The Psychology of Gender and Health: Conceptual and Applied Global Concerns

The Psychology of Gender and Health: Conceptual and Applied Global Concerns examines the psychological aspects of the intersection between gender and health and the ways in which they relate to the health of individuals and populations. It demonstrates how gender should be strategically considered in the most routine research tasks—from establishing priorities, constructing theory, designing methodologies, in data interpretation, and how to practically apply this information in clinical contexts.

The topics covered in its chapters answer the needs of professionals, students, and faculty, providing an up-to-date conceptual tool that covers the relationships that exist between gender and health. The book will not only help users build expertise in psychology in gender and health, but also contribute to the awareness and training of psychologists as dynamic actors in the implementation of the gender perspective in their studies, reflections, research, and health interventions.

• Offers specific literature on the gender perspective in health and psychology
• Addresses a broad and diverse audience, and its coverage is uniquely comprehensive
• Utilizes an intersectional approach to race, class, sexual orientation, nationality, disability status, and age
• Updates on the pressing concerns of gender violence
• Covers specific content on transgender and same-sex attracted populations that includes a focus on men and masculinity
• Deals with hot topics on infertility, immigration, and HIV/AIDS

• Language: English
• Publisher: Academic Press
• Release date: Dec 25, 2016
• ISBN: 9780128038666

Book preview

The Psychology of Gender and Health

Conceptual and Applied Global Concerns

Editors

M. Pilar Sánchez-López

Rosa M. Limiñana-Gras

Table of Contents

Cover image

Title page

Copyright

Contributors

Foreword

Chapter 1. Health From a Gender Perspective: The State of the Art

Determinants of Health

The Sex/Gender System

The Gender Perspective in Health: Integration of Sex and Gender in the Analysis and Research of Health

Incorporation of the Gender Perspective to Interventions in Health

Book Preview

Part I. Conceptual Approaches for Gender and Health

Chapter 2. Gender-Based Perspectives About Women’s and Men’s Health

Gender and Health

Sex and Health Studies

Approaches of Gender as a Determinant of Health

Gender Self-Categorization and Gender Beliefs

Gender Perspectives About Health: Common Aspects

Chapter 3. The Health Gender Gap: A Constrained Choice Explanation

The Health Gender Gap in Global Perspective

Constrained Choices: A New Approach to Health Disparities

The Constrained Choice Framework and Processes

Applications of Constrained Choice

Future Challenges for Constrained Choice

Chapter 4. Masculinities and Health: Whose Identities, Whose Constructions?

Hegemonic Masculinity

The Limitations of Hegemonic Masculinity

Masculinities Reconsidered

Conclusion

Chapter 5. Transgender, Sexual Orientation, and Health

Common Meanings: Gender, Self-Identity, Gender Identity, and Sexual Orientation

Health in Transgender People

Conclusion

Part II. Clinical and Health Contexts

Chapter 6. He’s More Typically Female Because He’s Not Afraid to Cry: Connecting Heterosexual Gender Relations and Men’s Depression

Masculinities and Men’s Depression

Heterosexual Gender Relations, Health, and Illness

Theoretical Underpinnings of Gender Relations

An Empirical Study

Conclusion

Chapter 7. Intimate Partner Violence Against Women: Prevention and Intervention Strategies in Spain

An International Framework for Violence Against Women

The Magnitude of the Problem: Global and National Prevalence Estimates of Intimate Partner Violence Against Women

The Severity of the Effects: Consequences of Violence on Women’s Health

Approaches to Gender-Based Violence

Strategies for Primary and Secondary Prevention

Intervention Strategies

Psychological Intervention With Victims and Perpetrators of Intimate Partner Violence Against Women

Chapter 8. Examining Migrants’ Health From a Gender Perspective

Situating European Migration

Women in Migration Studies From a Gender Perspective

The Healthy Immigrant Effect

Migrants’ Health From a Gender Perspective

Acculturative Stress and Its Impact on Health: Elements for a Psychological Intervention With Migrants

Health Care: Barriers to Services and Health Programs

Intersectionality: A Necessity When Studying Migrants’ Health

Chapter 9. An Integrity Model, Existential Perspective in Clinical Work With Men From a Gender and Health Perspective

Challenging the Myth of the Emotionally Defective Male

The Integrity Model in Working With Men: A Historical and Health Promotion Perspective

Theoretical Underpinnings: The Integrity Model

The Integrity Model: An Existential Perspective in Working With Men

Working With Men: Case Example

Conclusions

Chapter 10. Contributions of Gender Perspective to HIV Infection

Genealogy of an Epidemic

Epidemiology and Distribution by Sex

Gender Inequalities in HIV

Sex and Gender Determinants in HIV

Contributions of Gender Perspective to HIV Prevention

Contributions of Gender Perspective to HIV Interventions

Psychology, Gender, and Pediatric HIV: Contributions From Clinical Practice

Conclusions

Chapter 11. Breastfeeding and Health: A Gender Perspective

A Historical Perspective of Breastfeeding

Breastfeeding as a Biopsychosocial Phenomenon

Femininity, Motherhood, and Breastfeeding

Breastfeeding, Health, and Gender

Psychological Interventions in Breastfeeding

Chapter 12. Mainstreaming Gender Equality to Improve Women’s Mental Health in England

Psychology, Psychiatry, and Women’s Mental Health

The Case for Mainstreaming in Mental Health

Mainstreaming as a Potential Remedy

Mainstreaming in Practice

Revisiting Mainstreaming in Mental Health

Conclusions: Implications for Psychiatry and Psychology

Chapter 13. Health and Gender Perspective in Infertility

Infertility and Its Treatment

Health and Gender Determinants in Infertility

Health and Gender Differences in Infertility

Infertility in Reproductive Psychology: A Gender Perspective

Chapter 14. Epilogue

Topics to Discuss in a Health Psychology Course

Conclusion

Index

Copyright

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Cover Image: Hygeia, the daughter of the god of medicine, Asclepius. Hygeia was the goddess/personification of health and prevention of illness, cleanliness, and hygiene. She was represented as a young woman feeding a large snake coiled around her body. The snake was a beneficial and enlightening character in cultures of old. An animal between two worlds, it was able to live underground and to shed its skin. For Greeks, descent into the underworld (below consciousness and what is visible) is essential in obtaining a cure—one must descend to see what is happening there, to find the cure, with a fresh skin. Like the snake. Applying the gender perspective to health is also a descent, in some ways, below what is visible. We obtain a fresh skin, that enables us to better understand the importance of gender as a determining factor for health, and the need to include gender-related variables in order to correctly assess the set of causes that produce differences in health. Hygeia feeding a snake is particularly associated with the aim of this book.

Contributors

Marta E. Aparicio-García,     Complutense University of Madrid, Madrid, Spain

Joan L. Bottorff

University of British Columbia, Kelowna, BC, Canada

Australian Catholic University, Melbourne, VIC, Australia

Andreea C. Brabete

Complutense University of Madrid, Madrid, Spain

University of Montreal, Montreal, QC, Canada

Joan C. Chrisler,     Connecticut College, New London, CT, United States

Lucia Colodro-Conde,     QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia

Isabel Cuéllar-Flores

CoRISpe (National Cohort of Pediatric Patients with HIV Infection of Madrid), Spain

EPSY (Research Group of Psychological Styles, Gender and Health), Spain

Hospital Universitario Doce de Octubre, Madrid, Spain

Juan F. Díaz-Morales,     Complutense University of Madrid, Madrid, Spain

Karen Goodall,     University of Edinburgh, Edinburgh, United Kingdom

Julie Hepworth,     Queensland University of Technology, Brisbane, QLD, Australia

Joy L. Johnson,     Simon Fraser University, Vancouver, BC, Canada

Mary T. Kelly,     University of British Columbia, Vancouver, BC, Canada

Nedra R. Lander,     University of Ottawa, Ottawa, ON, Canada

Rosa M. Limiñana-Gras,     University of Murcia, Murcia, Spain

Chris McVittie,     Queen Margaret University, Musselburgh, United Kingdom

Danielle Nahon,     University of Ottawa, Ottawa, ON, Canada

Karen Newbigging,     University of Birmingham, Birmingham, United Kingdom

John L. Oliffe

University of British Columbia, Vancouver, BC, Canada

University of Queensland, Brisbane, QLD, Australia

Rosa M. Patró-Hernández,     University of Murcia, Murcia, Spain

Jennan G. Read,     Duke University, Durham, NC, United States

Patricia P. Rieker,     Boston University, Boston, MA, United States

M. Pilar Sánchez-López,     Complutense University of Madrid, Madrid, Spain

Londa Schiebinger,     Stanford University, Stanford, CA, United States

Sabrina T. Wong,     University of British Columbia, Vancouver, BC, Canada

Foreword

Doing research wrong costs lives and money. Ten drugs were recently withdrawn from the US market because of life-threatening health effects; eight of these posed greater threats for women. Not only did these drugs cost billions of Euros to develop, but when they fail, they cause death and human suffering. We can’t afford to get it wrong (United States General Accounting Office, 2001).

Doing research right can save lives and money. An analysis of the US Women’s Health Initiative Hormone Therapy Trial—a large, government-funded study done in the 1990s—found that for every $1 spent, $140 were returned. More importantly, the study saved lives; trial results lead to 4.3  million fewer postmenopausal women using combined hormone therapy, which in turn resulted in 76,000 fewer cases of cardiovascular disease, 126,000 fewer breast cancers, and 145,000 more quality-adjusted life years. Whereas most of the results were positive, the analysis found 263,000 more osteoporotic fractures (Roth et al., 2014). We need more measures like this of the actual benefits of sex and gender analysis in health research.

It is crucially important to identify gender bias in health research. But analysis cannot stop there. We need to turn it around; we need to get it right from the beginning; we need to harness the creative power of sex and gender analysis for discovery in biomedicine and health research (Schiebinger et al., 2011–2016).

Recognizing the importance of sex and gender to human health, granting agencies across Europe, Canada, and the United States now require that these variables be included in publicly funded research. Since 1990, The US National Institutes of Health (NIH) has required that women be included in medical research, especially clinical trials. Since 2010, the Canadian Institutes of Health Research (CIHR) has explicitly called for sex and gender-based analysis (SGBA) in health research and supports these requirements with training modules (because these topics still are not incorporated into most medical school curriculum) (CIHR, 2012; Mayo School of Continuous Professional Development [MSCPD], 2015). In 2013, the European Commission required that both sex and gender be included in Horizon 2020 research, where appropriate to the topic (European Commission, 2013). Finally, in June 2015, the US NIH released guidelines emphasizing the importance of sex as a biological variable (SABV) in preclinical, clinical, and population health studies (Clayton, 2015; Clayton & Collins, 2014; Collins & Tabak, 2014).

Despite these policy initiatives, the role of gender and its crucial interactions with biological sex have generally been neglected in biomedical and health research. It is now the responsibility of researchers to refine and sharpen methods, questions, and research priorities. What are the relative contributions of sex (biological characteristics) versus gender (cultural attitudes and behaviors) and intersecting social factors to human health? And how do we study sex and gender, and their interactions in biomedical research?

The Psychology of Gender and Health addresses these questions, focusing in particular on the psychology, economics, and politics of gender and health in a global context. Sex is defined as being male or female (or intersex) according to chromosomal complement and biological functions assigned by chromosomal complement. Whereas biological sex differences are initiated by genes encoded on the sex chromosomes, all other factors (eg, autosomal and mitochondrial genes) are believed to be equally inherited by males and females. Sex, however, exists along a continuum in which males or females differ on average.

Over the past 25  years, important sex differences in disease have been identified. Well-known examples include the underlying pathophysiology in patterns of women’s and men’s heart disease, where men typically have a severe pinching off of the coronary artery (that angiography, the gold standard for diagnosing heart disease, has been developed to detect), whereas women have a gradual narrowing of the coronary artery (that angiography typically does not detect). Or we might mention osteoporosis in men and women, where men’s disease has historically been underdiagnosed. Other examples include studies showing that low-dose aspirin may be protective against cardiovascular disease for men but not for women, that drugs metabolize differently in women and men, and that pain differs by sex (Oertelt-Prigione & Regitz-Zagrosek, 2012; Regitz-Zagrosek, 2012; Schenck-Gustafsson, DeCola, Pfaff & Pisetsky, 2012).

The study of sex differences (and similarities) is well underway with organizations such as the Organization for the Study of Sex Difference, devoted to this very question. Gender, by contrast, is less well understood in health research. In particular, we lack agreed-upon methods for measuring gender in ways that can be analyzed statistically while still preserving the integrity of the phenomena. Gender refers to sociocultural values and roles that shape attitudes and behaviors of men, women, and transgender persons. Social factors often influence biology such that gender becomes a modifier of biology (or sex). Gender is not only gender identity (how individuals and groups perceive and present themselves). Importantly, gender includes gender norms (spoken and unspoken cultural rules in the family, workplace, institutional, or global culture that influence individual attitudes and behaviors) and gender relations (power relations between individuals of different gender identities); see sidebar (Schiebinger et al., 2011–2016).

Analyzing Gender—Points to Keep in Mind

1. Gender attitudes and behaviors vary by culture, historical era, ethnicity, age, socioeconomic status, and other factors. For example, gender norms may be very different on the US West Coast versus the East Coast, or in Italy versus India.

2. Femininities and masculinities slide across continua and across cultures. Both masculine and feminine behaviors may manifest in any one individual. A single person may change behaviors over the course of a day or a lifetime, since gender norms often depend on context. A man, for example, may demonstrate masculine behavior in the boardroom but more feminine behavior at home with his children.

3. Gender does not necessarily match sex (Fig. 1).

Figure 1  Gender does not necessarily match sex.

This figure shows the distribution in men and women with premature acute coronary syndrome (ACS). Pelletier et al. developed new methodology to analyze gender as a variable in order to understand the association between gender, sex, and cardiovascular risk factors among patients with premature ACS. Importantly, they found no sex difference; that is, being a man or a woman did not predict accurately which patients were likely to relapse or die within 12  months from diagnosis. The team found, however, that gender matters. Patients with a higher femininity score, regardless whether they were a man or a woman, were more likely to experience a recurrence of ACS. This study showed that a man with a high femininity score was more likely to suffer a recurrence, and a woman with a high masculinity score was not. From Pelletier, R., Ditto, B., & Pilote, L. (2015). A composite measure of gender and its association with risk factors in patients with premature acute coronary syndrome. Psychosomatic Medicine, 77, 517–526. http://dx.doi.org/10.1097/psy.0000000000000186; Pelletier, R., Ditto, B., & Pilote, L. (2016). Sex or gender: which predicts outcomes after acute coronary syndrome in the young? Journal of the American College of Cardiology, 67(2), 127–135. http://dx.doi.org/10.1016/j.jacc.2015.10.067. Reproduced with kind permission.

4. It is important not to overemphasize gender differences, but instead to analyze and report within (intra-) and between (inter-) group differences.

5. A response bias may exist, for example, when men and women answer surveys. A gender difference reported may result, at least in part, from gender differences in responding behavior. Feminine-identified persons, for example, may be more likely to admit emotionality in responding to a standard distress scale than men.

6. It is important to consider factors intersecting with sex and gender (for example, age or socioeconomic status may be more significant than gender).

This volume investigates how the social influences the biological (and vice versa) in order to understand gender as a modifier of biology and, hence, health. Of note, in this volume are chapters on masculinities, femininities, and transgender identity, as these populations are shaped by and shape social, economic, religious, media, education, and cultural trends across the life course. The volume offers a panoply of examples and methods for understanding the role of gender in health. Coming back to our examples cited earlier, this volume adds the gender components to biological differences. In cardiovascular disease, in addition to the fact that women have different biological symptoms, they also have a longer door-to-balloon time, because emergency workers and physicians, and perhaps even the women themselves, believe that heart attacks strike primarily men. Women are also given fewer tests, and are less well represented in research, treatment, and preventive measures. Osteoporosis also has a gender as well as a biological determinant. Men, for example, may be more physically active in occupations, such as construction work, or leisure activities such as football, that build bone. Social norms and divisions of labor, by contrast, prescribe less weight-bearing activity for women.

The authors also provide important gender insights to the puzzles of mortality; women live longer, but have poorer health. Whereas biology has been vigorously investigated in this regard, social impacts also need to be taken into account. Smoking and alcohol consumption, for example, shorten men’s lives, as do risk behaviors and violence. The chapters focus on a rich variety of topics from intimate partner violence to migrants’ health to paternal postpartum depression to transgender and sexual orientation in health, and the gender paradoxes driving suicide.

Gender, of course, is not one variable, but a cascade of questions, factors, and methods that need to be integrated into health research. This volume wonderfully sets out methods, questions, analyses, and findings, which make it valuable reading. The European Union Gender Medicine group is also preparing a large meta-analysis of gender aspects of public health across Europe (EUGenMed Public Health Study Group, Sex and Gender Aspects of Risk Factors for Non-Communicable Diseases across Europe, major report in progress, 2013). Further, the Gendered Innovations project at Stanford University is launching new initiatives for studying gender variables in health research. The time for fully analyzing sex, gender, and their interactions in health has come. We welcome the rich perspectives provided in this volume, and the opportunity to collaborate with colleagues globally on these questions.

Londa Schiebinger,     John L. Hinds Professor of History of Science, Stanford University,     Director, Gendered Innovations in Science, Health & Medicine, Engineering, and Environment

References

Canadian Institutes of Health Research (CIHR). Sex, gender and health research guide: A tool for CIHR applicants. 2012 Retrieved from. http://www.cihr-irsc.gc.ca/e/32019.html.

Clayton J.A. Studying both sexes: a guiding principle for biomedicine. The FASEB Journal. 2015;30 fj.15–279554. http://dx.doi.org/10.1096/fj.15-279554.

Clayton J.A, Collins F.S. Policy: NIH to balance sex in cell and animal studies. Nature. 2014;509(7500):282–283. http://dx.doi.org/10.1038/509282a.

Collins F.S, Tabak L.A. Policy: NIH plans to enhance reproducibility. Nature. 2014;505(7485):612–613. http://dx.doi.org/10.1038/505612a.

EUGenMed Public Health Study Group. Sex and gender aspects of risk factors for non-communicable diseases across Europe, major report in progress.

European Commission. Fact sheet: Gender equality in horizon 2020. 2013 Brussels, December 09. Retrieved from. https://genderedinnovations.stanford.edu/FactSheet_Gender_091213_final_2.pdf.

Mayo School of Continuous Professional Development (MSCPD). Sex and gender-based medical education (SGME) summit: A roadmap for curricular innovation. 2015 Retrieved from. http://sgbmeducationsummit.com/.

Oertelt-Prigione S, Regitz-Zagrosek V, eds. Sex and gender aspects in clinical medicine. London: Springer Verlag; 2012. http://dx.doi.org/10.1007/978-0-85729-832-4.

Pelletier R, Ditto B, Pilote L. A composite measure of gender and its association with risk factors in patients with premature acute coronary syndrome. Psychosomatic Medicine. 2015;77:517–526. http://dx.doi.org/10.1097/psy.0000000000000186.

Pelletier R, Ditto B, Pilote L. Sex or gender: which predicts outcomes after acute coronary syndrome in the young? Journal of the American College of Cardiology. 2016;67(2):127–135. http://dx.doi.org/10.1016/j.jacc.2015.10.067.

Regitz-Zagrosek V, ed. Sex and gender differences in pharmacology. Berlin-Heidelberg: Springer Verlag; 2012. http://dx.doi.org/10.1007/978-3-642-30726-3. .

Roth J, Etzioni R, Waters T, Pettinger M, Rossouw J, Anderson G, et al. Economic return from the women’s health initiative estrogen plus progestin clinical trial: a modeling study. Annals of Internal Medicine. 2014;160(9):594–602. http://dx.doi.org/10.7326/m13-2348.

Schenck-Gustafsson K, DeCola P, Pfaff D, Pisetsky D, eds. Handbook of clinical gender medicine. Basel: Karger; 2012. http://dx.doi.org/10.1159/isbn.978-3-8055-9930-6.

Schiebinger, L., Klinge, I., Paik, H.Y., Sánchez de Madariaga, I., Schraudner, M., & Stefanick, M. (Eds.). (2011–2016). Gendered innovations in science, health & medicine, engineering, and environment (genderedinnovations.stanford.edu). Retrieved from http://ec.europa.eu/research/gendered-innovations/.

United States General Accounting Office. Drug safety: Most drugs withdrawn in recent years had greater health risks for women. Washington, DC: Government Publishing Office; 2001.

Chapter 1

Health From a Gender Perspective

The State of the Art

M.Pilar Sánchez-López¹, and Rosa M. Limiñana-Gras²     ¹Complutense University of Madrid, Madrid, Spain     ²University of Murcia, Murcia, Spain

Abstract

The chapter aims to present readers with a review of the most important concepts and developments around the area of gender and health. This will make it possible to correct skewing and stereotypes concerning gender that are common to the general public as well as students of and professional workers in psychology.

In the first section a brief description is given of the social, economic, physical, and psychological factors needed for an adequate study of health, including gender analysis intersecting all of them.

The second section brings together all the most up-to-date conceptualizations regarding sex and gender, and the relation between the two. Gender, understood as the result of interactions in a specific cultural and social context, and separated from being considered as a stable attribute of an individual, is presented to us here as a much more complex, changing reality, which stresses the social and cultural nature of differentiation between what is feminine and what is masculine by questioning essentialist and/or dichotomous definitions.

In the third section, the main results in health are explored from a gender viewpoint. The need to underline the inclusion of gender-related variables to be able to correctly evaluate the set of causes of health differences is stressed. There is a description of the need to always incorporate sex and gender–based analysis (SGBA) in the planning and preparation of health policies, because this tool makes possible a greater understanding of differences between people regarding epidemiology, illnesses, and treatments. There is also a review of the main gender approaches in research, how they are integrated into different theoretical frameworks, and the repercussion they have in programs, projects, policies, and results in health. From psychology the integration of these approaches is carried out from a differential, multidimensional approach, giving an account both of the impact exerted by sex and gender on health and the development of different important masculinities and femininities that are important for health. Integration of sex and gender into health analysis faces us with the challenge of incorporating tools and measures to enable us to correctly interpret the results obtained in the research, making these dimensions sufficiently operative. This is the purpose of the last part of this section. It answers the need to measure gender by proposing the concept of the social gender norm of Mahalik (2000) and Mahalik et al. (2003, 2005) to make the gender role operative. This approach provides a gender variable that is multidimensional and regardless of sex, and valid for incorporation from the beginning of evaluations or researches.

Finally, the fourth section aims to illustrate how gender interacts with social determinants by generating inequalities that affect health in different stages and contexts. Finally, postnatal paternal depression is one more example of simplifying differences in health from a biological and reproductive model.

The chapter ends by offering a panoramic view of the other chapters of the book, the topic of which has been referred to throughout the whole of this first chapter, which serves as an introduction to this volume, the Psychology of Gender and Health: Conceptual and Applied Global Concerns.

Keywords

Gender approach in research; Health and gender; Sex and gender; Sex and gender–based analysis (SGBA)

The complex construct of gender interacts with biological and genetic differences to create health conditions, situations and problems that are different for women and men as individuals and as population groups. This interaction, and how it plays out across different age, ethnic and income groups, should be understood by health providers and health policy makers. (p. 102)

United Nations (1998) Report, Women and Health, Mainstreaming the Gender Perspective into the Health Sector

The concept of health, as well as the responsibilities toward the target population of health interventions, has been changing and evolving in parallel and in response to the historic changes in the sociopolitical context. Although the biomedical model, referring almost exclusively to biological factors, is still in force in biotechnological applications in the field of health, the current conception of health recognizes and underscores ever more inclusively the relevance of psychological, social, economic, and political aspects that interact as determinants of health, emphasizing that the concept of health is not only a scientific issue, but also social and political, understanding as such the relationships of power within society.

In this sense, gender, as a central analytical category in health studies, has contributed to the development of this extensive concept of health, turning into an increasingly expanding field of research. Its development, both in the fields of biomedical and of social sciences, will facilitate the promotion of policies that recognize its magnitude and importance in public health issues.

This chapter aims to provide readers with a review of the most relevant concepts and developments concerning gender and health, which will allow correcting gender biases and stereotypes that are common both in the general public and among psychology students and professionals. In the first sections, we present a brief description of the necessary social, economic, physical, and psychological factors for the adequate study of health, including gender analysis at the intersection with all of them, and the most current conceptualizations of sex and gender and their relationship will be developed. Gender, understood as the result of interactions in a specific social and cultural context, and far from its consideration as a stable attribute of the individual, is presented herein as a much more complex and changing reality that emphasizes the social and cultural nature of the distinction between feminine and masculine, questioning essentialist (West & Zimmerman, 1987) or dichotomous definitions. We insist on the need to include gender-related variables in order to correctly assess the set of causes that produce differences in health, and we review the main approaches to gender in research, their integration in different theoretical frameworks, and their impact on health programs, projects, policies, and outcomes.

From psychology the integration of these approaches is carried out from a differential, multidimensional approach, accounting for the impact of sex and gender on health and the development of diverse health-relevant masculinities and femininities. The integration of sex and gender in the analysis of health also imposes the challenge of incorporating tools and measures that permit a correct interpretation of research outcomes, adequately operationalizing these dimensions. Finally, this chapter also aims to illustrate, with some examples, how gender interacts with social determinants, generating inequalities that affect health in different stages and contexts.

Determinants of Health

The appropriate approach to the study of health, both of the individual and the population, must take into account all the social, economic, physical, and psychological factors liable to have some influence on health, and it must provide the necessary indicators to clarify, guide, implement, and evaluate health interventions. In general, it is usually accepted that these determinants comprise factors such as income and social status, social support perceived by people, the level of schooling, employment (or its lack) and conditions at work, the social and physical environment, health habits, the person’s development across the life cycle, their biological and genetic heritage (including their sex), the health-related services of their environment, culture (ethnic and cultural identity), life conditions, geographic location, age, sexual orientation, personal characteristics, and many other factors. Along with and interacting with them, gender is also a determinant of health.

These determinants may influence the risks, possibilities, behaviors, and manifestations of health and illness throughout a person’s life. All the factors, and the interactions among them, are important in order to enjoy good health; they create the ecological niches, the varied and complex situations that, interacting with personal characteristics, allow each individual to display healthy or unhealthy behaviors that will influence health, and that will vary from one population to another and from one group/individual to another within the same population (Greaves, 2011; Johnson, Greaves, & Repta, 2007).

The influence of each of these determinants on people’s health can vary depending on their sex and gender. Deepening our knowledge and understanding of the role played by sex and gender in health can contribute to improving the health of individuals and populations. It is known that sex can influence health; for example, women and men who suffer from the same disease may present different symptoms (eg, myocardial infarction) and may respond differentially to drugs and treatments (eg, to psychotropic drugs), depending on their hormonal, physiological, and morphological characteristics. Or some diseases (eg, prostate cancer) only affect one of the two sexes, affect one more massively (eg, breast cancer), or have different consequences for men than for women (eg, smoking appears ever more clearly as a risk factor for breast cancer in women).

It is also known that gender is another important factor that influences health. For example, take the case of respiratory diseases caused by poor combustion of cooking materials, which are more common among women because owing to the traditional female role, women normally spend more time cooking. Also note that the different roles and responsibilities that are assigned to a person as a function of being male or female, which, for example, can cause masculinity to be associated with force, resistance, and, in short, with resilience. This can influence men who accept this masculine role to be reluctant to ask for help or consult health professionals, and to be more prone to take risks and have accidents (World Health Organization [WHO], 2007). In contrast, traditional femininity is associated with delicacy and softness, which can cause women who accept this rule to consider it inappropriate for them to participate in physical activities. This attitude can damage their health, both physically and mentally (Observatorio de Salud de la Mujer, 2005).

Thus the level of health of a person or a population can improve or worsen depending on the presence of multiple factors that interact with each other. These factors are of different types and include characteristics ranging from the individual to the social, work, environmental, and health contexts. The inclusion of the gender perspective in the analysis of these factors involves assessing how gender interacts with all of them, generating inequalities that affect the health of people at very different times and in many different ways, which can range from the unequal degree of exposure to different risks for men and women to differences in the health care received.

The Sex/Gender System

In order to study the relationships between sex, gender, and health, the aspects that make up this system must first be clarified. What is gender, what is sex, how is the sex/gender identity established, and what are relationships, roles, and stereotypes of gender?

Sex and Gender What’s the Difference?

The concepts of sex and gender, although related, are clearly distinct and not interchangeable; however, they are sometimes confused and used interchangeably in contemporary scientific literature. The term sex refers to a biological construction, whereas the term gender refers to a social construction, and the conceptual distinction when using these two terms is of utmost importance to ensure the accuracy of the scientific research methodologies employed. Clarity in the terminological distinction between sex and gender must be present, starting with the identification and operationalization of the study variables, through data collection processes, and ending with the presentation of results (Gahagan, Gray, & Whynacht, 2015; Krieger, 2003).

To use a classical definition, according to the World Health Organization (WHO) (2011a), the term sex involves the reference to biological characteristics (chromosomal, gonadal, hormonal, brain, and genital dimorphism) and includes aspects relating to reproduction and sexuality. As seen, it is a multidimensional concept, but one which ends up becoming a binary notion (man–woman), although most of the elements that compose it (eg, hormonal and chromosomal differences) are actually a continuum. This conversion of a continuous dimension into a dichotomous category causes problems and confusion when designing, managing, and interpreting health behavior outcomes related to the influence of the variable sex. Finally, the term sex is used also, correctly, in the differential tradition of psychology, in research comparing the behaviors of men and women, without reference to gender-related aspects. In this case, it refers to differences between sexes, without making assumptions about whether these differences are biological, psychological, or social, or because of an interaction between them. When this term is used, the male sex is differentiated from the female sex (eg, to quote only classical works, Anastasi, 1937; Maccoby & Jacklin, 1974; Tyler, 1947; and, as a modern classic, Ellis et al., 2008).

Gender, also according to WHO (2011a), refers to the characteristics of women and men, which vary from society to society, and which are constructed historically and culturally. Whereas sex is a biological difference, gender is used to define the ways of social construction in relation to the feminine or masculine nature of the behavior considered normal for each of the sexes. Thus unlike sex, gender will be a changing and dynamic category that will vary according to societies, cultures, and historical periods (Simonds & Brush, 2004).

Therefore gender is a relational category seeking to explain how certain types of differences between human beings are established. It establishes a social order that has traditionally been explained on the basis of biological sex, although this has been refined and questioned, indicating that even sexual differences should not be considered as purely anatomical facts, because the construction and interpretation of anatomical differences is in itself a historical and social process (Benhabib, 1992). The term gender, therefore, implies reference to roles, relationships, personality traits, attitudes, behaviors, values, influences, and power relations that are culturally constructed and that a given society attributes differentially to one or the other sex (Lovaas, 2005). Being a social category implies that no traits or behaviors inherently belong a priori to any particular group or to a particular gender.

Finally, gender is also often considered a bipolar concept (masculine vs. feminine). However, as in the case of sex, this bipolarity does not reflect the broad variety of experiences, identities, and behaviors that constitute gender. Human beings feel and express their gender along a continuum of characteristics and behaviors, not by mutually exclusive categories. And, as in the case of sex, the transformation of a dimension into a bipolar category sometimes produces errors in the interpretation of health behaviors. In modern times, the inclusion of the term trans, with all the nuances that can and should be made, is an attempt to be sensitive to this nonpolarity. There is, moreover, no necessary, exact, and, unique correspondence between man and masculinity or between woman and femininity. Sex and gender interact with each other naturally, but they do not completely determine each other. When gender identity or expression differs from the biological sex, the generic term of transgender is used (Teich, 2012), and its comprehension and inclusion in the analysis of health requires a more extensive and complete vision of gender, which will be included in Chapter 5 of this book. In other chapters, such as Chapter 13, reference is made to different aspects of transgenderism and health, in this case with respect to infertility.

Gender therefore is based on learning; it is a process that begins very early in life. Four concepts related to this learning process tend to be distinguished: gender identity, gender roles, gender stereotypes, and gender relations, which we will examine in greater depth in the following sections.

The Social Construction of Gender Identity

The concept of gender identity refers to multidimensional, heterogeneous, evolving, and open processes, which are in permanent construction. It is the result of an evolutionary process by which social norms and expectations are internalized. It refers to the individual’s psychological sense of being a man or a woman, with the social and psychological behaviors that society designates as masculine or feminine. In fact, it is a learning process with socially adaptive value, in which the maternal and paternal models and the social roles of close adults are of great importance. Indeed, the family and the school are socializing agents in the acknowledgment that each subject establishes his or her own gender category. In Chapter 4 the authors point out the process of constructing masculine identity and, subsequently, how this process relates to health.

These processes by which people become men and women are not exempt from social and cultural conditioning, and they usually take place within a structure that postulates the complementarity of the sexes and the regulations of heterosexuality (Lamas, 1995). Such is the case with male hegemony and its construction, given a detailed examination in Chapter 4. One of the conclusions arrived at by the authors is that it is not that the concept has no place in understanding men’s health; rather it is the case that its relevance and utility remain to be demonstrated. In the Western culture, for example, they contribute to the acquisition of patterns of courage and protection in boys and of attraction and kindness in girls. Generally, group membership is established in an asymmetrical relationship between different groups, and it constitutes the foundations of individuals’ collective identification. In most cultures, and certainly in the Western one, men (as a generic) belong to the dominant groups, whereas women (also as a generic) belong to the dominated groups (Lorenzi-Cioldi, 1998). Gender violence, dealt with in Chapter 7, is an excellent example of this, because its very denomination implies asymmetry of power between men and women.

Of course, the media are also involved in these socialization processes through the massive reproduction of essentialist information and, therefore, they contribute to the dualistic assumption of gender (Chrisler, 2013). This information assigns the status of opposites, natural and necessary to these gender roles, forgetting or ignoring that within the great human diversity, men and women are more similar than different, as evidenced by the review of the results of empirical research (eg, Hyde, 2005).

Why is gender identity so decisive in people’s lives? Gender identity enables each person to be located on this gender continuum that was discussed in the previous section. This identification established by each person influences his or her feelings and behaviors (Teich, 2012), and has to do with the feeling of being a man or being a woman, but it is different from the sexual orientation (a person can have a feminine identity and feel attracted to men, to women, to both, or to neither). In the majority of cases, gender identity develops depending on the social context, which determines the expression of the gender that is appropriate to the biological sex. That is, when a person learns to be considered as a woman or a man, they also learn which behaviors they should express, which emotions they should have, which relationships they can maintain, which possibilities are offered, and which kinds of work are more appropriate. In Chapter 6, a good example is presented regarding the way of thinking as to how a type of masculinity is constructed (ie, being tough, stoic, and neglecting self-care, as the authors point out); there may be a clash in the specific individual with lack of social power to attain these characteristics. This may give rise to depression, for example. Moreover, Chapter 9 centers on the myth of the emotionally defective man, casting doubt on what at times are assumed to be classic male characteristics and insisting on the repercussions brought about by these considerations in masculine therapy. However, it is necessary to note, as reflected in the chapters of this book, that the complex and permanent interaction of the dual reality sex/gender in these identity processes does not always allow free adhesion to gender expectations or standards; on the contrary, most of the time this occurs with the participation of many factors that are beyond the individual’s awareness and therefore beyond free choice. The influence of socially and culturally constructed rules and stereotypes in men’s and women’s lives and health is as strong as it is invisible (Chrisler, 2013). Gender, understood as a result of interactions in a specific cultural and social context and, beyond, its consideration as a stable attribute of the individual (West & Zimmerman, 1987), is presented as a much more complex and evolving reality in which gender socialization processes are open and in permanent construction, and in which the decision to do gender is far from a personal choice (See Chapter 3 on the Bird and Rieker framework of Constrained Choice, applied to help explanation of disparities in health). Gender identity should therefore be analyzed as a cross-sectional reality, for which analysis requires an interdisciplinary approach and a questioning of the binary categories that constitute a real threat to psychological development and the access to a broader and more realistic gender awareness.

Gender Relationships, Gender Roles, and Gender Stereotypes

The incorporation of the category gender to refer to the social construction of feminine and masculine underscores the relational dimensions and the cultural and changing nature of the distinction between feminine and masculine, and questions the essentialist definitions, favoring the social and symbolic aspects over the biological ones in the explanation of the differences and similarities between men and women (Arango, León, & Viveros, 1995). Gender relations define how people should interact with others and how others relate to them, depending on their attributed gender, and they should be analyzed within the cultural context in which they develop.

Gender roles are the form in which a person’s gender identity is expressed. They are standards of behavior that the social group defines as appropriate for men and women, and they influence people’s daily lives; they are the rules that tell them how they should feel, what to expect, what gestures are correct, how to dress, what they can aspire to, how to express themselves, and how to relate. From these definitions, the roles of women and men are described symbolically as expressions of femininity and masculinity, and they are regulated until they become rigid stereotypes that limit individual behavior and development.

Lastly, stereotypes are the most commonly studied examples of social categorization (Tajfel & Turner, 1979), and in the formation of all these identity processes, they hold an important position (Martínez Benlloch, 2007). The concept of stereotype evokes concepts of prejudice and discrimination when its meaning is negative, or a simplification of very schematic characteristics in a more positive sense. In both cases, it is a rigid and structured set of beliefs that are shared by members of society, referring to personal characteristics (personality traits, attributions, expectations, motivations, interests) or typical behaviors of a specific group. They are mental shortcuts based on an abusive use of generalizations and images that allow the confirmation of some of the subjects’ beliefs and their adaptation to their environment (Ashmore & del Boca, 1981). They are internalized in processes of social interaction and they promote the positive assessment of the ingroup and the justification of the person’s perceptions of the outgroup. Stereotypes are often based on three main characteristics: age, sex, and race (Fiske, 1998; Stangor, 2000). As they are a subjective construction, they include beliefs, expectations, and causal attributions, which means that stereotyped thoughts do not always coincide with reality, because they are basically mental images proceeding from high cognitive elaboration.

Table 1.1 summarizes some of the features that have been pointed out to describe the masculine and feminine stereotypes in current Western culture (Fernández, 2004; Martínez Benlloch, 2007; Moser, 1989; Sánchez-López, 2013a).

From the stereotypes about what men and women are like, sexism, understood as the attitude toward a person or group on the basis of his or her sex, is constructed. As in any attitude, in sexism three components are differentiated: (1) the cognitive component, understood as the way in which the target of the attitude is perceived. It is made up of thoughts, ideas, beliefs; these are stereotypes; (2) the emotional component, consisting of feelings or emotions derived from beliefs about the target of the attitude; these are prejudices, marked by ambivalence; that is, by the coexistence of positive feelings and rejection; and (3) the behavioral component or tendency to act, which is expressed in discrimination.

Table 1.1

Stereotyped Gender Roles

Adapted from Martínez Benlloch, I. (2007). Actualización de conceptos en perspectiva de género y salud. En Colomer, C. & Sánchez-López, M.P. (2007). Programa de Formación de Formadores/as en Perspectiva de Género en Salud: Materiales Didácticos. Madrid: Ministerio de Sanidad y Consumo and Sánchez-López, M. P. (2013a). La salud desde la perspectiva de género: el estado de la cuestión. En M.P. Sánchez López (Ed.), La salud de las mujeres. Análisis desde la perspectiva de género (pp. 17–40). Madrid: Síntesis.

Usually two types of sexist attitudes are mentioned: the hostile and the benevolent attitude (Glick & Fiske, 1997, 2001, 2011). Manifestations of hostile sexism still persist in those cultures that consider dominating paternalism as valuable, that defend women’s inferiority and the competitive differentiation of gender, that contrast the structural power of men (which enables them to control the political, economic, religious, and legal institutions) with the dyadic power of women (based on their reproductive capacity and dependence relations), and that endorse heterosexual hostility, which considers that women’s sexual power is dangerous and manipulative. Men’s hostility has been confirmed in some studies as an attempt to control women and intimidate them, to keep them in their place, not challenging the authority and power attributed to men (Jackman, 1999, 2001). As described in Chapter 7, violence against women is considered a gender-based violence because of the obvious effect of traditional gender norms and attitudes related to inequality between men and women.

Benevolent sexism is characterized by positive attitudes that stimulate prosocial behavior and foster relationships of intimacy, but they conceal exclusion processes. Attitudes underpinning it are mostly protective paternalism (ie, women must be cared for and protected) and complementary gender differentiation (ie, women’s contribution to life issues, primarily being a mother and wife, is very valid because their capabilities and features complement those of the men). Benevolent sexism is considered an important factor hindering social change in groups suffering from prejudice and discrimination, because it makes it easier for members of these groups to assume and agree with their position of inferiority (eg, Expósito, Herrera, Moya, & Glick, 2010; Jackman, 1994).

The Gender Perspective in Health: Integration of Sex and Gender in the Analysis and Research of Health

The distinction between sex and gender and the recognition of their interaction in individual development are increasingly common in health studies. However, the importance of this distinction is still not sufficiently recognized, and both terms still continue to intermesh in some scientific studies and official documents on health policy (Connell, 2012).

Historically, research and the design of health programs have placed much more emphasis on the differences between the sexes than on the complex interaction between sex, gender, and health (Oertelt-Prigione, Parol, Krohn, Preissner, & Regitz-Zagrosek, 2010). It is known that the different ways in which men and women fall ill cannot only—or even often—be explained by genetic differences with a biological foundation and traditionally attributable to sexual differences. Therefore it is necessary to introduce the concept of gender to explain some differences that depend on our way of life, our expectations, and other social and cultural aspects. The chapters of this book will go more deeply into different aspects of these relationships between sex, gender, and health.

Numerous works (eg, Bendelow, Carpenter, Vautier, & Williams, 2002; Bird & Rieker, 2008; Chrisler, Golden, & Rozee, 2012; Hunt & Annandale, 2011) and all the chapters of this book show how the fact of taking gender into account helps us to understand how the cultural and social environment in which the person is immersed can have a major impact on the differential exposure of women and men (and of boys and girls) to risks and accidents, on their access to basic resources to achieve good health, and on aspects such as the appearance, severity, and frequency of illnesses, as well as the reactions they provoke, socially and culturally. However, public policies in gender and