Illness behaviour therefore includes variables such as self-assessment of ill-health , general-practice consultations , consumption of over-the-counter medication , consumption of prescribed medication and sickness absence ( both certified and uncertified) .sx Early studies of stress outcomes have tended to infer the presence of illness by measuring illness behaviours such as sickness absence .sx However , the relationship between illness and illness behaviour is not a direct one-to-one relationship , and it is now well known that many complex , social , cultural and demographic factors contribute to the causation of sickness absence besides illness per se ( Johns and Nicholson , 1982) .sx We therefore find that the demographic aspects of illness are not necessarily the same as the demographic aspects of illness behaviour .sx Theoretical and Methodological Issues .sx In stress research the concepts of stress , coping and well-being are frequently confounded ( Edwards and Cooper , 1988) .sx The authors give the example in life-events research , where some 'stressful' life events may also be construed as an inability to cope ( e.g. divorce) .sx Personal illness may be regarded as a stressful life event or as a health outcome .sx Furthermore , some definitions of stress , such as those which describe stress as a situation where demands exceed abilities ( e.g. French , Rodgers and Cobb , 1974 ) , confound stress with the inability to cope .sx It is therefore essential , in stress research , for authors to clearly present the theoretical model which they are investigating .sx SEX DIFFERENCES .sx It has been argued that women , by virtue of the roles they occupy , experience more life events and chronic social stresses , and less social support than men , and that this differential exposure to risk factors explains women's greater vulnerability to depression .sx Sex Differences in Social Stress .sx The empirical data available so far suggest that there is no difference in the rates at which men and women experience acute life events or adversity ( Meyers et al. , 1971 ; Dekker and Webb , 1974 ; Newman , 1975 , Henderson et al. , 1980 ; Markush and Favero , 1974) .sx However , the possibility remains to be tested that women in general may experience more undesirable life events by virtue of their low socio-economic status overall ( Myers , Lindenthal and Pepper , 1975 ) , since there is much evidence that women in general enjoy lower status than men , both at home and at work , and frequently earn less even when in comparable jobs ( Office of Population Censuses and Surveys , Social Trends ) .sx There is no evidence that life events have more impact on women than on men ( Paykel , Prusoff and Uhlenhuth , 1971 ; Personn , 1980) .sx However , there is evidence that women experience more chronic social stress than men .sx Radloff and Rae ( 1979 ) reported that women were more exposed than men to low education , low income , low occupational status , fewer leisure activities , and more current and recent physical illness .sx Furthermore , there is evidence that men and women respond differently to the same number of stresses ( e.g. Russo , 1985) .sx In addition , there is ample evidence for sex differences in stress-induced physiological responses ( e.g. Frankenhauser , 1983 ; Stoney , Davis and Matthew , 1985 ) and also for differences in the ways people cope cognitively , emotionally and behaviourally in response to stress .sx According to Kessler , Price and Wartman ( 1985 ) gender differences in health are to a large extent attributable to differences in the appraisal of stresses and the selection of coping strategies .sx Vingerhoets and Van Heck ( 1990 ) explored gender differences in coping and found that males preferred problem-focused coping strategies , planned and rational actions , positive thinking , personal growth and humour , day - dreaming and fantasies .sx Women preferred emotion-focused coping solutions , self-blame , expression of emotions , seeking of social support and wishful thinking/emotionality .sx The same authors also found that men and women do not differ in terms of the amount of stressful events experienced .sx Sex Differences in Social Support .sx There are few studies which specifically address the question of whether women experience less social support than men .sx Miller and Ingham ( 1976 ) found that casual , less intimate friends as well as intimates afforded protection from developing illness , and that " psychological symptom levels probably vary with social support even when there is no serious life event present " .sx It is therefore apparent that contacts with colleagues at work may also be supportive to the individual , and it may be that the housewife often experiences relative isolation in the home , experiencing less frequent daily verbal exchanges with other individuals than does her counterpart in the office .sx Henderson et al. ( 1979 ) found that males reported more availability of social integration than females , while females scored higher on the quality or adequacy of the social integration .sx Females scored more on availability of attachment than males , but there was no sex difference on the quality or adequacy of the attachment .sx It was the author's view that special attention should be paid to those social bonds which promote self-esteem - both the esteem of self in terms of appearance , abilities , competence and position in a dominance hierarchy , as well as the degree to which one believes one is lovable to others .sx The question is , therefore , whether such self-esteem is more likely to be derived from social integration within a group , while the extent to which one believes one is lovable may be obtained from both kinds of social bond .sx If the important aspects of self-esteem are more likely to be derived from social integration , then Henderson's finding that males reported quantitatively more availability of social integration than females may be of crucial significance to the question of whether women experience less social support than men .sx While females report a better quality of social integration , in terms of self-esteem thus engendered , quality may not make up for quantity .sx Henderson found that for minor psychiatric morbidity social integration had a stronger association with symptom level than did attachment for women .sx For men , the strength of the association of symptom level with social integration and with attachment was the same .sx Henderson concluded that " social bonds " appear to be related to morbidity in a manner independent of the challenge of adversity " .sx While these primary questions afford some hope of elucidating the nature of the sex difference in the prevalence of minor psychiatric morbidity , it is clear that further work is required .sx In the mean time the evidence suggests that women do experience more chronic social stresses , e.g. low occupational status and low income , than men and also experience less availability of social integration - a factor with a strong negative association with minor psychiatric morbidity .sx Brugha et al. ( 1990 ) found that the explained variance in recovery from depression due to social support was equal in men and women .sx But according to subset analyses , the aspects of personal relationships and perceived support that predict recovery in men and women appear to be different .sx In women , the significant predictors of recovery appeared to be the number of primary group members named and contacted , and satisfaction with social support , while in men it appeared to be living as married , and the number of non primary group social contacts named as acquaintances or friends .sx Sex Differences in Illness .sx Men and women certainly differ in terms of the balance of role obligations in the occupational , marital and parental domain .sx If these distinctive role patterns are responsible for gender differences in health , it should be the case that where gender equality is achieved , gender differences in health should be reduced .sx Studies of men and women in similarly responsible and demanding jobs do seem to find a reduction in the substantially lower mortality rates among women ( e.g. Detre et al. , 1987) .sx Jenkins ( 1985 ) , in a study of young male and female executive officers , found that there was no sex difference in prevalence of minor psychiatric morbidity .sx Other studies of true homogeneous samples have found the same thing ( e.g. Parker , 1979 ; Golin and Hartz , 1977 ; Hammen and Padesky , 1977) .sx A paradox which has attracted considerable attention ever since John Graunt , the founder demography , commented on it in his 'Natural and political observations' , published in 1662 , is that while women attend doctors more often than men , their life expectancy is no less than that of men ( indeed , is now about 8% longer) .sx Graunt concluded that either the women were generally cured by their physicians or that the men suffered form untreated morbidity .sx In Western countries , where women's life expectancy is greater than men's , women are nonetheless reported to suffer more illness than men , are higher users of medical services and prescriptions , and take more time off work for sickness ( Verbrugge , 1976 ; Nathanson , 1977 ; Wingard , 1984 ; Verbrugge , 1985 ; Strickland , 1988 ; Jenkins , 1985) .sx Table 5.1 illustrates this paradox with figures taken from UK sources .sx It can be seen that , while females' life expectancy in England and Wales exceeds that of men by six years , women consult general practitioners ( GPs ) more often than men , they take prescribed drugs more often than men , they take more frequent spells of sickness absence ( although the total duration of the certified absence is not greater ) and , despite attending out-patient facilities in roughly equal numbers , women are admitted to hospital more often than men .sx In general it can be said that women suffer more from psychological distress and minor somatic disorders , whereas men seem to be especially vulnerable to life-threatening diseases , e.g. myocardial infarction and cancer ( e.g. Rice at al. , 1984 ; Bush and Barrett-Conner , 1985) .sx table&caption .sx Looking now at mental illness , GPs diagnose more episodes of mental illness in women than in men , women take more certified sickness absence for mental illness than do men ( both in terms of frequency and duration ) and women have more psychiatric admissions to hospital than do men .sx These comparisons are illustrated in Table 5.2. When specific diagnostic categories of mental illness are examined , using the International Classification of Diseases the picture becomes rather more subtle .sx Table 5.3 presents the general practice episode rates for psychiatric illness and the admission rates to psychiatric hospitals for the year 1972 by diagnosis and sex .sx Males predominate in the areas of alcoholism and personality disorders .sx Sex differences in reported rates of schizophrenia are negligible .sx However , for affective psychoses and the psychoneuroses , women predominate over men .sx tables&captions .sx These sex differences in illness have been variously ascribed to a number of explanations which may be categorised as in Table 5.4. These theories have been considered in relation to mental health in Jenkins ( 1985 ) , who concluded that :sx Clearly the relative importance of each of these variables is likely to vary from illness to illness .sx For mental health , we now have evidence that both manic depressive psychosis and schizophrenia have a multifactorial aetiology , involving both genetic and environmental factors .sx Both diseases are so severe that sex differences in reporting behaviour and diagnostic habits have minimal impact on reported rates .sx However for minor psychiatric morbidity , the depressions and anxiety states , the evidence for a genetic aetiology is small .sx While there is evidence that changes in gonadal hormones are sometimes linked to mood changes , there is no direct evidence that reproductive physiology is responsible for women's excess of reported depression .sx The evidence for the importance of environmental stress and support in the aetiology of minor psychiatric morbidity is much stronger , although the variance explained by such factors is not large .sx This chapter will therefore concentrate on environmental factors , rather than the biological factors of genes and hormones responsible for sex differences in illness .sx Sex differences in stress and support have already been discussed above .sx Differences in sex roles and their effects on health will be discussed below .sx Sex Roles and Their Influence on Constitutional and Environmental Vulnerability to Illness , and on Reporting Behaviour .sx Sex roles and their interaction with constitution .sx It has been suggested that sex differences in the early upbringing and social environment of males and females place a permanent stamp on the phenotype of the individual , thus affecting constitutional vulnerability to psychiatric illness in adult life ( Chesler , 1971 , 1972 ; Chodorow , 1974) .sx The learned helplessness model proposes that helplessness is the salient characteristic of depression and that it results from learning that one's actions do not produce predictable responses ( Seligman , 1975) .sx Cochrane and Stopes ( 1980 ) argued that women are traditionally more sheltered than boys , women have less initiative in selecting their spouses than do men , their life-styles face more disruption with the advent of children , and they have to follow their husbands geographically and socially .sx