Book Review

Gender and Health: The Effects of Constrained Choices and Social Policies

N Engl J Med 2008; 359:1187September 11, 2008

Article

Gender and Health: The Effects of Constrained Choices and Social Policies
By Chloe E. Bird and Patricia P. Rieker. 256 pp. New York, Cambridge University Press, 2008. $85 (cloth); $29.99 (paper). ISBN: 978-0-521-86415-2 (cloth); 978-0-521-68280-0 (paper).

We take for granted that on average, women in the United States live longer than men, even though they are subject to more chronic disease during their lifetimes. Research findings inform us as to how we can reduce our risk of various diseases and increase our life spans — we can stop smoking, drink less alcohol, exercise more, and eat less. Yet despite this simple advice, many people fail to take the steps necessary to maximize their health. This observation has prompted Chloe Bird and Patricia Rieker to write this book, in which they examine the opportunities and choices that men and women confront when making health-related decisions, the constraints that are imposed on that decision-making process, and the differential effect of those constraints depending on sex.

The authors direct their inquiry at three levels of social context: the larger society, the community, and the work and family environment. Many of the issues they raise have been addressed in other contexts. These issues include the value of family-friendly medical leave policies; the expansion of Medicare coverage; flexible work hours; the increasing costs of health care insurance; racial, ethnic, and socioeconomic segregation; and the search for a favorable balance between commitments at work and at home. The authors provide a broader and deeper understanding of these and other issues through their specific emphasis on the biological, psychological, and sociological implications of differences in sex. Variations in socioeconomic status, race, or ethnicity do not adequately explain the differences that exist between men and women with respect to longevity, health status, and health behaviors. The authors argue that a failure to recognize the differential gender constraints ultimately prevents us from developing interventions that will more successfully effect behavioral change so as to maximize health. Their examination of these gender differentials is reinforced by their portrayal of a hypothetical middle-class family that, like many families, is confronted with multiple impediments to its efforts to maximize the health of each of its members — all while simultaneously trying to operate within a finite household budget, manage the ever-growing costs of living, deal with increasing employer demands, and navigate the logistical complexities of everyday life.

Bird and Rieker do not confine their discussion to the United States but provide cross-national comparisons with respect to wealth, social policy, and health status. These comparisons lend further support to their premise: policy choices made at multiple levels of governance act directly and indirectly through their establishment, reinforcement, and transformation of social roles and gender relations to constrain our health-related choices and opportunities differentially by sex. Their comparison of health and economic indicators across countries with greater life expectancies and economic wealth underscores the irony of the position of the United States: even as we emphasize individual choice and responsibility for health, we fail as a nation to address and rectify the larger constraints that constitute barriers to opportunities and impediments to choice.

Gender and Health does not provide answers to the questions posed. Rather, the authors challenge their readers to adopt a broader perspective in their approach to the formulation and evaluation of social policy, the conduct of research, and the provision of patient care through an integrated consideration of the biological and social dimensions of gender.

Sana Loue, J.D., Ph.D., M.P.H., M.S.S.A.
Case Western Reserve University School of Medicine, Cleveland, OH 44106
sana.loue@case.edu