Health Consequences of Structural Sexism: Conceptual Foundations, Empirical Evidence and Priorities for Future Research

Abstract

A nascent body of work has begun exploring the health consequences of structural sexism. This article provides an overview of the concept of structural sexism and an elaboration of the potential pathways connecting it to health. Next, it reviews existing measurement approaches and the current state of empirical evidence on the relationship between structural sexism and health in the United States. Finally, it highlights key priorities for future research, which include: expanding and refining measures, increasing public data availability, broadening the scope of inquiry to include a broad range of outcomes, exploring mechanisms, incorporating intersectionality, and applying a life course lens.

Introduction

Decades of research have established that perceived interpersonal gender discrimination, sexual harassment, physician bias, and discrimination in health care are harmful for women’s health. For example, perceived gender discrimination and sexual harassment have been linked to a variety of negative health outcomes among women including anxiety, depression, gastrointestinal symptoms, and functional limitations (Krieger, 2014; McDonald, 2012; Pavalko et al., 2003; Swanson, 1999). Furthermore, in health care settings women are often subjected to physician bias and less are likely than men to receive accurate diagnoses and the most advanced/effective treatments (Borkhoff et al., 2008; Chapman et al., 2013; Greenwood et al., 2018). These literatures provide crucial evidence for understanding and reducing health disparities and they remain central concerns for health equity scholarship. However, on their own they do not provide a complete picture of how gendered power structures in a society shape health because they remain largely focused on the individual level. This work typically relies on surveys of self-reported sexist experiences, which requires that sexism be both directly visible to the respondent and understood/labelled as sexism in order to be measured. Furthermore, this approach primarily captures sexist behaviors of individuals, allowing more institutionalized forms of sexist discrimination to remain invisible. These limitations are notable because discrimination is not exclusively an individual or interpersonal level phenomenon. Instead it is systemic unfair treatment that can be expressed in several forms: in individual actors (interpersonal discrimination), in individual organizations and institutions (institutional discrimination), and in the interconnected web of social institutions that combine to constitute oppressive social stratification systems (structural discrimination/structural oppression) (Brown and Homan, 2023; Jones, 2000; Krieger, 2020, 2014). While the literature on gender discrimination and has expanded beyond the interpersonal level to show how discrimination against women is institutionalized in the health care system, this work has centered almost exclusively on the institution of medicine, rather than the multitude of social institutions that constitute a gendered stratification system (Homan, 2019).

In response to these limitations, a new line of research has emerged to identify how structural sexism can shape health. A structural sexism approach directs attention (1) beyond individual sexist actors, beliefs, and behaviors and (2) toward the comprehensive set of institutional arrangements in a society that privilege men and subordinate women (Homan, 2019). In this article, I begin by providing an overview of the concept of structural sexism (see also Homan 2019). Next, I present a new conceptual model illustrating the hypothesized pathways through which structural sexism shapes health and how these mechanisms may operate differently among men and women. I then summarize the existing measurement strategies for structural sexism and the growing body of empirical evidence on its association with health in the US. Finally, I highlight several key priorities for future research on structural sexism and health.

Theorizing Structural Sexism and Its Connection to Health

Over the last four decades, the majority of quantitative studies of gender and health have focused on sex differences or gender gaps. This approach involves measuring gender as an attribute of individuals and then examining the gap between people with the attribute of “male” or “female” in the prevalence of various health outcomes. [Note: This categorization rarely distinguishes between sex and gender, and in most large health surveys is self-reported as either male or female by respondents. For this reason, it also typically renders transgender/non-binary individuals invisible or explicitly excludes them from study.] This body of research has provided essential information regarding the distribution of health and illness in American society and has helped to identify unmet healthcare needs. Differences uncovered in this “gender gaps approach” are often used to make subsequent inferences about social inequality between men and women, but this approach leaves exposure to systemic gender inequality in society unmeasured. While it might seem plausible to consider the categories “male” and “female” proxies for exposure, this assumes men are either unexposed or unaffected by sexism. However, men living in different social contexts are exposed to varying levels of gender stratification and their health can be affected in a number of possible ways (discussed in further detail below) (Homan, 2019; Schofield, 2014). Greater gender inequality favoring men in social institutions may translate to a health benefit for men due to their increased power and resources, or it may harm their health through its detrimental impact on collective resources and toxic masculinity norms (Connell, 2012; Courtenay, 2000; Homan, 2019). The gender gaps approach is unable to distinguish between these scenarios.

Thus, the recent emergence of a structural sexism approach arose from the need to better integrate this health inequality research with feminist scholarship that understands gender as a multilevel social system of inequality and oppression rather than exclusively an individual attribute, role, or identity (Homan, 2019; Martin, 2004; Ridgeway and Correll, 2004; Risman, 2004). Such a system can have consequences for the health and well-being of all members of society, including both dominant and subordinated groups. To better capture these multilevel societal effects, a structural sexism approach to population health shifts the focus from comparisons of health outcomes between men and women to within-gender comparisons across varied levels of exposure to contextual gender inequality.

The term structural sexism refers to “systematic gender inequality in power and resources in a given gender system” (Homan, 2019). The gender system is a multilevel structure. Therefore, structural sexism is observable at each level of the gender system as gendered power and resource inequalities in: large-scale social, political and cultural institutions at the macro level, organizational and interactional settings at the meso level, and individual identities, beliefs and bodies at the micro level. Structural sexism does not require overt, intentional sexist behaviors and it is often unperceived; it is fundamentally about gender-based hierarchy and inequality rather than interpersonal mistreatment. Structural sexism typically enables interpersonal sexist harassment and abuse, but it is conceptually distinct (Homan 2019). The subsections that follow describe the different levels of the gender system, the contexts within which each level of sexism is understood to operate, and examples of structural sexism at each level.

Macro-Level Structural Sexism

At the macro level, the gender system involves widespread norms and the distribution of resources, rights, and power along gender lines in a society’s major institutions (Homan, 2019; Ridgeway and Correll, 2004; Risman, 2004). Examples of key institutions include the labor market, government, organized religion, educational system, health care system, and criminal-legal system. The degree of gender inequity imbedded in these institutions varies across US states, regions, and countries, which tend to be the primary units of analysis for examining macro-level structural sexism. This type of sexism can also be measured at smaller geographic scales such as cities and counties, although these have been studied less frequently. Common examples of macro level structural sexism include underrepresentation of women in state legislatures (e.g., women occupied only 11.9% of legislatures seats in West Virginia in 2023 (CAWP, 2023), and the gender wage gap (e.g., the wage gap in Wyoming was over $21,000 in 2019 (US Census Bureau, 2019)). These examples each represent sexism in a single institution (i.e. institutional sexism), but similar to structural racism, structural sexism is best conceptualized as a system of gender inequality that operates across institutions in several interconnected and mutually reinforcing domains (Brown and Homan, 2023; Homan, 2019; Martin, 2004; Risman, 2004). Inequality in one domain can perpetuate and magnify inequality in others. For that reason, studies of structural sexism typically examine multiple institutions concurrently by using an index (See Table 1 and measurement section below).

Table 1.

Measures Used to Quantify Structural Sexism and its Impacts on Health in the US

Study Authors	Geographic Level/ Measurement Context	Measures	Outcomes Examined
Homan 2019	US States	Index including: ratio of men’s to women’s labor force participation; ratio of men's to women's wages; ratio of women’s to men’s poverty rates; proportion of state legislature seats occupied by men; proportion of women that live in a county without an abortion provider; proportion of population composed of religious conservatives.	Health outcomes among both men and women: chronic conditions; self-rated health; physical functioning (SF-12 score)
	Heterosexual marriages	Index including: logged ratio of husband’s-to-wife’s past year earnings (with $1 added to all values to preserve the ratio format given that some individuals reported no earnings); ratio of husband’s-to-wife’s years of education; and husband-to-wife age ratio in years.	Health outcomes among both men and women: chronic conditions; self-rated health; physical functioning (SF-12 score)
	Individual beliefs	Internalized gender ideology that reinforces power and resources inequalities. Index included 4 items: a woman’s place is in the home, not the office or shop; it is much better if the man is the achiever outside the home and the woman takes care of the home and family; men should share the work around the house with women (reverse coded); and women are much happier if they stay home and take care of children.	Health outcomes among both men and women: chronic conditions; self-rated health; physical functioning (SF-12 score)
Nagle & Samari 2021	US States	Same as Homan 2019 (state-level).	Unnecessary cesarean sections among pregnant people
Homan & Burdette 2021	Religious Congregations	Binary measures: women prohibited from serving as member of governing body, women prohibited from serving as head pastor/priest/leader; Index: count measure of number of roles women are prohibited from occupying in congregation including: governing board, head pastor, teacher of co-ed classes, speaker in religious service.	Self-rated health among both men and women
Price et al. 2021	US States and Counties	Focused on cultural/ideological dimension of structural sexism. Implicit association test (IAT) scores from Project Implicit (aggregated at the state- and county-levels); gender role attitudes/beliefs from the General Social Survey (aggregated at the state-level only). Both continuous and dichotomized versions were used.	Efficacy of psychotherapy among girls
Rapp et al. 2021; Rapp et al. 2022	US States	Index including: ratio of men’s to women’s labor force participation; ratio of men's to women's wages; ratio of women’s to men’s poverty rates; proportion of state legislature seats occupied by men; proportion of women that live in a county without an abortion provider; paid family and medical leave; Medicaid expansion (2022 study only); and gun ownership restrictions for domestic violence offenders.	Barriers to health care access among both women and men; Patient-provider communication among both women and men
McKetta et al. 2022	US States	Index including: ratio of men’s to women’s labor force participation; ratio of women’s to men’s poverty rates; proportion of state legislature seats occupied by men; ratio of men to women in management occupations; ratio of men to women who are self-employed. (Index dichotomized into high vs. low sexism)	Alcohol consumption frequency among women; Binge drinking among women
Beccia et al. 2022	US States	Index including: scores on 4 sub-indices reflecting political participation, employment and earnings, social and economic autonomy, and reproductive rights created by the Institute for Women's Policy Research. Sub-indices contained 4 - 9 absolute and relative measures. Sub-index scores were standardized and summed to create an overall sexism index, which was then dichotomized to reflect high sexism (top tertile) vs. low sexism (bottom two tertiles) in a given year.	Four measures of disordered eating among young women and men: chronic dieting, purging, binge eating, and overeating

Note: Indices were treated as continuous in statistical analyses unless otherwise noted.

Meso-Level Structural Sexism

At the meso level, structural sexism involves interactions, patterns of behavior, and organizational practices (Homan 2019). This level is vital to the gender system, and is often considered the level at which inequality is reproduced (Ridgeway, 2011). At this level, gender norms and beliefs about fundamental gender difference combine with structurally unequal relationships leading men and women to recreate unequal gender systems in everyday interactions (Ridgeway and Smith-Lovin, 1999; West and Zimmerman, 1987). Interactional settings in which structural sexism can manifest include: marriages, families, workplaces, organizations, neighborhoods, etc. For example, in the workplace cultural expectations that require women to be team-oriented and nurturing can result in women doing more unrewarded work tasks, thereby reducing their likelihood of promotion (Babcock et al. 2017; Winslow 2010) and reproducing gender inequality. Similarly, “doing gender” in heterosexual marriages and families typically results in women performing the majority of unpaid household labor, limiting their personal access to resources, their opportunities in the paid labor market, and their relational bargaining power (Collins et al., 2021; Fenstermaker Berk, 1985; Orkin, 1989). These processes may not be perceived (unlike workplace sexual harassment), but may nonetheless shape women’s health through direct and indirect pathways, including increased stress and diminished access to material resources.

Micro-Level Structural Sexism

Finally, the micro level of the gender system consists of gendered selves, identities, beliefs, and embodied practices. These features of individuals are shaped by ongoing processes of socialization and identity construction. Micro-level structural sexism does not refer to all gender-related beliefs and expression, but specifically to those which generate and uphold power and resource inequalities between men and women. For example, adherence beliefs such as “it is much better if the man is the achiever and the woman takes care of the home and family” can be an indicator of internalized structural sexism because this belief restricts women to unpaid labor and thereby reinforces gender inequality (Homan 2019). Another example is the gender confidence gap which refers to the way individual men report higher levels of knowledge, skills, performance, confidence, self-efficacy and preparedness and lower levels of imposter syndrome compared to similarly skilled/qualified women (Betsworth, 1999; Sterling et al., 2020). A third example of structural sexism expressed at the individual level is the embodied practice in which girls make themselves small and quiet in response to social expectations of adults, which in turn limits their autonomy. In her study of preschools, Karin Martin (Martin, 1998) finds that girls are told to be quiet three times as often as boys, training their voices to be softer and “nicer.” This practice reduces their physicality, constrains their play, and limits their ability to resist others’ mistreatment of them. Thus, over time girls come to embody gender norms that disempower them and reinforce inequality. Despite being embodied by individuals, this type of inequality generating process is considered structural sexism because it is critical to the reproduction and maintenance of sexist gender systems (Homan 2019). (For further discussion of structural sexism at each level of the gender system and its relevance for health see Homan 2019.)

Connections Between Structural Sexism and Health

From a theoretical perspective, there are numerous ways structural sexism may shape health. Ecosocial theory (Krieger, 2012, 2001) describes the processes through which oppressive social relations (such as racism or sexism) determine exposure to living and working conditions such that individuals come to embody (i.e., literally biologically incorporate) social systems of inequality. Krieger identifies multiple pathways of embodiment through which structural oppression harms the health of marginalized groups, four of which are particularly relevant for understanding how structural sexism gets under the skin: economic and social deprivation, toxic/hazardous living conditions, socially inflicted trauma, and inadequate healthcare (Krieger, 2012, 2001). Combining Ecosocial theory with other research on the social determinants of health suggests several specific pathways through which structural sexism may harm women’s health. Specifically, living in a context of high structural sexism may limit individual women’s access to health promoting factors (such as access to material resources, goods, and services with which to pursue a healthy lifestyle, safe and healthy living conditions, supportive social relationships) and increase women’s exposure to health harming factors (such as violence, harassment, unsafe working conditions, low social status, and perceived discrimination) (Adler and Newman, 2002; Aizer, 2010; Homan, 2019; Krieger, 2014; Link and Phelan, 1995; Pascoe and Richman, 2009; Song et al., 2021). These social determinants may harm women’s health directly (as in the case of physical violence) or through their impact on more proximate mechanisms including psychosocial resources, stress, health behaviors and health care quality and access (Denton et al., 2004; Elstad, 1998; House, 2002; Pearlin et al., 1981; Rapp et al., 2022; Taylor, 2011; Taylor and Broffman, 2011; Thoits, 2010). These pathways of influence are illustrated in the top panel of Figure 1 (Panel A).

Figure 1.

Conceptual Diagram Illustrating the Potential Mechanisms Through Which Structural Sexism Shapes Health Among Women and Men

The middle panel in Figure 1 (Panel B) shows the pathways connecting sexism to health among men in a pattern that is the inverse of those depicted in the top panel among women. This scenario is what would be predicted if gender relations are a zero-sum game, with women’s losses in resources, status, and power resulting in direct benefits to men which then enable men to achieve better health (Homan 2019). In this scenario, structural sexism entails the subordination of women to men and thus individual men may experience improved access to material resources, social status, living and working conditions, and social relationships (e.g., men may extract more personal benefits from their marriages (Umberson and Kroeger, 2016) and more power and resources from their social networks with other men (Blommaert et al., 2020; Padavic and Reskin, 2002)), thereby resulting in health improvements through the same proximate mechanisms outlined for women’s worsened health.

Alternatively, there is substantial theory and growing evidence that suggests greater structural sexism, although it advantages men in many ways, does not entail a health benefit for men and, in fact, is harmful (Homan, 2019; Kavanagh and Graham, 2019). The bottom panel (Panel C) depicts this type of scenario in which structural sexism affects the collective culture and distributions of collective resources in ways that undermine men’s health. In this case, structural sexism involves the disempowerment of women which in turn shapes social political and economic processes that allocate resources critical for population health. Historical and cross-national research shows that when women are empowered, there tends to be greater investments in health care, public health, education, welfare and other social programs that improve health for the entire population (Boehmer and Williamson, 1996; Bolzendahl and Brooks, 2007; Little et al., 2001; Miller, 2008; Young, 2001). Thus, greater structural sexism would lead to reduced public investment in these health and social safety net policies and programs to the detriment of health for all, and particularly for marginalized groups. In addition, theories of universally harmful inequality suggest that structural sexism may increase competition for dominance among men, damage social relationships, undermine social cohesion and collectivist orientations, and diminish the safety, productivity, and health of an entire society (Homan, 2019; Lucas, 2013; Wilkinson and Pickett, 2011; Wilkinson, 2005). Finally, patriarchal social systems that exhibit a high degree of structural sexism increase the pressure for men to preserve their status and privilege by conforming to hegemonic masculine norms (e.g., strength, dominance, and self-reliance) that undermine their health by encouraging violence, risk-taking, substance use, risky sexual behaviors, health care avoidance, and other negative health behaviors (Connell, 2012, 2005; Courtenay, 2000; Fleming and Agnew-Brune, 2015; Kavanagh and Graham, 2019; Mahalik et al., 2007). In sum, these collective processes may shape men’s resources, risks and exposures in ways that worsen their health through downstream mechanism similar to those operative among women.

It is important to note that both processes illustrated in the second and third panels are likely to be occurring to some degree among men. To the extent that the relationships illustrated in the second panel are stronger or more widespread we would observe a positive association between high structural sexism and health among men; whereas, to the extent that the relationships in the third panel are stronger we would observe a negative association between high structural sexism and health among men. A third possibility is that the two illustrated processes operate with similar strength/frequency and cancel each other out, resulting in a null association between sexism and health among men. Thus far, empirical evidence primarily supports a negative (Beccia et al., 2022; Homan, 2019; Kavanagh et al., 2017) or null association (Homan and Burdette, 2021; Rapp et al., 2022) between sexism and health among men, but the findings are context specific (i.e., results differ for sexism within states vs. churches vs. marriages. See next section for details.) and further research is needed. Furthermore, although all of the possible mechanisms proposed here are based on theory and previous research, they remain largely untested as formal mediators of the sexism-health relationship among either women or men.

Measuring Structural Sexism and Documenting Its Health Consequences

Prior to Homan 2019, a handful of studies linked women’s status and health in the US (Chen et al., 2005; Kavanagh et al., 2017; Kawachi et al., 1999; Koenen et al., 2006; McLaughlin et al., 2011) and a larger body of somewhat similar cross-national comparative work focused on low- and middle-income countries (for reviews see (King et al., 2018; Pratley, 2016). Building on these studies and integrating feminist theories of gender as a multi-level social structure, the emerging line of structural sexism research in the US has recently begun developing a variety of new measures and examining their connections to health. Table 1 lists the 8 existing empirical studies that were identified through a search of google scholar using the terms “structural sexism” and “health” in February 2023. The majority are focused on measuring structural sexism at the US state-level with an index similar to Homan 2019, but studies have also examined structural sexism in other contexts including counties, religious congregations, marriages, and individuals. The indicators most commonly used to measure structural sexism capture material and social inequities such as the gender wage gap and the underrepresentation of women in political office, but some studies have also begun to include targeted laws and policy measures (such as paid leave) as well as geographically based cultural/attitudinal measures (e.g., Implicit Association Test scores) as part of an overall index or a distinct type of sexism indicator. (See Table 1 for a detailed description of the measures used in each study.)

Across the various types of measures, higher levels of structural sexism appear to have relatively consistent negative effects on women’s health, with the exception of alcohol abuse (a health behavior rather than a health outcome in the traditional sense), which is lower among women in high sexism environments (McKetta et al., 2022). The patterns of association between high sexism and health are less consistent among men, and vary depending on the measurement context. At the macro level, greater structural sexism is associated with worse health among men (Beccia et al., 2022; Homan, 2019) -- consistent with theories of universally harmful inequality (Homan, 2019; Lucas, 2013; Wilkinson and Pickett, 2011) -- but is not associated with barriers to health care access (Rapp et al., 2022). At the meso level, greater sexism within heterosexual marriages is associated with improved health among men and sexism within religious congregations has either no effects or a very small negative effect on men’s health (Homan, 2019; Homan and Burdette, 2021). Only 4 of the 8 structural sexism studies included men, so further research is needed. Additionally, future research using intersectional approaches may be particularly fruitful for understanding the mixed results among men because men who are better positioned in socioeconomic and racial hierarchies are more likely to benefit from patriarchy than less privileged men (Connell, 2005; Homan, 2019; Homan et al., 2021; Wilkinson, 2005).

Across all 8 studies, structural sexism has been linked to roughly 9 different types of health and health care related outcomes (listed for each study in Table 1). These outcomes are important, but by no means exhaustive. Furthermore, these outcomes have been primarily examined in adolescence/early adulthood (e.g. Beccia et al., 2022) and mid-life (e.g. Homan 2019), leaving the impact of structural sexism on health and longevity in late life largely unknown. Indeed, only health care quality and access (Rapp et al., 2022), self-rated health (Homan and Burdette, 2021), and alcohol use (McKetta et al., 2022) were examined in populations that included any people over age 50. Thus, continuing to build this burgeoning body of evidence on structural sexism is a critical need for future health equity scholarship.

Priorities for Future Research: Measures, Outcomes, Mechanisms, Intersections, and a Life Course Lens

The development of structural sexism and health research over the past five years has uncovered a variety of new questions, challenges, and opportunities for health equity scholarship. Below I identify five areas that represent urgent priorities for future research in on structural sexism and health. Within each area, I offer examples and recommendations to help guide inquiry. (See also (Brown and Homan, 2023) for a more general discussion of future directions for studying the health impacts of a variety of forms of structural oppression.)

Measures

The first priority for future research is to expand and refine the measurement of structural sexism. This can be accomplished in at least three different ways: including additional domains and including additional measures within currently existing domains, measuring sexism in different contexts/settings, and creating longitudinal measures that are consistent across time. In Homan’s (2019) original formulation, US state-level structural sexism was measured with 6 items across 4 domains. While this index captures the systematic exclusion of women from power and resources in several key areas, it is not exhaustive. Other have since added a handful of additional items (see Table 1), but measurement remains far from comprehensive. There is a great deal of opportunity for creativity and novel ideas about how we can capture systemic gender inequality between men and women in power and resources. For example, possible new measures could include inequality in: educational attainment and labor market returns to education (as part of a newly added educational domain), workplace authority and business leadership/C-suite representation (as a part of the economic domain), exposure to sexual violence (as part of the physical/reproductive domain), and media representation (as part of the cultural domain). We can also develop a more complete array of policy measures including: paid family leave, divorce and tax laws, new state laws and practices restricting bodily autonomy of people who can become pregnant and/or people who identify as women. Some policy measures may be difficult to incorporate (depending on the type of analysis) due to limited variation between states and/or over time (e.g., few states have paid family leave policies). Nevertheless there is growing interest in cataloguing state policy contexts/climates as features of structural oppression, particularly for structural racism and structural LGBT stigma (Agénor et al., 2021; Hatzenbuehler, 2014; Philbin et al., 2023; Samari et al., 2021), and this represents an important area for expansion of sexism measurement.

Most of the existing research has focused on measuring structural sexism US state-level environments, but researchers should also develop new measures at different levels of the gender system. For example, families, workplaces, organizations, neighborhoods, local governments, and counties all represent meso-level contexts within which structural sexism and its health consequences can be measured. Scholars working in fields of family science and gender, work and organizations have employed a variety of measures capturing gender inequality in power and resources between men and women in workplaces and families (Bagarozzi, 1990; Blumberg and Coleman, 1989; Glauber, 2023). These measures can be reconceptualized as measures of meso-level structural sexism and examined with relation to health and to structural sexism in other parts of the gender system. Additionally, there is a need for further development in measuring the ways structural sexism is manifest at the micro level within individuals through beliefs, identities and embodied practices that reinforce gendered power and resources inequalities. In particular, psychologists have developed a wealth of theory and measures for concepts such as internalized sexism, internalized misogyny, internalized oppression, self-objectification, male prioritization, ambivalent sexism, modern sexism, etc., that can be incorporated into a structural sexism framework at the micro level (Bozkur, 2020; David, 2014; Fredrickson et al., 1998; Glick and Fiske, 1996; Han et al., 2023; Han and Lee, 2023; Swim and Cohen, 1997).

Homan 2019, was one of the only studies that employed measures of structural sexism at different levels of the gender system simultaneously. Measuring structural sexism at multiple levels can enhance our understanding of the different ways that institutions, interactions and individuals interface to create and resist systemic gender-based oppression. A multi-level approach to measurement within a single study may not always be possible or even desirable, but examining structural sexism in as many manifestations as possible, at multiple levels, across many studies will generate a more robust body of theory and evidence.

As efforts to measure structural sexism progress, it is important for the research community to recognize that there is no single “correct” way to measure structural sexism, just as there is no one “right” way to measure structural racism (Hardeman et al., 2022). Although Homan’s 2019 sexism index is the most long-standing and frequently used measure and has been shown to be a robust predictor of a number of different health outcomes across different samples/settings, our understanding of the field is constantly expanding, and new policies/practices relevant to structural sexism (e.g., Dobbs) continue to emerge and shift. Thus, researchers may wish to include alternative, additional, or fewer indicators of sexism depending on their goals, research questions, setting, and data availability. Given the potential need for different indicators depending on the aforementioned issues, scholars should avoid insisting on the use of a specific measure, context, or geographic scale, particularly as new measures are proposed and identified as relevant. In some cases, it may be beneficial to use data reduction techniques (e.g., factor analysis) to create a pared-back sexism measure with only the most highly correlated indictors and therefore greater specificity. In other cases, theory might lead researchers to retain indicators that are less correlated with others, but capture sexism in a more comprehensive way that includes more dimension of the concept and is global enough to be applicable across different settings and populations. For example, the overall correlations between some of the sexism indicators used in a scale might be on the weaker side if there are different “flavors” of sexism, meaning that it manifests slightly differently in some places compared to others. Thus, a measure that includes a broad range of theoretically-justified indicators, even retaining those with somewhat lower correlations, can be quite valuable even if it is not the most parsimonious.

Developing of a variety of new measures aiming to capture structural sexism is important because employing different versions of measures for the same concept and finding similar health consequences would bolster the body of evidence and move science forward. As the science advances, researchers can test the validity and reliability of these measures, assess stability and change over time, determine which ones are most closely linked to health, and eventually build scientific consensus around many measurement issues. Nevertheless, all measurement approaches will have varied strengths and limitations and it is therefore essential that measurement choices be guided by theory (Brown and Homan, 2023; Hardeman et al., 2022) and that the conceptualization and operationalization of structural sexism are closely linked. In sum, casting a wide net in terms of measurement possibilities is a valuable approach given that this literature remains in such an early stage of development.

We also need to lower the barriers to conducting this type of research by building a publicly-available data infrastructure with measures of structural sexism. As of July 2023, no comprehensive publicly available data source yet exists to provide researchers with valid and reliable longitudinal measures of structural sexism that are linkable to a broad range of individual and state-level data. However, a new IPUMS dataset on the contextual determinants of health has begun to provide some indicators of structural sexism, but the majority only date back to 2015 (Kamp Dush et al., 2023). Making a publicly available encyclopedic data resource of structural sexism measures available to the scientific community will allow for more innovation and accelerate the pace of research on the relationship between structural sexism and health. Funding data collection and dissemination as well as facilitating data linkages (between sexism measures and existing large-scale health datasets) are strategic investments that the National Institutes of Health and other funding agencies should consider a top priority to catalyze further research.

Outcomes

Because research linking structural sexism to health in the US has only gained momentum over the past five years, the scope of health outcomes examined remains somewhat limited. Thus far studies have linked structural sexism to 9 types of health outcomes including: chronic conditions, self-rated health, physical functioning, unnecessary cesarean sections, efficacy of psychotherapy, barriers to health care access, patient-provider communication, alcohol use, and disordered eating. Additional research is needed to examine a broader range of health outcomes to generate a more complete picture of the consequences of sexism. For example, it is largely unknown how structural sexism shapes: maternal and infant health, biomarkers, mental health, health behaviors (e.g. sleep), preventive health care use, disability, dementia and cognitive decline, life expectancy, and later life health (ages 65+). These outcomes and many more are available in large health studies – such as The Health and Retirement Study, The Behavioral Risk Factor Surveillance System, Add Health, The National Couples Health and Time Use Study, The Youth Risk Behavior Surveillance System, The Adolescent Brain Cognitive Development Study, etc. – that either contain geographic identifiers which can be used to create linkages with state or county-level sexism measures or that already/soon will contain contextual sexism measures. Examining a variety of different outcomes is useful because they differ in etiology and onset, some are likely to be more sensitive than others, and some are more amenable to intervention. Such examinations can also provide important information about gendered patterns in health and the mechanisms linking sexism exposure to health. For example, if we study the impact of structural sexism on biomarkers (which captures physiological health even absent health care use/access), preventive health care use (e.g. doctor visits and cholesterol checks etc.), heart disease diagnosis, and heart disease mortality, we can observe how and when sexism impacts the processes of disease onset and course and whether this differs for women and men. This information can potentially be leveraged to reduce health disparities and improve population health.

Mechanisms

Knowledge regarding the relationship between structural sexism and health in the US is only beginning to accumulate; therefore, the pathways through which the relationship operates are poorly understood. Several pathways are theorized to connect structural sexism and health as discussed above, but these pathways have not yet been empirically tested. Qualitative and quantitative studies are needed to document the mechanisms connecting structural sexism to health. Qualitative studies can amplify community voices to identify new mechanisms as well as provide rich detail regarding how and why specific mechanisms operate to shape peoples lived experiences and their health (Hardeman et al., 2022; Philbin et al., 2023). Quantitative studies can use formal mediation analyses to test the extent to which sexism harms health through specific downstream risk factors such as intimate partner violence, stress, or health care access/quality. It is also important to conduct mixed-methods research that can capitalize on the strengths of both approaches. Assessing the mediating role of a variety of risk factors will enable theory building and will furnish foundational knowledge needed to understand the complex and multifaceted mechanisms linking structural sexism and population health. The identification of influential pathways can also help uncover potential intervention levers to improve population health.

Intersections

Incorporating intersectionality is another key priority for future research. Intersectionality theory holds that sexism does not work in isolation but instead is part of a complex web of overlapping systems of structural oppression that shape individual’s lives (Collins, 2022; Collins and Bilge, 2020; Crenshaw, 1991; Taylor, 2017). Homan, Brown, and King (2021) integrated insights from intersectionality perspectives with the emerging literatures on the health consequences of structural racism and structural sexism to develop a structural intersectionality approach to population health. Homan and colleagues explored how structural racism, structural sexism and income inequality are related to one another across US state contexts and investigated how these forms of structural oppression combine to shape the health of various population groups defined by constellations of individual-level statuses. They found that structural inequalities: 1) vary considerably across U.S. states, 2) intersect in a variety of ways but do not strongly or positively covary, 3) jointly shape health, and 4) differentially shape health along race and gender lines, and are most consistently associated with poor health among black women (Homan et al., 2021). The Homan et al. 2021 study represents an early attempt to integrate structural and intersectional approaches, and points to a promising new direction for health disparities research moving forward.

In addition to racism, sexism, and economic exploitation, there are many other systems of oppression to consider including: heterosexism, cissexism/gender binarism, ableism, nativism, ageism, etc. (Krieger, 2020). More research is needed to develop structural measures of these systems of oppression (rather than using individual status categories as proxies) and to assess how these systems intersect and jointly influence health. In particular, more conceptual and empirical work is needed to interrogate the connections between structural sexism and structural gender binarism. Structural sexism research examines inequality in the distribution of power and resources across binary gender categories, but research has not yet examined 1) how this inequality may (or may not) be associated with the prevalence of structural discrimination against trans and other non-binary individuals, and 2) how structural sexism -- alone and in combination with gender binarism -- may (or may not) impact the health of trans and other non-binary individuals.

Furthermore, incorporating intersectionality involves not only thinking about how different forms of structural oppression intersect in terms of the analytic approach (as in Homan et al. 2021), but also beginning to develop measures of structural inequalities that are themselves intersectional. For example, Everett et al. (2022) developed an intersectional measure of structural heteropatriarchy which reflects the combination of structural sexism and heterosexism in US states. Similarly, Laster Pirtle and Wright (2021) developed the concept of structural gendered racism and examined its impact during the COVID-19 pandemic. Intersectionality can also be incorporated into study design by influencing decisions about sample selection. For example, balanced samples with equal sample sizes can ensure equivalent statistical power to detect effects across groups representing varied intersectional categories (Homan et al. 2021). Similarly, thoughtfully constructed within-group designs are important intersectional strategies for uncovering complexity and heterogeneity within marginalized communities (Volpe et al., 2022). These types of intersectional approaches to both measurement and analysis are essential to understanding the health consequences of overlapping systems of oppression.

Life Course

Finally, applying a life course lens also represents an important opportunity for future research (Homan, 2021). Although structural sexism research is naturally grounded in historical time and place, the field has rarely incorporated the life course principle of interplay between individual’s life-long development and historical time. Additionally, the integration of structural sexism research with other life course principles such as the timing of events and linked lives has been limited (Elder et al., 2003; Homan, 2021, p. 20). Thus, numerous questions remain about how structural sexism and its health consequences may fluctuate and compound over time.

For example, we need to examine whether there are certain stages of the life course that are sensitive periods during which structural sexism exposure is particularly harmful (e.g., childhood, adolescence, young adulthood, midlife or later life). Research points to midlife as a potential sensitive period for exposure to structural sexism because of the large gender wage gap and unequal caregiving burden that occur at this life stage (Bird and Fremont, 1991; Goldin et al., 2017; Grigoryeva, 2017; Homan, 2021). Furthermore, evidence suggests that economic and health disadvantages women face as result of midlife sexism exposures accumulate as they age to create vast gender inequalities by retirement, such that by age 65 women are 80% more likely to be impoverished than men (Brown et al., 2016; Meyer, 1990).

Other pressing life course related question include the following: Are there lagged health effects of exposure to structural sexism? How does duration and accumulation of exposures matter for health? To what extent does the principle of linked lives explain the harmful effects of sexism among men? For example, the degree of state level sexism in a given time and place may serve as a general link between men and women, collectively shaping their opportunities for health and well-being. Additionally, married men are more harmed by state-level structural sexism than single men because of their close ties to women. And are there intergenerational effects that can be observed? Does structural sexism exposure of parents of grandparents shape the exposures and outcomes of their children? Answering these questions requires longitudinal data and life course perspectives and methods. Thus far, only one study on structural sexism in the US has taken a life course approach: Beccia et al. (2022) showed an association between greater cumulative exposure to structural sexism (across a 10-year period) and higher risk of disordered eating. Much more research is needed to fully understand the correlates and consequences of structural sexism exposure across the life course.

Conclusion

Conceptualizing structural sexism as the degree of systematic gender inequality in power and resources manifest in a given social context directs attention to the fact that gender is not only an individual-level role or identity but is instead a stratification system that can vary in intensity and inequity across time and place. The unequal gendered distribution of power, status, resources, rights, roles, exposures and opportunities in a society has profound implications for the life chances, health and wellbeing of all its members regardless of their awareness of these inequalities. A small but growing body of evidence has begun to document the harmful health consequences of structural sexism for women and men in the US. This work shows that structural sexism is a pressing public health concern. More research and advocacy is needed to understand the wide-ranging health impacts of structural sexism, to uncover potential intervention levers to improve health outcomes for individuals in high sexism environments, and to make progress in reducing structural sexism to create a more just and healthier future.

Highlights.

• A growing body of research documents the health consequences of structural sexism

• More research is needed to expand and refine sexism measures

• Future research should also examine a broad array of health outcomes

• Research should incorporate Intersectionality and life course perspectives

• Increasing public data availability can accelerate the pace of research