Human sickness behavior: Ultimate and proximate explanations
Eric C. Shattuck* andMichael P. Muehlenbein
Article first published online: 13 JAN 2015
DOI: 10.1002/ajpa.22698
© 2015 Wiley Periodicals, Inc.
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Sex, gender, and cultural factors
Sex (genetic/gonadal typology) and gender identity (personal, subjective experience as masculine, feminine, or other) may also play important roles in the expression of sickness behavior within and between human populations. Unfortunately, we are aware of only a single study specifically addressing mechanisms underlying sex differences in sickness behavior in humans. In a small sample (N = 20) of participants receiving LPS, increases in IL-6 levels were significantly associated with increases in depressed mood in females but not males (Eisenberger et al., 2009). Interestingly, IL-6 increases in females were also associated with increased activity in brain areas (assessed via fMRI) associated with social pain (dorsal anterior cingulate cortex and right anterior insula under conditions of social exclusion) (ibid).
There is also evidence for female bias in symptom severity across a variety of cultural contexts (Torsheim et al., 2006). Typically, women report more illnesses and/or symptoms, take more sick days, and have more frequent hospital trips than men, even after accounting for reproductive health concerns (Hinkle et al., 1960; Gove and Hughes, 1979; Verbrugge, 1985; Arber and Lahelma, 1993; Macran et al., 1996). Men are significantly less likely than women to have contact with a physician, regardless of income and ethnicity (Courtenay, 2000). Women report more chronic conditions, including kidney/liver trouble, urinary infections, and allergies, and days confined to bed due to disability than men (Cleary et al., 1982). Women with chronic pain conditions report more severe pain, more frequent pain bouts, and longer-lasting pain than men (Goodin et al., 2013). Migraine, irritable bowel syndrome, temporomandibular joint disorder (TMJ), and pain associated with rheumatic diseases are all more frequent in women than men (Goodin et al., 2013), and Ruau et al. (2012) find that women report increased pain intensities for acute inflammatory conditions, including sinusitis and arthropathies. Women report more angina-related chest pain than men, as well as more symptoms, including dyspnea, irritability, nausea, and dizziness (Granot et al., 2004). Women also show lower pain thresholds and tolerances to experimentally induced pain than do men (Goodin et al., 2013). Another consistent finding is greater female absence from work due to sickness, though there are a variety of factors, including gender composition of the workforce, that appear to affect these absences (Laaksonen et al., 2012). In general, these results suggest that women typically experience their illnesses differently than men.
A mechanistic explanation of this bias in symptomology may be variation in endocrine and immune functions. Clearly, estrogens and progestins influence immune functions (Weinberg, 1984), with estrogens stimulating both cellular (Th1) and humoral (Th2) immune responses (Butts and Sternberg, 2008; Loram et al., 2012). Women have higher serum levels of IgM and IgG, and estrogen has been shown to increase the production of both antibodies from white blood cells in vitro (Bouman, 2005).
Another very plausible mechanism for differences in symptomology, health-seeking behaviors, and conceptions of sickness is variation in gender roles (culturally expected norms of behavior). These social norms often associate seeking help or “complaining” with women, or femininity more generally, while males and “masculine” individuals are assumed to maintain a stereotypical stoicism, and interestingly, men and women who self identify as less masculine/more feminine experience more symptoms of illness monthly (Annandale and Hunt, 1990).
Men who report being more masculine may be less likely to seek out preventative health care (Springer and Mouzon, 2011). However, this also likely depends upon different cultural conceptions of sickness and responsibility. Among African-American men there has been reported a relative lack of negative health effects of typical adherence to masculine beliefs (Springer and Mouzon, 2011). For example, self-reliant attitudes were associated with personal wellness (as well as health awareness, motivation to maintain good health, and the belief that one can influence one's health for good or ill) in a sample of African-American men, age 18–71 years (Wade, 2009). This may be a function of how self-reliance is perceived in different ethnic groups, with this group of participants possibly associating self-reliance with responsibility, discipline, and confidence. An individual may associate each of these with maintaining good health, contrary to previous results in which self-reliance was associated with risky health behaviors in Australian men (Mahalik et al., 2007).
There is also a considerable literature covering the cultural context of illness, which often overlaps with gendered experiences of illness, as described above. For instance, machismo refers to Latin American conceptions of masculinity, both negative and positive (Arciniega et al., 2008). Positive aspects can include dignity, wisdom, defense of family and its honor, and hard work, while negative aspects include violence, aggression, and highly sexualized behavior (Arciniega et al., 2008), as well as fetishism of women's bodies and a hypersensitivity towards an idealized view of women as virgins or mothers (the concept of Guadalupismo) (Sternberg, 2000). Machismo has been identified as a barrier to both health seeking in general in a sample of Mexican American men (Hunter et al., 2007), as well as to HIV prevention in Chile (Cianelli et al., 2008).
Researchers have also reported significant differences in measures of self-perceived health between populations. For instance, Hispanic American children reported more health concerns than did their European American counterparts in a non-clinical sample (Silverman et al., 1995). This finding is in accord with other results showing that Mexican American adults report more symptoms and somatization (i.e., a preoccupation with physical symptoms that likely have a psychological, rather than physical cause) than do Caucasian adults (Escobar, 1987). Similarly, there are data suggesting that Chinese individuals (both living in Asia and as immigrants in Western countries) report more somatic symptoms of depression than do Caucasians (Ryder et al., 2008).
Cultural factors like ethnomedical beliefs, the value placed on family, collectivism, and religiosity may all mediate some of the differences in symptom reporting and perceived health between populations. For example, illness severity in Mexican Americans is often measured by two factors, pain and the appearance of blood, as well as from the basis of family members' and acquaintances' experiences, with illnesses “common” to this group being perceived as relatively “normal” and inconsequential (Gonzalez-Swafford and Gutierrez, 1983). This emphasis on community, family, and interdependence stands in contrast to the Anglo-American valuation of autonomy and individualism which contributes to self-control over pain and illness, as well as a reduced number of protective social factors in comparison to other ethnic groups that might otherwise assist in buffering the effects of stress and disease (Sharp and Koopman, 2013; but see Voronov and Singer, 2002 for a critique of the individualism-collectivism construct). Other personality traits, such as stoicism and religiosity, may help shape individual or even group-level interpretations and experiences of sickness. The ability to endure pain and illness is a valued sign of strength in Mexicans and Mexican Americans (Calvillo, 2013), and high rates of self-reported stoicism in the face of pain have been reported in Andean Quichuas (Incayawar and Maldonado-Bouchard, 2013). A similar phenomenon has been reported in Chinese men (Hong-Gu and Vehviläinen-Julkunen, 2013). Confucianism, as practiced in China, is possibly associated with stoical attitudes towards pain and illness, particularly in males (Hong-Gu and Vehviläinen-Julkunen, 2013). A belief that illness is an act of God may predispose individuals against reporting the condition and/or seeking treatment, as has been observed in Mexican Americans (Gonzalez-Swafford and Gutierrez, 1983). It has also been reported that Anglo-Americans are less likely to use religion as a coping mechanism during chronic pain, in comparison with African-Americans (Sharp and Koopman, 2013).
Based on the findings that socially appropriate behaviors during illness (e.g., complaining of symptoms, seeking health care or other assistance, suspending economic or other social obligations to rest or recuperate etc.) vary by sex, gender, cultural context, and individual personality, it is a reasonable assumption that sickness behavior expression is also modulated by the same factors. For instance, sick individuals scoring higher on a measure of collectivism might downplay the effects of sickness behavior for relatively minor complaints (e.g., a cold, minor influenza), to avoid “becoming a burden,” but to actively seek support for a more serious health problem. Similarly, more individualistic people could sublimate the effects of sickness behaviors and avoid soliciting social support at all times, perhaps preferring medical consultation to social support. Males, or individuals who exhibit more “masculine” behavioral and psychological traits, would under-report sickness behavior symptoms (lethargy, depression, and so forth) in cultural contexts that associate “male-ness” and masculinity with stoicism, dismissal of pain, etc., and the opposite may be true for females or highly feminine individuals. Finally, it should be noted that the evidence presented above is predominantly derived from industrialized, Western populations. Similar research in societies with different medical practices, gender roles etc., would be highly illuminating, and a welcome contribution to the field
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