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Bird, 1999 PDF
Bird, 1999 PDF
Center for Gerontology and Health Care Research, Brown University, Box G-H3, Providence, RI 02912, USA
b
Dana Farber Cancer Institute, Harvard University, Boston, USA
Abstract
Health research has failed to adequately explore the combination of social and biological sources of dierences in
men's and women's health. Consequently, scientic explanations often proceed from reductionist assumptions that
dierences are either purely biological or purely social. Such assumptions and the models that are built on them
have consequences for research, health care and policy. Although biological factors such as genetics, prenatal
hormone exposure and natural hormonal exposure as adults may contribute to dierences in men's and women's
health, a wide range of social processes can create, maintain or exacerbate underlying biological health dierences.
Researchers, clinicians and policy makers would understand and address both sex-specic and non-sex-specic
health problems dierently if the social as well as biological sources of dierences in men's and women's health were
better understood. # 1999 Elsevier Science Ltd. All rights reserved.
Keywords: Gender; Health
1. Introduction
Although signicant dierences in men's and
women's morbidity and mortality are well documented,
the sources of these dierences remain in dispute. This
situation prevails, in large part, because clinical and
social researchers have seldom explored whether health
dierences may not simply be either biological or
social in origin, but instead may typically result from
some combination of the two. In practice, the social
and biomedical sciences operate as distinct paradigms
with dierent research questions and often conicting
ndings. Because these two elds compete for scarce
resources in the form of research funding, researchers
from both elds tend to ignore and often even disparage the other's perspective and work. This competition results in a form of intellectual parochialism
which fragments both thinking and funding (Levine,
1995). Consequently, scientic explanations often proceed from reductionist assumptions that dierences are
either purely biological or purely social. Such assumptions and the models built on them have consequences
for research, health care and policy. Although biological factors such as genetics, prenatal hormone exposure
and natural hormonal exposure in adults may contribute to dierences in men's and women's health, a wide
range of social processes can also create, maintain or
exacerbate underlying biological health dierences.
American women's life expectancy has exceeded
men's since the turn of the century. Part of women's
gain in life expectancy is due to a 90% reduction in
maternal mortality from 73.3 deaths for every
100,000 births in 1950 to 7.3 for every 100,000 births
in 1989 (National Center for Health Statistics, 1991).
However, since 1980 the gender gap in life expectancy
has been closing in the US as men's gains have begun
to exceed women's. Adjusted for years spent living
with a disability, men's longevity is increasing while
women's longevity is not (Pope and Tarlov, 1991).
Despite women's greater longevity compared to men,
0277-9536/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.
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subjects and to reduce the risk of fetal exposure to experimental treatments (Mastroianni et al., 1994).
However, it is not valid to assume that treatments
developed by studying men are directly generalizable
to women. Furthermore, single sex studies fail to provide a complete picture of the similarities in men's and
women's health and morbidity.
Circular logic has been used both to justify the
assumptions of biological bases of men's and women's
health dierences and to exclude women subjects from
biomedical research on non-sex-specic diseases
(Hamilton et al., 1994). For example, one prevalent
argument for excluding women from clinical trials is
that the study will have more power if a homogenous
group is studied. However, if the rationale for excluding women is that they are dierent, it does not follow
that the results from studies of exclusively or predominately male samples are generalizable to women3.
Consequently, excluding women from these studies
leads to a lack of information on the eectiveness of
the treatments in women and of their risk of iatrogenic
and other side eects. Hamilton (1995) illustrates the
negative impact such reasoning has had for understanding the ecacy and safety of drugs for the treatment of depression among women, which is ironic,
given the clear excess of depression among females of
all ages and their resulting higher use of antidepressants.
To paraphrase C. Blee (1996), research that excludes
women subjects assumes that what is important about
human health is knowable by studying men. We argue
that the inclusion of women as subjects in clinical
research provides additional information not only on
women's health but also on possible interventions that
would benet men's health as well. For example, a better understanding of biological dierences which confer
a health advantage to one sex could be used to develop
pharmaceutical interventions to benet members of the
opposite sex. This benet would be maximized by
studying both sexes and by developing interventions
based on the advantages experienced by either sex.
Even when women subjects are included, researchers
need to go farther than simply including them in the
sample. Sampling and statistical techniques that simply
adjust or control for dierences in men's and women's
overall health or response to a given treatment fail to
tell us whether the results are the same for men and
women. However, additional subgroup analyses by
3
Women have also been excluded from research by fetal
protection policies designed to protect women and their
fetuses from potentially dangerous and exploitative research
(Mastroianni et al., 1994). Moreover, women of all ages have
been excluded from many research studies including those on
the population over 65 years of age (Bird, 1994).
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7
This nding of a sex dierence in immune system response
is common across a wide range of animal species.
Because social and biological models describe dierent aspects of men's and women's health dierences, it
is crucial that we begin to combine studies of social
and biological health risks if we wish to fully understand the determinants of men's and women's health
and illness. So long as research funding and practice
have barriers discouraging interdisciplinary research, it
will be dicult to systematically examine the social
and biological sources of men's and women's health
dierences. However, we propose that in order to
advance health research, a special programmatic eort
be made to solicit projects which examine both social
and biological factors. Although both the National
Institutes of Health and many private foundations
have made women's health a research funding priority,
to date none have advocated the integrated model proposed here.
In order to address inequity in men's and women's
health, it is necessary to understand sex and gender
dierences and the interaction of the two. Therefore,
researchers must study both biological and social factors simultaneously. A health advantage for one sex
may arise from dierences in men's and women's biology, in their social circumstances or a combination
of the two. Depending on the nature of the disadvantage and its health consequences, the appropriate interventions might be either biological or social and either
individual or societal. In general, we contend that
social inequalities should be addressed with social
rather than medical interventions even where the
inequality has health implications. In other words,
minorities, women and the socio-economically disadvantaged should not just be treated medically for
higher levels of psychological distress without also
addressing the mechanisms through which social
inequalities put them at higher risk of distress.
By isolating research into social and biomedical
domains, science policy-makers and individual
researchers maintain separate models of health, and
fail to explore the complex processes by which social
and biological processes combine. One unfortunate
result of this isolation of research into social and biological paradigms is the failure to test competing hypotheses about the determinants of health. More
importantly, science and health care advance more
slowly and less eciently than might be achieved
under more ambitious and better integrated
approaches.
6. Research implications
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