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. .-.-:-:-:-:-:-:-:-:-:-:-.-.-. . .. -:-::::-:-:-:-:-:-:-:-:-::::::::-:-.- ::--- :::-. ~ .-:-:-:-:-:-:-:-:-:-----------:-:-:-:-:-:-:-:-:-:-: . -:-:-. .-::-:-::::: ::-:: :'::-:-::-. -:-:::::::::::::::-:- :::-. I-:- : - = - :-: ::- .: ~ - :-:: -I - - at - . ..- - -:. - : - .:.-:-- -: - - .. ::- -.-.- .- ' 2----:-.- -:-:--:-- ::: Roots of Difference Mapping precisely how and how much women's health differs from men's presents researchers a formidable task. But the challenge of discovering causes for those differences is greater still. Purely physical factors clearly account for some discrepancies; no woman, for example, can develop prostate cancer. Behavior obviously explains others; men have more industrial accidents because more of them work in dangerous industries. But the most intriguing and probably most revealing questions fall in between these poles of certainty. Why do women have more osteoporosis but later heart attacks? Why do men suffer more drug addiction but fewer eating disorders? The origins of various behavioral gender differences in inter- ests, attainments, social position, and the like have long sparked debate. For generations, intellectual fashion has swung from nature to nurture and back again. During the decades when the memory remained fresh of World War II atrocities committed in the name of inborn character, schol- ars and commentators of every kind abjured any explanation that accepted the notion of innate or unchangeable predilections. As those harsh recol- lections faded, though; as new generations of thinkers began to question their elders' assumptions; and as unprecedented progress in genetics and molecular biology laid bare basic mechanics of human life, the pendulum traveled far back to the nature side. Demonstrated or surmised links be 35

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I N H E R O WN R ~ G HT tween specific genes or chromosomal markers and conditions as diverse as Alzbeimer's disease and homosexuality began to dominate discussion. Some enthusiasts now view the imminent mapping of the human genome as a step toward explaining why humans behave as we do. On the health research front, though, opinion has remained more moderate, moving increasingly toward a consensus that recognizes both biology and behavior. Advances in genetics have, of course, strongly influenced recent thinking about the origins of disorders from breast and colon cancer to schizophrenia. But in a seeming paradox, many such purported biological connections seem also to suggest important roles for environment and behavior. Heredity appears to set up a variety of specific susceptibilities. Circumstance then may or may not transform them into full-blown disorders. Gender differences in physical and mental well-being, accord- ing to this view, thus mirror the complex interplay of bodily endowment and life experience. Males' and females' distinctive physiological proper- ties can each produce characteristic vulnerabilities. Their divergent life courses exert differing stressors. Together, nature and nurture mold an individual's and a gender's total health profile. Neither factor alone offers a complete explanation. Together, though, they provide useful in- sights into the dynamics of health and illness. Indeed, researchers have only recently begun to appreciate the true subtlety and multiplicity of the connections between body and be- havior, between genetics, physiology, and personal history. Some ties are as simple and straightforward as men's higher incidence of lung cancer, which obviously reflects their historically greater consumption of ciga- rettes. Other connections are as complicated as the influence of gonadal hormones on various functions not directly involved in reproduction. The way an individual handles stress, for example, influences such important aspects of health as immunity and blood pressure. Recent studies of the hormonal system controlling the stress response, for example, reveal close links to the system that regulates the reproductive hormones. Thus "the consequences of stress appear to differ in males and females," states Bruce McEwen, professor of endocrinology at Rockefeller University, noting a potentially very significant, but as yet incompletely understood, gender divergence. Primate studies even suggest that "the 36

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C HA P T E R 3 Cal Roots of Difference female brain may actually be protected from some destructive effects of stress," he adds, "perhaps through mechanisms involving gonadal hor- mones, perhaps through other mechanisms." He submits that "wear and tear of stress hormones and sex hormones . . . can actually wear out ctrl~rtl~r - c ~A Brat - ~c; - the has; - vv ~ Be v ~ v,vv ant ~ is .... Since brain cells are not regener- ated during adult life, this can lead to the actual wearing of brain struc- tures and contribute to the rate of the aging process.") Huda Akil, Ph.D., of the Mental Health Research Institute at the University of Michigan, whose research has explored the ties between females' reproductive and stress hormone responses, notes that scientists' assumption that these sys- tems are separate has helped obscure the link.2 Adds Maureen Henderson, "the interplay of reproductive and other hormones has to be a central theme and top priority for allocation of research resources."3 Another connection deserving further investigation, experts agree, links gender differences in brain structure or function with vulner- ability to a variety of psychological and cognitive conditions. Mental and addictive disorders were formerly thought to arise mainly from emotional causes. But increasingly strong evidence now suggests that physiology plays an influential role in the genders' differing patterns. "The more we study gender differences, the more we find physiologically significant dif- ferences in brain structure, in brain chemistry, and in peripheral areas such as liver metabolism of hormones and drugs," states McEwen.4 Some of these distinctions focus on the way the brain is orga- nized, some on the mechanisms that activate its various structures. Dis parities such as boys' higher rates of learning disabilities, for example, persuade McEwen that "there's a fundamental difference in cerebral de- velopment that can lead or predispose more males" to show such prob- lems. Various other features, including "differences at the level of auto- nomic and more vegetative and regulatory functions" and the effects of hormones on various neurological systems, are known to affect the actions of certain psychoactive drugs.5 These discrepancies lead McEwen to the conclusion that "in all studies of drug effects, addictive disorders, mental disorders . . . males and females, men and women, are in fact two distinctly different populations and should be treated as such . . . until evidence shows that it's not necessary to further consider gender differences." Still, he adds, "we know 37

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I N H E R O WN R ~ G HT very little up to this point about the underlying mechanisms. a great need for further investigation."6 . . There's Just how great is that need becomes obvious when we consider the tremendous power of those "underlying mechanisms." "Complex dif- ferences between the two sexes ultimately stem from very minor or simple differences" during embryonic development, says lean Wilson, M.D., pro- fessor of medical sciences at the University of Texas Southwest Medical Center and a leader in hormone research. Scientists know a great deal about the biology of this process, but "in some ways we know nothing. The challenge for the 90s is understanding the behavioral and functional consequences of these small differences during embryogenesis, and how these differences are amplified by sociological, psychological, and second- ary endocrine effects." The task of tracking gender differences to their origins "is going to be more complicated than what we've accomplished to date."7 CULTURAL CONSIDERS {IONS Clearly, physiology alone cannot answer questions like why males and females suffer such different patterns of mental illness, any more than it totally accounts for variations in physical ones. "I would under- score the need to integrate the biological and psychosexual studies," says Ellen Frank, Ph.D., professor of psychiatry at the University of Pittsburgh. "All of these disorders and problems are happening within one skin, and unless we study the same individual from both perspectives, we will never understand how the vulnerability factors fit together with the stressors. It's almost . . . pointless to look only at one dimension or the other. Until we fit these pieces together, we will never understand what is happening."8 Behavioral, social, and psychological differences between the genders thus require analysis as painstaking as any in the biological realm. Within many societies, as we have repeatedly noted, female health differs from male. But between societies, women's or men's physical or mental well-being can also vary sharply, revealing the extreme importance of specific social and economic conditions. In developed nations like the United States, researchers ponder the mystery of why women live so 38

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C HA P T E R 3 Cal Roots of Difference much longer than men, weighing possibilities ranging from immunity to employment. In many other countries, though, investigators confront a quite different mystery, the one that Susan Scrimshaw, Ph.D., of the UCLA School of Public Health, terms the whereabouts of the "missing women, . . . the issue of skewed sex ratios in countries where women receive less than equal treatment." European and North American censuses find 96 males for every 100 females, with the gap widening as people age. But in the developing world, this ratio "flips," in Scrimshaw's word. India counts 93.5 females to every 100 males; Bangladesh, 94 females to every 100 males; and Egypt, 105 males to every 100 females.9 By U.S. standards. therefore, "over 1 million Egyptian women are missing, victims of higher than biologically expected mortality throughout the life span."~ In addition to the Egyptian women prematurely dead at least by North American standards large numbers of their living female fellow citizens suffer disabilities that relate to pregnancy but are relatively rare in the United States. For every Egyptian woman who dies in pregnancy or childbirth, an estimated 10 to 15 others "survive severe, life-threatening morbidity," Scrimshaw states. A study in one Egyptian city found more than half the women suffering reproductive tract infections, with equally large numbers living with anemia and uterine prolapse. "We don't have studies of this depth in other countries, but we do have the same kinds of figures for missing women," Scrimshaw observes. "The life expectancy of women in the northern countries, . . . Europe and the U.S., is 30 years longer than for women in developing countries." The apparently "natural" longevity advantage of American women thus emerges as at least a partial product of their widespread access to adequate nutrition and safe maternity and gynecological care. Through- out the developing world, surveys show, more than half of women want no more children or want them more widely spaced than is possible .' . or .. .. . r 1 .. without ettectlve contraception or access lo sate anortlon. Many women die from botched illegal abortions, from births separated by less than a year, or from childbearing either very early or very late in one's life. Half of Egypt's annual mortality, for example, consists of women older than 30 attempting to bear child number three, four, five, or even higher. Other American gender differences that appear equally "natural" to us perhaps 39

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I N H E R O WN R ~ G HT our discrepant rates of heart disease or cancer, for example may well also arise from social rather than medical disparities likewise obscured by a particular culture's notion of what constitutes the "normal." Many such disparities clearly exist. "We know of no culture that has said articulately that there is no difference between men and women except in the way they contribute to the next generation; that otherwise, in all respects, they are simply human beings with varying gifts," said the anthropologist Margaret Mead.~3 For Scrimshaw, this state- ment by her scholarly mentor emphasizes the "one underlying cultural theme tthat] emerged with surprising consistency and intensity" from the scientific literature on women's health worldwide: "the inequalities."~4 In nearly every culture known, she notes, the genders have unequal access to social and economic resources; unequal family responsibilities and work roles; unequal abilities to control expenditures, fertility, and time; unequal power to exercise their own choices. Nor, in evaluating how life experience affects health, can we regard any given society's female populations as uniform. Who represents the "typical" American woman facing "normal" health threats? A farm wife exposed to pesticides and fertilizers and stranded scores of miles from the closest primary care? An inner-city welfare mother in danger of HIV infection from a drug-using partner and dependent on Medicaid and a nearby emergency room for what care she manages to get? A thirty something single attorney subject to intense job stress and downtown air pollution? A college student experimenting with recreational drugs and casual sex? A prosperous suburban housewife? A single mother employed as a factory hand? A poor immigrant from a developing nation who resorts first to a practitioner of her homeland's folk medicine? A nursing home resident? Even in countries far less diverse than our own, even in societies where tradition still provides the script for most biographies, "women" do not constitute a unitary mass. Ethnic affiliation, social class, and economic position everywhere mold personal experience. Age also plays a crucial role in health status, its influence vary- ing according to an individual's particular social setting and life history. "If women have differential access to food, work and health care," Scrimshaw notes, "it is more different at some stages of their lives than others.... Women's roles are not static but dynamic."~5 In some places a pregnant 40

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C HA P T E R 3 Cal Roots of Difference woman must eschew various foods; in others she is stuffed with special delicacies. In some places a young girl risks her life by smiling at a man outside her family, but a postmenopausal grandmother moves freely about the town. In some places, women are pressed to bear children in their mid-teens and become matriarchs by their forties. In others, women de- vote their first three decades to education and career and only commence motherhood in their mid-thirties. The cultural norms of many countries expose females in other parts of the world to health risks quite different from those faced by females in North America. Where poor parents value male offspring mark- edly more than female, fewer girl babies survive infancy. Where respect- ability requires female circumcision, girls suffer bleeding and infection both at the childhood ceremony and repeatedly later on during sexual intercourse and childbirth. Where men and boys have first crack at the most nutritious foods, growing girls and pregnant or nursing women may lack needed nourishment. Where standards of modesty restrict the move- ments of postpubescent girls and young wives, earning money or obtain- ing health care may present serious obstacles. Where women lack birth control, many closely spaced pregnancies fill the years between late ado- lescence and middle age. Where pregnancies are frequent and nutrition inadequate, anemia weakens mothers and complicates deliveries. Where medical attention is scarce, many expectant mothers join the half-million worldwide who die each year from problems related to pregnancy. Where wives bear heavier responsibilities than their husbands for cooking, cleaning, marketing, child care, tending kitchen gardens and small ani- mals, and working in the fields, they suffer increased fatigue. Where form- ing dung into fuel cakes or washing and cooking in contaminated water are normal housewifely tasks, parasites are normal housewifely ailments. Where married men customarily visit prostitutes, their wives routinely contract venereal diseases. Where widows have no support but their chil- dren, the childless live in penury. To understand any gender variation in health patterns that we observe, therefore, Scrimshaw insists we must first ask a basic question: "Why women?" What is there about their lives that opens them to a specific possibility? What particular realities of their time and place pro- duce a certain combination of vulnerability and stressor? The answer may 41

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I N H E R O WN R ~ G HT come from any realm that touches women's lives, from biochemistry to fashion. In the spring and summer of 1980, for example, exactly that combination of factors challenged American public health officials. Hun- dreds of women, mostly previously healthy whites between 15 and 19, came down with a sudden, sometimes deadly, but theretofore rare illness that only two years earlier had been named toxic shock syndrome (TSS). The patient's temperature shot up, her heart raced, her blood pressure dropped, her breathing became rapid, and she broke out in a rash. The skin peeled from her palms and soles. She became lethargic. Sometimes her kidneys began to fail. In several dozen cases, the patient died. By September of that year, investigators had found a strong association between TSS, the bacterium Staphylococcus aureus (an organism already well-known as the culprit in a number of human diseases), and the use of tampons during menstruation, especially a superabsorbent brand known as Rely. The scientific evidence then available did not permit an IOM committee studying the outbreak to identify either the exact mecha- nism connecting these sanitary products to the disease or the reasons that the condition preferentially targeted young whites. It did conclude, how- ever, that "a marked reduction in the number of cases would be expected in the absence of tampon use."~7 Put in other words, this finding meant that the dictates of fashion, combined with advances in fiber technology, had placed Ameri- can women at risk for a potentially deadly disease. In 1980, U.S. tampon sales topped 5 billion, with 70% of the nation's 50 million menstruating women choosing internal protection. Most teenagers used napkins for their initial menstrual periods but switched to tampons within two years. Disposable sanitary napkins first appeared on the American mar- ket after World War I, when firms making surgical dressings sought re- placements for their vanished military customers. Until then, women had contented themselves with diapers or squares of cloth, confident that bustles and petticoats hid any telltale outlines. The more form-fitting fash- ions of the late 1920s and early 1930s created demand for protection that did not show, and manufacturers responded with devices that could be worn internally. Similar esthetic constraints had led women in ancient Greece and Rome to insert cylinders of rolled wool into their vaginas. 42

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C HA P T E R 3 Cay Roots of Difference Cotton tampons hit the American market in the early 1930s. By the late 1970s, newly developed superabsorbent synthetic fibers prom- ised to make them ever more reliable and long-wearing. For reasons not fully understood, though, these new, improved models also increased cer- tain women's vulnerability to severe staph infections.~9 Experts do not know whether the racial and age differentials observed in TSS cases relate to differing patterns ot . . . . . . ~ sanitary protection or to some other factor.20 clearly, though, solving this puzzle would require a very detailed knowl- edge of women's daily habits. The collection of this kind of information has hardly begun. MAPPING LIVES Gender differences that affect health start out small and begin to expand in early childhood. By adolescence, American boys and girls are well along the diverging paths that will carry them to their very different adulthoods as men and women. Puberty is one of the major milestones along the route, the first of several major life transitions that demarcate American lives. Like the passages to parenthood, the post-reproductive years, and old age, adolescence involves its own distinct health risks. How an individual responds to them helps establish physical, psychological, and behavioral patterns that can significantly affect later health. Each new life stage also imposes particular developmental de- mands, as an individual adjusts to new roles, responsibilities, opportuni ties, and limits. Meeting these in a health-enhancing way is an important challenge of development, one complicated or eased by the individual's circumstances and the expectations of those around her. The task is often difficult. "Most of us were brought up on a naive psychoanalytic notion of development as a kind of continuous linear model," says Dr. Bertram Cohler, professor of psychology at the University of Chicago. "In fact, development is more like a series of wrenching transformations across the course of life" 21 That course begins in childhood, a period when boys and girls traditionally faced quite similar health issues. "In earlier times, the child- hood diseases that people studied had very little to do with gender," notes Eleanor Maccoby, Ph.D., professor emeritus of psychology at Stanford 43

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I N H E R O WN R ~ G HT University and a leading researcher in the development of gender differ- ences. In the days before vaccinations and antibiotics had wiped out measles, mumps, whooping cough, rheumatic fever, polio, and the many other contagions that afflicted children, "the disease entities, their diagno- sis and treatment were generally the same for the two sexes."22 But what used to be called "childhood illnesses" have all but vanished from American childhoods. A new set of ailments now poses the major threat to our young. Violence, depression, drug abuse, eating disorders and the like differ from old-time maladies in three ways: they strike in adolescence, they preferentially target one Bender or the other, 1 1 1 ~1 ~1 {{ ~ O 0 7 and they have, in Maccoby~s words, Ida more behavioral component," resulting, at least in part, from the choices that youngsters make, often under the influence of peers.23 Researchers have yet to pin down the origin of these problems. Clearly, though, boys' and girls' quite different experiences in and after puberty contribute significantly. But do the divergent patterns that produce the first significant gender-based health distinctions actually arise in adolescence? Or does their source, as Maccoby's research suggests, lie much earlier in the life span? "I want to argue," she asserts, "that the behavior patterns that so importantly affect adolescent health have their roots in childhood, and that the relevant developmental history differs for boys and girls."24 As far back as the preschool years, she believes, males and females inhabit gradu- ally diverging subcultures. The attitudes and behaviors they learn help set up the quite disparate vulnerabilities that emerge a decade or more later. ROLES AND RITUALS This process of gender differentiation begins very subtly. Until the age of 2 or so, boys and girls are "remarkably alike," differing by personal temperament much more than by gender-related traits.25 By age 3, however, children know which gender they belong to and have begun the long process of figuring out what that membership means. From about age 4, given the opportunity, they begin favoring playmates of their own gender. Distinctive styles of interaction now begin to emerge within the all-male and all-female groups. Research among primates has shown a 44

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C HA P T E R 3 Cal Roots of Difference similar pattern of segregated play groups, with juvenile males doing lots of roughhousing and juvenile females mostly stepping aside to avoid the ruckus. This suggests to Maccoby that "something biological" may lie behind the desire for separation. But the habit of clustering by gender, whatever its basis, "then takes on a life of its own, that is stamped by the culture" in which the children live.26 A small biological divergence, per- haps in energy level or aggressiveness, and possibly based on boys' higher androgen levels, thus becomes magnified by customs and values into in- creasingly significant behavioral differences.27 In the culture of the American schoolyard and playing field, "boys are more concerned with dominance issues, with who is tougher," developing "dominance hierarchies that are quite stable." Girls' cliques, meanwhile, are "less hierarchical and their play more integrated by a joint script," Maccoby says. They "increasingly use polite suggestions and ques- tions such as 'Why don't we . . .?' or 'Wouldn't you like to . . .?' to influence their playmates." Boys use more and more "direct commands, such as 'Bring me that.' "28 With their tough-guy style and their focus on heroics (both their own and those of sports stars or superheroes), boys become increasingly impervious to the gentler style of persuasion that works in the more harmonious female play groups. By grade school, the habit of sorting themselves by gender has come to dominate children's social life. Male play emphasizes dominance and competition. Boys often gather in large groups for organized games that use well-defined rules to determine winners and losers. They brag, heckle, joke, bluff, misbehave to demonstrate their daring, show off for one another, and generally try to appear at least as rugged as the next guy. Girls, meanwhile, gather in sets of twos or threes, where they endeavor to create closeness. "Speech serves a more egoistic function among boys and a more socially binding one among girls," Maccoby notes.29 As puberty approaches, girls begin to spend more and more time speculating about romance. Boys, meanwhile, expand their repertoire of tough talk to the subject of sex, recounting purported exploits, sharing pornography, and telling dirty jokes. Contact with the opposite sex once again becomes socially legitimate, although most youngsters still spend their time over~vLelm- ingly with friends of their own gender. Among themselves, boys and girls 45

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I N H E R O WN R ~ G HT continue getting along in their accustomed ways. "Girl-girl friendships are typically more intimate, mutually supportive," Maccoby observes. "When they talk to each other, their style is more sociable, less confrontational. Males continue to play to their male audiences with risk-taking displays."30 PROBLEMS ATPUBERTYAND BEYOND There is now, however, something decidedly new under the youngsters' suns: contacts with the opposite sex that carry potentially significant health consequences. "When young boys and girls emerge from the gender-segregated social groupings of childhood and begin to interact with each other, the two sexes are not on a level playing field," Maccoby says. Entering the age of budding sexuality, girls come equipped with the cooperative habits of their social set, and a mode of persuasion that sounds tentative and unconvincing' to boys accustomed to a more as~s~ressive. O J 00 combative style. And "of course," Maccoby notes, "the implications for being sexually active are different for the two sexes."3i Who can get pregnant is only one of the many important differences. Another is the "asymmetry in the importance of physical ap- pearance."32 Though nearly all youngsters hope the opposite sex finds them attractive, boys give looks more weight in choosing a partner than do girls. Squiring a beauty adds a great deal to a boy's social stature. For girls, the mere fact of having a boyfriend may well outweigh the details of his appearance. Her wardrobe, her figure, her hair, and her skin become major female preoccupations. "These concerns are so central for young girls that they often take priority over other girls, and even academically gifted girls can lose self-esteem, lose interest in their school work, and become depressed if they think they are too fat or otherwise unattractive," Maccoby says.33 Not only a girl's grades but also her health can suffer perma- nent damage from the relentless demands of appearance. The ideal of the muscular, athletic man may be "difficult enough for boys to reach," Con- ger says, but today's archetype of slender feminine beauty is "an impos- sible one for girls." Growing into their adult bodies, boys put on weight mainly as lean muscle tissue, but girls gain mostly fat. "Thus, whereas physical maturation brings boys closer to the masculine ideal, for most 46

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C HA P T E R 3 Cal Roots of Difference girls it means the development away from what is currently considered beautiful," Conger laments. "Not surprisingly, then, girls are far more likely than boys to be dissatisfied with their appearance and body image, particularly in the early adolescent years."34 Fighting their natural bent in search of an unattainable silhou- ette sets up girls, especially those developing earlier than their friends or "genetically programmed to be heavier than the svelte ideal," for eating disorders.35 The right combination of biology and psychology can turn a teenager's normal concern about her figure into anorexia nervosa or bu limia. Nearly all young women diet at some time or other, but only a minority of the biologically vulnerable appear to tip over into these life- threatening exaggerations of weight control, says Dr. Katherine Halmi, professor of psychiatry at Cornell University. When a susceptible person begins dieting, "various other physiological effects cascade" toward a full- fledged illness. "Disturbed perceptions of hunger and satiety" distort eat- ing patterns. As the pounds fall away from an increasingly emaciated body, victims develop a satisfying feeling of control, although, "in reality, they have lost all control. Even if they want to, they cannot start eating nor mally."36 "Three major neurotransmitters, serotonin, norepinephine and dopamine, are heavily involved in the hypothalamus in regulating eating behavior," Halmi explains. "There is accumulating evidence that bulimia patients have a disregulation of serotonin function," and "that bulimics have a disregulation of norepinephrine" imbalances that also affect hor- mone responses "in producing the full-blown syndrome."37 Depression and irritability set in as starvation advances. Anxiety, personality disorders, and other psychiatric ailments plague many of these young women as well. Culture's contribution consists of some impossible contradic- tions. Women between 18 and 40 on average weigh more than they did three decades ago, a fact that in itself encourages dieting. At the same time, the media's standard of fashionable weight has fallen sharply. And advertisements for sweet, fatty foods barrage today's teens. Families can also unwittingly foster troubled eating. A genetic element is likely, given the higher incidence of the disorders among the relatives of bulimics and anorexics; these disorders, Halmi says, "breed true."38 But Conger also 47

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I N H E R O WN R ~ G HT notes psychological factors. "In addition to being overly involved emo- tionally, overprotective and rigid," parents "appear to be unduly con- scious of appearance and to attach special meaning to food and eating. The first generation of daughters of the first group of women who went to Weight Watchers had an unusually high incidence of bulimia. I don't know if that's an advertisement or not."39 Either way, other advertisements seem to help insecure girls worried about their weight adopt another health-destroying habit, smok- ing. Teens of both genders experiment with cigarettes, but by tenth grade more girls than boys regularly light up. Many girls believe that smoking helps control weight. Scientific evidence also indicates that "smoking is a momentary reliever of anxiety and stress," Maccoby says.40 Athletics may encourage boys to eschew tobacco after their initial attempts. But if present trends persist, soon the United States could have, for the first time in its history, more females smoking than males.4i But just as a remorseless teen culture may push girls toward behaviors indicating mental illness, it may guide boys into actions that mask similar problems. Delinquency and drunkenness, some experts be- lieve, may be mood disorders in macho disguise; although they may well express similar feelings of worthlessness and hopelessness, they are not currently classified as symptoms of depression. Among Amish adolescents, says Paula J. Clayton, M.D., of the Department of Psychiatry at University Hospital in Minneapolis, such outlets do not exist; "alcoholism and drugs are culturally prohibited and acts of violence and crime are infrequent." The sect's boys and girls suffer mood disorders at similar rates. Adding together the delinquency and depression rates for America's mainstream adolescents also produces similar incidence levels for both genders.42 With the passage to adulthood, though, as the demanding male role begins to close in on young men, the tables may turn. Social expecta- tions may now cause more males to appear among the ranks of the men- tally ill. Schizophrenia, for example, often strikes in early adulthood and frequently takes a less favorable course in men than women. Male schizophrenics spend more time in hospitals, are readmitted more often, and generally do worse in their work and social lives. Might not one reason be that families feel differently toward schizophrenic sons and daughters and those feelings affect treatment decisions? Although the 48

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C HA P T E R 3 cry Roots of Difference disease's severity may actually differ in males and females, Jill Goldstein, assistant professor of psychiatry at Harvard University Medical School, believes that "social role expectations" might also contribute.43 The strictures of adult roles take their toll on feminine health, as well. "The impact of sexuality and the concept of childbearing" are "strongly different" for the two genders, Maccoby observes.44 The over- riding disparity is society's assumption that the mother will bear the major burden of rearing the children, a responsibility that often translates into lesser career prospects, financial and psychological dependence on a mate, and willingness to subordinate one's own interests to others'. The female role has also traditionally dictated that girls and women take less part in sports than boys and men. And even for those active in youth, physical activity tends to decline as one advances into womanhood. "From 45 onwards, when fitness really begins to count, less than one third of women exercise regularly and less than one in ten exercises intensively and regularly," Henderson notes. Rates of exercise "go downhill instead of uphill as women get older." Bone mass, cardio- vascular fitness, stamina, and mental attitude all suffer as a consequence. Do women's "four bad years" at the end of life result as much from "earlier social conditioning as tBrom] ill health"?45 IN CONCLUSION Such a question appears at once obvious and unanswerable. Clearly, choices made throughout the life span affect health at every age. Just as clearly, we do not now know, and perhaps never will, just how much one's physical and mental state depends on culture and experience and how much on physiological and anatomical traits, both those unique to the individual and those shared with an entire gender. Armed with our ever-advancing biological knowledge and a powerful new life-span per- spective, investigators are just beginning to ask the right questions. An- swers lie far in the future. NOTES 261. 1. Assessing Future Research Needs: Mental and Addictive Disorders in Women (Transcript), 49

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I N H E R O WN R ~ G HT 2. Ibid., 121. 3. IOM 1992 Annual Meeting, 19. 4. Assessing Future Research Needs (Transcript), 260. 5. Ibid. 6. Ibid. 7. IOM 1992 Annual Meeting, 36. 8. Assessing Future Research Needs (Transcript), 288. 9. Scrimshaw (1991), 4. 10. Ibid., 5. 11. Ibid. 12. Science and Babies: Private Decisions, Public Dilemmas, 54-5. 13. Quoted in Scrimshaw (1991), 2. 14. Ibid. 15. Ibid., 6. 16. Ibid., 12. 17. Toxic Shock Syndrome: An Assessment of Current Information and Future Research Needs, 85. 18. Ibid., 47-8. 19. Ibid., 45-7. 20. Ibid., 56. 21. Assessing Future Research Needs (Transcript), 166. 22. IOM 1992 Annual Meeting, 73. 23. Ibid. 24. Ibid. 25. Ibid. 26. Ibid., 94-5. 27. Ibid., 95. 28. Ibid., 77. 29. Ibid., 80. 30. Ibid., 82. 31. Ibid., 74. 32. Ibid., 83. 33. Ibid., 84. 34. Assessing Future Research Needs (Transcript), 157. 35. Ibid., 158. 36. Ibid., 212. 37. Ibid., 214-5. 38. Ibid., 210-1. 39. Ibid., 158. 40. IOM 1992 Annual Meeting, 90. 41. Ibid., 55. 42. Ibid., 187. 43. Assessing Future Research Needs (Transcript), 202. 44. Ibid., part 2, 46. 45. IOM 1992 Annual Meeting, 14. 50