Health Psychology of Women

Catherine Niven, Doug Carroll, Niven

• Publisher: Psychology Press
• Year: 2013
• Print ISBN:
  9780367108380
• eBook ISBN:
  9781134350377
• Topic: Medicine
• Subtopic: Health Care Delivery

First Published in 1993. Since health psychology is concerned with the universal values of life and death, well­being and suffering, it might be expected that its researchers would be keen to examine both male and female experiences of these phenomena. In practice, however, health psychology has followed health research in adopting a largely male perspective, both in its general approach and selection of topics. Women are different from men, not only in terms of anatomy, but in terms of the socialization processes to which they have been exposed and the social and economic positions they occupy. These differences have a significant impact on women's health, predisposing them to some disorders and protecting them from others. While it is true that male mortality exceeds female mortality from conception to old age, women's survival has the price of increased mental and physical illness. Men die, but women suffer. Despite a growing awareness of these differences there continues to be a distinct bias towards using male subjects for research and studying those diseases which affect more men than women. The Health Psychology of Women is a response to this imbalance and a challenge to the attitude which explores the behavior of half the population in order to draw conclusions about the experience of the whole. It is essential reading for students and researchers of psychology and health, and health professionals in training and practice.

1
Gender, Health and Stress

DOUGLAS CARROLL AND CATHERINE A. NIVEN
Department of Psychology, Glasgow Polytechnic, Cowcaddens Road, Glasgow G4 OBA, UK

According to Matarazzo (1980), health psychology encompasses the total sum of the contributions that the discipline of psychology has to make to matters of health and well-being. The realms of contribution range from the etiological to the therapeutic; health psychology is concerned with untangling the psychological factors that contribute to health, to the onset and course of illness and disease and also with the application of psychological knowledge and techniques to the amelioration and prevention of illness and disease and the promotion of health.

Clearly health psychology has set itself an ambitious agenda for a project of recent vintage. In practice, though, health psychology has focused on more circumscribed areas than those defined above. Given such a broad brief, it is perhaps hardly surprising that some issues have occupied more attention than others. Particular areas of investment have been cardiovascular disease and cancer and more recently HIV and AIDS. This has lead some to object that, for the most part, the dominant preoccupation of health psychology has been with men and men's ailments. However, it is not just the selection of topic, but also the orientation toward it, that has fuelled this protest.

Gender Differences in Research Focus

As Rodin and Ickovics (1990) pointed out, "White men continue to be almost exclusively studied in major health-care and pharmacological research. Even in animal-model research, male animals are almost always used" (Rodin and Ickovics, 1990, p. 1025). Examples are not hard to find. The Western Collaborative Group Study (Rosenmanef al., 1975) provided the stimulus for, as well as setting the tone of, much of the research into the relationship between heart disease and type A behaviour, a coping style characterized by competitive striving, time urgency and hostility. It involved a prospective investigation of over 3000 male, middle-aged non-manual workers. The subsequent Multiple Risk Factor Intervention Trial (Shekelle et al., 1985), which posed perhaps the greatest challenge to the type A concept was also directed exclusively toward men. Ninety percent of the subjects in the Recurrent Coronary Prevention Project (Friedman et al., 1986), which examined the impact of the psychological modification of type A behavior on the recurrence of heart disease, were men.

A number of justifications have been offered for this bias. In studies examining human cardiovascular reactions to psychological stress, women have, until recently, frequently been excluded on the grounds that their normal hormonal fluctuations might serve to contaminate results, rendering interpretation difficult. In the case of large scale intervention studies, the desire to protect women of child-bearing age from possible exposure to toxic substances or procedures has been cited, as has the additional cost of increasing the sample size by including women. However, undoubtedly the most consistently voiced justification for a male bias in the study of cardiovascular disease is men's substantially higher mortality rate.

It is true that in most Western countries the cardiovascular disease gender mortality ratio is 2:1 in women's favour, ie. that twice as many men die from heart disease as women. In terms of premature mortality, ie. in the age range 45-64, men's relative disadvantage is almost 3:1 (see, eg. Hart, 1989). However, there are compelling reasons for suspecting these various justifications as a sound basis for excluding women as subjects in the study of cardiovascular disease. First of all, research on the effects of women's hormonal status on cardiovascular reactions to psychological stress could contribute valuable information on the pathophysiology of cardiovascular disease. Secondly, as Rodin and Ickovics (1990) pointed out, while the protective policy of excluding women from health trials is almost certainly well-intentioned, there are groups of women, who, since they are at little or no risk of becoming pregnant, could easily be included. Finally, and most importantly, men's disadvantage in terms of cardiovascular disease mortality constitutes a poor justification for excluding women from study. After all, in most Western countries, cardiovascular disease is the leading cause of death for women as well as for men. Further, by studying women and cardiovascular disease, we may gain insight into what is affording women their protective advantage and this may yield dividends for both men and women.

Turning now to cancer, it again appears that women are under-represented in studies exploring possible psychological factors. Given that certain cancers are specific to women, we would anticipate that they might have attracted greater scrutiny in this context than with regard to cardiovascular disease. Nevertheless, although women have received somewhat more equitable study, large scale prospective investigations have tended to concentrate on men. For example, perhaps the largest prospective exploration to date of the contribution of psychological factors to cancer was the study conducted at Western Electric Company near Chicago (Persky et al., 1987). Its 2000 subjects were men. While the overall gender mortality ratios for cancer hover around 2:1 in women's favour, in most Western countries men and women register far less of a difference in the 45-64 age range. In fact, in some countries, eg. Sweden, the gender cancer mortality rates for this age range are almost equal. It is also perhaps worth noting that it is for cancers developing within this age range that psychological factors have been most implicated (eg. Fox, 1978).

Almost certainly, HIV and AIDS presents health psychology with one of its foremost challenges. However, its initial appearance in Western countries among homosexual and bisexual persons has tended to give a particular direction to psychological and biomedical research. Again, to date, men, mostly the white middle-class and middle-aged, have been the predominant focus of study. As Rodin and Ickovics (1990) attested, "beyond prevalence and basic epidemiology the issue of women and AIDS has received only limited research attention" (p. 1027). It remains the case that in both North America and Europe, AIDS continues to be far more common among men than women. However, the incidence of the disease among women is starting to rise sharply, as are estimates of their numbers infected with HIV. In the United States for example, the present rate of increase of AIDS in women is two and a half times that in men. In addition, around a third of women in Western countries have contracted AIDS through heterosexual intercourse, whereas the comparable statistic for men is under five percent.

Further, if we consider the epidemiology of AIDS in the area of its greatest prevalence, i.e. sub-Saharan Africa, a different gender distribution emerges. Since the mode of transmission in such countries has been almost exclusively that of heterosexual sexual intercourse, as many, if not more, women are affected as men. Chin (1990) estimates that some two and a half million women in sub-Saharan Africa had been infected by HIV by the end of the 1980s and that some quarter of a million had already developed AIDS.

Chin's projections for 1992 indicate the rate of spread of HIV and AIDS in sub-Saharan Africa. Some four million women were predicted to have been infected by the virus by then, and the cumulative AIDS total was predicted to be 600,000. Since the bulk of such women are, as in the case in Western countries, of child-bearing age, this clearly has massive implications for HIV infection and AIDS in children. While in the West we are only beginning to be confronted with the problem of children being infected with HIV prenatally from infected mothers, Chin reckoned that by the end of the 1980s HIV infection was the lot of some half a million African children and this figure was estimated to rise to one million by 1992. The corresponding figures for AIDS were 290,000 and 600,000 respectively. During the late 1980s in many central African cities, 5-10 percent of all infants were HIV positive. These figures not only give some idea of the pandemic character of the disease but also of its significance for women. In the West, where the resources that can be directed to biomedical and social psychological research are manifestly more substantial than those available in African countries, it is critical that the research focus shifts to incorporate the study of women.

Gender Differences in Mortality and Morbidity

From the foregoing, the reader will rightly infer that there are marked overall differences in the mortality rates of men and women in Western countries, which, to an extent, have directed the health psychology agenda. In almost every decade of life men die at a greater rate than women. If anything, these discrepancies in life expectancy in the West have increased in the last forty years, although there is evidence of at least some modest narrowing of the gap in some countries, eg. the US, in the last decade.

Nevertheless, according to the most current statistics (National Centre for Health Statistics, United States, 1989) life expectancy in the US is 71 years for men compared to 78 years for women, a seven-year advantage for women. In the UK (Office of Population Censuses and Surveys, 1989), the analogous figures are 72 and 78, an advantage of six years. Further, even in countries where male life expectancy is at the high end of the distribution, women still live longer. For example, in Japan male life expectancy in 1986 was 75 years; for Japanese females, though, it was 81 years (Marmot and Davey Smith, 1989).

In contrast, women have higher levels of morbidity than men. Morbidity simply refers to ill-health and almost every index of ill-health testifies that women suffer predominantly more than men: women consult physicians more often than men; they have higher levels of prescription and non-prescription drug use; they undergo more surgical procedures; in self-report studies, women report suffering from more illness and experiencing poorer health than men. Thus, although men have higher rates of some of the chronic diseases (such as cardiovascular diseases) that constitute the leading causes of death, men are actually sick less often than women.

These gender differences in mortality and morbidity raise interesting questions about why, if women are consistently favoured by lower risk of premature death, they generally experience poorer health and seek medical help more often than men. Such questions reinforce the contention that women's health merits a more prominent focus within health psychology. In fact, the apparently paradoxical gender differences in mortality and morbidity argue very strongly for a comparative approach.

Many factors could potentially contribute to the differences between men and women in mortality and morbidity. At a psychological level, it is almost certain that gender differences, in attention to and representation of symptomatology, play a part, as do differences between men and women in their willingness to report symptoms to physicians and others. At a biological level, it is probable that men and women vary in their constitutional predispositions to certain disorders. Clearly, women suffer exclusively from disorders related to their particular reproductive role and, while men may be more likely to develop cardiovascular disease, women are much more vulnerable to some disabling chronic diseases such as rheumatoid arthritis. In fact, the existence of health concerns that are exclusive to women (such as issues surrounding pregnancy and birth, menstrual cycle disorders, hysterectomy, breast and cervical cancer) or that disproportionately affect women (rheumatoid arthritis, eating disorders, depression) constitutes another important reason why the study of women's health deserves a higher priority.

Psychological Stress

A key concept in health psychology is psychological stress. It is also a concept that may help make some sense of these apparently paradoxical gender differences in mortality and morbidity. Men and women may vary in the degree to which they encounter stress. They may also differ in the sorts of stresses to which they are conventionally exposed, in their appraisal of stress, in the psychological and biological impact of stress and in their characteristic coping strategies and behavior in the face of stress. As Baum and Grunberg (1991) argued, psychological stress "has been linked to differences in health and illness among different groups nf people and, in particular, provides a rich array of points of interaction with gender" (p. 80), They further asserted that "differences in stress appraisal, in coping, or in one of the many forms of response or adaptation could singly or together predispose men and women to different illnesses and health problems" (p. 80).

Let us first try to indicate what we mean by the term psychological stress. In spite of its pivotal position in health psychology, it has proved surprisingly difficult to obtain agreement among researchers as to the precise meaning of psychological stress. However, given the extent to which the term is now part of everyday vocabulary and that most people have some common understanding of what it signifies, issues of precise definition need not detain us over-much.

The American physiologist, Walter Cannon (1935) was among the first to use the term stress in a non-engineering context and clearly regarded it as a disturbing force, something which upset the person's equilibrium, disrupted the usual balance. Cannon applied the term homeostasis when referring to this equilibrium or balance. From a perspective such as this, then, psychological stress refers to those events or situations that challenge a person's psychological and/or physiological homeostasis. Stressful circumstances are those which do not permit easy accommodation. Because of their meaning and the nature of the information they contain, individuals have to mobilize extensive psychological and/or physiological resources to deal with them; they cannot be handled 'on automatic'.

Stress is not, however, an objective characteristic of the environment. The point is nowhere better illustrated than in the research and writings of Richard Lazarus, Susan Folkman, and colleagues. For an event or situation to be stressful, according to Lazarus and Folkman (1984), we have to perceive or appraise it as such. Other, i.e. nonthreatening appraisals would serve to diminish the disruptive impact of the event and short-circuit the stress. An experimental study reported by Lazarus et al. (1965) affords a good illustration here. Subjects viewed a potentially stressful film called Woodshop, which depicted a series of gruesome accidents at a sawmill, such as a worker severing a finger. One group of subjects were encouraged to adopt a denial appraisal, by informing them prior to viewing the film, that the participants in it were actors, that the events were staged, and that no one was really injured. A second group were encouraged to use an intellectualization appraisal and view the film from the vantage of its likely impact as a vehicle for promoting safety at work. A third group of subjects viewed the film without prior instructions. Heart rate and skin conductance were monitored throughout to gauge the physiological impact of the film and subjects were asked to rate subjective feelings of stress. Those who had received either denial or intellectualization instructions showed less physiological reaction to the film and reported that it was less stressful than subjects given no appraisal instructions.

Thus, particular appraisals can ameliorate the impact of a potentially stressful event. There is a lesson of general significance to be learnt from this demonstration; there are psychological mechanisms at our disposal which serve to combat potential stress. The existence of such devices has been recognized for some time. Freud referred to them as defense mechanisms, although today they are generally called coping strategies and, to an extent, they help explain why, in the face of a potentially stressful situation, some people become stressed but others do not. Part of the explanation is that some individuals have a fuller repertoire of psychological coping strategies. However, this is far from a complete explanation. Most current models of stress and illness, for example, postulate that stress is more likely to precipitate illness where there is an existing vulnerability, a diathesis as it is usually called.

It is possible to regard this vulnerability as operating on a number of levels. First of all, it can operate on a biological level. Some individuals may simply be predisposed to suffer disruption to specific biological systems in the face of stress, for example individuals have been found to vary markedly in their cardiovascular reactions to psychological stress. This variability, to an extent, reflects genetic predisposition; monozygotic twins show much greater concordance of reaction than dizygotic twins (see eg. Carroll et al., 1985). Consider briefly the case of pepsinogen and susceptibility to ulcers. Pepsinogen secretory activity also shows a marked genetic influence (Mirsky, 1958. A classic study reported by Weiner et al., (1957) indicated just how stress and biological vulnerability can interact to produce disease. The subjects were new recruits in the U.S. army. Prior to their basic training, which is generally conceded to be extremely stressful, gastrointestinal examinations were undertaken. On the basis of the results, two groups of soldiers were selected, a group of oversecretors of pepsinogen and a group of undersecretors. None of the selected soldiers had ulcers at this stage. Approximately four months later, at the end of basic training, the soldiers were re-examined. Fourteen per cent of the oversecretors had now developed ulcers, whereas none of the undersecretors had. Thus stress itself is a necessary but insufficient condition for illness; diathesis, in this case in the form of biological predisposition, must also be present.

Vulnerability may also operate at a purely psychological level. People vary in the stock of coping strategies they can tap and in their habitual coping styles. Not all of these are beneficial to health. For example, type A behaviour is a coping style where diverse environmental provocations are dealt with by competitiveness, time urgency and hostility. While some counter-evidence exists, it would appear that, for those employed in white collar occupations at least, some components of type A behavior, most notably hostility, constitute a risk factor for coronary heart disease (see, eg. Bennett and Carroll, 1990). On the other hand, repressed hostility and passivity seem to characterize ulcer patients (eg. Lyketsosef al., 1982). Other coping styles are more positively indicated. Aside from type B behaviour (ie. the absence of type A characteristics) offering protection in the context of coronary heart disease, there is now evidence emerging that a coping style which involves denial is associated with a more positive prognosis following mastectomy (surgical removal of the breast performed as a treatment for cancer).

Pettingale and colleagues (1985) characterized four broad styles of coping from women's responses to interviews conducted four months after mastectomy. These were 'stoic acceptance', 'denial', 'fighting spirit', and 'helplessness/hopelessness'. Examination five years after the operation indicated that coping style was related to recurrence-free survival. Women who adopted either the 'denial' or 'fighting spirit' approaches fared much better. In addition, Pettingale et al, (1981) found that immune functioning, as indexed by immunoglobulin levels, was better in women using denial to cope than in those relying on the other strategies. In a more recent study, Dean and Surtees (1989) again interviewed women with breast cancer three months after mastectomy, and allocated them, on the basis of their ...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Preface
• List of Contributors
• Chapter 1 Gender, health and stress
• Chapter 2 Women, mood and the menstrual cycle
• Chapter 3 Reproductive issues: Decisions and distress
• Chapter 4 Women and the experience of pain
• Chapter 5 Cardiovascular health and disease in women
• Chapter 6 Cancer
• Chapter 7 Women and HIV/AIDS: Challenging a growing threat
• Chapter 8 Women, food and body image
• Chapter 9 Women and depression
• Chapter 10 Medical screening for women
• Chapter 11 Contraception
• Chapter 12 Gender, social circumstances and health
• References
• Index