Why Men Don't Have To Die So Early (But Do Anyway): Sex and Gender Differences in Longevity

[Source] Data from August/September, 2001.

In a recent course on gender role socialization, I had the opportunity to do a bit of research into longevity, which is becoming a pet topic of mine. In doing so, I found a lot of information about why men die earlier - about 5.4 years earlier in the U.S. - than women. It seemed silly for only one person, a professor, to read it after I'd spent time on it. Especially since there is so much that men (both very gender-typed ones and males who eschew the label) in the internet audience, can do a lot to change health trajectories and add years to life. In just one testament to the amount of control we really have over our health, Dan Buettner, a researcher who focuses on twins' health outcomes and longevity, says that people, regardless of sex, have it within their power to add as much as 10 years onto their lives. With that in mind, enjoy factsnacking on this bloggofied version of the paper.

[Oh, and please forgive the writing style; I'm a social sciences person and we can be a little stiff like that. This is by no means a complete or exhaustive review of the literature on this, just a lil' something to raise awareness. As with all my original content, comments enouraged]

For more on why gender roles do real, measurable damage on men and women, see William Pollack, A New Psychology of Men, and the wiki on gender roles.

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Despite the longstanding patriarchic belief that females are naturally the weaker sex, modern research clearly demonstrates that men have significantly more impairments in physical health behaviors, predispositions, and outcomes. The mortality rate in the U.S. for men is consistently 1.5 to 3 times higher until 85 years of age. Men make up 70% of heart attack fatalities before the age of 65 as well as the majority of cases of mouth, throat, skin, and urinary organ cancer (Kilmartin, 2010, p. 178-9). Typically, men die 5.4 years earlier than women and have a 43% greater age-adjusted mortality rate (class notes). This has been the status quo long enough that the New Oxford American Dictionary makes reference to women as exemplar for longevity: “the greater longevity of women compared with men” (Longevity, 2005). Why should it be the case that so many more men die at younger ages? Why is it that women have a lead in longevity? Some theorists point to biological rationales, saying that differences in specific attributes of physical development are the root cause. Others point to social and psychological sources for the gender gap. These explanations are not mutually exclusive; framing the issue as nature versus nurture is a false dichotomy. In fact, the biological, socio-cultural, and psychological realms interact in a complex and recursive fashion.

Biological Factors

The biological contributions to the gender gap in mortality typically involve either a protectant predisposition for females or an innately harmful risk for men. For instance, it is commonly accepted by the scientific community that men are more vulnerable to disease because of their genetics: females have two X chromosomes whereas males have one X and one Y. Having an extra copy of the X chromosome provides females with an increased resiliency to X-linked disease because both X chromosomes must have copies of the (recessive) gene that codes for that disease in order for it to be expressed phenotypically (Kilmartin, 2010, p. 182). That is, the “effects of deleterious recessive genes on the X chromosome… are exposed [for men] because there are no corresponding genes on a paired chromosome as there are for females” (Kruger & Ness, 2006, p. 80).

This means that men more likely to experience debilitating X-linked disorders, whether they be dominant or recessive, the most common of which include Hemophilia A & B, Fragile X syndrome, and various types of muscular dystrophy (General Practice Notebook, 2009). However, disorders such as these comprise a relatively small effect on the overall mortality gender gap. As Waldron (quoted in Kilmartin, 2010) succinctly stated, “Most of the common X-linked diseases aren’t fatal, and most of the fatal X-linked diseases aren’t common” (p. 182). This consideration is crucial to the argument being made here: a great number of small to moderate influences add up to create a longevity crisis for men. Genetic predisposition is just one factor of many biogenic and psychogenic causes.

A much more powerful type of biogenic influence on mortality rate is the different levels of hormones in males and females. In humans and many mammalian species, postpubertal males typically exhibit substantially higher levels of the androgen testosterone than do postpubertal females (Regan & Berscheid, 1999). Several sources suggest that having higher levels of testosterone puts men at a significantly greater risk for many health-related problems, such as stress- and aggression-related illness as well as heart disease. For example, females are partially protected from the influence of “bad cholesterol” (LDL) because of their lower levels of testosterone and higher levels of estrogen, which exacerbate and retard the development of atherosclerosis, respectively (Kilmartin, 2010, p. 182-3; Lawlor, Ebrahim, and Smith, 2001). Men, however, have the opposite mixture, which provides no benefits and leaves men vulnerable to heart disease.

The direct link between testosterone and physical aggression in animals is well established (e.g. Breuer, McGinnis, Lumia, & Possidente, 2001; McGinnis, Lumia, Breuer, & Possidente, 2002), and has been typically experimentally investigated by direct injection of male laboratory animals with androgenic steroids (which produce androgens, i.e., testosterone). The link between the two in humans is less clearly defined, due to the methodological and ethical problems in experimentally manipulating hormone levels in human subjects and the resulting paucity of data. All the same, literature reviews and meta-analyses suggest a weak to moderate correlation between testosterone levels and physically aggressive behavior (Hyde, 2005, p. 584; Regan & Berscheid, 2005, p. 300).

This suggests that men are predisposed to higher levels of physical aggression, which is itself further positively correlated with incidence of numerous frequently fatal health issues including heart disease, cancers, ulcers, and hypertension (Johnson, 1990). This is likely because increased physical aggression often leads men to hostile, competitive problem-solving strategies, creating a feedback loop where stress and anger beget more of the same and frequently put men in dangerous situations. Overtime, this regulates the body to be used to higher levels of cortisol and, consequently, blood pressure (a leading cause of hypertension; Johnson, 1990). Moreover, it has been observed that males who do no produce testosterone have greater longevity. Historical anecdote, numerous research observations, and classic studies comparing eunuchs and “intact” males that eunuchs, whose bodies produce little or no testosterone, tend to live longer (Kilmartin, 2010, p. 183) – an average of fourteen to fifteen years longer (Owens, 2002, p. 2009)! Contrarily, females’ naturally lower levels of testosterone and higher levels of estrogen act in combination to protect them. Females exhibit higher levels of the pituitary hormone oxytocin, which is associated with the inhibition of the sympathetic nervous system and facilitation of the parasympathetic nervous system (i.e. an overall calming effect). This could explain why females observed in experimental settings are far more likely to respond to stressors with much more heart healthy “tend-and-befriend” strategies (Taylor, et al. 2000). It should hold, therefore, that men stand a much worse chance at surviving disease based on their natural hormonal levels.

Owens (2002) goes further to explain that the significantly higher levels of testosterone in males has direct influence, not just on aggression, but also on “differences in male and female structural, physiological, endochrineological, and immunological systems (Kruger & Nesse, 2006, p. 80). These differences frequently have the effect of favoring female longevity and shortening the lives of males. For example, testosterone results in men having physically bigger bodies, putting them at increased risk for heart-disease, bone and joint problems, and developmental issues (Kruger & Nesse, 2006, p. 80).

 Further, for reasons not fully understood, testosterone acts as an immunosuppressant, making males remarkably more vulnerable to the influence of bacterial, viral, and parasitic disease (Owens, 2002). This demonstrated biological disadvantage harms men more than women across the board, but is moderated by environmental hazards and geographic location: in the U.S., U.K., and Japan, men are approximately twice as vulnerable as women to parasite-induced death; in Kazakhstan and Azerbaijan, where the overall incidence of parasite-induced death is much higher, men become four times more likely to die from parasites (Owens, 2002, p. 2009).

 These demographic data suggest the need for integrative interpretations of the effect of hormones on the sex difference in longevity: the environmental conditions interacted with naturally occurring biological differences between males and females to produce effects that were advantageous for one group (females) and disastrous for another (males).  In the next section, it will be demonstrated that the role of society further moderates and complicates the gender gap in longevity.

Socio-cultural Factors

While there is ample evidence to support the conclusion that men are biologically and naturally at risk for disease and earlier deaths, it should be noted that social and cultural factors aggravate this problematic biological reality. It is estimated that approximately 50% of the mortality gap can be attributed to behavioral factors (JAMA finding reported in class lecture), which are influenced by cultural and social standards.

  

The largest single factor of this kind is certainly the influence of prescriptive gender norms, which guide and constrain the cognition, affect, and behavior of men and women. These roles define what it means to be a gender-typed person, one who embodies (or especially strains themselves to fulfill) the recommended vision of what a man or woman should be. Traditional gender norms dictate that men be strong, tough, independent, and rigidly unemotional whereas women should be chaste, self-conscious, emotionally expressive, and concerned with their appearance, to name a few. The result is that women construct femininity in ways that promote positive health behaviors and men construct masculinity in ways that exacerbate their biological disadvantage, leading to very different life-style choices. 

Thus, women, by societal standard, are expected and encouraged to engage in physically and mentally healthy activities such as exercising and eating “light”, regularly visiting and asking questions of a physician (for reproductive health if for nothing else), avoiding smoking and chewing tobacco, moderating their alcoholic consumption, and actively seeking interconnectedness and cooperation. Men, on the other hand, are further burdened by the expectations that they continue to work when they are sick, gorge themselves on foods high in fat and sodium, chain smoke cigarettes and cigars, chew tobacco, fight for dominance, eschew the help of mental health professionals, and remain “strong and silent”. That is, women are encouraged to see “eating light and staying fit” as a part of what normal women do, as a part of what makes them women, whereas men are encouraged to bond over excessive alcohol, smoke, and red meat. The cumulative effect of this difference in social programming and expectation is that men have far more problems with obesity, heart disease, and tobacco, alcohol, and drug related diseases.

Taking the health risk into account, it seems pertinent to ask: why would so many men still wish to hold fast to traditional gender prescriptions? Gender norms are so pervasive because they provide common social ground on which to connect to, bond, build, and maintain relationships with same-sex individuals. Men are socialized from an early age to know what “safe topics” there are with other men: sports and women, for example. Topic selection like this demonstrates how norms act as a quick and easily referenced set of instructions. They are close at hand because they have been instilled in men and women since they were boys and girls. Consequently, it can be much more difficult for an individual trying to break the norms. For one, it becomes harder to figure out what to do in an ambiguous situation without relying on norms to shape behavior (e.g. attempting to throw “men drink beer and talk about sports” out the window and instead focus on cooking with the guys might get one called shaming words like “fag”). This second concern of avoiding the experience of social isolation or shame is common as social punishment is the de rigueur response to disregarding norms from gender-typed individuals.

Another valid explanation for why men continue abominable social and health behaviors in the face of health research is the influence of those in direct contact with them. Specifically, one’s same-sex friends, family, and co-workers are the greatest single factor in predicting one’s health behaviors (lecture notes). This is because seeing other people’s behaviors – especially when one is close to the other people and likes them – strengthens the perception that these habits are normal, typical manly or womanly behavior, thereby encouraging it. This influence is the strongest when 1) the norm in question in observed in all of those around you (unanimous), 2) the norm is observed in an important group of people, such as upperclassmen to a college freshmen (salience) and 3) when it is observed in people very similar to the observer (identification with the familiar).

As an example, imagine four male friends in their mid-twenties getting in a pick-up truck, heading out for an evening together. When they get in the cab, three of them (the gender-typed males) do not buckle up their seat-belts. Two of those same three light up cigarettes, as the third had been chewing tobacco most of the night. What goes through the mind of the fourth guy, the one who is normally inclined to intelligently practice motor vehicle and pulmonary safety, is some equivalent of “Oh shit! I need to do what a man does here in order to fit in! I certainly don’t wish to be ridiculed, shunned, or mocked”. The result is that this type of social influence – where it is experienced as unanimously upheld, in a salient group, with similar individuals – often leads men to make poor health decisions, even when they are well informed of the dangers. This is true for a wide array of high-risk activities that men often die from, e.g. diet, needless violence, eschewing social support, not getting an annual physical, and not exercising (class notes).

As this is true for males with male friends, this is also true for males with male family members; these sorts of poor health behaviors are socially reinforced through the generations:

Communities with high rates of father absence, incarceration, or other features that mimic high extrinsic mortality rates may be especially prone to encouraging shorter-term, higher-risk strategies, which will in turn lead to higher rates of early mortality… Thus, multiple generations may exhibit similar behavioral and health patterns (Kruger + Nesse, 2006, p. 80).

Without the social support of loving fathers, many men learn few low-risk, alternative strategies to survival by observation. The simultaneous guidance and constriction of gender norms – and indeed, all social norms – must be all the more attractive to such men, as they are pervasive and aid in building relationships with other men. In combination with friendships and work-relationships that likely reinforce the same stereotypes and negative health behaviors, men in situations like the ones described by Kruger + Nesse may have few protective health factors and, consequently, develop high-risk life-styles.

As one might suspect, this has a direct impact on the male to female mortality ratio (M:F MR): the most male and the least female deaths occur in young adulthood (Kruger + Nesse, 2006, p. 92). Male deaths at this age result mainly from external causes of death (such as high-risk stunts, drinking and driving, male-on-male violence). The next spike in the M:F MR comes in mid to late adulthood, the result of death from behaviorally moderated internal causes (e.g. more men die from smoking, eating foods high in fat, cholesterol, and sodium, etc. at this age). This is consistent with “the lag in the impact of health-related behaviors on mortality” (Kruger + Nesse, 2006, p. 92) that had been learned from peers and family at a young age.

Is it inevitable, then, that this male morbidity is a natural and necessary consequence of biological and social life? Of course not. There is a further level of processing affecting health behaviors needing consideration: the individual psychological.

Psychological Factors

In the previous section, it was demonstrated that individuals feel pressure to play into their gendered norms because, psychosocially, we have an innate desire to belong to groups. For men, making poor life-style choices often helps individual males feel more connected to their male peer groups and to “Men” as a whole. Recalling Pleck’s sixth proposition that “an actual or imagined violation of gender roles leads to an overperformance of those roles” (lecture notes), this illogical behavior can be explained in terms of proto-typicality threat. That is, that men tend to be overly aggressive and overly carefree about their physical health in order to seem like the proto-typical Man, domineering and never needing external aid. Physical health risk becomes a form of posturing to secure social position in this way, barring men from avenues toward genuine expressions of self-care.

Aside from physical health behaviors, another way that the proto-typicality threat becomes manifest in men is in their experience with emotional restriction. According to traditional masculinity, men are taught that there is only one emotion that is socially acceptable for men to display publicly: anger (Pollack, 1999). The rest of the broad spectrum of human emotion is kept locked away for the gender-typed man, and the only way he has to show it is through enraged outbursts. This has already been shown to have numerous adverse biological consequences (Johnson, 1990). Conversely, women are, across cultures, more prone to disclosure of emotions and more apt to use emotionally descriptive language in their conversation and writing (Kilmartin, 2010, p. 162).

It has been noted that the mere act of emotional disclosure is both normal and very frequently beneficial to the person’s psychological health (Lepore + Smyth, 2002; Pennebaker, 1997; Frattaroli, 2006). More specifically, numerous studies confirm the finding that expressive written disclosure has directly measurable immunological benefits and subsequent drops-off in disease related doctor’s visits (e.g. wherein the effects lasted two months after writing: Pennebaker, Kiecolt-Glaser, and Glaser, 1988; Greenberg and Stone, 1992; Richards, Beal, Seagal, + Pennebaker, 2000; wherein the effects lasted 6 months after writing: Pennebaker, Colder, and Sharp, 1990; Francis and Pennebaker, 1992; wherein the effects lasted 1-4 years after writing: Pennebaker, Barger, and Tiebout, 1989, Gidron, et al., 2002), as well as emotional processing (Russ, 1992; Bodor, 2002; Campbell, 2003) and behavioral functioning (Francis and Pennebaker, 1992; Spera, Buhrfeind,  Pennebaker, 1994; Pennebaker and Francis 1996; Cameron + Nicholls, 1998; Krantz and Pennebaker, 2007). Based on the evidence presented by Kilmartin (p. 162), it would seem men are getting none of these benefits because they are so discouraged from disclosure. What is worse is the sense that this rigid stance toward emotional life is a normal part of “being a guy” and that breaking from this norm is deviant. This deviance is avoided by overperformance (never, ever expressing normal feelings) continuing the vicious cycle of non-expression. This large body of research suggests there is a range of psychological and physical health benefits that men are denied to emotionally straitjacketed, gender-typed men.

As a result, men underreport psychological illness and are less likely to seek mental health services despite high success rates in treatment with common problems such as depression or anxiety (class notes). Common “manly” alternatives to these methods of treatment are simultaneously self-medicating and self-destructive— substance abuse, which men are more likely to be diagnosed with (class notes), suicide, which men are four times as likely to complete than women in the U.S. (Kilmartin, 2010, p. 184), tobacco use, which kills twice as many men as women in the U.S. (Kilmartin, 2010, p. 186), and distracting themselves from the problem by engaging in high risk behaviors such as “drunk driving, drug dealing, sharing hypodermic needles, use of firearms, high speed driving, [and] engaging in gang violence… many more males than females participate in these behaviors” (Kilmartin, 2010, p. 188). This strong psychological tendency of gender-typed males to engage in so many self-harming activities and participate in so few psychologically rewarding ones constitutes further addition to the overall sex-difference in longevity.

A "Biopsychosocial" Explanation

Taking into account the numerous harmful biological predispositions, intense social pressure to engage in self-harm and self-neglect, and the psychological need to belong and to avoid shame, it is no wonder that men die so much earlier than women. Over the course of the life-time, biology favors the longevity of women and curtails that of men. But, biology per se does not cause sex differences in mortality; by itself, biology can only account for at most two thirds of the variation and at the least one quarter of it (Kilmartin, 2010, p. 182). Social forces exacerbate these basic biological differences. Females – who already are biologically inclined toward less hostile, less competitive solutions to problems because of their low testosterone, high estrogen, and oxytocin, and therefore, toward living longer – become Women, having been socially programmed to know that women are creatures who care about their appearance, ask questions about health, and maintain their bodies. Males – who are biologically inclined toward aggression and competitive solutions to problems because of their high testosterone, low estrogen, and lack of oxytocin, and therefore, toward dying earlier – become Men, who are socially programmed to be violently competitive, independent at all costs, and inexpressive unto death. In each case, biology interacts with social and psychological forces— males and females overperform as Men and Women in order to conform to gender roles and to avoid the psychological costs of shame and ostracism. It is truly a harmful and outdated system for all involved. Yet, only for men is the summation of the biological, social, and psychological interaction over a lifetime of development work out to poor health and tragically shortened lives.

Conclusion

 

What is vital to retain from all this research is that only the biological factors are completely out of the reach of individual influence. Recall the non-gender-typed man in the example about smoking and seat-belt usage: for him, as for all men who observe they are in the minority on traditional “manliness”, there is a way out. It takes boldness, certainty of will, and clear judgment – virtues few gender-typed males ever truly develop. But if that fourth man can take a stand in favor of healthy choices and a return to common sense, then over time the cumulative effect of social change will start to level out the sex differences in mortality rates. Men need to see one another being smart about their bodies and their mental health. And as this happens, as men are made aware of biopsychosocial explanations for differences, and as research continues to demonstrate the need for new definitions and appreciations of what it means to be men, perhaps more will find the will necessary to take a stand, to live a life well and long.

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