Gender differences in health: Are things really as simple as they seem?

Abstract

It is conventional wisdom in medical sociology and social epidemiology that in industrialized societies men die earlier than women, but that women have poorer health than men. A number of explanations for these differences have been postulated and tested (for example, different biological risks, acquired risks, reporting biases and experiences of health care). Using two recent British data sets we find that the pattern of sex differences in morbidity is more complicated than the conventional wisdom often suggests. The direction and magnitude of sex differences in health vary according to the particular symptom or condition in question and according to the phase of the life cycle. Female excess is only consistently found across the life span for psychological distress and is far less apparent, or reversed, for a number of physical symptoms and conditions. Detailed inspection of papers on gender differences published in the last decade reveals that our findings are not unique, but that a relatively undifferentiated model of consistent sex differences has nevertheless continued to predominate in the literature. We believe that the topic of gender differences in health warrants periodic re-examination.

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Vol. 42, No. 4, pp. 617-624, 1996
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GENDER DIFFERENCES IN HEALTH: ARE THINGS
REALLY AS SIMPLE AS THEY SEEM?
SALLY MACINTYRE, KATE HUNT and HELEN SWEETING
MRC Medical Sociology Unit, 6 Lilybank Gardens, Glasgow GI2 8RZ, Scotland
Abstract--It is conventional wisdom in medical sociology and social epidemiology that in industrialized
societies men die earlier than women, but that women have poorer health than men. A number of
explanations for these differences have been postulated and tested (for example, different biological risks,
acquired risks, reporting biases and experiences of health care). Using two recent British data sets we find
that the pattern of sex differences in morbidity is more complicated than the conventional wisdom often
suggests. The direction and magnitude of sex differences in health vary according to the particular
symptom or condition in question and according to the phase of the life cycle. Female excess is only
consistently found across the life span for psychological distress and is far less apparent, or reversed, for
a number of physical symptoms and conditions. Detailed inspection of papers on gender differences
published in the last decade reveals that our findings are not unique, but that a relatively undifferentiated
model of consistent sex differences has nevertheless continued to predominate in the literature. We believe
that the topic of gender differences in health warrants periodic re-examination.
Key words--gender
differences, morbidity, life course
INTRODUCTION
One of the most frequently made observations in
medical sociology or social epidemiology is that in
industrialized countries males tend to die earlier than
females but that females tend to have higher rates of
morbidity. The following quotations from the
authors of the present paper are typical of statements
commonly made about such differences:
It has consistently been reported from developed countries
that although male death rates are higher than women's at
all ages, women report more symptoms, disability days, use
of medications and contacts with the medical profession [1]
(p. 15).
The excess of female over male morbidity in adulthood has
been one of the most consistent findings in social science
research on health and illness [2] (p. 24).
Differences in morbidity between men and women are well
known ... females give poorer self evaluation of health,
show higher rates of acute illness, have more (but less severe)
chronic conditions, use more outpatient services and
consume greater amounts of both prescription and non
prescription drugs [3] (p. 77).
Very similar summary statements are found in
more general discussions of health. For example
At all ages women experienced, or were more ready to
describe, more illness and higher rates of psychosocial
malaise than men. This is, of course, an invariable finding
in health surveys [4] (p. 50).
As elsewhere, the findings showed that women reported
higher rates of illness at all ages [5] (p. 7).
They are also used to introduce many of the recent
articles which examine more specific aspects of gender
differences in health, such as amongst older ages
[6, 7], at younger ages [3], in developing countries [8],
amongst people with a specific diagnosis [9], when
seeking to pursue particular explanations for these
apparent differences, or when the focus is on struc-
tural inequalities amongst women [10, 11]. The exist-
ence of these gender differences in health is so taken
for granted in medical sociology and social epidemi-
ology that it has become
Standard good practice to present and analyse data separ-
ately for men and women.., this separate treatment of men
and women can become routinised to such an extent that all
curiosity about differences between men and women seems
to disappear [12] (p. 57).
But is the literature on gender differences in health
in the developed world really so clear cut? Can we
assume that gender differences described in one
decade and in one culture are generalizable to other
decades and other cultures? Is there any virtue in
further descriptive accounts of gender differences in
health, or should we be concentrating on expla-
nations for well-established differences? Our original
intention in preparing this paper was to further the
work on explanations for gender differences, in par-
ticular by examining the effect of role occupancy on
gender differences by controlling for social class,
domestic circumstances and age. However, in exam-
ining our own and other recent British data we were
struck not by the consistency of a female excess in
reported ill health, but by the lack of the predicted
female excess, and by the complexity and subtlety of
the pattern of gender differences across different
measures of health and across the life course.
For example, the British General Household Sur-
vey annually asks approximately 25,000 individuals a
617

618 Sally Macintyre
et al.
Table 1. Percentage of males and females reporting longstanding
illness by age group. British General Household Survey 1992
Age group
0~4 5~15 16~4 45~64 65-74 75+ Total
Males 15 19 23 42 60 64 31
Females I 0 18 24 43 58 67 33
Source: Thomas M., Goddard E., Hickman M. and Hunter P. (1994)
General Household Survey 1992.
Office of Population Censuses
and Surveys, HMSO, London.
range of questions, including some about health.
Although it is widely believed in Britain that this
shows a marked female excess of self-reported long-
standing and limiting longstanding illness [13], this is
not the case if one examines the data by age. Table 1,
for example, shows that in 1992 males were reported
as having more longstanding illness in early child-
hood, and that thereafter up to the age of 74 there
was little difference in reported prevalence between
males and females; it was only after 75 that there was
a female excess of more than 1%. Similarly, Table 2
shows, for the same year, a male excess of limiting
longstanding illness in childhood, and a small female
excess (of 3%) in only two age groups (16-44, the
childbearing years, and 75 plus). Given the very large
sample size of this study, such 3% differences in
reported prevalence may be
statistically
significant,
but it is doubtful whether Tables 1 and 2 can
legitimately be interpreted as showing a large, and
socially or biologically significant, consistent female
excess as is often described. (Table 3.1 in the 1992
GHS report shows rates by sex and age group since
1972, and although this demonstrates a rising preva-
lence over time in longstanding and limiting long-
standing illness, it does not show variation over time
in the male/female differences [14]).
In this paper we therefore address the question:
what is the direction and magnitude of gender differ-
ences in health, using a variety of measures of health,
at different points in the life course in contemporary
Britain?
DATA AND METHODS
We use two main data sources, the West of
Scotland Twenty-07 study (hereafter called Twenty-
07), and the Health and Lifestyles Survey (hereafter
called HALS).
The Twenty-07 study is a longitudinal study of
three age cohorts, aged 15, 35 and 55 when first
studied in 1987/8, resident in the Central Clydeside
Conurbation, a socially varied but mainly urban area
centred on Glasgow in the West of Scotland. The
initial sample sizes were around 1000 per cohort.
Participants are interviewed in their own homes by
nurses trained in interviewing techniques. A wide
range of measures of self-reported health, of physical
development and functioning, and of personal and
social circumstances, has been collected (for further
details see [15, 16, 17]). Thus far the youngest cohort
has been re-contacted for interview at 18, and by
postal survey at 16 and 21; the older two cohorts were
re-interviewed at 39 and 58.
HALS was a national survey of health and
lifestyles among adults in Britain, first undertaken in
1984/5. The achieved sample size was 9000 with an
age range from 18 upwards. Respondents were inter-
viewed in their own homes, using a similarly wide
range of measures of health and social circumstances
as the Twenty-07 study (though some of the measures
differ slightly between the two studies; for further
details see [18, 4]).
In this paper we present data from both studies to
check for the consistency (or otherwise) between
them in observed relationships between gender,
age and a variety of health measures. Because
the Twenty-07 study consists of three single age
cohorts twenty years apart, and the youngest subjects
in HALS are 18, we examine the Twenty-07 subjects
at the time of their second interviews (i.e. at 18,
39 and 58), and compare them with HALS subjects
in five year age groups (to get sufficient numbers)
as close as possible to the Twenty-07 cohorts, i.e.
18-22, 36-40 and 56-60. The numbers in the Twenty-
07 cohorts at these ages were: 430 males and
478 females in the youngest, 379 males and
473 emales in the middle, and 399 males and 459
females in the oldest cohort. The numbers in the three
HALS 'synthetic cohorts' were 364 males and 445
females in the youngest, 423 males and 548 females
in the middle, and 312 males and 367 females in the
oldest. In order to look in more detail at trends over
the life span, we have also looked at the HALS data
decade by decade (i.e. teenagers, twenties, thirties
etc.).
The measures we use are
• three general measures, namely, self-assessed
health, and the presence of longstanding illness, and
of limiting longstanding illness. HALS asked about
self-assessed health "for someone your age" (excel-
lent, good, fair or poor). The same measure is
available for the Twenty-07 cohorts.
• experience of a list of 18 symptoms in the last
month (these were headaches, sleep problems, con-
stipation, back trouble, nerves, colds/flu, persistent
cough, bladder/kidney problems, stiff/painful
joints, concentration difficulties, palpitations,
worrying over every little thing, indigestion,
sinus/catarrh/blocked nose, fainting/dizziness,
trouble with eyes, trouble with ears, always feeling
Table 2. Percentage of males and females reporting limiting long-
standing illness by age group. British General Household Survey
1992
Age group
0-4 5-15 16-44 45 64 65-74 75+ Total
Males 5 8 10 26 40 49 18
Females 2 7 13 26 38 52 20
Source: Thomas M., Goddard E., Hickman M. and Hunter P. (1994)
General Household Survey t992.
Office of Population Censuses
and
Surveys, HMSO, London.

Gender differences in health
Table 3. Percentage of men and women at 3 ages reporting (a) health as 'fair' or 'poor' for own age, (b) any
limiting longstanding illness. Twenty-07 Study and Health and Lifestyles Survey
619
longstanding illness and (c)
Twenty-07
Males Females
Age (%) (%) Sig.
Health and Lifestyles
Males Females
Age (%) (%) Sig.
Health 'fair' or 'poor" 18 35.9 43.6
39 20.1 24.1
58 33.1 29.5
Any longstanding illness 18 17.4 17.4
39 46.4 44.8
58 70.2 71.7
Limiting longstanding illness 18 10.7 11.9
39 29.3 30.9
58 53.1 50.3
18-22
28.8 34.0
36-40 19.7 20.7
56-60 35.3 37.1
18-22 19.2 14.6
36-40 21.7 22.4
56-60 46.0 40.5
18-22 8.0 7.0
36~0 8.7 9.3
56q50 25.9 27.2
*P < 0.05.
tired). Two sub scales were devised, one of 'malaise'
symptoms (sleep problems, concentration
difficulties, nerves, worrying over every little thing,
always tired), and the second of 'physical, symp-
toms (constipation, colds/flu, bladder/kidney prob-
lems, stiff/painful joints, sinus/catarrh/blocked
nose, trouble with eyes, trouble with ears). We are
well aware that making this distinction between
'malaise' and 'physical' symptoms is necessarily
somewhat arbitrary. Sleep problems or always feel-
ing tired could, for example, result from pain or
discomfort arising from physical disorders, and
those who are depressed or anxious might report a
higher prevalence of 'physical' symptoms. [For a
discussion of these categorizations from the HALS
data see [4] (p. 48), [19] (p. 116) and [20] (p. 657)].
• lists of chronic or episodic conditions. In the
Twenty-07 study subjects were asked to say whether
they were
currently
experiencing each of a list of
conditions (sixteen conditions at the age of 18, and
thirty five at the ages of 39 and 58). In HALS,
subjects were asked whether they had
ever
experi-
enced a list of eighteen conditions. The conditions
which were directly comparable in the two studies
and at all ages were asthma, bronchitis, diabetes,
heart trouble, high blood pressure, migraine,
epilepsy, heart trouble, arthritis/rheumatism,
cancer and stomach or other digestive disorders.
RESULTS
We first present results for the measures of general
health. As Table 3 shows, although in both studies
the proportions reporting their health as being 'fair'
or 'poor' for their age are higher among women in
most age groups, these differences do not reach
statistical significance except among the 18 year olds
in Twenty-07. There were no significant gender differ-
ences in the percentages reporting any longstanding
nor any limiting longstanding illness at any age for
either study.
Turning now to the experience of particular symp-
toms in the past month, as Table 4 demonstrates, if
we simply compare mean number of symptoms, we
find that in both data sets there is a consistent and
significant female excess at all ages examined. How-
ever, when the symptoms are categorized as either
'malaise' or 'physical' a different picture emerges: a
female excess in total 'malaise' symptoms at all ages
in both studies (P < 0.001), but in 'physical' symp-
toms only at 39 years in Twenty-07 (P < 0.05) and at
56-60 years in HALS (P < 0.001).
This is demonstrated in more detail in Table 5
which shows the patterns of sex differences for each
of the 18 symptoms reported. 'Worrying', 'nerves',
'always tired', 'headaches', 'constipation' and 'faint-
ing or dizziness' show the most consistent female
excess, followed by 'difficulty concentrating', 'sleep-
ing problems' and 'bladder or kidney problems'. Two
symptoms show a significant female excess in only
one stud2~ at a single age: 'sickness, nausea or
stomach trouble' (among 18 year olds in Twenty-07)
and 'trouble with eyes' (among 56-60 year olds in
HALS). In contrast, two symptoms, 'palpitations'
and 'trouble with ears' show a male excess among 58
year olds in Twenty-07, while in both studies the
Table 4. Mean number of symptoms reported at 3 ages. Twenty-07 Study and Health and Lifestyles Survey
Twenty-07 Health and Lifestyles
Males
Females Males Females
Age (%) (%) Sig. Age (%) (%) Sig.
All symptoms 18 2.80 3.56 *** 18-22 1.98 2.64 ***
39 2.07 2.62 *** 36~0 2.04 2.81 ***
58 2.77 3.40 *** 56-60 2.61 3.86 ***
"Malaise' symptoms 18 0.72 1.02 *** 18-22 1.06 1.30 ***
39 0.65 0.92 *** 36-40 0.56 1.02 ***
58 0.80 1.16 *** 56-60 0.73 1.30 ***
"Physical' symptoms 18 1.33 1.43 18-22 1.02 1.09
39 0.69 0.83 * 36-40 0.88 0.95
58 1.09 1.17 56-60 1~07 1.42 ***
***P < 0.001: *P <0.05.

620 Sally
Macintyre
et
al.
excess reporting 'stiff or painful joints' shifts from
males at younger ages to females at older ages. Finally,
'back trouble', 'colds or flu', 'sinus, catarrh or blocked
nose' and 'persistent cough' show no significant gender
differences at any age in either study.
Finally, we present results in respect of chronic or
episodic conditions reported as being
currently
(Twenty-07) or
ever
(HALS) experienced. Since it is
harder to make a direct comparison between the two
studies, and more complicated to present the data
than it is for symptoms, they are shown separately.
The general pattern of results is, however, similar. As
Table 6 demonstrates, in Twenty-07 only one current
condition (migraine) shows a consistent female ex-
cess, while six (respiratory disorders, diabetes, hernia,
epilepsy, cancer and high blood pressure) show no sex
differences at any age. Arthritis or rheumatism was
much more common among females in the oldest
cohort though no sex differences are apparent at
younger ages, and asthma was more common
among males in the youngest cohort only. Digestive
problems showed the most complicated pattern, with
a female excess at 18, a male excess at 39 and no sex
differences at 58.
Table 5. Patterns of sex differences for 'malaise' and 'physical' symptoms reported at 3 ages. Twenty-07 Study and Health and Lifestyles
Survey
Twenty-07 Health and Lifestyles
Males Females Males Females
Age
(%) (%) Sig. Age (%) (%) Sig.
'Malaise'
symptoms
Worrying
18 8.4 18.8 *** 18-22 13.7 24.3 ***
39 7.4 14.8 ** 3~40 10.2 24.8 ***
58 10.8 20.7 *** 56-60 16.2 30,7 ***
Nerves
18 6.8 12.6 ** 18-22 6.3 10.6 *
39 13,2 21.1 ** 36-40 2,8 11.9 ***
58 15.8 22.7 * 56-60 8.3 16.3 **
Difficulty concentrating
18 13.0 14.2 18-22 11.5 12,4
39 7.4 12.5 * 36~0 9.0 15,0 **
58 9.5 13.7 5~60 9.3 18.2 **
Always tired 18 23.5 33.3 ** 18-22 20.9 32.6 ***
39 15.0 22.6 ** 3~40 18.4 31.2 ***
58 20.6 23. I 56~0 19.5 26.6 *
Sleeping problems
18 20.9 22.8 18-22 16.5 23.1 *
39 21.6 20.5 36-40 16.5 19.0
58 23. l 35.5 *** 5~60 19.2 37.8 ***
'Physical"
symptoms
Headaches
18 26~3 45.4 *** 18-22 24.7 40,0 ***
39 25.9 43.3 *** 3~40 26.5 38.7 ***
58 17.3 33.1 *** 56~50 17.6 31.5 ***
Constipation
18 0.9 I 1.1 *** 18-22 3.6 9.2 **
39 3.2 14.2 *** 36-40 2,4 10.4 ***
58 6.8 11.5 * 56-60 3.8 12.8 ***
Fainting or dizziness
18 4.9 10.9 ** 18-22 5.5 10.1 *
39 2.1 6.1 ** 36-40 1.7 7.3 ***
58 5,8 8.3 56-60 6.7 8.4
Bladder or kidney problems
18 0.0 3.1 *** 18 22 0.8 4.7 **
39 1.8 5.1 * 36-40 1.7 2.9
58 8.0 7.8 56-60 3.8 5.2
Sickness/nausea/stomach trouble
18 13.7 24. I *** 18-22 9.6 9.7
39 3.2 4.2 36-40 17.7 14.6
58 3.0 5,4 56-60 19.8 20.4
Trouble with eyes
18 13.5 15.7 18-22 1 I. 0 14,8
39 8.7 5.9 3(r40 9.0 11.3
58 I 0.0 9.8 56-60 9.9 22.3 ***
Palpitations
18 4.7 6.9 18-22 5,8 6.1
39 5.5 7.8 36-40 6.9 8.8
58 16.8 11.8 * 56~50 18.8 21.7
Trouble with ears
18 7.7 10.0 18 22 5.2 5.8
39 6,6 7.0 36~0 6.4 5.7
58 16.5 9.6 ** 56-60 12.5 t3.0
Stiff/painful joints
18 28.1 20,5 ** 18-22 9.1 6.5
39 16.6 16.3 36-40 13.7 15.0
58 33.8 43.1 ** 56-60 31.6 39. I *
Back trouble 18 15.6 15.9 18-22 12.4 14.2
39 20.3 17.8 36-40 15.6 18.1
58 20.3 25.5 56-60 18.8 24.5
Colds or ttu
18 45.0 48.1 18 22 43.1 45.2
39 14.2 15.9 36-40 34.0 30.3
58 14.8 14.2 56-60 31.3 29.6
Sinus, catarrh/blocked nose
18 37.5 34.3 18-22 21.2 16.0
39 17.9 18.4 36-40 21.3 19.7
58 19.3 20.7 56-60 14.1 19.8
Persistent cough
18 9.1 11.1 18 22 8.0 10.3
39 6.9 5.5 36-40 8.3 8,8
58 12.0 10.0 56-60 12.1 12.8
Significance of male-female difference,
*P < 0.05, **P < 0.01, ***P < 0.001.

Gender differences in health 621
Table 7 shows the patterns of sex differences in 17
of the 18 conditions (lung cancer is excluded because
of small numbers) ever experienced among HALS
subjects, using the full eight decades covered by HALS
rather than just the three synthetic cohorts created
for direct comparison with Twenty-07, since this gives
a better purchase on changes over the life course.
However, it must be noted that the numbers become
smaller in the older age groups, and that the effect of
selective mortality is likely to be greater with increasing
age; we are, of course, by definition looking at non-
fatal morbidity. Given the number of comparisons
made here, we comment only on differences that are
statistically significant at P < 0.01 or less (although
differences at 0.05 < P < 0.01 are marked in the table).
Only six out of the seventeen conditions (depression
or nerves, varicose veins, high blood pressure,
migraine, piles or haemorrhoids, and cancer) show
a female excess at all or most ages and very few of
the differences are significant for cancer. Another six
(bronchitis, other chest problems, diabetes, liver
trouble, epilepsy and stroke) show no significant sex
differences at any age. As in Twenty-07, rheumatism
or arthritis is more common in older females, and
asthma in younger men, while three conditions
(digestive disorders, back trouble and heart trouble)
show a more complicated pattern. The heart disease
patterns are particularly difficult to interpret since
this is a leading cause of death, and we are dealing
here with reported non-fatal events in survivors.
DISCUSSION
Although like many other medical sociologists all
three authors of this paper are on record as stating as
a matter of known fact that females consistently
Table 6. Patterns of sex differences for conditions
currently
experi-
enced, reported at 3 ages. Twenty-07 Study
Age
18 39 58
Female excess at all ages
Migraine m 5.6 6.1 2.5
f 10.0* 13.3"* 9.6***
No sex differences at an), age
Respiratory disorders m 2.6 4.0 I 1.3
f 2.9 4.0 8.7 '
Diabetes m 0.2 0.8 3.0
f 0.4 0.4 2.4
Hernia m 0.5 1.1 2.5
f 0.4 1.9 5.0
Epilepsy m 0.7 1.3 1.5
f 0.4 0.8 1.7
Cancer
m 0.0 0.5 1.8
f 0.2 2.1 3.3
High blood pressure m 0.2 4.0 16.5
f 1.5 3.8 17.4
Variable gender differences
Arthritis/rheumatism m 1.6 5.0 22.6
f 2.3 7.2 39.4***
Asthma m 8.4* 2.6 3.3
f 4.8 4.4 3.3
Stomach trouble, ulcers m 2.8 10.8"* 13.8
or
gastric problems f 5.9* 4.9 10.7
Significantly greater proportion, *P < 0.05, **P < 0.01,
***P < 0.001.
report higher levels of ill health than men, we have
found on more detailed inspection of two recent
British data sets that the pattern is in fact more
complicated than this. The direction and magnitude
of sex differences in health vary according to the
particular symptom or condition in question, and
according to the phase of the life cycle. Female excess
is only consistently found across the life span for the
more psychological manifestations of distress, and is
far less apparent, or reversed, for a number of
physical symptoms and conditions.
This finding might not surprise members of the
general public, or clinicians dealing wit!l more specific
diseases, who might expect sex differences in exposure
to health risks to vary between different types of risk
and between different parts of the life cycle, problems
relating to reproduction to show a female excess in
the childbearing years, and hormonal differences to
show different effects before and after the menopause.
What is perhaps surprising is the predominance for so
long within medical sociology and social epidemiol-
ogy of a relatively undifferentiated model of sex
differences, with the hypothesis of female over-
reporting or willingness to accept the sick role usually
being assumed to apply across most or all conditions.
We wish to suggest that, even when one focuses on
commonly used measures (such as self-assessed
health, aspects of mental health, or use of health
services), the "story' about gender differences in
health as presented in much recent sociological and
epidemiological literature has become oversimplified,
and that over-generalization has become the norm,
with inconsistencies and complexities in patterns of
gender differences in health being overlooked. In the
face of an apparently clear pattern, there has been a
tendency to downplay (or maybe not even report)
data that conflict with rather than confirm the general
pattern (thus fitting Thomas Kuhn's model of scien-
tific development, in which anomalies can be accom-
modated for a considerable period of time without
disturbing the dominant scientific paradigm [21]).
We do not deny that there is substantial evidence
of gender differences in a wide range of health
outcomes during much of adult life in industrialized
countries. Verbrugge, for example, has reported that
of 67 different measures of health status and be-
haviour amongst a sample of white adults in Detroit,
U.S.A., 60 demonstrated higher morbidity and health
care use among women (P < 0.10), with 42 of these
differences significant at conventional levels of signifi-
cance (P < 0.05). One of those to show a difference
was self-ratings of health, with women rating their
health as poorer than men's [22] (p. 286). Haavio-
Manila has reported a female excess of longstanding
illness and anxiety in Denmark, Norway and
Sweden [23], and Wingard
et al.
have reported a
female excess of functional disability and heart dis-
ease morbidity among the Alameda County popu-
lation in California [24]. Such findings fit the
conventional wisdom. However, inspection of other

622 Sally Macintyre
et al.
Table 7. Patterns of sex differences for conditions
eoer
experienced, reported decade by decade (> 20 to 80 +). Health and Lifestyles Survey
Age 18-19 20-29 30-39 40-49 50-59 604/9 70-79 80-89
m 153 743 772 649 591 542 367 83
No. respondents f 159 935 1056 848 748 738 446 153
Female excess at all/most ages
Depression/nerves m 3.9 9.0 8.8 13.9 17.1 12.2 15.3 14.5
f 9.4 14.9"** 21.8"** 27.7*** 27.0*** 26.0*** 19.3 22.2
Varicose veins m 1.3 1.1 3.8 10.2 12.7 18.5 22.3 15.7
f 0.6 5.8*** 17.2"** 26.5*** 31.6"** 29.7*** 30.3* 25.5
High blood pressure m 0.7 2.6 5.3 8.9 17.4 23.6 21.5 14.5
f 4.4 13.0"** 16.4"** 15.2"** 22.1" 22.2 30.7** 27.5*
Migraine m 21.6 12.8 16.3 16.0 14.4 11.6 7.9 7.2
f 22.6 22.6*** 25.6*** 27.7*** 30.3*** 24.1"** 20.4*** 15.7
Piles/haemorrhoids m 0.7 6.7 14.0 21.4 22.2 28.2 25.1 13.3
f 1.3 17.3"** 30.4*** 31.4"** 29.5** 27.5 26.0 22.9
Cancer (excluding lung) m 0.0 0.0 0.5 0.5 1.0 2.6 1.9 2.4
f 0.0 0.5 2.2** 1.7 3.6** 4.9 4.3 7.8
No sex differences at any age
Bronchitis m 5.9 4.8 8.5 8.2 12.7 17.5 20.7 19.3
f 4.4 6.5 6.0 I 1.0 13.0 16.7 19.3 17.0
Other chest problems m 11.8 13.2 16.7 18.8 17.9 21.8 22.1 18.1
f 15.1 10.7 15.6 16.6 18.4 22.2 17.1 17.0
Diabetes m 0.0 1.1 0.3 t.2 4.6 3.9 3.5 8.4
f 1.3 0.6 0.7 1.3 2.1" 2.7 3.1 3.9
Liver trouble m 1.3 1.6 2.2 3.4 3.0 3.5 3.5 3.6
f 0.6 1.6 2.2 2.7 3.3 3.1 2.7 2.6
Epilepsy m 0.0 1.7 1.3 1.5 0.8 0.7 0.5 1.2
f 1.3 1.9 2.0 1.7 1.9 0.9 1.3 0.7
Stroke m 0.0 0.0 0.3 1.1 1.9 3.0 7.4 7.2
f 0.0 0.1 0.7 0.4 0.9 1.8 4.7 3.3
Variable gender differences
Rheumatism/arthritis m 2.0 5.5 10.0 20.0 27.1 37.8 38.1 43.4
f 4.4 5.0 13.8 24.8* 41.2"** 52.3*** 60.8*** 68.6***
Asthma m 12.4 9.3** 6.3 6.3 4.6 5.2 4.6 4.8
f 6.9 5.3 4.9 5.0 5.9 4.3 5.6 2.0
Digestive disorders m 7.2 19.1"** 21.2"** 22.0 27.2 28.6 34.3 31.3
f 13.8 11.8 13.8 21.2 22.6 29.4 26.9* 28.8
Back trouble m 21.6 25.7 35.6* 41.9 48.4 38.6 38.7 37.3
f 15.l 24.3 31.1 39.3 46.5 44.3* 46.2* 46.4
Heart trouble m 3.3 0.5 2.6 3.2 12.0" 19.7"** 20.7 19.3
f 0.6 1.9" 2.7 3.5 8.4 11.7 18.4 22.2
Significantly greater proportion, *P < 0.05, **P < 0.01, ***P < 0.001.
research during the last decade reveals much that
does not fit the dominant paradigm, and much that
is consistent with our own data.
For example, Verbrugge has pointed out that the
'paradox' of females reporting more illness and males
dying earlier seems less paradoxical when one exam-
ines specific conditions; men have an excess of serious
disability and disease, i.e. of the sort of conditions
which might shorten life, while women's excess tends
to be in symptoms and less serious conditions [25, 22].
Haavio-Manila found no female excess in Finland for
longstanding illness, anxiety or restricted activity due
to illness [23], and a study of the elderly in the U.S.A.
found no sex differences in the number of chronic
conditions reported, diabetes, or cardiovascular mor-
bidity [26]. A study in Winnipeg, Canada, found no
significant gender differences in a wide range of
measures, including self-reported past and present
health status, days off work because of sickness, and
attitudes to health. Although the authors of this study
described this apparent lack of gender differences as
being "paradoxical" [27] (p. 584), they did not seem
to regard it as challenging the rationale of their paper,
which was "to move the level of discourse from
description toward an explanation of sex/gender
differences" [27] (p. 579).
Even when very broad statements about gender
differences in morbidity are qualified, it is often
assumed that these qualifications do not apply to
mental health and symptom reporting. However,
mental health problems show a more complex picture
than is sometimes suggested. While women are more
often diagnosed as having neuroses, affective psy-
choses, and vague mental disorders, men are more
often diagnosed as having schizophrenia, personality
disorders, alcoholism and vague psychosomatic
disorders [28, 23].
One frequently cited explanation for apparently
higher rates of morbidity among females is that they
are more sensitive than men to bodily discomforts,
and more willing to report symptoms of distress and
illness. Yet the evidence, though limited, is conflict-
ing. One study, of mildly hypertensive patients
treated by beta adrenoceptor blocking agents, re-
ported marked gender differences in health appraisal
and symptom perceptions [9]. However, other studies
have found that when one controls for specific con-
ditions, either there are no sex differences in pain or
symptom reporting, or that men are more likely to
complain. Among people with cancer of the colon or
rectum, women were no more likely than men to
recognize and respond to cancer symptoms, and were

Gender differences in health 623
actually more likely than men to delay seeking care
[29]. Among people with X-ray evidence of osteoar-
thritis, men were more likely to report pain than
women, independently of severity of disease and of
treatment behaviour; among those with no X-ray
evidence of osteoarthritis there was no difference in
symptom reporting [30]. Among volunteers attending
a common cold research unit in England, whose signs
and symptoms of colds were monitored on a daily
basis by the subjects and a clinical observer, men were
more likely than women to over-rate the severity of
their condition compared with the rating of the
observer [1, 31].
There is a widely accepted belief that women use
health services, particularly mental health services,
more than men. Haavio-Manila has, however, re-
ported that while women had higher psychiatric
admission rates than men in Norway, in Finland and
Sweden men had higher rates [23]. Leaf and Bruce
showed that in New Haven, U.S.A., although women
were more likely to consult a physician about mental
health related problems in the
general
medical sector,
there were no differences in the use of mental health
specialty
services. They point out that many previous
studies of service use have been selective in the mental
health services they have chosen to include, and
suggest that "by not including the full range of
potential sites for mental health treatment, prior
research may have overestimated the extent to which
women use more services than men" [32] (p. 172).
They argue that the issue of women's generally
greater use of health services "warrants periodic
re-examination because changes in the funding
and/or organization of mental health service may
affect patterns of use" [32] (p. 171).
We suggest that, given the data we have presented
above which indicate that the picture of 'female
excess' in ill health is more complex than it is
sometimes described, the whole topic of gender differ-
ences in health warrants periodic re-examination. The
research which has accumulated over the last decade
or so seems increasingly to support the view that
gender differences in health are rooted in social roles,
against the backdrop of some male biological disad-
vantages [25]. There have been many changes in
gender roles in the last few decades, and some of these
may produce changes in men's and women's experi-
ences of health and illness; but the predominance of
the 'women's higher morbidity' paradigm may have
prevented people from noticing the 'anomalies', such
as those cited above, which might provide evidence
about the consequences of such changes.
How can we account for the fact that our data
show a more complex picture of gender differences,
and a picture of less consistent female excess in
illness, than is often suggested in the literature? One
possibility is that female/male differences in health
have changed over time (in the same way that
male/female differences in life expectancy may have
changed over time [12]), so that whereas there was
once a female excess, there is now less of one.
Certainly in Finland women's excess reporting of
restricted activity declined between 1964 and 1976
[23], and in the U.S.A. women's excess of reported
chronic conditions decreased between 1957 and 1972
[33]. There have been changes in the participation of
men and women in education, employment, recre-
ation and domestic life, and although it seems un-
likely that changes in the gendered allocation of roles
in Britain have already been sufficiently widespread to
alter the expected pattern across all three age groups,
it would be interesting to explore the ways in which
gender differences in health vary across different his-
torical periods and social settings within Britain.
Another possibility is that self-reported illness rates
do not differ as much between men and women in
Britain as they do elsewhere, but the data from
Finland, the U.S.A. and Canada [23, 26, 27] suggest
that our findings are not unique to Britain. Again, it
would be interesting systematically to examine health
survey findings from different societies; for example,
from northern, southern and eastern Europe, north
and south America, and various African and Asian
cultures. Gender differences in health may vary, as do
gender differences in life expectancy [12], between
societies at different stages of economic and industrial
development and with differing religious or cultural
attitudes towards appropriate gender roles. There are
likely to be differences between more and less devel-
oped countries, given that in the latter health is still
threatened by infectious disease and by unregulated
environmental and occupational exposures, and the
penalties of reproduction are higher because of press-
ures towards early and repeated childbearing [34, 35];
there are also likely to be differences between devel-
oped countries depending on labour market and other
conditions, as shown for the Nordic countries [23].
Thus, in conclusion, we support those who have
argued that summarizing the morbidity experiences
of men and women is "'exceedingly difficult" [36, 2],
and those who have shown that gender differences in
health vary by age, morbidity measure, and social
context [23, 24, 33]. Despite their arguments and find-
ings, the picture of near universal female excess
morbidity has tended to persist in the general litera-
ture, taking on the characteristics of a dominant
scientific paradigm with anomalous or inconsistent
findings not being noticed or seriously discussed [21].
(Indeed when an earlier version of this paper was
presented at the 1994 European Medical Sociology
conference in Vienna, several listeners afterwards told
us that they had not found the 'expected' gender
differences in self-reported health in their surveys, but
had never drawn attention to this because they
assumed it was due to a peculiarity in their sample or
social setting, or to some other 'anomalous' circum-
stance.) We believe that if we are to make progress
towards understanding the processes (whether social,
psychological or biological) which produce or main-
tain gender differences in health, it is important to

624 Sally Macintyre
et al.
pay attention to the social and historical context of our
observations, and to take a more differentiated age-
specific and condition-specific view of 'health' when
examining differences between the sexes. This is not a
new recommendation [23, 24, 33] but seems worth
repeating since previous suggestions to this effect do
not seem to have had much impact on the general
medical sociological or epidemiological literature.
Acknowledgements--The
authors are employed by the
Medical Research Council of Great Britain. They gratefully
acknowledge all those involved in the Twenty-07 data (the
participants, the interviewers, Barbara Jamieson, the survey
manager, Lindsay Macaulay and Patricia Fisher). Thanks
also to Graeme Ford and Patrick West who supplied some
of the Twenty-07 data included here, and to the HALS
survey team who deposited their data with the ESRC Data
Archive at Essex. Thanks are also due to Carol Emslie,
Graeme Ford and Anne Ellaway for comments on an earlier
draft, and to those who provided comments when an earlier
version of the paper was presented at the ISA 1994 confer-
ence in Bielefeld and ESMS 1994 conference in Vienna. The
authors alone are responsible for the views expressed in this
paper.
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