gender differences in health. Pick just one if you like.
2. Unlike other axes of social stratification, the role of biological factors in generating gender/sex differences in health outcomes is irrefutable. Meaningful debates persist about types and degrees of biological influence across a wide array of health outcomes, but not about the fact of biology playing some role. In a nod to biology, I’ve included the article by Taylor et al, positing an alternative biohavioral model of stress to the classic “fight or flight” paradigm that has dominated research (and popular discourse) on human and animal stress responses (see McEwen, Sapolsky, allostatic load, etc.). Their theory of a “tend or befriend” stress response in females has been described in some psychological circles as a “groundbreaking evolutionary analysis of women’s neuroendocrine and social responses to threats and other stressors” (Geary and Flinn, 2000).
The authors acknowledge there are significant gaps in empirical evidence to support their theory. What do you think of this theory in its own right? What do you think of its potential and limitations as an explanatory factor implicated in the mortality gap between men and women (as suggested by the authors on page 424)? Women’s relatively greater social connectedness has long been posited as a source of good health and buffering against the injurious effects of social hazards. If this new theory holds up, do we gain anything by it?
More contentious than the role of biology in gender/sex differences in health is the role of biology as a determinant of social difference. As with race and class, supposed biological sex “differences” have been used historically to construct and justify social inequalities. Taylor et al take pains (on pages 422-3) to “frame” their analysis in such a way as to expressly avoid discounting the role of the social environment in shaping social roles and behavioral responses to stress. Are you satisfied with this? Is there “risk” in adopting their theory that outweighs its potential benefits for explaining health patterns?
3. The article by Lennon and Rosenfield addresses a frequent preoccupation in the sociology of gender – the division of household labor – reflecting the well-documented phenomenon that women’s strides in the labor force have not been matched by men’s increased investment in domestic labor. They discuss different theoretical approaches to the question of perceived fairness and then ask, “Who is more likely to be depressed, employed women who are angry about how little housework their husbands do or those who are resigned to it?” Their findings point to the importance of context and, specifically, the role of options outside marriage in shaping women’s perceptions of fairness. In this analysis, women can either tolerate injustice or be depressed. This (hopefully) does not amount to a prescription to stay healthy by accommodating gender inequality, but what exactly are the empirical and normative implications of these findings? Erika will no doubt have something to say about “deformed preferences”…… How, if at all, can this analysis inform our question about (the relative lack of) gender inequalities in health?
4. For those who may not have thought much about gender before and are interested, the optional reading by Hall can serve as a sort of primer on gender theory, reviewing past and present conceptualizations of the construct. I’m under whelmed by this article in many respects, especially her explication of ‘the gender relations perspective’ in the latter sections (and need for a good editor overall). But it covers some key concepts and some of the evolution in thinking about gender that will provide a useful background to our discussion both weeks.
Week 2: Is patriarchy bad for everyone?
In this week’s readings and discussion we will address the second question above. If we conclude that extending the “social disparities in health” framework to gender doesn’t work, one reason may be because women are buffered, by social and/or biological mechanisms, from the potentially deleterious health consequences of patriarchy (among other noxious exposures). Another reason may be that any negative health effects of patriarchy for women are overshadowed by the negative health effects of gender for men. Is the latter necessarily “patriarchy”? Is a framework positing that the gender social order is potentially bad for the health of everyone (men and women alike) the most useful and/or accurate contribution of gender to population health? If so, what would that look like? What are the costs/risks of such an approach? In your opinion, what are the reasonable parameters of research and policy concern around “men’s health”?
Readings for Week 2
The following readings will hopefully get us started in addressing these questions, among others:
Rabin, R. Health Disparities Persist for Men, and Doctors Ask Why. Science Times, November 14, 2006.
Stanistreet D, Bambra C, Scott-Samuel A. 2005. Is patriarchy the source of men’s higher mortality? Journal of Epidemiology and Community Health. 59:873-76.
Courtenay WH. 2000. Constructions of masculinity and their influence on men’s well-being: a theory of gender and health. Social Science & Medicine. 50:1385-1401.
Notes on the readings
1. The NYT article is an example of how science is used to inform (or legitimate) one strand of public discourse about sex differences in health. How and how well is gender being invoked here as an explanatory framework? What does a gender analysis suggest about the assumptions underlying this article? To what extent do/should justice claims rest on the nature of the mechanisms generating inequality?
2. Stanistreet et al will surely give the methodologically-minded among us reason to complain. If you can suspend your disbelief, how would you justify this hypothesis? (The authors don’t specify mechanisms for their hypothesized association, other than vague ideas about “alienation that results from internalizing the “privileges” of oppression.” What would more specific, plausible mechanisms be?) How would you better test this idea?
3. The piece by Courtenay applies gender theory on “masculinities” to a growing preoccupation with “men’s health”. Broadly speaking, this framework of “gender and men’s health” is premised on the view that there are gendered aspects of health that apply to men as well as to women, and that interpreting gender exclusively in terms of women tends to neglect the important gendered aspects of men’s health.
Courtenay is very much preoccupied with one mechanism – “health-related beliefs and behavior.” Rather than simply a health-harming response to social structure, behaving badly is posited as a means by which (gendered) social structure is (re)produced. How does his approach square with our dominant models of material and stress pathways to health? Despite the (nominal?) attention to structure, power, and relational context, is this in effect a sufficient improvement over sex-role constructions of gender? Where does privilege (and men’s presumed interests in maintaining it) fit in here? What are the strengths and limitations of this approach for guiding research and policy?
