What does being female mean in terms of a woman’s health across her lifetime? Will it affect the sorts of diseases she could suffer? Secondly, could her gender mean that a woman experiences wellness and illness differently from men, and receives different health care than a man? This section will endeavour to answer these two questions. To illustrate the main points of the chapter, we will refer to Sara’s health experiences. Sara is a 51-year-old woman, living in regional Australia.

Many readers would realise that, on average, women live longer than men in many parts of the world. This is certainly the case in all developed countries, although there are a few noteworthy exceptions. In a few countries in South Asia, such as Bangladesh and Nepal, men have longer life spans than women (Cockerham 2004).

Why do women in most parts of the world live longer than men, and has this always been the case? The evidence available to us suggests that in preindustrial times, women and men lived to approximately the same age. This situation continued until relatively recently; in the 1850s, in England and Wales for example, both men and women had a life expectancy of around 59 years (Cockerham 2004). However in the early 1900s this picture changed, and the gap between the average woman’s and the average man’s lifespan increased to the point where, for example, as a group, Australian women live more than five years longer than Australian men. There is some evidence now that this gap may have peaked and could be shrinking (Cockerham 2004). Possible causes for this include women’s increasing uptake of traditionally male pursuits, including wider commitment to having a successful career (and the stresses that come with it, especially when combined with the traditional women’s work of caring for family), and cigarette smoking.

An interesting paradox within women’s health is that, whilst women do live longer than men, they also consistently report more illness and a poorer health-related quality of life than men. In other words, they appear to get sick more often, and the symptoms associated with their sickness can reduce their life enjoyment. For example, in the 2001 Health Survey, 21% of women reported suffering arthritis, as compared to 15% of men (ABS 2003), whilst 12.2% of women said they had experienced a mental or behavioural problem, as compared to 8.7% of men.

There are a variety of factors contributing to this apparent paradox. One is that women may be more willing to acknowledge their illnesses and seek help than men. For example, in 2001 it was estimated that 27% of females had consulted a doctor in the previous two weeks, compared with 21% of males (ABS 2003).

The second factor is that the diseases which more often afflict women cause suffering but not necessarily death. The opposite is true for men. They report fewer non life-threatening conditions, but are more likely to be grappling with life-threatening conditions. For example, in the 2001 Health Survey, 2.5% of the men who participated said they currently had cancer, compared to 1.8% of women (ABS 2003).

The third factor is the nature of women’s lives, as opposed to men’s. Whilst there have been significant changes in women’s lives in the past forty years, driven particularly by the second wave of feminism begun in the 1960s, there continue to be significant differences between how men and women live. For example, women continue to do the bulk of unpaid caring for children, the elderly and the disabled, and there is evidence that women find the ‘superwoman’ expectations overwhelming (Pretty 1998). These expectations lead women to believe that they must be successful in domesticity, the traditional female domain, whilst also excelling in the male dominated domain of work (Novack & Novack 1996, Philpot et al 1997). These dual sets of expectations create high levels of stress for women who are working and managing a home and family, or caring for elderly or disabled relatives, as well as a lack of time to engage in self-care activities such as exercise and relaxation. Sara’s recent heart attack fits with this picture. As a sole parent she’s found it difficult to find time to manage work and home life. This has left her very little time to take care of herself by preparing healthy food and taking regular exercise which, coupled with her long-term smoking habit, has no doubt increased her vulnerability to cardiovascular disease.

Although the evidence suggests that women do experience more ill health than men, there appears to be no significant difference between men’s and women’s perceptions of their health status. In 2001, the majority of Australians aged 15 years and over perceived themselves as being in good health, with 82% reporting their health as good, very good or excellent (ABS 2003). This suggests that overall, whilst women appear to experience more health concerns, these concerns do not jeopardise women’s perceptions of their own health and wellbeing.

Often, discussion of ‘women’s health’ leads to a discussion about women’s reproductive health. After all, women’s reproductive functions lead to bodily experiences such as menarche, menstruation, fertility, pregnancy, childbirth, breastfeeding and menopause. Health problems related to women’s reproductive functions are diverse and include such things as dysmenorrhoea (painful periods), sexually transmissible illnesses leading to chronic problems such as pelvic inflammatory disease and infertility, birth-related problems, mastitis (a common infection of the breast tissue in women who are breastfeeding) and cancers of the breast, uterus, cervix and ovaries.

The list of reproductive-related women’s health problems is quite long, and perhaps it’s not surprising that ‘women’s health’ is often thought to be synonymous with women’s reproductive health. At times, this analogy is relevant. Later in this chapter there is a discussion about obstetric fistulae, a serious women’s reproductive health issue affecting many women from underdeveloped countries, who lack access to the type of maternity care to which women from western societies have ready access. As you will read later, women who live with obstetric fistulae have a profoundly reduced quality of life because of this problem.

Despite the range of women’s health concerns related to their reproductive functioning, women also face a myriad of health problems which are not related. Health problems unrelated to reproductive health are more likely to be the cause of morbidity and mortality in women. For example, an editorial in the influential medical journal Lancet recently identified heart attacks and stroke as the ‘greatest threat to women’s health’ on a worldwide basis (2003, p 1165). Twice as many women die from cardiovascular disease as from all forms of cancer, and women are more likely to die from cardiovascular disease than men.

This may be surprising for some readers, because it is contrary to ‘common knowledge’. Heart disease is generally viewed as a problem affecting men, and tends to conjure images of middle-aged men having sudden and sometimes fatal heart attacks. Even amongst health professionals, there has been a perception that women do not get heart disease prior to menopause, despite evidence to the contrary (Miracle 2004). As you will recall from Sara’s story, she was unconcerned when she first experienced chest pain, thinking that it was just indigestion. Obviously the thought that she might have heart disease had not occurred to her, even though she is a nurse.

Of particular concern is that this lack of awareness is also evident amongst health professionals. Research suggests that women may receive less thorough and less intensive investigations of their cardiovascular symptoms than men (Ayanian & Epstein 1991, Miracle 2004, Steingart et al 1991). In the first instance, this happened to Sara, whose GP did not consider the possibility that Sara might have heart disease at such a relatively young age. This failure to assess women’s cardiovascular symptoms with the same vigour as when they occur in men could stem from the pervasive belief that heart disease is not as dangerous for women as it if for men (Broom 2002). In this scenario, we see the dangers of assuming that reproductive health is the key component of women’s health.

There are significant differences around the world in relation to the health of women. In Australia and other developing countries, the health of women has markedly improved over time and this is related to better nutrition, access to clean water, sewage systems, better health care, and so on. In the past twenty-five years, since the beginning of the women’s health movement, the health needs of women have received special attention, with a suite of women’s health services targeting particular health problems as well as selected groups of women. For example, in Sara’s home town in regional Australia, specialist women’s health services include a young women’s service targeting young disadvantaged women and girls with a specialist antenatal and postnatal service; three breast cancer diagnostic clinics; and a women’s health nurse service.

This is not necessarily the case worldwide. The health of women, men and children everywhere around the world is linked to their financial status, but the social roles and status of men and women also play a major role. The health of women is linked strongly to the status of women, and this is very evident in countries where women occupy a lesser position in society than men. As the World Health Organization states in its Gender Policy (2002, p 1):

The example of obstetric fistula in women in developing countries provides compelling evidence of this link. Obstetric fistula is a health problem caused by obstructed labour in birthing women. When the baby’s head is pushed against the woman’s pelvis for a long period of time, death of the surrounding tissue can result. This can cause a hole to form between the woman’s bladder and vagina, leading to urinary incontinence, or between the rectum and vagina, leading to faecal incontinence. Usually, the woman’s baby is stillborn. For women, the consequences of obstetric fistulae are tragic. They have lost their baby, they smell bad because of their incontinence, and are often shunned by their husbands, families and communities (Donnay & Weil 2004).

In developed countries, high quality midwifery and obstetric care means that obstetric fistulae rarely occur. Yet, over two million women worldwide have this problem (Murray & Lopez 1998). It is caused by malnutrition, generally poor health, and early marriage leading to pregnancy before physiological maturity (Donnay & Weil 2004). Early marriage is related to lack of education. Girls who have the opportunity to go to school delay having children, and this reduces their risk of developing obstetric fistulae (Bangser, Gumodoka & Berege 1999). Furthermore, many women living with obstetric fistulae usually are not aware that surgical treatment is effective in resolving the problem and, even if they are aware, are unlikely to have access to this treatment.

Another significant women’s health issue highlighted by governments, community groups and women themselves is violence against women. Violence against women can involve the threat or use of physical violence to frighten or harm a woman; or sexual assault, which is any sexual act forced upon a woman without her consent (ABS 2002). Violence against women is strongly linked to perceptions of a woman’s ‘place’ in society. The United Nations Declaration on the ‘Elimination of Violence Against Women’ noted that it is a symptom of unequal power relationships between men and women, and is a primary violation of basic human rights (Oswomen 1992).

A survey in 1996 revealed that 7% of Australian women (490,400) had experienced at least one incidence of violence in the past twelve months, with 404,400 of these women reporting physical violence and 133,100 reporting sexual violence. Women were over four times more likely to be assaulted by a man than by a woman. A particularly distressing finding was that 22% of women (109,100) reported that more than one perpetrator had abused them in the preceding twelve months (ABS 2002).

Nurses and other health professionals need to be aware that a woman’s response to recent or past violence can lead to mental and physical health problems such as insomnia, anxiety, eating disorders, depression and suicide attempts, headaches or heart palpitations (Anderson, Harris & Madl 1998). Violence against men by men is also common, and of concern. However, violence against women by men is particularly traumatic because it is characterised by an abuse of power, which usually occurs within the confines of a relationship or at the time of separation due to relationship failure. Sara says that her abuse started when she was pregnant with Tania. Her husband could be a kind and generous partner, but when he drank too much alcohol his whole personality changed and this led to him hitting her. In the beginning this happened rarely, but as the years went by it happened a lot more often. Sara loved her husband, and was scared because she didn’t know how she would cope on her own, but eventually she could see that her children were being badly affected. With the help of the local domestic violence service, Sara was able to gather her strength to leave her husband and begin life again. This took a couple of years because she was suffering from depression and needed a lot of support to believe in herself again.