Help seeking for cardiac symptoms: Beyond the masculine–feminine binary

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Abstract

Empirical and theoretical literature suggests that stereotypical gender roles shape men’s and women’s health help-seeking behavior, and plays an important role in the treatment seeking delays of cardiac patients. We were interested in exploring the ways in which gender informs the experiences and help-seeking behavior of men and women who experienced the symptoms associated with acute cardiac events. We undertook 20 in-depth interviews between October 2007 and July 2008 with 11 men and 9 women recently diagnosed with an acute coronary syndrome in British Columbia, Canada. Participants were encouraged to tell their ‘story’ of the event that led to hospitalization and diagnosis, with a focus on the symptoms and decision making processes that occurred before and during the activation of health services: seeking the advice of others including colleagues, family members and healthcare professionals; calling 911; and attending an emergency department. Although we anticipated that distinctive patterns of help-seeking behavior aligned with stereotypical masculine and feminine ideals might emerge from our data, this was not always the case. We found some evidence of the influence of gender role ideology on the help-seeking behavior of both male and female participants. However, men’s and women’s experiences of seeking health care were not easily parsed into distinct binary gender patterns. Behavior that might stereotypically be considered to be ‘masculine’ or ‘feminine’ gender practice was shared by both male and female participants. Our findings undermine simple binary distinctions about gendered help-seeking prevalent in the literature, and contribute towards setting the direction of the future health policy and research agenda addressing the issue of gender and health help-seeking behavior.

Introduction

Women’s and men’s health-seeking behavior are purported to be closely tied to stereotypical/traditional ideals of femininity and masculinity. Within Western culture, the predominant stereotype of women has placed a heavy emphasis on beauty, youth, and physical attractiveness (Avsec, 2006, Baker-Sperry and Grauerholz, 2003, Beben, 2002, Cole and Zucker, 2007, Stankiewicz and Rosselli, 2008, Wu et al., 2006). This stereotype is accompanied by the traditional gender role ideology of women as primary care givers and the perception that women are gentle, emotionally expressive, reluctant to bother others with their problems, sensitive and sociable (Prentice & Carranza, 2002). Accordingly, women are typically viewed as possessing a desire to have and raise children, as nurturers who have domestic skills, take care of their own and others’ health, and have a need for intimacy, connectedness, and self-disclosure (Barnett, 2006, Cole and Zucker, 2007, Emslie and Hunt, 2008, Kristofferzon et al., 2003, Wood et al., 2005). Thus, in Western cultures, feminine ‘ideals’ (in the context of health help-seeking behavior) are typically seen as asking for help, caring about health, nurturing and monitoring partners’ and children’s health and well being, and pressuring male partners to see a physician if they are reluctant (Courtenay, 2000b, O’Brien et al., 2005).

By contrast, the espoused masculine ideal in Western culture emphasizes toughness, controlled emotions, decisiveness, heroism, and independence (Seem & Clark, 2006). Men are typically viewed as risk takers who possess a high threshold for pain or discomfort, enjoy challenges, are self-reliant, and are responsible for the family’s economic protection. Rather than emotional, ‘real’ men are considered to be stoic and rational, and typically suppress the need for self disclosure, intimacy, and connectedness (Connell, 1995, Courtenay, 2000a, Emslie et al., 2006, Mahalik et al., 2007, Wu et al., 2006). Although recent work has identified differences and diversity among men and masculinities in the context of health and help seeking (Galdas et al., 2007, O’Brien et al., 2005, Robertson, 2006), these culturally-dominant masculine ideals have been implicated to play out in some men’s reluctance to seek health care promptly (Galdas, 2009). Indeed, despite variations in how gender has been understood and conceptualized by social scientists and health researchers, the aforementioned (Western) gender roles and stereotypical ideals of masculinity and femininity have been widely used to inform a variety of studies of health behavior.

Mahalik, Lagan, and Morrison (2006) found that men who reported greater conformity to the ‘masculine norms’ of sexual promiscuity, self-reliance, and violence were less likely to engage in health-promoting behavior, and were more likely to engage in health risk behavior. Regardless of nationality, conformity to traditional norms was associated with unhealthy alcohol use, neglect of preventive health care, such as health screenings and skin cancer protection, entering into fights, and taking general as well as specific risks related to sexual behavior and the use of cars. Parslow, Jorm, Christensen, Jacomb, and Rodgers (2004) reported that being married or in a relationship was positively associated with men making an initial family physician visit, and also with making further visits, indicating that, for married heterosexual men, women were monitoring and successfully ensuring that their male partners sought health care. However, men are less likely to discuss mental and emotional problems with their primary care providers, and spend less time in office visits than do women (Smith, Braunack-Mayer, & Wittert, 2006). When the use of reproductive services have been accounted for, Western men use health services less often than do women, especially after the age of 16 years, and are twice as likely to have gaps of two or more years between physician visits (Mansfield et al., 2003, Mason and Strauss, 2004, Smith et al., 2006). The reasons for these differences may include perceptions of invulnerability and espousing the masculine ‘ideals’ of independence, self-reliance, stoicism, and fear of discrimination for mental or physical health problems (George and Fleming, 2004, Smith et al., 2006, White et al., 2006). Mahalik, Burns, and Syzdek (2007) found that men who rated themselves as having higher ‘traditional masculinity’ scores reported more health risk behavior and less health promotion behavior, and were less likely to consult a mental health professional if feeling sad or depressed for longer than a month, or to consult with a health care provider when having unfamiliar symptoms.

According to the popular press, women are seen as experts in terms of diet and health (Gough, 2007), which is framed as women’s work, with a caretaking role expected of them (Barnett, 2006). Similarly, compared with men, women have been found to have more positive overall attitudes toward professional help-seeking, a greater willingness to recognize the need for help, and a greater tolerance for any societal stigma associated with help seeking (Ang et al., 2004, Krogh, 2007). Hunt, Lewars, Emslie, and Batty (2007) reported that higher ‘femininity’ scores in men were associated with a lower risk of coronary heart disease death, while no such relationship was observed with the women in their study. Thus it would seem that traditional gender roles and stereotypes exist and influence the health behavior of men and women. Moreover, researchers continue to rely on these notions to explain health behavior.

The literature concerning help seeking and cardiac care is conflicting in that some researchers have reported that women delay seeking help, compared with men’s responses (Ottesen et al., 2004, Ting et al., 2008), and others have reported that there is no sex/gender difference in the interval between the onset of cardiac symptoms and seeking care (Løvlien et al., 2007, Moser et al., 2005). Those who have reported that there is a sex-based difference (anatomical or physiological in nature) have postulated that women do not recognize their cardiac symptoms because health educators’ characterizations are based on men’s experiences when women’s symptoms are different from the “hallmark” symptoms – they are “atypical” and consequently not recognized as serious (O’Keefe-McCarthy, 2008). Canto et al. (2007) however hypothesized that this apparent difference is more likely the result of differences in age at the time of a cardiac event, rather than being a sex difference (women are generally older than men when they first experience an acute coronary syndrome and age influences the symptom experience). Others have suggested that there are gender differences in help-seeking behavior and they are social in nature. For example, Moser et al. (2005) reported that being concerned about troubling others led to delay for women but not for men. They argued that the importance placed on their numerous social demands may cause women to ignore their own health needs. Galdas et al. (2007) reported that some men need to portray high tolerance for pain and to avoid appearing weak or hypochondriacal, which influences their help seeking.

Whether there is a difference in the timing of help-seeking, much of the empirical literature suggests that stereotypical (or “traditional”) gender roles and norms – culturally dominant behavior considered to be essentially “masculine” and “feminine” – are an important factor that shapes both men’s and women’s health help-seeking behavior. Indeed, these masculine and feminine gender roles are purported to play an important role in treatment seeking delays in cardiac patients. We were interested in exploring the ways in which gender informs the experiences and help-seeking behavior of men and women who have symptoms of an acute cardiac event.

Section snippets

Sampling and data collection

We used purposive sampling to recruit a heterogeneous sample in terms of gender, age, socio-economic status and health status. Participants were invited to be interviewed based on the following criteria: an admitting diagnosis of chest pain suspected to be of cardiac origin or confirmed Acute Coronary Syndrome (ACS); completion of a survey questionnaire while in an acute care facility for ACS; an expressed interest in participating in a qualitative interview once discharged home and medically

Findings and discussion

Although we anticipated that distinctive patterns of help-seeking behavior aligned with stereotypical masculine and feminine gender roles might emerge from our data, we found that this was not always the case. Indeed, our findings reveal that men’s and women’s behavior is not easily parsed into distinct binary gender patterns. Behavior that might stereotypically be thought of as “masculine” or “feminine” was shared by both men and women. We begin by discussing the responses of men and women

Conclusion

Our findings contribute towards setting the direction of the future health policy and research agenda addressing the issue of gender and health help-seeking behavior. Previous research has largely focussed on single sex samples and emphasized the differences between men’s and women’s help-seeking behavior for acute cardiac symptoms, when it is apparent that there are many important similarities. Our findings illustrate that men’s and women’s decisions to seek or delay seeking treatment for

Acknowledgements

This research was supported by a Canadian Institutes of Health Research (CIHR) operating grant (MOP 145706). Dr. Ratner is supported by the Michael Smith Foundation for Health Research.

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