Introduction

Gender, like socioeconomic status, shapes individual opportunities and experiences across the life course. While many experiences of childhood are similar for boys and girls, they are exposed to different risks. Men and women occupy different positions in the labour market and in the home, which again bring different health risks.

Inequality

Mortality and life expectancy
Mortality is greater in males at all ages. In childhood, from 1 to 14 years, the higher mortality rates in boys are because they are more likely to die from poisoning and injury, including motor vehicle accidents, fire and flames, accidental drowning and submersion. The gender difference in mortality rates widens in the teenage years so that by the age of 15 years boys have 65 per cent higher mortality than girls. Over the last 20 years, the difference in childhood mortality rates between boys and girls has remained constant, despite falls in overall mortality62.

In adult life, mortality is also greater in men. This is most pronounced in youth and early adulthood. For instance, the mortality rate is 2.8 times higher for men than for women aged 20-24 years. In youth and early adult life, the cause of the differences in mortality rates is the higher rates of male death from motor vehicle accidents, other accidents and suicide. Furthermore, mortality rates for women aged 25-40 have declined over the last 20 years, whereas those for men of the same age have increased469,470.

Across the whole of adult life, mortality rates are higher for men than women for all the major causes of death. These include cancers and cardiovascular disease. However, the specific cancers vary between the sexes. In women, breast cancer is the most common neoplasm to cause death (lung cancer is the second most common), whereas in men it is lung cancer (prostate cancer is the second most common). The overall fall in mortality rates since 1971 has been accompanied by a slight reduction in the differential death rates between men and women. In 1971 males had a 64 per cent higher mortality rate than women. By 1996 this had reduced to a 55 per cent higher rate in men25.

Life expectancy is 5 years longer in women than in men. Overall life expectancy has increased for both sexes throughout this century26. Recently, the increases have been slightly greater for men than women, reversing an earlier slight trend in the opposite direction. However, for healthy life expectancy, that is years of life free of disability or chronic illness, there is a smaller gender difference. Women have a 2 to 3 year greater expectancy of healthy life than men. Overall healthy life expectancy has changed little over the last 10 years and the difference between men and women has also remained constant27.

The choice of measure of socioeconomic status may influence the pattern of health inequalities observed. For example, measures based on occupation may reflect different facets of life for men compared to women, but the extent to which this affects observed patterns of health between and within sexes is unknown. Using the Townsend index as a measure of deprivation, the different effects of socioeconomic status and gender are such that the least well off women still have lower mortality rates than the most well off men (figure 16)73. In general, gender differences in mortality are smaller in areas of relative affluence and greater in the most economically deprived areas471,472.

Furthermore, there are differences between the genders in the magnitude of the socioeconomic gradient in mortality. Analyses have shown that, for all-cause mortality, the gradient is steeper in men than in women, and that this is also the case for the major causes of death, with the exception of cardiovascular disease471,472. These differences between and within genders have important policy implications.

They suggest that policies which decrease socioeconomic inequalities will have a differential effect by decreasing male mortality, and particularly mortality in more disadvantaged men. They also suggest the need for gender specific policies to reduce inequalities, because the causes of inequalities may be different for men and women.

Morbidity
A traditional view of gender differences in morbidity has been to highlight an apparent paradox: that males have higher mortality rates but females have higher rates of morbidity473,474. However, in more detailed analysis, this generalisation often does not hold true. For example, in adults, gender differences in global measures of health and well-being are relatively modest475. In people over 60 years of age, for instance, the difference in proportions of men and women in 5 year age bands who reported that they were in good health seldom varied by more than 5 per cent474. Furthermore, broad assumptions that females experience more ill-health than males conceal specific gender differences in both directions.

For children, boys are more likely to report long standing illness, 18 per cent for boys and 15 per cent for girls, although the difference is only 1 per cent greater in boys for limiting long standing illness. Boys are 30 to 40 per cent more likely than girls to have consulted at a general practice for serious conditions, but about 10 per cent less likely to have done so for minor conditions. Hospital admissions are higher for boys, although the difference from rates for girls has decreased somewhat28. A review of the interaction of gender and age during childhood concluded that while boys had higher rates of chronic physical illness in childhood, this pattern was reversed in early to mid- adolescence, when there were higher rates for girls. This pattern was repeated for psychological disorders, mostly neurotic, where an excess in young boys was replaced by an excess in girls by mid-adolescence476. One possibility is that the increased levels of physical complaints in adolescent girls arise, at least in part, as a result of the lowering of their psychological well-being at this age476.

Women have more morbidity from poor mental health, particularly those related to anxiety and depressive disorders38. Furthermore, psychosocial health in women is strongly influenced by socioeconomic status. For example, a recent analysis of the socioeconomic patterning of women's health found that psychosocial well-being displayed the steepest socioeconomic gradient. Lone mothers had particularly poor psychosocial health, even after controlling for household income, employment status and occupation477. On the other hand, men have higher rates of alcohol and drug dependence38.

Osteoporosis deserves special mention as it is a disabling condition which is more common in women. The lifetime risk from the age of 50 years of fracture of the hip, spine or distal forearm - for which osteoporosis is a major determinant - is 14 per cent, 11 per cent and 13 per cent respectively for women compared to 3 per cent, 2 per cent and 2 per cent for men. The causes of the differences in fracture rates between men and women are not fully understood, but differences in bone density, size and architecture, together with a gender difference in falling, are likely to be major contributors478.

Women have much higher rates of disability than men, especially at older ages479. Data from the 1994 General Household Survey showed that older women were more likely to experience restrictions of mobility, self-care and ability to perform household tasks than older men480. For instance, under a fifth of men over the age of 85 years were unable to go out and walk down the road, compared with nearly half of women. When measures of functional impairment are combined - ability to get up and down stairs, walking outside, getting around the house, ability to bathe or wash oneself, to cut toenails and to get in and out of bed - 14 per cent of women over the age of 65 years suffer from functional impairments sufficient to require help on a daily basis to remain living in the community, compared to only 7 per cent of men. By the age of 85 and over, these figures have risen to nearly 40 per cent for women and 21 per cent for men474. As a consequence, the 1991 Census showed that twice as many women as men over the age of 65 years lived in a communal establishment, 6.4 per cent of women compared to 3 per cent of men481.

Health related behaviour
The proportion of both men and women who smoke has decreased over the last 20 years, but this decrease has been proportionately more in men so that there is now no differential in rates between men and women smoking. About 6 to 7 per cent of men drink alcohol very heavily, based on the (now discontinued) definition of more than 50 units per week. This compares to 2 per cent of women, drinking more than 35 units per week. These proportions, and the proportions who drink heavily, have changed little over the past 10 years. Women are more likely than men to eat wholemeal bread, fruit and vegetables at least once per day, and to drink semi-skimmed milk35. They are also more likely to diet270. Levels of physical activity are higher in men than women, but this is mainly due to men's higher levels of occupational activity35.

In children and adolescents, the patterns are slightly different, and may herald differences in future gender patterns of adult health related behaviour. Secondary school-aged girls have higher rates of regular smoking than boys, although boys who are regular smokers smoke more tobacco63. Higher smoking prevalence among girls has been reported since regular national surveys of school children were first conducted in 1982. If these gender differences were carried forward into adulthood, there should now be evidence of higher rates of smoking among women than men in the 16-24 age group, and to a lesser extent, in the 25-34 age group. Since these trends are not in evidence, it appears that the gender difference in smoking observed among school children is transient482. Boys tend to drink alcohol more often than girls and to consume more when they do drink63. But girls are more likely to have been offered illegal drugs117. Girls tend to eat fruit and vegetables more often than boys, but also eat more less "healthy" foods, such as cakes and chips, and tend to go without breakfast. By year 11 of secondary school, 23 per cent of girls are dieting and only about half are happy with their weight117. Girls spend less of their free time playing games or sport483,484.

Socioeconomic determinants
There are important gender differences in factors which are associated with health, and which the Inquiry has taken the view are determinants of health. Despite women's increased participation in paid employment over the past 30 years, women and men occupy very different positions in and outside the labour market. Nearly 30 per cent of women of working age are economically inactive, and only 35 per cent work full-time; among men, 16 per cent are economically inactive and nearly 60 per cent work full-time42. Over half the female labour force is employed in the clerical, personal and retail sectors as secretaries, waitresses, hairdressers, checkout operators etc., sectors characterised by low paid work485,486. Among men, less than one fifth work in these services485. Outside the labour market, it is women rather than men who take primary responsibility for keeping the home and family going: doing the shopping, cooking and housework and caring for children and other relatives487. Forty per cent of women spend over 50 hours a week caring for someone living with them488.

Gender differences in educational qualifications vary by age and measure. In 1997, 23 per cent of women of working age had no qualifications compared with 16 per cent of men45. By contrast girls are more likely to gain 5 or more GCSEs at grades A star to C than boys41.

Women's different positions in the labour market and in the home means that they live more home-based and community-based lives, where they provide for the health needs of vulnerable groups, including children and adults with long term needs for care. Their different occupational and domestic positions also make women more vulnerable to poverty than men, both during their reproductive and working lives and in old age. It has been estimated that two thirds of adults in the poorest households are women, and women make up 60 per cent of adults in households dependent on Income Support76. Because women are more likely to have breaks in employment and to work part-time in low paying jobs, they are less likely to be eligible for and in receipt of contributory benefits than men and more likely to be on means-tested benefits, both before and after retirement age77,489. Among those aged 65 or over, for example, there are three times as many female as male recipients of Income Support77. Social isolation is also more likely in women than men. Women are less likely to be able to drive or to have access to a car40,282. Older women are more likely than older men to be widowed and to live alone420,421.

In summary, despite their more favourable position with respect to socioeconomic determinants of health, males have higher mortality rates. Gender differences in morbidity vary according to the age group under consideration, the type of morbidity being measured and the measure used.

Evidence
The Inquiry has considered the evidence on gender inequalities in three ways. Firstly, there are obvious differences in the health of males and females which relate to their different biology. Such differences include, for instance, the differences between the sexes in specific diseases of the reproductive organs, and the ill health that may be associated with childbearing. The Inquiry has sought to identify determinants of or solutions to gender-specific health states which are amenable to policy intervention. An example is policies to prevent unwanted teenage pregnancy. Unwanted teenage pregnancy is more common in girls from disadvantaged backgrounds and is associated with a range of adverse health outcomes. Gender inequalities of this type have been considered at appropriate points in the preceding text and are not considered again in this section.

Secondly, there are gender differences in health that do not appear to be predicated on inevitable differences in biology. An example is the higher rate of accidental death in young adult males. Accidental death is associated with lower socioeconomic status, yet low socioeconomic status (as measured by employment status) is more common amongst young women than young men490. This suggests that the gender difference in death rates from accidents reflects social and cultural influences which have a differential impact on men and women. These types of inequalities are likely to be amenable to policy interventions. They have been considered in the appropriate sections of the preceding text and the main examples are re-considered in this section with a summary of their relevance to gender differences. Other recommendations may also have some relevance to gender inequalities.

Thirdly, there are differences between genders in wider aspects of health, particularly mental and social health. An example is the existence of food poverty amongst lone mothers living on state benefits93,94. This is likely to be less common amongst men of the same age because they are less likely to be living in these circumstances. Going without food because of lack of money might not be within the definition of morbidity but it can hardly be described as a healthy state. Similarly, cultural expectations of male and female roles may mean that the frustrations, hopelessness and loss of self-esteem associated with unemployment are felt more keenly by the male partner of an unemployed couple, even if both are seeking work. Again, such feelings are not compatible with good mental health, although they would not be described as psychiatric morbidity. In addition to their earlier consideration in appropriate parts of the preceding text, the main examples of recommendations to address gender differences in these wider aspects of health are considered specifically here, with a summary of their relevance to gender inequalities. Again, other recommendations, not reconsidered here, may have relevance to such gender inequalities to some degree.

We have focused our recommendations in three areas: reducing death in young men; improving health is disadvantaged women with young children; and reducing disability in older women.

Benefit
In general, the benefits from policies considered here will decrease gender inequalities by decreasing disadvantage to either males or females. The benefit of such policies should therefore be relatively wide, and be felt by those males or females who are least well off. However, the mechanisms which link social and cultural influences to differences in male and female health are not well understood. Partly as a consequence, the differential effect on male and female health of policies is often unknown.

Finally, it should be noted that policies which improve the health of women of childbearing age may, in addition, improve the health of the next generation21. This may itself have implications for gender differences in health, as males may be more susceptible to some adverse events in utero and early life than females21. For example, boys are more susceptible than girls to the long term effects of postnatal depression in their mothers342.

Reducing death in young men

Our policies in this area aim to reduce deaths from accidents and suicide. Mortality from road traffic accidents is higher in males of all ages25. The policies which we recommend may have a differential effect on males, particularly those in lower socioeconomic groups, because they are aimed at reducing the opportunity for, or enforcing limits on, risk-taking behaviour as a pedestrian or motor vehicle user.

In England and Wales in 1996, the age-standardised mortality rate for suicide was three times higher in males than in females - 137 and 44 per million respectively29. The overall rate has fallen by nearly a half in women over the last 20 years, but there has been little change in men. For men under the age of 44 years, however, there has been a rise of 20-30 per cent, compared to a fall of about the same magnitude in men over this age32. There is a steep social class gradient in deaths from suicide. In 1991-1993, rates for men were 4 times higher in social class V than in social class I. Our policies aim to reduce the causes of social exclusion which lead to despair and to improve mental health services for people who are already mentally ill. Detailed evidence in support of these recommendations is given at appropriate points in the preceding text.

34. We RECOMMEND policies which reduce the excess mortality from accidents and suicide in young men. Specifically:

we recommend policies which improve the opportunities for work and which ameliorate the health consequences of unemployment (recommendation 8).

We recommend policies which improve housing provision and access to health care for both officially and unofficially homeless people (recommendation 11).

We recommend further measures to encourage walking and cycling as forms of transport and to ensure the safe separation of pedestrians and cyclists from motor vehicles (recommendation 15).

We recommend further steps to reduce the usage of motor cars to cut the mortality and morbidity associated with motor vehicle emissions (recommendation 16).

We recommend further measures to reduce traffic speed, by environmental design and modification of roads, lower speed limits in built up areas, and stricter enforcement of speed limits (recommendation 17).

We recommend policies to prevent suicide among young people, especially among young men and seriously mentally ill people (recommendation 24).

We recommend policies which reduce alcohol-related ill health, accidents and violence, including measures which at least maintain the real cost of alcohol (recommendation 26.5).

Improving health in disadvantaged women with young children

Women are more likely than men to take primary responsibility for caring for children and other relatives487. Forty per cent of women spend over 50 hours per week caring for someone living with them488. Improving the conditions - financial, social and environmental - in which women in poorer circumstances care for their families is likely to be an essential part of any strategy to reduce socioeconomic inequalities in health. People on low incomes or reliant on state benefits are more likely to be lone parents, most of whom are women65. Furthermore, current levels of benefit fall short of the level which independent experts determine to be the modern minimum78,80,81,84,85. Lone mothers may go without food because of lack of money, and some have nutritionally deficient diets93-95,116.

Caring for young children in disadvantaged circumstances, particularly as a lone mother, carries with it an increased risk of poor mental health. In the Health and Lifestyle Survey, the most important factor associated with the mental health of married women aged under 45 years, was the age of their youngest child. Women with children under the age of 5 were most likely to show signs of psychological disturbance. The age of youngest child had no association with physical health491. In a survey of 11,000 mothers 8 months after birth (the Avon Longitudinal Study of Pregnancy and Childhood), material disadvantage was more strongly related to stress-related conditions such as depression, anxiety and headache/migraine, than to conditions like backache, haemorrhoids and cough/cold. For the former conditions, higher levels of self-reported morbidity and general practitioner consultation were associated with a cluster of social disadvantages - living in rented housing, non-employment, younger age, lower educational status. Having more than one child was associated with higher self-reported morbidity for both depression and anxiety492.

Women of all ages are more likely than men to be reliant on public transport, especially buses. Fewer women than men can drive, and fewer women than men own or have access to a car40,282. Surveys in a number of UK cities have found that around two thirds of women are afraid to go out alone at night, and that significant numbers will not use public transport because of fears for personal safety493. This combination of lack of access to transport and fear for safety is likely to decrease opportunities for access to family and friends, facilities and services.

Policies aimed at the material, social and emotional support of women who are pregnant or who have young children should lead to improved psychosocial health in the mother and related improvements in the health of their children. These improvements should be felt in many aspects of health and its determinants, and be apparent in the short and long term. Detailed evidence in support of these recommendations is given at the appropriate points in the preceding text.

35. We RECOMMEND policies which reduce psychosocial ill health in young women in disadvantaged circumstances, particularly those caring for young children. Specifically:

we recommend further reductions in poverty in women of childbearing age, expectant mothers, young children and older people should be made by increasing benefits in cash or in kind to them (recommendation 3.1).

We recommend uprating of benefits and pensions according to principles which protect and, where possible, improve the standard of living of those who depend on them, and which narrow the gap between their standard of living and average living standards (recommendation 3.2).

We recommend measures to increase the uptake of benefits in entitled groups (recommendation 3.3).

We recommend policies which improve the availability of social housing for the less well off within a framework of environmental improvement, planning and design which takes into account social networks, and access to goods and services (recommendation 10).

We recommend the further development of a high quality public transport system which is integrated with other forms of transport and is affordable to the user (recommendation 14).

We recommend policies which will increase the availability and accessibility of foodstuffs to supply an adequate and affordable diet (recommendation 20).

We recommend policies which reduce poverty in families with children by promoting the material support of parents; by removing barriers to work for parents who wish to combine work with parenting; and enabling those who wish to devote full-time to parenting to do so (recommendation 21).

We recommend an integrated policy for the provision of affordable, high quality day care and pre-school education with extra resources for disadvantaged communities (recommendation 21.1).

We recommend policies which improve the health and nutrition of women of childbearing age and their children with priority given to the elimination of food poverty and the prevention and reduction of obesity (recommendation 22).

We recommend policies which promote the social and emotional support for parents and children (recommendation 23).

We recommend the further development of the role and capacity of health visitors to provide social and emotional support to expectant parents, and parents with young children (recommendation 23.1).

We recommend policies which promote sexual health in young people and reduce unwanted teenage pregnancy, including access to appropriate contraceptive services (recommendation 25).

Reducing disability in older women

People on low incomes or reliant on state benefits are more likely to be lone parents, especially women, or pensioners, the majority of whom are women. Only a quarter of older women have an occupational or personal pension compared to two thirds of older men494. Low income decreases their chances of maintaining autonomy and independence by rendering them unable to pay for transport, social care and aids or adaptations to compensate for functional disability474.

Properties in poor condition are occupied disproportionately by single older people, the majority of whom are women209. These homes have higher heating costs. The combination of living alone, and on a low income, puts older women at high risk of fuel poverty96,97,474.

Women of all ages are more likely than men to be reliant on public transport, especially buses. Fewer women than men can drive, and fewer women than men own or have access to a car. This gender difference is most pronounced for older women40,282. Surveys in a number of UK cities have found that around two thirds of women are afraid to go out alone at night, and that significant numbers will not use public transport because of fears for personal safety220,493. Fear for personal safety is greater in older women than those of younger ages. Older women are more likely to live alone than older men420,421, and thus need to go out in order to access social networks.

Older women are more likely than older men to suffer from functional impairments sufficient to require help on a daily basis to remain living in the community474. Changes in community care policies in the early 1990s made it more difficult for older people to obtain local authority residential or home care. Such policies have had a greater effect on older women. Older men are more likely than older women to have the financial resources to pay for such care, and are more likely to be living with a wife, who can contribute to care420,421. Older disabled women are twice as likely as men with a comparable level of disability to live alone474.

Our recommendations are aimed at the reduction of disability in older women, by improving the material support to them, the environment in which they live, and access to the services which they need. Detailed evidence in support of these recommendations is given at appropriate points in the preceding text.

36. We RECOMMEND policies which reduce disability and ameliorate its consequences in older women, particularly those living alone. Specifically:

we recommend further reductions in poverty in women of childbearing age, expectant mothers, young children and older people should be made by increasing benefits in cash or in kind to them (recommendation 3.1).

We recommend uprating of benefits and pensions according to principles which protect and, where possible, improve the standard of living of those who depend on them and which narrow the gap between their standard of living and average living standards (recommendation 3.2).

We recommend measures to increase the uptake of benefits in entitled groups (recommendation 3.3).

We recommend the development of policies to reduce the fear of crime and violence, and to create a safe environment for people to live in (recommendation 13).

We recommend the further development of a high quality public transport system which is integrated with other forms of transport and is affordable to the user (recommendation 14).

We recommend concessionary fares should be available to pensioners and disadvantaged groups throughout the country, and that local schemes should emulate high quality schemes, such as those of London and the West Midlands (recommendation 18).

We recommend the quality of homes in which older people live be improved (recommendation 28).

We recommend the further development of health and social services for older people, so that these services are accessible and distributed according to need (recommendation 30).