Structural Sexism and Health in the United States
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ASRXXX10.1177/0003122419848723American Sociological ReviewHoman 848723research-article2019 American Sociological Review 2019, Vol. 84(3) 486 –516 Structural Sexism and © American Sociological Association 2019 https://doi.org/10.1177/0003122419848723DOI: 10.1177/0003122419848723 Health in the United States: journals.sagepub.com/home/asr A New Perspective on Health Inequality and the Gender System Patricia Homana Abstract In this article, I build a new line of health inequality research that parallels the emerging structural racism literature. I develop theory and measurement for the concept of structural sexism and examine its relationship to health outcomes. Consistent with contemporary theories of gender as a multilevel social system, I conceptualize and measure structural sexism as systematic gender inequality at the macro level (U.S. state), meso level (marital dyad), and micro level (individual). I use U.S. state-level administrative data linked to geocoded data from the NLSY79, as well as measures of inter-spousal inequality and individual views on women’s roles as predictors of physical health outcomes in random-effects models for men and women. Results show that among women, exposure to more sexism at the macro and meso levels is associated with more chronic conditions, worse self-rated health, and worse physical functioning. Among men, macro-level structural sexism is also associated with worse health. However, greater meso-level structural sexism is associated with better health among men. At the micro level, internalized sexism is not related to physical health among either women or men. I close by outlining how future research on gender inequality and health can be furthered using a structural sexism perspective. Keywords structural sexism, gender, inequality, health “Gender is an institutionalized system of ways (Berkman, Kawachi, and Glymour social practices for constituting people as 2014). Much of our current understanding of two significantly different categories, men how social systems of inequality shape health and women, and organizing social relations is based on three broad strands of research: of inequality on the basis of that difference.” — Ridgeway and Correll (2004:510) aFlorida State University Social inequality in the United States is sick- ening. Literally. Individuals’ positions in Corresponding Author: social hierarchies as defined by race, class, Patricia Homan, Pepper Institute on Aging and Public Policy, Florida State University, 636 W. gender, and other axes of inequality can influ- Call Street, Tallahassee, FL 32306 ence their health and longevity in powerful Email: [email protected] Homan 487 (1) studies examining how directly perceived physical health outcomes among women, experiences of discrimination, mistreatment, including emotional distress, anxiety, depres- or low status in various social contexts influ- sion, headache, gastrointestinal symptoms, ence health; (2) studies of physician bias or and functional limitations (McDonald 2012; discrimination within medical institutions; Pavalko, Mossakowski, and Hamilton 2003; and (3) studies of the patterns/disparities in Swanson 1999). These studies provide a valu- health outcomes across social categories rep- able but incomplete picture of the effects of resenting relatively advantaged versus disad- systemic gender inequality on health, because vantaged statuses. the processes creating and reproducing In the case of gender inequality and health, unequal gender systems are often not per- these three lines of inquiry take the form of ceived or are not conceptualized as unfair or studies on the health consequences of sexual discriminatory (Fenstermaker Berk 1985; harassment or perceived gender discrimina- Ridgeway 2011; West and Zimmerman 1987). tion; investigations of how physicians and For example, in the labor market, gendered medical institutions fail to offer equitable, organizations and discriminatory practices unbiased, appropriate medical care for women; shape the allocation of women and men to and examinations of gender differences in various positions and compensation levels in health outcomes.1 Each approach is vital to our ways that are typically outside the awareness understanding of gender inequality and health, of individuals whose lives they affect (Acker but all have important limitations. As I will 1990; Correll, Benard, and Paik 2007; Rivera demonstrate, these three dominant approaches 2017; Rivera and Tilcsik 2016). Similarly, the to gender inequality and health leave unan- allocation of roles, responsibilities, and swered questions about how the broader struc- authority within marriage and family life in tural inequalities that characterize gender ways that systematically disadvantage women systems can potentially influence health. is often cast as simply a natural result of Therefore, I advance a structural sexism and inherent gender difference (Fenstermaker health perspective. This study contributes to Berk 1985; Ridgeway 2011) and thus goes this literature by developing concrete measures unnoticed. But regardless of individual aware- of structural sexism—defined as systematic ness, the degree to which a society distributes gender inequality in power and resources—at valued resources and opportunities in gender- the macro, meso, and micro levels of the gen- stratified ways, or otherwise unequally treats der system in the United States, and examining individuals along gender lines, may have a their relationships to the health of men and powerful influence on health (Krieger 2014). women in middle age. The second line of gender discrimination and health research examines bias among phy- sicians and medical institutions. This work GENDER DISCRIMINATION shows that women are less likely than men to AND HEALTH receive the most effective, advanced treatments The growing body of research on gender dis- and diagnostic procedures available for a vari- crimination and health consists largely of two ety of health conditions (Arber et al. 2006; types of studies documenting how women’s Chapman, Tashkin, and Pye 2001; McMurray health is harmed by discrimination: studies on et al. 1991; Raine 2000). Studies have also directly perceived discrimination or sexual found evidence of anti-woman gender bias in harassment (often measured in the work- medical education and textbooks (Alexander- place), and studies on gender bias in medical son, Wingren, and Rosdahl 1998; Andrikopou- institutions (Krieger 2014). The first line of lou et al. 2013) and in Medicaid reimbursement research links self-reported experiences of rates, which are roughly 30 percent lower for perceived gender discrimination and harass- female-specific (versus male-specific) surgical ment to a variety of negative mental and procedures (Benoit, Ma, and Upperman 2017). 488 American Sociological Review 84(3) This line of research uses multiple methods, explanations for patterns of difference.3 This including content analysis and audit studies, approach generally does not examine how allowing it to illuminate the ways gender dis- inequality in gender systems varies across crimination shapes health beyond individual social contexts in ways that may influence the perceptions. However, it is limited in scope, as health of both men and women (Schofield healthcare is only one of many factors that 2015), although recent scholarship has called contribute to health, and many people only for increased efforts to contextualize gender interact with medical institutions after they differences in health research (Read and become ill. Scholars and policymakers have Gorman 2010). increasingly recognized the primary impor- A more structural perspective that begins tance of social factors as determinants of health with the concept of gender as a social system (see Braveman, Egerter, and Williams 2011; of difference and inequality (rather than an U.S. Department of Health and Human Ser- individual attribute) might instead ask the vices 2010). The social conditions in which related, but distinct, question: How does the people live and work, and the social policies inequitable distribution of power and that shape them, have far greater impact on resources characterizing the gender structure population health than does medical care or of a society shape the health of its members? health policy (Bradley et al. 2016; House The existing research on gender differences in 2015). Thus, although the labor and healthcare health is invaluable for producing knowledge markets are key venues of gender discrimina- of who is and is not healthy, but it cannot tion, existing research in these domains cannot fully answer this question because exposure account for the myriad ways individual health to discriminatory gender structures remains may be affected through other social institu- largely unmeasured. Gaps between men and tions and processes that constitute a society’s women on health outcomes can provide clues gendered stratification system. about how a gender system works, but they do not provide all the information needed to understand how the degree of systematic gen- GENDER DIFFERENCES (GAPS) der inequality in power and resources—that IN HEALTH OUTCOMES is, structural sexism—to which individuals The most long-standing and influential tradi- are exposed shapes their health. tion of gender and health research examines To illustrate this point, Figure 1 shows three gender differences in health and mortality. different scenarios, depicting hypothetical This line of research, which began in earnest relationships