Invisible Labor: Gendered Responsibilities and Women's Diabetes Management

1.

Type 2 diabetes mellitus is a highly prevalent chronic condition and a major public health concern. In 2023, the prevalence of diagnosed diabetes mellitus (hereafter referred to as diabetes) in the United States was about 12% of the adult population, or more than 29 million individuals, with projections indicating continued growth over time [1]. Globally, diabetes has become one of the leading causes of morbidity and mortality, with the number of people living with diabetes increasing dramatically and expected to exceed 850 million by 2050 [2]. Although the prevalence of diabetes is similar among men and women (10.6% and 9.1%, respectively), accumulating evidence suggests that the consequences of diabetes, including patterns of care, self‐management experiences, and quality‐of‐life outcomes, differ by gender [1, 3].

Here, it is important to distinguish gender from sex. Sex refers to biological and physiological characteristics, such as chromosomes and anatomy differences, that differentiate male and female bodies, while gender refers to socially constructed roles, expectations, and power relations that society typically assigns to males and females [4]. These constructs are distinct. Differences in type 2 diabetes prevalence, complications, and treatment response may be driven by biological sex while differences in caregiving roles, household labor, and self‐management behavior, which are the focus of this commentary, are a gendered phenomenon shaped by social constructs and norms rather than biology. Misattributing socially modifiable disparities and biological differences has implications for how interventions are designed, delivered, and succeed [4].

Gendered dynamics are not uniform across all women in all cultures. The magnitude and characteristics of role strain vary substantially by socioeconomic status, cultural context, and household composition [5]. As with most medical condition, women with greater resources may be more likely to outsource household chores and caregiving, opening up more mental capacity to care for their own conditions while women from lower SES backgrounds cannot. Immigrant communities often face different cultural norms, family obligations, and gender roles that vary by cultural background, shaping how many resources these women have left over for self‐care [5]. Employment status also impacts the dynamics of women's roles. Women who balance employment outside of the home with caregiving inside the home face distinct time and energy constraints compared to those who are not externally employed. Future research and clinical assessments should refrain from treating “women with diabetes” as a homogeneous group, and instead account for individual role strain the woman is experiencing.

Gender differences in medical care have been documented across multiple chronic conditions, such as rheumatoid arthritis, reflecting broader social and cultural norms embedded within health care systems [3, 6]. Research has demonstrated systematic bias against women in the diagnosis and treatment of coronary heart disease, a major complication of diabetes and a leading cause of mortality among women with diabetes. Inequities in diabetic care delivery have been documented separately [7], and among women with T2D, role strain has been associated with poorer self‐care [8]. In a study of medical students and residents, women who presented with ideal symptoms of CHD were less likely to receive accurate diagnosis and treatment than men, especially when their presentation included psychological stressors [9]. Despite this, women's symptoms and care needs are often minimized or attributed to psychosocial factors [9]. These patterns are shaped by socially constructed expectations regarding women's roles as caregivers and family managers, which influence both clinical decision‐making and women's own health‐related behaviors. Consequently, women frequently conceptualize their health as contingent upon the well‐being and functioning of their families, prioritizing collective outcomes over individual needs when making decisions about daily diabetes management [10, 11, 12].

Women's social roles commonly include responsibility for childrearing, housekeeping, emotional labor, and, in many cases, paid employment [10, 11, 12]. Managing these multiple roles is often socially expected and culturally reinforced, particularly for married women, and can result in emotional overload. Among women with diabetes, social role strain has been consistently linked to poorer self‐care behaviors, reduced diabetes self‐efficacy, and lower quality of life (QoL), largely because competing caregiving and household responsibilities constrain the time, energy, and cognitive resources women have remaining for sustained disease management [3, 12, 13]. Women report that diabetes management is deprioritized relative to family needs, financial responsibilities, and caregiving obligations, even when they are aware of recommended self‐care practices [10].

The cumulative burden of caregiving and household responsibilities has important implications for QoL. Among women with diabetes, higher role strain and diabetes‐related stress have been prospectively associated with poorer QoL, particularly in domains related to emotional well‐being and physical functioning [14, 15]. When diabetes management is layered onto existing social roles, women may experience heightened distress, fatigue, and role conflict, all of which undermine sustained engagement in self‐care behaviors, leading to increased risk of adverse health outcomes.

From a public health and clinical perspective, these findings underscore the importance of incorporating women's lifestyle choices into diabetes care planning. Education and treatment recommendations that fail to account for competing role demands may be unrealistic or difficult to sustain. Integrating assessments of role strain and caregiving burden into routine care may improve the relevance and feasibility of diabetes self‐management plans. Addressing the social organization of care within families is therefore essential for improving QoL and health outcomes among women living with chronic disease.

One tool commonly used in the literature to assess diabetic self‐care is the Self‐Care of Diabetes Inventory (SCODI) [16]. SCODI is a validated instrument grounded in the middle‐range theory of self‐care of chronic disease, which measures self‐care monitoring, self‐care management, self‐care maintenance, and self‐care confidence [16]. Incorporating SCODI into regular assessment tools could provide clinicians with a validated method for identifying the mental effort required for diabetes management in individual women. This could in turn help them suggest tools for reducing mental burden, such as closed‐loop insulin pump and continuous glucose monitoring systems, to increase time in target blood glucose range, thereby increasing treatment adherence.

2. Gendered Divisions of Labor and Role Strain

The division of labor by gender is a longstanding feature of social organization, reinforced and reshaped through its interaction with class, skill, and institutional power [17]. Although women's participation in paid employment has increased substantially, unpaid domestic and caregiving labor remains highly feminized across societies [18]. Tasks such as cooking, cleaning, and caregiving are often treated as naturalized extensions of femininity rather than skilled labor, contributing to their low valuation in both economic and social terms. This devaluation directly contributes to persistent gender wage gaps and underscores the need to intentionally teach and normalize men's participation in these essential forms of labor, given their fundamental importance to individual, family, and societal functioning.

Importantly, these dynamics are rarely the result of explicit negotiation. Qualitative research indicates that women frequently assume additional household labor to avoid conflict or maintain relationship harmony, effectively compensating for men's disengagement or claimed incompetence [19]. Over time, this pattern reinforces unequal divisions of labor, increases role strain, and contributes to women bearing a disproportionate burden of unpaid work alongside paid employment, leaving less time and mental capacity for them to manage their diabetes.

3. Capabilities, Power, and Unequal Labor

Sayer's capabilities framework provides a useful lens for understanding how gendered divisions of labor translate into health inequities [20]. Sayer emphasizes that individuals' opportunities to act are not determined solely by internal capacities‐ such as skills, knowledge, or motivation‐ but are shaped by external social conditions, such a norms, institutions, and power relations [20]. Unlike SDOH frameworks, which identify structural conditions that are linked to worsened health outcomes, or role‐strain models, which describe the burdens of competing responsibilities, the capabilities framework addresses why women with adequate diabetes knowledge may be unable to translate that knowledge into self‐care. Sayer's framework reframes this gap as an injustice rather than a personal failure, which is exactly what motivates this commentary's call for structural change. Figure 1 illustrates this pathway from role strain limiting women's mental capacity to forgoing diabetes self‐care to worsened health outcomes.

Figure 1.

Capabilities framework pathway.

Unequal household labor arrangements can be understood as mechanisms that restrict women's capabilities by limiting their time, energy, and opportunity to engage in diabetic self‐care. For example, women are often expected to manage household food preparation, including making separate meals to accommodate partners' preferences or dietary demands, but have often stated that if they are the family member who needs accommodations, they fail to make the diabetic friendly version of the meal [5, 21]. Even when women possess strong health knowledge and self‐management skills, these expectations can undermine their ability to prioritize their own nutritional or medical needs, as additional energy is required to meet others' expectations first, leaving their own health to be forgotten. Importantly, these constraints are not merely logistical but normative, rooted in cultural assumptions about gender and responsibility, especially in cultures where households include more than nuclear family members.

Although the academic literature rarely uses the term weaponized incompetence, and instead refers to the unequal division of labor, popular discourse increasingly employs the term to describe situations in which men avoid domestic or caregiving labor by performing tasks poorly or claiming inability due to lack of knowledge, thereby reinforcing unequal divisions of labor. This phenomenon reflects not only individual shortcomings but socially sanctioned asymmetries in responsibility. By allowing some household members to opt out of unpaid labor, these arrangements systematically shift the burden onto women, constraining their ability to prioritize their own health and well‐being.

4. Diabetes, Role Strain, and Self‐Management

Diabetes provides a clear illustration of how gendered role strain constrains health capabilities. Effective diabetes management requires continuous attention to diet, medication, physical activity, and glucose monitoring. All of these activities demand time, planning, and flexibility, which may conflict with family obligations and, thus, be neglected.

Studies of Korean women with type 2 diabetes can be used as a case study of the consequences of these competing demands. Park and Kim found that greater social role strain was associated with lower diabetes self‐efficacy, while increased social support was positively associated with self‐efficacy [13]. Their regression analysis indicated that decreased role strain, greater social support, and older age accounted for 19% of the variance in diabetes self‐efficacy [13]. Similarly, Park and Wenzel documented how women's diabetes management was frequently deprioritized when faced with competing family needs, financial strain, and employment [10].

Women in these studies often reported abandoning or modifying diabetic diets due to family resistance or the burden of preparing separate meals [10, 13]. Family was not the only conflicting demand in women's lives. Women were unlikely to reduce paid working hours if household finances would be jeopardized, even if their self‐care had to be neglected. These findings underscore that women's diabetes outcomes cannot be understood solely through individual knowledge of health behaviors; they are embedded within household labor arrangements and outside commitments that prioritize the family's well‐being over the women's health.

5. QoL and Long‐Term Implications

The consequences of constrained health capabilities extend beyond diabetes self‐care measures to broader measures of QoL. Individuals with diabetes consistently report lower QOL than those without the condition, with women experiencing particular disadvantages compared to men [14, 21]. As global diabetes prevalence is expected to continue to rise to 850 million by 2050 [2], the number of women managing diabetes alongside extensive unpaid labor is expected to increase substantially. Given women's increasing longevity, these patterns have significant implications for population health and healthcare costs. Failure to address the structural drivers of role strain risks perpetuating cycles of poor disease management, diminished QoL, and escalating medical expenditures.

Notably, much of the empirical literature examining role strain and diabetes self‐management among women has been conducted outside the United States and in type 2 diabetes. This represents an important gap, given evidence that gendered divisions of unpaid labor remain pronounced in U.S. households, and type 1 diabetes has differing health implications than type 2 diabetes. Greater attention to these dynamics in U.S.‐based research is necessary to inform culturally and structurally responsive interventions.

6. Conclusions

Women's diabetes management cannot be fully understood without considering the social demands of household, caregiving, and work responsibilities. Women frequently prioritize the needs of their families and workplaces over their own health and sacrifice their diabetes self‐care, diet adherence, and monitoring routines to meet these obligations. Many women report abandoning diabetic diets due to family preferences, social pressure, or the burden of preparing separate meals. These findings highlight that women's diabetes outcomes are shaped not solely by individual knowledge but by socially structured role demands that systematically place women's health last.

Interventions focused only on patient education or motivation risk mischaracterizing constrained self‐management as nonadherence rather than as a rational response to competing personal demands. Clinicians should therefore incorporate household labor, caregiving responsibilities, and work obligations into care planning, recognizing that these social roles directly affect women's capacity to follow medical recommendations. In future research, investigators should measure role strain, unpaid labor, and social support in studies of diabetes outcomes. These results can also help policymakers address gendered inequities in both unpaid and paid labor as a strategy for improving women's health.

Unequal divisions of domestic and caregiving labor remain a fundamental yet underrecognized determinant of women's health. These arrangements are structural constraints that limit women's ability to convert internal capacities into realized health outcomes. Diabetes provides a clear example of how gendered role strain undermines self‐efficacy and QoL: not through individual failure but through socially patterned expectations and power relations. Efforts to improve women's health must move beyond individual behavior change to confront the gendered organization of labor that continues to determine who is able to care and who is expected to sacrifice.

Author Contributions

Kylie B. Lovett is the sole author of this commentary and is responsible for the conceptualization, literature review, writing (original draft), and writing (review and editing) of the manuscript.

Ethics Statement

This commentary does not involve original research with human data or animal subjects. IRB approval was not required for this work.

Conflicts of Interest

The author declares no conflicts of interest.

Declaration of Generative AI and AI‐Assisted Technologies in the Manuscript Preparation Process

During the preparation of this work, the author used Claude (Anthropic) to assist with editing for clarity, organization, and formatting along with reference formatting in Chicago Note Style. All content was reviewed and revised by the author, who takes full responsibility for the content of the manuscript.

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.