Elizabeth Gilbert, in her book Committed: A Skeptic Makes Peace with Marriage, offers a bleak picture of what the state of matrimony means for women. ‘The cold ugly fact,’ she states, ‘is that marriage does not benefit women as much as it benefits men. From studies, married men perform dazzlingly better in life, live longer, accumulate more, excel at careers, report to be happier, less likely to die from a violent death, suffer less from alcoholism, drug abuse, and depression than single man… The reverse is not true. In fact, every fact is reverse: single women fare much better than married women. On average, married women take a seven per cent pay cut.’ All of this, she writes, adds up to what sociologists call the ‘marriage benefit imbalance’.
Gilbert’s marriage benefit imbalance seems particularly evident in patients with heart disease. Studies have shown that for those with heart disease, being married is associated with better prognosis in men, whereas married women have a greater risk of dying compared to unmarried women. This is thought to be due, at least in part, to men enjoying the social support and control provided by a wife, particularly because women typically take more responsibility in organising and providing health care. In essence, for married women with heart disease, this may represent an increased burden and daily stress.
More importantly, increased career and educational opportunities for women has not much changed traditional feminine roles in the domestic sphere. In a recent study one woman told us: ‘After heart surgery men go home to be taken care of by a wife — I went right back to everything I was doing. My heart health was the last thing on my list.’
While we may not be able to identify the causal connection, extensive literature identifies that the outcomes of patients with heart disease differ based not only on their sex but also their marital status. To understand these connections more precisely we sought to measure how gender-related characteristics might affect health outcomes (two of the relevant studies are here and here).
The GENESIS-PRAXY was an observational cohort study looking at men and women less than 55 years old who were hospitalised with acute coronary syndrome know as a myocardial infarction or heart attack. We collected an extensive array of gender-related characteristics like personality traits, gender/social roles, gender identity and institutionalised gender, which are present at different levels in men and women. We hypothesised that gender-related attitudes and roles (including being a husband/wife) would be associated with worse outcomes following treatment for heart disease.
Our study demonstrated that personality traits such as shyness and being sensitive to the needs of others, along with social roles typically ascribed to women, like being responsible for the household including family health care, increased the risk of worse outcomes in young patients with heart disease.
However, the most important result of our study was the recognition of the influence of gender-related roles on outcomes as opposed to ascribing all the blame on marital status. In fact, men who reported gender-related roles typically ascribed to women also reported worse outcomes following treatment for heart disease. Rather than ascribing worse outcome to marital status or the ‘accepted wisdom’ about what being married implies, we identified that it is more likely the social roles within the bonds of matrimony that ultimately determine health outcomes.
A large factor, of course, is the quality of the marriage. One of the variables we collected to tease apart this idea was asking patients to rate their stress level at home on a scale of one to 10. This variable (high stress at home) was highly related to worse outcomes regardless of marital status.
I imagine readers thinking ‘that’s a no brainer‘ — clearly high stress levels at home will affect health outcomes. Interestingly, though, it was the patients who reported the combination of high stress levels at home, along with being responsible for managing the household and not being the primary income earner, who also reported the worst outcomes at one year. In fact, they were four times more likely to be readmitted for another heart event. These patients were predominantly married women. However, and this is the key here, men who also reported high stress at home, responsibility for household management and not being the bread winner, fell into this same group.
So maybe it is time to stop blaming marriage. The bottom line is that supportive relationships, whether with partners, family or friends, are likely to improve your health, regardless of your sex — but then I am not sure we needed a study to tell us that.
Dr Colleen Norris is professor at the University of Alberta’s Faculties of Nursing, Medicine and School of Public Health