Gender and Death

Males and females have different risks of dying with regard to both age at, and cause of, death. The male-female differential depends on level of economic development; however, there are some universal characteristics that appear to be biologically determined. These "universals" are most pronounced at young ages.

Biological Differences

It has universally been found that more male than female babies are born. While the magnitude of the sex ratio at birth (the number of male births per 100 female births) varies somewhat, it is almost always in the range of 103 to 107. There is some debate about why male births exceed female births, in part centered on the issue of sex differences in the number of conceptions. It has been argued that considerably more males are conceived, but that the male fetus is biologically weaker. The data available suggest that males do have higher mortality from around the third to the fifth month of gestation age. While it is extremely difficult to know about mortality risk during the first few months of pregnancy, the limited evidence suggests that there are more male embryos by the second month after conception. This means either that more males are conceived or that female embryos have higher mortality risk in the weeks after conception, or both.

While there is uncertainty about sex mortality differentials in the early gestational period, data for the first year of life are very clear. In virtually all places and times infant mortality rates are higher for males than for females. Quite a bit of evidence points to biological factors playing an important role in the higher mortality of infant males. Despite their higher birthweights (a factor associated with infant survival), male babies are more likely to suffer from congenital abnormalities that lead to death and to have immune deficiencies associated with X chromosome-linked genetic defects and with exposure to testosterone prenatally and in early infancy. This latter factor may also contribute to greater activity levels associated with higher accident mortality.

Other biologically based factors contributing to gender differences in mortality include the protective effect of women's XX chromosome structure against heart disease, especially at ages under fifty-five, and a propensity to violence among men that can have lethal consequences. The degree to which men are more violence-prone than women and the reasons for it are, however, hotly debated and it cannot be stated if and how biology may be implicated. While biological factors can explain part of gender differences in mortality, these differences vary too much by time and place to be accounted for by biology to any great extent.

Gender Differences in Mortality in Less Developed Countries

According to the Population Reference Bureau, circa 2000 in less developed countries the life expectancy at birth of females exceeded that of males by three years (66 versus 63 years). In the 1950s the differential was approximately two years (42 versus 40 years). While considerable progress in life expectancy at birth has been made, and approximately equivalently for males and females, there is much concern that women in third world countries are disadvantaged in terms of mortality. In part, this concern stems from the gender mortality gap favoring females in developed countries that is interpreted to mean that, given more equal treatment, females will have lower mortality than males.

The clearest evidence of female disadvantage comes from demographic research on the third world, which estimates that between 60 million and 100 million girls and women are "missing." They are missing as a combined result of female infanticide, sex-selective abortion and health care neglect, nutritional deficiency, and mistreatment that lead to death. Also, maternal mortality plays a role; the World Health Organization (WHO) and UNICEF estimate that more than half a million women die per year due to pregnancy-related problems, most in developing countries. Worldwide, women face a 1 in 75 lifetime risk of dying due to maternity-related causes. This risk varies from 1 in 4,085 in industrialized countries to 1 in 16 in the least developed parts of the world (see Table 1).

The female mortality disadvantage varies substantially across developing countries. For example, in substantial portions of the third world, mortality rates at ages one through four are approximately equal for girls and boys. However, populations of the Indian subcontinent and China have childhood mortality rates favoring males by a substantial margin. Indeed, it is likely that most of the world's missing girls and women are from these two regions. It appears that the female mortality disadvantage in the third world is less the result of societal economic deprivation (as many countries are poorer than India and China) than it is the by-product of cultural values and practices that favor males. China's one-child-only population policy also plays a role, given a pre-existing preference for sons in that patrilineal society.

Within the third world in general, there is not any systematic evidence that females are less well-nourished than males. However, research suggests that differential access to preventive and curative health care, such as vaccinations, favors males in

much of the third world. Another factor that negatively affects female mortality relates to birth spacing. In countries with son preference, the birth of a daughter will be more quickly followed by another birth than is the case when a son is born. This disadvantages young girls because a short interval between siblings is related to higher mortality for the older child.

An aspect of gender inequality in death concerns cultural practices related to widowhood. In some societies it is cultural practice for widows to also die when their husbands pass away. A well-known case of this practice is sati in India, in which a widow is expected to commit suicide by throwing herself on his funeral pyre. A widow who resisted might be pushed into the pyre by her inlaws. While religious reasons are purportedly at the root of such practices, it is also argued that other motives can prevail, such as repossession of the widow's inheritance by her husband's family. While sati was legally banned in the 1800s by the British colonial rulers in India, it persists only in a few Indian states and other parts of south Asia.

Gender Differences in Mortality in Developed Countries

In developed countries, females outlive men by seven years: life expectancy at birth for females is 79 and for males it is 72. However, there is variation across the developed world in the magnitude of the sex difference in life expectancy. It ranges from a low of five years in many of the countries that made up the former Yugoslavia (averaging 75 years for females and 70 years for males) to a high of twelve years in Russia (73 years for females; 61 years for males).

In mid-twentieth century the average difference in life expectancy at birth in more developed countries was approximately five years. At the beginning of the twentieth century, the difference was estimated at two to three years.

Trends in mortality favored women in the more developed countries from at least the beginning of the twentieth century to the early 1980s. Mortality trends in different age groups contributed differentially to this overall trend of widening the sex gap in mortality. Nearly two-thirds of the widening can be attributed to mortality among people aged sixty-five and over. In other words, death rates for older women declined more quickly than death rates for older men. Onequarter of the increase resulted from mortality trends among people aged fifty-five to sixty-four, for whom, as well, female death rates declined more than male death rates. Very little of the increase was due to mortality among children aged one to fourteen, less than 3 percent. (This is unlike the case in the third world, where death rates among children figure prominently in mortality trends and differentials.) In contrast, trends in infant mortality operated in opposite fashion, to narrow the sex difference in mortality. High male infant mortality was overcome to a considerable degree so that eventually, for the most part, only the genetically caused higher susceptibility of male infants to death remained.

Differential trends in various causes of death contributed to the widening of the sex mortality difference. By far the most important cause of death in the widening is diseases of the circulatory system, which include ischemic heart disease and strokes. While there is variation from country to country, the overall fact that male deaths due to circulatory disease declined less than female deaths is responsible for approximately three years of the widening gap. Of the different kinds of circulatory diseases, trends in ischemic heart disease played the biggest role in this three-year widening, with men's death rates increasing over most of the twentieth century while women's death rates were stable or declined. Rheumatic heart disease and strokes (for which women and men have approximately equal risks of death) have decreased in importance as causes of death. Thus, the composition of the circulatory disease category—with an increasing prevalence of ischemic heart disease—played a role in widening the sex mortality differential.

The second most important cause of death in explaining the widening sex differential in mortality is malignant neoplasms (cancer). At the turn of the twentieth century, female mortality from cancer (especially due to breast cancer and cancers of the female genital organs) tended to be higher than male cancer mortality. However, over the course of the twentieth century increasing rates of male mortality due to respiratory (e.g., lung) cancers served to widen the male-female mortality difference. In the United States for the period from 1900 to the early 1980s shifts in the trends and pattern of cancer mortality accounted for more than one-third of the widening sex mortality differential; in other Western countries such as England and Australia, the contribution made by malignant neoplasms to widening the sex mortality ratio was even greater.

Other causes of death are much less important contributors to the widening sex mortality differential. For example, declines in maternal mortality, although very substantial, have had only a small effect. Trends in accident mortality and suicide—two causes of death that are higher for males—have not played a big role either. In contrast, declines in infectious and parasitic diseases, for which males in the West tended to have higher mortality than females, had an opposite effect, that is, to narrow the sex gap in mortality.

The increase in respiratory cancer among men and the slower decreases in circulatory system mortality among men have been attributed to smoking differences, in large part. Over the earlier years of the twentieth century, men (much more so than women) took up cigarette smoking, the effects of which show up in mortality statistics among older age groups being that cigarettes are slow killers.

Since the early to mid-1980s the sex differential in mortality has narrowed a bit in developed countries, although it is still the case that male mortality is higher than female mortality for every major cause of death. For example, in the United States, life expectancy at birth favored females by 7.6 years in 1980; by 1990 and 2000, the difference was 6.7 years and 6.6 years, respectively. Trends in cancer, particularly respiratory cancers, account for some of the decrease. Since 1980 in the United States, men's rates of lung cancer mortality, although still increasing, have slowed down in pace; in contrast, women's rates of lung cancer mortality have skyrocketed. This trend reflects, in large part, the later adoption of smoking by women.

If the sex differential in mortality is to be reduced, the preferable route is by decreasing male mortality, not increasing female mortality. Smoking cessation is clearly required in order to achieve this. Also, research has shown that the sex gap in mortality is much smaller among the educated and economically advantaged segments of the U.S. population. This suggests that mortality level is, to a large extent, determined by social and economic factors, and that reductions in male mortality closer to female levels are attainable.

The topic of gender and death is one that is inherently political. On the surface it appears that in most populations in the world females are advantaged in that they live longer. One might wonder, then, why both international and national efforts are concentrated with women's health. Three issues are to be acknowledged in attempting to answer this question. One, there are clear indications that, at least in the area of the Indian sub-continent and in China that account for a large proportion of the world's population, females are treated in ways that risk their lives. Two, in most parts of the developing world females are not living as long as they could, given historical data from the West. Three, although females live longer in the developed countries, all evidence suggests that they are sicker than males, especially in adulthood and older adulthood. Efforts to combat premature mortality and morbidity should be cognizant of the often nuanced way that gender affects life and death.

Gender differences are also involved in matters associated with death, and not just death per se. In a classic work on cross-cultural aspects of grief and mourning, Rosenblatt and colleagues reported that men and women tend to vary in emotional expression of bereavement. Women are more likely to cry and self-mutilate whereas men tend to direct the anger associated with bereavement to others and away from themselves. It is possible that this gender difference in expressivity reflects a more general pattern of gender inequality; that is, women, given their lower status, may be used as the persons who are expected, and perhaps coerced, to engage in activities that publicly symbolize a death that has occurred. Women are also often expected to publicly display their bereaved status much longer than men. For example, in many southern European countries, it was traditionally expected, and still is to varying degrees, that a widow wears black clothing for the rest of her life. Such rituals have the effect of silencing women and their sexuality.

Women tend to be more involved with death than men, given their role as "carers of others." Women, either as family members or as paid workers, are the ones who care for the dying in all societies. In Western societies, in which women outlive men by a substantial degree, elderly women are often the chief caregivers to their dying husbands, although they obtain assistance from other women, notably their daughters and daughters-in-law. They then face the prospect of their own death, typically partnerless because widows are not as likely to remarry as are widowers.

See also: Infanticide; Mortality, Childbirth; Suicide Influences and Factors: Gender

Bibliography

Boyd, Neil. The Beast Within: Why Men Are Violent. Vancouver, BC: Greystone Books, 2000.

Cline, Sally. Lifting the Taboo: Women, Death and Dying. London: Little, Brown, 1995.

Coale, Ansley J. "Excess Female Mortality and the Balance of the Sexes." Population and Development Review 17 (1991):517–523.

Cohen, Alex. "Excess Female Mortality in India: The Case of Himachal Padesh." American Journal of Public Health 90 (2000):1367–1371.

Lopez, Alan D., Graziella Caselli, and Tapani Valkonen, eds. Adult Mortality in Developed Countries: From Description to Explanation. Oxford: Clarendon Press, 1995.

Population Reference Bureau. 2001 World Population Data Sheet. Washington, DC: Author, 2001.

Retherford, Robert D. The Changing Sex Differential in Mortality. Westport, CT: Greenwood Press, 1975.

Rogers, Richard G., Robert A. Hummer, and Charles B. Nam. Living and Dying in the USA. San Diego, CA: Academic Press, 2000.

Rosenblatt, Paul C., R. Patricia Walsh, and Douglas A. Jackson. Grief and Mourning in Cross-Cultural Perspective. New Haven, CT: HRAF Press, 1976.

Sen, Amartya. "Missing Women." British Medical Journal 304 (1992):587–588.

United Nations. World Population Prospects: The 1998 Revision, Vol. 3: Analytical Report. New York: Author, 2000.

United Nations. Too Young To Die: Genes or Gender? New York: Author, 1998.

United Nations Secretariat. "Sex Differentials in Life Expectancy and Mortality in Developed Countries: An Analysis by Age Groups and Causes of Death from Recent and Historical Data." Population Bulletin of the United Nations 25 (1988):65–106.

Waldron, Ingrid. "Factors Determining the Sex Ratio at Birth." In Too Young To Die: Genes or Gender? New York: United Nations, 1998.

Waldron, Ingrid. "Sex Differences in Infant and Early Childhood Mortality: Major Causes of Death and Possible Biological Causes." In Too Young To Die: Genes or Gender? New York: United Nations, 1998.

Waldron, Ingrid. "What Do We Know about Causes of Sex Differences in Mortality? A Review of the Literature." Population Bulletin of the United Nations 18 (1985):59–76.

Women's International Network News. "Africa: High Maternal Mortality Continues Unabated." Women's International Network News 25, no. 4 (1990):51.

World Health Organization, UNICEF, and UNFDA. Maternal Mortality in 1995: Estimates Developed by WHO and UNICEF. Geneva: Author, 2001.

Wright, Russell O. Life and Death in the United States. Jefferson, NC: McFarland, 1997.

ELLEN M. GEE