Virtually every woman can expect to experience at least one chronic illness or disorder in her lifetime, and the incidence of chronic health problems increases with age. By age 55 years, more than 80% of women experience at least one chronic health problem. Major attention to and support for women’s health research has only emerged in the past dozen years, however, and the scientific pursuit of knowledge about women’s health and gender differences in health has been legitimized in the same time period. Research on the psychology of women’s health, field in its infancy only a decade ago, is growing healthily into its adolescence, and the quality and quantity of work in the area have grown impressively.
The topic of women’s health is a broad one, and is continually evolving. It covers the psychological, social, cultural, economic, and political processes that affect women’s physical health as well as how gender influences the relation between behavior and health. Many people, particularly in medicine, equate women’s health with reproductive health: menstruation, fertility, childbearing, and menopause. However, the study of women’s health goes beyond this, to encompass those illnesses more common among (but not limited to) women or some subgroups of women, for example, breast cancer, arthritis, and eating disorders. It also involves health psychological phenomena as they apply to women and their health: stress; coping and adapting to illness; interpersonal processes in health, illness, and health care (e.g., social support, caregiving); behavioral, psychological, social, economic, and cultural risk factors for particular diseases; factors related to the promotion of good health (e.g., exercise, diet, screening); social problems (e.g., poverty, violence) and their related health consequences; and preventive interventions to enhance health and well-being.
This article cannot cover all of these topics, and instead focuses on a few illness conditions that affect women disproportionately, and for which there exists a knowledge base regarding gender or gender differences. Heart disease and cancer are the two leading causes of mortality for women; arthritis and rheumatic diseases are the greatest cause of disability. The incidence of HIV/AIDS is increasing at an alarming rate for women, and is a public health priority.
Additional accounts of the excellent work in the psychology of women’s health can be found in the references listed in the bibliography.
Braiding Together Gender and Health
Why do we need a separate article on women’s health? After all, many of the topics just described are equally applicable to women and men. Unfortunately, for most of the last century, the results of research done only with men were considered to be applicable to both women and men. The idea that there might be meaningful differences between men and women in their experience of illness, or in the factors that lead to illness, was generally ignored unless a hormonal (biological) difference was suggested. Moreover, these hormonal differences, most often related to reproductive processes, were used to justify the exclusion of women from medical and even, in some cases, psychological research. That is, the restriction of medical research to men was the result of efforts to protect women, particular women in the childbearing years, from the risks of experimentation.
Medical doctors have actively promoted the notion of gender differences in health since the early 18th century. However, the differences they emphasized centered on reproductive health and often were used to establish that women’s primary role was that of mother and wife. Medicine, as any other human enterprise, is determined by political and social forces that shape the social construction of the phenomenon. Thus, the study of women’s health has been determined by culturally held beliefs about women’s roles. When the society constructs women’s role as subordinate, the research topics and interpretations of the research confirm the need to protect, decide for, and even exclude women from certain activities.
In the early 19th century, Helmholtz’s principle of energy conservation was used to justify limitations imposed on access to higher education for women. Higher education was considered to be too much of a burden for women’s fragile physiology. Intellectual activities were believed to take too much energy away from reproductive activities. Fast-forward ahead a century: With the women’s movement of the 1960s, the increase of women in higher education, and the fight for reproductive rights, there is a different social construction of women’s roles. An outcome of this has been greater interest in women’s health, including women’s own choices regarding health.
We know now that it is important to understand biological, psychological, and social factors in health and health behavior among both women and men, and that the benefits of including women in health research outweigh the risks. Research guidelines instituted by the National Institutes of Health in the mid-1990s dictate that research studies must include women and men unless there is a very good reason for excluding women. This policy has been but one social structural factor that has increased the amount of research on women’s health in the last decade.
Many studies examine the linkages between women’s behavior and their health outcomes. This is part of a move within the behavioral sciences and within medicine to use a more comprehensive biopsychosocial model to understand health. The biopsychosocial model goes beyond a biomedical model, which emphasizes only biological causes of illness, to include psychological and social determinants as well. Thus, behavioral or psychosocial factors are pivotal in the prevention, development, and progression of disease.
Recently, the World Health Organization has recognized the existing gender inequities in health. These inequities are concentrated in the areas of health risks and opportunities to enjoy health, health needs, access to health resources, responsibility in the health sector, and power in the health sector. Women have a greater chance of having a health problem, but they have fewer opportunities to enjoy good health because they tend to have less education, employment, and income than men. Women make up the majority of the working population, yet do not have as much control over health policies and decision making as men because they tend to hold lower-status jobs.
Gender Differences in Health and Illness
Let’s start with the big difference: Women live longer than men in almost all developed countries, and have lower death rates at virtually every age and for most causes of death, even when taking reproductive status and age into account. However, women consistently report worse health status and greater morbidity (symptoms) than men do. Health surveys repeatedly show that females have higher rates of illness, disability days, and use of health services. Intuitively, this seems contradictory. Why should the sex that has a health disadvantage end up with a mortality advantage?.
One reason is that women’s reports about their health are probably a combination of real morbidity and (less accurate) symptom perceptions. Data from both community surveys and interviews show higher rates of acute and chronic illnesses for females (although injury rates are higher for males). This difference remains stable even when reproductive health conditions are removed. However, these conditions are less severe and are often non-life-threatening diseases. Women do report more disability overall (limitations on daily activities) than men do. However, reports of disability depend not only on the type of illness and its severity, but also on social roles and obligations. Men report more limitations of their usual activities when they are ill than women do. One explanation is that women’s caregiving roles—as mother, spouse, and household manager—leave them less time for not performing daily activities.
Many illnesses are linked to gender, either by genetics, physiology, or lifestyle factors. For example, many autoimmune disorders (such as rheumatoid arthritis), some gastrointestinal disorders (irritable bowel syndrome), some forms of cancer (e.g., breast cancer), and osteoporosis are more prevalent among women. Recent studies show that lifestyle factors such as stress and smoking not only differ in their prevalence between women and men, but may effect men and women differently at a physiological level.
Cardiovascular disease refers to all diseases related to the heart or blood vessels, including coronary heart disease (CHD), stroke, hypertension, and congestive heart failure. Coronary heart disease and other cardiovascular diseases are the leading causes of death in women in the United States despite the fact that they are considerably more common among men. Between the ages of 35 and 74 years of age, the death rate for CHD is 2.7 times higher among men than women, but this gender gap narrows with age. Although CHD is sometimes associated with menopause, there is not a sharp rise in CHD at this time; most heart disease occurs in both men and women after the age of 65 years. Initial episodes of myocardial infarction (MI) are more often fatal in women than men, and women have more unrecognized Mis. What might be the cause of this?
More than 2.5 million U.S. women are hospitalized for cardiovascular-related diseases annually, yet little is known about cardiovascular diseases in women in terms of their course, differential diagnosis, treatment, and prognosis. This is due in part to the historical exclusion of women from clinical trials and in part because of differential medical care. We are also learning more about the protective role of estrogen in preventing heart disease.
Heart disease continues to be viewed as a disease of men, not women. Physicians are less likely to attribute the same symptoms to heart disease in women than they are in men. Women’s symptoms are often attributed to noncardiac causes such as psychological issues or hormonal changes (e.g., during menopause). Women may seek care more slowly than men following onset of symptoms, so their condition is more likely to be more serious at the time of hospital admission.
In general, women are then treated less aggressively than men for CHD. Women are less likely to be referred than men for either coronary artery bypass surgery or angioplasty. Women may receive less benefit from bypass surgery than men; some studies suggest that women appear to have a higher mortality rate from bypass surgery, but one must consider that women entering cardiac surgery tend to have poorer health status, be older, and have fewer psychosocial resources than men who undergo similar surgical treatment.
There are known gender differences in risk factors associated with cardiac diseases. Physiological/biological factors include family history of heart disease, hypertension, diabetes, obesity, and older age. Behavioral risk factors include use of oral contraceptives, smoking, and lack of exercise and physical activity. Psychosocial factors include hostility and use of social resources. For example, hostility is risk factor for CHD and social support a protective factor. However, for women with high hostility levels, social support may be a less protective factor for women than it is for men with the same hostility levels. Recent studies also show that marital quality may be a stronger predictor of women’s survival after heart attack than men’s.
Smoking is a strong risk factor for CHD and a greater risk factor for women than for men. Moreover, women often perceive smoking as a reliable way of managing stress and controlling their weight. Advertising encourages smoking in women as a way of staying thin, attractive, and “cool.”
Little is known about recovery from heart attack and bypass surgery because most studies have included only male patients. Women take longer to recuperate from their surgery, are more restricted in their activities, spend more days in bed, are less likely to return to work, and take longer to resume activities than men. Women are less likely to participate in cardiac rehabilitation and exercise programs, but when they participate at the same level, women gain the same health benefits as men do. In addition, several studies have shown women to be more anxious and depressed, and those women who retire from work after surgery have worse emotional adjustment than male patients do. Again, it is not clear whether these are true gender differences or attributable to the fact that women who undergo bypass surgery start out in poorer health, are older, and have fewer economic and social resources.
The disease women fear most is breast cancer. The incidence of breast cancer in North American women has increased steadily over the last 50 years, culminating in the present l-in-8 lifetime risk for developing the disease. As scientists improve methods of prevention, early detection, and treatment, growing numbers of women are living with breast cancer for longer periods of time. In response to this trend, clinical researchers have increasingly focused on quality-of-life issues. Although 20% to 30% of women with breast cancer experience significant psychological distress, this distress is substantially reduced in the year following diagnosis, and the majority of women with breast cancer are well adjusted. One to 2 years after treatment, women with breast cancer do not differ from healthy women in psychological status.
Research has documented numerous psychosocial and physical effects of breast cancer, including emotional difficulties, problems associated with sexuality, negative changes in body image, pain and suffering, threats to one’s self-esteem or self-concept, disruptions in daily activities, challenges to one’s beliefs about the world, and problems with interpersonal relationships.
One difficulty that appears to be shared by many women with the disease is the fear of recurrence. Between 60% and 99% of women voice this fear. Moreover, fears about breast cancer recurrence, unlike overall psychological distress, do not necessarily dissipate over time. Although 57% of women survive to 15 years after diagnosis, approximately 70% of breast cancer survivors still fear the possibility of recurrence 5 years after diagnosis. These fears have been associated with psychological distress among both current cancer patients and cancer survivors. Younger women have stronger fears, a finding that may be due to the generally more aggressive nature of breast cancer among younger women, or a sense that a cancer diagnosis early in the life cycle is particularly unexpected.
A number of medical characteristics influence psychosocial adjustment to the initial breast cancer diagnosis. Treatment decision making (e.g., choosing mastectomy as opposed to breast-conserving surgery), undergoing treatment itself (e.g., chemotherapy, radiation, hormone therapy), and time since diagnosis have been associated with adjustment. Chemotherapy has been associated with decreased adjustment, varying with its toxicity and assaults on the body (nausea and vomiting, hair loss, weight gain, fatigue). In some studies, however, psychological distress increases again after the termination of treatment because women no longer feel they are actively fighting the disease and have no concrete evidence of disease processes (e.g., a shrinking tumor).
Results regarding the type of surgery have been equivocal. A recent meta-analysis (a statistical technique for combining the results of many studies) suggests that there may be modest benefits to having breast-conserving surgery (BCS), in terms of psychological, marital-sexual, and social adjustment, body/self-image, and cancer-related fears. In contrast, a longitudinal study showed that women who had BCS were more distressed and perceived less social support than women who had mastectomies. In another study, women who had chosen BCS rated their physicians’ support of their choice as more important than did women who chose mastectomy, perhaps because they needed reassurance that BCS was as likely to have a positive medical outcome.
Coping with breast cancer, or any cancer, means different things for different people at different points in the illness, in part because it occurs in the context of other life circumstances. Instead of producing global distress, cancer often produces what psychosocial cancer researcher Barbara Andersen has termed “islands” of psychosocial disruption that vary across the course of the illness. That is, not only are there many different aspects or adaptive tasks of breast cancer to cope with, but these islands rise above the water at different times. Thus, when women are asked to report how they cope with their breast cancer, it is impossible to know which aspects of breast cancer they are thinking about. Which aspects of having cancer are most salient for that woman at that time? For example, studies of women undergoing chemotherapy or taking tamoxifen suggest that adjustment may be disrupted with new treatments or even in the absence of treatment, which gives no cues of remission or recurrence. Even asking women how they cope with a more focused aspect of their cancer, such as chemotherapy or cancer-related pain, has a limitation. A woman undergoing chemotherapy may have to deal with excessive fatigue, fears about the long-term physical effects of this treatment, or sexual difficulties resulting from induced menopause. Likewise, the pain caused by a woman’s cancer may prevent her from completing daily activities or may heighten fears about the progression of her illness.
As with other stressors, women with breast cancer use a wide range of coping techniques: cognitive, behavioral, problem-focused, and emotion-focused strategies, involving approach and avoidance of the stressor. The coping strategies of cognitive reappraisal, seeking social support, and avoidance consistently have been identified as among the most common strategies for coping with breast cancer. Overall the strategies of acceptance, positive reframing, and seeking and using social support have proved to be beneficial for women with breast cancer. Accepting the illness, or “learning to live with it” (as opposed to accepting responsibility for the illness), is conceptualized as a functional or beneficial coping response, and research with breast cancer patients has found it to be related to improved adjustment. Similarly, positive reframing involves a cognitive attempt to reappraise the stressor of illness, to change its meaning, in order to view it in a more positive light. For example, a woman undergoing chemotherapy may think of the accompanying nausea as evidence that the treatment is working, rather than evidence that the drugs are harming her body. Positive reframing has been identified as one of the most common strategies for coping with breast cancer and has been related to greater psychological adjustment.
Avoidant coping, including denial, behavioral or cognitive disengagement, and some tension-reduction strategies, such as using drugs or drinking, are consistently related to increased distress. Denial is the refusal or inability to acknowledge facts about the breast cancer. There is some controversy over whether denial is a beneficial coping strategy for women with breast cancer. Evidence suggests that it may be helpful at the time of diagnosis, when the woman is flooded with emotional reactions, and detrimental if it delays treatment decisions or is used continually or as a primary coping strategy. Avoidant coping has predicted greater distress after cancer diagnosis and after surgery, and in one study predicted cancer progression 1 year later.
Arthritis and Rheumatic Diseases
The rheumatic diseases, arthritis, and musculoskeletal conditions constitute more than 100 different illnesses and conditions, affecting nearly 40 million people in the United States. Arthritis and musculoskeletal disorders are the most common self-reported chronic conditions affecting women. Rheumatoid arthritis (RA) is a chronic, systemic illness whose cardinal manifestations of joint inflammation, swelling, and stiffness result in severe pain, joint destruction, fatigue, and physical disability. The course of RA is unpredictable and highly variable, with symptoms that flare and remit. The average age of onset of RA is between 25 and 50 years, although the incidence and prevalence of the disease increase with age. The prevalence of RA is much greater for women than for men: at different points in the lifespan, between two and six times as many more women than men have RA. Systemic lupus erythematosus (SLE) is an autoimmune disease that involves multiple systems of the body. Symptoms may include malaise; fever; weight loss; joint pain; renal, cardiac, neurological, and liver problems; and skin and mucous membrane problems. Almost 90% of patients with SLE are women, and it occurs more often among African-American women. Osteoarthritis (OA) is the most common form of arthritis, and is most prevalent among older people; it is marked by pain in an involved joint (or joints) that worsens with activity, joint stiffness and enlargement, and functional impairment. Women are twice as likely as men, and African-American women are twice as likely as White women, to have OA of the knee, and OA of the knee is more likely to result in disability than OA in any other joint.
Most forms of arthritis pose a set of common stressors, including recurrent severe joint pain, potential disability, loss of role functioning, increased risk for developing depression, and frequent medical care. The treatment regimens, especially for RA and SLE, can involve medications with unpleasant side effects. Except for SLE, most forms of arthritis pose no immediate life threat, but the experience of symptoms and the course of the disease are unpredictable. Therefore, successful adaptation requires that one cope with uncertainty as well as with concrete illness symptoms.
Women with RA report more symptoms than men, but when disease severity is taken into account, women actually have fewer symptoms than men. This finding suggests that women do not overreport symptoms, but have more severe disease and may in fact be less likely to complain about symptoms than men are.
The symptoms associated with arthritis often lead to functional limitations. As a result, women with arthritis have lower participation in the labor force, and it is generally reported that the economic impact of arthritis is much more severe for men than for women. The economic impact of women’s work disability due to arthritis is underestimated, however, because arthritis and its disability significantly affect women’s “home” work (nurturing, raising families, housework), which is economically undervalued for ill and nonill women alike.
Physical disability affects quality of life in other ways as well. In one study of women with rheumatoid arthritis, approximately 40% of the women reported limitations in such important role activities as making arrangements for others and taking them places, maintaining social ties by writing or calling, and visiting or taking care of sick people. In addition, women who experienced these types of limitations were less satisfied with their ability to provide support to family and friends compared to unimpaired women. The nurturing role—a very important role for women—has been neglected in most past research on adaptation to illness. The presence of chronic disease is a risk factor for depression when it involves the loss of the ability to perform valued social roles. Again, this suggests that to understand the impact of chronic disabling illness, we must examine not just physical limitations, but women’s psychological interpretations of the meaning of those limitations.
The most frequently studied effect of arthritis on psychological functioning has been its impact on depression. Depressive disorders and depressive symptoms are more prevalent in people with rheumatic diseases than in people without any serious, chronic illness. Women not only are at greater risk than men for some of the more common and serious rheumatic diseases, but also are at greater risk for depression. If depression in women with rheumatic diseases is overlooked, then declines in functioning caused by depression could be mistakenly attributed to the rheumatic disease and result in overtreatment. Alternatively, if symptoms of depression are mistakenly assumed to be a natural part of the disease process that does not warrant treatment, women may suffer unnecessarily.
Wishful thinking, self-blame, and other avoidant coping strategies have been associated with poorer psychological functioning for both women and men with rheumatic disease. Active coping strategies, and strategies such as information seeking and cognitive restructuring, have been associated with better psychological functioning. However, in a study of daily coping processes in which RA patients were studied over 75 consecutive days, women and men differed in the use of only one of seven coping strategies: Women tended to seek social support to a greater degree. Women made a greater number of coping efforts overall and used a greater diversity of coping strategies than men. These findings suggest that women may be more flexible in their coping efforts.
AIDS is the third-leading cause of death among women aged 15 to 24 years. The prevalence of AIDS among women continues to increase, although it has decreased among men (Centers for Disease Control and Prevention, 2001). The proportion of AIDS cases reported among women more than tripled between 1985 and 1999, going from 7% to 25% of the total cases. The statistics are even more tragic for minority women. African-American and Hispanic women together represent less than one-fourth of U.S. women, yet they account for more than three-fourths (78%) of AIDS cases reported to date among women in the United States. In 2000, African-American and Hispanic women represented 80% of HIV/AIDS cases reported in women.
Among the major routes of HIV/AIDS transmission for women are heterosexual intercourse and needle sharing among injection drug users. In 2000, 38% of women with AIDS were infected through heterosexual exposure to HIV, and injection drug use accounted for 25% of cases. Many women infected heterosexually were infected through sex with an injection drug user (CDC, 2002). To understand and combat the epidemic of AIDS/HIV among women, one needs to understand and combat substance abuse and risky sexual behaviors in women. Moreover, these two risk factors are interdependent: Use of alcohol has been implicated in spread of HIV/AIDS among women, particularly among adolescent girls, because it often impairs judgment, leading to more risky sexual behaviors. Studies suggest that use of alcohol during or before sex often leads to risky sexual practices, such as unprotected intercourse, multiple sexual partners, and partners whose HIV status is unknown (or not communicated).
Although condom use is the only contraceptive method that prevents both sexually transmitted diseases and pregnancy, it is also a method controlled by men. Psychosocial factors play a great role in the process of negotiation of condom use. Although women need to exercise a proactive stance to use condoms to avoid undesirable pregnancy and the transmission of HIV, they are rarely encouraged to be assertive in terms of sexual behavior, and may even suffer undesirable consequences such as loss of income, loss of sexual relationship, and even violence.
The Centers for Disease Control and Prevention (CDC, 2003) has identified several directions for preventive efforts to reduce the transmission of HIV among women: (1) target risky behaviors that are associated with HIV/AIDS, (2) increase preventive efforts among female adolescents and minority women, (3) focus more on drug use and HIV transmission among women, and (4) provide women with female-controlled contraception methods. It is hoped that research in the next decade will address these issues in depth.
Growth and Resilience
Recent trends in psychology have highlighted the importance of positive psychology, that is, looking at health and positive growth as well as illness and pathology. It is critical to acknowledge women’s strengths in the face of adversity rather than focus solely on their weaknesses. Recognizing women’s strengths means focusing on positive aspects of well-being, such as personal growth or strengthened social ties, as well as on distress. In many studies of women with cancer and other illnesses, women spontaneously describe positive outcomes of their experience.
The concept of resilience (alternatively called thriving, personal growth, and benefit finding) is a new way to look at the outcomes of facing health problems. Resilience refers to how some individuals are able to maintain strength and experience personal growth in the face of severe or prolonged adversity. Some researchers propose that there are resilient individuals, who have a definable set of characteristics that enable them to adapt successfully to stressful circumstances. Others suggest that resilience may be the coping process of fending off maladaptive responses to stress, thus leading to better mental health. Resilience can also be thought of as the long-term end product of facing a severe stressor or challenge, such as chronic illness. Whichever approach is used, the focus of a resilience perspective is one of positive adaptation, not simply the absence of pathology.
Resilience or thriving does not depend solely on physical health outcomes, but includes psychological, social, and spiritual growth. More to the point, thriving may be possible in the absence of physical recovery from disease, as in the case of an individual fighting an illness such as ovarian cancer or HIV/AIDS.
Resilience and thriving offer a new way to include gender in our definitions of health because it moves beyond viewing health issues solely in terms of vulnerability, deficits, or risk factors and refocuses on strengths and capabilities. Although women experience greater degrees and different types of stress than men, they also have a broader fund of stress-resistance resources. On the biological level, hormones provide a protective health advantage to women, at least until menopause, reducing risk of cardiovascular disease and osteoporosis. On the psychosocial level, social relationships may be a key to women’s resilience. Research has found that women have stronger support networks and more ability to mobilize help in a crisis than men, both of which have been linked to better adaptation. Moreover, there is recent evidence that the expression of emotions, long considered a coping strategy linked to depression, may be an adaptive strategy for women and not for men. Clearly, in health psychology research, we need to adopt gendered approaches, not and define phenomena not simply relative to a male norm or in terms of gender differences, but as they vary within a heterogeneous population including women, with various strengths and competencies.
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