Current Trends in the study of Gender Norms and Health Behaviors

Abstract

Gender norms are recognized as one of the major social determinants of health and gender norms can have implications for an individual’s health behaviors. This paper reviews the recent advances in research on the role of gender norms on health behaviors most associated with morbidity and mortality. We find that (1) the study of gender norms and health behaviors is varied across different types of health behaviors, (2) research on masculinity and masculine norms appears to have taken on an increasing proportion of studies on the relationship between gender norms and health, and (3) we are seeing new and varied populations integrated into the study of gender norms and health behaviors.

Introduction

Gender is recognized as one of the major social determinants of health. According to the American Psychological Association, gender norms refer to, “the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for boys and men or girls and women” [1]. While gender is sometimes viewed as something that an individual is, current social science understandings of gender emphasize that it is something that an individual does through their behaviors and interactions with others [2]. Thus, a person’s behaviors are critical to their ability to fit into cultural gender norms. These gender norms can play a powerful role in a person’s life since deviating from the norms associated with one’s biological sex can be met with censure from peers, social exclusion, and sometimes even emotional or physical violence [3, 4].

Conforming to gender norms can have implications for an individual’s health because certain behaviors considered to be normative for a particular gender may be associated with health outcomes [4, 5]. For example, it is normative for men in many cultures to drink alcohol excessively [6], avoid certain healthy food options [7], or avoid health-care [8]. Each of these behaviors has implications for the overall health of men. Similarly, for women, gender norms may have effects such as lessening decision-making power over family planning behaviors [9] or limiting physical activity out of a concern for appearing less feminine [10]. The role of gender norms on health behaviors is typically slightly different for men and women. Risky health behaviors are expressions of masculinity for men, but, for women, gender norms can constrain women’s power and limit their ability to take control of their health [11, 12]. In both cases, the influence of gender norms on health operates through health behaviors.

In a foundational article, Mokdad and colleagues identify the major health behaviors that are the leading causes of death in the United States [13]. Below, we review the recent advances in research on the role of gender norms on each of these types of health behaviors. While numerous studies explore gender differences in health behaviors (e.g. differences in smoking patterns between males and females), we focus on those articles that are exploring and explaining how gender norms, masculinity, or femininity influences these behaviors.

Gender and Health Behaviors

Diet and Physical Activity

Empirical research on the role of gender norms in diet and physical activity related behaviors is limited and lacks coherent trends. Two articles examined the role of gender dynamics – specifically the role of wives as food-preparers – in men’s eating habits [14, 15]. These studies highlight the lack of power and control that men have over their diets because food preparation is a traditionally female domain. Other research explored whether or not food choices are used to construct one’s gender identity. One study found that men sometimes eat meat is because it makes them feel more masculine [16], and another study showed that women’s choice of being a meat-eater or vegetarian is unrelated to how closely she conforms to feminine norms [17]. These studies suggest that the choice of eating meat is more associated with masculinity and unrelated to femininity. Another area of this research explores the role of gender norms in eating disorders. Research has long recognized the role of feminine norms in women’s eating disorders related to striving for thinness, but two recent studies have explored how men’s disordered eating may be related to feminine or masculine norms [18, 19]. These studies suggest that eating disorders among men may be more related to conformity to constructs of femininity rather than masculinity. Though, muscularity-oriented eating disorders are associated with masculine norms [18]. Finally, a few recent studies in this area examine media portrayals of diet and physical activity and how they influence men and women. Media portrayals of men depict them as unconcerned about weight issues and that dieting is exclusively a female behavior [20]. Two other studies showed that consumption of certain types of media (e.g. men’s magazines) were associated with both men and women’s drive for muscularity [21, 22]. Taken together, the recent literature suggests research on diet and physical activity is increasingly considering the importance of gender and gender norms but the research is still limited.

Sexual Behaviors

Research on the role of gender norms in sexual behaviors is relatively well-developed compared to other types of health behaviors. In recent years, researchers have continued to add to the evidence that attitudes towards gender norms are associated sexual risk behaviors. These studies find that men who believe in traditional gender roles (i.e. separate roles for men and women) are more likely to have a greater number of sexual partners or avoid condom use [23–27]. Though these studies are not the first to document this relationship, they document this relationship within a wider range of populations and measures. Notably, Nelson finds that there is no relationship for women between attitudes towards gender roles and sexual behaviors, indicating that the mechanism may be more salient for male populations [25].

Recently, there have been several articles that explore gender dynamics and gender roles within sexual and gender minority populations. For example, two articles explored the concept of ‘gender affirmation’ within transgender individuals sexual risk behaviors [28, 29]. Given that penetrative sex is socially constructed as a masculine individual penetrating a feminine individual, these studies find that some transgender women who have sex with a man consider that act to affirm their femininity and status as a woman [28, 29]. These transgender women describe seeking out sexual relationships with men or engaging in sex work in order to affirm their feminine identity. Two studies with men who have sex with men similarly demonstrate that sexual roles (insertive vs. receptive sexual partner) usually translate to gender roles where the insertive partner is considered masculine and has greater sexual decision-making power and the receptive partner is feminized and has less power [30, 31]. Another study showed that for men who have sex with both men and women, condom use with women is negatively associated with their gender role conflict (i.e. concerns about demonstrating masculine characteristics), but there was no relationship between gender role conflict and their condom use with men [32]. Each of these studies highlights the ways that gender and power dynamics can vary across different types of relationships and that the resulting association with sexual behaviors can also vary.

Substance Use

Unlike sexual health behaviors, substance use research has a less developed history of examining gender roles. However, recent articles addressing gender norms and their influence on substance use behaviors have typically focused on three content areas: 1) alcohol, 2) tobacco, and 3) other forms of substance misuse, including injection drug use, prescription drug abuse, etc. Articles discussing gender norms and alcohol often linked problematic drinking to different types of masculinity that equated drinking with demonstrating masculine traits [33–37] and also how masculine ideas that discourage help-seeking may prevent men from entering treatment programs [38, 39]. Of research examining gender and tobacco, multiple articles focused on men and highlighted that smoking cessation programs can be successful by encouraging positive masculine ideas such as responsibility and fatherhood [40–43]. There was also research suggesting increasing gender equality by challenging traditional gender norms may encourage women to engage in unhealthy behaviors like smoking [44] and problematic drinking [45, 46]. Specifically, women who endorse more equitable roles for men and women may adopt what they view as traditionally masculine behaviors as a means of demonstrating parity. However, other research suggests that increased gender equity may reduce alcohol consumption among both men and women [47]. Both sets of findings point to the potential importance that gender norms play in substance use and health behaviors writ large and the need to continue to examine it in future studies on substance use. There were few articles that examined gender norms and other forms of substance use beyond alcohol and tobacco. Those that did were focused on the intersection of sexual/violent behaviors, substance use, and gender norms, not on the direct relationship between gender roles and substance use [48, 49]. There seems to be an emerging trend to examine the role masculinity plays in substance use; however, more research is needed to better understand conflicting findings and extend beyond alcohol and tobacco to other forms of substance use.

Injury and Violence

The discussion of gender within the field of injury and violence is varied. Research on injuries tended to focus solely on gender differences with the exception of research on suicide which has a well-developed body of literature on the role that masculinity plays in suicide. Several recent articles argue that suicide rates among men are persistently higher than among women due to the difficulty they face attaining traditional masculine norms, including personal autonomy and socio-economic security [50–52]. Further, researchers suggest that adhering to certain masculine norms that discourage help-seeking when emotionally distressed further encourage suicidal behaviors among men [53, 54]. Similar to suicide, articles focused on violence have seen a wealth of publications examining the role of gender norms, particularly research focused on gender-based violence. Multiple gender-based violence researchers called for reducing harmful masculine norms in order to encourage increased gender equity and reduce in men’s violence perpetration – including a special issue of the journal Lancet dedicated to this topic. Recently interventions targeting unhealthy masculine norms to decrease gender-based violence have recently shown positive results both in the United States [55] and globally [56–58]. Intimate partner violence and domestic violence has increasingly moved to focus on primary prevention efforts by targeting perpetrators, typically male, that endorse unhealthy masculine norms [59–62]. While most recent studies on other types of violence (e.g. child abuse, peer violence, youth violence, and sexual aggression) tends to confirm that supporting traditional masculine norms play a role in violence perpetration, one study on sexual aggression found that men who experience high levels of shame about their bodies often react aggressively to women in sexual situations when they perceive that the women is slighting their appearance [63]. Though injuries and violence are usually categorized together, the literature from the past two years demonstrate the divide between the study of injury and violence with respect to gender roles. Apart from suicide, the examination of gender roles and norms – and masculinity in particular – seems limited to research on violence perpetration.

Preventative Health Behaviors

Preventive health behaviors include those behaviors related to getting vaccines, screened for cancer or other health problems, or seeking help for health problems. Several recent articles explored the role of masculine norms in men’s screening behaviors related to getting a digital rectal exam, including within new populations [64–67]. An article by Christy reviews some of the evidence over the past decade and highlights the specific aspects of masculinity that impact men’s decision to get screened: self-reliance, avoidance of femininity, heterosexual self-presentation, and risk-taking [65]. One recent study found that even men who do get screened frame their decision within masculine norms, but they focus on the masculine norm of responsibility [66]. Screening services (e.g. breast and cervical cancer screening) for women were also shown to be related to women’s adherence to masculine norms, but that women who adhered to masculine norms were more likely to be screened rather than less likely.

Seeking health services is often examined through a gender lens. Studies over the past two decades show that women are sometimes constrained by gender norms that limit their decision making power, and several recent studies echoed these ideas in various settings [68–70]. Studies have highlighted men’s avoidance of help-seeking behaviors as a strategy to demonstrate their masculinity [71]. One recent study explored men’s health seeking behavior in a new way. Sanchez and colleagues interviewed identical male twins where one identified as gay and the other identified as straight [72]. They showed that the straight men were more likely to endorse traditional masculine norms and less likely to seek health care services than their co-twins. These studies demonstrate the interrelation of sexual identity and gender identity and their role in seeking health services.

Conclusions

There are several key findings and trends to note. First, the study of gender norms and health behaviors is varied across different types of health behaviors. There were far more articles examining gender norms and sexual or violent behaviors, and those fields have had a longer history of researching this relationship. Thus, the studies discussed here are more varied and tackle more dimensions of the relationship. In contrast, research on other types of health behaviors appears to be more nascent, and there were fewer studies to draw upon. Second, research on masculinity and masculine norms appears to have taken on an increasing proportion of studies on the relationship between gender norms and health. Historically, gender studies was often associated with research on women [12] and focused on the limitations gender norms placed on their health behaviors. But, recently, more articles explore the role that masculinity plays in men’s – and sometimes women’s – risk behaviors. In fact, in 2013, there was a special issue of Health Psychology titled ‘Men’s Health: Masculinity and Other Influences on Male Health Behaviors.’ Third, we are seeing new and varied populations integrated into the study of gender norms and health behaviors. Transgender individuals are a population that is gaining increasing attention in the research on sexual behaviors, and we are seeing research on gay and lesbian populations integrated into research on health behaviors beyond just sexual behaviors [73]. Researchers are also exploring culturally specific forms of masculinity and/or gender norms in various countries beyond just the United States or Europe.

Researchers need to continue building the evidence base for the relationship between gender norms and health behaviors. To move the field forward, researchers will need to focus on examining the mechanisms by which these norms influence behaviors. Additionally, we need further exploration on how gender norms lead to health outcomes differently for men and women. As a social determinant of health, gender norms play an important role in the health of individuals and documenting and exploring this relationship can help improve health at the population level.

Highlights.

• Gender norms play an important role in men and women’s health behaviors

• Research on gender norms is most developed in studies of sexual behaviors

• Recent studies of gender norms and health behaviors are more focused on masculinity

• Gender norms and health research is expanding to new populations