Both sex and gender strongly affect health status. Sex refers to the biological cat- egories of male and female to which we are assigned based on our chromosomal structure, genitalia, hormones, secondary sexual characteristics such as facial hair, and so on; those with two X chromosomes and a vagina are sexually female, and those with one X chromosome, one Y chromosome, and a penis are sexually male. (Later in this section, we will consider those who don’t fit neatly into these categories.) In contrast, gender refers to the social categories of masculine and feminine and to the social expectations regarding masculinity and femininity that we are expected to follow based on our assigned sex. Because these categories are social, they vary across time and across culture.

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Basic epidemiological data show that both sex and gender affect health. For example, before the 20th century, complications of pregnancy and childbirth often cut short women’s lives, so women died younger than men on average. These days, however, American women (regardless of race) live longer than men, even though the same diseases (including heart disease, cancer, and cerebrovascular disease) eventually kill most people. The differences between men’s and women’s life expectancies suggest that sex may directly affect health, but the changes in these differences across time suggest that gender affects health: Women now live longer than men not because their biology has changed, but because their social position has changed.

Mortality differences tell only part of the story. If we look only at life expec- tancy, we might conclude that women are biologically hardier than men. When we look at morbidity rates, however, the picture blurs. At each age, men have higher rates of mortality and fatal diseases, even though women have higher rates of mor- bidity and nonfatal disease. Ar- thritis, for example, is the most common chronic, nonfatal condition among both men and women older than age 45 years, but it strikes women around 50% more often than it does men. In addition, at each age, women experience a 20% to 30% greater incidence of acute conditions (not including health problems related to their reproductive systems). In sum, women live longer than men but experience more illness and disability, whereas men experience relatively little illness but die more quickly when illness strikes.

How can we explain these paradoxical findings? Some researchers have hy- pothesized that women’s higher rates of illness are more apparent than real—that women don’t actually experience more illness than men but simply label them- selves ill and seek health care more often. Most research, however, suggests that the health differences between men and women are rea. These differences stem from both the biological differences of sex and the socially reinforced differences of gender.

Sex does seem to offer females some biological health benefits. Around the globe, more females than males survive at every stage of life from fetus to old age as long as they receive adequate nutrition. Although the exact mechanisms through which this works are unknown, some theorize that estrogen and other “female” hormones (which, in fact, also occur in males but in lower proportions) somehow protect the heart and other organs from fatal disease.

Gender, too, protects women from fatal disease and injury. Most important is that female gender roles lead women to abuse alcohol less often than men, drive more safely, avoid dangerous sports, and so on. Women are also less likely than men to work in dangerous industries such as agriculture or commercial fishing. In ad- dition, women’s gender roles often bring them into routine contact with medical care, whether for themselves or for children or elderly parents. Finally, unlike men, who are socialized to downplay physical problems as signs of weakness, women are more comfortable seeking health care when they experience problems. As a result, women are more likely to have health problems identified and treated early enough to make a difference.