BBH 302- L9

Unique Challenges to Health in Men and Women

*Physical Activity and Inactivity* Data from the 2015 National Health Interview Survey show that more men than women reported higher levels of *leisure time physical activity* that included aerobic activity and muscle conditioning (25.3% vs. 17.9%). More women than men reported being *sedentary* or inactive (31.7% vs. 28.9%). This is also true for *female high school students*, based on 2015 data from the Youth Risk Behavior Surveillance (YRBS). Despite higher levels of physical activity, which is protective of a number of poor health outcomes, men are burdened by more chronic diseases than women at most ages. *Injury and Risky Behaviors* Researchers attribute a number of explanations to the differences in mortality between men and women. Although men and women share the first two leading causes of death (cardiovascular diseases and cancer), deaths from unintentional injuries were almost 75% higher in men than in women in 2015. This could partially be explained by higher risk-taking behaviors that are evident in males as young as teenage years, which may explain why substance use and motor vehicle-related injuries are higher in men. Data from the 2015 YRBS show that more male than female high school students (1) carried a weapon, (2) were in a physical fight, and (3) rarely wore a seatbelt. Men also experience fatal occupational injuries at a substantially higher rate than women, which is a unique exposure that may account for the higher level of death from unintentional injuries. *HIV/AIDS* Men bear the greatest burden of HIV in the U.S. Data from UNAIDS showed that women bear the greatest burden in countries in which transmission is primarily through heterosexual contact. In the U.S., the primary mode of transmission is through male-to-male sexual contact (Figure 7). However, sexual risk appears to be greater for adolescent females than males. Data from the 2015 YRBS showed that although adolescent males (43.2%) were slightly more likely than females (39.2%) to have ever had sexual intercourse, more females (48%) than males (38.5%) reported not using a condom during the last sexual experience. Furthermore, more than 3 times the rate of adolescent females than males reported ever being forced to have sex (10.3% vs. 3.1%). FIGURE 7: Diagnoses of HIV Infection among Adults and Adolescents, by Transmission Category, 2016 Source: CDC. Epidemiology of HIV Infection, 2016 The UNAIDS lists several* potential causes for the sex differences in HIV in most part of the world*, where transmission is mainly via heterosexual sex: *Biology*: The viral load of semen is higher than the viral load of vaginal fluid, increasing the likelihood that HIV will spread from the male to the female. In addition, vaginal penetration during sex creates small tears in the vagina, increasing the risk of HIV transmission. This is also why male-to-male sexual contact carries such a high risk, because anal penetration also results in small tears in the anus, which increases the risk of transmission. *Gender norms*: For example, expectations that women should please men may increase the risk of sexual violence and non-consensual sex, or may reduce women's power in sexual relationships. Some cultures also have norms around polygamy (for men, but not women), which exposes women to risk. *Forced sex*: In the majority of the world, females are the victims of forced sex with vaginal penetration, increasing the risk of transmission from male to female. *Power in sexual relationships*: In many patriarchal societies, men are in power in sexual relationships. Thus, women's desires to protect themselves - wearing a female condom or requesting that a male partner use a condom - may not be honored. *Health Care Utilization* Data from the 2013 Medical Expenditure Panel Survey show that more women than men reported expenses for health care and prescription medicine (61.6% vs. 49.5%). This is an indicator of health care utilization. More men (19.5%) than women (10.8%) reported having no health care visits in the past year in 2015, while more women (26.9%) than men (20.3%) reported having 4-9 visits in the past year. Data from the 2015 National Health Interview Survey showed that more men (7.0%) than women (2.9%) report not having had contact with a doctor or health care professional in more than 2 years. Again, given the stigma associated with showing pain or discomfort, men may be more likely to self-treat or ignore symptoms, and they may avoid seeking medical health or treatment.

Males and Females in the 2010 Census

Approximately 49% of the population was male in 2010. Growth rates between 2000 and 2010 were similar between the sexes, around 10%, with males growing at a marginally faster rate than females. There were more males than females in age groups between ages 0-34, but a greater number of females for all age groups after age 35. This is most likely due to sex differences in *longevity*, with women outliving men...we will discuss this later in this lesson. A greater percentage of adult women were living in *poverty* in 2015, than were adult men (Figure 1). Lesson 10 will further address disparities in socioeconomic status. The next few sections will focus on health disparities by sex.

Health Disparities by Sex

As we examine some of the specific diseases that are disproportionately high in men and women, I would like to first draw your attention to the use of the term *sex *rather than *gender*. The term sex will be used throughout sections of this lesson to describe differences or disparities based on biological sex. *Sex* is the term used in most national surveys that collect information on health behaviors and outcomes. The majority of data described in this section of the lesson were drawn from (1) the "Health, United States, 2016" report, and (2) data from the 2015 National Health Interview Survey. *Life Expectancy* Despite the fact that there were more males ages 0-34 in the U.S. in 2010 than females in the same age range, *women live longer than men*. Figure 2 shows life expectancy from birth between 1975 and 2015, by race, ethnicity and sex. Given that we have focused on racial and ethnic disparities in previous lessons, I would like to focus your attention on disparities by sex. On the left side of the chart, you can see that between 1975 and 2015, males had consistently lower life expectancy than females. It is important to note that despite disparities in life expectancy by race, black females had a slight advantage over White males at most time points. On the right side of the chart you will see that, on average, females from all races had a higher life expectancy than males. For the oldest old in the U.S. in the 2010 census, defined as 80 years or older, 64% were female. In fact, there were nearly 5 times as many females than males in the centenarians (100 years+) group in 2010. FIGURE 2: *Life Expectancy at Birth* Table 3 lists a number of diseases and health behaviors that differ between men and women. Each will be reviewed separately, below. TABLE 3: *Health Disparities by Sex* Disease/Health Behavior (Age-Adjusted) Males Females Cancers incidence (all sites) Trachea/Bronchus/Lung Cancer/Oral Cancer Heart Disease/Hypertension (Morbidity & Mortality) Undiagnosed diabetes Drug poisoning, Smoking, Substance Use Suicide and Homicide Motor vehicle-related injuries and firearm-related injuries HIV Asthma, Attention Deficit Hyperactivity Disorders, Emotional Problems (in youth) Psychological Distress past 30 days Disability/Activity Limitations (all ages) Chronic Pain Severe Headache/Migraines/Lower Back Pain/Neck Pain *Cancer* The incidence of cancer (in all sites) was* highest in males in 2013* (454.4/100,000) compared to women (397.6/100,000), regardless of race or ethnicity. Apart from cancers for which disparities cannot be explained due to biology (i.e., *prostate, breast, cervical or ovarian*), *men had higher incidence rates in all other sites in 2013*. These sites include *lung and bronchus, colon and rectum, oral and pharynx, stomach, pancreas, urinary bladder, lymphoma and leukemia*. However, *prevalence rates* from cancer (all sites) *were higher in women* (7%) than in men (5%) in 2014-2015. This is important, as it suggests that while men may be developing cancers at a faster rate than women, women may have been living with cancer for a longer period of time. This may explain why septicemia is a leading cause of death for women, but not men. These disparities in cancer incidence and prevalence may be partially explained by women's longer life expectancy, thus, a longer possible period of time that women are alive with cancer. It is also possible, given men's shorter life expectancy, that those who make it past age 65 are healthier in general, which may explain the lower prevalence rate. Figure 3 shows the number of new cases of all cancers in males and females, by race and ethnicity, using estimates gathered between 2010 and 2014. The rates were higher in men than women across all racial and ethnic groups. FIGURE 3: *Leading Sites of New Cancer Cases Each Year, 2010-2014* Source: cancer.gov *Cardiovascular Disease (CVD), Hypertension and Stroke* The prevalence of heart disease was higher in men (11.9%) than in women (9.8%) in 2014-2015; the prevalence rates were almost 50% higher in men ages 55 years and older. Figure 4 shows the rate of uncontrolled blood pressure in hypertensive individuals between 1988 and 2014. Men had a higher rate of uncontrolled blood pressure than women across time. In 2011-2014, men ages 20 to 64 had a higher rate than women, after which point the trends shifted toward women ages 65 and older having higher rates than men. Stroke prevalence rates were similar between men and women in 2014-2015 (2.5% and 2.3% for males and females, respectively). *Mortality Rates for Selected Causes of Death* In 2015, mortality rates for specific diseases differed between males and females. Rates below are age-adjusted, and are listed per 100,000/U.S. population: Ischemic heart disease (a condition that often leads to heart attack): males had almost 2 times the rate of females (133.2 vs. 70.5) Chronic lower respiratory diseases: males had a higher rate than females (46.0 vs. 38.6) Influenza and pneumonia: males had a higher rate than females (17.7 vs. 13.5) Chronic liver disease and cirrhosis: males had almost 2 times the rate of females (14.5 vs. 7.6) Diabetes: males had a higher rate than females (26.2 vs. 17.3) Alzheimer's disease: females had an almost 50% higher rate than males (32.8 vs. 23.7) Human immunodeficiency virus (HIV): males had almost 3 times the rate of females (2.8 vs. 1.0) Unintentional injuries: males had more than 2 times the rate of females (58.7 vs. 28.7) Motor vehicle-related injuries: males had more than 2 times to rate of females (16.7 vs. 6.4) Poisoning: males had more than 2 times the rate of females (19.8 vs. 9.8) Kidney-related diseases and conditions: males had a higher rate than females (16.3 vs. 11.3) Suicide: males had more than 3 times the rate of females (21.1 vs. 6.0) Homicide: males had more than 4 times the rate of females (9.1 vs. 2.2) Firearm-related injuries: males had more than 6 times the rate of females (19.4 vs. 3.2) Occupational injuries: males had more than 13 times the rate of females (total number of deaths in 2015 = 4,492 vs. 344) *Mental Health Problems* Women were more likely than men to report serious psychological distress in 2014-2015 (3.9% vs. 2.7%). In 2015, women also reported a higher prevalence of severe headache or migraine (20.9% vs. 9.9%), lower back pain (30.4% vs. 27.6%), and neck pain (17.4% vs. 13.9%). Data from the 2015 National Health Interview Survey showed that men were less likely than women to report feelings of sadness, hopelessness or worthlessness. Given social norms regarding males and females in the U.S., there may be a certain level of stigma associated with males reporting pain, sadness and distress. Thus, these rates may be sorely underestimated in men. Women were more likely to report the use of antidepressants and anxiety medication than men in 2011-2014; this may indicate better mental health treatment-seeking behavior in men. This may partially explain higher rates of suicide in men. Men die from suicide at a substantially higher rate than women. Figure 5, showing data from 2014, provides a picture of the stark disparities in suicide and homicide between men and women. Older men, ages 45 years and older, bear the greatest burden of suicide. Younger men bear the greatest burden from homicide. A report from the Centers for Disease Control and Prevention stated that women have more thoughts of suicide, but the data show that men are more likely to follow through on their thoughts. This pattern was also evident for youth in 2013; more females than males considered attempting suicide (22.5% vs. 11.6%), and attempted one or more times in the past month (10.6% vs. 5.4%). FIGURE 5: *Suicide and Homicide Death Rates, 2014* Source: CDC/NCHS, Health, United States, 2015 *Tobacco and Other Substance Use* While the prevalence of smoking declined from the early 1970s to 2015 in both men and women with a high school degree or less, or some college education, the rates remained higher in men at all time points. Smoking prevalence rates were similar in men and women with a Bachelor's degree or less (Figure 6). Data from the 2015 National Health Interview Survey shows that more males (16.7%) than females (13.7%) reported being current smokers and every day smokers (12% vs. 10.8%). This may explain higher rates of certain cancers (lung, tracheal, bronchus and oral) in men, as well as higher mortality rates from chronic lower respiratory diseases. Smoking is a leading risk factor for chronic obstructive pulmonary disease and emphysema. FIGURE 6: *Cigarette smoking among adults aged 25 years and over*, by sex and education level: United States, 1974-2015 Source: NCHS. Health, United States, 2016 Males ages 12 and older also had a higher past-month use of illicit drugs than females in 2015 (12.5% vs. 7.9%); a similar pattern was seen for marijuana use 10.6% vs. 6.2%. Male high school students were more likely than females to report past-month use of marijuana, cocaine and ecstasy in 2015; female high school students reported a higher use of inhalants. Males had almost twice the death rates (per 100,000) from drug poisoning than females in 2015 (20.8 vs. 11.8). With regards to drinking, males ages 12 and older reported greater alcohol use than females in 2015 (56.2% vs. 47.4%). Males also reported a higher level of binge drinking than females (29.6% vs. 20.5%), and more than twice the rate of heavy alcohol use as females (8.9% vs. 4.2%). Rates of alcohol use were similar among male and female high school students, but reports of binge drinking were higher among high school males than females. In general, women tend to seek emotional support to deal with distress, while men tend to turn to substance use. This may explain a number of male-female disparities in mental health, suicide and substance abuse.

Leading Causes of Death in Men and Women

Table 1 shows the leading causes of death for men and women in 1980 and 2015. 1980 2015 1 Diseases of the heart Diseases of the heart 2 Malignant neoplasms Malignant neoplasms 3 Unintentional injuries Unintentional injuries 4 Cerebrovascular diseases Chronic lower respiratory diseases 5 Chronic obstructive pulmonary diseases Cerebrovascular diseases 6 Pneumonia and influenza Diabetes mellitus 7 Suicide Suicide 8 Chronic liver disease/cirrhosis Alzheimer's Disease 9 Homicide Influenza and pneumonia 10 Diabetes mellitus Chronic liver disease and cirrhosis TABLE 2:Top 10 Leading Causes of Death for Females 1980 2015 1 Diseases of the heart Diseases of the heart 2 Malignant neoplasms Malignant neoplasms 3 Cerebrovascular diseases Chronic lower respiratory diseases 4 Unintentional injuries Cerebrovascular diseases 5 Pneumonia and influenza Alzheimer's Disease 6 Diabetes mellitus Unintentional injuries 7 Atherosclerosis Diabetes mellitus 8 Chronic obstructive pulmonary diseases Influenza and pneumonia 9 Chronic liver disease and cirrhosis Nephritis, nephrotic syndrome and nephrosis 10 Certain conditions originating in the perinatal period Septicemia Did you notice that septicemia was a leading cause of death for women in 2015? If you remember from the lesson on health disparities in Black populations, *septicemia* (blood poisoning or infection) is most highly associated with serious, typically long-term, diseases such as *cancer*, as well as *long stays in intensive care* units. in 2015. You will also notice the 10th leading cause of death for women in 1980 was related to conditions originating in the *perinatal period*, such as *hemorrhage or infection*. This is an example of a *health difference*; this is something that is a higher burden in women due to biology (only women give birth).

The Sex-Health Paradox

We have already seen the data that shows that women live longer than men. The sex health paradox is based on the finding that women have higher rates of morbidity, but lower rates of mortality compared to men. This can be further explained by 2 main findings regarding this paradox, as outlined in the reading for this lesson (Short, Yang, and Jenkins, 2013). In 2015, *men and women had the same top 2 leading causes of death*; cardiovascular diseases and malignant neoplasms. *However*: women are burdened with more acute illnesses, non-fatal daily symptoms and chronic conditions (e.g., arthritis and other autoimmune diseases), while men are more burdened by fatal conditions. men die from more life-threatening chronic diseases (such as cardiovascular disease, cancer, cerebrovascular disease, emphysema, cirrhosis of the liver) at younger ages. Reiker and Bird (2005) reviewed potential biological and social explanation for mortality differences in males and females. Potential biological explanations for these disparities often focus on hormonal and chromosomal differences between men and women, including women's childbearing potential, which carries unique health protection against cardiovascular disease. Much of this protection disappears after menopause. In addition, sex health disparities can emerge due to gene-environment interactions. That is, disparities may exist when certain genes are activated in a particular context. *Potential socio-psychological explanations for health disparities between men and women* include: unique exposures for men who may be exposed to injuries or illnesses due to occupation (risk for greater unintentional injuries and exposure to environmental toxins) differences in resources, such as income, net worth and wealth higher rates of health care utilization in women Both biological and social factors should be considered as contributors to disparities in mortality between men and women. However, biological and social factors most likely work together to produce disparities.