Pauline M. Prior

The Relationship Between Marital Status and Health An Empirical Investigation of Differences in Bed Occupancy Within Health and Social Care Facilities in Britain, 1921-1991

Based on census materials collected in Britain from 1921 to 1991 and using bed occupancy as a proxy for health, this study focuses on the relationship between marriage and physical health. The results confirm the positive association between marriage and physical health within this society. Married people consistently make less use of residential health and social care facilities than do nonmarried people, and this relationship holds across all census years. This is not to deny, however, some important health differences within the nonmarried population, such as the increasing vulnerability of widowed females aged 65 years and older and of never-married males of working age.

Changing Places: Men Replace Women in Mental Health Beds in Britain

Based on census materials collected in England and Wales from 1921 to 1991, this study focuses on gender differences in occupancy rates in hospitals and other mental health facilities in Britain. The results suggest that since 1991, or for the first time in the twentieth century, there are more males than females in residential mental health facilities in Britain. Furthermore, this pattern of association holds for all age groups except those aged 65 years and over. Second, there are currently two distinct subpopulations in mental health facilities—a male group which is predominantly of working age, and a female group, which is predominantly of retirement age. The existence of these two “care” populations will impact significantly on current and future resourcing of mental health services. The policy implications of the research findings are discussed within the context of the debates on the changing relationship between gender and mental health.

Gender trends in occupancy rates in mental health beds in Northern Ireland

Based on census material from 1926 to 1991, this study focuses on gender differences in occupancy rates in mental health beds in Northern Ireland. More specifically, using two sets of research literature--the relationships between war and mental health and gender and mental health respectively--it explores changing patterns in bed occupancy in terms of both gender and age differences within this society. The results suggest that, although men and women no longer vary in terms of their overall occupancy rates within mental health facilities in Northern Ireland, within their respective male and female sub-populations, however, some notable age-specific differences have now emerged. Since 1981, whereas increases in mental health bed occupancy among women have been exclusively confined to the old (65 years or older), among males, it is the very young, specifically men aged 15-24 years, who have demonstrated the most dramatic rise in bed usage. It is important to note, however, that these age-specific gender increases cannot be accounted for by demographic changes in the general population. The authors suggest that, at least as far as men are concerned, the increasing pattern of vulnerability among the young may be attributed to the impact of changing definitions of mental disorder rather than to the effect of political violence on mental health. It is to this group of individuals--the cohort of men born since the outbreak of civil unrest in Northern Ireland in 1969--that future research should be directed.

A Historical Account

While much has been written on the history of the health care system in the UK, to date the impact of gender in relation to its development has rarely been assessed. Contrary to political rhetoric on the implicitly neutral nature of health care provision, it has been highly gendered in its impact. Irrespective of whether one considers the implementation of the first public health programme at the start of the twentieth century or the introduction of the National Health Service (NHS) in 1948, it is women, and not men, who have been the most adversely affected by developments in health care provision. With this understanding in mind — of the differential impact on gender — this chapter provides an historical account of health care provision in the UK throughout the twentieth century.

Women as the ‘Madder’ Sex

Until recently, it was widely believed that women were more prone to mental illness than men, as indicated by their higher visibility in most statistics on mental illness. This numerical predominance of women in psychiatric statistics confirmed stereotypical notions of women as ‘mad’, and led to extensive debates on the reasons for the greater vulnerability of women both to the experience of mental health problems and to treatment in a psychiatric setting (for discussion, see Chapter 7). In recent years, however, this belief has been increasingly challenged. This is particularly the case in the USA, where a number of empirical studies have found a notable increase not only in the number of men reporting psychiatric symptoms but also in terms of their use of institution-based mental health care. Examples of these empirical studies, which have been discussed in earlier chapters, include the ECA and the NCS, in which men reported higher levels of mental disorder over their lifetimes than did women (Kessler et al., 1994; Robins and Regier, 1991). Studies on institution-based care, particularly those examining statistics on involuntary (compulsory) admissions, have also found this pattern. For example, men formed the majority (58 per cent) of the 2,200 patients admitted on an involuntary basis to hospitals in Philadelphia in the early 1990s (Sanguineti et al., 1996).

Marriage is Good for Health

Traditionally, marriage has been seen as the central institution in legitimising and regulating sex in almost all societies. It was regarded not only as the norm for most people but also as a permanent arrangement. Couples were expected to stay together — in good times and in bad, for richer and poorer, in sickness and in health — throughout their lives. Church leaders, politicians and social analysts defended the permanency of marriage by pointing to its economic and psychological benefits for both the individual and society. However, this view of marriage has been increasingly challenged in modern western society. Undermined internally by the sex-role revolution and externally by the rise of non-traditional family living patterns, such as co-habitation and single/never married parenthood, the institution of marriage no longer holds prime position as the best way of defining sexual relationships. Thus, in spite of its positive image in the past, marriage is no longer regarded as either a preferred or permanent way of life by an increasing number of people.

Researching Gender and Health Care

The debate on the relationship between gender and health in Western Europe and in the USA has been ongoing since the early 1970s (for a review of the literature, see Hunt and Annandale, 1999; Lahelma et al., 1999). This is particularly the case when physical health is considered. In the early years of the debate, it was generally accepted that two seemingly contradictory trends tend to operate at the same time. The first trend is that women consistently show high rates of morbidity — that is more self-reported illness and higher use of health services than men. The second and, seemingly, contradictory trend is that men have higher rates of mortality — on average, their life expectancy is five years shorter than that of women.

Gender and Physical Health

The academic debate on gender and physical health, which began in the 1970s (Mechanic, 1978; Nathanson, 1977;Waldron, 1976), has continued since then on both sides of the Atlantic. For most of this time, it has been generally accepted that women experience more illness than men and are higher users of health services but that, in spite of this, they live longer. As briefly discussed in Chapter 1, these facts are summarised in the phrase — ‘women are sicker but men die quicker’. This seemingly contradictory statement is based on substantial research evidence of higher levels of morbidity in the female population and higher levels of mortality in the male population.

Young Men as Reluctant Help-Seekers

In the past, young men have not featured prominently in mental health statistics, a fact that contrasts sharply with their high visibility in crime statistics (Daly, 1994). This pattern confirms the accepted view of young men as individuals who show their emotional or psychological problems in acts of violence and other socially unacceptable behaviour, rather than in seeking help from health services. In other words, illness behaviour is not as acceptable for young men as it is for young women (see Shorter, 1990). As we have discussed in Chapters 7 and 8, young men are now becoming more visible in psychiatric statistics in the USA, mainly due to the inclusion of substance dependence and personality disorder in the calculation of these statistics in recent years. In Chapter 8 we found that this pattern has not yet emerged in England and Wales in one very important area of mental health provision, institution-based care, when overall bed occupancy in mental health facilities was investigated. However, there is some evidence of an increase in young men in admission rates (Payne, 1996, 1995) and in the new long-stay population in psychiatric hospitals (Lelliot et al., 1994).

Older Women are Most Vulnerable

In common with the rest of the western industrialised world, the UK has an ageing population. In 1901, about one person in 20 was over the age of 65 and one in 100 was over the age of 75. By 1998, this increased to just over one in six for those over the age of 65 and one in fourteen for those over the age of 75. At the same time, the proportion of the population under the age of 16 fell from a third to just over a fifth. Demographic projections suggest that these trends will continue. For example, by 2011, it is predicted that the number of people over the age of 65 will be greater than the number under the age of 16 — 11.9 million as compared to 11.3 million — and the majority of dependants in the UK will be retired people (ONS, 2000a: 8).