Women's Health Review and Research Agenda as We Approach the 21st Century Judith Rodin and Jeannette R. Ickovics

Yale University

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ABSTRACT." This article reviews past research and projects future research directions regarding women's health. Sex differences in mortality and morbidity, along with evidence that the quality and quantity of these differences are changing, are examined. Over the past decade, concurrent with dramatic changes in lifestyle and social roles for women, mortality rates have shifted, resulting in a decreasing advantage for women. Explaining the consequences of these dynamic changes requires understanding the health effects of such variables as perceived control, the experience of life roles, perceived and actual social support, and redefinition of gender roles. The future portends additional changes that will significantly affect women's health. In establishing an explicit psychological research agenda on women's health, (a) general recommendations for research are provided and (b) important issues that have not yet received a great deal ~f research attention (e.g., women and AIDS, psychopharmacology, reproductive technologies) are highlighted. This article expands the current discourse in health psychology and raises a number of issues for serious consideration. R e v i e w o f the Literature Health is a complex and multidetermined issue, influenced by a wide variety of factors: physiological, biochemical, psychological, environmental, and social (Rodin & Salovey, 1989). As society approaches the 21st century, we believe that it is an important time to assess what we k n o w - - a n d what we do not know--regarding women's health in particular. One may ask "Why a focus on women's health?" The answers are clear. Certain health concerns are unique to women (e.g., hysterectomy, dysmenorrhea, cesarean section, breast cancer ~) or disproportionately affect women (e.g., rheumatoid arthritis, lupus, osteoporosis, eating disorders). Even for health issues that affect both women and men, most research has been Preparation of this article was supported by the John D. and Catherine T. MacArthur Foundation Network on Health and Behavior. The authors would like to thank the followingpeoplefor their comments on an earlier draft of this article: Chris Hsee, Michaela Kiernan, Lynn Larsen, and William Sieber. Correspondence concerningthis article should be addressed to Judith Rodin, Department of Psychology,Yale University, P.O. Box 11A Yale Station, New Haven, CT 06520-7447. Men may get breast cancer, but the prevalencerate is negligible. 1018

limited to male subjects, leaving a large gap in our knowledge base concerning women's health. Sex differences in morbidity and mortality have been documented. Furthermore, health risks and enhancements may operate differently for women and men, thereby confirming the need to examine women's health as distinct from men's health. Psychosocial factors are also likely to differentially affect women's and men's health. Women and men engage in social roles that often differ, if not in quantity, certainly in quality. Sex differences in role expectations, environmental qualities, role burdens related to the domains of work and family, and abilities to adapt and cope with stressful situations may also have a distinctive impact on health. Imbalances in social roles, and subsequently in power, equality, and control, are likely to affect women's health adversely. Within these roles, women are more likely than men to be subjected to interpersonal violence, sexual discrimination, and harassment. Health treatment also raises concerns specific to women. For instance, 70% of all psychoactive medications (e.g., antidepressants, tranquilizers) are prescribed to women (Ogur, 1986), in part because of the stereotype that women's health complaints are more emotionally laden and psychosomatic than men's. In addition, two thirds o f all surgical procedures in this country are performed on women (Travis, 1988a). Obstetrical and gynecological surgery is the most frequent category, with 1,700 hysterectomies performed daily. The medical benefits of these surgeries do not seem to outweigh the health and psychological risks (Cutler, 1988; Korenbrot, Flood, Higgens, Roos, & Bunker, 198 I). Ironically, although in the reproductive area women are exposed to a large number of technologies, in other areas of medical practice such as coronary health (Fiebach, Viscoli, & Horwitz, 1990; Tobin et al., 1987), they may inappropriately receive fewer technological interventions. Inadequate access to quality health care and health insurance is more likely to affect women (Guilliland, 1986), in large part because women are more likely than men to be poor (Wilson, 1988). Finally, women are underrepresented as health care professionals. Although women are entering medical school in greater numbers, sex biases persist in training and professional status; furthermore, the sex of the physician does affect treatment and patient-doctor interaction (Travis, 1988a). Perhaps there has been less study of women's health because, despite the risks just specified, women live longer. September 1990 ° American Psychologist Copyright ~990 by the American Psychological Association, Inc. 0003-066X/90/$00.75 Vol. 45, No. 9, 1018-1034

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Although women continue to maintain a mortality advantage over men, this advantage has been steadily declining over the past decade (U.S. Bureau of the Census, 1990). Moreover, regardless of whether this declining trend continues, the future portends major changes that will significantly affect women's health. For instance, looking toward the 21 st century, we must now begin to consider threats to women's health because of environmental factors such as acquired immunodeficiency syndrome (AIDS) and scientific developments such as reproductive technologies. Psychosocial factors that have a major impact on health--social roles, social support, selfefficacy, stress, and coping--are also likely to change in their degree and complexion over the coming decade. These reasons provide a strong rationale for the urgent need to study women's health. In this article we begin by reviewing the sex differences in mortality and morbidity. We consider evidence that the quality and quantity of these differences are changing and explore reasons for these changes. In particular, we explore the effects of shifting trends in women's labor-force participation and substance use. We then set forth an explicit research agenda regarding women's physical health. This agenda is not intended to serve as an exhaustive list; rather we highlight important issues in women's health that have not yet received a great deal of research attention. This review and agenda for physical health issues complements recent multidisciplinary work on mental health issues, such as Developing a National Agenda to Address Women's Mental Health Needs (Russo, 1985), supported by the American Psychological Association, 2 and Women's Mental Health: Agenda for Research (Eichler & Parron, 1987), supported by the National Institute of Mental Health. Together, these reports provide a comprehensive review regarding the status of women's mental health, rates and patterns of mental disorders, selected issues of concern (e.g., depression, chronic mental illness in women, violence against women, sex role socialization, and effects on mental health), and recommendations for prevention, treatment, and scientific inquiry. The present article considers the major issues that relate to physical health outcomes.

Sex Differentials in Mortality and Morbidity Mortality. As Strickland (1988) has noted, "At every moment across the life span, from conception to death, girls and women are on the average biologically more advantaged and live longer than boys and men" (p. 381 ). Approximately 125 male fetuses are conceived for every 100 female fetuses, and 27% more boys than girls die in the first year of life. For those who celebrate a century of life, only one man is alive for every five women. At every age in between, more men than women die (see Table 1).

These data vary according to social class and ethnic backgrounds, but nonetheless, Black women still have lower overall mortality rates than both Black and White men (Figure 1). Men and women also differ by cause of death. In the United States in 1980, the age-adjusted mortality rate for each of the 12 leading causes of death was higher for men than women (Wingard, 1984). The sex ratio, men to women, varied, respectively, from 3.86:1 for homicide to 1.02:1 for diabetes. Those causes, with nearly a twofold or greater difference in the sex ratio in decreasing order after homicide, were respiratory cancer, suicide, chronic obstructive pulmonary disease, accidents, cirrhosis of the liver, and heart disease. Although the actual number of men who die of coronary heart disease (CHD) is greater than the number of women who die of coronary disease, it is important to note that C H D is the leading cause of death for both women and men (Centers for Disease Control [CDC], 1989b). Two major categories of explanation have been proposed to account for the sex differential in mortality: first, a biological explanation that women are biologically more advantaged than men, and second, a social or lifestyle explanation that men behave in ways more damaging to their health. There are many ways that biological protection could be conferred for women. Some investigators suggest that genetic differences are one mechanism: The additional and redundant genetic material furnished by females' second X chromosome may be protective. In contrast, the male Y chromosome is specialized solely for the development of the male reproductive tract, and it carries no significant additional information (Ramey, 1982; Travis, 1988a). Others believe that understanding hormonal differences between women and men across the life cycle may be the pivotal element in understanding

Table 1

Age- and Sex-Specific Mortality Rates and Sex Ratios in the United States in 1987 Deaths per 100,000 Age

Under 1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85 & older All ages

2 This report was published by the American Psychological Association (APA). It was a joint project of the APA Women and Health Roundtable and the Federation of Organizations for Professional Women, supported by a grant from the Ittleson Foundation.

September 1990 • American Psychologist

Males

Females

Sex ratio (Male/female)

1,129 58 32 146 193 292 644 1,624 3,618 8,232 18,031

902 45 19 52 74 139 360 900 2,063 5,118 14,261

1.25 1.29 1.68 2.81 2.61 2.10 1.79 1.80 1.75 1.61 1.26

935

813

1.15

Note. From Statistical Abstract of the United States: 1990 by the U.S. Bureau of the Census, 1990.

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Figure 1 Age-Adjusted Death Rates by Race and Sex in the United States, 1960-1988 14 O

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Year Note. 1988 data based on preliminary data from a 10% sample of deaths. From StatisticalAbstract 1990.

sex differences in health (Hamilton, 1989a, 1989b; Hamilton, Parry, & Blumenthal, 1988a, 1988b). For example, some of the most widely cited evidence for hormonal protection from cardiovascular disease comes from longitudinal prospective studies of death due to cardiovascular disease among more than 2,000 women who either did or did not use estrogen therapy following menopause. Data indicate that in every age category, estrogen users have lower cardiovascular mortality rates than do nonusers, even after adjusting for age, systolic blood pressure, and smoking (Bush et al., 1987). Results suggest that estrogen may serve to keep high density lipoproteins (HDL) elevated and low density lipoproteins (LDL) lower. It is also likely that estrogen use is protective through mechanisms beyond any effects on these lipoproteins; for instance, in an animal study, Hough and Zilversmit (1986) found that estrogens retard atherogenesis by interacting directly with the arterial wall and modifying plasma components other than lipoproteins. Although many studies support the protective effects of estrogen with regard to cardiovascular disease, there are several inconsistent results as well. For instance, oral contraceptives, particularly when used in conjunction with smoking, are associated with increased risk of coronary heart disease, peripheral vascular disease, and stroke (see Matthews, 1989, for a review). Clearly, the phenomenon of female protection from cardiovascular disease cannot be accounted for by biology alone. Indeed, in recent years research has focused on sex differences in life-style. Compared with the turn of the 1020

of the United States: 1990, by the U.S. Bureau of the Census,

century when most people died of epidemics and infectious illness, in modern times the largest burden of illness comes from diseases complicated by behavior. As much as 50% of mortality from the 10 leading causes of death in the United States today can be traced to aspects of lifestyle, including cigarette smoking, excessive consumption of alcoholic beverages, use of illicit drugs, harmful dietary habits, reckless driving, nonadherence to effective medication regimens, and maladaptive responses to social pressures (Hamburg, Elliot, & Parron, 1982). Although most people are aware of research that suggests an increased risk from life-style factors such as cigarette smoking or alcohol use, perhaps fewer are aware of the synergistic effects of these life-style variables• For example, with increasing amounts of tobacco smoked per day, high alcohol use has a significantly greater effect on relative risk for developing cancer of the esophagus (Doll & Peto, 1981). Taking another example affecting women in particular, Petitti, Wingerd, Pellegrin, and Ramcharan (1979) found that cigarette smoking and use of oral contraceptives are synergistic for risk of stroke. Contrary to simple main effects of either biological or life-style factors, Matthews (1989) suggested that the interaction of biological and behavioral characteristics is a stronger predictor, at least of coronary health. The interaction model suggests that gender may have an indirect effect on CHD by operating through three potential pathways: "(1) altering the degree of exposure to environmental factors that contribute to disease development, (2) modifying the individual's responses to such exposure, September 1990 • American Psychologist

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and (3) modifying the relationship between a given level of a risk factor and disease development" (p. 377). Morbidity. In spite of women's biological and behavioral advantage with regard to mortality, women appear to have greater morbidity than men. Morbidity can be defined as generalized poor health, a specific illness, or the sum of a number of illnesses. These may be identified by self-reported occurrence, restricted activity, number of doctor visits or hospitalizations, or actual screening examinations. In a review of morbidity figures, Wingard (1984) found that most categories of self-reported chronic conditions and all acute conditions were more c o m m o n for women then men, except injuries. Hypertension is usually more c o m m o n in men before the age of 60 and in women after the age of 60. Obesity is higher for women in most samples, and results from most studies indicate that women have poorer vision and dental status, whereas men have poorer hearing. Higher proportions of women than men have diabetes, anemia, and respiratory and gastro-intestinal problems. Rheumatoid arthritis is three times more c o m m o n in women than men, and systemic lupus erythematosus (lupus) is 10 times more likely among women than men (Strickland, 1988). Considering health behaviors, women report more acute symptoms than do men, and the epidemiological evidence supports this. As illustrated in Table 2, women have higher rates of restricted activity, disability, and physician visits; they also have higher levels of prescription and nonprescription drug use. On the other hand, men have longer hospital stays, and there is no difference in

total work-loss days. In an attempt to reconcile these seemingly contradictory data on morbidity and mortality, the following interpretation has been put forth. Although women are more frequently ill, they suffer from problems that are serious but not life-threatening; these conditions lead to symptoms, disability, and medical care, but not death. Men are sick less often, but their illnesses and injuries are more severe; men have higher rates of chronic diseases that are the leading causes of death (Verbrugge, 1989). Explanations for the sex differences in morbidity come from a variety of sources. Some are more clearly psychological. For example, there are thought to be differences between women and men in how they judge their own health and in subsequent health-reporting behavior. However, these beliefs about gender differences in health perceptions and reporting behavior have not received consistent empirical support. Second, stress has emerged as a central explanatory construct to account for sex differences in physical health. This is not surprising inasmuch as stress has a prominent place in the conceptual frameworks of research into psychological distress. Demographic variables have also been invoked as explanations. For instance, socioeconomic status is clearly related to morbidity; poverty rates are significantly higher for women than for men (Wilson, 1988), compounding the rates of women's morbidity. Furthermore, the sex differential in age, with many more women than men in the oldest age groups, also contributes to women's excess morbidity.

Changing Trends in Mortality and Morbidity Table 2

Morbidity Indicators by Sex and Sex Ratios in the United States in 1987 Indicator

Restricted activity days Total days of disability (millions) Days/person Bed disability days Total days of disability (millions) Days/person Work loss days Total (millions) Days/person Hospital utilization rates Patients discharged per 1,000 persons Days of care per 1,000 persons Average stay (days) Physician visits Total (millions) Visits/person

Females

Males

Sex ratio (Female/male)

1,984 16.1

1,464 12.7

1.35 1.28

879 7.1

595 5.2

1.48 1.36

304 6.1

299 4.8

1.02 1.27

159

116

1.37

968 6.1

860 6.9

1.20 0.88

765 6.2

523 4.5

1.46 1.38

Note. From Statistical Abstract of the United States: 1990, by the U.S. Bureau of the Census, 1990.

September 1990 • American Psychologist

Although women continue to hold a mortality advantage, this advantage has decreased in recent years. Figure 2 reveals that the sex-mortality ratio has taken a clear turn downward and has been slowly but steadily declining over the past decade. This indicates a declining advantage for women. The sex-mortality ratio has been declining especially for persons aged 45 years and older. There are several changes in the epidemiology of the major diseases that appear to have caused this shifting mortality trend (Strickland, 1988). The death rate from heart disease has been decreasing steadily across the last 30 years for men, and staying about the same for women. Cancer rates, which rose more rapidly for men than for women until 1979, declined more rapidly for men than for women in the 1980s. We propose that these epidemiologic shifts are attributable, in large part, to the psychological and behavioral effects of major social trends--in particular, changes that women and men have undergone during the past few decades in social structure and roles. To the extent that variations in health are related to variations in life-style, there should be corresponding shifts in the rates of disorder. As reported earlier, these changes are evident. We consider two major social and life-style changes-women's increased substance use and work-force partici p a t i o n - t h a t have led to psychological and behavioral outcomes with consequences for health. 1021

Figure 2 Age-Adjusted Sex-Mortality Ratio (Male~Female) in the United States, 1900-1988 2.0

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Women's health. Review and research agenda as we approach the 21st century.

This article reviews past research and projects future research directions regarding women's health. Sex differences in mortality and morbidity, along...
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