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Gender as a Consideration When Designing Health and Risk Messages

Summary and Keywords

Given the impact of gender on health, healthcare decisions, and treatments for illness, as well as the increased inequities encountered by non-white men and women, messages about health and health risks are affected by purposeful assumptions about gender identity. While the term sex denotes the biological sex of an individual, gender identity is about the psychological, cultural, and social assumptions about a person associated with that person because of his or her sex. Gender and health are intimately connected in a number of ways, and such connections can differ based on race, ethnicity, age, class, religion, region, country, and even continent. Thus, understanding the myriad ways that notions of gender affect the health of females and males is fundamental to understanding how communicating about risks and prevention may be tailored to each group.

Gender role expectations and assumptions have serious impacts on men’s health and life expectancy rates, including self-destructive behaviors associated with mental health and tobacco use, self-neglecting behaviors linked to the reluctance of men to seek treatment for ailments, reluctance to follow a physician’s instructions after finally seeking help, and risk-taking behaviors linked to drug and alcohol use, fast driving, guns, physical aggression, and other dangerous endeavors. Because gender role expectations tend to disfavor females, it is not surprising that gender generally has an even greater impact on women’s health than on men’s. Even though biological factors allow women, on average, to live longer than men worldwide, various gendered practices (social, legal, criminal, and unethical) have serious impacts on the lives and health of women. From sex discrimination in research and treatment regarding issues linked to reproductive health, depression, sexual abuse, alcohol and drug abuse, the sex trade, and normalized violence against women (such as rape, female genital mutilation, forced prostitution/trafficking, and domestic violence), women’s lives across the globe are severely affected by gender role expectations that privilege males over females.

While some general consistencies in the relationships between gender, women, and health are experienced worldwide, intersections of race, ethnicity, class, age, country, region, and religion can make for very different experiences of women globally, and even within the same country.

The recent years have seen an increasing call to reconsider the binary means by which we have defined sex and gender. Advances in our understandings of lesbian, gay, bisexual, intersex, and transgendered individuals have challenged traditional notions and definitions of sex and gender in important and complex ways. Such an important shift warrants a stand-alone discussion, as well as the recognition that sexual orientation should not be automatically linked to discussions of sex and gender, given that such categorization reifies the problematic sex/gender binaries that ground sexist and homophobic attitudes in the first place.

Keywords: sex, gender, risk-taking, violence against women, masculinity, femininity, gendered healthcare, reproductive health, depression

Some General Impacts of Sex and Gender on Health and Healthcare

The role of gender in health and risk messaging has been in the foreground for some time, making females the target of most communication about reproductive health (see Parrott & Condit, 1996, for a historical overview), and assigning responsibility to females for their families’ well-being (e.g., Horowitz, 1985). Less attention has been given to the sociocultural, biological, and experiential constructions of gender that explain its role in strategic message design and the impact of those gendered health and risk messages. While the most familiar gendered health messaging may be based on the differences between males and females in terms of reproductive health, research recognizes that a “wide range of genetic, hormonal, and metabolic influences play a part in shaping distinctive male and female patterns of morbidity and mortality,” including “growing evidence of sex differences in the incidence, symptoms, and prognosis of many other health problems including HIV/AIDS, tropical infectious diseases, tuberculosis, autoimmune problems, and coronary heart disease” (Doyal, 2001, p. 1061; also see Regitz-Zagrosek, 2012).

Internationally, the top five causes of death for females in 2015 were ischemic heart disease, stroke, lower respiratory infections, chronic obstructive pulmonary disease, diarrheal diseases, and Alzheimer’s disease and other dementias. The top four causes of death for males around the world were the same as the top four causes of death for women, but the fifth most common cause of death for males was trachea, bronchus, and lung cancers (WHO, 2017b). The difference in the fifth leading cause of death for males and females may have some links to biological sex differences and/or gendered expectations. For instance, it is theorized that women are more likely to be diagnosed with Alzheimer’s and other dementias due to the impact of the AOPe4 gene on females, a stronger likelihood of depression, and the tendency to outlive men, who die before Alzheimer’s or dementia has a chance to take hold (Kunkle, 2014). In addition, it is theorized that the sex differences in lung cancer rates can be attributed to higher rates of smoking in men (Hitchman & Fong, 2011). The rates of lung cancer in men and women in some countries, however, are starting to converge due to an increase in female smoking (Alberg & Nonemaker, 2012).

Of equal importance to the published research documenting the science associated with actual gender differences in health and health status is the role of gendered expectations of women and men, as well as how those expectations may affect their short- and long-term health. When it comes to health, although the most common causes of death are shared by males and females, the experiences and decisions of men and women are noticeably different in terms of contrasting perceptions, behaviors, expectations, and opportunities based on gender. Women and men experience different risks because of gendered work and family responsibilities, their unequal status in society, and their risk-taking preferences (Vlassoff, 2007). Women become ill more frequently than men due to stressors that include child care, elderly parent care, and attempts to balance work and home expectations (Jacklin, 1989; Rosenfeld, 2001), and although they are more likely to seek healthcare than men, they are often treated by male physicians who talk down to them, fail to take their complaints seriously, fail to respond to their questions, and treat women less aggressively for coronary heart disease, even though it is the number one killer of both men and women (Gamble & Gamble, 2014; Zimmerman & Hall, 2001). When sick, typically men work hard to avoid showing any signs of bodily weakness (Sheehy, 1998; Rudman & Mescher, 2013), primarily because they are conditioned to fear vulnerability and dependency and wish to avoid the appearance of losing strength and control (Kilmartin, 2001).

Moreover, gender bias and economic inequality also may limit women’s access to health services. Evidence suggests women are treated by some doctors as less valuable than men, which can lead to condescending attitudes and unequal distribution of medical resources (Raine, 2000). This gender bias is particularly apparent in the area of medical research studies, where women often have been excluded (Mastroianni, Faden, & Federman, 1994; Holdcroft, 2007).

Further complicating issues of gender and health, the gendered tendencies of males and females are also affected by issues of race and class, as well as other categories (Wamala, Ahnquist, & Mansdotter, 2009). Thus, for example, while men in the United States generally tend to avoid seeking healthcare when ill, college-educated men do so because they have a strong interest in maintaining perceptions of themselves as members of the “stronger sex,” while blue-collar men seek health care more often than college-educated men because they need to be in good physical condition for their jobs (Groves, 2009). Meanwhile, Black women in the United States are often more vulnerable to illness than their white counterparts (King, 1988; Painter, Wingood, DiClemente, DePadilla, & Simpson-Robinson, 2012; Schultz et al., 2000) and, once seen by doctors, are often treated differently than white women. For example, Black women in the United States are more likely to report not receiving advice about various prenatal and postnatal health concerns, such as breastfeeding (Spencer & Grassley, 2013) and are at much greater risk for not receiving possibly life-saving treatment for breast cancer because they are diagnosed later, which means that the size of the cancer is greater and the stage is more advanced (Nelson, 2007). Hispanics and Blacks in the United States also face barriers to receiving care and treatment that whites encounter less frequently (Agency for Healthcare Research and Quality, 2013).

Gendered Interpersonal Communication in Healthcare Settings

The gender roles that affect our health, as well as our decisions regarding caring for our health, are further affected by the gendered tendencies of doctor care, which begins with the choices that females and males make about their areas of practice. As of 2015 in the United States, the only medical specializations with more than 50% females practicing are child and adolescent psychology, geriatric medicine, internal medicine/pediatrics, obstetrics and gynecology, pediatric hematology/oncology, and pediatrics. Moreover, women make up more than 40% of practicing physicians in only four other specialties, including dermatology, endocrinology/diabetes/metabolism, neonatal/perinatal medicine, and rheumatology (Association of American Medical Colleges, 2016).

In addition to this gendered hierarchy, patient and physician behaviors are affected by gendered roles in communication. Male and female physicians do not differ in their use of social conversation, technical language, and emotional support (measured through explicit verbal statements), as well as the amount of information presented to patients; however, appointments with female physicians are longer, include more talk between physician and patient, employ more positive statements and more “we” language, cover more questions about medical and psychosocial issues, feature more backchannel responses, and use more smiles and nods. Attempts to create positive climates and be good listeners in medical settings are consistent with gendered patterns of communication linked to all females (Hall, Irish, Roter, Ehrlich, & Miller, 1994). Hall et al. (1994) also find that female physicians tend to use patient-oriented styles that include higher levels of friendliness, responsiveness, an acknowledgment of emotions, and communication that encourages discussions of issues related to health, such as personal and family concerns. Such a style tends to encourage a patient to ask questions, participate in decision-making, and even to disagree with the physician.

Females in the United States have also been found to engage in more supportive talk than males, although the race of the patient can predict the extent to which supportive talk occurs generally, with white patients receiving more supportive communication and Black patients receiving the least amount of supportive communication (Street, Gordon, Ward, Krupat, & Kravitz, 2005). In situations with female physicians and male patients, females in the United States used the least amount of technical language, smiled the most, exhibited a voice quality perceived as more interested and anxious, and were rated as using a voice quality that was more dominant at the beginning of the visit and less friendly late in the visit. These differences may be linked to a female physician’s attempts to placate male patients older than them in a male-dominated profession (Hall et al., 1994).

More recent studies in the United States show that in outpatient, inpatient, and emergency room settings, females are perceived as more patient centered, although males earn more credit from patients when they are patient centered than do females (Hall, Gulbrandsen, & Dahl, 2014). Although many studies recognize gendered differences in male and female physicians and suggest that women produce a more “health-promoting therapeutic milieu,” researchers warn that these results are only speculative “since no study has directly investigated whether patients of female physicians fare better on clinical measures” (Roter, Hall, & Aoki, 2002, p. 763).

Males, Masculinity, and Health

Because the gender stratification of issues such as power, work, economics, and politics tend to favor men, significant potential health drawbacks linked to masculinity tend to be ignored (Cohen, 2000). “Precarious manhood,” however, keeps American men in a consistent state of needing to prove or validate their masculinity because of a lack of institutionalized rites of passage (Vandello, Bosson, Cohen, Burnaford, & Weaver, 2008). The pressure on males in many cultures to externalize pain and “prove” their masculinity may partially explain the higher levels of self-destructive, neglectful, and risk-taking behaviors that are often seen in men in these cultures (Verma & Mahendra, 2004; Kilmartin, 2001; Courtenay, 2000).

One area of well-being where men tend to be particularly self-destructive is the area of mental health. In Western countries, males are formally diagnosed with depression at about half the rate of females (Kessler et al., 2005; Wilhelm, Parker, Geerligs, & Wedgwood, 2008). Symptoms often observed in men battling depression include anger, aggression, substance abuse, and risk-taking behaviors (Martin, Neighbors, & Griffith, 2013). Some suggest that lower male report rates may be due to diagnostic criteria not being crafted to account for depression in men (Winkler, Pjrek, & Kasper, 2006; Kilmartin, 2005; Winkler, Pjrek, & Heiden, 2004), while others recognize men’s reluctance to communicate concerns about their mental health and seek treatment (Emslie, Ridge, Ziebland, & Hunt, 2006; Winkler et al., 2006). And while women attempt suicide more often, successful suicide rates for men in the United States are significantly higher in all age categories, with suicide being the seventh-leading cause of death for all men in 2014, while not even registering in the top ten causes of death for all women that year (Centers for Disease Control and Prevention, 2014). In addition, men die from suicide at higher rates globally (WHO, 2014). The studies just reviewed challenge the suggestion of the reported data that men suffer from depression at lower rates than women. It is likely that suicide is more common among men—in part, because the rules of masculinity require men to act on problems, to eschew dependence on anyone else, and to avoid concern for their own emotions while at the same time making it difficult for them even to talk about their problems, much less seek help for them (Cohen, 2000; Courtenay, 2000).

Another form of self-destruction is the use of tobacco. The World Health Organization (WHO, 2010) reports that in all regions and in most countries, men smoke more than women by significant margins, although in a few countries, women use smokeless tobacco at higher rates than men. Youth smoking rates around the world tend to be more equal between the sexes. More men in the United States smoke than women, although that difference continues to shrink; Native Americans and Alaskan Natives have the highest levels of smoking, followed by Black and white Americans smoking at an intermediate level, and Hispanics and Asian Americans at even lower levels (Giovino, 2002). Advertisers worldwide have long used notions of masculinity (e.g., the Marlboro Man) to link smoking to masculinity, including self-assuredness, independence, and adventurousness (Cohen, 2000; Kaufman & Nichter, 2001; Nichter et al., 2009).

In addition to self-destructive behaviors, men tend to stay more silent than women when it comes to discussing their health, to preserve their image of masculinity (Gamble & Gamble, 2014), thus tending to neglect their individual health needs and concerns. As Courtenay (2000, p. 1390) notes:

Men's denial and disregard of physical discomfort, risk, and healthcare needs are all means of demonstrating difference from women, who are presumed to embody these “feminine” characteristics. These behaviours serve both as proof of men’s superiority over women and as proof of their ranking among “real” men. A man's success in adopting (socially feminised) health-promoting behaviour, like his failure to engage in (socially masculinised) physically risky behaviour, can undermine his ranking among men and relegate him to a subordinated status.

The results of this tendency include higher death rates in the United States for men by all 15 leading causes of death and men dying nearly seven years earlier than women, on average, in part because of their unwillingness to engage in behaviors linked to health and longevity and their higher levels of risky behavior (Courtenay, 2000). We idealize men as healthy, self-sufficient, and independent rather than concerned with self-health, illness, or injury (De Visser, 2009), and these notions of masculinity have negative impacts on the health of men, who fail to communicate health concerns or to seek help when needed. Men tend to die early because they wait longer to acknowledge that they are sick, take longer to ask for help, and do not comply with their doctors’ orders as well as women once they do seek treatment (Real, 2001; “Adolescent health: Boys matter too,” 2015).

Adding to issues of self-destructive and self-neglecting behaviors, males engage in higher levels of risky behavior, including heavy drinking (WHO, 2016a); driving that leads to car crashes (Hill & Fickling, 2010; “Road Traffic Injuries,” 2016); using drugs such as cannabis, cocaine, and amphetamines (UN Office on Drugs and Crime, 2015); owning firearms (“Women and Gun Ownership,” 2014), and drinking and driving (Kilmartin, 2001). Proving one’s manhood requires that males enact masculine strength, power, and disregard for danger (Capraro, 2000). Moreover, physical aggression may be the most attractive option to males because it is often a publicly visible option that is risky to enact and unlikely to be faked (Cohen & Vandello, 2001). And even when not public, physical aggression is an active, physical, and dangerous way to prove one’s manhood (Archer, 2004). When it comes to violence, males seem to be exceptionally vulnerable. Three out of four deaths in the age group 15–25 are attributable to violence between males, and males are five times as likely as females to be victims of homicide (Canada, 2000). In addition, more than 90% of those arrested for alcohol and drug abuse violations are men (Cohen, 2000).

Although the majority of research on masculinity and health points to the many ways that problematic ideals of masculinity affect the health of males, some research is beginning to point to notions of masculinity as a catalyst for positive male behaviors, such as a decrease in fat intake or reduced drinking (Sloan, Gough, & Conner, 2009). These behaviors can be a means of communicating a rational, decisive, and autonomous masculinity, wherein the male actively fights off illness while promoting his own health (Oliffe et al., 2010). Thus, we must be careful to avoid monolithic understandings of masculinity and health.

Females, Femininity, and Health

Just as the health of males is influenced by notions of gender, so too is the health of females. The “patterned, purposeful, structured social inequality by sex that constitutes gender contributes to women’s morbidity and mortality” (Landrine & Klonoff, 2001, p. 577). While biology certainly plays a role in women’s health because of the reproductive functions associated with their bodies, the devaluing of females and femaleness, which leads to much violence against females by males, also plays an important role in the complex relationships between women and health. Thus, discussions of general inequities in healthcare, reproductive health, depression and addiction, sex work and pornography, violence against women in the form of rape and forced prostitution, and domestic violence are fundamental to understanding the various intersections of femininity and health.

Biologically, women tend to live longer than men because of protections offered by the lack of testosterone at birth and the presence of estrogen later in life, though race, ethnicity, class, and citizenship also have impacts on life expectancy for women. North American women have an average life expectancy of 81.5 years, followed by European women at 80 years, Latin American and Caribbean women at 77.9 years, women in Oceana at 75.4 years, women in Asia at 73.4 years, and women in Africa at 59.6 years (Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, 2013). As averages, these numbers do not account for differences in life expectancy based on race, ethnicity, and social class, three markers that can reduce or raise life expectancy, in these countries. About 50% of the difference between male and female longevity can be attributed to biological advantages, while the other 50% is attributed to the sociological differences in male risk-taking discussed previously (Landrine & Klonoff, 2001). Some countries defy these longevity statistics for women, but those exceptions are often the result of biological advantages being “canceled out by their social worthlessness due to gender” (Landrine & Klonoff, 2001, p. 579).

Sex discrimination against women in healthcare begins at the most basic level—medical research. For example, although cardiovascular disease is the number one killer of women in the United States and is a disease that Black women are more likely to have and die from than their white peers (Go et al., 2010), only one-third of clinical trial subjects in this field are female and only 31% of trials that include women report outcomes by sex (Melloni et al., 2010). And although lung cancer is the leading cause of death among U.S. women (Centers for Disease Control and Prevention, 2010) and nonsmoking females are three times as likely to get it as nonsmoking males (Gorlova et al., 2006), again researchers often fail to analyze their data by sex (Donington & Colson, 2011). With regard to depression, even though major endocrine changes throughout a woman’s life have been directly linked to this disease, and even though research has shown that women metabolize drugs differently from men, fewer than 45% of animal studies on anxiety and depression use female lab animals (Johnson, Fitzgerald, Salganicoff, Wood, & Goldstein, 2014). And although two-thirds of U.S. citizens with Alzheimer’s disease are women, women living longer is likely the reason for this difference, rather than hormonal changes at menopause or sex differences in gene expression, which are most often cited as the reason for women’s higher rates for the disease (Johnson et al., 2014).

Sex discrimination against women in healthcare services is also prevalent and varies in severity and cause depending on country of origin. In developing countries, governments may simply choose to treat males before females (Landrine & Klonoff, 2001), while in developed countries such as the United States, women pay more for health insurance than men via a process called gender rating; many plans fully cover diseases that often occur in men (e.g., lung cancer), while not fully covering diseases that disproportionally affect females (e.g., breast cancer) (National Women’s Law Center, 2013). Class, race, and ethnicity in the United States affect levels of discrimination in the diagnosis and treatment of disease (LaViest, Rolley, & Diala, 2003; Meyer, 2003; Karlsen & Nazroo, 2002); this discrimination negatively affects the health of underserved citizens (Nelson, 2007; Williams & Williams-Morris, 2000).

Sex discrimination in health matters is crystalized in the currently available information on HIV and AIDS worldwide. Rates of HIV and AIDS are higher in places where the intersections of poverty, lack of education, political instability, and devaluation of female life are the most extreme (Levison & Levison, 2001). Almost 18 million women worldwide are HIV positive (WHO, 2016b). Moreover, a woman’s anatomy makes it more likely that she will contract HIV from heterosexual sex than a man, and the impacts on her body are usually more severe (Levison & Levison, 2001). Women involved in the sex industry and/or who are illegally trafficked and victims of rape in war-torn countries are especially vulnerable to infection. Moreover, because the expense of treatment is so high and access to treatment in many countries is so low, prevention is key to women’s lives. Nonetheless, because women are often subjected to the criminal sexual behavior of men (or even the common gendered notion that encourages male sexual conquest), a woman’s susceptibility to HIV/AIDS can be very dependent on the behavioral choices of men.

Reproductive healthcare is a primary concern of women around the world, with important regional variances affecting women’s reproductive health in different ways (Khan, Wojdyla, Say, Gülmezoglu, & Van Look, 2006). In developing nations, a third of pregnant women receive no healthcare during pregnancy, 60% of babies are delivered outside of health facilities, and only about 60% of deliveries are attended by healthcare staff (WHO, 2005, 2006). Rates of unsafe abortion are linked to the effectiveness of family planning programs, abortion legislation and its execution, and the availability and quality of abortion services (Glaser, Gülmezoglu, Schmid, Moerno, & Van Look, 2006). At the beginning of the 21st century, abortion in cases of rape and incest was prohibited in 101 of 145 developing countries, abortions were prohibited for fetal impairment in 108 countries and for economic or social reasons in 118 countries, and they also were prohibited in 65 countries even if they were needed to protect the health of the mother (WHO, 2004). In many countries, access to safe abortions is restricted, and in some of those countries, unsafe abortions are the cause of 30% of maternal deaths (Glaser et al., 2006). Of the 29 million unsafe abortions that take place every year, 97% happen in developing countries (WHO, 2004). In 2008, an estimated 47,000 deaths occurred due to unsafe abortions, with almost two-thirds of those deaths occurring in Africa. The same report notes that the number of deaths due to unsafe abortions in the United States was zero to negligible (WHO, 2011).

Sexually transmitted diseases are an additional concern for women globally. It is estimated that over one million sexually transmitted infections are acquired each day worldwide (WHO, 2016c). The WHO’s most recent report on sexually transmitted infections finds that in the African region, 5.1 million women have chlamydia, 4.4 million women have gonorrhea, 6.8 million women have syphilis, and 38.9 million women have trichomoniasis vaginalis. According to the same report, in the Americas region, 18.2 million women have chlamydia, 2 million women have gonorrhea, 3.1 million women have syphilis, and 52.7 million women have trichomoniasis vaginalis. In the South-East Asia region, there are 5 million women with chlamydia, 3.4 million women with gonorrhea, 6.1 women with syphilis, and 25.7 million women with trichomoniasis vaginalis. The European region reports these numbers as 8.7 million, 0.7 million, 0.2 million, and 13 million for these respective ailments, and the numbers for the Eastern Mediterranean region are 1.6 million, 0.5 million, 0.8 million, and 23 million for the same diseases. Finally, WHO reports these numbers in the Western Pacific Region as 20.5 million, 6.9 million, 0.6 million, and 27.2 million, respectively (WHO, 2008). Industrialized countries have substantially lower rates of sexually transmitted infections despite having sexual behaviors that are similar to the rest of the world (Slaymaker, Walker, Zaba, & Collumbien, 2004).

While depression is the disease that leads the world in health impact, it disproportionately affects women. In the United States, twice as many women as men are diagnosed with depression (WHO, 2012). Research links sex hormones to the development of regions in the brain that regulate mood and responses to stress, thus changes throughout a woman’s life (e.g., puberty, pregnancy, and menopause) are directly linked to an increased risk of depression (Johnson et al., 2014). In addition, depressed women tend to complain about fatigue, sleep disturbance, anxiety and pain and thus are misdiagnosed 30 to 50% of time with another illness (Johnson et al., 2014). Despite the greater risk of depression for women, studies in neuroscience, pharmacology, and physiology still have strong sex biases in favor of males (Johnson et al., 2014).

The greater rates of reported depression in women have an impact on addiction rates in women. Research supports the notion that girls and young women who are susceptible to depression and anxiety are at a particularly high risk of addiction (National Center on Addiction and Substance Abuse at Columbia University, 2003). Regardless of age, female alcoholics are twice as likely as nonalcoholic females to be depressed and almost four times more likely than male alcoholics to be depressed (National Center on Addiction and Substance Abuse at Columbia University, 2006). Globally, men are three times more likely than women to use cannabis, cocaine, or amphetamines, but women are more likely than men to misuse prescription drugs, particularly prescription opioids and tranquillizers (UN Office on Drugs and Crime, 2014a). Women may be less likely than men overall to develop drug-use disorders and dependence, but once they have begun to abuse substances, their rate of consumption of alcohol, cannabis, opioids, and cocaine increases more rapidly than men’s (Becker & Hu, 2008) and may progress more quickly to stages of addiction (Green, 2006). Globally, females who inject drugs are more likely than males to become infected with HIV (Pinkham, Stoicescu, & Meyers, 2012), perhaps because of the stigma associated with female drug use, which encourages women to be less careful with their injection practices (UN Office on Drugs and Crime., 2014b). Women with substance use disorders are less likely to enter treatment than their male counterparts, regardless of age, due to barriers that affect their access and entry to drug treatment (Greenfield et al., 2007).

The more negative experiences that a child has with abuse (physical, emotional, or sexual) and household dysfunction (e.g., having family members in prison, dealing with chronic or mental illness, or being victims of violence), the higher the child’s risk of smoking, drinking, and using drugs in adulthood (Felitti, 2002; UN Office on Drugs and Crime, 2014a). Teen girls who have been sexually victimized begin abusing substances earlier (nearly twice as many girls who began abusing substances before the age of 11 were victims of sexual abuse, compared to those with no history of sexual abuse), do so more often, and are more likely to have used sedatives, painkillers, and opiates at least once per month (National Center on Addiction and Substance Abuse at Columbia University, 2006).

The negative impact of abuse on females continues into womanhood. Women who have been sexually abused are more likely to drink, get drunk, experience alcohol-related problems and dependence, and abuse psychoactive prescription and illicit drugs (National Center on Addiction and Substance Abuse at Columbia University, 2006). The combination of sexual abuse, depression, and propensity for drug abuse in women plays an important role for a significant number of women in the sex industry. Studies show that prostitution is one of the most dangerous, if not the most dangerous, occupation in the United States and London (Ward & Day, 2006; Potteratl et al., 2004). There are links between general childhood victimization (Logan, Cole, & Leukefeld, 2003), childhood sexual victimization (El-Bassel, Witte, Wada, Gilbert, & Wallace, 2001; Molitor, Ruiz, Klausner, & MacFarland, 2000; Tyler, Hoyt, Whitbeck, & Cauce, 2001; West, Willams, & Siegel, 2000), and engagement in sex trading.

With the advent of the Internet, pornography has become a much more easily accessible area of the sex industry. Although research does not support a direct cause-and-effect relationship between males engaging in the viewing of pornographic films and sexual aggression (Seto, Maric, & Barbaree, 2001), the impacts of pornography do exist, especially with the emergence of easily accessible Internet pornography. A meta-analysis by Oddone-Paolucci, Genuis, and Violato (2000) notes that exposure to pornographic materials puts viewers at increased risk for sexual deviancy, sexual perpetration, difficulty in intimate relationships, and the acceptance of rape myths. In addition, Malamuth, Addison, and Koss (2000) concluded that there are reliable associations between frequent use of pornography use and sexual aggression and that the relationship was particularly strong when violent pornography is consumed and/or the men consuming are at high risk for sexual aggression. And as Manning (2006) notes, Allen, Emmers, Gebhardt, and Giery (1995) found that both violent and nonviolent pornography increase the acceptance of rape myths in men and women, a trend that likely decreases support for rape victims and discourages females from reporting the crime or offering social support to a victim. In addition to the impact on human perceptions of sex and sexual aggression, research indicates that Internet pornography has a negative impact on marriage and family relationships (Manning, 2006), with compulsive users reporting decreased sexual intimacy with their partner (Schneider, 2000) and men and women perceiving online sexual activity as being authentic and real as offline acts (Whitty, 2003).

A final area of investigation into the relationships between sex, gender, and health for females is violence against women in the forms of rape, female genital mutilation, forced prostitution/sex trafficking, and domestic violence. Common gender role expectations can create a climate where men feel entitled to sex and are rewarded for their sexual conquests, while women who enjoy sex on their own terms or who are sexually assaulted are stigmatized. Forced sexual contact can take place at any time during a woman’s life and includes a variety of behaviors, from forcible rape to nonphysical forms of pressure that compel women to engage in sex against their will (Heise, Ellsberg, & Gottmoeller, 2002). In some countries, sex in exchange for goods and services has become a norm for adolescent girls (Glaser et al., 2006) and sexual violence and harassment can become normalized in places such as schools in sub-Saharan Africa, where violence is perpetrated on females by peers and teachers, some of whom force sex on their female students in exchange for good grades (Wellesley Center for Research, 2008). A multicountry study by Garcia-Moreno, Jansen, Ellsberg, Heise, and Watts (2006) found that 15% to 71% of women experience physical or sexual violence in their lifetime, with two sites having a prevalence of less than 25%, seven between 25% and 50%, and six between 50% and 75%.

In spite of these statistics, the stigmatizing nature of rape, a number of rape myths, and shifting political contexts such as war, discourage the reporting of rape worldwide and, in some cases, even make it impossible to report. Global statistics are thus difficult to obtain. While there is a vast amount of data surrounding rape in Western cultures, less documentation occurs in societies where political and social structures do not support criminalization of sexual assault, or where “culturally established norms further devalue women’s experiences to such a degree that the lines between men’s dominant sexual rights and women’s subordinate ones are entrenched” (Parrott & Cummings, 2006, p. 93). Rape during war is not uncommon and, as Ojiambo Ochieng (2002, p. 2) notes, women’s bodies are the battleground on which the war is fought, as they become objects “over which warring factions demonstrate their power and control through rape and torture.”

In the United States, 1.1 people out of 1,000 were victims of rape/sexual assault in 2014 (Truman & Langton, 2015). Moreover, from 2005–2010 in the United States, 91% of all rapes and sexual assaults were perpetrated against women, and in those cases, 78% of the perpetrators were family members, intimate partners, friends, or acquaintances (Planty, Langton, Krebs, Berzofsky, & Smiley-McDonald, 2013). Marital or spousal rape statistics are also difficult to uncover because of general biases against reporting rape, but also because even in countries where it is illegal, the definition of marital or spousal rape can be difficult for some to understand, or it may be a part of larger efforts to control wives through a variety of types of violence. Some studies put the rate of marital/spousal rape at 8% to 10%, and it is understood that marital/spousal rape often will occur in marriages that also are physically abusive (Bennice & Resnick, 2003).

Another form of sexual violence against women is female genital mutilation (FGM), a practice affecting 2 million girls each year (Cook, Dickens, & Fathalla, 2002), usually before they reach 10 years of age (Glaser et al., 2006). The procedure varies slightly in its different forms of Sunna (often misnamed “female circumcision”), clitoridectomy, and genital cutting or FGM. The practice is most common in Africa, the Middle East, and Asia (WHO, 2017a). The clitoris may be removed to maintain a woman’s “purity” because it is believed that if she enjoys sex less, she is less likely to have it, or to, in effect, remove the “masculine” part of the woman’s body—that part that becomes erect during sexual excitement in the same way the penis does (WHO, 2017a). Common reasons noted for the practice include continuing cultural traditions and religious practices, preparing girls for marriage (Population Council, 2000), and controlling female sexuality (Rudman & Glick, 2008). Immediate issues with the procedure include shock, infection, damage to the urethra or anus, scar formation, tetanus, bladder infections, septicemia, HIV, and hepatitis B, while long-term complications can include chronic and recurrent urinary and pelvic infections that can lead to sterility, cysts and abscesses around the vulva, nerve pain, difficulty in urination, painful menstrual cycles and the pooling of blood in the abdomen, difficulty with labor and delivery, sexual dysfunction, depression, and death (WHO, 2017a).

Women around the world also must endure sexual slavery and forced prostitution/trafficking. Sexual enslavement can take many forms, including bonded labor, forced marriage, child labor, human trafficking, forced prostitution, sexual servitude, and traditional slavery (Hertzfeld, 2002). Although slavery affects men and women globally, some forms are sex-specific and focus on sexual behavior, and these forms disproportionately affect females. It is estimated that 800,000 people are trafficked across international borders each year, of which 80% are females and 50% are minors (Deshpande & Nour, 2013). In some countries, men believe (erroneously) that sex with a virgin will cure them of HIV/AIDS, and thus virgins are sold for particularly high prices (Kristof, 2006; Norland & Rubin, 2010).

Some forms of forced prostitution/slavery/trafficking are protected by religious and social structures around the world, and thus they are not considered slavery and forced prostitution (Parrott & Cummings, 2006). One such system is Trokosi, which is practiced in parts of Ghana, Togo, Benin, and Nigeria; estimates are that as there are as many as 20,000 or 30,000 slaves in these countries combined (Rinaudo, 2003; Aird, 2000). Under this system, when a crime is committed, a young female virgin from the family of the accused must be given to the local shrine priest to appease the gods of war, and these girls are expected to serve for their entire lives (Aird, 2000; Boaten, 2001). In India, the Devadasi system operates similarly and, though outlawed, is difficult to end because of its basis in religion. It is estimated that 15,000 girls are doomed to a life of slavery each year in this system, as they are sold to members of higher castes, symbolically “married” to God, and used at the will of their owners (Parrott & Cummings, 2006).

In the 1990s, most Tutsi women in Rwandi were murdered by radical Hutus in an infamous genocide, but some were kept to serve as sexual servants to the Hutu troops until after the war ended, and then they were banished to neighboring countries (Green, 2002). In a final example, from 1992–1995, thousands of women and girls were the victims of rape and physical abuse in rape camps and detention centers created during the conflict in Bosnia and Herzegovina; and in October 2002, the United Nations (UN) Mission in Bosnia and Herzegovina suspected that roughly 227 bars and nightclubs in Bosnia were participating in the trafficking of human beings (Human Rights Watch, 2002).

Forced prostitution/trafficking is a problem that faces both males and females globally, but females account for about 70% of people trafficked around the globe, with adult females accounting for roughly 49% of those trafficked and female children accounting for approximately 21% (UN Office on Drugs and Crime, 2014c). Women are trafficked as brides in some countries, including China, where the forced infanticide and feticide of females have left women in Vietnam vulnerable to people willing to sell them as brides to men in China (Quy Le, 2000). In addition, the Internet has made such “purchases” much easier to accomplish, with some men buying “brides” with the intention of forcing them into work in the sex industry (Hughes, 2000).

Sex industry work is very demanding physically and mentally on women; hence, issues of turnover and the need to replace those women who become physically and mentally ill encourage even more sex trafficking (Hughes, 2000). Female trafficking victims contend with a number of health risks associated with the practice. Some of these risks include increased HIV and other sexually transmitted diseases, disability, pregnancy (and forced abortions), injury, mental difficulties related to the social stigmas placed on them, social isolation, and cultural disgrace (Parrott & Cummings, 2006).

Gender, conflict, and domestic violence are the final areas of importance relative to understanding the impact of gender on the health of women. Domestic violence is often the result of patriarchal cultures that accept male dominance (Esquivel-Santoveña, Lambert, & Hamel, 2013). The extent to which the issue of domestic violence affects men and women is unclear, as the social stigma connected to a man reporting abuse by a woman, as well as the extent to which a woman can actually do physical harm to a man (who is generally bigger and stronger than she), may make it less likely for men to report abuse by an intimate partner. Approximately one in four men in the United States has been slapped, pushed, or shoved by an intimate partner in his lifetime, while nearly one in seven men has experienced severe physical violence by an intimate partner in his lifetime (Black et al., 2011). Future studies are needed in this area.

The impacts of domestic violence against women after the initial act of aggression are varied and can include substance abuse, psychiatric disorders, depression and suicide, high-risk sexual behavior, eating disorders, sexual dysfunction, reproductive problems, recurrent vaginal infection, and chronic pain (Landrine & Klonoff, 2001). Domestic violence is a worldwide epidemic. Between 4% and 54% of respondents reported physical or sexual partner violence, or both, in a single year. Men who were more controlling were more likely to be violent against their partners. In all but one setting, women were at far greater risk of physical or sexual violence by a partner than from violence by other people (Garcia-Moreno et al., 2006).

The battering of women has implications for healthcare and the high cost of health insurances in places like the United States, where battered women make up 22% to 35% of all women seeking emergency room treatment, 14% to 28% of all women seeking treatment in clinics, 24% of all women seeking prenatal care, 50% of all female psychiatric outpatients, and 64% of all women in psychiatric hospitals (Landrine & Klonoff, 2001). These rates are often even higher in developing nations (Landrine & Klonoff, 2001). For example, Papua New Guinea has reported that 66% of all married women have been beaten, while South Africa has reported a rate of 60% in the same category. Rates can be even higher in countries experiencing war or other significant conflicts (Landrine & Klonoff, 2001). Research has found that worldwide, 10% to 50% of women have been severely and repeatedly beaten by a male partner, and in up to two-thirds of those cases, the physical abuse is accompanied by rape (Population Reports, 1999).

Although the rate of battering worldwide (as well as the ancillary health issues that emerge from it) make it a worldwide health catastrophe, it is a problem that remains hidden in plain sight because of prevailing notions of gender that protect men from personal or public rebuke. Reasons, extents, and justifications for the large-scale battering of women differ based on cultural specifics and justifications for male dominance. As such, the cultural contexts of battering can differ, too. Acid attacks, bride burning, dowry death, sati (self-immolation by a widow who blames herself for not prolonging her husband’s life), and honor killings are less recognized means of battering that women endure across the globe (Parrott & Cummings, 2006).

Future Directions for Research on Sex, Gender, and Health

A number of consistent themes relating to the role of sex and gender identity for health persist over decades of research in this area, each of which is important for considering the design of strategic health and risk messages and for the processing of this form of communication. First, the basic research conducted in scientific labs continues to exclude female participants in many cases. In turn, this prejudice limits the content for accurate messages between women and their healthcare providers and thwarts the likelihood that campaign communication in public health arenas associated with issues, such as depression in women, will include valid content on which to base ameliorative messages. Second, and perhaps most problematic for health and risk message designers, is the neglect of policy and advocacy efforts associated with the implicit gendered expectations associated with biological sex and causes of poor health in men and women.

For men, these gendered expectations reside in exposures associated with living up to expectations of what it means to “be a man,” ranging from use of firearms to reckless driving to use of equipment and tools associated with traditionally male-dominated jobs; and this also includes exercising control in relationships with women in ways that harm both parties. For females, gendered expectations too often have a greater impact on their health than for males. In some cases, the health concerns of females are ignored in medical research and practice, and in other cases, gender roles assigned to women leave them vulnerable to higher rates of depression, violence, and sexually transmitted diseases, often as a result of the gendered behavior of males. Gendered expectations linked to femaleness affect the rate of deaths linked to childbirth, depression, and addiction, as well as sexual abuse ranging from intimate partner violence, to acquaintance rape, to the sex trafficking of women and girls worldwide. Moreover, the extent to which gendered expectations affect women’s health in these ways also plays an important role in rates of sexually transmitted diseases, including HIV and AIDS.

As was noted earlier, issues related to lesbian, gay, bisexual, and transgendered populations complicate our more traditional and binary understandings of sex and gender and thus deserve their own categories of investigation. Issues of doctor bias, depression and suicide, the impact of so-called conversion therapies, and higher rates of HIV and AIDS in some populations, as well as other issues important to these groups, need further study, and that research needs to recognize the distinct differences in issues related to sex and gender that affect these populations. Such research also could encourage redefinitions of our traditional and binary notions of sex and gender.

To achieve significant health gains and reduction of risk through communication, 21st-century message designers must consider the assumptions being made regarding sex and gender. In addition, these messages must understand that ideas about sex, gender, and health are very much affected by a number of important factors, such as race, class, and world/national region. The creators of health messages need an understanding of the importance of intersectionality when creating their messages. We need further research that distinctly categorizes health findings based on age, race, sex, socioeconomics, and region, but studies also must consider how these factors intersect to complicate health outcomes and health communication campaigns.

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