Womens Health at Work

women’s
health at work
Åsa Kilbom, Karen Messing
and Carina Bildt Thorbjörnsson (eds.)
The National Institute for Working Life is sweden’s national
centre for work life research, development and training.
the labour market, occupational safety and health, and work
organisation are our main ields of activity. the creation and use
of knowledge through learning, information and documentation
are important to the Institute, as is international co-operation.
the Institute is collaborating with interested parties in various
development projects.
the areas in which the Institute is active include:
• labour market and labour law
• work organisation
• musculoskeletal disorders
• chemical substances and allergens, noise and electromagnetic
ields
• the psychosocial problems and strain-related disorders in
modern working life
Graphic design & lay-out: lena karlsson and eric elgemyr

© Cover photo: Gary Buss / FPG / tiofoto
© national Institute for working life & authors 1998

arbetslivsinstitutet
SE-171 84 solna
Phone: +46 8-730 91 00 Fax: +46 8-730 19 67
IsBn 91-7045-477-9
Printed by aB Boktryck, helsingborg
Preface
women in working life have received considerable attention in the last few
years, in sweden as well as in other western countries. the voice of women
in the media is loud and clear, and it is certainly not easy any more to disre-
gard issues of equality. nevertheless, at the workplaces little has happened.
segregation, both vertically and horizontally, is nearly as common as before,
and women have little inluence over factors that govern their working lives.
this appears to inluence the health of women, as manifested both at the
workplace and in their private life.
In this book, specialists in different ields have drawn together available
knowledge and current lines of scientiic discourse with a bearing on women’s
health at work. we have not aimed for reviews covering all aspects, but have
concentrated on health issues important for women in sweden and issues where
swedish researchers can continue to make a signiicant contribution.
the irst chapter gives the reasons for studies of women at work, both from
the sake of scientiic rigour and as a basis for action. In the next chapter women’s
place at swedish workplaces are described based on oficial statistics, and an
attempt is made to predict women’s future prospects. In two chapters differ-
ences between women and men of relevance for working life are described.
Biological and psychological gender differences have often been presented
as the only factors that explain both allocations of work tasks and ensuing
ill health; this view is exaggerated. In the following chapters methodologi-
cal considerations on how to measure health are presented, and a number
of reviews of speciic health outcomes are given. although the main focus
of this book is on women’s health, we must acknowledge that the health of
men at the workplace is rarely investigated with a gender perspective. thus
one chapter is dedicated to a discussion about men’s ill health at work. In
the inal chapter the main conclusions are drawn together and their use for
research and prevention is discussed.
During the past year, a group of researchers at the swedish Institute for
working life have discussed the main issues and themes of a multidisciplinary
research and development programme “Gender, work and health”. the work
has been coordinated by Åsa kilbom and lena Gonäs at the institute. the
present book provides some of the background needed for such a programme
and thus serves to indicate important areas for further research.
For the conceptualization, planning and writing of this book many thanks
are due to my co-editors karen messing, whose vast knowledge and interna-
tional experience have been invaluable, and Carina Bildt thorbjörnsson. all
authors have contributed their knowledge generously and in a constructive
way, in particular considering the tight deadlines of this production. thanks
are also due to those scientists who, patiently and with an open mind, reviewed
the contributions: Gunnar Johansson, staffan marklund, hans michélsen,
Birgit Pingel, hans robertsson, Joan stevenson, töres theorell, eva Vingård
and Jan wahlberg. Finally, excellent technical editing has been provided by
lena karlsson and eric elgemyr.
It is my hope that this book will be used as a source of information, as an
indicator of where research is needed and as a support for those engaged in
improving women’s working conditions and health.
solna, august 1998

Åsa Kilbom
Contents
1. towarDs a GenDer-sensItIVe researCh PersPeC-
tIVe
why study women separately? K Messing and Å Kilbom ................... 11
2. DIFFerent worlDs
where are women in today’s workplace? H Westberg ....................... 27
3. FaCts anD PreJuDICes
Psychological differences between men and women.
M Lindelöw and C Bildt Thorbjörnsson ................................................. 61
4. equally DIFFerent
Identifying biological speciicities of relevance
to work-related health. K Messing and Å Kilbom................................99
5. measurInG health
Indicators for working women. K Alexanderson............................... 121
6. the heart — a weak sPot
Gender, work and cardiovascular disease. P Westerholm ................. 165
7. hazarDous ContaCts For soFt skIn
work-related skin-disease. B Meding .............................................. 185
8. aChes anD PaIns — an aFFlICtIon oF women
work-related musculoskeletal disorders.
Å Kilbom and K Messing ...................................................................203
9. JoB stress amonG women
Psychiatric ill health and conditions at work
C Bildt Thorbjörnsson and M Lindelöw ............................................... 231
10. women reCeIVe less ProteCtIon
the neglect of women in occupational toxicology. S O Hansson .... 267
11. men also are GenDereD
men, work and health. A Kjellberg ................................................... 279
12. anD the Future?
Conclusions. Å Kilbom, K Messing and C Bildt Thorbjörnsson ........... 311
8
Chapter 1
towarDs a GenDer-sensItIVe
researCh PersPeCtIVe
women’s health at work
10
towards a gender-sensitive research perspective
why study women separately?

by Karen Messing and Åsa Kilbom
the so-called gender paradox in health, i.e. that women are considered to
require more health care and report more sickness than men while their
mortality is lower, has been described and discussed in numerous publica-
tions in the last decades (oakley 1994; socialstyrelsen 1994; Verbrugge
1989; Östlin et al. 1996). the excess morbidity has been ascribed to life style
factors, psychosocial conditions and health-reporting behaviour, whereas
a tentative explanation of women’s lower mortality has been that they are
biologically more robust.
In the last few years, new statistical data have emerged that throw some
doubt on these standard explanations. In sweden, the expected remaining
life in full health has gone down among women, in particular in blue collar
professions (socialstyrelsen 1994). In a recent study from norway, it was
demonstrated that the gender difference in long-term sick-leave due to
musculoskeletal disorders could, to a large extent, be explained by differ-
ences in socio-economic status (Brage et al. 1998). these indings, as well
as results of several other studies (alexanderson 1995; Verbrugge 1985), can
in part be explained by life-style factors, but they also draw the attention to
women’s situation in working life.
In the last three to four decades, the proportion of occupationally active
women has increased considerably in all nordic countries, as well as in the rest
of the western world. In sweden 55 percent of the female workforce between
age 25 and 54 were employed in 1965, while the proportion had increased to
92 percent in 1996. the downturn in the economy in the beginning of the
1990’s saw a slight decrease, but the igures have now stabilized.
11
In view of these changes, and the statistical data presented above, it is

pertinent to investigate the interrelation between women’s work and health.
surprisingly, women have been nearly invisible as subjects in occupational
health research up to this century. Frankenhauser et al. (1991) and hall
(1990) made important contributions to our present knowledge of women’s
responses to stress at work. messing studied the working conditions of, and
tasks undertaken by, men and women, even in the same occupations, and
highlighted large differences that could explain the gender differences in
musculoskeletal morbidity (messing et al. 1994; messing 1998). In 1993
a working party of the oeCD published a report on “women, work and
health”. the aim of the report was to establish the current level of knowledge,
focusing on work-related health issues of particular relevance to women,
and to formulate recommendations identifying information and research
needs (lagerlöf 1993). In the same year, ekenvall et al. (1993), in a review
in the swedish medical association Journal, drew attention to the scarcity
of information on occupational exposures of women, chemical, psychosocial
and physical alike.
although some progress has been made in the last few years, women’s
work-related health problems are still not the subject of mainstream occupa-
tional health research; in fact they are almost “invisible.” In this introductory
chapter we will explain why we think that these issues are important, not
only for women, but also for the scientiic rigour of the occupational health
ield as a whole.
the chapters in this book have been organized to let researchers, all
specialists in their ield, describe the current knowledge of the subject of
women, work and health and where they think that information is missing.
we have selected these ields using several criteria. First, the area should
represent a great need for gender-sensitive research in sweden. second, it
should be an area not well researched in other countries and where there
is expertise in sweden. on this criterion occupational cancer research was
eliminated, since it is the subject of a vast effort in the united states. the
stage is set by describing the segregated labour market situation of women
in sweden and some of the ensuing differences in working conditions. In
the next section psychological and biological gender differences, genetic
or acquired, as possible explanations for gender differences in health, are
12
discussed. the main section of the book presents dermatological, mental,

cardiovascular and musculoskeletal health outcomes with regard to occupa-
tional and interacting family/occupational conditions of women. Different
statistical sources to explore the work-related morbidity of women are also
described. Finally, a gender perspective on occupational health, from the
male point of view, is presented. thus we do not claim that women always
have poorer health prospects at work than men. But we do claim that many
health complaints among women are associated with work, and that many
of them are unrecognised.
In this book the traditional concepts “occupational disease” and “work-
related disease” have been modiied. according to the who, an occupational
disease is caused by work, whereas in a work-related disease work, among
other factors, contributes to the disorder. although most of the health condi-
tions in this book are wholly or in part caused by work, there are also many
conditions that do not emerge from work, but still have an effect on women’s
working life. For instance, chronic fatigue, when caused by heavy family
burdens, will probably inluence women’s ability and motivation to work as
well as increasing sick-leave. the same applies to dificult menstruations and
pregnancy. It is important that the occupational health community, especially
care-givers, are aware of this and ready to organize work in such a way (e.g.
by lexible hours) that the consequences can be minimized.
In this introductory chapter some of the reasons for a gender-sensitive
research programme are discussed.
Information is missing
this missing information is of ive types. the simplest kind to identify is
an overall scarcity of information on women workers. For example, zahm
found that of 1 233 cancer studies published in 1971–90 in the eight major
occupational health journals, only 14 percent presented analyses of data on
white women (zahm et al. 1994) and only 10 percent on non-white women.
as mentioned above, ekenvall et al. (1993) found a corresponding lack of
relevant information in a review.
In some ields, such as skin disease and musculoskeletal disease, many
studies have been done on women. however, the orientation of these stud-
ies is rarely gender-sensitive. In yet other ields, there are hints that women
13
have been neglected. some evidence seems to suggest that most scientists
who have studied heart disease by occupation have restricted their samples to
men. an article by, among others, robert karasek, the pioneering researcher
into stress and heart disease, mentions (p. 179) that all the group’s studies
relating blood pressure to job strain have been done on men, although they
intend to expand these studies (Pickering et al. 1991).
of 36 studies relating job strain to cardiovascular disease symptoms or
risk factors, reviewed by schnall in 1994, 22 concerned only men, twelve
both men and women, and two only women (schnall et al. 1994). the av-
erage all-male study involved 2 533 subjects and was therefore fairly large,
expensive and deinitive; the two all-female studies involved a total of 576
subjects. this may be because, although coronary artery disease is the most
common cause of death among women (steingart et al. 1991), and as many
women as men report hypertension, heart disease is still thought of as a man’s
problem (Doyal 1995).
For example, in discussing a 1996 article relating heart disease to psy-
chosocial working conditions among 12 517 men, a scientiic journal editor
spoke of the results as though they related to all heart disease (Fine 1996).
without reference to the gender limitation, he praised the authors because
they “further expand our understanding of the possible causal contribution to
(...) coronary artery disease, of occupational and nonoccupational psychologi-
cal demands, control of the work process by employees and social support
at work.” It is impossible to tell from the editorial or the paper whether the
relationships mentioned apply to women.
the second type of missing information is that on occupational effects
on health problems speciic to women or most common among women.
For example, from 1983 to 1994 there were only 16 articles in the medical
literature (searched by medline) relating working conditions to effects on
menstrual pain or regularity. there was only one paper in this literature
relating working conditions to age at menopause, none relating working
conditions during pregnancy to health in later life, only one studying work-
ing conditions that produce varicose veins, etc. (messing 1998). and (as with
men) there is no information on the effects of working condition on sexual
functioning: desire, orgasmic capacity or sexual interest, whether related to
neurotoxic exposures or to sexual harassment at work.
14
the third type of missing information is that on prevention efforts in

women’s jobs. It has been shown that some jurisdictions have devoted rela-
tively little effort to prevention of occupational disease or injury in women’s
jobs (messing and Boutin 1997). For example, 40 percent of men, but only
15 percent of women, are included in programmes providing for paid occu-
pational health representatives and mandatory prevention plans in québec,
Canada. Inspections are eight times more common in two traditionally
male employment sectors with 15 percent women (including construction
and forestry) than in the other employment sectors which have 49 percent
women (including hospitals, schools and other services). In sweden, more
resources and more efforts are spent on occupational rehabilitation of men
than of women (andersson and lidwall 1997).
the fourth type of missing information concerns differential exposures
of women and men in the same jobs. In some jobs, it has been shown that
women and men with the same job titles are not assigned to the same work
or that they do the same work in different ways. we know very little about
this subject, although job title is routinely used as an indicator of exposure
in epidemiological studies (ekenvall et al. 1993).
the ifth type of information that is missing is harder to describe, but it
relates to the theoretical constructs underlying occupational health research
and to the traditional deinitions of occupational and work-related disorders.
Is occupational health approached in the right way? are women’s most im-
portant problems identiied and studied using orthodox occupational health
science practices or should other methods be used? are important parameters
being ignored? are women’s major occupational health concerns being ad-
dressed? we will discuss this area in some detail, since we have to think in
terms of identifying appropriate exposure and effect variables.
Exposures
In the past, occupational health scientists concentrated on the most visible
physical dangers: lifting heavy loads, falls, injuries from knives or machinery.
women have traditionally been excluded from occupations with these risks
— the exceptions being those occupations where the weights are sick people
or children (ljungberg et al. 1989) — and therefore they have low accident
rates in most countries (wagener and winn 1991). In sweden in 1990,
15
men had 6.3 times as many work accidents as women (lagerlöf 1993). the
low rates and the fact that women do not usually lift heavy weights do not,
however, mean that women’s jobs have few physical risks. nursing aides, for
example, exert only about 30 percent of the force of male warehouse workers
while lifting and carrying weights (patients or boxes). on the other hand,
each lifting manoeuvre among the nursing aides in a traditional ward lasted
on the average for 10 seconds, while the warehouse workers performed short
manoeuvres of about 2–3 seconds. (ljungberg et al. 1989). Prolonged lifting
manoeuvres expose the worker to static exertions which are acknowledged
to trigger musculoskeletal disorders.
In the last decade, disorders associated with the highly repetitive tasks,
and static/constrained postures of the upper limbs have attracted attention
and their association with musculoskeletal disorders has been demonstrated
in a large number of epidemiological studies (Bernhard 1997; kilbom 1994).
static efforts involved in prolonged standing (stvrtinova et al. 1991) and sit-
ting (winkel and oxenburgh 1990) have also been studied to some extent.
thus, even such apparently “light” occupations as secretary, shop clerk and
bank teller can involve important physical stress.
similar re-thinking is required in the area of work schedules. understand-
ably, scientists who have thought about work schedules have concentrated
on the dramatic risks associated with very long hours or with shift work.
they have found that night work is associated with more illness (kwachi et
al. 1995). usually, women (except health care workers) have been excluded
from such jobs; in fact, up until recently, women were excluded from night
work by law in some countries.
however, the work schedule considered has only been the paid work
schedule — no law prevented mothers from staying up all night with a
sick baby! now, the combined effects of paid and unpaid work are begin-
ning to be examined (lundberg et al. 1994; walters et al. 1995). although
several methods have been used to examine women’s domestic work, from
questionnaires to time budgets, only the ongoing “moa-study” in sweden
(härenstam, personal communication) tries to assess the domestic workload
in the context of the paid job. should domestic dishwashing be considered
differently for a woman who works with her hands in water during the paid
workday, since the relation to skin problems may be cumulative? how should
16
we calculate the workday of a nursery school teacher who is the mother of

young children? a cleaner or cook with a large family at home?
the question of limits on working hours could be looked at in a new way.
we can ask how to assess and consider real-life situations such as that of a
worker with a new baby who “chooses” to work the night shift so that her
husband can baby-sit, but must care for the baby during the time she herself
should be sleeping. this question is, of course, related to deinitions of the
purview of occupational health. the integration of a gender perspective in
occupational health should make us ensure that work is safe and healthy for
both men and women, taking into account their social speciicities. If we
integrate consideration of women’s family roles, we may also have to make
a different deinition of a risky paid work schedule, in order to include those
that make it particularly dificult to combine work and family. rotating work
schedules, for example, make it almost impossible to arrange for child care
(Prévost and messing 1997).
a gender perspective can also be integrated into questions of chemical
exposure, by considering the types of exposures found in jobs traditionally
done by women. women can be found in jobs where they are exposed to toxic
chemicals in high doses — one thinks of hairdressers, agricultural workers,
laboratory technicians and cleaners (nielsen 1996).
But their most common exposures will usually be more subtle and com-
plex. sewing machine operators, for example, complain of particular batches
of cloth because of irritations from the dye. health care workers may be
exposed to many different toxic agents at sub-pathological levels. ofice
workers may be exposed to contaminants leaking from badly ventilated ga-
rages and to fungi from dirty air ilters. this type of exposure indicates the
need to consider multiple simultaneous exposures at low levels which may
have a cumulative effect.
assessing exposure in these less dramatic types of situations found in
women’s traditional work is not straightforward. It is easy to weigh heavy
loads that are to be lifted; it is harder to assess repetition and duration. how
can the length of a work day be assessed if one worker does one job at a time
and another has multiple simultaneous responsibilities? how to decide what
chemical or biological agents to test for in indoor air and how the combined
results should be expressed?
17
Characterisation of aggressors is particularly dificult when the exposures

are psychosocial. If women are asked to identify their most pressing occu-
pational health problems they will often answer “stress.” however, deining
“stress” operationally and characterising workplace determinants of stressed
states pose problems for scientists. again, women have often been eliminated
from jobs with dramatic stressors such as exposure to violence, so that their
jobs (and many men’s jobs as well) involve exposures to many low-level
stressors probably having a cumulative effect. teachers, for example, may
be required to hold the attention of a class of people who speak little swed-
ish and who may suffer from many social problems, under dificult physical
conditions such as loud, noisy or uncomfortable temperatures.
scales have been developed to assess psychosocial stressors, but they have mostly
been developed on male populations for work conditions that were prevalent some
20 years ago, and only later applied to women (karasek and theorell 1991).
the question has been raised as to whether the same stressors and sources of
support are important for women as for men (Johnson and hall 1996).
Outcomes
outcomes studied in occupational health have usually been diseases.
however, diseases experienced by women seem to cause problems for the
occupational health community. women are an overwhelming majority in
those situations where there have been intense public debates about the “re-
ality” of health problems. women suffer 1.5–2 times more often from pain
and discomfort in the hand and wrist, are 2–4 times more likely to get sick
building syndrome (stenberg and wall 1995), 3 times more likely to suffer
from multiple chemical sensitivity and 2–9 times more likely to suffer from
ibromyalgia — all problems whose reality has been questioned vociferously
in the press and in the scientiic literature. they are more than 95 percent of
those involved in episodes diagnosed as “mass hysteria” or “collective stress
reaction” (Brabant et al. 1990).
women more often than men have vague symptoms like fatigue, head-
aches, discomforts, unspeciic chronic pain and slight depressions which do
not it into well-deined diagnostic syndromes (oakley 1994). attempts have
been made to ascribe such symptoms to existential issues. others refer to
conlicts of interest in women’s lives, such as between care for children, home
18
and husband, versus being ambitious at work. the “caring” nature of many
female jobs (e.g. health care), with a high risk of never completely satisfying
the needs of patients, appears to imply a risk of such unspeciic symptoms.
Certainly, it is dificult for women to gain recognition for their illnesses
(reid et al. 1991). the same dificulty in gaining recognition was found
among “match girls” in england suffering from phosphoros poisoning
that destroyed their jaws in the late 1800s (harrison 1996). But another
problem is that these are new or at least newly identiied illnesses and their
characterisation takes time. another is that, as mentioned before, they are
not unambiguously associated with recognised toxic agents. research must
be done in order to characterise them.
we may presume that other new illnesses will be identiied in the future,
if we become sensitive to the problems of women at work. effort is needed
to develop new indicators of problem situations, to complement the use of
accident, illness and sick leave reports. one approach that has been taken in
Canada has been to ask groups of women to identify problematic work situ-
ations. another approach was used by ekberg (1994) who involved patients
in active planning of their own occupational rehabilitation.
this reliance on workers themselves poses the question of how to enlist
the help of women workers in research in occupational health. It has been
suggested that patients should play more of a role in orienting and guid-
ing health researchers in the investigation of their problems (Cornwall and
Jewkes 1995).
this may be particularly relevant in ground-breaking research direc-
tions, or in situations where patients have had little credibility in the past.
women workers can be involved in research either as individuals or through
organizations that represent them, if these have demonstrated sensitivity to
their problems (seifert et al. 1997).
Women and men are not so different

although women are a majority among those who struggle to combine work
and family, men are playing an increasing domestic role, particularly in re-
gard to child care. and working hours are, by their length and distribution,
encroaching increasingly on the domestic lives of both sexes (schor 1991).
neither male nor female workers can now be considered as though their
19
lives were spent working for eight hours between nine and ive o’clock, ive
days a week, then at leisure for the rest of the time.
although women are almost always in the service sector of the economy,
men are losing their jobs in manufacturing and will be found in services
more and more in the future. they will share the jobs that women now do
and will assume the same risks.
Considering women raises questions relevant to men

In england, when women were irst employed as letter carriers, the mailbags
were too heavy for some of them. the women protested and smaller mailbags
were used. the musculoskeletal injury rate fell for both sexes. similarly,
when a woman whose job it was to repair gas pipelines in québec brought a
case against her employer because she found the tools too heavy, her smaller
male co-workers testiied that they too found the tools heavy. since the size
and weight differences among members of one sex are much greater than
those between the male and female, making jobs more adapted to women
means making them more accessible to all. this argument also applies to
differences between young and old employees, as lack of physical strength
is frequently used as an overt reason to discriminate against aged individu-
als. It also applies to some techniques for pre-employment strength testing,
found to be unfair to women because they require more physical stress from
shorter applicants; they must also be less fair to shorter men (messing and
stevenson 1996; stevenson et al. 1996).
Gender-sensitive data are better data

when questionnaires ask about current pain in the lower back, but do not ask
whether the woman is menstruating, the resulting errors affect the analysis
concerning back pain (tissot and messing 1995). Ignoring saleswomen’s
complaints of varicose veins limits our knowledge of the constraints of
prolonged static standing.
adjusting statistically for gender instead of analysing data separately for
women and men can limit information on the entire population. when re-
searchers analysed data from a large study of poultry processing separately for
men and women, they found that musculoskeletal problems and respiratory
problems were related to workplace variables that were different for each sex.
20
when the data were analysed while controlling for sex, most relationships
disappeared for both sexes, with a consequent loss of information (messing
et al. 1998). thus, treating sex as a confounder when it may be a proxy for a
speciic exposure may obscure important relationships. moreover, the effects
of other confounders and covariates may differ between the genders.
sometimes, being gender-sensitive means being sensitive to men’s needs.
For example, consideration of reproductive damage in the workplace has
almost exclusively concerned hazards to women and, more particularly,
foetuses. only recently have scientists started to examine damage to sperm
(lindbohm et al. 1991) and other aspects of male reproduction are almost
never considered.
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test fairness and the incremental lifting machine. Applied Ergonomics 27, 45–52.
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24
Chapter 2
DIFFerent worlDs
26
different worlds
where are women

in today’s workplace?
by Hanna Westberg
to make visible and upgrade women’s working conditions is an important

step in the process of eliminating health hazards from the working life of
women. although research in a gender-perspective has made many and
important contributions to working life research in recent decades, most
research within the sphere of working life has a gender-neutral perspective,
in which gender as a social category has no signiicance. thus, inadequate
explanatory models continue to be produced.
For a number of reasons it is important to impose a perspective of gender on
women’s and men’s working life. one fundamental reason is that it is assumed
that the conditions in working life are the same for women and men.
In the following I shall discuss the inadequacies of the gender-neutral
perspective in working life in relation to differences in women’s and men’s
working conditions and in relation to trends and prospects in the labour
market and in work organisation.
the foundations of the swedish well-fare system were laid when the
single bread-winner family was still the norm. that is, men were primarily
responsible for earning income through gainful employment to support
the family, while women were responsible for the reproduction-oriented
work in the family. the man’s income would support the family, allowing
the woman to stay home providing the housework and care necessary to
keep the family together. the household and family with a woman in the
home was the basis for the irst welfare policies. Production was organised
on the assumption that its workers had a woman’s support at home (Baude
and Gonäs 1989). to ensure his and his family’s survival, it was important
for the man to receive inancial compensation for income lost due to injury,
death, or unemployment.
27
Industrial society grew, and production increased even as it changed. these

changes brought more women into the work force which, especially after the
second world war, created the conditions necessary to increase the services
offered by society. this encouraged more women to take gainful employment.
new jobs were created which were either typically gender-speciic in themselves,
or were soon seen as being either female or male jobs (acker 1989).
The notion of “employee”

a worker in sweden is either self-employed or an employee. It is important
to be able to distinguish between these two categories because different laws
are applicable. labour laws and collective agreements apply to an employee
and general and contractual law apply to a self-employed person.
swedish labour laws are in principle based on a uniform and broad deinition
of an employee. the implementation of the laws is however not demarcated
in a uniform manner due to the fact that different courts have to interpret
different laws with different purposes. In the employment Protection act
(1982:80), it is also explicitly stated that certain categories of workers, such as
the employer’s family members and workers who are hired to work in her/his
household, are excluded from its scope (Bruun and Johnson 1995).
Certain basic criteria must always be fulilled before a person can be con-
sidered an employee in a legal sense. there has to be an agreement which
refers to work. If the worker has not applied to the tax authority to be treated
as self-employed, the presumption is that he/she is employed by the person
requesting her/his services.
a worker is an employee according to the preparatory work to the In-
dustrial Co-Determination act if a majority of the following ten criteria
are fulilled.
• the person should personally perform the work.
• he/she has by herself/himself, or virtually all by herself/himself, actu-
ally performed the work.
• her/his commitment includes being available for upcoming tasks.
• the relationship between the parties is of a more sustainable character.
• he/she is prevented from performing the same kind of work to any
signiicant extent for anybody else.
28
different worlds
• he/she is subject to certain directives or control, concerning how,

where or when a task is performed.
• equipment is provided by the other party.
• her/his expenses are paid by the other party.
• he/she works for remuneration.
• he/she is economically and socially regarded as equivalent to an em-
ployee.
the place of work is not mentioned in the list. where the work is performed
does not seem important.
Sweden — a strictly gender segregated labour market

Gender segregation, and the structure on which women’s relatively subor-
dinate position in the work force is based, keeps women working at lower
level jobs, concentrating power in the hands of men. (statistics sweden 1990;
westberg-wohlgemuth 1996; Östlin 1996).
this subordination is most clearly seen at the overall level in two dimen-
sions: lateral subordination, where female-dominated sectors and occupations
have lower status and are given lower values than male-dominated sectors and
occupations, and subordination in the vertical dimension, where women as a
group are to be found at a lower level in the hierarchies than men.
women are thus often found in different occupations from men. examples
of the most typical female occupations are (percent):1
• secretary 99
• day care assistant 97
• home help assistant 96
• nurse 94
• nursing assistant/assist nurse 94
• pre-school teacher/recreation instructor 93
• typist 90
• kitchen-maid 89
• cleaner 87
• administrative/bookkeeper 85
29
examples of the most typical male occupations are (percent):

• building and construction worker 100
• driver (short and long-haul) 97
• technical/mechanical engineer 95
• telecommunications engineer 93
• bus/taxi driver 92
• construction or installations engineer/architect 91
• motor and machine repairman 89
• manufacturing mechanic 84
• sales (wholesale) 81
• system designer/programmer 77
only 10 percent of the swedish employees are working in nonsegregated
occupations (between 40 and 60 percent of either sex).
within many occupations there are also signiicant differences between
the tasks men and women perform. For instance, in the manufacturing sector,
the percentage of women employed increased from 3 in 1960 to 16 in 1990.
But still most of these women perform different tasks from men, even with
equal training. women tend to have more stationary, short series, repetitive
tasks. they work in the less qualiied tasks, which require shorter training
and also pay less. examples are: assembly (routine), packaging, inspection
and electronics/telecommunications (westberg-wohlgemuth 1996).
another example comes from the medical profession, where the pattern
is similar. the percentage of women doctors increased from 13 percent in
1960 to 34 percent in 1990, increasing to 37 percent by 1997. even here,
women often have different tasks, or specialties, from men. each gender
generally specialises in different areas, so more women concentrate on skin
and venereal diseases (59 percent), geriatrics (58 percent), rehabilitation (58
percent), and paediatrics (57 percent), for example. men are specialised in
thoracic surgery (96 percent), orthopaedics (92 percent), urology (90 percent)
and cardiology (86 percent) (läkarfakta 1997).
Gender segregation at the workplace contributes to reducing lexibility in
the labour market. Jobs are sex marked. this means that women are offered
female jobs and men, male jobs. mobility exists within each gender-speciic
area, but rarely between them (westberg-wohlgemuth 1996).
30
different worlds
that women are often found in different occupations from men, and that
in many occupations there are signiicant differences between the tasks women
and men perform, naturally leads to their experiencing different problems
related to the work environment. as a consequence, for example, women
incur repetitive stress injuries more often and earlier than men (indings of
the work environment Commission 1990).
In many job sectors where women predominate, the percentage of re-
petitive, monotonous tasks is high. this makes women a high risk group for
strain injuries. since their labour market is limited to these kinds of tasks,
many women remain in monotonous, physically heavy jobs despite the risk
that sooner or later they will incur a work related injury (Baude 1989; Baude
1992; westberg 1994b; westberg-wohlgemuth 1996).
Changes in the labour market

the swedish labour market is changing in many ways. For one, many factories
are being closed to move production to lower wage countries. as a result,
certain areas in sweden have high unemployment. new technology is being
developed and used in both new and old industries. Demand for outdated
skills therefore shrinks, while workers with training in the newer techniques
are in high demand. “Flexible specialisation” production has been developed,
resulting in quick changes to the products made. new forms of training are
developed within the company rather than in colleges and universities.
other jobs are restructured in a presumably more democratic form. In-
stead of working at an assembly line, work groups are created to assemble
the entire product. these patterns tend to be more frequent in sweden as
compared to other countries.
at the same time, new forms of production and working are being used.
these include systems such as lexible tasking, distance work, “just-in-time”
employment, short-term employment, and “consultant” hiring. the public
debate is focused largely on the conlict between the goals of a proit ori-
ented economy and the goals of public well-being aimed at meeting certain
societal needs.
a consistently large proportion of female workers in both the public
and private sectors are employed part-time. the number of temporary
31
and short-term contractual jobs is steadily increasing. this weakens com-

mon pay policies, starting a trend towards more local and individual pay
agreements.
Budget cutbacks in the public sector, which already has undervalued jobs
(as compared to the private sector) in care occupations, worsen conditions for
the majority of working women. the current emphasis on giving preference
to market solutions has also aggravated these cutbacks.
when building families, men are usually learning their trade or occupa-
tion, and establishing their position in the labour market. women still have
responsibility for care, both at home and in the public sector. she therefore
plans a larger part of her life around the combination of gainful employ-
ment and her responsibilities in the home and for the family. she does this
using different strategies for both caring for the family and maintaining her
employment. only by itting together different working hours, part-time
work, and temporary jobs, and relying extensively on public services, can
she meet these varying demands.
Employment
Gainful employment2 (the percentage employed — self-employed and em-
ployees — of the population aged 16 to 64) for the nation as a whole was
68.9 percent for women and 72.4 percent for men in 1997.
the relative work force (employed or unemployed) for the population
between the ages of 16 to 64 totalled approximately 77 percent in 1997
— nearly 75 percent for women and 79 percent for men (statistics sweden
1998).
It is interesting to note that the relative work force (nation as a whole)
for men with children under seven years was as high as 92 percent, while
for women in the same category it was 78 percent. thus, the igures for
parents of young children was higher than for the total work force. while
the difference for women is less signiicant, the difference for men is worth
noting. the relative totals for both men and women whose youngest child
is between 11 to 16 years of age (84 percent and 93 percent, respectively)
are also higher than the total (table 1). there is no deinite explanation for
this but one can assume that both age and gender are part of it.
32
different worlds
Table 1. Employed by age in relation to the total number in age group, within the age group
and relative workforce by age (total in workforce/total in age group): Total, females, females
with child under 7 years, males and males with child under 7 years. Thousands and per cent.
Source: Statistics Sweden 1998.
Age Total in Total in Number Relative Employed %
age group workforce employed workforce %
Total
16–24 962 450 380 46.9 39.5
25–54 3 699 3 212 2 984 86.8 80.7
55–64 888 601 557 67.6 62.7
16–64 5 550 4 263 3 922 76.8 70.7
Females
16–24 469 213 183 45.4 39
25–54 1 814 1 532 1 426 84.4 78.6
55–64 447 289 271 64.7 60.6
16–64 2 730 2 034 1 880 74.5 68.9
Females with
child under
7 years 574 450 408 78.4 71.0
Males
16–24 490 236 197 48.2 40.2
25–54 1 886 1 681 1 558 89.1 82.6
55–64 441 312 286 70.1 64.9
16–64 2 817 2 229 2 041 79.1 72.4
Males with
child under
7 years 512 473 440 92,4 86.0
Unemployment
relative unemployment was 7.5 percent for women and 8.5 percent for men
in 1997. Compared with 1995 these igures relect increased unemployment
for women, while it has generally remained constant for men. this trend
has continued for 1997.
relative unemployment is greatest in the youngest age groups, decreas-
ing progressively in the older age groups, again to increase for those 60 and
over (table 2).
33
Table 2. Workforce by age and unemployed by age in thousands, and unemployed in relation
to the workforce within the age group in per cent. Source: Statistics Sweden 1998.
age workforce (total) unemployed unemployed (%)
Total
16–24 450 69 15.3
25–54 3 212 228 7.1
55–64 601 44 7.3
16–64 4 263 341 8.0
Females
16–24 213 31 14.6
25–54 1 532 105 6.9
55–64 289 17 5.9
16–64 2 034 341 7.5
Females with child
under 7 years 450 42 9.3
Males
16–24 236 38 16.1
25–54 1 681 123 7.3
55–64 312 27 8.7
16–64 2 229 188 8.5
Males with child
under 7 years 473 32 6.8
a greater percentage of men are unemployed in all age groups. also, a greater
percentage of men are latent unemployed, that is, they could have worked
but did not report to the employment ofice during the week for which sta-
tistics were gathered. Furthermore, once unemployed, an individual tends
to become unemployed again, no matter how long they have worked (or
otherwise been occupied) between periods of unemployment.
workers unemployed during the recession in the early 1980s were to a
large extent unemployed during the growth period up to the early 1990s,
remaining unemployed into the recent recession and its aftermath. every
third man who was unemployed in 1985 was unemployed in 1993, while
out of those employed in 1985, only one in ten was unemployed in 1993
(statistics sweden 1996c).
of those unemployed at any one time during 1990, 55 percent of the
women and 60 percent of the men were also unemployed in 1993. the cor-
34
different worlds
responding igures for women and men employed in 1990, but unemployed
in 1993, were 14 and 15 percent, respectively (statistics sweden 1996c).
In conclusion, those unemployed for longer periods more often become
unemployed again.
today a growing number of young people are spending longer at school.
an estimated 80–90 percent of all young people complete upper secondary
education.
In a look at the course of study chosen for secondary school, clear gender
differences become apparent. the schools are legally coeducational, however
the secondary education system can actually be said to have one large “boys’
school”, one large “girls’ school” and one small “co-ed school”. this clear
gender segregation of courses follows through to higher education. men
predominate in the technical sector while women attend courses in the care,
teaching and culture/information sectors. men predominate in the so-called
prestige courses while women predominate in the shorter courses. the pat-
tern of segregation is the same as in working life.
only 34 percent of all secondary school graduates were gainfully employed
one year after they left school as compared to 73 percent of college graduates.
a study of employer attitudes showed that approximately 40 percent re-
sponded that a history of unemployment is a negative factor when choosing
between equally qualiied job candidates (statistics sweden 1997c).
the unemployed have worse health than those employed. the exact re-
lationship is unclear, though, as to whether unemployment leads to poorer
health, or poorer health more often leads to unemployment (Järvholm 1996).
there are some indications from recent research that the relationship works
in both directions (hallsten 1998) and we know that unemployment is sig-
niicantly higher for those with less training and education.
the increase in unemployment during 1996 affected women most, due
to cutbacks in the health care sector. employment in the industrial sector
generally remained unchanged as compared with 1995. unemployment rate
during 1997 remained unchanged as compared with 1996.
unemployment for women with children under seven years was 9.3 percent
for 1997. For men this igure was 6.8 percent. looking at the totals for unem-
ployed women and men, the proportion of those with small children is somewhat
higher for women than for men (table 2) (statistics sweden 1998).
35
the igures reported below cover parents with small children as compiled
from a study of child care conducted in spring 1996 (ministry of labour
1997a; ministry of labour 1997b).
single mothers with small children work full time to a greater extent than
mothers living with a partner (table 3). and signiicantly more single mothers
with small children study or are unemployed, as compared with those living
with a partner. Compared with the women in the study, the men were much
better off. also, both single fathers and those living with a partner barely
utilised parental leave — two percent and one percent, respectively.
Table 3. Number of parents with small children (6 years or less) according to marital status
and gender, with distribution according to employment. Source: Ministry of Labour 1997a, b
(SAK Project).
total full-time part-time parent- unem- studies not in
1 000s % % leave % ployed work
Women with a partner 706.2 26 31 23 8 7 5
Men with a partner 706.2 83 3 2 7 4 1
Single mothers 87.4 30 25 9 16 17 4
Single fathers 8.6 71 6 1 11 7 3
Temporary employment
the number of permanent jobs has decreased signiicantly between 1990
and 1998, for both women and men. over the same period, the number of
temporary employees has increased substantially. up to now, this has involved
more women than men. For both women and men, permanent employees
work longer hours and more often full-time than temporary employees. For
both women and men, the number working full time has increased, while for
temporary employees, full time work has decreased, for both genders.
In 1996 (statistics sweden 1997a),3 part-time workers (working less than
35 hours per week) were 24 percent of the total number of employed. of the
male work force, 9 percent worked part-time, while for women 38 percent of
all workers were part-time. of the entire workforce 5 percent worked less
than 20 hours per week (less than half-time), but for men this was 3 percent
while for women 7 percent.
women and men working part-time include a signiicantly larger propor-
tion of temporary employees as compared with full time workers. this ap-
36
different worlds
plies especially to those working short part-time ((ministry of labour 1997a;

ministry of labour 1997b). In 1997, 16 percent of all women aged between
16 and 64 had temporary employment. For men, this was 10 percent. men
are self-employed more often than women (table 4).4
table 5 illustrates the distribution of temporary employees in the various
forms of employment — in 1996 for national igures.
together, the tables 4 and 5 illustrate that women have temporary em-
ployment more often than men. women more often work as substitutes
than men — representing nearly half of all women with temporary jobs.
only 24 percent of the men with temporary employment had this type of
job. the proportion of employees available on the request of the employer
has increased throughout the 1990s. In total, nearly 100 000 persons have
this form of employment (ams 1997). one ifth of women with temporary
employment are available on request — the second most common form of
temporary employment for women.
the most common form of temporary employment for men is object or
project employment. this employment form has become more common
during the 1990s, now involving over a quarter of all men with temporary
employment. trial employment, which more often leads to a permanent job,
Table 4. Percentage of the work force employed divided according to relation to the labour
market and regular work hours, and by gender (1997). Source: Statistics Sweden 1998.
Perm. Temp. Self 35+ 20–34 1–19
empl. empl. empl. hrs/wk hrs/wk hrs/wk
Women 78 16 6 62 31 7
Men 74 10 15 90 6 3
Total 76 13 11 77 18 5
Table 5. Percentage distribution 1996 of temporary employees aged 20–64.

Source: Ministry of Labour 1997a, b (SAK Project).
National women men
Substitute 48 24
Available on request 20 13
Object or project 12 28
Summer- and Seasonal 7 13
Trial- and Practice 7 14
Other 6 8
37
is also rather prevalent among men (14 percent). For women, trial employ-
ment is less prevalent (7 percent).
more than one in ive, of both women and men, working in the service
sector have temporary jobs (table 6). For women, most of these jobs are
found in the health care sector, while for men they are in manufacturing
industry.
Table 6. Percentage of temporary employees among all employed aged 20–64, divided by
occupation 1996 (national igures). Source: Ministry of Labour 1997a, b (SAK Project).
Occupation women men
Service work 22 21
Health care, Social work 19 28
Commercial work 18 9
Transport and communication 16 14
Technical, Science, Social science,
Humanities, Art, Military work 15 9
Mining, Quarrying 11 11
Administrative 8 8
Agricultural, Forestry, Fishing – 22
nearly 90 percent of the jobs available within the agricultural, forestry and
isheries sector, as reported to the employment ofice, are temporary. these
are mostly seasonal jobs lasting less than one month. In the health sector,
the corresponding igure is 75 percent of the total number of jobs reported.
these usually last between one and three months. however, this cannot be
seen as seasonal work (ams 1997).
temporary jobs are also more usual among the young. For those aged
16 to 24, the proportion of permanently employed has shrunk signiicantly,
with a corresponding increase in the number of those in temporary employ-
ment. so now, more than two in ive have temporary jobs. of women in these
ages, 53 percent have temporary jobs, while among the men this igure is
37 percent. these changes to the labour market can also be seen in the next
age group, 25 to 34 years. the proportion of those with temporary jobs has
increased from 10 to 17 percent since 1990 (ams 1997).
of all temporary employees, 43 percent are members of lo (blue collar),
18 of tCo (white collar) and 7 of saCo (academic) unions. women have a
greater percentage temporary jobs in each confederation (table 7 and 8).
38
different worlds
Table 7. Permanent and temporary employees in the central national union organisations
(1 000s). Source: Statistics Sweden 1997a.
Union organisation Permanent Temporary Temporarily employed as %
/employee* employment employment of all temporarily employed
LO 1 323 208 42.6
TCO 963 87 17.8
SACO 269 36 7.4
other 30 4 0.8
non-member 455 154 31.5
Total 3 040 489 100
* LO – Swedish Trade Union Confederation; TCO – The Swedish Confederation of Profes-
sional Employees; SACO – Swedish Confederation of Professional Associations.
Table 8. Proportion of temporary employees in each confederation divided by gender in

relation to the total number of women and men employed, respectively. Source: Statistics
Sweden 1997a.
Union organisation Men % of temporary/total Women % of temporary/total
/employee employees employees
LO 11 16
TCO 6 10
SACO 10 14
other 7 33
non-member 22 30
Trends and prospects in the labour market

sweden has been a leading example in having full employment as a national
goal. For this, legislation has been passed at different times aimed at satisfy-
ing the various needs of workers during their entire working life — such as
varying work hours, parental leave, leave for studies, and more.
the support regulated by law comes in various forms. there are gen-
eral subsidies such as child allowances and basic national pensions. some
subsidies are related to income. housing allowance is such a subsidy. this
allowance is based on the household income and provided with an upper
limit. Considerations such as rent, dependents etc. are taken into account.
most subsidies are income-related, such as sickness beneits, parental al-
lowances, unemployment beneits based on unemployment insurance funds
administered by the union, (Bruun and Johnson 1995).
39
all employees have the right to sick pay. whether a person is employed
full-time, or part-time, temporarily or for an indeinite period of time, is of
no importance regarding the right to sickness beneits, but the right to sick
pay ceases the very moment the employment does. an employee is paid by
the employer during the irst two weeks of illness. this beneit is income-
related (Bruun and Johnson 1995).
the social security system is based on the assumption that all people have
an income from work and are therefore able to contribute to the system and
then beneit from it when need arises.
swedish welfare policy has been, and is, unique. no other country devotes
such a large portion of its resources to common social goals. this principle
has been essential in furthering national equal opportunity efforts. without
the well developed child care, elderly care, and social services, swedish women
would not have been able to enter the work force in the large numbers they
have. also, the public sector has provided a job, the chance to earn a living
for many women. women dominate the public sector while men dominate
the private sector. seventy-three percent of the public sector employees were
women while 62 percent of the private sector employees were men in 1997
(statistics sweden 1998).
the recent budget cutbacks, though, have caused concern for their effects
on social well-being and women’s ability to provide for themselves, both
during their working life and after retirement.
Current changes are designed to generate savings or improve resource
utilisation. many times these changes are instituted without considering
women’s needs or life situation. the experiences of women as both employee
and consumer of services is not always considered either. social well-being
and material standards are often equated in the public debate.
the public sector in sweden has experienced large cutbacks, and policies of
just-in-time hiring in the public sector have especially affected women’s work.
the assumption is that it will be dificult in the short term to create new jobs
for women who have lost their jobs in the public sector. In particular, many
of the elderly women who lose their positions will end up outside the labour
market (aronsson and sjögren 1994; westberg-wohlgemuth 1996).
Internationalisation, new technologies, adapting to market ideologies
all bring about swift changes. this political re-evaluation and the changes
40
different worlds
brought about have also changed the labour market so that employment
conditions can vary widely (aronsson and sjögren 1994).
the new types of jobs being created will probably demand another type
of employee from those who have become redundant over the last six to
seven years. the just-in-time concept, developed by industry, now has its
counterpart in employment conditions in the public sector. aronsson and
sjögren (1994) use this expression to describe what is happening on the
labour market regarding employment conditions. the trend is away from
permanent jobs towards a system of “just-in-time” jobs. that is:
“around a core of permanent employees with secure positions, good pay
and career development possibilities, there are a number of people working
under various terms of employment that are temporary in nature, such as
substitute with no permanent employment, trial employment, practical
training, public relief work, training substitute, introductory training,
summer work, seasonal employment, object/project employment, avail-
able on request. these temporary employees guarantee a company the
greatest lexibility regarding the number of workers it must pay to adapt
to differing periods of greater or lesser demand in production” (aronsson
and sjögren 1994).
Buying, trading, or renting services increases this lexibility for the com-
pany, as does leasing and franchising or instituting varied work hours.
the leaner organisations using many just-in-time employees to adjust
to short-term demand for goods or services will put a lot of pressure on
permanent employees even though they will be harder to replace because
of their special skills. For example, they will run a high risk of greater
overtime demands to meet temporary high work loads. the just-in-time
employees, for the strategy of lexibility with just-in-time hiring, are given
little chance to control their working conditions and hence, to inluence
the work organisation.
since the service sector is growing, and services cannot be stored (rather,
they have to be produced on demand), employers are also taking a lot of
interest in lexible hours of work. For example, new technology can measure
activity levels during the workday or longer periods to help adjust to the
pattern of demand.
41
several changes to labour legislation in the last years have made it easier
to hire temporary employees. Private employment agencies are now legal
(as of July 1993), and these can also hire out temporary employees.
saF, the swedish employers’ association, has had a great impact on what
is happening on the labour market. saF stresses the importance of concen-
trating resources in areas where each company has its core competence.
saF has identiied requirements for lexible organisations in the follow-
ing way (saF 1992):
• accelerating transformation increases the need for lexible — preferably
hyper-lexible-organisational solutions.
• the development of information technology demands networking
between organisations and within organisations.
• when enterprising becomes more and more knowledge-intensive many
companies choose to concentrate business and resources in their own
core competencies. Companies develop in various areas and offer special
services and may be contracted on demand, so-called out-sourcing.
• Due to the costs in managing and co-ordinating large hierarchies,
market solutions replace hierarchies and administrative solutions.
• the demand for high pace in all processes in an organisation is better
attended to by network and low-directed structures than by traditional
functional and hierarchical systems.
employers consider the existing legislation which regulates the relationship

between employers and employees an impediment to lexibility.
Previously stable relationships with set work hours and permanent em-
ployment contributed to building up trust. But the transformation currently
under way, with greater lexibility and downsizing, disrupts the patterns
existing between employees and employers. this can lead to a lack of con-
idence in the employer, which in turn may lessen the individual’s desire to
take risks, despite the fact that exactly the opposite demands are placed on
her/him (aronsson 1997).
Segmented labour market

one can describe the attempts to increase lexibility as creating a segmented
labour market with marked differences in both employment conditions and
42
different worlds
working conditions. In sweden, by comparision with other countries, the

secondary labour market5 is small. labour laws and labour regulations have so
far limited the extension of segmentation in the labour market, thus avoiding
the possible result of creating a pool of unskilled, low paid temporary labour.
edling and sandberg (1993) divide the current segmentation into two groups,
while aronsson and sjögren (1994) add a third group. the irst group of
“closed positions” consists of employees with relatively secure employment,
qualiied job tasks, and opportunities for career development.
the second group with “open positions” have a less secure situation
leading to weaker bonds with their employer. they are hired and paid at
market rates, and their employment is highly dependent on luctuations in
the demand for manpower.
the third group consists of individuals with no permanent jobs. the cur-
rent high unemployment rates increase the probability of a labour market
developing where jobs carry no security, either from labour laws or as part
of the social security system.
Technical/economical versus responsible rationality

models such as just-in-time employment are based on assumptions for
business rationality. underlying these assumptions is a view of human
individuals as mere components in the machinery, without needs of their
own, to be taken out and suitably placed at the suitable time and then
removed when not useful any more, much in the same way as other tools.
But human beings are not components. they need to consider the entire
situation from the point of view of both their inancial position and the
use of their time. they want the means to plan their future, at least for
their immediate needs. assumptions of business rationality lie behind the
development of a technical/economical rationality, which is seen as char-
acterising the way men think.
women’s experience of paid and unpaid care work has led to their develop-
ing their own type of rationality, responsible rationality, a term irst used by
sörensen (1982), to describe the rationality characterising the way women
think (Ve 1989). Ve uses the term responsible rationality as a construction
which brings to the fore certain aspects of women’s pattern of thinking for
the purpose of comparing this pattern with that of men.
43
this indicates that the different experiences of women and men have
resulted in their respective ways of thinking (their rationality) becoming
different. that is, different kinds of rationality are socially-structured and
rooted in the gender division of labour in a modern society. a basic, and
possibly the most important, difference between these two rationalities is that
they involve different approaches to other people. responsible rationality
sees people as an end in themselves while technical/economical rationality
sees them as the means to an end.
this explains why measures of eficiency in modern industrial enterprises
cannot be simply applied to the care sector. the proit-driven inancial goals
of industry, based on values dominant in technical/economical rationality,
conlict with the goals of national well-being based on caring values concerned
with meeting social needs as in responsible rationality.
Conclusions and commentary

Despite the recent increase in the proportion of the work force with tem-
porary employment, most employees still have permanent jobs. those most
affected are younger workers and, primarily, young women. the service,
health care, and child/elderly care sectors also offer most of the temporary
jobs. the current labour market conditions will probably lead to the crea-
tion of more temporary jobs, primarily in response to short-term peaks in
demand or to meet speciic short-term requirements. the latter usually
involves a project or object employment, which has become more prevalent
as employers concentrate the number of permanent jobs to cover only their
primary business activities.
the majority of the temporarily employed — the young — are also those
just starting out in working life. this is also the group with the highest un-
employment in recent years. Comparatively, if employment levels were the
same in 1995 as in 1990, over 70 000 more young women 20 to 25 years of
age and nearly 80 000 more young men would have been employed.
those who tried to change occupation have had more dificulty inding
permanent employment than those staying in the same occupation.
aronsson and sjögren (1994) suggest that “temporary jobs provide a
bridge from unemployment to permanent employment” and this includes
both women and the young.
44
different worlds
the qualiication proile for temporary jobs is highly polarised, in that

some jobs involve qualiied tasks requiring higher education (largely trial
and project employment), while others are simple jobs needing no training
(mostly substitute and “available on request” type of jobs). the former are
more commonly illed by men and the latter by women. thus, these inse-
cure types of employment are rather common and are illed by women to a
greater extent than by men. During recent years slightly more women than
men have acquired higher education up to the basic university level. this
fact does not change the mentioned patterns.
the patterns of unemployment for women and men are generally alike
up to 45 years of age, though women in higher age groups have managed
better than men (statistics sweden 1996c).
the unemployed have the same skills proile as those in temporary em-
ployment. People with less education have, to a greater extent, lost their
jobs. In female dominated professions, many nursing assistants and assistant
nurses have been laid off, and the number of child care workers has been
reduced signiicantly. these redundancies have primarily affected the young
(statistics sweden 1996c).
women aged 25 to 35 are more concerned about losing their jobs than those
in other age groups. these women are therefore less willing to criticise poor
work conditions. twice as many women as men are willing to accept a poor
work environment and not express criticism (tidningen arbetsmiljö 1997).
Compared with similarly situated men, women of child-rearing age or with
small children experience a greater conlict between responsibilities for care
at home and children on the one hand, and gainful employment — now that
the labour market has become so insecure (tidningen arbetsmiljö 1997).
younger women are also less willing to take risks and they accept worse
conditions at work. women, primarily, also have less conidence in their
employers.
the increasing proportion of women in insecure, temporary jobs — in
conjunction with the indings described above — increases the likelihood of
the spread of a new ill-health syndrome resulting from lost trust between the
employee and employers. Ill-health due to this lack of trust may be described
as social, psychological, and somatic illness related to the limits of individuals’
ability to manage insecurity in their lives (aronsson 1997).
45
another problem resulting from temporary employment is that these

temporary jobs and the need to hire extra hands most often result from
heavy production loads with short completion requirements, causing heavy
work loads both on the permanently employed and on those called in. this
will probably, in addition to the lack of trust syndrome, increase the risk of
work injuries, including repetitive stress injuries.
How do working conditions correspond with the notion

of good work organisation?
the structures in a work organisation are often seen as gender neutral, as
independent of whether the organisation’s members are women or men.
however, one has to question how gender affects the processes and struc-
tures of the organisations. organisational structures must be understood and
analysed as gendered systems. Different forms of organisation have different
gender-political effects. the so-called gender power systems, i.e. underlying
conceptions, standards and practices in modern companies, are constituent
elements in the logic of organisations and in fact more or less make women’s
conditions “invisible”. (acker 1987; Baude et al. 1987; Gunnarsson et al.
1991; kvande and rasmussen 1990).
researchers have shown that women’s chances of development are better
in network organisations than in hierarchical organisations (Gunnarsson and
ressner 1983; kvande and rasmussen 1990; ressner 1985). In one study,
kvande and rasmussen compared the hierarchical organisation with the
network organisation. they summarised their indings of the two organisa-
tional types in the following characteristics:
Hierarchy
• specialisation and strict division of labour
• Vertical communication
• Centralised decision-making systems
• Inluence according to hierarchical position,
Network
• Flexible and team-based work organisation
• transverse communication
46
different worlds
• Decentralised decision-making systems

• Inluence on basis of knowledge and experience.
a comparison between hierarchy and network organisations shows that a

hierarchical organisation limits people’s exposure to new challenges. the
work assignment structure is rigid and sets the limit for development through
work. one gets new work assignments by applying for new positions, either
vertically upwards in the hierarchy or to a different part of the organisation.
In both cases the work tasks are new and unknown. the chances to acquire
new competence are wholly related to the kind of work tasks one is allowed
to try out.
on the other hand a network organisation offers considerable, in prin-
ciple limitless, challenges. tasks are in a constant state of change and em-
ployees are involved in the process of deining and redeining them. the
employees themselves can explore new work areas and work assignments.
they have considerable latitude to try new work assignments and take on
more responsibility. the organisation often expects this of them. neces-
sary skills are acquired by carrying out the work. through trying new areas
the employees ind that they can master different work tasks and are thus
emboldened to take on new work assignments and more responsibility. the
employees work together, very often making lateral connections across group
and departmental boundaries, and everyone contributes their knowledge to
the decision-making process. they get feedback and assistance in carrying
out their work assignments and they gain conidence in their occupational
skills and competence.
hierarchical organisations are likely to make women invisible as bear-
ers of knowledge, and isolate them, often at the bottom of the hierarchy.
a hierarchical organisation promotes a gender order where men are given
pride of place over women. network organisations become more female-
friendly, largely by virtue of their lexibility. network organisations are more
amenable to change, make women visible as working individuals and allow
all employees to take on greater challenges. network organisations are also
more female-friendly because they better relect women’s attitude to work,
women’s values and their general way of being (Gunnarsson 1991; kvande
and rasmussen 1990).
47
What characterises good work organisation?

Issues affecting men’s and women’s work environment cannot be treated
satisfactorily without considering how the work is organised. the problem
of women’s working conditions, in particular, must lead to efforts to improve
occupational safety and health based on the reality women face in working
life and in work organisation. the aim should be to produce a good work
organisation which reduces health risks. the characteristics of a good work
organisation can be described as follows (san 1997; westberg 1996).
• work should contain some variation. the employee herself/himself or

her/his team should decide how the work should be organised in terms
of methods, routines etc.
• the employee should be able to see where in the process her/his
contribution its in. the employee must feel that the work performed is
meaningful, and receives respect and understanding.
• the nature of work should give opportunities to fulil the employee’s
need for social contact with fellow workers and it should be possible to
co-operate with them.
• the work should be such that the employee has the opportunity to
make decisions within her/his own ield of work. It should be possible
for the employee to have inluence on decision making regarding work
organisation, tasks and work environment.
• the work organisation and tasks should stimulate learning and develop-
ment. the work should provide openings for the future.
• technology, work organisation and job content should be designed in such
a way that the employee is not subjected to physical or mental strains which
can lead to ill-health or accidents. Forms of remuneration and the distribu-
tion of working hours should also be taken into account in this connection.
Closely controlled or restricted work should be avoided or limited.
What does it look like in reality?

as discussed above, sweden has a strictly sex segregated labour market. It
was also noted that many jobs where women predominate are repetitive and
monotonous in nature, which leads to a signiicant incidence of upper limb
disorders. even though heavy work is seen as male work, these monotonous
48
different worlds
and/or heavy jobs are often done by women. the tasks in male dominated
occupations are still seen as requiring greater physical strength (meaning
men only), even as such jobs continue to disappear. Physical strength is still
seen as a qualiication held by men. however in the care sectors, for example,
involving tasks generally thought of as caring and therefore female, physical
strength is also needed (westberg-wohlgemuth 1996).6
Preconceptions about physical strength as a characteristic that makes men
more eligible for some jobs (in predominantly male occupations), and about
women having characteristics or qualiications that make them suitable for
care (in predominantly female occupations) and for simple, repetitive tasks
(in male dominated sectors) are seen by many as objective facts. that these
preconceptions contribute to an increase in the risk of occupational injuries
among women cannot be ignored.
Poor psycho-social working conditions, in the form of high demands,
little inluence, poor development and prospects of improvement, and weak
social support at work all have a close relationship with reduced psychologi-
cal well-being.
In women, reduced psychological well-being is most common among
teachers, psychiatric care workers, social workers, restaurant personnel, and
cleaning personnel. In men this is most prevalent among doctors, psychiatric
care workers, and drivers (bus and taxi). the poor psycho-social working
conditions listed above are also prevalent in these professions.
the proportion of those employed who (according to the working en-
vironment report 1995 (statistics sweden 1996a)) experienced their work
as psychologically stressful was 46 percent for women and 38 percent for
men. this study also found the professions involving contact with others,
such as social workers, welfare oficers, health care workers of all categories,
teachers, and such, were the most psychologically stressful.
over 40 percent of all those employed stated that every week they could
not stop thinking about their work when away from the job. as many as 16
percent stated they had dificulty sleeping due to concerns about work, and 14
percent felt disinclined to report to work (exactly the same for both sexes).
the working environment 1995 report found that 43 percent of women
and 35 percent of men have jobs where during at least half of their working
hours they repeat the same movements many times an hour (table 9). not
49
being able to set the pace of work or even decide when the work is done is
often characteristic of the more routine jobs.
Table 9. Proportion in percent of women and men, respectively, in the same occupations
who must repeat the same movements many times an hour for at least half of their work
hours (1989/1995). Source Statistics Sweden 1996a.
Women Men
Social administration 23 9
Chemical and physical lab. 31 15
Sales assistant 67 38
Electronics, teletronics 76 24
Packaging, warehouse 79 53
Postal and telecom work 84 60
women are allowed to decide when to complete their job tasks to a lesser
degree than men, and have repetitive tasks to a greater degree. In more than
ten female dominated occupations, more than 70 percent of the workers
must repeat the same movements many times an hour for at least half of their
working hours. the corresponding number of male dominated occupations is
three. even within the same occupations, differences in this respect between
the tasks of men and women can be seen. this indicates that women are
assigned the more monotonous, repetitive tasks.
statistics sweden reports that in 1995, 35 percent of those employed
stated they had so much work to do each week that they felt forced either
to reduce time spent at lunch, work late, or to take work home to complete
— more so for men than women (40 to 31 percent, respectively) (statistics
sweden 1996b). this involved persons in occupations requiring longer
education more often than those in occupations with shorter educational or
training requirements.
Fifty-four percent of the women and 52 percent of men felt their work
loads were too heavy — more than half of all those employed. the propor-
tion was higher in the health care sector (medical doctors), administrative
investigations, pedagogical occupations (pre-school and school teachers,
recreational instructors) and social workers, administrators, and similar oc-
cupations. many of those employed — 63 percent of women and 54 percent
men — felt the pace of work has increased over the last ive years. this is
50
different worlds
most true of mid-level white-collar workers such as nurses, or bank admin-

istrators (statistics sweden, 1996b).
of all those employed, 52 percent feel they have an opportunity to learn
something at work every week and to develop in their occupation. In total,
men have greater opportunities for development at work, but with wide
variation between occupations. up to 64 percent of the men and 58 percent
of women have jobs that require recurrent education or training.
opportunities for personal development at work are found least often in
non-skilled occupations — like kitchen assistants, sales assistants, packaging and
warehouse workers, and cleaners — where 30 percent of the women and 31
percent men feel they have opportunities to develop. next are women at lower
administrative levels (at 40 percent), such as secretaries, typists, and bookkeep-
ers (with lower level qualiications7), as well as female skilled workers, such as
workshop mechanics, cooks, and more. only one in four women in this last
group have the opportunity for professional development, while at least half
of the men have duties where this is possible (statistics sweden, 1996b).
the computer is widely used in the swedish workplace. roughly 56
percent of all those working use some kind of computerised equipment and
over 50 percent work at a computer monitor. Computer usage is particularly
high in certain occupations, such as administration, bookkeeping, and among
chemists and physicists, at 90 percent. Computerisation — expressed as the
proportion of those working with monitors — has increased dramatically
over the last eleven years (for which statistics are available from the working
environment surveys). the number of women in this kind of work increased
from 16 percent to 47 percent of all women, while the increase for men was
from 17 percent to 54 percent, a threefold increase in this kind of work for
both genders (statistics sweden 1996b).
the psychosocial work environment reported in the working environ-
ment 1995 (statistics sweden 1996b) also includes issues of violence, threats,
harassment and sexual harassment, though statistics are only available from
1995. over the last twelve months, 16 percent of all women and 8 percent
of men were the victims of violence or threats on the job. the group most
affected, women in occupations requiring only the lower level of qualiica-
tion (health care workers like assistant nurses, psychiatric assistants), had a
28 percent annual incidence rate.
51
Just over 8 percent of all workers suffered harassment from co-employees

or managers over the same period. this igures includes approximately as
many women as men.
women suffer sexual harassment more than men — 1.5 percent of the
women and 0.5 percent of the men were sexually harassed by either co-workers
or their bosses at least once during the same 12-month period. a signiicantly
greater number, nearly 5 percent of the women and 1 percent of the men
suffered sexual harassment from persons other than co-workers or managers.
the latter occurs most often in predominantly female occupations, such as
in health care, hotel and restaurant, or cleaning services.
non-skilled workers feel more exposed to health risks than other groups
of workers. In general, those with shorter secondary education are the most
exposed.
In predominantly female occupations, workers often have little inluence
at the work place. women working in predominantly male occupations
also have monotonous tasks, usually with poor working positions. Cleaning
personnel, mostly women, have an unambiguously negative work situation
with low employment requirements, monotonous tasks, and little chance for
personal development and learning on the job (statistics sweden 1996b).
the situation of health care workers, including those working with the
elderly and handicapped, is also vulnerable. they face several types of serious
dificulty — irst, their position in the labour market is insecure, since a large
proportion of these jobs are temporary. second, the work involves a signiicant
risk of injury from heavy physical lifts, exposure to chemicals, and the risk of
infections. they are also exposed to psychological stress as a result of their
contact with others.
this is peculiar to health care — to be exposed at the same time to very
high mental stress and high physical demands. nurse assistants and psychi-
atric assistants also have little opportunity to exert inluence when certain
of their tasks are done. and, all care workers are exposed to a great risk of
violence, threats, harassment and/or sexual harassment.
Consequences of the new labour market — summary

as a consequence of the new conditions in the labour market, there is a strong
tendency to demand a work force which is available only when needed. these
52
different worlds
changes to the labour market affect the unemployed, those with temporary
employment, and even permanent employees.
the recent changes in the work and jobs environment place higher
demands especially on women for greater lexibility and adaptability. this
means that women will have greater dificulty in planning and combining
work and family life. however, women feel greater anxiety than men about
the changes to the labour market that will affect them, even though so far
employment has decreased most among men. But this pattern is changing so
that now these men are being re-employed to a greater extent than women.
a look at total employment for women indicates they have a more insecure
situation on the labour market. women have temporary jobs to a greater
degree than men. and to a much greater extent, they feel they must adapt
their working life to their family despite the fact that exactly the opposite
demands are placed on them by the work environment.
the individual’s outlook on the future employment situation, considering
both the possibilities and risks, can be related to such problems as fatigue,
listlessness, indigestion, insomnia, and more — among both women and
men there are problems which are work related but have not yet been ac-
knowledged as such.
the point at which work related problems will be legally accepted as a
work injury depends on the current social climate and is related to historical
and cultural factors in society including attitudes to women.
societal values and preconceptions are changed by new messages expressed
through the transmission of “know-how”. these transmissions contain more
or less hidden messages and processes that unconsciously affect society.
among other consequences of this, young women between 25 and 35 years
are more afraid of losing their jobs than other age groups. they therefore
tend to accept working conditions which were not acceptable just a few
years ago. they also know that the fact that it is the woman who gives birth
is often used as a pretext (openly or not) for excluding women from certain
jobs. this is so even though not all women will have children nor do they
always prioritise childcare over their careers.
the new conditions also affect employee attitudes towards employers.
the worsened conditions at the workplace and in working life may result
in decreased conidence in employers. so, perhaps a new work injury can
53
be identiied here — “the lost trust syndrome” — ill-health caused when

patterns of reliance between employees and employers break down as a
result of the insecure labour market. loss of conidence in employers and
the welfare state can be seen as the cause of a type of ill-health syndrome
and can be described as social, psychological and somatic ill-health. Because
women have a more insecure position in this market, they are more likely to
experience symptoms related to this ill-health syndrome than men are (see
following chapters about other health problem issues).
these patterns relect one aspect of the gender paradox where women seem
to suffer more illness than men while generally living longer. the cause of this
paradox is dificult to determine, but it seems likely that it can be linked to the sex
marking and segregation present in society (westberg 1997). women and men
are raised to act and react differently, so it is reasonable that this also should
apply to work related situations. to a great degree, women and men also have
different labour markets, and so are exposed to different health risks. this dif-
ference in their prerequisites (both biological and social) most likely explains
the differences in work related problems women and men experience.
the loss of conidence will affect various groups of women owing to their
exposed position on the labour market in relation to the limited ability of
human individuals to manage insecurity in their lives.
From the indings reported and based on predictions for the future labour
market, the risk of increased ill-health in sweden is signiicant. this applies most
to women. there are, however, efforts being made to improve working life. In
many instances the individuals and institutions involved are taking a compre-
hensive view to improve workplace organisation and the work situation.
notes
1. these statistics are based on the nordic Classiication of occupations (a classiica-
tion used in censuses etc.) the classiication contains many more occupational
titles in male-dominated areas than in female-dominated areas. the industrial
sector, for example, has very detailed occupational classiications, often related to
the machine the operator uses. the classiications of female-dominated occupa-
tions in the public sector, for example, are more general in nature and contain
fewer occupational titles. the statistics presented are from 1990, and are based on
54
different worlds
information about working conditions in the census 1990 (westberg-wohlgemuth

1996). statistics of more recent date used a broader classiication of occupations
and are even more inaccurate than the classiications made up to 1990.
2. terms used in the text:
Work force covers all persons employed or employable, or occupied in government
work programs.
Not in the work force covers persons not seeking employment e.g. students, people in
early retirement, housewives etc.
Employed or occupied persons have worked at least one hour per week or are temporarily
absent from an established workplace during the measurement period.
Unemployed covers persons without (any) gainful employment but seeking it.
Temporary absence covers persons not at their regular place of employment due to
vacation, sickness, childcare leave, studies, military service, and such. this is only
for absence longer than one week.
Relative work force rates relect the percentage of the population in the work force.
Relative unemployment rates relect the percentage of unemployed in the work force.
Relative absence rates relect the percentage of employed temporarily absent from
regular jobs. absence both of part of a week and over one week are included.
3. the age group 16–64 years is nearly always used for these comparisons.
4. the percentage of self-employed also includes employed family members.
5. the secondary labour market is associated with atypical and precarious employ-
ment conditions and also with unstable, low paid jobs with no security.
6. with repetitive movements in so-called static work, muscle cells are strained so
circulation is restricted until the cells are eventually damaged, giving rise to repeti-
tive stress injuries, sick leave, and early retirement. It doesn’t matter that the work
is physically “light”. heavy lifts, using different muscle groups can actually lead to
better circulation in the muscles in so-called dynamic work. heavy lifts are simpler
to correct or eliminate mechanically. men usually perform single tasks requiring
strength in dynamic work. since women usually have less arm strength they are
placed in the physically “less demanding” tasks — however, these are exactly the
kind of monotonous tasks that lead to static strain.
7. the lower qualiication level means less than two years’ education after elemen-
tary school, while the higher level involves at least two years’ education after
elementary school.
55
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acker J (1989) En paraplyproblematik. Ett diskussionsunderlag. alC.
ams (arbetsmarknadsstyrelsen) (1997) Anställningsformer. ura 1997:4. ams.
aronsson G (1997) Personalminskningar ger lera negativa effekter. artikel i Svenska
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57
58
Chapter 3
FaCts anD PreJuDICes

60
facts and prejudices
Psychological differences
between women and men
by Malin Lindelöw and Carina Bildt Thorbjörnsson
we describe ourselves in many ways, but of all these our gender is perhaps
the most central theme of all. our womanhood or manhood, and that of
others, is a fundamental dimension guiding our social interaction, because
it gives rise to expectations about behaviour, personality, goals, and aspira-
tions, that is, about the way in which we can and should relate to each other.
although it does not stand on its own, but interacts with other social catego-
risations, such as race, ethnicity and occupation, it cuts across all these and
guides behaviour. In this way, gender is not simply another categorisation,
but rather an organising principle (lundgren 1992). as such, it impinges on
individual functioning in countless ways, some of which are more dificult
to quantify than others.
In particular, it will be argued, sex-speciic role expectations create dif-
ferent life circumstances for women and men, which affect their health in
important ways across the life-course. In order to demonstrate this, how-
ever, it is necessary to explore the extent to which psychological differences
between men and women have been documented, how they emerge, and
in what way they result in tangible differences between women’s and men’s
life situations.
now, the study of gender differences is not uncomplicated. It has been
described as the dificult child of thoroughly mixed up parents (see oakley
1972). scientiic endeavours have been entangled with political considera-
tions, which has contributed to a heated controversy, as well as leading to the
development of numerous competing perspectives. the point of departure
for much of the work that has been undertaken so far is the way in which
femininity and masculinity have been conceptualised. Both historically and
61
cross-culturally, they have been thought to represent complementary domains

of traits and behaviours. while scholars have conceptualised and described
these in different ways, certain themes appear to recur. thus, masculinity has
been associated with an instrumental orientation, while the focus of femininity
was thought to be expressive. others have suggested that masculinity relects
an “agentic” orientation, a concern for oneself as an individual and a focus
on ones actions in the world, and femininity with a “communal” orientation,
a concern for the relationship between oneself and others (Bakan 1966). In
addition, a considerable degree of consensus has been documented between
women’s and men’s descriptions of which characteristics are more desirable
in either sex. Being affectionate, cheerful, childlike, compassionate, gentle,
shy, tender, warm and yielding were thought to be typical of women, and
aggressiveness, ambitiousness, assertiveness, dominance, independence and
self-reliance were considered masculine (Bem 1987).
although apparently simplistic, the notion that men and women are
guided by different principles is relected in a number of areas of research.
men are seen as achievement oriented while women are guided by a desire
to connect to others. From this distinction lows differences in the way in
which girls and boys are treated within the family and the educational sys-
tem and the way in which they play, as well as women’s and men’s ways of
communicating, making moral judgements, thinking about themselves and
being vulnerable.
In this chapter the evidence of quantiiable psychological differences
between men and women and their origin will be discussed. since a com-
prehensive overview of this area would demand its own volume, at the very
least, the aim has been at least to bow in the direction of the major areas of
relevance here. there are four different parts to this discussion. First, the
socialisation of children and the potential sources of sex differences associated
with this is explored, both in order to provide a conceptual framework for
thinking about the origin and meaning of sex differences and to create some
expectations about in which domains such differences may be expected. sec-
ond, the evidence of observable and signiicant psychological sex differences
is discussed. third, the role of biology, and to some extent the importance of
biological sex differences, is discussed, if only to create an awareness of the
importance of this area in relation to social theories. Fourth, and inally, the
62
different strands of literature are drawn together in an attempt to provide

some overall conclusions and informed speculations about the implications
of psychological sex differences to the area of health and work that may be
helpful in planning future research. Due to the limitations imposed by the
format of this presentation, the nature of these discussions had to be very
brief, and many issues could not be raised. For this reason we would like to
encourage the reader to dig deeper when inding something of interest, with
the hope that the references provided may be of some use.
The sources of sex differences

there are three different sources of sex differences, those that are linked to
biology, those that stem from variations in socialisation and social experience,
and those that originate in an interaction between the two. since the relevance
of biological differences is discussed elsewhere (chapter 4), this chapter will,
with a small number of exceptions that are not covered elsewhere, focus on
social factors and their consequences. In so doing, the most obvious point of
departure is to account for the forces that act to mould the developing child
into the forms that social expectations stipulate for their sex. such socialising
agents include family, peers, and the educational system.
The early years: Sex typing within the family

the family, in particular, is thought to play a fundamental role in sex typing,
as it is the primary context of the young, impressionable child for many years
to come, and as it fulils so many of the individual’s most important needs over
such an extensive period of time. there are at least four competing theories
that seek to account for this process: psychoanalytic theory, social learning
theory, cognitive-development theory, and gender-schema theory.
Psychoanalytic theory emphasises the child’s identiication with the same-
sex parent as the most important mechanism by which children become
sex-typed. this clearly presupposes the discovery of genital sex differences.
For boys, very briely, identiication is motivated by castration anxiety. that
is, around age four his love for his mother is thought to become increas-
ingly sexual and the father is viewed as a rival. his jealousy is, however,
cured at the sight of the clitoris. the little boy is thought to conclude that
all girls have been castrated. In perceiving the size and power of his father,
63
the boy concludes that he has the ability to castrate competitors, and ceases
to compete with his father out of fear. Instead he tries to be like him. the
girl’s identiication with her mother, by contrast, is argued to be motivated
by penis envy. this develops at her sight of the male genitals, which over-
whelm her by their superiority, causing a sense of incompleteness, jealousy
of boys, and disdain for her mother alongside all women, since they share
her deformity. she focuses her love on her father, who possesses the coveted
penis, and identiies with her mother as a means to win him.
to some extent psychoanalytic theory has fallen out of favour with much
of academic psychology. one of the reasons for this is that it is dificult to
test empirically. But, more importantly, evidence that has been available for
some time does not appear to justify the emphasis on the child’s discovery of
genitalia, and fails to verify the very existence of castration anxiety in boys
and penis envy in girls (Frieze et al. 1978; sherman 1971). In addition, it is
dificult to overlook the anti-female bias in Freud’s writings. women are, by
their very nature, redeined as inadequate, jealous, and inferior (Bem 1993),
and femininity is construed as pathology (Brennan 1992), a view which has
become decreasingly acceptable in recent times.
Feminist theorist nancy Chodorow (1978, 1990) has, however, offered a
revision of Freud’s identiication theory. her aim was to explain why women
grow up to be care givers and to have closer affective ties with children than
men do. her suggestion is that while girls identify with their mother, iden-
tiication is more dificult for boys, who psychologically separate from their
mother and seek to model themselves after a parent who is largely absent, the
father. this leads to emotional detachment and repression. Girls, by contrast,
enjoy an intense and ongoing relationship with their mother, which leads to
the feminine personality coming to deine itself in relation to, and connec-
tion with other people more than the masculine personality does, and thus
develops their psychological capabilities for mothering (Chodorow 1978).
this distinction, between women’s orientation towards “connectedness”
and men’s towards “separateness” is one which is built in to many different
areas of research, including communication and moral reasoning. together
with the view of men as “agentic”, it has guided much of the thinking to be
explored later in this book.
64
another dimension which has received considerable attention is the

impact of environmental inluences and prevailing social values. this draws
on the principles of social learning theory, derived from behaviourism,
which emphasise reinforcements. Gender-appropriate behaviour is learned
by means of rewards and punishments that the child receives for desirable
and undesirable behaviour, respectively. Furthermore, the child is thought
to model his/her behaviour on the same-sex parent, learning by example
as well as by direct instruction. social learning theory thereby locates the
source of sex-typing exclusively in the surrounding community (for an
overview, see renzetti and Curran 1995). much of the appeal of this theory
comes from its generality. the same principles are applied to sex-typing as
to many other kinds of behaviour, and is thought to operate in similar ways
for both sexes. additionally, gender is construed as something plastic and
changeable, a consequence of culture, as opposed to biology. yet, in spite of
its appeal, social learning theory has suffered from damaging criticism. the
child is viewed as a relatively passive recipient of environmental inluences,
rather than an active agent, motivated by an urge to understand and organ-
ise the social world conceptually, which is inconsistent with much available
evidence (e.g. Bem 1983).
Cognitive-developmental theory, by contrast, focuses on the child as the
primary agent of his or her own socialization, and sex typing is thought to
follow naturally from universal principles of cognitive development. this is
based on the work of Jean Piaget and lawrence kohlberg, and children are
seen as actively seeking to comprehend the world and to seek labels to classify
themselves and others. through this process, she or he comes to understand
gender, to assign her or himself to either category, and thereby prescribe
appropriate and inappropriate behaviours. Cognitive-developmental theory
has been extremely inluential, but has been criticised because it fails to ac-
count for the primacy of gender. why is gender such a pervasive category,
cutting across race, ethnicity and occupation?
Gender-schema theory, drawing on both social learning theory and
cognitive-development theory, has sought to address this very question, by
proposing that sex typing largely derives from gender-schematic process-
ing, a generalised readiness by the child to encode and organise information
according to the culture’s deinitions of maleness and femaleness. thus, sex
65
typing is mediated by the child’s own cognitive processing. But the theory
further proposes that gender-speciic processing in itself is derived from
practices in the social sphere, making it a learned phenomenon which is
neither inevitable nor unmodiiable (Bem 1981, 1987).
Play, peer relationships and their consequences

Independently of the way in which the inluence of the family is internalised,
it remains that sex differences are further accentuated by differences in girls’
and boys’ peer relationships and play. It is long established that children’s play
is far more than an enjoyable past-time. rather, it is an important arena for
learning, both practically and socially. It is also an area where girls and boys
are exposed to largely different environments and stimuli, both with regard
to the toys they play with and the ways in which they play, and compelling
arguments have been put forward that this has important consequences for
later functioning.
there is evidence that children already show a preference for gender-
stereotyped play material by age two (robinson and morris 1986; roopnarine
1986), and this is further reinforced by their parents, television commercials,
toy packaging, and the typical way toy stores have of arranging stock in dif-
ferent sections for boys and girls (schwartz and markham 1985; shapiro
1990). while this subject deserves analyses from many different angles,
perhaps the most important difference between toys intended for girls and
boys is that they foster different traits and abilities. toys for boys typically
invite exploration, manipulation, invention, construction, competition and
aggression, while girls’ toys foster creativity, nurturance, attractiveness, as
well as rating high on manipulability (Bradbard 1985; miller 1987; Peretti
and sydney 1985).
at the extreme, boys are expected to enjoy the various means of
transportation, military devices, and construction toys, while girls are
conined to miniature versions of household appliances and dolls in pink
dresses. renzetti and Curran (1995) screened a number of american toy
catalogues and jokingly noted that the only dolls speciically produced for boys
were “a vinyl 6-foot inlatable Godzilla; ‘Big Frank’, a talking Frankenstein
construction toy that has a gear box that says ‘Fix me’ if he needs ixing; and
the ‘totally awesome Duelin’ Dudes’, which requires two players, aged 3
66
years or older, to use the ‘multi-action control to knock (their) opponent’s

head off!’’’ (p. 94).
miller (1987) concluded that “data support the hypothesis that playing
with girls’ vs. boys’ toys may be related to the development of differential
cognitive and/or social skills in girls and boys” (p. 485). they may be seen as
extending and reinforcing differences in aggression, and direct girls towards
a nurturing role, while boys are encouraged to compete and, in this way,
foster male and female stereotypes.
similar interesting issues are raised by differences in the way boys and
girls play and conduct their relationships with their peers, which forms a
vital part of children’s socialisation. research shows that children actively
socialise with each other in their everyday interactions, and that this experi-
ence varies signiicantly between the sexes. Children from the age of two
voluntarily segregate themselves into same-sex groups or select same-sex
playmates, and this tendency grows stronger as children move from early to
middle childhood (Feiring and lewis 1987; maccoby and Jacklin 1987).
But it is not merely the preference of same-sex groups which distinguish
boys and girls, but also the kinds of activities that they engage in. Girls typi-
cally seek to avoid conlict, and their interaction is more aimed at maintaining
good relationships, in particular with a frequently occurring best friend. Boys,
by contrast, usually play in larger groups, and their play is characterised by
more aggressiveness and competitiveness as compared to the girls, which
to some extent is accounted for by their greater involvement in organised
sports (Corsaro and eder 1990; maccoby 1988; thorne 1986).
In summary, we see a tendency for girls to emphasise nurturance and
to value close relationships, while boys are more group- and rule-oriented
and are more comfortable with conlict. It has been speculated that this is to
the advantage of boys in future work settings, although the changing labour
market, where social skills are being increasingly valued, should come to
favour women more over coming decades.
there has been criticism of much of the research on peer socialisation
on the grounds that it focuses on sex differences and ignores similarities and
cross-sex interaction (thorne 1993). Clearly, there are numerous situations in
which both boys and girls co-operate and play, especially in school and more
organised or formal settings. yet, it remains that there is a tendency to prefer
67
same-sex peers and gender stereotyped activities in their leisure time, and
that this is likely to have an important effect on their future adjustment.
Schooling and the educational system

encounters with the educational system present a further basis for distinctions
between girls and boys, as well as, later, women and men. there is compel-
ling evidence that teachers’ interactions with female and male students vary
both with regard to their frequency and content. Perhaps not surprisingly,
boys receive comparatively more of their teachers’ attention than do girls
in primary school, even when allowing for their greater proneness to make
unsolicited contributions to class (sadker and sadker 1994). Boys also get
more praise for the intellectual quality of their work, whereas attention tends
to be drawn to the neatness of girls’ work (Dweck et al. 1978).
scholars have talked about the invisible glass ceiling that is imposed on
young women’s ambitions. this is related to the general belief that girls are
not as gifted as boys, relected in evidence about both parents’ and teachers’
interpretations about boys’ and girls’ achievements, or failure to achieve. If
boys perform well they are thought to be clever, while dificulties are thought
to indicate bad luck. By contrast, girls who achieve a good result are thought
to have been lucky, while dificulties are described as consequences of their
limited abilities (Deaux 1976). Bush (1987) noted that indings regarding sex
differences are analogous to those for teacher expectations linked to class
and race, where teachers respond more positively to middle- and upper-
class students than to working class students, or to white students relative
to minority students.
thus girls are consistently undervalued, and the implicit message ap-
pears to be that boys are expected to develop and expand intellectually
and creatively, while girls will be limited by the very fact of their sex. the
consequences of this should not be underestimated. teachers are igures
of authority, and their word carries considerable weight in their students’
development. messages received both in home and school settings contrib-
ute to the individual’s understanding of self and expectations of his or her
future, which, in turn, contribute to the creation of future reality. Females
of all ages should therefore be expected to have a relatively low evaluation of
68
their competencies and potential, compared to males, and it is likely that this
is relected in their lower aspirations and achievement. one of the central
tasks of contemporary work organisation should be to unlock this potential
and create a mental climate where women, as well as men, can develop and
make a full contribution.
another area of importance with regard to the educational system is the
encouragement for both women and men to enter into professions which are
considered to be appropriate for their respective sex. while this tendency
may have various explanations, active encouragement by school counsel-
lors (e.g. marini and Brinton 1984), schools’ own limited representation
of female teachers within maths and sciences and male teachers in subjects
such as home economics and health (Commission on Professionals in sci-
ence and technology 1992), and the increasing prevalence of male teachers
the further one climbs the educational ladder (sCB 1986) are all likely to
contribute signiicantly to both men’s and women’s occupational aspirations
and achievements. the psychological consequence is that neither sex may
choose a profession freely, based on capabilities and interest, but both are,
at least to some extent, limited by gender stereotypes that are imposed by
schools and the general environment. these systematic differences in men’s
and women’s professional choices have implications for everybody: those
who limit their range of choices due to explicit or implicit expectations by
others, and those who defy traditional gender boundaries, ind themselves
as members of a minority within their profession. the former may experi-
ence frustration and disappointment from not realising their potential, while
the latter may experience the stress of being in a minority, and dificulties
associated with being accepted or advancing as a consequence. either way,
gender plays an important role, and may potentially create dificulties within
the work place or in relation to work.
Socialising agents: Concluding comments

Drawing together the effects of the various socialising agents, there is ample
reason why girls and boys should develop differently, in accordance with pre-
vailing stereotypes, which, in turn, are culturally deined. these also stipulate
appropriate adult behaviour, with important consequences for women’s future
work lives and health. there is a range of professions which are dominated
69
by females, which essentially represent an extension of their nurturing role,

providing for others and responding to the needs of others. most obviously,
these include nursery and primary school teachers, counsellors, nurses, sec-
retaries and personal assistants. these professions, and the caring professions
more generally, are typically plagued by a considerable amount of emotional
strain and relatively poor inancial compensation (Forsberg 1992), both of
which have unavoidable consequences for these women’s general situation.
men, by contrast, are typically found in occupations concerned with technol-
ogy, construction and transportation (sCB 1996).
But the inluence goes far beyond professional choices. the same under-
lying attitudes and range of behaviours inluence how women make choices
about priorities in their personal lives, how they conduct relationships, and
how they negotiate the demands of their different roles. here, again, women
have been shown to award extensive importance to the needs of others, often
at the expense of their own (thompson 1995).
although these effects are considerable and important, there is another
layer of inluence which ought to be borne in mind. that is, culture does not
only deine what behaviours are appropriate for each gender, it also dictates
the extent to which these are valued and the social consequences of failure
to adhere to the prescribed rules.
one of the central themes of the feminist critique of the prevailing social
order has been that masculinity and men are more valued than the feminin-
ity and women. this places women in a double bind, where they are forced
either to conform to a less valued feminine role and thereby fail to achieve
formal recognition, or to reach for the more valued masculine role, but be
punished for their failure to conform to what is expected of them in the
context of their gender. Put in popular words, “damned if you do, damned
if you don’t”.
It is, therefore, important to go beyond the analysis of how gender sociali-
sation impinges on the individual, in order to consider how it extends into
the choices that are made in both the professional and personal arenas across
the life course, and how they inluence the total situation of the individual
in both the short and long term.
the recommended analysis, therefore, is a holistic, person-oriented
one (magnusson 1998), where risk and protective factors from all areas of
70
the individual’s life are studied in conjunction, with the person, rather than
particular variables, as the organising unit.
Empirical evidence
now, given the variations in upbringing and social experience, what irm
evidence is there of observable, signiicant differences between girls and
boys and women and men with regard to psychological characteristics and
functioning?
research done in this area is abundant, and many debates span over decades,
but remain unresolved. the reason for this poor resolution lies only partly
with the complexity of the subject matter. Preconceived ideas about the two
sexes, variations between cultures, changes over time as a consequence of
changing social circumstances, and concern over the political implications
of the various indings have affected the discourse. the discussion on sex
differences has been particularly vulnerable to this, as any conclusions made
have extensive social implications and may be used, and indeed misused,
for political means. this has coloured the debate considerably, as will be
evident in due course.
another complication is that changes over time in values, laws and so-
cial custom are linked to the way in which both men and women develop,
and there is evidence emerging that many previously noted differences are
diminishing. It is, therefore, important to remain critical, and carefully
consider not only the methodology used to study the various issues, but
also the nature of the populations under investigation and the likely origin
of any observed differences.
of the areas investigated, many originate in the debate about psychoana-
lytic theories of women. others stem from observations of sex differences on
dimensions that have been studied in their own right, and from theoretical
work, not infrequently based on observations made in psychotherapeutic set-
tings. Particular interest has been awarded to sex differences in self-construal
and self-esteem; intellect and ability; language and communication; moral
reasoning; personality, aggressiveness, and alcohol and drug use; stress and
coping; social support; brain structure and its implications; and differences in
women’s and men’s life cycles and their interaction with general functioning.
while this list of subjects is not exhaustive, it serves to highlight some of
71
the most important debates concerning psychological differences between

women and men.
Self-construal and self-concept in the context of gender

one of the areas where sex differences have been discussed at some length
is with regard to the ways in which the self is constructed. that is, each
individual has a view of who she or he is, a self-description which forms the
basis of their identity. this self-view guides the way in which we understand
ourselves and our role in the world. It provides a basis for interpreting events,
deining priorities, and making plans. It is thereby irmly anchored both
within the individual and her or his behaviour.
In a recent comprehensive review of models of the self and gender it was
argued that, in general, men construct and maintain independent self-con-
struals, where representations of others are independent of the self, whereas
women are thought to construct and maintain interdependent self-construals
(Cross and madson 1997). this makes it intimately linked with conceptu-
alisations of femininity and masculinity discussed in the introduction to this
chapter, but it has also been noted in other contexts. In one study, concerned
with women’s work and life styles, it was observed that women have a ten-
dency to take responsibility for the consequences of their own actions to
others. “their actions always occur in a context which include others. to
see themselves as part of a relationship seems to be central in these women’s
lives” (thompson 1995, p. 5).
these same ideas have been presented in a very different strand of litera-
ture, originating from the therapeutic setting. eichenbaum and orbach, two
feminist psychotherapists, have identiied two psychological requirements
lowing from a woman’s social role.
the irst is the need to defer to others, that is, to follow their lead and
articulate her needs only in relation to others’. this means that she is not al-
lowed to see herself as the main actor in her own life, that she is not important
in herself for herself. the second is that she must always be connected with
others and shape her life in accordance with a man’s. together these lead to
another concominant of a woman’s social role: she must learn to anticipate
the needs of others, thereby putting her own needs second (eichenbaum
and orbach 1983).
72
while the scientiic community often fails to capitalise on lessons learned

in therapeutic situations, it will soon become evident that much of the re-
search to be presented here supports this distinction. Furthermore, as we
will argue, conceptualisations of the self, and systematic differences across
gender as well as culture, may inspire future research into widening the
range of characteristics under investigation, and inform us of the mechanisms
underlying already observed sex differences.
Women, men and self-esteem

a related aspect of psychological functioning which has attracted much
interest, presumably due to its popular appeal, is self-esteem. this refers to
one’s evaluation of oneself, or, as a classic scholar in this area put it, “one’s
personal judgement of worthiness that is expressed in the attitudes held
toward self ” (Coopersmith 1967).
there are various reasons why we might expect there to be differences in
the self-esteem of men and women to the disadvantage of the latter. women’s
greater social and inancial dependency (olowu 1985; thompson 1972),
derogation of the female body and sexuality (thompson 1950), conlicting
role expectations towards females (Burns 1979; hacker 1951), and female sex
role stereotypes being less valued than male sex role stereotypes (Broverman
et al. 1972; mckee and sheriffs 1957) have all been discussed as important
contributing factors to women’s lower social standing and lessened esteem as
compared to men’s. while these objections may be somewhat dated, many
of them continue to be relevant in contemporary context. women continue
to earn signiicantly less than men, and to have generally less advantaged
inancial circumstances (sCB 1986). In addition, women on the whole do not
enjoy as much prestige and power as men, as relected in the frequency with
which women reach the highest ranks in the various professions, business and
politics. In an elitist and capitalist society, it has been argued, achievements
in these areas cannot be ignored.
however, results from empirical studies do not appear to conirm these
expectations. two early, widely cited reviews of the literature both failed to
ind any evidence for consistent sex differences (maccoby and Jacklin 1974;
wylie 1979). their result seems less surprising when viewing them in the
light of the more dominant theories of the determinants of self-esteem, which
73
focus on the nature of the individual’s close relationships and the attitudes of
signiicant others, particularly parents (see e.g. Beck 1967; Coser 1977).
others have conceptualised self-esteem as a consequence of one’s criticality
to oneself, again intimately linked to parental approval. Blatt (1974) proposed
that the development of self-criticism is driven by fear of losing the approval
of parents who are cold, harsh, demanding and judgemental. mckay and
Fanning (1992) refer to the “pathologic critic” to describe the negative inner
voice that attacks and judges the self. this, it is argued, is largely dependent
on messages one has received from one’s parents in childhood. with such a
view, the extent to which cultural values affect self-esteem is only indirect.
even so, many scholars have been hesitant to accept the lack of evidence
for sex differences in self-esteem. In later review, skaalvik (1986) argued that
the previous negative indings may be partly due to problems in the research
designs and measures used. In particular, concern was expressed about the
great range of indicators used to assess self-esteem , and the relatively limited
strength of the correlations between them, as well as the lack of consideration
for possible age- and race-variations. with these considerations in mind,
skaalvik (1986) reviewed 29 studies published between 1975 and 1985,
concluding that there were indications that males had higher self-esteem
than females. In conclusion, then, there is some, albeit not unanimous, evi-
dence that men do indeed have higher self-esteem than do women, but the
magnitude of and grounds for this, and its implications for work and health
are poorly understood.
Different intellects and abilities: Fact or fiction

another vein of the literature, in which there has been extensive research
exploring sex differences, is with regard to intellect and ability, much of which
stems from suggestions in what today may be regarded as a classic piece of
work by maccoby and Jacklin (1974). In essence, they noted that there is
some indication that girls have better verbal abilities than boys, while boys
excel more than girls regarding visual-spatial skills. however, the authors
expressed some reservations, and underscored the need to remain critical
to this evidence, stating that the differences were small and sometimes
inconsistent, and some indings may not be observed until late childhood.
74
Furthermore, they correspond to prevailing stereotypes of women as social

and talkative, and men as non- communicative and interested in construc-
tion, technology and mathematics.
more recent evidence has conirmed that the gender gap, when found,
is small, typically less than ive percent variation between male and female
test takers of visual-spatial ability (Deaux and kite 1987). later studies have
also shown that some indings are inconsistent across measures (Deaux and
kite 1987; linn and Petersen 1985, 1986) or across cultures (harmatz and
novak 1983), and that differences often do not emerge until adolescence
(Fausto-sterling 1985). all in all, this seems to echo the reservations outlined
by maccoby and Jacklin, and suggest that the small sex differences that may
exist are quite possibly the consequence of learning and culture. Indeed, it
is not unlikely that they, at least to some extent, represent a self-fulilling
prophecy, where the expectations of surrounding adults and sex stereotyped
toys and play, have fostered different competencies.
while debates concerned with Iq have been particularly controversial due
to the enormous importance attached to intellectual ability, and the frequently
exaggerated conidence in Iq tests competence in measuring these, other
mental capacities have also been attracted some attention, including creativity
and memory processes. although there is little indication of sex differences
in creativity (raina 1982; shukla and sharma 1986), it also appears that this
area has not received much attention in recent times.
regarding memory and learning, following maccoby and Jacklin’s (1974)
conclusion that there was no evidence of sex differences in this area, there
have been limited attempts to pursue the issue further. the developments
that have occurred are rather a by-product of studies conducted with an-
other focus. some of these have noted sex differences to the advantage of
males with regard to episodic memory, that is, memory of autobiographical
records of unique events in the individual’s experience (for an overview, see
herlitz et al. 1997).
Clearly, systematic investigations of sex differences in memory function
need to be undertaken to conirm this, assess the magnitude of the suggested
differences, and seek to understand the underlying mechanisms. If success-
fully accomplished, this may lend insights not only to gender research, but
also to memory research in its own right.
75
Language and communication

another suggestion that relates back to the proposed differences in women’s
and men’s fundamental orientations is that women and men communicate
differently. women’s communication, it is argued, seeks to preserve inti-
macy and avoid isolation, while men’s communication is largely directed by
an attempt to preserve independence and avoid failure. though there are
hierarchies in women’s worlds too, these are more concerned with friendship
than with accomplishment, and though women also may be concerned with
achieving status, these are generally not the goals they focus on. similarly,
while men may seek involvement and intimacy, this is not what primarily
guides them.
the way in which these basic orientations translate to human interac-
tion and communication has been eloquently explored and popularised by
Deborah tannen (1992) in a book appropriately named “you just don’t
understand.” while it would be over-ambitious to seek to summarise this
here, it remains that gender differences in orientation and communication
provide fertile ground for misunderstandings and conlict in work settings.
this may result in both organisational and individual disadvantage, perhaps
particularly for women, as male styles of communication tend to dominate
in the public sphere.
Female disadvantage is further accentuated by linguistic relativity, the view
that cognitive processes vary with the structural characteristics of the language
used (sapir 1949; whorf 1956). the use of sexist language was attacked by
linguists and psycholinguists already over two decades ago (Bodine 1975;
henley 1977; lakoff 1973) on the grounds that it embodies and transmits
sexist thought from generation to generation. that is, in english the third
person masculine, “he”, is used as a substitute for nouns of an indeinite
gender, such as somebody, person, or reader. Furthermore, in both english
and swedish words such as chairman and foreman have prevailed, assuming
that the holders of such responsibility are males rather than females.
even so, the effect of sexist language on the behaviour of its users has not
yet been well documented, and calls for non-sexist language have sometimes
been ridiculed, largely due to the inconvenience of having to change old
habits and initial awkward soundings of new, gender-neutral terms. But it
would be wrong to fail to recognise their importance. language is a power-
76
ful communicator, and if it assumes that the Chair is a man it may restrict
our expectations and considerations of what is possible. a clear illustration
of this was provided by Gloria steinem in a speech on the language reform
at yale university in 1981, “If the men in the room would only think how
they would feel graduating with a spinster of arts degree they would see
how important this is.”
Perhaps the most important effect, then, lies not in the restriction of
thought, which may be overcome, but in the attitudes of the institutions
and individuals that have failed to incorporate the changing status of women
and awareness of gender issues into something as elementary as their use
of language.
Moral reasoning
another issue which has attracted some interest is the suggestion that men
and women differ in their moral reasoning. while this has been discussed
historically, the work by Carol Gilligan in the early 1980s revived the debate
considerably. Building on Chodorow’s work, outlined above, Gilligan noted
that women are more oriented toward attachment and “connectedness” to
others, while men seek individuation and “separateness” from others to a
larger extent. this has consequences for women’s and men’s moral develop-
ment, where women are thought to be guided by “ethics of care”, while men
adhere to “the ethics of justice”.
Based on this, Gilligan developed a critique of kohlberg’s well-known
stage theory of moral development (Gilligan 1982; kohlberg 1976). ac-
cording to kohlberg’s framework, women’s orientation places them at level
3, characterised by a regard for “what pleases others,” while men tend to be
placed at the more mature level 4, concerned with law and justice, making
women morally inferior to men. according to Gilligan, however, this does
not relect the lower moral standing of women, but is a consequence of
kohlberg’s error in adopting male behaviour as the norm. Gilligan notes the
paradox that the traits that tend to be associated with the goodness of women,
such as sensitivity to others and caring, are precisely the characteristics that
place them below men on moral-judgement scales.
the empirical evidence supporting these notions has been somewhat
contradictory. some of Gilligan’s own work was based on responses to ques-
77
tions about abortion, which impinges very differently on women and men.
It has therefore been criticised on the ground that a certain element of sex
bias was built into the design of the study (Colby and Damon 1987; see also
walsh 1987, pp. 274-277). others have noted a failure to consider the race,
religion, class and ethnicity of her subjects as alternative variables inluenc-
ing moral decision making.
equally damaging is the fact that more recent studies have failed to ind
any signiicant difference in the moral reasoning of men and women (Colby
and Damon 1993). It therefore seems that Gilligan’s suggestion should be
viewed with some caution. although men and women may reason differently
with regard to some issues, and may give different weight to certain aspects
of a dilemma, the evidence for pervasive differences is hardly convincing.
Personality, aggressiveness, alcohol and drug use

the evidence that women and men differ in terms of personality functioning,
aggressiveness, and alcohol and drug use and abuse is perhaps more convin-
cing. while not all aspects of personality have been found to distinguish
between men and women, compelling sex differences have been noted in
relation to emotional expressiveness. women have been found to be more
willing to disclose negative emotion, such as depression, anxiety, and fear
than are men (snell et al. 1989). women have also been shown to be more
willing than men to express feelings about a same-gender friend or relation-
ship (hayes 1984; rands and levinger 1979), and they tend to score higher
than men on measures of interpersonal trust (Johnson-George and swap
1982). In addition, women have been found to have higher trait anxiety
(stoner and spencer 1986).
unfortunately, much of this work has been conducted in the us, typically
on relatively small samples of undergraduate students, and it does not neces-
sarily adequately describe swedish women and men in the general population.
Furthermore, there is evidence that both men and women change across the
life cycle, in that they tend to decline in dominance, enthusiasm and tension
and increase in sensitiveness, social values, and restraint with age (stoner
and Panek 1985). this highlights the need to remain sensitive to the way in
which gender interacts with other individual characteristics.
78
there is also evidence of sex differences when we move into the sphere
of explicit dysfunction. In one study, examining sex differences in personality
disorders, women were found to predominate with regard to self-defeating and
borderline personality disorders, while antisocial personality traits were more
common in men, who also had higher prevalence of obsessive compulsive and
schizoid personality disorder as compared to women (ekselius et al. 1996).
another dimension where sex differences have been observed is with regard
to aggression, although this is only true for certain aspects of aggression. For
example, men have been found to score higher than women on physical ag-
gression, while results for verbal aggression are less consistent and no parallel
differences have been observed with regard to hostility and anger (harris
1996; harris and knight-Bohnhoff 1996). In several studies of violence within
the family women have been found to aggress as much as men, or even more
(arias et al. 1987; straus 1977–1978). there is also evidence that increasing
age and education were associated with lower aggressiveness in both sexes
(harris and knight-Bonhoff 1996). sex differences in aggressiveness are,
therefore, more complex than we often assume, and like with personality,
other characteristics interact with gender to determine behaviour.
however, in spite of these reservations, it remains that men are over
represented in the extreme groups. men have higher rates of engagement in
recorded acts of violence and criminality than do women (sCB 1996; simon
and landis 1991). men also drink more alcohol and have more alcohol prob-
lems (silbereisen et al. 1995). the same gender gap is found with regard to
use and abuse of illicit drugs. the male/female ratio of drug addicts is between
two and four to one across countries (hanel 1991; klingemann 1992).
Stress and coping

another important sphere of functioning is how individuals respond to prob-
lems, seek to resolve them, or sustain everyday life in the face of considerable
stress. thus, coping, or “purposeful efforts to manage or vitiate the nega-
tive impact of stress” (Jensen 1991), has been widely studied for a variety of
purposes. there are numerous classiications of its underlying dimensions.
one of these is to distinguish between strategies that focus on the problem,
as opposed to those aimed at dealing with the negative emotions associated
with it. It has often been assumed that problem focused strategies should be
79
more frequently occurring among men as compared to women, while ap-

proaches that center around emotions are thought to be preferred by women
(mainiero 1986, Pearlin and schooler 1978, rosario et al. 1988).
another categorisation contrasts active measures, such as minimising
pain through preventive exercise, and passive strategies, such as giving
up hope or taking medication. Given men’s and women’s different social
circumstances and role expectations one may well expect that coping strat-
egies, both in general and in relation to own and relatives’ health, differ
between the sexes.
empirical studies of sex differences in coping have, however, not neces-
sarily yielded the expected, or indeed consistent, results. In a longitudinal
study of individuals aged 35 to 74, more men than women were found to
solve their problems through planned action, while women were more likely
to seek to convince themselves of future improvements. But coping strategies
were also found to vary depending on the nature of the problem, and with
chronological age (Folkman et al. 1987).
In a review of sex differences in cognitive strategies to handle stress, results
were found to vary between studies (miller 1987). In one of the studies women,
as expected, were found to use strategies focused on emotions more than
men, but they were also as likely as men to use problem focused strategies.
however, other studies disputed this, inding the predicted preponderance
of men with regard to problem focused strategies, a inding that subsequent
work has conirmed (Ptacek et al. 1992). yet another studie found no sex
differences at all (miller 1987).
a relatively recent review, focusing on stress, coping and social support
among female managers further reinforced these inconsistencies (korabik et
al. 1993). an interesting observation here was that few differences in terms
of choices and strategies may be observed when studying men and women
in similar circumstances. It is possible that the differences that have been
observed are consequences of factors related to men’s and women’s differ-
ent circumstances and the range of options available to them, rather than
to their gender per se.
yet it may not be meaningful to only consider men’s and women’s coping
strategies in isolation. one’s state of health is not solely dependent on one’s
own efforts, but also on the contributions of signiicant others. many studies
80
have observed the differential importance of having a partner for men’s and
women’s both physical and psychological health, where being married or co-
habiting has been shown to be advantageous to a man to a much higher level
than a woman (Gove 1973; house et al. 1982, house et al. 1988; umberson
et al. 1996). one study has proposed a mechanism for this in showing that
women often assume responsibility both for their own and their partner’s
health through attention to diet and encouragement of exercise.
Social support
as has been discussed above, women and men differ in their emphasis on
interpersonal relationships, and this is associated with parallel differences in
the extent of social support available to them when encountering dificul-
ties. antonucci (1990) summarised lessons learned about sex differences and
social networks, and concluded that women’s networks are usually larger
and include individuals from a greater number of different social contexts,
as compared to men’s, while men’s most important source of social support
tends to be their wife or life partner.
however the consequences of this are not always obvious. much of the
confusion has to do with the variety of ways in which social support has been
conceptualised. Frequency of interpersonal contacts, continuity of relation-
ships, emotional support, informational support and instrumental support
have all been discussed in this context, and it is clear that these have very
different meanings and that their usefulness depends not only on individual
needs and characteristics, but also on the nature of the problem at hand.
In general, lack of social support is positively associated with mortality for
both sexes, although the strength of this association is greater for women than
for men (shumaker 1991). qualitative support appears to be more beneicial
than quantitative support, although a large social network may be protec-
tive during particular phases across the life cycle, such as during periods of
ill health, when separating from a partner, or when entering widowhood.
men’s typically inferior networks may therefore be one of the reasons why
they ind it more dificult than women to adjust to widowhood and divorce
(stroebe and stroebe 1983; rowland 1977).
however, large social networks appear to be a mixed blessing for women.
there are indications from research on coronary heart disease that large
81
social networks may pose a strain to women, while being undividedly posi-
tive for men, presumably due to the associated social responsibilities and
work commonly performed by women and not men (antonucci 1990; Jung
1984; rook 1984).
Biological differences in relation to psychological functioning

so far the main focus has been on socialisation, and the psychological sex
differences that are often argued to have part of their origin in girls’ and
boys’ or women’s and men’s social or educational circumstances. however,
it is not only the circumstances and expectations that differ between women
and men, but also their biology, down to the level of each single cell. and,
indeed, some of the sex differences already discussed have been argued to
be linked to hormonal differences between women and men.
the popular view of biological differences is that they are inborn, and
that the social world works upon these to either diminish or accentuate
them. Clearly, this is misleading as biological differences include both those
that are evident at birth and those that later emerge as a consequence of
environmental or genetic programming. newborn boys and girls show
hormonal differences and there are systematic differences, albeit small,
in body size. however, the rate of growth and maturation show similar
variations across childhood and adolescence, with girls reaching puberty
earlier than boys. Furthermore, the biological impact of puberty is very
different for the two sexes, and biological differences between men and
women persist across the life-span. Child-bearing and menopause have a
signiicant impact on most women’s biology, but ageing does not affect
men in the same way, and dificulties and diseases associated with ageing
vary between the two sexes.
there are, then, ample reasons for continuing to consider the impact of
biological factors on sex differences across the life course. while a review
of biological differences of the two sexes and their implications for psycho-
logical functioning lie beyond the scope of this paper, two areas that are
intimately linked with psychological functioning and that have stimulated
much interest recently will be mentioned, if only to highlight the need to
consider biological factors alongside social ones: differences in women’s and
men’s brains and differences in women’s and men’s life cycles.
82
His and her brain

the notion that there are differences between men’s and women’s brains
has a long-standing history well worth a moment’s relection. the observa-
tion, by nineteenth-century scientists, that women’s brains were smaller
than men’s was designed purely to support the notion that they were,
by nature, less intelligent. this was quickly amended in the light of the
counter argument that if brain size determined intelligence, then other
species, such as elephants, should surpass humans by far. the subsequent
hypothesis was that it was not brain size per se, but in relation to body
weight which determined intelligence. however, this hypothesis too was
abandoned when it was discovered that it led to the prediction that women
were more intelligent than men (Fausto-sterling 1985; Gould 1980; har-
rington 1987).
having explored the potential implications of size, attention was directed
towards differences in brain organisation. During the 1970s and 1980s
much of the discussion of sex differences focused on brain lateralisation.
this was based on work by sperry and colleagues who, working on severe
epileptics, found that the right and left hemispheres seem to specialise on
certain functions (sperry 1982). one of the observations was that while the
left hemisphere seemed to be responsible for speech, the right appeared to
be concerned with visual perception. this led to speculation that sex differ-
ences in verbal and visual-spatial abilities were a consequence of males’ and
females’ differential lateralisation (Green 1987; lambert 1978). although
interesting, research exploring this hypothesis has failed to provide any con-
vincing evidence. Instead, contradictory results, coupled with the relatively
limited knowledge of the functioning of the brain that prevailed at the time
halted the debate (see e.g. Fausto-sterling 1985).
Perhaps the most interesting recent development in this area is research
showing that the corpus callosum, the mass of tissue and nerve ibres connecting
the two hemispheres, is larger in women than in men (allen and Gorski 1991),
potentially allowing for comparatively greater communication between the
two hemispheres in women. while still in need of further investigation, this
hypothesis appears to be particularly relevant as it ties in with other indings.
It would explain both why women recover from strokes more quickly than
men and why they are less likely to suffer from certain kinds of brain damage
83
(witelson 1989). there has also been some suggestion that it may also shed
light on differences in men’s and women’s verbal and visual-spatial abilities
(see Gorman 1992 for a discussion).
while this is fascinating, the area of brain research is expanding fast and
new technology will allow scientists to examine the working of the brain in
much more detail than has been possible in the past. It is, however, important
to remember that the brain responds to experience, and develops according
to the demands that are put to it, and differences found between men’s and
women’s brains may well relect culture and differential roles, rather than
being innate. as Gorman (1992) conclude, “in the inal analysis, it may be
impossible to say where nature ends and nurture begins because the two are
so intimately linked” (p. 52).
Differences in men’s and women’s life cycles

another important factor is the different stages of women’s and men’s lives,
and the differences in timing between these stages (e.g. Cohn 1991). such
differences are, at least in part, directed by biological factors. In relation
to work, perhaps the most signiicant difference is women’s greater role in
child bearing and child rearing. It is clearly only women who are pregnant
and who can breast-feed, making them more important to children, at least
during the earliest stage of their life. Due to this early bonding, as well as to
other cultural, organisational, inancial and social factors, women continue
to assume the prime responsibility for their children, taking more of the
parental leave and being more likely to stay at home with them when they are
ill (sCB 1986). typically, this period in life coincides with intense demands
at work, when young men and women are trying to establish themselves in
their careers, and when frequent absences may be particularly damaging both
to career development and, on a more basic level, employment itself.
later in life, when children are more independent, men are more pre-
pared to relax while many women ind themselves free and eager to fulil
their ambitions. the opportunity to take the conventional route to success
is, however, long gone, and alternative career patterns have to be invented.
Interestingly, many women report that it is not only the practical demands
that they experience as taxing, but also the fact that the labour market is
adjusted to male life patterns.
84
Concluding comments
although a complete overview of sex differences in psychological func-
tioning lies far beyond the scope of a single chapter, a variety of aspects of
psychological functioning have been reviewed, with the aim of describing
relevant differences between women and men. In summary, women have
been found to be oriented towards others to a greater extent than men, and
this tendency may be relected in women’s greater emotional expressiveness,
different communicative styles and, possibly, moral reasoning. there is also
evidence that men, at least in some ways, are more aggressive, more likely to
be antisocial, more prone to criminality, and more frequent users of alcohol
and illicit drugs as compared to women. recent evidence also indicates that
there may be structural differences between women’s and men’s brains, and
that these may have implications for psychological functioning. In addition,
there are some suggestions, although less convincing, that women have lower
self-esteem, slightly better verbal ability and somewhat worse visio-spatial
ability than men, and that the sexes differ in their use of coping strategies as
well as availability, use and implications of social support.
as previously stated, however, it is important to note that sex differences,
when found at all, tend to be small and unstable, in that they not infrequently
vary across measures or methodologies used. It would seem that the conclu-
sion that observed sex differences are less frequent and of smaller magnitude
than predicted differences based on stereotypical beliefs, drawn by whissell
(1996) in a study of sex differences in personality, may be applied more gen-
erally. Furthermore, it is also worth noting that group differences never are
informative of individual characteristics. while belonging to a gender group,
a particular girl or a boy may be close to or far from the group mean. thus,
for example, there are females of extremely high visual spatial ability and
of poor language ability, as there are males with extremely low self-esteem.
while this point may be obvious it is often forgotten in practice, which may
result in inappropriate use of research indings.
some have gone even further in their critique of gender analysis, stating
that there is a danger in viewing gender relations dichotomously, as this
creates a false polarity (e.g. Bacchi 1990). and, indeed, a large proportion
of both females and males do not fall within the stereotyped categorisations
identiied by sex-role inventories. this has led to the development of the
85
concept of adrogyny which describes individuals who score highly on both

masculinity and femininity (Bem 1974; spence et al. 1974), relecting a
fragmentation within the sexes which may also be observed in occupational,
economic and political spheres. women’s professional ambitions have been
increasing for many decades, and many women seek to achieve a chair in
the board room, the parliament or the highest rank in their particular area.
meanwhile, a growing number of men play a fundamental role in child rear-
ing and home making. this does not mean that the circumstances of the
two sexes are becoming increasingly similar. the woman in the board room
faces very different challenges than her male counterparts, and the father on
parental leave copes with attitudes and reactions his female partner would
not need to address. there is, therefore, every reason to seek to identify
meaningful sub-groups within the sexes, not all of which may be captured
by Bem’s conceptualisation.
essentially, this leads to methodological concern about how best to examine
sex differences. If there are different sub-groups within each sex, comparing
means, which has been a common approach in the past, may not be meaningful.
we need at lest to supplement such analysis by looking at the distribution of
the scores, and the way in which certain patterns of scores emerge as more
frequent, in order to identify and understand potential sub-groups.
now, to the extent that sex differences exist, it has been evident that many
of these are the result of social learning or individuals’ current circumstances,
rather than their sex. this leads us to another important methodological issue
which must not be overlooked; that of confounding variables, that is, vari-
ables that tend to covary with sex or gender and that may account for gender
differences. For example, more women than men take prime responsibility
for children and may be found in the caring professions. It is possible that it
is experiences these women have in their homes and work life which affect
their moral reasoning or communicative styles, rather than their gender
per se. studies of sex differences should, therefore, always allow for alterna-
tive hypotheses regarding other social characteristics of known or expected
importance to the phenomenon being studied, the wider social context in
which sex differences are observed, and examine the developmental pathway
throughout life, including the adult life pattern, of the women and men being
86
studied. there are important variations in these, as there are regarding biol-
ogy and socialisation, and a comprehensive understanding of sex differences
requires all of these to be considered. when reviewing the literature, we
have found that this is often overlooked. this makes it especially important
to remain critical, as well as implying that most of the signiicant differences
that may be observed between men and women may well be diminished as
a consequence of intervention.
Implications for work and health

these differences, as well as the lack of differences, have implications for
women’s and men’s work and health, on many different levels. Perhaps most
fundamentally, women’s greater orientation towards others and expressiveness,
as opposed to men’s orientation towards individuality and instrumentality,
lead them to different professional and life choices. this distinction is then
further reinforced by cultural stereotypes and expectations. thus, women
are more likely to choose professions where contact with others and caring
for others are a predominant feature, while men choose work that allow for
independence and activity of a more concrete kind. In sweden, women are
particularly over represented in secretarial work, nursing, child care, teaching
and cleaning, while men dominate the occupations related to technology,
construction, electricity, mechanics, architecture, and professional driving
(sCB 1986). It is interesting to consider this in the light of evidence regard-
ing Iq, which suggests that the reason for these differences have little to do
with sex differences in actual capabilities.
But it is not only the selection of occupation that is affected by these
differences in orientation. rather, throughout their careers they also direct
how women and men make choices about how to prioritise their time and
how to negotiate the interface between work and home life. In this process,
women will typically choose not to enhance their own professional advance-
ment at the expense of the needs of other family members, and they will, at
least in sweden, often choose to work part-time and assume main respons-
ibility when the need to care for others, be it children or elderly parents,
arises. In 1995 approximately 40 percent of the women who were in paid
employment worked part time, as compared to less than 10 percent of the
men (sCB 1986)
87
when examining how this impinges on women’s and men’s health one
may only conclude that the stresses and strains of women’s and men’s lives
are generally different. many women carry the burden of responsibility of the
lives and well-being of others, a demand lowing both from their professional
and personal lives, as well as the stress of constantly balancing the different
needs of others against each other, often at the expense of their own needs
(eichenbaum and orbach 1983).
women also have to deal with the frustration of marginally smaller
inancial compensation for their work than men, as well as less status and
recognition in the public sphere (sCB 1986), in spite of convincing docu-
mentation that their abilities are comparable. the lower income is not nec-
essarily a consequence of women’s lesser pay for the same work, but rather
of the work typically performed by women being less valued. while much
public attention has been directed at correcting the former, the lower status
and pay associated with professions dominated by women continues to be a
signiicant problem. or, in the words of alice rossi (1973) “equal pay for
equal work continues to be seen as applying to equal pay for men and women
in the same occupation, while the larger point of continuing relevance in our
day is that some occupations have depressed wages because women are the
chief employees. the former is a pattern of sex discrimination, the latter of
institutionalised sexism” (the Feminist Papers, “the right to one’s own
Body”). this lower income, in particular, has extensive ramiications for the
control and range of choices women have about their lives, with important
implications for both their physical and psychological health.
now, this clearly does not apply to all women. many women earn con-
siderable salaries, and a very large proportion of women share their lives
with men, and enjoy the inancial beneits this often bring with it. again,
therefore, we return to the conclusion that differences between men and
women are not simple and easily quantiiable. when analysed on a group
level, differences in women’s and men’s role expectations and orientations
impinge on the life circumstances they are exposed to at work as well as
at home in a systematic manner, and create different sets of physical and
emotional burdens for the two sexes, as well within the sexes. It is these
authors’ belief that it is only by examining the totality of that burden that
we can begin to understand the way in which different factors contribute to
88
individual health. this makes it necessary to study not only the way in which
psychological sex differences impinge on working life and its consequences
for health, but the way in which gender and role expectations contribute
to individuals’ total life situations, and how risk and protective factors tend
to cluster together as a consequence, and contribute to health. In so doing,
the study of gender, work and health necessarily departs from a sometimes
overstated dichotomy, and becomes the study of sub groups, within which
gender often will play a fundamental role.
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95
96
Chapter 4
equally DIFFerent
98
equally different
Identifying biological speciicities

of relevance to work-related health
by Karen Messing and Åsa Kilbom
Why compare men and women?

Before starting on a discussion of male-female biological differences, we
must acknowledge that this is a dificult area to explore, for several reasons.
male-female biological differences are intimately associated with notions
about normality. when the average “normal” woman is smaller and has less
muscle mass than the average “normal” man, then a tall woman with large
muscle mass is sometimes being considered abnormal for her gender. her
other characteristics are also suspected of being more similar to the aver-
age male, be it personality or sexual characteristics. thus, a value of some
biological parameter that characterizes the average woman may be confused
with a value typical of, or even recommended for, all women. If the average
woman has less muscle mass than the average man, then it is belived that all
women should be excluded from physically heavy tasks, such as ireighting
for example. thus, it is dificult to discuss biological differences without
invoking the spectre of discrimination.
In some cases, given the relative power of women and men in swed-
ish society (and others), the characteristic associated with males may be
considered to be more important, or more valuable, or just more normal.
thus, menstruation and menopause are sometimes spoken of as abnor-
mal states. similarly, a look at contemporary fashion models shows the
typically female distribution of weight in the thighs and buttocks to be
unacceptable, and a higher value is ascribed to the male pattern of thin
thighs and small round buttocks. It is dificult for anyone to escape societal
attitudes when examples of male-female comparisons, with men as norm,
are so pervasive.
99
Biological differences are sometimes considered to be synonymous with

genetic differences. In other words, if women and men produce different
hormones in reaction to stress, some people may infer that this is necessar-
ily an inborn difference, although in fact many biological differences stem
from the environment. hormone secretions, for example, can be affected
by stress or illness.
Finally, for some, “biology is destiny” and biological differences are un-
changeable. If hormones do give females less muscle mass and thereby less
lifting strength than males, on the average, some ignore the diminution of
this difference by exercise and training.
while reading the discussion that follows, we must therefore recall that
for almost all biological differences studied, including hormone types (Briscoe
1978), differences among members of one sex exceed average between-sex
differences. also, when adults are considered, it is impossible to separate
out genetic effects from those in nutrition, training, work history, personal
habits etc.
Despite the confusion, it is worthwhile describing male-female differ-
ences in order to make sure that, whatever their origins, such differences
are respected when workplaces are designed, when training programs are
set up and when standards are set. a woman (or any worker) will be at a dis-
advantage in a situation designed for someone with different characteristics.
moreover, biologic differences can play a role for the gender speciic patterns
of ill health in working life, and must therefore be explored.
Genetic differences
at conception, fertilized ova, whether destined to be male or female, have 46
chromosomes. only one of these 46 differs between the sexes. the female
has two X chromosomes, while in the male one of the Xs is substituted by the
much smaller y chromosome. while the X chromosome has a large number
of genes, very few of which have anything to do with sex, the y chromosome
has fewer than ten genes. Genetically, therefore, the effects of having an Xy,
versus an XX chromosomal complement, are twofold:
1) the second X confers a protective effect, compensating for mutations or
abnormalities in the irst. there are more than 150 diseases associated with
genes on the X chromosome. this explains, for example, the relatively high
100
equally different
mortality among male foetuses and newborns. thus, for every 100 females
conceived, there are 120 males, but this ratio has dropped to 100:105 at
birth. It also explains why colour blindness (determined by a gene on the X
chromosome) is ten times more common among men than women.
2) one, or several genes on the y chromosome, begins to produce testes,
wolian ducts and penis in male foetuses, after six weeks of foetal life. the
ovary, uterus, Fallopian tubes and vagina begin to appear in females at about
the same time, although the mechanisms are less well known. there have been
suggestions that hormone levels during foetal life may have lasting effects
on brain anatomy and morphology, but these are a subject of controversy
among biologists (Fausto-stirling 1992).
males and females have similar size and strength until puberty, when
differential hormonal secretions occur. males become taller and more
muscular, while females acquire gynoidal fat distribution (sanborn and
Jankowski 1994).
Physical differences among adults

men and women are, on the average, different in size and shape, although
both women and men come in many shapes and sizes (sanborn and Jankowski
1994). the data in table 1 show percentile values for some measurements
of swedish adults.
Table 1. Approximate measurements of Swedish adults in cm. Source: Pheasant (1986).

Percentile* for men Percentile for women
Dimension 5th 50th 95th 5th 50th 95th
Height 163 174 185 154 164 174
Distance reached up 193 206 219 182 194 206
Sitting height 83 90 97 80 86 92
Arm length 72 78 84 66 70 75
Hand breadth 7.5 8.5 9.5 7.0 7.5 8.0
*Half of Swedish men are taller than the 50th percentile for men, 5 percent are taller than the
95th percentile, etc.
this table shows that, in general, for most dimensions, the average woman
is about the same height as the shortest 5 per cent of men and the average
101
man is about the same height as the top 5 per cent of women. It has been
calculated that, in random encounters between a woman and a man, the man
will be taller than the woman 92 per cent of the time (Pheasant 1986, p 45).
as discussed in chapter 8, these gender differences in body size can have
consequences for musculoskeletal disorders unless workstations and tools
are itted to the individual worker.
For weight, the differences are somewhat smaller. In 25 per cent of chance
encounters between a woman and a man, the woman will be heavier. a larger
proportion of women’s body weight is fat (about 25 per cent compared with
15 per cent for men) and a smaller proportion is muscle. men and women are
also shaped differently. women’s feet are proportionately smaller, the upper
leg and lower leg are in different proportions, the pelvic girdle and hip joint
is constructed somewhat differently, young women’s joints are somewhat
more lexible (Pheasant 1986, chapters 3 and 4).
Physical capacity
Physical capacities relevant to working life are muscle strength, endurance,
and maximal aerobic power. testing differences in physical capacity between
women and men is more complicated than evaluating differences in body size,
and it should be recalled that training affects these comparisons. men’s and
women’s capacities are usually compared on speciic tasks which test either
whole body performance (cycle ergometry,or treadmill walking/running), or
strength/endurance of certain body regions, or muscle groups. test strategies
have been developed using three approaches:
• Physiological tests examine body functions such as oxygen consumption
and heart rate during exercise.
• Biomechanical tests measure the load on the musculoskeletal system
exerted while doing a task, and the results can then be compared to data
bases.
• with psychophysical tests, subjects are asked to assess the perceived
load of a certain task, or, alternatively, select a load which they ind ac-
ceptable. In particular, this type of testing has been used to assess the
capacity for the manual handling of loads. as the name implies, these
tests include both motivational and physical factors. In fact, all tests of
102
equally different
physical capacity are inluenced by motivation, especially when testing

maximal, or near maximal performances.
the average difference in aerobic power, expressed as liters of oxygen uptake
per minute, between women and men is approx. 30 per cent, and about 10–15
per cent when differences in body weight are accounted for. the variation
within a group of women (or men) of the same age is very large, and depends
mainly on hereditary factors but also on training. when calculated by fat-free
body mass, the gender difference disappears. actually, because of their small
body size, women should have a slightly higher aerobic power per kilogram
fat-free body mass than men, but the lower hemoglobin content of women’s
blood reduces their oxygen transporting capacity somewhat (Åstrand and
rodahl 1986, chapter 7).
In the last few years, the performance of women and men in prolonged
exhaustive exercise has been studied more extensively, and some new data
have emerged that indicate gender differences not previously identiied.
thus speechly et al. (1996) found that women and men matched by equal
performance when running 42 km, differed in performance when running
a longer distance (90 km). the women performed signiicantly better than
men, and this was achieved by their use of a higher proportion of maximal
aerobic power, and not related to a better running economy or differences
in fatty acid metabolism. whether these indings have relevance for women’s
performance in working life remains to be investigated.
aerobic power is sometimes suggested to be of little importance for work
performance in modern society. automatisation in industry, and the decline
in the number of traditionally heavy jobs in farming and forestry, has reduced
the physical demands on some of the male workforce. the construction in-
dustry, and many transport jobs, still takes a heavy toll on many male workers,
however. the proportion of physically demanding female jobs appears to
have remain unchanged. health care, and the service professions of clean-
ing, catering and restaurant work, employ a nearly unchanged proportion of
women. using traditional measures of total oxygen uptake, these jobs appear
to be light, in comparison with, for instance, manual forestry or ire-ighting
(Åstrand and Åstrand 1988). But when calculating the relative work load,
that is, the proportion of the maximal aerobic power actually used in these
103
jobs, they can be just as taxing, since the capacity of the employed women
is relatively low (torgén et al. 1995). the maximal aerobic power in a mid-
dle-aged woman may be only 50 per cent, or less, than that of a young, it
male. note also that the static work involved in these jobs also taxes worker
capacities (see chapter 8).
many researchers have investigated sex differences in the number of muscle
ibres and their size in relation to force output (cf. Costill et al. 1976; mannion
et al. 1997; miller et al. 1993; schantz et al. 1983; Åstrand and rodahl 1986,
chapter 7). there is scientiic consensus that women and men have the same
muscle strength when normalized according to muscle cross-section. men
have larger muscle ibers, mainly because of the inluence of male hormones
after puberty, and women’s muscle strength therefor constitutes between
50 and 85 per cent of men’s depending on the muscle group investigated
(laubach 1976). this gender difference is most marked in the muscles of the
upper extremity, especially the shoulders. these differences appear to have
a large signiicance for the ability of women to perform manual handling
tasks (see below). however, women’s lower muscle strength is to some extent
compensated for by longer endurance. thus, at a given relative level of static
effort, the average woman can sustain this load longer than the average man
(Clarke 1986; Jørgensen 1997). the likely explanation for this inding is that
women’s muscles, being more slender, on average, than those of men, have
a better perfusion of blood.
muscle ibers involved in physical tasks are of two general types. type
I ibers (slow-twitch ibers) are mainly involved in endurance and posture
maintenance while type II (fast-twitch) ibers are involved in dynamic move-
ments (cf. Jørgensen 1997; Åstrand and rodahl 1986, chapter 2) there is
generally less difference between women and men in type I ibers than in
type II. women have been found to have larger type I ibers relative to
the size of their type II ibers in a posture-maintaining muscle (the erector
spinae) , and this inding is the likely explanation of greater endurance at back
extension (Biering-sørensen test) among women than among men (Biering-
sørensen 1984a; mannion et al. 1997a,b). similar female/male differences in
type l/type ll iber area ratios have been found in other skeletal muscles (Bell
and Jacobs 1990). It is thought that at least some of this difference is related
to different types of physical activity between the sexes (Glenmark 1994) and
104
equally different
it is possible that women, who seem to have more static work tasks requiring
the maintenance of awkward postures, adapt to these demands.
strength capacity declines with age, but at somewhat different rates for
different occupational groups and muscle groups. while strength of the
upper extremities remains relatively unchanged until age 40 to 50, there is
usually a decline in leg muscle strength, probably because of lack of training
(larsson et al. 1979). this is believed to have great consequences in working
life, because it implies that the manual handling of loads cannot be done in
the preferred way, i.e. by using leg muscles instead of trunk bending, which
may hurt the back.
traditionally, workers in physically heavy jobs have been expected to be
stronger than white collar workers. this has been veriied for young men, but
cross-sectional studies of middle-aged and elderly men have demonstrated
that the relationship between blue and white collar workers is reversed at
higher ages (era et al. 1992).
similar indings have been made in longitudinal studies of municipal
workers in Finland (nygård et al. 1991). these indings suggest that there is
a long-term, deleterious effect of physically heavy work on muscle function.
the nature of this effect is not known; one may speculate about repeated
micro-traumata or muscle injury, due to long-term, static efforts. studies
are under way to investigate if these results also hold for women (torgén,
personal communication).
the difference in muscle strength between women and men, has been one
of the explanations suggested to explain the higher prevalence and incidence
of musculoskeletal disorders among women. unfortunately, few studies have
investigated this with a longitudinal study design, and only two studies have
compared the risk for women (with a low average strength) with that for men
(with a high average strength). a few studies indicate that in jobs with high
demands on force exertion, individuals with a low maximal isometric strength
seem to run a higher risk of developing disorders (Chafin 1988; kilbom
1988). In tasks where the demands for force exertion are moderate, as in
repetitive or static jobs, results are contradictory. In one study, a relationship
between high isometric strength of the shoulder, and subsequent development
of shoulder-neck disorders, was found among women performing assembly
work (Jonsson et al. 1988). similar results were obtained in a one-year fol-
105
low-up among men (kilbom et al. 1993). thus these studies do not suggest
that women’s higher rate of musculo-skeletal disorders stems primarily from
their lower strength. howevere, in the same study a low handgrip strength
predicted the development of neck and/or shoulder disorders among women.
a more likely candidate for the cause of musculoskeletal disorders may be
a requirement, in many women’s jobs, for endurance at a submaximal level,
since many work tasks demand long-term static, or repetitive, exertions.
however, Biering-sørensen (1984a,b) found that a low, static back extensor
endurance predicted low back problems within the next year among men,
but not among women. one reason why the results are so contradictory, may
be that the inluence of strength or endurance has mostly been evaluated
without consideration to work demands.
there are suggestions in the literature that women may be more lexible
than men (Barnekow-Bergkvist et al. 1996), and have better balance with
eyes open or closed (Golomer et al. 1997), but these capacities have not been
systematically tested. Barnekow-Bergqvist found that 34-year-old women had
more lexible hip joints than men (Barnekow-Bergqvist et al. 1996).
Manual handling
the manual handling of loads, i.e. lifting, carrying, pushing, pulling and
holding, whether patients or objects, is common in working life. Female/male
differences in capacity for manual handling are frequently used as reasons for
distributing the heaviest manual handling tasks to men and the lighter, more
repetitive, tasks to women. manual handling is a much more complex task
than merely exerting muscle force. It requires both strength and endurance,
as well as balance and experience. therefore, experimental studies of static
or dynamic muscle strength, should not be used in isolation, when trying to
predict the manual handling capacity of an individual. using biomechanical
devices and psychophysical methods, it is usually found that men lift more
than women, both under experimental conditions and in working life. the
degree of difference depends on details of the task, being more pronounced
for upper-body tasks and those repeated frequently (laubach 1976). For
reasons of task adaptation related to height (stevenson et al. 1996) and an-
thropometric measurements (Fothergill et al. 1991), as well as the proportion
of static/dynamic task components (Fothergill et al. 1996), and stage of the
106
equally different
menstrual cycle (Davies et al. 1991) women’s performances range from equal,
to half of that of men, on lifting tasks.
when women’s and men’s manual handling activities in working life are
compared, the gender difference, in kilograms handled per working hour,
is often very large. For example, ljungberg compared manual handling
activities between nurse’s aides (women) and warehouse workers (men)
(ljungberg et al. 1989). the warehouse workers lifted three to four times
as many kilos per hour as the nurse’s aides. however, the sex difference was
reversed for lift duration. nurse’s aides on a ward without mechanical aids
took an average ten seconds per patient transfer, while warehouse workers
took about two seconds per lift. this implies a much larger static stress for
the nurse’s aides.
other aspects of manual handling that may differ between sexes are the
posture employed while lifting. here again the health care workers are more
heavily exposed. scientists are now trying to create a more balanced way to
assess the stressors of manual handling, for example by revising the nIosh
lifting equation (waters et al. 1993).
Pregnancy
Paul (1995) has reviewed changes affecting the musculoskeletal system during
pregnancy. strength of the upper body does not appear to change, but the
increased mass in the abdominal area affects abdominal muscle strength and
movement at the articulations of the lower body. the weight gain, averaging
12.5 kg, results in a gradual shift of the center of gravity, requiring increased
effort from the muscles in the back. a hormone, relaxin, is secreted from
early in pregnancy and lowers the strength of connective tissue, relaxing
ligaments.
Considering physical demands in traditionally male jobs

many of the questions of itness arise when asking whether women entering
non-traditional jobs are at higher risk of injury. however, no data yet gathered
allow us to answer this question. although women in general have lower
rates of accident than men, women in non-traditional jobs have sometimes
been found to have higher accident rates. this has been interpreted as an
indication of lack of itness to do the job or, at best, task design that takes
107
insuficient account of biological differences (Furber et al. 1997). however,

before such a conclusion can be drawn, gender differences in age, seniority,
working hours and speciic task assignments, must be veriied (messing et
al. 1994). For example, in the cited study by Furber, the authors concluded
from crude rates of injury that women ambulance oficers had a higher
injury rate and concluded on a necessity to “take into account the physical
differences between men and women” (Furber et al. 1997). But they also
concluded that younger workers and those working in metropolitan areas,
had higher accident rates, without verifying whether (as would seem likely)
women entering a non-traditional profession would tend to be younger and
work in metropolitan areas (salminen et al. 1992).
recently, an attempt was made to introduce women into one of the full-
time working ire-brigades in sweden (Gavhed et al. 1998). eight women
were selected, based on legislative demands on aerobic capacity (treadmill
test), good swimming ability and some additional tests of mathematics and
swedish. they were given a ten week ire-ighting training period and
were subsequently placed at different ire stations for six months. the inal
evaluation of their ability to perform ire-ighting tasks was based on the
judgement of their supervisor, who in seven cases out of eight considered the
women to be suitable for ire-ighting. the eighth woman was considered
provisionally suitable within a year or two. they were also given a range
of physical tests used for the annual check-up of male ire-ighters (mainly
push-ups and similar strength-demanding basic tasks), together with a set
of ive work-related tests (e.g. ability to raise and climb a ladder, transport
an injured person, couple hoses, etc.).
one of the most interesting results was that there was little or no sta-
tistical relationship between the results of the traditional tests used by the
ire-brigade and those of the work-related tests. similar results have been
obtained by misner et al. (1989) studying female ire-ighter applicants in
Chicago. another noteworthy result was a very large improvement in the
work-related tests over the year. some of this was ascribed to very hard
physical training undertaken by the women during the year, but also to their
increased familiarity with the technical aides used by the ire-brigades. a fast
adaption to simulated ire-ighting tasks by women have also been observed
by misner et al. (1987).
108
equally different
there is an urgent need to develop and validate such work-related tests,

but also to consider the drawbacks that many women have when faced with
technology that they have not previously come into contact with. similarly,
women in québec who have to undergo testing in order to access non-
traditional jobs in public utilities and public works, have needed time to
familiarize themselves with equipment and to obtain tools of the right size
and shape for them (Boucher 1995).
the methodological approach when attempting to develop itness screen-
ing protocols for physically demanding jobs has been discussed by Jamnik and
Gledhill (1992), stevenson et al. (1994) and messing and stevenson (1996).
traditional methods have usually not been based on a suficiently thorough
analysis of the work demands, and alternative work techniques which can
be used by women have often not been considered.
Differences in reactions to chemical exposures

For a long time, research on female metabolism was lacking (Berg 1997;
Greenberg and Derwent 1994; silvaggio and mattison 1994). some scien-
tists argued that it was reasonable to test men only, since the metabolism of
pre-menopausal women changes cyclically, and metabolism also varies with
pregnancy and menopause. however it has recently become recognised that,
just for these reasons, female metabolism cannot be extrapolated or inferred
from that of males. male-female differences in muscle-to-fat ratios and in me-
tabolism may have consequences for the metabolism of toxic substances.
average women and men show differences, on a whole-body basis, in
various parameters relating to oxygen transport and metabolism (see also
under Physical capacity). For example, women’s levels of the oxidating en-
zyme lactate dehydrogenase (lDh) are lower than men’s, and this difference
persists after training (liljedahl et al. 1996).
the situation is made more complex due to variations in metabolism
as well as body water (blood volume may be used as the denominator for
some studies) with the menstrual cycle and the fact that this is rarely con-
trolled. Conlicting reports are found with regard to variations in cardio-
vascular parameters with the menstrual cycle (Dunne et al. 1991; weidner
and helmig 1990). suggestions have been made that double blinding is
necessary before doing studies related to menstrual cycle phase and that
109
results attributed to phase may in fact be due to different fat consumption

at various phases.
silvaggio and mattison (1994) have discussed male-female differences in
the metabolism of toxic substances. absorption by men and women differs, on
the average, because of males’ higher surface-volume ratio, lower respiration
rates, lower proportion of adipose tissue, higher lung volumes, and thicker
epidermis. a cause or a consequence of some of these differences may be
the gender average differences in the concentration of trace elements such
as lead, cadmium and zinc (takacs and tatar 1987).
Pregnancy may accentuate some of these differences. Cardiac output and
blood low changes during pregnancy, as well as increases in respiration rates,
may impact absorption. the distribution of toxic substances in the body is
expected to differ because of women’s lower body water content and blood
cell volume. absorption of fat-soluble toxins may be facilitated by women’s
higher proportion of adipose tissue, accentuated during pregnancy. elimina-
tion of toxins is affected by men’s higher rates of renal function. Pregnancy,
however, increases women’s glomerular iltration rate to a level higher than
men’s (silvaggio and mattison 1994).
In a review article, legato (1997) pointed out that there appears to be
sex differences in the cytochrome-450 system, which is the collection of
isoenzymes in the liver that oxidize toxins, including carcinogens. moreover,
the P-450 system is inluenced by hormones, which implies sex differences
in drug metabolism. Perera (1997) has recently summarized gender differ-
ences related to sensitivity to carcinogens. she mentions that absolute cancer
rates are higher among males than females, but that women and men may be
differentially sensitive. an instructive example is smoking, which appears to
induce lung cancer preferentially in women. the mechanisms proposed range
from an interaction with hormone replacement therapy, to slower plasma
clearance of nicotine, to mutations affecting detoxifying enzymes.
some anecdotal evidence indicates that women are more sensitive to odours
than men. If so, women’s higher incidence of multiple chemical sensitivity
syndrome (kipen et al. 1995) and sick building syndrome (stenberg and
wall 1995) could be associated with this sensitivity (Bell et al. 1992) as well,
of course, as with differential job assignments.
110
equally different
the little that is known about male-female differences in sensitivity to

chemicals does not suggest a consistent pattern of differences. In addition,
generalizations cannot be made about women’s sensitivity, since physiologi-
cal states differ among women, due to pregnancy, lactation, menstruation
and menopause, in a way they do not among men. In their overview, the
us Committee on Gender Differences in susceptibility to environmental
Factors (setlow et al. 1998), concludes that, although gender is not always
relevant to environmental health, enough instances exist where it is relevant
that research designs should take gender into account.
Emotional states and pain tolerance

It has been suggested that studies of workplace stress have paid insuficient
attention to gender differences (Johnson and hall 1996; theorell 1991).
researchers at the swedish national Institute for Psychosocial Factors and
health (IPm) are examining the responses of women and men to stressful
situations. theorell and colleagues (1997) have summarized the results of
some studies of the effects of emotional states on blood pressure and hor-
monal secretions. In general, these studies have not been designed so as to
examine gender differences, and in some studies where gender is included,
it is treated as a confounder, so that its effects are not visible (undén et al.
1991). some indications are emerging that women and men react somewhat
differently to stress. the wolF study, now in progress, seeks to gain infor-
mation on the hormonal and other physiological correlates of stress in both
sexes (theorell, personal communication).
hall (1995) has shown that women’s hands are sensitive to pressure at a
lower level than mens’ and other studies indicate that similar sex differences
exist for other sensory stimuli (nevin 1996). this may indicate a higher
sensitivity in the female sensory nerve endings, or differences in epidermal
thickness (silvaggio and mattison 1994).
however, other studies indicate that men may be more ready than women
to express momentary discomfort (macintyre 1993; stenberg and wall
1995) while women appear to report more symptoms in the past (Gijsbers
van wijk and kolk 1997) (see also chapter 8). thus available information is
conlicting, and gender differences in perception and expressions of painful
stimuli need further study.
111
Figure 1. Physical capacities of women and men in relation to a set of work tasks with
varying requirements (hypothetical diagramme). Most tasks might require physical abilities
possessed by 85 percent of women and 99 percent of men, occasional very very hard tasks
might require physical abilities possessed by only 0.5 percent of women and 5 percent
of men. Extrapolated from a study of physical requirements of tasks of hospital orderlies
(Messing K, Elabidi D. La collaboration entre préposés et préposées aux bénéiciaires dans
les tâches impliquant de la force physique. CINBIOSE, Université du Québec à Montréal).
Number
of people
most tasks often hard always hard very, very hard

(occasional)
women
men
Physical capacity
Menopause
In the past, menopausal women have not been massively present in the labour
force. however, women’s increased participation is resulting in increased
numbers of older working women. according to statistics sweden, about
70 per cent of the swedish female labour force, aged 50–59, is occupation-
ally active. among the 60–65-year-olds the labour force participation rate is
about 35 per cent. although very few studies have been done, it seems that
menopause may occur earlier among those exposed to certain environmental
factors, such as tobacco smoke (Cramer et al. 1995), carbon disulphide (stanosz
et al. 1995) and possibly, sulphur dioxide and shift work (kolmodin-hedman
et al. 1982). It has been hypothesized that menopause may make women more
sensitive to carpal tunnel syndrome, although evidence conlicts and there
112
equally different
may be confusion between the effects of menopause and those of prolonged

exposure (messing 1998).
Conclusions
there are many biological differences between the sexes that may interact
with workplace characteristics to affect health. however,we cannot conclude
from the literature on biological differences that men and women are “it”
for different jobs. For many, or most, the range within a sex is larger than
the difference between the averages for the two sexes. (many of these same
structures apply, mutatis mutandis, to questions of race or ethnicity.) It is,
nevertheless, unwise to assume that a job held primarily by members of one
sex has been restricted only by prejudice. It is possible that the requirements
of the job are so extreme, that only a small proportion of workers can meet
them (see igure 1). Careful thought and policy-related research should be
done in order to arrive at job design principles that can maximize the safe
access of women and men to all jobs. this research will necessarily involve
observations of women as they do jobs traditionally assigned to men.
For some parameters, such as chemical sensitivity, we cannot apply to
women the results of studies done on men alone. we must also be sensitive
to changes in sensitivity that may occur with menstrual cycle parameters,
during pregnancy, or after menopause.
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Chapter 5
measurInG health
119
120
measuring health
Indicators for working women

by Kristina Alexanderson
“To fully understand women’s health experience, we need to look at both women’s
social roles, e.g. paid worker, wife, mother, and the material circumstances under
which these roles are enacted” (macran et al. 1996).
Health and ill health: two different dimensions

the picture of ill health in a population depends largely on how ill health
is measured (alexanderson and hensing 1994a), which is the subject of this
chapter. In this context, it seems appropriate to begin with a short discussion
of health and ill health, two concepts that irst might give the impression
of being direct opposites. however, it soon becomes evident that this is not
the case. For instance, many persons with diagnosed diseases or handicaps
consider themselves as healthy. obviously health and ill health instead must
be regarded as two different dimensions.
Health
health is a very broad concept, historically not often discussed or delineated.
Boorse (1981) deined disease as a dysfunction within an organ or a system
of an individual and then deined health as the opposite of disease, but this
bio-statistical view is often challenged.
For instance, nordenfelt (1987), from a holistic view, deined a healthy
person as someone who, within standard or accepted circumstances, is able
to realise her or his vital goals or, more precisely, the set of goals that are
necessary and together suficient for minimal happiness. according to this
deinition a person can have different types of diseases and still be healthy,
that is, attain vital goals.
121
In 1946 who deined health as a state of complete psychical, mental and

social well-being (1986), and now has moved to regarding health as one of
many resources that allow individuals to achieve their goals in life (lindberg
et al. 1994). From this perspective, gender differences in health, as well as in
other such resources (e.g. education, housing and inances) affect women’s
opportunities to reach their goals.
when studying the health of a population, it might also be important to
gain information on different individual notions about health and ill health.
these can vary largely, from absence of symptoms of illness, physical itness
or strength, psychological well-being, to having the energy to do housework
(Blaxter 1995; macran et al. 1996).
Furthermore, one often discriminates between health in general and cur-
rent health, and between “good” and “poor” health where “poor health” is a
long-lasting state involving a disposition to easily become ill (alexanderson
1995; macran et al. 1996). according to this distinction, a person with “poor
health” might, on a certain day, be perfectly healthy (i.e. free from ill health)
and nevertheless react earlier or differently to a particular occupational
exposure from a person in “good health”. this has implications for aspects
of vulnerability.
so far research efforts have focused mainly on risk factors for ill health and
have hardly touched upon factors that might promote the health of persons
who are or are not in ill health. In the words of antonovsky (1987) research
has been pathogenic instead of salutogenic. that means that the knowledge
base on health, how to measure health, and health-promoting factors is very
limited as compared to that on ill health. supportive environments are often
mentioned as a factor affecting health. what this actually means for women
at home, at work and in the community warrants further investigation.
Mortality
Data on mortality has long been used as an indicator of ill health in a popula-
tion. historically, such data was often all that was available. mortality data
are, of course, tremendously important and the immense increase in life
expectancy over the past hundred years has had a radical effect on both
society and the lives of individuals (Gove and hughe 1979; Imhof 1996).
however, partly due to this change, when studying work-related health of
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measuring health
women, mortality data cannot be the major outcome measure because of

the, fortunately, low mortality in this group.
In general, mortality rates are higher for men than for women; in other
words, men have a shorter life expectancy. Inarguably, extensive actions
must be continually taken to prevent premature death among both women
and men. however, as the outcome measure in public health has often been
mortality this has led to a strong focus on causes of death among men, the
group showing higher mortality. thus, much of the resources for research
and prevention have been used in programmes directed towards phenomena
that have the greatest impact on mortality of men, such as cardiovascular
disease, accidents, and more recently, suicide (hägglund and riska 1991).
this has been based on an underlying assumption that women and men
ought to have the same length of life. From a gender perspective, that might
call for discussion: perhaps women are biologically programmed to live longer
than men. In most parts of the world, in all age strata, women have a longer
life expectancy than men (Danielsson 1997). even at times when maternity
mortality was high, on average, women lived longer than men (socialstyrelsen
1997). hence, instead of asking why the average life expectancy is ive years
shorter for men than for women, it might be more appropriate to inquire
why women do not live ten years longer than men (Östlin et al. 1996).
Morbidity: illness, disease and sickness

It is fairly easy to gather data on mortality, as compared to information on
morbidity, especially with regard to the state, if not always the cause, of death.
In sweden the overall gender differences in morbidity are increasing, while
the differences in mortality are decreasing; the life expectancy of men has
increased faster than that of women in the past few decades (lindberg et al.
1994; sCB 1991/92). Data on morbidity are mainly of three types: self-re-
ported illness; disease diagnosed by medical science, given a more “objective”
status; and the social role of sickness, for instance in terms of sickness absence
(alexanderson 1995; twaddle and nordenfeldt 1994). the concepts of illness
and disease and how they are interrelated are often discussed in the literature
(sachs 1987), whereas the concept of sickness is given less attention. these
concepts are here deined as in igure 1.
123
Figure 1. Different types of morbidity.

Illness
Deinition: Subjectively experienced ill health, sensations such as pain, itches, weakness,
shortness of breath, fatigue, lowered competence. Can include physical, psychological and
social factors.
Main sources of data:
• Surveys based on interviews or questionnaires
• Data on utilisation of health care
Disease
Deinition: That which medical science, in a speciic culture and time, would categorise as
a disease. Usually a pathological process or a state (including injuries and defects) that is a
deviation from a biological norm.
• Registers of disease
• Registers of occupational injuries and diseases
• Registers of utilisation of medical care
• Hospital discharge data
• Registers of sale or prescribing of medical drugs
• Surveys
Sickness
Deinition: The social role a person is given/assumes in a cultural context, normally when ex-
hibiting illness and/or disease. This often implies exemption from social duties, such as work.
• Registers of sickness absence, disability pension, handicap allowance
• Hospital discharge data
• Surveys
the forms of data indicated in igure 1 partly cover different aspects of ill
health in the working population and are complementary in several ways.
moreover, using one type instead of another can result in dissimilar pictures
of levels of ill health in a population, depending on the symptom or disease
under consideration (Blomqvist 1998; sCB 1991/92) and none of them alone
provides a “correct” description.
In some cases it is dificult to clearly delimit data on illness, disease and
sickness. registry data on health care utilisation, in terms of diagnosis-classi-
ied visits to primary care centres, are often based on illness behaviour related
to symptoms experienced by the patient, and can therefore be considered to
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measuring health
represent illness data. other visits are due to check-ups, for instance, related
to reproductive functions, whereas recurrent visits due to a known, often
chronic, disease can be deemed disease data. Depending on the purpose of the
study, it might be important to distinguish between those kinds of data.
another type of information used is registers of inpatient care, which
usually can be regarded as disease data. however, patients are sometimes
hospitalised to determine whether or not they actually have a disease, and
in such cases it will be complicated to assign data to the categories illness,
disease and sickness.
many surveys include questions on disease (concerning speciic diagnoses)
and sickness (in terms of e.g. sick leave and hospitalisation). Caution should
be observed when using such data to ascertain the inluence of recall bias,
possible misunderstanding of message from health care, misunderstanding
of the purpose of a particular health care procedure, or misinformation by
health care.
It is also important to remember that not only traditional but also alter-
native health care, as well as the possibility that other persons might have
provided the surveyed person with what she or he has comprehended as a
diagnoses.
there is no sharp boundary between illness and disease. moreover, today
many illnesses are given diagnostic codes, based on e.g. international clas-
siication systems, such as DsmIII, and thus given a diagnostic “stamp”. Data
from the cause-of-death register include diagnoses but might be considered as
a category of its own (twaddle and nordenfeldt 1994). the relation between
sickness, illness and disease is illustrated in igure 2.
within all three dimensions, performance in terms of physiological, psy-
chological (including cognitive) and social abilities is of importance. to the
employer, this is related to the work capacity of the employees;to society, it
is associated with the capacity to participate in the democratic process and
in societal development and reproduction; and to the individual, it is cor-
related to the possibilities to inluence one’s own life, to achieve goals, and
to participate in society (Doyal 1995).
one often distinguishes between illness and illness behaviour. the latter
refers to the action a person takes due to the illness experienced, for example
125
going to bed, taking an aspirin, or seeking medical care (Gijsbers van wijk
et al. 1991). this is not the same as sickness, which is the role a person
chooses or is given in a group or society. another way of categorising illness
is to take into account whether or not a person interprets the symptoms and
bodily sensations of illness as belonging to the “medical sphere” (Gijsbers
van wijk and kolk 1997; honkasalo 1985). nordenfelt (1994) stated that
“sickness is ontologically very different from both disease and illness”, and
twaddle (twaddle and nordenfeldt 1994) pointed out that “illness and disease
are embodied while sickness is not”. sickness is a social role, a negotiated
position (Parsons 1952).
Figure 2. Relationship between illness, disease and sickness.
Illness b c Disease
a
e
f d
g
Sickness
a = Illness a person experiences but which medical science does not recognise as a dis-
ease.
b = Illness experienced by a person which medical science deines as a disease.
c = Disease, as deined by medical science, but not experienced as illness by the affected
person. Whether or not a person experiences a disease as illness can vary with the type
of disease, with culture and the individual affected, and can differ over time for the very
same individual and disease (Alexanderson 1995).
d = The same as c, but, due to the disease, the person also has chosen or been given a sick
role.
e = The same as b, but the disease or illness also entitles or forces the person into a sick
role.
f = The same as a, but the person also has a sick role, for example, is on sick leave due to
the experienced symptoms.
g = A person who has a sick role without showing illness or a disease; could be due to
misdiagnosis or disability pension granted due to the labour market situation.
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measuring health
although good health is usually considered as something beneicial and

positive (tegern 1994), it is given different priority and in some situations a
sick role may be something desirable in a person’s life (alexanderson 1995;
sachs 1987).
Gender issues
In all three dimensions, women exhibit more ill health than men do. more
speciically, women report more illness, more frequently suffer from disease,
and more often adopt a sickness role, for instance, they are on sick leave more
often and for longer periods of time (alexanderson 1995; Gove and hughe
1979; lindberg et al. 1994; Vogel et al. 1992). however, much of the higher
morbidity rates of females is due to higher rates of relatively mild forms of
illness and psychological manifestations of distress. By comparison, men
have higher rates of more serious forms of physical illness that can lead to
death or disablement (Gijsbers van wijk and kolk 1997; Gove and hughe
1979; macintyre et al. 1996).
Due to gender bias in medical research and practice (alexanderson 1995,
1998a, 1998b; angell 1993; Cotton 1992; Fee 1982; miles 1991; Palca 1990;
rosser 1993; schei et al. 1994; sechzer et al. 1994; wenger et al. 1993) there is
a larger body of knowledge concerning disease in men than concerning disease
in women, with regard to health risks, diagnostic procedures, and treatment
and rehabilitation measures. Furthermore, there are medical diagnoses for
a larger part of the illnesses more often experienced by men than for those
more often experienced by women (album 1991; Boston 1992; Clarke 1990;
Fabrizio 1991; Jeleff 1995; koblinsky et al. 1993). this means that, from a
gender perspective, the circles in igure 2 that represent illness, disease and
sickness probably overlap to a larger extent for men than for women. In fact,
the relationships might actually be more like those shown in igure 3.
accordingly, women more often experience that the illness they present to
the physician is not given a diagnosis. Balint (1972), among others, has pointed
out that it is important that a patient receives a diagnosis when experiencing
illness. this also means that, for women, a larger part of the “sickness circle”
is congruent with the illness circle than with the disease circle. the effects
this has on the ill health of women needs to be further elucidated.
127
Figure 3
Men Women
Illness Disease Illness Disease
Sickness
Sickness
Due to these gender differences, when studying women’s health it is essential

to be cautious regarding the type of data collected. when exclusively using
disease data many of the actual illnesses experienced by women might be
overlooked. this might also be the case when employing illness data obtained
with standards or methods developed with the male as the norm.
Factors influencing gender differences in morbidity data

there are several factors that can inluence data on morbidity in different
ways for women and men: outcome is often measured as changes in the
endocrine, autonomic or immune defence systems, or as effects of such
changes on various aspects of organ performance, in terms of, for instance,
electrical activity in muscle cells, blood pressure, sweating, and rate of heart
beat. here it is of the utmost importance to be aware of possible gender bias
in research methods.
methods and instruments used to compile data on outcome and exposures
of interest are seldom gender sensitive, and must thoroughly be scrutinised
so that they catch the situation of women. moreover, indings and theories
regarding gender differences in ill health date back decades (Gove and hughe
1979; macintyre et al. 1996), whereas many aspects of the life circumstances
of women and men (such as education, employment rates, sex roles, the em-
ployment market, and lifestyle) have changed substantially over the years. a
large number of the instruments presently in use (e.g. questionnaires) were
constructed and validated more than 20 years ago and therefore in many
cases do not include all of the issues that are relevant today.
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measuring health
although we have all experienced ill health in one form or another, the
distribution of both incidence and prevalence of morbidity is extremely uneven
in the population (Vogel et al. 1992); the risk of assuming and remaining in
a sick role varies much with socio-economic status, as well as with gender
and age (lindberg et al. 1994).
according to medical anthropologists, all concepts of health and ill health,
including the biomedical, are based on cultural conventions, which is import-
ant from a gender perspective. the sick, or abnormal, does not exist on its
own, outside a cultural norm (sachs 1987; sachs and kantz 1991). young
(1982) pointed out that “social forces help determine which people get which
sicknesses” when having the same symptoms, a fact of large importance here
due to the large differences in such for women and men.
Instruments, e.g. questionnaires, used for collecting data of illness are
sometimes designed so that they are understood differently by a man than by
a woman (wahl 1992). often such tools are constructed for male populations,
which means that factors of speciic relevance for women, such as painful
menstruation (dysmenorrhoea) or swollen breasts, might be missing. Gender
differences in norms may also entail admitting overall ill health or concern
speciic symptoms (Botten 1994; Gijsbers van wijk et al. 1991; honkasalo
1991), or how symptoms are recognised, perceived, evaluated, and acted upon
(Gijsbers van wijk and kolk 1997). Gender differences in data might also
depend on aspects of interview situations (Botten 1994; Gijsbers van wijk et
al. 1991), for instance, the gender, ethnicity, and social class of the interviewer,
and whether the interview is conducted at home in the presence or absence
of family members. the latter can be one reason why more single women
than cohabiting or married women report being physically abused.
In addition to measurement of symptoms, the outcome of studies on
gender differences is affected by whether the time period to which symp-
toms refer is retrospective, momentary, or prospective (Gijsbers van wijk
and kolk 1997).
however, there seems to be little evidence that gender differences in
readiness to take on a sick role and report ill health, or in sensitivity to
symptoms, can explain the higher morbidity rates among women (Gove
and hughe 1979; macintyre et al. 1996). In fact, the opposite seems to be
true concerning sensitivity to symptoms: men are more likely than women
129
to complain when experiencing the same level of symptoms (Gijsbers van

wijk and kolk 1997; Gove and hughe 1979; macintyre et al. 1996).
when using data on disease one should be observant regarding tenden-
cies toward both medicalisation of female states (Boston 1992; Clarke 1990;
Corea 1977; Fabrizio 1991; kitzinger 1992; miles 1991; oakley 1980, 1993;
topo et al. 1991; worcester and whatley 1988) and misclassiication of
women’s symptoms as being related to mental problems (armitage et al.
1979; Boston 1992; ehrenreich and english 1979; Fabrizio 1991; Gijsbers
van wijk et al. 1995; miles 1991). Designating symptoms as mental problems
may be due to an inclination to view women as psychologically less stable
(miles 1991) or to the fact that these diagnoses more often are diagnoses of
exclusion and consequently more often given to women, as less is known
about female symptoms.
also, there could be gender differences in how symptoms are presented
(Botten 1994; honkasalo 1991) or in care-seeking behaviour (Gijsbers van
wijk et al. 1991; Johannisson 1995). Described symptoms can be interpreted
differently, depending on the gender of both the patient and the physician
(Colameco et al. 1983; honkasalo 1991; waller 1988; weisman 1986).
Data on sickness might be inluenced by gender differences in readiness
to accept or report a sick role, as well as by possible gender bias in practice
regarding sickness certiication, disability pension, referrals, hospitalisation,
home care, or rehabilitation measures taken (alexanderson 1995; Bernstein
and kane 1981; Bertrand 1991; Botten 1994; Bäckström 1997; Josefsson and
törnblom 1995; kindlund 1989, 1992; malterud 1994; marklund 1997).
so far, studies of work-related health have been based mainly on data
concerning disease and injuries, and to a lesser degree on sickness data.
however, of interest in this context is not only the symptom or disease per
se but also the effect of illness and disease on work capacity. thus, in addition
to mortality and morbidity, work capacity is of fundamental importance,
because the focus on health issues in the work force has both a humanistic
and an economic basis. some methods have been developed to measure
functional capacity but there are hardly any scientiically based methods to
determine work capacity, which is a functional ability related to speciic work
demands (alexanderson et al. 1996b). Consequently, there may be gender
differences in how work capacity is concluded and measured (Bäckström
130
measuring health
1997). the effects of gender differences and ill health on work capacity
and the measurement of such effects are central issues that call for further
investigation and development.
Severity, vagueness and degree of stigmatisation

when discussing morbidity, three dimensions of ill-health are often neglected:
namely how severe, how distinct or vague, and how stigmatising the type of
ill health being considered is.
neither illness nor disease is an “either-or” concept; both can be expe-
rienced and diagnosed as more or less severe, rated on a continuum scale
from perfectly healthy to almost dead. Furthermore, a speciic illness can be
experienced and tolerated differently at a certain time, depending on both the
individual characteristics and the life circumstances of the affected person.
the degree to which an illness must be manifested before an individual will
declare that she or he is ill or sick varies during the person’s life time and
with occurrence and degree of other illnesses or diseases, with the level of
demands in paid and unpaid work, with social obligations or other life cir-
cumstances, and with attitudes in the different social networks surrounding
the person (kristensen 1995).
In biomedicine some diagnoses are often considered more “hard core”,
strict and distinct, whereas others are regarded as more vague or diffuse
(marinker 1975). this relects two dimensions: how easy it is for a physician
and others to verify and certify a disease with standard diagnostic means;
and the status or value of different diagnoses in the eyes of both the public
and the medical profession (album 1991). most people are not ashamed of
receiving a more “hard core” diagnosis, but they might be if given more
diffuse or vague diagnoses. this means that the validity of data on illness,
disease and sickness varies depending on the diagnosis, especially when in-
formation is gathered in interviews. many of the more vague diagnoses that
cannot be veriied by medical science are instead based on illness reported
by the patient; a large part of the diagnoses on sickness absence certiicates
belong to this more vague category.
there may be gender differences in whether individuals experience dif-
ferent diagnoses or symptoms as stigmatising (solomon 1986) which would
affect the validity of data. that is, if gender roles dictate that it is more stig-
131
matising for women to have a speciic symptom, women themselves might

underreport the symptom in surveys or avoid telling physicians about it, or
physicians might be reluctant to report it in medical charts or on sickness
certiicates.
Sources of data on ill health

In sweden, at both the local and the national levels, several large oficial
databases have been created that contain information on health determinants
and outcomes relevant to studies on work-related health. many of these can
also be utilised to detect changes over time, because they comprehend data
covering several years or decades. a multitude of research databases are also
available.
In most studies related to occupational health, at least one register is
utilised, if nothing else for identiication of study population or subjects.
however, it is not unusual that several registers are included, and they should
be chosen meticulously to ensure that they contain pertinent information.
also from a gender perspective great caution should be taken when choos-
ing the relevant registers. moreover, linkage of registers requires a high
level of conidentiality in handling of the data, as well as permission from
the swedish Data Inspection Board, other relevant authorities, and ethical
research committees.
It is often advantageous to combine data from different databases to
include a wide spectrum of exposures or to compare various types of
outcome measure such as death, disease, and sickness, the latter in terms
of, for instance, disability pension (Blomqvist 1998). In such instances, it
is essential to consider whether the databases can be related at either an ag-
gregated level or be linked at an individual level. In other words, whether
data are available at an aggregated or an individual level, and, in the latter
case, whether the individuals can be identiied in the same way in the differ-
ent registers through, for instance, a personal code. In most of the oficial
registers and many research registers in sweden, individual data include a
universal personal code identiication number, allowing linkage. however,
for some research questions, an ecological design is more appropriate, that
is, taking groups and not individuals as the unit of study (schwartz 1994;
susser 1994).
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measuring health
some registers contain data on prevalence and others on incidence, and,

again, the choice of register should be related to the speciic aim of a study.
another important aspect to be noted is whether the register is based on a
population or on patients. Data from patient-based registers are inluenced by
factors such as practice and costs of, attitudes towards, and access to medical
care. all these aspects are important from a gender perspective. Furthermore,
the quality of data in different registers can vary, which should be taken into
account in relation to the speciic research question.
Data on illness
Data on illness are mainly obtained in surveys, by use of interviews or
questionnaires (Bjorner et al. 1996). the methodology and instruments
presently used need to be scrutinised for gender bias and for possible omis-
sion of factors of importance for women. It might be necessary to develop
new procedures for collecting illness data, or to revise existing methods,
possibly by including questions on other aspects or by trying new types of
questions, for instance life lines and health lines (Bjerén 1994; ringsberg et
al. 1998; wahl 1992).
Information on illness is particularly interesting in this context, as in-
formation on many of the symptoms women experience cannot be detected
in disease or sickness data, partly due to the gender bias of medical research
and practice. Data on health care utilisation can, as mentioned, be regarded
as a mixture of information on illness, illness behaviour or coping strategies,
and disease.
the surveys of living Conditions, performed by statistics sweden, are
important sources of data on illnesses. each year at least 7 000 randomly
selected persons above the age of 16 are interviewed in their homes for one
hour. these surveys have been performed since 1974 and include questions on
health, illness, disorders, functional capacity, and medications. also included
are questions on exposures of importance for ill health, such as life circum-
stances (social, economic, educational, occupational etc.) and lifestyle.
In addition many counties conduct local population-based surveys, and
such data can also be found in many of the existing research registers. on the
whole, there are many registers that contain high quality data on morbidity
(and exposures) that are rarely used for research purposes.
133
Data on disease
there are many national registers that contain information on diseases: the
swedish Death register, the Cancer register, the medical Birth register
(includes data on both infants and mothers), the malformation register
and the hospital Discharge register (with data on diagnoses, time spent
in hospital, operations etc.); registers of assisted conception, compulsory
institutional care of adult drug abusers, and statistics of incidence of certain
contagious infections (swedish Institute for Infectious Disease Control); and
the swedish occupational Injury Information system.
Furthermore, there are now several national registers of health quality
that contain information on speciic diagnoses or areas of treatment, such
as diabetes mellitus and myocardial infarction.
there are also a number of local registers concerning use of health and
medical care services. additional registers comprise data on other health-
related aspects of interest, such as abortion, sterilisation, breast feeding, and
persons receiving social beneits; these can also be used as a source of exposure
data. the quality of the data in the different registers varies, especially with
regard to diagnoses.
sweden has had one of the most comprehensive systems in the world for
compensating workers who have developed occupationally related diseases
or been injured at work (work Injury Insurance act). therefore, to some
extent, it is dificult to compare the swedish data in this area over time or
with data from other countries. In the 1980s, especially during the second
half of that decade, there was a great increase in the number of occupational
musculoskeletal diseases reported. the swedish occupational Injury system
keeps a register of claims and approved cases of work injury or disease iled
with the swedish workers’ Compensation system. men report more occu-
pational accidents, and women more occupational diseases, which relects
the different work tasks performed by women and men in the swedish labour
market today. however, in some jobs women are also exposed to high risks
of, even fatal, accidents (lagerlöf 1993).
when discussing health, in sweden, data on dental health and care are
not normally included, probably because they are administrated by an or-
ganisation of its own. nevertheless, teeth are an important part of the body.
women tend to take better care of their teeth and visit dentists more often
134
measuring health
then men, although the latter difference has diminished during the last few
decades (Cohen and Gift 1995; håkansson 1991). Furthermore, many women
attribute the symptoms they experience to the material used to ill their teeth,
and it is not yet known how that affects the quality of life.
many women who have been physically abused contact dentists for help
with injuries, and that represents an untapped source of data on abuse. how-
ever, there is no national register of consumption of dental care, although
a few local registers covering different counties are available. Dental care
is largely private, and there is a register of the costs of the dental insurance
system that is stratiied by gender and according to private or public care.
use of medical drugs can be regarded both as a risk factor of particular
importance for women, as illness behaviour related to experienced symptoms,
and as an outcome measure of, for instance, speciic diseases e.g. diabetes
mellitus or depression. Data on use can be acquired mainly through surveys,
although a few registers are of interest as well. the national Corporation of
swedish Pharmacies, through which all medical drugs subject to prescription
and most others are administrated, keeps detailed statistics on all licensed
drugs sold in sweden. Both general and speciic data on drug types, are
available stratiied by gender and geographical area at an aggregated level.
In addition, a register of drugs purchased with a medical prescription will
soon be available at an individual level.
to curtail the costs of medical care and medicines, a person who has
bought prescription drugs or paid for care services for a speciied amount of
money during part of a 12-month period is issued a “free pass” that entitles
her or him to free medicines or care during the remainder of the period. an
accessible register of persons with such a free pass exists. of course, these
data include nothing about compliance. there is also a register of persons
who have experienced adverse effects of prescription drugs.
regarding drug consumption among women it would probably be of
interest to complement data on medicines sold from pharmacies with data
on certain medicines and remedies sold in health-food stores and by persons
practising different kinds of alternative medicine. examples of the latter are
preparations supposed to have effects on depression, sleeping problems,
premenstrual symptoms, and menopausal distress.
135
Less studied areas of ill health

Detailed data is lacking in several areas of importance for women’s health, such
as pain, maternal health, depression, obesity, emaciation, anorexia, bulimia,
swollen legs, varicose veins, urinary incontinence, fatigue, drug dependency,
swollen breasts, dysmenorrhoea, genital infections and disorders, eczema,
infertility, allergy and burn out.
also of importance in the context of this book are several “new” illnesses,
such as ibromyalgia, chronic fatigue syndrome, multiple chemical sensi-
tivity, sick building syndrome, and electrosensitivity. these disorders are
often referred to as psychosomatic, some authors call them “the fashionable
diagnoses” referring to the fact that they change over time and, with the
help of media, have occasionally reached epidemic proportions (Ford 1997;
Johannisson 1995; lamberg et al. 1997; shorter 1992). however, others
think they are due to changing exposures (messing 1998). Due to the new
diagnostic category “somatoform disorders” in DsmIII many of these are
now classiied as disease data.
Common psychological and physical symptoms in most of these disorders
are fatigue, headache, malaise, dizziness, concentration problems and pain.
Diagnostic criteria to a large extent overlap between the different disorders,
for example between ibromyalgia and chronic fatigue syndrome, and many,
but deinitely not all, of the patients have psychological disorders in terms
of, e.g., current or past depression. Ford (1997) has stressed that these syn-
dromes are “simultaneously medical, psychological, and social phenomena”.
For instance, most of the persons with sick building syndrome also report
factors at work, such as boredom, dissatisfaction, work pressures and poor
psychosocial work environment including relations with superiors.
not only at present, but also in the past, most of the patients in these
diagnostic groups have been women, and many so-called treatments earlier
offered, e.g. genital mutilation, are highly questionable, as are the attitudes
towards persons with these problems (shorter 1992).
Data on sickness absence

Data on sickness absence and sick-leave insured persons can be obtained from
the local social insurance ofices and from the national social Insurance
Board. the validity of these data is very high, mainly because they are
136
measuring health
compiled for administrative purposes, not for scientiic research. Data are
available on start and end date for each case of sickness absence, maternity
leave, parental leave for child birth and for tending to a sick child, and also
on whether the absence was full or part time.
however, data on the following are not registered in computers: diag-
noses stated on the sickness certiicate, occupation, certifying physician and
rehabilitation measures. such data have to be compiled manually, either
from the iles kept at the local insurance ofices (all certiicates are saved
for ten years, after that only a sample) or from other research data registers
(alexanderson et al. 1994b; alexanderson 1995). of interest in this context
might also be data concerning to what degree and when during the year
fathers use parental leave days.
Furthermore, data on incidence and prevalence of temporary or permanent
disability pension (full or part time) are computerised together with legitimat-
ing diagnoses. other sickness data accessible at local social insurance ofices
cover granted handicap allowances (including diagnoses), and care allowance
granted to parents for care of long-term disabled children; the former pro-
vide information on reduced function and the latter on work load in unpaid
caring work.
Data on sickness absence can also be obtained in different kinds of sur-
veys. Gender aspects of recall bias with regard to sickness absence have not
yet been studied. In what is referred to as the labour Force survey, some
17 000 individuals are interviewed each year about their work situation and
absence from work due to various reasons, including ill health. these surveys
have been conducted since 1961 and constitute a substantial source of self-
reported data on sickness in terms of absence from work or as an explanation
for not being employed. like the previously mentioned survey on living
Conditions, the labour Force survey also comprises exposure data, mainly
regarding work-related factors, but also on some other aspects, such as
family situation. as in many of the registers compiled by statistics sweden,
the labour force data are combined with data from other registers (e.g. on
educational background of the subjects), through linkage.
employers, not the local sickness insurance ofices, register the sickness
absence of employees and pay sickness beneits for the irst 14 days of a
sick-leave spell. there are mainly three ways to obtain those data of short
137
term sickness absence; self reported by the individual employees, from the
employers, or from a register of statistics on short-term absence in the private
sector where 1200 workplaces are asked for data on absences. these data are
less accurate than those acquired from insurance ofices.
In sweden, a physician’s certiicate is required from the eighth day of sick-
ness absence, which means that diagnoses for spells longer than seven days
might have somewhat greater validity, because they are negotiated on by two
persons, at least one of whom is a medical professional. however, studies have
not been performed to determine whether the validity of diagnoses for the irst
seven days of absence periods is actually lower. many of the shorter sick-leave
spells are due to upper respiratory infections, although other diagnostic areas
of interest here are painful menstruation and headache or migraine.
Measures
a vast number of different measures of sickness absence have been used in the
literature, and the terms used to describe these measures vary greatly (alexan-
derson 1995; hensing et al. 1998a; kristensen 1991; muchinsky 1977; Paulino
et al. 1973; tellnes 1990). many of them are adapted to suit administrative
purposes rather than research questions. Data mainly concern number of
sick-leave spells, number of absence days, number of absent persons, or costs
associated with absence during a speciic time period. working days lost and
number of sick-leave spells are of interest from a management perspective,
whereas the number of calendar days with sickness absence is more important
from a public health perspective.
the large variation in measures not only makes it dificult to compare
studies but use of different measurements also leads to different consequences
for interpretations of results (Isacsson et al. 1992). It is imperative that ap-
propriate measures are used for the speciic research question, as illustrated
by the following examples:
• to focus on number of absence days per sick-leave spell is not recom-
mended if persons in one group have many but short spells and those in
the other have few spells of longer duration. In that case, it might be better
to consider the number of absence days per year per sick-listed person.
138
measuring health
• In studies of sickness absence due to psychiatric disorders, gender dif-

ferences vary with measures used: women have higher incidence and men
longer duration (hensing et al. 1996).
the social Insurance Board keeps records of as many as six different vari-
ables of civil status, none of which is “cohabitation”, a factor of importance
in sweden, where cohabiting is a very common alternative to marriage.
Furthermore, data on full- or part-time employment are not recorded by
the social Insurance ofices and therefore must be obtained from other
sources.
Sickness absence as a measure of social consequences of ill health

sickness absence data based on sick leave or on temporary or permanent
disability pension cannot be used as the sole measure of the incidence or
prevalence of a speciic disorder, or of total morbidity.
sickness insurance beneits cover work incapacity due to disease, injury
or illness. the level of work capacity is to be decided upon in relation to
the particular demands of an individual’s ordinary work, which means that
a certain disease or injury might give the right to and need for sick leave in
one occupation but not in another.
For example, the consequences of a broken inger, in terms of work ca-
pacity and right to sickness absence, are different for an assembly worker,
a guitarist and an english teacher. Initially, this might seem to represent a
disadvantage of using sickness absence as a measure. however, instead of
measuring the occurrence of disease, sickness absence can be a highly ap-
propriate indicator of the social consequences of ill health, for instance with
regard to work incapacity, for persons in different groups, e.g. women and
men with different tasks or diagnoses.
Interestingly, marmot et al. (1995) view sickness absence as a way to
operationalise who’s concept of health. they deine ability to function
at work as one aspect of health in relevant age groups and, consequently,
sickness absence as an indicator of reduced health in the terminology of the
who; thus state that sick leave is “useful as an ‘end-point’ in studies of the
determinants of healthy functioning in working populations”.
139
A multifactorial phenomenon
sickness absence, like ill health, is a multifactorial phenomenon, affected by
a variety of elements at different structural levels (alexanderson 1995; alex-
anderson 1998b), several of which are important from a gender perspective.
an example of this is that there are fewer female occupations in the labour
market, which means that it is often more dificult for a woman than for a
man to ind a new job as an alternative to being on sick leave (Vogel et al.
1992). there might also be a difference in the share of male and female jobs
that can be considered “high in resources, such as control and social support,
and beneits (such as pay, vacation and positive organisational climate)” (hall
1990). In these matters, it is important to remember that not only profes-
sional life, but also most other activities (unpaid work and leisure activities)
are to a large degree differentiated by gender (hall 1990; lahelma and arber
1994; lundberg 1990; oakley 1994).
one problem with data on sickness absence is that the sick leave among
pregnant women is much higher than among women of childbearing ages
who are not pregnant. this means that such data will be affected if the rate
of pregnant women differs between occupational groups being compared.
however, when using diagnoses from sickness certiicates, only half of the
pregnant women on sick leave can be identiied as pregnant (sydsjö et al.
1998). therefore, it would be useful to have access to data on the state of
pregnancy.
not only sickness absence but also degree of “sickness presence” (i.e. going to
work despite being ill) could be measured, for instance by performing surveys.
In the long run, this factor might have a negative effect on the health of a
woman who is ill. moreover, it will affect her work mates if she exposes them
to a contagious disease, or if she cannot manage her part of the work or be as
attentive as required and thereby endangers the health and safety of others.
to sum up, the disadvantages of using data on sickness absence are that
information on diagnoses legitimating the absence is not always easy to obtain,
and for the employed, only data on sickness absence exceeding 14 days are
accessible through the social insurance ofices. advantages are that data on
sickness absence comprise useful information on the sickness dimension of
morbidity, that is to say the social consequences of illness and disease. Both
prevalence and duration can be obtained. sickness absence data also provides
140
measuring health
information on the large diagnostic groups of central importance for work-

ing women, such as musculoskeletal and psychiatric disorders (lindberg et
al. 1994; 1997), on which it is dificult to acquire information from other
registers. Furthermore, data obtained from social insurance ofices are of
exceptionally high quality.
Population at risk — denominator data

Information on persons with a certain disease, illness or injury can be obtained
from several sources, among them the Death register, the Cancer register,
and data on sickness absence. For proper analyses, background data on the
population at risk for a studied outcome is also needed and can be acquired
from a variety of databases.
sweden has been keeping records of vital statistics longer than most other
countries in the world. these data, which e.g. cover the number of persons
born, deceased and living in a county, and the number moving to and leaving
each county, can be obtained from statistics sweden.
the Population and housing surveys collect data on socio-economic
status and occupation; these surveys were formerly conducted every ifth
year, but are now done less frequently. unemployment statistics may also
be of interest, and possible sources of data in this area are the previously
mentioned surveys of living Conditions, the labour Force surveys, as well
as various research registers. the labour Force survey can be complemented
with speciic questions that it the requirements of individual studies. the
register of persons who are sickness insured, which is kept by the national
Insurance Board also can be utilised for speciic studies. registers of em-
ployees or of members of labour unions are other important sources of data
on populations at risk.
Exposure to risk factors and effect modifiers

the main focus of the discussion thus far has been outcome measures in
terms of ill health. work-related risk factors for ill health, and factors that
might modify the effects of such exposures, are discussed in other chapters of
this book, therefore only a few aspects of exposure will be mentioned here.
Data on exposure to different chemical, physical, ergonomic, biological,
and psychosocial factors at remunerative work are used in studies in oc-
141
cupational medicine, often in combination with data on speciic life-style

factors (e.g. smoking).
when examining the various types of data on exposure to risk factors,
the following aspects should be taken into consideration:
• Does the factor at issue have the same effect on women as on men of
different ages (ekenvall et al. 1993)?
• are the reasons for being exposed the same (e.g. do women and men
smoke for different reasons?) and, if so, does that affect the outcome?
• Do the methods used to compile data lead to gender differences in
validity?
often excluded are exposures of speciic interest to women, which could well
be the following: vertical and horizontal gender segregation (alexanderson
1995; hensing 1997), lack of support from subordinates, circumstances in
unpaid work, a large social network (shye et al. 1995), leisure activities, sex
discrimination, awareness of being the subordinate gender, discrepancy be-
tween educational level and job status (Gijsbers van wijk and kolk 1997),
required to be nice, unemployment, fear of unemployment, and exposure to
an unemployed husband. there is also a growing knowledge base on nega-
tive health consequences of being abused (Bendixen et al. 1994; Bewley and
Gibbs 1991; Gilbert 1994; mullen et al. 1988; randall et al. 1994; roesler
and mckenzie 1994; schei et al. 1994; wijma and wijma 1993). Being
exposed to sexual harassment leads not only to health problems (hensing
and alexanderson 1998; hensing et al 1998b) but also to a decrease in work
performance (Doyal 1995).
It is dificult to obtain data on risk factors for mortality and morbidity
that are clearly related to work, because many women have not been exposed
to particular occupational hazards of interest for many years or have not
been in full-time employment. (the same might also be true for men, e.g.
due to change of jobs or periods of unemployment.) thus it is important to
include data on duration and intensity of exposure when studying female health,
and it would be especially auspicious to develop a life-course perspective in
research on women.
several factors that are often measured and used in research (e.g. self con-
idence, attitudes, locus of control, sense of coherence, sensitivity to illness
142
measuring health
(Gijsbers van wijk et al. 1991), illness-behaviour/coping strategies (lindgren

1985)) can be considered as exposures, personality traits or individual char-
acteristics, or as outcomes, depending on the theoretical framework and the
research question being addressed. In the following, they are chiely referred
to as modifiers of results, because they are seldom regarded as confounders.
Gender differences in these factors are frequently looked upon as essential,
or, in other words, as genetic or as acquired in early childhood through
gender socialisation in a genderised culture (wahl 1992). however, they can
also be initiated or manifested in situations such as an appointment with a
physician. the practical consequences are very different if a physician or a
superior at work deines a problem as being associated with the individual
rather than as related to work — as personal rather than structural (Josefsson
and törnblom 1995; wahl 1992).
other modiiers of interest for women’s work-related health are work done
for social relations (both within and outside the workplace), maintaining the
gender contract, not appearing to be more competent than male colleagues
(kanter 1977; lindgren 1985), strategies for coping with sex discrimination
(wahl 1992), and the ability to relax (lagerström Östlund et al. 1998).
research on women’s health has focused more on the signiicance of dif-
ferent social roles than on social gradients; the latter has been the focus of
research on men (macran et al. 1996). most studies show that employment
status is a very important factor for health in women, although different work
environments can obviously be more or less hazardous to the health of both
women and men. as among men, there are large differences in health with
social status among women.
until recently, relatively few studies have explored differences in women’s
health by type of occupation. although women in general exhibit greater
morbidity than men do, irrespective of the method of measurement (Blank
and Diderichsen 1995; Chevalier et al. 1987; Diderichsen 1990; Diderichsen et
al. 1993; hensing et al. 1995; kindlund 1989; marmot et al. 1993; mckeown
and Furness 1987; north et al. 1993; Pines et al. 1985; Prins and De Graaf
1986; stansfeld et al. 1995), this is not the case at a more detailed level in
different occupations. that means that the circumstances in different sub-
groups must be analysed in order to obtain a solid basis for interventions.
143
an important area that has received limited attention is possible gen-

der bias in measures of rehabilitation of sick persons taken by employers,
care givers, and the social insurance system. such bias might lead to affect
modiication of exposures or represent a factor contributing to ill health,
especially in terms of sickness (alexanderson et al. 1996a; Bäckström 1997;
marklund 1997).
Further methodological considerations

In sweden a much higher proportion of women than men work part time
(Vogel et al 1992). there are four major reasons for part-time employment:
1) health problems; 2) other demands or activities, such as the unpaid work
load or studies; 3) scarcity of full-time jobs; or 4) a person simply does not
want to work full time. the effects that working part time has on morbidity
probably differ between these categories. In studies of gender differences,
it would be an advantage if women and men had equal employment rates
and equal rates of working part time. notwithstanding, despite apparent
differences in that regard, comparisons might still be appropriate, because
part-time employment among women does not normally mean that their
total (paid and unpaid) work load is lighter than that of men (Frankenhaueser
et al. 1991).
a problem encountered when attempting to apply a gender perspective
to studies of occupations is that in the classiication systems (e.g. the nordic
Classiication of occupations) traditionally male jobs are classiied at a much
more detailed level than traditionally female jobs (alexanderson 1995; hall
1990) making comparisons dificult.
Determining the socio-economic status of women is a delicate problem with
no obvious solution (arber 1989; Carr-hill and Pritchard 1992). tradition-
ally, a woman has been classiied according to the socio-economic status of
her husband or father, a method which is often unsatisfactory (arber 1989).
to instead base such classiication solely on women’s own occupations does
not, however, solve the problem, especially when considering women who
do not have an occupation (erikson and Goldthorpe 1992). the “real”
socio-economic status of women, as well as that of men, is affected either
by the socio-economic status of a partner or by the fact that she does not
have a partner. Further, a woman’s situation might be more affected by the
144
measuring health
socio-economic status of her partner than vice versa (erikson and Goldthorpe
1992; lundberg 1990). moreover, macran et al. (1996) has stated that “in-
come is only a proxy measure for a person’s access to and control over the
resources in their environment, which may have an effect on their health.
simply measuring a household does not take into account how its resources
are distributed”. there are parallel problems in deining unemployment
status for women (macran et al. 1996).
two main arguments have been used to justify the exclusion of women
from studies on work-related health. First, as women to such a large degree
are exposed to factors in unpaid work, it would be dificult to determine the
extent to which the outcome was attributed to exposure in paid employment.
second, women are “different” due to a more luctuating hormone pattern,
in both a short-term (menstrual period) and a long-term (pregnancy, breast
feeding, menopause) perspective. For example, the “stable” male hormone
pattern is often looked upon as normal, whereas the cyclic female pattern
is considered deviant and problematic (Boston 1992; miles 1991), although
it is dificult to understand why a more static hormone pattern should be
regarded as the norm. rather than adapting research methods and theories
also to it women, females were merely often excluded from studies (hall
1990). men generally represent the norm for good and poor somatic, mental
and social health (Boverman et al. 1970; miles 1991; ministry 1996; wenger
et al. 1993). all of this means that extra caution should be observed when
designing studies to ensure that they will be gender sensitive.
the vast majority of studies and data-collecting operations presuppose
heterosexual, monogamous relationships. survey questions are often de-
signed so that they exclude answers dealing with a woman having a female
cohabitant or living in a community, and thus provide a false picture of the
situation of the studied population.
regarding pregnancy, occupational studies have focused largely on detri-
mental effects on the outcome of pregnancy, not on women’s health during and
after pregnancy. During pregnancy, women go through enormous physiologi-
cal and psychological changes (meyer et al. 1994; Paul et al. 1994; Petersen
et al. 1989; usher 1989). little is known about how the work environment
might inluence women’s health and work capacity in a positive or negative
manner in either a short- or long-term perspective. Perhaps we should view
145
pregnancy as work, as part of the important reproductive task performed

by women in society, which might justify reducing other work tasks during
pregnancy. Furthermore, there is a tendency to victimise employed women
with regard to negative effects on the health of offspring (alexanderson et
al. 1998). By comparison, effects on offspring due to occupational exposure
of fathers are rarely scrutinised.
In studies of women’s health it is of the utmost importance to be speciic
about the structural levels on which different factors of exposure and modiiers
Figure 4. Factors at different structural levels that affect ill health in working life.
Individual factors
Physiology Psychology psychosocial13 environ-

Heredity; disposition Mental health5 ment in unpaid work
and constitution Mental ill health6 Hours in paid and unpaid
Age Psychological, intellectual work14
Gender and social capacity Time and method of travel-
Health1 Personality7 ling to work
Ill health2 Sleep8 Duration of employment
Functional capacity Attitudes toward work, Earlier jobs
Physical status health, sick-leave, health Economic situation
If pregnant, date of care Housing15
conception Capacity to relax Life events16
Earlier pregnancies3 Sexual preferences Social network17
Menstruation period4 Libido Family situation18
Menopause, approximate Self esteem Leisure time; amount
onset and type
Life circumstances Violence, sexual abuse
Behaviour Education and harassment
Coping strategies9 Employment status Quality of life
Illness behaviour Occupation and work tasks
Utilisation of health care Immigrant status, ethnic
and rehabilitation group11
measures Socioeconomic status12
Medication Lifeform
Birth control method Partner’s employment
Lifestyle10 status
Earlier lifestyle Physical, chemical, ergo-
Use of parental leave nomic, biological, and
146
measuring health
can be found. Furthermore, it is essential to include basic factors at higher

structural levels to allow comparison of studies over time and between dif-
ferent countries or regions. Factors at different structural levels in society
that have been found to be of importance for women’s health are listed in
igure 4. the indicated factors can interact in different ways, resulting in
additive, multiplicative or counteractive effects. Furthermore, if the pur-
pose of a study is to identify risks and possibilities for preventive actions,
it is imperative that outcome measures are both detailed and speciic also
regarding diagnostic groups.
Workplace factors Local community factors National level

Size Organisation of the local Constitution
Category community State of the market
Characteristics of Demographic variables21 Socioeconomic conditions
employees19 Socioeconomic conditions Unemployment rate
Work organisation Labour market Employment frequency
Work content Types and varieties of in- and intensity
Status of workplace dustries and enterprises Composition of labour force
and occupation Unemployment rate Organisation and struc-
Socioeconomic conditions Local access to and prac- ture26 of labour market
Reorganization, now or tice of medical and of unpaid work
plans for and health care Gender differences27
Occupational health service Local practice in social Laws and actions against
Selection mechanisms in welfare and sickness gender inequity
and out of the work place insurance Norms for male and female
and occupation Schools22 behaviour
Retirement age Geographical area General attitudes28
Physical, chemical, Epidemics Organisation, practice
ergonomic, biological Level of crime and violence and accessibility of health
and psychosocial work Public transportation care29
environment Actions taken against gen- Design and practical ap-
Threats and violence der inequity plications of the social
Sex discrimination Public care of chldren, and sickness insurance
Sexual harassment the sick and elderly23 system30
Culture/attitudes20 General attitudes24 Degree of differences in
Pollution25 income distribution
Weather/climate
147
The female working population in Sweden

when examining the various aspects of the employed population that are
presented in igure 4, it soon becomes evident that, in an international
context, the situation of working women in sweden is unique. For instance,
the employment frequency is not only very high for both women and men,
but also fairly equal between the genders. the unemployment rate for both
women and men was very low, two per cent, until the beginning of the
1990s, when it rapidly rose to eight per cent. In 1992 only four per cent of
all women aged 20-64 worked solely in their homes.
moreover, to a large degree, the female working population is perma-
nently employed, although the number of persons with temporary jobs is
increasing. Due to extensive legal regulation of the labour market and terms
of employment, very few persons are completely dependent on the black
labour market.
most employees have ixed working hours and are members of a legal
labour union. For women it is rather easy to get a part-time job but often
dificult to ind full-time employment. In 1995, 45 per cent of employed
women and 71 per cent of employed men worked full-time (sCB 1996).
everyone who has reached the age of 65 is entitled to an old-age pension that
ensures a fair standard of living, and to a supplementary pension; the level
of the latter is related to earnings and the total number of years employed.
Periods of parental leave are also included when calculating old-age pension.
Furthermore, numerous steps have been taken to facilitate the employment
of persons with different types of handicaps and disabilities.
according to the public sickness insurance scheme all are entitled to
health care at very reduced costs and to sickness absence beneits based on
a percentage of their ordinary income. there is no limit to the length of a
sick-leave spell. maternity care and health care for children are free of charge,
as are family planning, abortion and sterilisation counselling services. the
decision to have an abortion is up to a woman during the irst 18 weeks of
pregnancy. a pregnant woman with monotonous or strenuous work can use
50 days of pregnancy leave with beneits. Parental allowance is granted for
450 days when a child is born; 60 of these days can be used before delivery.
Compensation is also paid to parents caring for a sick child for a maximum
of 60 days per year, until the child reaches the age of twelve. It is provided
148
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by law that women giving birth to or adopting a child have the right to
remain off work for up to 18 months and subsequently return to the same
work situation they had before their leave of absence. working mothers
also have the right to reduce working time by 25 percent until the youngest
child is eight years old.
there is good access to different forms of child care, arranged by the lo-
cal municipalities. Compared to other countries, a larger part of the care of
children and the sick and elderly is done by employed persons, mainly women.
accordingly, although most care tasks are still performed by women, without
pay, in many cases home help or nursing is provided through society. all
of the laws and oficial goals adhere to gender equity, which also is verbally
favoured by most swedes. Governmental societal policy objectives include
equally high labour participation by women and men, as well as gender eq-
uity regarding responsibilities, risks and rights. however, the possibility of
engaging private help for care and household work is limited.
From an international perspective, this means that the female working popu-
lation in sweden is unique with respect to such things as the healthy worker
effect, the possibility to combine motherhood with education or a career, and
access to social security. It is therefore extremely important that studies be per-
formed to analyse if and how the mentioned social circumstances affect health
and ill health. also of importance is distinguishing various aspects of the work
environment at different structural levels as a means of revealing the effects
of implemented measures on health. Considering present developments in
sweden, perhaps the employed population will represent a suitable object
of study, a “natural experiment”, for analysing the effects on public health
that are induced by a decline in the social security system and possibly also
by feelings of conidence or concern about the future.
Conclusions
the following issues should be considered when studying work-related health
among women in sweden:
• Different aspects of ill health are discerned depending on the types
of data used, that is, whether the data employed concerns mortality or
morbidity in terms of sickness, illness or disease.
149
• It is imperative that gender-sensitive research methods and theories be

developed that include both interdisciplinary approaches and utilisation
of quantitative and qualitative methods.
• knowledge is needed regarding the mechanisms and prevention of ill
health and the risk factors presently identiied. research is also required
to identify additional forms of ill health, risk factors, and health-promot-
ing factors in women.
• the salutogenic perspective, i.e. knowledge on health and health-
promoting factors, warrants further development, with special focus on
empowerment and supportive environments.
• the total life circumstances of women should be examined, including
aspects of paid and unpaid work, family and society. a life-course perspec-
tive would be useful in this context.
• Factors at different structural levels in society must be considered.
• sweden represents an excellent object of study when examining work-
related health in women, because it exhibits several unique features:
- a fairly equal and high employment rate among women and men.
- relatively speaking, a very high level of gender equity, health, living
standards, medical care, social security, and the possibility to combine
motherhood with paid work.
- the existence of several large national and local registers on health
determinants and outcomes that contain data of high quality and have
high response rates.
- the extent to which ill health is presently inluencing work capacity,
at a time when some of the advantages for women in the labour market
seem to be decreasing; the situation in sweden can be regarded as a large
natural experiment that will provide important scientiic knowledge con-
cerning effects on ill health.
notes
1. Good or poor health.
2. In terms of illness, disease and sickness.
150
measuring health
3. number and year of full-term pregnancies and induced or spontaneous abor-

tions.
4. length of cycle and of period. Date of last period. Physical or psychological
symptoms during cycle.
5. In terms of good or poor.
6. In terms of illness, disease and sickness related to psychiatric disorders; also
regarding everyday symptoms such as anxiety, worries, etc.
7. For example: passive/active, external/internal control, type a/type B, level of
hostility, sense of coherence, sense of control of destiny, feminine/masculine.
8. how much, how often interrupted, problems with sleep, getting enough sleep.
9. Individual strategies to handle new situations or reactions of stress.
10. Includes factors such as diet, physical exercise, alcohol consumption, use of
tobacco, risk-taking behaviour, sexual activities, exposure to the sun.
11. ethnicity, culture, how long in the country, knowledge of the predominant
language, and religion.
12. related to occupation, education, income (own and household income), back-
ground, and partner’s background.
13. Psychosocial work environment includes factors such as stress, sense of con-
trol, job satisfaction, social support, role conidence, reward for efforts, and the
possibility to learn new things.
14. In paid work: shift work, full- or part-time work, overtime, frequent change of
schedules, lexible working hours, having more than one job. In unpaid work:
when a during 24-hour period, actual time working and time on call.
15. type, size, condition, indoor air quality etc.
16. actual events or how these events are experienced by the individual.
17. quantitative and qualitative aspects of social network and social support.
18. single, married, cohabiting, widowed, divorced; number and age of children,
living with adults other than partner; size and health status of family. all as-
pects at present and in a life-time perspective.
19. age distribution, number employed in different work tasks, rate working part
time, employee turnover rate, health status, level of horizontal and vertical
gender segregation, rate of immigrants and different ethnic groups, educa-
tional level.
151
20. Including absence culture, illness behaviour, psychological contract at work

as well as attitudes towards women, work performed by women, and gender
equity.
21. Population density, age and gender structure, rate of immigrants, ethnic
groups, etc.
22. access to education at different levels, type of, quality of and costs for attend-
ing.
23. access to, cost and quality of.
24. towards gender equity, women in paid work, persons with different forms of
handicap or ill health etc.
25. of air, water, and food; electromagnetic ields, radiation (including radon),
level of noise.
26. Including gender segregation.
27. In income and access to different forms of power.
28. For instance, towards gender equity, ill health and health, preventive and
health-promoting measures.
29. Including contraceptives and legal abortion, as well as knowledge on and at-
titudes towards women’s health problems.
30. Including right to maternity and parental leave and economic and legal situa-
tion during such; quality and costs of care during pregnancy and delivery and
postpartum and health care of children.
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161
162
Chapter 6
the heart
— a weak sPot
164
the heart — a weak spot
Gender, work
and cardiovascular disease
by Peter Westerholm
this chapter deals with the differences between men and women that have
been observed with regard to risk of chronic heart and cardiovascular disease
— where cardiac infarction is one of several possible manifestations — adding
comments to these observed differences. In addition, issues which have arisen
in efforts to ind explanations for the differences due to social circumstances,
and work related factors, will be considered.
It is a known fact that men are at greater risk of coronary heart disease
than women. this risk can vary quantitatively by a factor of 2–6 and tends to
be higher in younger age groups. table 1 contains details of age standardised
coronary heart disease mortality rates for men and women in the 40–69 age
group in different countries.
the table shows that in most countries men are 3–4 times more suscept-
ible to heart disease than women and at higher risk in all countries. It is
important to note that even though the annual mortality rates per 100 000
in different age groups vary as widely as from 15 to 512, the difference
between the sexes remains relatively stable. this would indicate that the
factors which inluence the risk of coronary heart disease in men also affect
women, albeit to a lesser extent.
another statistical source which illustrates the difference between the sexes
is the heart attack register set up by stockholms läns landsting (stockholm
area health authority). From 1993 to the end of 1995 over 16 000 incident
cases of heart attack were recorded in Greater stockholm region, of which
4 007 were irst-time cases — 2 410 men and 1 597 women.
as table 2 indicates, the male bias in the risk of heart attack also continues
in higher age groups. the male/female risk ratio in the 75–79 age group is
165
Table 1. Age standardised chronic heart and cardiovascular disease mortality rates per
100 000 for men and women in the 40–69 age group in different countries 1987–1988.
Source: WHO Statistics Annual.
Country Men Women Ratio men/women
Northern Ireland 511.9 175.4 2.9
Scotland 507.3 183.2 2.8
Finland 469.1 114.9 4.0
Czechoslovakia 457.8 134.2 3.4
Ireland 456.5 144.1 3.2
Hungary 431.4 115.8 3.7
New Zealand 399.6 130.3 3.1
England and Wales 384.9 117.6 3.3
Norway 364.3 115.8 3.1
Denmark 306.7 89.2 3.4
Sweden 301.5 70.2 4.3
Israel 284.0 106.9 2.7
Australia 283.3 89.1 3.2
USA 282.6 101.7 2.8
Bulgaria 276.4 87.8 3.1
The Netherlands 260.1 65.6 4.0
East Germany 251.2 72.4 3.5
West Germany 244.1 62.4 3.9
Austria 239.5 64.8 3.7
Belgium 202.1 52.0 3.9
Greece 186.1 48.0 3.8
Italy 176.0 41.4 4.3
Poland 140.3 44.9 3.1
Spain 139.1 30.7 4.5
France 109.4 22.9 4.8
Japan 44.0 15.2 2.9
approximately 2:1, while the ratio in the 45–49 age group is approximately
5:1.
Both behavioural factors, mainly attributed to those grouped under the
heading of lifestyle, and biological explanations have been put forward to
explain this sex differential. For instance, male lifestyles can include a greater
aggregation of risk factors compared with female lifestyles. an alternative
explanation is that women are biologically less susceptible to coronary heart
disease or the various risk factors that contribute to this risk. this would
mean that men react more to fatty foods, or higher levels of serum cholesterol
leading to a more rapid development of diseases linked to hardening of the
166
Table 2. Incidence of irst-time heart attacks in Stockholm 1993–1995, in categories of age,

cases deceased and cases per 10 000 population in age segment. Source: Stockholm Area
Health Authority (see Hammar et al. 1998).
Men Women
Age Total Deceased Per 10 000 Total Deceased Per 10 000
30–34 5 0 0.7 2 0 0.3
35–39 17 5 2.7 3 1 0.5
40–44 44 6 7.3 10 2 1.7
45–49 107 21 16.0 22 5 3.3
50–54 161 35 28.6 28 8 5.1
55–59 173 49 43.0 55 15 13.5
60–64 218 68 65.2 75 25 20.5
65–69 299 99 96.1 125 37 33.2
70–74 439 187 146.2 253 99 63.4
75–79 401 193 194.7 319 136 99.4
80–84 346 184 267.5 378 203 148.0
85–89 200 123 365.0 327 185 218.5
30–89 2 410 970 49.1 1 597 716 29.7
arteries which affect the heart’s coronary arteries. such factors can naturally
be affected in different ways by factors linked to the social environment or
lifestyles such as physical activities or hormonal relationships (for a review
of these issues, see khaw and Barrett-Connor 1994).
Gender differences in health behaviour and treatment

In considering gender differences observed in coronary heart disease mortality
and related disease incidence it should be kept in mind that there are studies
suggesting differences between men and women with regard to diagnosis
and treatment. wenger (1998) has summarized the observations supporting
the notion that coronary heart disease in women is subject to less aggressive
diagnostics and management in comparison to male. wenger makes the
point that cardiologists in the us have, in relation to coronary heart disease
diagnosed in men, neglected those occurring in women on all levels includ-
ing prevention, diagnostic procedures and therapeutic action. this point is
supported by the observations made by Dellborg and swedberg (1993) in
reporting less frequent use of both surgical and thrombolytic therapies in
coronay care units (see also krumholz et al. (1992).
167
as a diagnostic factor with obvious practical importance Dellborg (1998)

has also observed that men have more distinct ischemic electrocardiograph-
ically registered st-changes than women with cardiac infarction. this has
the practical implication that whenever st-changes are used as a criterion
for initiating aggressive therapy, women will be disavantaged.
Gender differences and known risk factors

when the gender differentials in coronary heart disease risk were irst
observed, many researchers found it attractive to link them to differences
between men and women in the incidence of already known risk factors such
as high blood pressure, high levels of cholesterol in the bloodstream, and
tobacco smoking. these risk factors are often more common in men than
women. It has, however, become increasingly apparent that this fact cannot
explain — at least not more than partially — the sex differential observed.
smoking is generally, but not always more prevalent in men. women have,
as a rule, lower blood pressure and lower cholesterol levels pre-menopause,
but this can rapidly change at the onset of the menopause. Despite this, the
sex differential in the risk of heart attacks and fatal coronary heart disease
continues well into the upper age groups (see wingard 1984).
an attractive explanation is naturally the obvious differences that exist
between men and women in respect of hormonal factors. Common sup-
positions have been that endogenously produced oestrogen in women can
be a protective factor against the development of coronary heart disease,
and that male sex hormones can cause an increased risk in men, respec-
tively. one should, however, be aware that the proof for this assumption
is tenuous and that the studies which have been done have primarily been
geared towards men and women who are prescribed hormone treatment for
medical reasons. Consequently there are numerous epidemiological studies
showing a distinct reduction in the risk of coronary heart disease in women
who have been prescribed hormone replacement therapy after the onset of
the menopause. this can be combined with the observation that women
who reach the menopause prematurely following a hysterectomy run an
increased risk of chronic heart and cardiovascular disease. this increased
risk can be counteracted with hormonal replacement therapy (hrt) (see
Bush and Barrett-Connor 1985; stampfer et al. 1985). In this connection it
168
is of interest to note that hrt post menopause has been observed to lead to
increased levels of hDl cholesterol and reduced levels of lDl cholesterol
in the bloodstream (see hirvonen et al. 1981; matthews et al. 1989). on the
other hand, hrt does not appear to provide any protection against coronary
heart disease for men.
one is forced to accept that even if post-menopausal hrt seems to offer
a degree of protection, this is not the case for men, and nor for pre-meno-
pausal women. the problem of interpretation which arises with studies such
as those referred to here, is related to the fact that hrt medication is com-
monly carried out at dosage levels which are not physiologically relevant.
Furthermore, one cannot simply discount the fact that other hormones may
also play signiicant roles in this context, something which, as a rule, has not
been taken into consideration.
where information on the endogenously produced sex hormones and the
risk of coronary heart disease are concerned, there is a striking absence of
unequivocal indings. this is largely due to problems of methodology. sex
hormone determinations have been time consuming and expensive and, at
the same time, they have been dogged by uncertainties as to reliability and
precision.
to sum up, it is fair to say that the role of sex hormones can offer an in-
tuitively attractive explanatory model but that, in actual fact, there appears
to be only tenuous proof that high endogenous levels per se are a protective
factor against coronary heart disease in women. In the same way, it is un-
certain whether endogenously produced male sex hormones per se, increase
the risk of heart and cardiovascular disease in men.
Psychological and social factors

From the survey of literature on the subject, it is clear that factors such as
smoking, high blood pressure, high fat diets, high lipid blood levels — referred
to here as conventional risk factors — have only weak predictive capacity when
it comes to assessing individual risk of cardio vascular heart disease. this is
true for men and — as it seems, even more so — for women. other factors
have been cited as explanatory reasons. these include social, psychological
and behavioural factors which in recent decades have been the subject of
considerable research for men, but much less for women (see la Croix 1994;
169
orth-Gomér 1998). In these studies, psychologic stress factors, a lack of

social support and personality factors (so called type a behaviour) have been
put forward as contributory factors to an increased risk of coronary heart
disease. In the case of women, there have been signiicantly fewer studies on
these subjects and it is therefore uncertain whether the conclusions that have
been drawn can be applied to women without reservations. Clearly, there
are major differences between the sexes in this respect. men spend more
time than women in paid employment. women generally experience more
conlict between work and family than men. added to this, women and men
often have differing employment conditions. In addition, as mentioned above,
the comparative biological prerequisites for the development of heart and
cardiovascular disease in men and women can be very different indeed. In
men, work-related psychologic stress has been put forward as an important
contributory factor in coronary heart disease (see karasek and theorell 1990;
orth-Gomér and schneiderman 1996; theorell 1994).
In many of these studies observations have been made suggesting that
work-related mental strain, as deined by karasek and theorell’s demand-
control model, increases the risk of fatal heart and cardiovascular disease and
also the risk of heart attack. schnall and landsbergis (1994) summarised a
survey of epidemiological studies in this area with the statement:
“in those cases where comparisons could be made between the sexes, ef-
fects [of work-related mental strain] of the same magnitude can be shown
in both working men and women.”
to sum up, the effects of work-related psycho-social and social stress fac-
tors do not seem to differ for men and women. It should however be added
that those studies which were examined by schnall and landsbergis did not
include a review of non-work-related stress factors. this is an important
reservation, as the social role of women in modern society to a large extent
includes assuming responsibility for home and family duties with the attend-
ant signiicant stress this may entail when off work.
For instance, the association between work-related stress and overtime
work and the risk of heart attacks in men and women, was studied by hammar,
alfredsson and theorell in 1994. the study revealed a connection between
increased risk of heart attack and work-related psychological stress. this was
170
true for both men and women. the exception was the factor overtime work.
It was observed that men with much overtime work were at a lower risk of
coronary heart disease compared with the risk in the general population. For
women who did more than 10 hours overtime a week, the equivalent risk
increased by 30 per cent, again in comparison with the risk in the general
population. one attractive explanation for this is that this studied group with
responsibilities outside work added to the work related stress gave rise to
a high overall work load and, accordingly, the risk of cardio vascular heart
disease. the division of paid and unpaid work respectively between men
and women in sweden has been more closely investigated and reported by
Frankenhauser, lundberg and Chesney (1991).
Social support and cardiovascular disease

studies of men have shown that different forms of social support can protect
against many kinds of health disorders, and particularly the incidence of
fatal heart and cardiovascular disease (see Berkman and orth-Gomér 1996;
Chesney 1992).
when looking at surveys of social support, it is important to remember
that the quantity and the quality of the social support can be an issue. It is
far too simplistic to merely count the number of contacts without paying at-
tention to the quality. the functional dimensions which are usually included
in the concept of social support are as follows:
• emotional support or attachment, usually from close friends or family
members,
• material or instrumental support, involving practical help,
• guidance support, involving good advice and help in identifying, evalu-
ating and overcoming problems and dificulties,
• afiliation, involving the need to belong to, and feel an afiliation with,
groups with whom one shares interests and values.
emotional support is usually provided within the family and close circle of
friends. the last three kinds of support named above are often found in an
extended social network, e.g. at work, where guidance, advice and practi-
cal help may be obtained and a sense of afiliation and belonging may be
experienced.
171
as mentioned above, there is a good deal of scientiic support for the no-
tion that active, positive support leads to improved health and to prevention
of cardiovascular disease. one should, however, be aware that the associa-
tions between social support and the risk are complex, and especially so for
women. accordingly, marriage can be a source of emotional support but it
may at the same time also be conducive to caring obligations and respon-
sibilities which may become psychologically burdening. the studies which
have been carried out to date, have primarily focused on the social support
received by study populations studied. only to a limited degree have such
studies considered the individuals who provide this social support. In other
words, extensive social support may become a burden.
In an overview of the current level of understanding and scientiic debate
on the differences between the sexes with regard to the connection between
social support and health, shumaker and hill (1991) point out that such
proven differences can stem from:
• differences between the sexes with regard to receiving or providing social
support and the composition and functions of the supporting network,
• differences in the mechanisms through which social support affects
health,
• differences in mortality and morbidity.
Social strata
In recent years, the signicicant social differences in heart and cardiovascular
fatalities have been observed in both international and swedish literature on
the subject. socially disadvantaged and underprivileged groups or population
segments in the industrialised world are at greater risk of suffering heart
and cardiovascular disease than those which are well educated, have a good
economy and enjoy high professional and social status.
on a closer look, these differences, which include social class, have
been found at least partly to be age dependent and that for both men and
women the social inequality in heart and cardiovascular disease mortality
diminishes with age. the fatality is most socially divisive in the 30–35 age
group, but becomes less so with increasing age. this pattern is particularly
172
evident in men. For an overview of this literature and references, see sBu
(1997).
socio-economic grouping describes an individual’s social position within
a society. the basis for social stratiication in a society can vary over time.
there are different methods of measuring social and socio-economic status.
a person’s status in this respect is clearly linked to health. the upper stratum
according to such a ranking scale, generally speaking, has a higher degree
of inluence and control over their own life and circumstances, income,
education, standard of home, opportunities and freedom of action in their
choice of lifestyle and many other things. these observed differences in the
risk of heart and cardiovascular disease between socio-economic segments
cannot be easily explained by the differences in the incidence of hitherto
known risk factors. they explain partially but not fully the difference be-
tween socio-economic groups in risk of heart attack. the contribution of
work-related factors in the form of work-related psychological stress have
been put forward by a growing number of research groups in recent years
(see marmot et al. 1997).
the question of how and to which extent the socio-economic differences
in the risk of heart and cardiovascular disease can be explained by the effects
of already known risk factors, such as smoking, high blood pressure, over-
weight, high fat diet, high lipid levels in the bloodstream, etc., constantly
recur in the medical scientiic debate. many estimates have suggested that
these known factors represent slightly less than 50 per cent of the risk dif-
ferential. a common belief is that work-related mental strain is an impor-
tant contributory factor, partly to the risk per se, and partly — as claimed
by some authors — also to the socio-economic risk gradient. there is a
great deal of uncertainty in these types of estimates. notes of warning have
been expressed by hallqvist and colleagues (1998) with a reminder that the
causal mechanisms behind the diseases and the mortality observed are not
known. this means that for example if (a hypothetical case) 23 risk factors
that have been identiied as making up 100 per cent of the risk differential
between socio-economic groups, one could still discover a 24th factor which
can explain up to 100 per cent of the same differences. In which case, this
could depend on the interactive effect between this most recently identiied
173
factor and the previously known 23. In general, the differences in observed
risk can depend on:
• difference in exposure,
• difference in susceptibility.
susceptibility here refers to various individual characteristics such as genetic
and immunological make-up and also perceived social support or control
— alternatively their absence — at the workplace.
If the onset of illness is dependent on the presence of a large number of
causal factors in suficient quantity and intensity, all necessary factors have to
be present and in operation at some time during the whole process of disease
development. If the set of necessary factors is incomplete nothing will occur
— by this we mean that there is no clear manifestation of risk to be seen
— until the missing necessary factor(s) appears. It is only when the complete
set is in place that the necessary conditions arise for an evident manifestation
of risk. the determinant factors in this causal web, where interaction between
several factors determines the outcome, may be sex dependent.
when it comes to the socio-economic differences in the risk of heart
and cardiovascular disease, it has been possible to explain, in line with the
growth in the number of risk factors which have been identiied, the excess
risk in lower socio-economic groups. many questions remain to be answered,
however. Is it the number of socially unevenly distributed risk factors which
are signiicant or are some factors of greater signiicance than others? what
is the reason for the accumulation of risk factors in certain social groups?
how do the various risk factors affect each other in certain social groups?
are there some causal factors still not yet identiied contributing to the social
differences in disease or mortality risks ?
a fundamental question in this context concerns where and how the sex
factor could play a part in the causal chain. as there are many types of risk
factors in personal characteristics, lifestyle and social and cultural factors,
which can each contribute to the risk, we have in reality a complex and mul-
tifaceted collective risk structure. Does the sex factor inluence directly one
or several of these factors, or does it in some way affect their interaction?
when seeking explanations for the associations between disturbances of
health or illnesses and psychological, social and environmental factors, it may
174
be helpful to structure the issues involved using the general model for the
interaction between stresses, hereditary factors, experiences and reactions
originally introduced by kagan and levi (1971). the model has later been
modiied and amended in several important regards by theorell (1991) taking
into account the dynamic nature of our interactions with our environment.
our perceptions of and reactions to environmental conditions form the basis
of experiences which in turn affect selection and use of coping strategies. It
can also be used as a formalised model for how a person’s immediate environ-
ment can trigger reactions of importance for the development of, for instance,
heart and cardiovascular disease. In the box containing the term “individual
program” in the illustration below are included the strategies we all may use
in coping with a mentally stressful situation. mental strain is, in other words,
something we experience ourselves and also something we manage and try
to eliminate or relieve by “coping” (see chapter 3). we can be more or less
successful in doing this, which means that we can react physiologically or
psychologically in such a way and with such an intensity that we become
susceptible, or disposed, to develop a health disorder. Both personality factors
and previous experiences can be of signiicance in this regard.
Figure 1. Theoretical model of the relation between surroundings, individuals and reactions.
Source: Theorell (1991) modiied from Kagan and Levi (1971).
175
when considering a model such as the illustration above, it should be

borne in mind that the environmental conditions may have an effect on the
health of the person exposed to them either as a direct effect or, indirectly, via
the perceptions or emotions they may induce. Combinations are, of course,
quite possible. this relationship between what is sometimes referred to as
“objective” and “subjective” effects, respectively, of working conditions con-
stitutes in fact a major fundamental conceptual and methodological issue in
social and working life research. this may for instance apply to work-related
stressors. the “objective” model usually refers to work-related circumstances
based on a theoretical model identifying the factors at the workplace or in
the social environment judged to be most important as health determinants.
the “subjective” model uses the person’s perceptions of the situation at work
or in life for point of departure. one source of dificulties in the “subjective”
model are the substantial variations in individual experiences. a work situa-
tion or work task described and deined by objective means, in as far as this
is possible, may be perceived and experienced very differently by different
persons. this may depend on previous experiences, social background, ex-
pectations, personality and a whole range of other factors. Contextual factors
may also have an inluence on how a situation is perceived. appalling working
conditions may be experienced as quite reasonable and indeed acceptable if
it is the only work available and the alternative is unemployment.
In reviewing data on gender differences in heart and coronary artery
disease where factors in the psychological and social environment are re-
ferred to as explanations for gender differences, one should be aware that
there are many good reasons for differentiating between men and women
in epidemiological studies — which is in actual fact standard practice — and
simply proceeding from the view that receptivity for heart and coronary
artery disease can differ between men and women. It can involve differences
related to differences in exposure to or differences with regard to effects of
risk factors which come into play separately or in combination in a causal
chain of events. Diderichsen and hallqvist have formalised the following
model in studying socio-economic health differentials:
one type of risk determinant may be represented by socio-economic status,
sex, race or geographic region. a different type of risk factor is for instance
176
Figure 2. Two different mechanisms within a web of causation showing how socio-economic
status and job strain might be interrelated in producing myocardial infarction.
Source: Hallqvist et al. (1998).
tobacco smoking, work-related psychological stress, biochemical parameters

of various kind or some other known or unknown risk factor.
effect path I implies that social position inluences a person’s smoking
habits. smoking is a well known risk factor for heart and cardiovascular
disease. the increased risk is clearly dependent on how much the person in
question smokes, or has smoked, and the duration of the smoking habit.
In the second effect path (II), social position inluences the individual’s
susceptibility with regard to health consequences of smoking. In this model,
a totally different kind of causal mechanism is construed. the model starts
from the assumption that the observed health-event phenomenon is not
caused by one single factor, such as smoking, but rather a number of mutually
interacting factors, including job strain. For a risk situation to arise, all these
factors must be present — possibly also in a certain quantity and intensity
— either currently or in the past. It may also be possible that they act in a
particular time sequence, which implies that they are not necessarily required
to be present at the same time. If one of the necessary risk components is
missing, this means that the risk will not be triggered. one of the corollaries
inherent in this model may also be that the risk factor component having the
lowest concentration or representing the lowest exposure may determine the
ultimate manifestation of risk.
177
with the aid of such formalised models, risk factors and risk modifying
factors can be manipulated in epidemiological analyses. In so doing, the ef-
fect of one factor at a time may be investigated and, in using the model its
interaction with other factors and personal characteristics (see hallqvist et
al. 1998 for an analysis of observations and data in the sheeP study).
the relationships between work, mental strain and health are very
complex indeed. Physiological and mental reactions to stress are modiied
by such factors as personal coping capacity and work stimulants, social
support, emotional ties to work and work colleagues, work content, home
and family relationships, to mention some of the most important factors to
consider. In examining all these sets of factors, differences between men and
women may emerge on an aggregate level. once and for all, it is important
to remember that the individual variations are signiicant, meaning that we
are well advised in adopting a cautious stance when confronted with general
and sweeping judgements on how men and women, respectively, behave in
general (see chapter 3 and 4).
In a 1989 study of a major swedish industrial company Frankenhauser
et al. recorded physiological and psychometric stress indicators in a group
of employees at middle management level who did work which could be
considered as mentally stressful. It appeared that the women took longer to
recover after work than men. this was interpreted as relecting the dificult-
ies of the women, due to home and family commitments, in securing the
necessary recovery time at the end of their working day.
to sum up, the question that must be addressed is whether the observed
differences in risk for men and women affect our view on prevention. strictly
speaking, they should not. there is no reason for the a priori assumption that
the complex network of risk- and causal factors for cardiac infarction and
heart and cardio vasculardisease in women in any speciic or conclusive way
operates differently from that of men in a qualitative respect. Clearly there
may be considerable quantitative differences concerning both exposition
and susceptibility, but one should bear in mind that chronic heart disease
is highly prevalent in both men and women. In a scientiic approach there
is a natural ambition to clarify as far as possible the possible differences in
risk, irrespective of whether these can be attributed to differences in contact
with, or exposure to — in terms of occupational hygiene — risk factors or,
178
alternatively, differences between the sexes with regard to susceptibility.

For the practical purposes of disease prevention and health promotion, the
differences between the sexes actually appear to be less pertinent than the
similarities.
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Bush t l & Barrett-Connor e (1985) non-contraceptive oestrogen use and cardio-
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Chesney m & Darbs l (1998) social support and heart disease in women — impli-
cations for intervention. In: orth-Gomér k, Chesney m & wenger n (eds.)
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Dellborg m (1998) less prominent electrocardiographic changes during myocardial
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Disease. lawrence erlbaum associates, new Jersey, pp 19–24.
Dellborg m & swedberg k (1993) acute myocardial infarction; Difference in treatment
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hammar n, alfredsson l, theorell t. (1994) Job characteristics and the incidence
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181
182
Chapter 7
hazarDous ContaCts
For soFt skIn
184
hazardous contacts for soft skin
work-related skin disease

by Birgitta Meding
Introduction
skin disease caused or worsened by factors in the working environment is one
of the most commonly occurring work-related illnesses. the predominant
condition is hand eczema, since in many jobs the skin on the hands is subjected
to damage caused by contact with skin irritants and allergens. unequivocal
reports in industrial injury registers, epidemiological studies and clinical
records indicate that women are affected far more than men. however, oc-
cupational skin disease has never been studied from a gender perspective to
any great extent. a summary of a number of dermatological text books was
drawn up in 1996 at the university of linköping Faculty of health sciences
(rosdahl and Coble 1996), which aimed to study how the authors of the
books had treated existing sex differences for skin diseases in their presen-
tation. these text books contain a collective overview of knowledge within
the area of dermatology, and are used in areas such as medical training and
as reference books by both dermatologists and other categories of doctors,
as well as by other medical personnel. the analysis showed that the gender
perspective had largely been overlooked, even for common dermatoses such
as hand eczema, clearly documented to be predominant among women. hand
eczema caused by exposure to wet work, irritant dermatitis, is still in the
1990s often called “housewife’s dermatitis”, even though the woman’s role as
a housewife has been replaced by an occupational role in the modern western
society. many cases of irritant dermatitis on the hands are clear occupational
injuries. examples are also given of how a teasing tone is sometimes used,
for instance to describe nickel allergy. measures for analysing causes and
prevention of occupational dermatoses have to date been covered to only
185
a modest degree in relation to how common these complaints are, and the
impact they have on society and the individual. one possible explanation is
the uneven distribution between the sexes and the fact that the most highly
affected occupations are typical female occupations. the fact that women are
treated unfavourably in terms of rehabilitation has recently been pointed out
in a report from the national social Insurance Board (marklund 1997).
Hand eczema
hand eczema accounts for an estimated 90 per cent of skin disease caused by
factors in the working environment. In many jobs, the hands act as a working
tool, and can come into contact with substances which harm the skin. eczema
is an inlammation of the skin. Eczema caused by external factors is called
contact dermatitis, and can arise in various ways, either by a contact allergic
reaction or through a direct injury to the skin by chemicals or mechanical
factors. Exposure to airborne substances can give rise to symptoms appearing
also on other parts of the body, especially on skin unprotected by clothes,
such as the face. there are also other types of eczema than contact dermati-
tis, known as endogenous eczema, of which the causes are not fully known,
though external factors appear not to bear such a great signiicance. however,
exposure to skin irritants can in many cases contribute to a deterioration in
condition. there is a clear connection between heredity and environment
as regards the risk of developing hand eczema, and this is described further
in the section “risk factors”.
hand eczema can have a tangible effect on society and the individual in
the form of care consumption and sickness absence, and in a few per cent of
cases a change of job is inevitable. in a population-based survey 69 per cent of
individuals having hand eczema reported medical consultations, 21 per cent
reported sick leave for more than seven days and eight per cent had changed
job because of the hand eczema (Meding 1990). for more than half of those
who had been on sick leave, the total sick leave time was more than eight
weeks; the mean was 19 weeks. hand dermatitis also has an impact on the
individual’s quality of life. in the study mentioned above, over 1 000 people
who suffered from hand eczema were interviewed about how the condition
affected their working life, private life, sleep and mood. Eighty-ive per cent of
the women and 74 per cent of the men reported some kind of negative effect
186
on their everyday lives. restraining effect on leisure activities and handicap

in occupation was each reported by half of the individuals and disturbances
of sleep and mood was admitted by one third. negative inluence of the hand
eczema on social contacts was also experienced by one out of three. Women
reported a higher degree of discomfort in most of the questions.
Occurrence
different countries have different systems for registering industrial injuries,
and different rules regarding which illnesses are covered by industrial injury
insurance. in the swedish system, musculoskeletal conditions have been ap-
proved as industrial injuries on a relatively broad basis, and these conditions
are predominant in swedish industrial injury statistics, skin diseases being the
second most common recorded condition (arbetarskyddsstyrelsen/swedish
Board for occupational safety and health 1995). reports are registered by
the occupational injury information system with the arbetarskyddssty-
relsen. a compilation has been made of all reported cases of occupational
skin disease in sweden in 1980–92 (hedlin et al. 1994). this indicates that
the number of reported cases of skin disease per thousand paid employees
during the whole period was higher for women than for men, and twice
the number of cases were reported in the 16–24 age group compared with
other age groups, see igure 1. Young women therefore constitute a clear risk
group for work-related skin disease. in a report regarding danish industrial
injury statistics for the years 1984–91, two thirds of the eczema sufferers
were women (halkier-sørensen 1996). figures taken in other countries
also indicate a clear over-representation among women (Cherry et al. 1994;
diepgen et al. 1991; Vital and health statistics 1997).
Epidemiological studies of hand eczema also show that women are more
often affected than men. during the 1980s, the occurrence of hand eczema
in Gothenburg was studied using a postal survey to 20 000 randomly selected
people of working age, 20 to 65 years (Meding 1990). the diagnoses were
veriied by clinical examination. the reported 1-year prevalence for women
was 15 per cent, and for men nine per cent. it also become clear that young
women were most affected with a 1-year prevalence of 19 per cent in the
20–30 age group, see igure 2. the results indicated twice the prevalence
187
Figure 1. Frequency of skin disorders reported to the Occupational Injury Information Sys-
tem in Sweden 1980–92 Source: Hedlin et al. 1994.
Number per
1,000 employed
2.0
women age 16–24 men age 16–24
women age 25–64 men age 25–64
1.5
1.0
0.5
0
1980 1982 1984 1986 1988 1990 1992
of hand eczema compared to a similar study conducted during the 1960s

(agrup 1969).
Very limited information is available in dermatological literature on the
incidence rates of hand eczema, but several epidemiological studies are un-
der way in which this illness occurrence parameter is being used. a current
swedish survey-based study has found an incidence rate of hand eczema
among women of 11.3 cases/1 000 person-years, compared to 4.4 cases among
men, in a number of randomly selected subjects from the population, which
involves a relative risk of 2.6 (Brisman et al. 1998).
Irritant dermatitis
the most common type of hand eczema is irritant dermatitis, an effect of
repetitive damage on the skin. Early symptoms are dry, chapped skin. the
most common cause is wet work, i.e. skin contact with water and detergents.
Many female-dominated occupations involve extensive wet work. this applies
188
Figure 2. 1-year prevalence of self-reported hand eczema in relation to age and sex.
Source: Meding 1990.
Percent
20 women
men
15
10
20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 Age
to most occupations in care and in the service sector, such as hairdressing,

catering and cleaning. Contact with water and detergents harms the protec-
tive skin barrier, which makes it easier for skin irritants and contact allergens
to penetrate the skin and give rise to eczema. since women are affected by
irritant dermatitis to a greater extent than men, the question has arisen as
to whether women have more sensitive skin. skin irritation can be studied
using several objective methods. Most common is to measure trans epidermal
water loss (tEWL) by evaporimetry and the blood low using laser dop-
pler technology. Major differences have been observed between individuals,
although no difference between the sexes has as yet been conirmed (agner
1992). Gender differences in irritant dermatitis are therefore most likely due
to differences in exposure. Exposure at the workplace is probably the most
important factor due to the amount of time spent at work, although many
women spend a further number of hours performing wet work at home,
especially young women with small children. a prospective study of female
189
nursing staff in northern sweden showed that the presence of children un-
der four in the family and the absence of a dishwasher increased the risk of
developing hand eczema fourfold (nilsson et al. 1985).
Allergic contact dermatitis

allergic contact dermatitis occurs on contact with certain substances. the
immunological background is a cell-mediated reaction in the skin, called type
iV reaction, or a delayed hypersensitivity. Contact allergy is never congenital,
but contracted by exposure to the relevant allergen. individuals probably have
a varying propensity to develop contact allergy, although no deinite genetic
markers or gender differences have been identiied. the most signiicant
factor to contact allergy development is the degree of exposure regarding
the concentration of the allergenic substances as well as the duration.
to date, over 3 700 different substances have been identiied which can
cause contact allergy (de Groot 1994). these substances have a low molecu-
lar weight, below 1000. to form a complete allergen/antigen a binding to
proteins in the skin takes place. it takes at least one week after exposure to
develop contact allergy (sensitization) and symptoms manifest themselves
as an inlammation in the skin — eczema at the point of contact. on further
contact, the symptoms appear earlier, normally within 24–48 hours. some
very potent contact allergens can sensitize at the irst contact, while less
potent allergens tend to sensitize only after years of exposure.
in order to determine whether a person has contracted contact allergy, a
patch test is performed by a dermatologist. test substances are applied to the
skin during a 48-hour period using adhesive tape, and the results are read,
preferably on two occasions, after three to seven days. the most common
contact allergens are nickel, perfume agents, rubber chemicals, preservatives
and colophony (natural rosin). these substances are present in our everyday
environments at home, at work and at play. only limited details are available
regarding the occurrence of contact allergy among the population. a danish
population-based study showed that 19 per cent of the female subjects and
twelve per cent of the men gave at least one positive reaction in the patch
tests (nielsen and Menné 1992). this would suggest that a gender difference
does exist, though this requires further investigation.
190
Nickel allergy
nickel allergy is the most common contact allergy, and is one area in which
a pronounced gender difference does exist. at least ten per cent of women
in the nordic countries are allergic to nickel, but only one to two per cent
of men (Menné et al. 1989). nickel allergy is more common among young
women (approximately 20 per cent), and is common even among schoolgirls
(Larsson-stymne and Widström 1985). Many develop their allergy through
contact with jewellery, watches and metal clothing details. Ear-piercing in-
volves a risk if nickel-emitting jewellery is used. over time, 30–40 per cent
of people who are allergic to nickel develop hand eczema. these eczemas
can be extremely troublesome, and have an impact on work ability in manual
occupations. for nickel allergy sufferers, wet work involves an increased risk
of developing hand eczema, as water and detergents harm the skin barrier,
so that much less nickel is required to cause or worsen hand eczema. other
often occupationally used objects which emit nickel are coins, keys and hand
tools (Lidén and röndell 1997). nickel hand eczema can become chronic
— most probably due to the fact that it is dificult to completely avoid nickel
contact in everyday life — and can lead to long-term sickness absence or
even forced early retirement (Menné and Bachmann 1979).
Risk factors
hand eczema occurs as a result of exposure to skin irritants and allergens,
but endogenous factors are also of importance. one particular factor of
great signiicance is atopy. atopy denotes a hereditary propensity to develop
allergic rhinitis, asthma or atopic eczema. atopic constitution is very com-
mon among the scandinavian population — at least one third are atopics.
in recent decades, symptomatic atopic disease has become more common.
it has not been possible to identify the cause of this increase with any cer-
tainty, though there is much to indicate that factors in the western lifestyle
bear some signiicance. several major studies have shown a clear connection
between atopic eczema in childhood and hand eczema in adulthood (Lam-
mintausta and kalimo 1981; rystedt 1985). a population survey of hand
eczema conducted in Gothenburg in the 1980s indicated a threefold increase
in the prevalence of hand eczema among individuals who had suffered from
childhood eczema (Meding 1990). according to population-based studies
191
in scandinavia, the female/male ratio of atopic eczema is about 1.4:1, which

may also contribute to the higher prevalence of hand eczema among women
(schultz Larsen 1993). People with atopic eczema have more sensitive skin,
which is why hand eczema is more easily contracted when exposed to skin
irritants. this should be borne in mind in situations where people who have
suffered from eczema in childhood are choosing a career, in order to avoid
any troublesome hand eczema symptoms in the future, with such potential
consequences as sickness absence and job changes.
Grading the risk of hand eczema in different types and degrees of exposure
is not easy, and has not been researched enough. a study of certain swedish
industrial injury records showed that in half the reported cases, exposure to
water and detergents had been given as the cause of the skin disease (Med-
ing and Bengtsson 1994). in practice, wet exposure probably also accounts
for a further proportion of the number of eczema cases. nickel stands on
its own as the major contact allergen, although contact allergic reactions to
perfume agents and preservatives are also given as causes of, or detrimental
factors, in many types of hand eczema. another common cause of work-re-
lated skin conditions is allergy to glove materials, particularly rubber, which
can cause contact allergy to rubber chemicals, and igE-mediated allergy to
natural rubber latex.
Wet work
Wet work is a well-documented risk factor for hand eczema, and is the single
most signiicant exposure factor in the development of hand eczema. in a
survey-based study of hand eczema in female cleaners in denmark, just over
80 per cent reported wet hands for over a quarter of their working time, and
there was a positive correlation between the number of hours per week the
hands were wet and skin disease symptoms (nielsen 1996).
a finnish follow-up study of people with atopic eczema in childhood
found that 90 per cent of subjects performing wet work for two hours or
more per day developed hand eczema (Lammintausta and kalimo 1993).
as described above, water and detergents have a direct impact on skin ir-
ritation. More recent research has also shown that ingredients in everyday
detergents (surfactants) have an allergenic effect (Bergh et al. 1997; 1998a;
1998b). Ethoxylated surfactants can be oxidised by oxygen in the air during
192
storage and handling. formaldehyde has been found to form in the products,
together with substances that have shown to have contact allergen potential
in experimental studies on laboratory animals. it is not yet certain to what
extent this is also a problem as regards hand eczema in wet work, although
research is ongoing.
High-risk occupations
risk occupations for hand eczema are primarily those in which the skin on
the hands is exposed to water and detergents to such a degree that the skin
barrier is harmed. if the job also involves exposure to substances which can
cause contact allergy, the risk of hand eczema is even higher. industrial injury
statistics provide an indication of the occupations in which the most skin
damaging exposure exists. it is reasonable to assume that the problems of
working in these occupations with an established hand eczema are greatest,
and have contributed to the illness being reported as an occupational illness.
figure 3 shows which occupations in sweden have the highest number of
reported cases of occupational skin disease in relation to the number of indi-
viduals employed in each occupation. this clearly indicates that most cases
occur within female occupations involving extensive wet work.
the fact that these occupations involve an increased risk of hand eczema
has been reported in several publications. it is well known that hairdressing is
a high-risk occupation in terms of hand eczema (Conde-salazar et al. 1995;
frosch et al. 1993; van der Valle and Brunsveld 1994). one population-based
study (Meding 1990) indicated a signiicantly higher prevalence of hand
eczema among female cleaners (22 per cent) than in other occupations, and
several other studies report a high risk of hand eczema in this type of work
(hansen 1983; nielsen 1996). food handling and bakery work are other
risk areas with a high occurrence of hand eczema, especially among women
(Brisman et al. 1998; tacke et al. 1995).
nursing involves extensive wet work, and the sector predominantly em-
ploys women. Cumulative prevalences of hand eczema of between 30 and
40 per cent have been reported in sweden and finland (Lammintausta and
kalimo 1981; nilsson et al. 1985 ). in the netherlands, a 1-year prevalence of
hand eczema of 30 per cent has been noted among nurses (smit et al. 1993).
on comparison with population data, an age-adjusted prevalence ratio of 2.2
193
Figure 3. Occupational groups with an elevated incidence of reported skin disorders

1990–1991. Source: Hedlin et al. 1994.
women
Hairdressers
men
Machine fitters
Cooks
Cooks
Dental assistants
Mechanics
Cleaners
Kitchen assistants
Nurses
1 2 3 4 5 6 Relative risk
was found for female nurses. at an italian hospital, the risk of hand eczema
was found to be highest among young female nurses (stingeni et al. 1995).
Because of the risk of blood-transmitted infections, protective gloves are
used extensively in nursing. in recent years, many employees in the nurs-
ing sector have developed an igE-mediated allergy to natural rubber latex.
apart from nettle-rash on the skin, symptoms have included rhinitis and
asthma, and some cases have resulted in serious general allergic reactions,
anaphylaxis. rubber latex allergy is reported to affect up to 17 per cent of
nursing staff who use protective gloves (turjanmaa et al. 1996). since the
majority of nursing and care staff are women, most sufferers of rubber latex
allergy are also women.
Preventive measures
the occurrence of contact dermatitis and its prognosis are clearly related
to the skin exposure to the causal factors. for this reason, there should be
a good potential for prevention by reducing exposure to skin irritants and
allergens in different ways. Legislation is an important and powerful instru-
ment in reducing exposure to harmful substances. regulations exist which
aim to lead to reduced skin contact with certain allergens in the workplace.
194
Examples of such regulations are the addition of iron sulphate to cement,

which binds and inactivates the allergenic chromate, and the directives re-
lating to the use of thermosetting plastic. it should however be noted that
many of these regulations are primarily intended for work environments in
male-dominated occupations. since wet work involves the highest risk of
hand eczema, rules restricting such exposure are of course desirable. there
are currently no such rules in sweden, though Germany has recently initiated
measures for regulating wet work (Gefährdung det haut durch arbeiten im
feuchten Milieu (feuchtarbeit) 1996).
due to the high costs nickel allergy involves for society, the Eu decided on
a nickel ban in 1994 (European Parliament and Council directive 1994). the
ban regulates on the one hand materials used in connection with ear-piercing,
and on the other materials in objects intended for direct, long-term contact
with the skin, e.g. jewellery, buttons, buckles and watches. Prohibition will
come into force as soon as analysis methods for the various parts of the ban
have been adopted as European standards (Lidén et al. 1996). however, the
ban applies only to “private objects”, and therefore not to hand tools, keys,
coins and other everyday objects. an extension of the ban to include such
objects would therefore be desirable.
another prominent preventive measure is the Eu directive on cosmetics,
which demands an obligatory declaration of contents on all cosmetics and
hygiene product packaging (European Council directive 1993).
in certain situations, the use of protective gloves is necessary and desir-
able. Eu regulations exist pertaining to control of the design and production
of gloves (Mellström and Carlsson 1994). for gloves used in medical care
standards regarding quality and physical properties have been elaborated
(CEn/tC205). tight gloves often involve a strain on the skin, and there is
also some risk of allergic reactions towards glove materials.
one preventive measure would be to manufacture work and leisure prod-
ucts which are gentle on the skin. it is important to study the allergenic and
skin irritant properties of the substances used, and to take the results into
account when launching the products on the market.
a basic precondition for success with preventive measures is to ensure
good levels of knowledge as regards identifying risks and potential protective
steps. there is a wide information gap concerning skin care and protective
195
measures for the skin. such information should be spread during training for
various professions, especially manual occupations, and then be followed up
at the workplace. Young people with a high risk of contracting hand eczema,
i.e. atopics and nickel allergics, should be given vocational guidance.
Requirements for continued research and development

When it comes to work-related skin diseases, a great deal of background
data regarding occurrence and risk factors — which must constitute the
basis of preventive efforts — is still missing. Much of our existing knowledge
comes from clinical studies on patients who seek treatment at dermatology
clinics, which means a basic selection has already taken place. a need exists
for population-based studies in which risk factors and preventive potential
is studied for both female and male working environments.
in order to have an impact on hand eczema risks in female working
environments, it is essential to study, quantify and analyse exposure levels
in wet work, which is the basic cause of at least half the number of cases
of hand eczema, and which contributes to the worsening of a further large
proportion of cases, in order to produce a sound platform on which to base
research into preventive measures. it is also of interest to investigate whether
it is possible to reduce wet exposure at work through oficial regulations, and
to study any effects of such measures.
Continued research into the surfactants used in soaps and detergents
is important. it is crucial that skin irritation properties and any allergenic
characteristics are established in order to maximise the accessibility of gentle
products on the market.
skin irritation is the main cause of hand eczema predominantly in the
working environment of women. Continued research on skin irritation
with objective bioengineering methods will increase our knowledge of the
mechanisms and of possibilities for prevention.
nickel allergy is one of the major causes of hand eczema. there ought
to be continued efforts to reduce the risk of nickel sensitization. the Eu
nickel ban is one stage in this development. it is essential that the effects of
this are studied and documented.
the use of protective gloves is necessary in many lines of work, especially
within the nursing sector, but in far too many cases wearing gloves unfor-
196
tunately results in unwanted side effects. Continued efforts to identify the

risks and to produce glove materials with as little side effects as possible is
also essential.
in the long term, research into the situation of women in the labour market
may be expected to lead to changes and improvements which result in less
monotonous work tasks, thereby reducing harmful exposure.
it is important to integrate exposure in the home and the total situation
of life when studying work-related skin diseases, as these factors can differ
considerably between women and men.
how changes in work organisation might inluence the risk for diseases
and provide possibilities for improvements is an interesting new ield for
research in the area of occupational skin disease.
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200
Chapter 8
aChEs and Pains

— an affLiCtion of WoMEn
202
aches and pains — an afliction of women
Work-related
musculoskeletal disorders
by Åsa Kilbom and Karen Messing
Many studies indicate that women have a higher musculoskeletal morbidity

than men. this has been found in studies of the general population as well
as in different occupational groups. the reasons for these gender differences
are not always obvious. according to the traditional model of explanation,
biological differences in body size, muscle strength and aerobic capacity, in
combination with excessive physical demands, are suficient causes of the
observed differences. In the last decade, psychological characteristics of the
individual, as well as the psychosocial environment, have also been discussed,
either as causative, confounding, or effect modifying factors and as possibly
being gender speciic. thus the relative importance of different risk factors,
in women and in men, still remains to be clariied, but there is consensus
that musculoskeletal disorders have multiple causes.
In this chapter, gender differences in musculoskeletal morbidity will
be described, possible causes of gender speciicity will be discussed, and
research paths will be suggested so as to identify risk factors for women and
in women’s jobs.
Gender differences in the prevalence of musculoskeletal disorders

most studies on the general working population have been concerned with
low back disorders and demonstrate that the prevalence among women is very
similar to that of men although for men it is slightly higher (table 1). For the
neck and upper extremity, however, the prevalence among women exceeds
that of men. the data presented by de zwart (1997) were obtained by ques-
tionnaire on a large sample of working Dutch men and women, subdivided
by age and demands at work into groups with predominantly heavy or light
203
Table 1. Female/male prevalence of musculoskeletal disorders in population studies. PR=

prevalence rate female/male, OR=odds ratio female/male. Sources: 1. Guo et al. (1995) 2.
Heliövaara et al. (1991) 3. Linton (1990) 4. Tanaka et al. (1995) and 5. de Zwart (1997).
Body region Population Study method Female/male ratios Source
Back pain, 12 480 US Interview PR 0.92 1
past 12 months working pop.
Unspec. low back 5673 general Clinical examin. OR 1.0 2

back pain, past month population
Sciatica, past month “ “ OR 0.77 2
Back pain, 22 180 Swedish Questionnaire PR 0.97 3

past 12 months working pop.
Neck pain, past “ “ PR 1.64 3

12 months
Carpal tunnel 44 200 US Interview OR 2.2 4

syndrome working pop.
Regular back 44 486 active Questionnaire PR≈1 5

pain/stiffness Dutch workers
neck “ “ PR>1 5
upper extremity “ “ PR>1 5
lower extremity “ “ PR>1 5
physical work, mental work or mixed mental and physical work. the data is
undergoing more statistical analysis, but, preliminarily, the prevalence among
women was higher than among men in all subgroups for the neck, upper and
lower extremities, whereas back problems were equally common.
in a recent, very comprehensive review by niosh on “Musculoskeletal
disorders and Workplace factors” the prevalence of female musculoskeletal
disorders appears to exceed male prevalence in many studies, although the
statistical analysis often does not permit a thorough investigation of gender
differences (Bernard 1997). thus in many studies, gender is controlled for
in a multivariate statistical analysis and not by stratiication, which may ob-
scure relevant gender differences, as well as hiding associations with working
204
conditions among both genders (see chapter 1). in many studies, the study
population consists of either men or women. the reviewers conclude that
gender comparisons are extremely dificult to make because of the large dif-
ferences in work tasks. In order to further analyse the role played by biologi-
cal differences, nIosh suggests that future studies should be conducted in
occupational groups where men and women perform similar jobs.
recently, Punnett and Bergqvist (1997) reviewed the epidemiology of
upper extremity musculoskeletal disorders in work with visual display units.
they conclude that among ten studies, only three failed to indicate a sub-
stantial excess of neck and shoulder discomforts among women, compared
to men. In those studies where work was routine, or where women and men
had similar work tasks, the gender differences tended to be smaller.
Identifying the occupational component of these problems is not simple,
since they usually appear with age, especially among women, and can be
confounded with effects of ageing (andersson et al. 1990). Cross-sectional
studies have been used with some success to identify musculoskeletal problems
in the workplace, but they have large drawbacks when trying to identify the
cause-effect relationship. moreover, it is reasonable to assume that persons
in physically demanding jobs report more musculoskeletal problems than
those in “light” jobs, not necessarily because their job has caused an injury,
but because symptoms from previous injury are aggravated in heavy jobs.
thus, the distinction between causative and symptom-aggravating factors
at work is dificult to make.
It is also reasonable to suppose that some work-related disorders escape the
notice of researchers, because injured or symptomatic workers may change
from physically demanding occupations to lighter ones. since musculoskeletal
problems, unlike cancer, reproductive problems or heart disease, cause pain that
is perceptible to the worker and is associated with the task, affected workers
may change jobs or change their way of working, and statistical associations
between exposures and effects may thus be weakened (Östlin 1989). such
injured workers may be lost to follow-up, even in prospective studies which,
however, are very rare. whether such effects vary by gender, is not known. In
conclusion, the ascertainment of disease and linkage with job characteristics
are a problem with all musculoskeletal disorders.
205
despite the problems of identifying work-related disorders, statistics

sweden undertakes surveys by interviews on work-related circumstances
every two years with approx. 10 000 of the working population. Questions
include information about work-related problems in different body regions,
and the results can be cross-tabulated against information about working
conditions. results from 1995–96 demonstrate that the prevalence of prob-
lems in women exceeds that of the men in all body regions, especially in the
upper extremity (table 2).
for both women and men, the prevalence of pain increases considerably
with twisted postures, work above shoulder level, manual handling and poor
control over the work situation.
another source of information about work-related musculoskeletal dis-
orders in sweden, is the annual statistics on reported work-related injuries
(statistics sweden 1994). these reports are subdivided into accidents, i.e.
injuries with a sudden onset, and diseases. Musculoskeletal disorders occur
under both these headings, and consistently show a higher incidence of re-
ports from women than from men. among the musculoskeletal accidents,
the majority occur during manual handling; for women in health care while
lifting patients and for men while lifting objects, for example in the build-
ing industry.
Lines of business at high risk for musculoskeletal diseases among women
include, for example, the food products and beverage industry, the metals
industry and several manufacturing industries. among men, the construction
industry and many manufacturing industries demonstrate high risks. among
the 25 occupations demonstrating high risks of both accidents and diseases,
the vast majority are occupied primarily by women.
Table 2. Prevalence in percent of work-related pain in shoulders/arms, hands/wrists, low

back and lower extremity among a representative sample of working Swedish women and
men in 1995–1996. Source: Statistics Sweden 1997.
Body region Pain at least once/week Daily pain
Females Males Females Males
Shoulders/arms 33.0 20.8 11.3 7.0
Hands/wrists 15.6 10.5 5.9 3.0
Low back 25.4 21.9 7.5 6.0
Lower extremity 23.6 19.5 8.3 6.0
206
the total number of reported cases of musculoskeletal injuries reached a

peak in the late 1980s, and have since then gone down markedly. this down-
ward trend is probably due to several factors; one of the most important is
the gradual change in policy towards a more restrictive attitude by the insur-
ance courts (sundström 1997). during the 1980s, the cost of occupational
injuries increased far beyond what had been expected, and as a consequence,
the legislation was changed. Musculoskeletal injuries are now approved at
a lower rate and in particular, myalgias of the shoulder and neck, common
among women, are usually not recognised. thus, the statistics show large
luctuations over time and also between regions of sweden. however the
pattern of high-risk groups among women and men appears to be reason-
ably stable.
Explaining women’s excess symptoms

when women have a higher prevalence of musculoskeletal disorders (msDs)
than men, this may be explained by some, or all, of the following:
• the women’s working conditions are different from those of the men
and involve more risk factors for msDs, either
a. because the assigned tasks differ.
b. because the interaction between the worker and the work station dif-
fers (e.g. poorer it with shorter workers, tools too big for small hands).
c. because the duration (in years) of work implying high risk is longer.
• the women have less muscular strength than the men, so the same
conditions have a greater effect.
• the women’s family responsibilities combine with working conditions
to produce more risk of msDs.
• the women have hormonal factors that interact with working condi-
tions or act alone to produce msDs.
• women are more likely to express or report msDs.
• Psychologically, women are more likely to react to work organisational
factors that act with physical stressors to produce msDs.
Few epidemiologic studies have tried to clarify whether risk factors for mus-
culoskeletal disorders differ between the genders. recently, however, some
preliminary results from a large case-control study of the general population
207
have been presented (Vingård et al. 1998). interestingly, physical risk factors
for reporting low back pain to local caregivers among men were forward
bending, while for women, the most important risk factors were high physical
load, assessed as multiples of resting metabolic rate, and vehicle driving.
in the following, some important possible explanations of gender differ-
ences in musculoskeletal risk factors and manifestations will be discussed.
Biological and psychological gender differences

one reason why women may have speciic musculoskeletal problems, relates
to biology. the most obvious kinds of biological speciicity are those related
to body size, muscle strength, aerobic power and reproduction. Gender
differences in body size may inluence the way women perform their work,
e.g. force them to work in awkward postures and exert larger relative forces,
which will be discussed below under “Gender differences in work tasks”.
the possible inluence of women’s strength and aerobic power on mus-
culoskeletal disorders, is discussed in chapter 4, on biological differences.
these aspects of biological differences have been insuficiently covered in
research; the possible inluence of pregnancy and menstruation has hardly
been investigated at all.
Pregnancy and menstruation

Pregnant women’s bodies interact with work stations in different ways from
those of non-pregnant women, or men. at around four months of pregnancy,
the shape of women’s bodies has changed suficiently so that they interact
in new ways with their physical work station. For example, Paul has shown
that the growing uterus may push women further away from a working
surface, forcing them to reach further (Paul and Frings-Dresen 1994).
Changes associated with pregnancy, such as relaxed ligaments and increased
blood volume, can accentuate problems due to constrained positions at
work, such as prolonged standing or sitting. little research has been done
to identify precisely what aspects of the physical workload are incompatible
with pregnancy. that there are many problems, is shown by the fact that 60
percent of precautionary leave for pregnant workers in quebec is granted
for “ergonomic” reasons (malenfant 1993). no research has been done to
see whether strain during pregnancy has permanent effects.
208
discomfort in the abdomen, lower back and legs, associated with the
menstrual periods, is experienced by a large proportion of women, particu-
larly young women. dysmenorrhea has been found in 30–70 percent of the
female population in cross-sectional studies (sundell et al. 1990; teperi and
rimpela 1989; Wood et al. 1979; Woods et al. 1982). smoking raises and the
use of oral contraceptives lowers the likelihood of dysmenorrhea (Messing et al.
1993). Many studies on low back pain do not consider menstrual problems or
pregnancy, as contributing causes. however, in a study of self-reported back
pain among the working population in the us, 4.8 percent of the women
attributed their pain to pregnancy. Little research has been done on the epi-
demiology of menstrual pain, or on its relation to occupational variables.
Pain associated with the menstrual cycle may interact in some women
with other sources of musculoskeletal discomfort. Working conditions that
have been associated with mentrual pain in the abdomen, back and legs are:
work in the cold, a high work speed, prolonged standing and effort exerted
with the arms (Mergler and Vézina 1985; Messing et al. 1993; seifert et al.
1996; tissot and Messing 1995; Videman et al. 1984). in one study, work in
the cold intensiied the pain to such a degree, that workers were obliged to
absent themselves from work (mergler and Vézina 1985).
a relationship between pregnancy and carpal tunnel syndrome has been
hypothesized, a likely cause being that pregnancy or estrogen use may cause
swelling that compresses the median nerve in the wrist (Voitk et al. 1983). we
have not, however, been able to conirm this in searches in the epidemiologi-
cal literature. a long-term effect of estrogen on carpal tunnel syndrome, e.g.
among women taking estrogen replacement therapy, or those who were older
at menopause has also been suggested. strong epidemiological evidence has
not been found for this either (messing 1998).
Psychological characteristics
In their review on VDu work and musculoskeletal disorders, Punnett
and Bergqvist (1997) also discuss the hypothesis that women report more
discomfort in surveys, but when examined, are less likely than men to have
a clinical diagnosis. some results supporting this hypothesis have been ob-
tained in the stockholm-musIC study, when comparing the prevalence of
discomforts and clinical indings among women and men from the general
209
population (toomingas et al. 1991). however, the study of visual display

workers by Bergqvist (reviewed by Punnett and Bergqvist) indicates the
opposite: discomfort among women is much more likely to fulil criteria
for a clinical diagnosis than discomforts among men (Bergqvist et al. 1995).
similar results have been obtained when comparing symptom ratings with
clinical signs among patients; either no gender differences, or a male excess
in symptom reporting, have been found, as reviewed by Gijsbers van wijk
and kolk (1997). women and men also differ in symptom reporting, de-
pending on the time frame studied. thus female college students reported
more symptoms than male students, when asked about symptoms during
the previous year; when they were asked about momentary symptoms, the
gender difference disappeared (Pennebaker 1982).
nevertheless, women appear to report more symptoms than men in surveys,
independent of the symptom measured, or the response format (Gijsbers
van wijk and kolk 1997). whether these gender differences are caused by
neurophysiological factors, and/or the interpretation and meaning given
to a perceived sensory signal, is uncertain. the pain-pressure threshold in
the hand, for example, is lower in women, suggesting that musculoskeletal
symptoms in women are triggered more easily than in men (Brennum et al.
1989; Byström et al. 1995; hall 1995). similar indings have been obtained
for other stimuli, e.g. heat, cold, electric shock (nevin 1996). however, the
pressure pain threshold has also been demonstrated to be positively associated
with strength, which suggests a more complex relationship between sensory
thresholds and symptoms.
In conclusion, the difference between women and men, with regard to
reporting, describing and consulting, for musculoskeletal problems, has not
been well characterised.
Gender differences in work tasks

Probably the most important reason for gender speciicity is a difference in
physical work activity. only about ten percent of swedish men and women
work in gender-integrated jobs, i.e. where women or men constitute 40–60
percent of the workforce (see chapter 2). this segregation of the labour
market means that women and men are not exposed to the same working
conditions.
210
in the work environment statistics compiled among swedish men and

women, information about some major risk factors for musculoskeletal
disorders is also obtained by interview. Women, on average, perform more
repetitive and Vdt work, while men are exposed to more vibrations and
heavy manual handling (table 3). Work in awkward postures appears to be
equally common. in many occupational groups, gender differences are even
more marked. it is also worth noticing, that the combination of e.g. repetitive
work and the inability to set one’s pace, or regulate the performance of one’s
work, is much more common among women than among men.
in fact, segregation may be even greater, if task content is considered,
since men and women with the same job title may be assigned different tasks
(Messing et al. 1994). in a study of female and male workers on a swedish
automobile assembly line, female workers reported more repetitive work and
work with hand held tools, while the men performed more manual lifting and
work with powered hand tools (fransson-hall et al. 1995). silverstein and
colleagues found that women in six factories were more often in low-force,
high repetition jobs and men in high-force, low repetition jobs (silverstein
et al. 1986).
Because of their different anthropometric proportions, women and men
may perform even identical tasks in different ways (Courville et al. 1991; Mess-
ing and stevenson 1996). a study of the work activity of gardeners found that
the height and weight of gardeners inluenced their ways of digging with a
spade. heavier gardeners could use their weight to push on the spade, while
Table 3. Percentage of working men and women in Sweden exposed to certain potential
musculoskeletal risk factors. N≈12 000. Source: Statistics Sweden and National Board of
Occupational Health and Safety.
Risk factor Women Men
Lifting 15–25kg several times/day, ≥ 2 days/week 22.3 30.0
Work requiring heavy breathing, ≥ 75 percent of time 2.5 5.1
Vibrations through hand-held machines, ≥ 75 percent of time 0.5 3.2
Forward bending without arm support, ≥ 75 percent of time 10.0 8.5
Work with arms raised, at or above shoulder, ≥75 percent of time 5.5 5.6
Repetitive work many times/hr ≥75 percent of time 32.3 23.9
VDT work ≤75 percent of time 15.9 11.9
Repeated, simple work tasks 17.8 12.5
211
lighter people were obliged to deploy more force with their arms, for example
(Boucher 1995). no doubt anthropometric differences play a large role in the
requirements on work station and tool design. as demonstrated by Pheasant
(1996), work stations adjusted for 90 percent of the male population will have
dimensions too large for about 50 percent of the female population. Women
are disadvantaged and have more discomfort when using handtools designed
for men (ducharme 1973). recently, it was demonstrated that women have
more awkward wrist and arm postures than men during work on ordinary
keyboards, probably because of smaller shoulder width (karlqvist 1997).
Yet another reason why women have higher prevalences of musculoskel-
etal disorders may be that their career development is different from that of
men. as shown by torgén and kilbom (1997) in a population sample, women
on the average had an unchanged physical workload over a 24 year period
(from around age 18–36 to around age 41–58) while that of men gradually
declined. improved technology over time in industry may have had a larger
impact among men than among women, who were predominantly employed
in service and health care jobs. in addition, men may have been promoted to
managerial jobs more often than women. the issues of life-time accumulated
exposure to physically heavy work, and possible gender differences in career
development, therefore needs further study.
When women enter non-traditional jobs, i.e. jobs where men are in the
vast majority, they may face heavy opposition from their male colleagues
(Cockburn 1991). they may face screening tests that have been derived from
male populations and are not fair measures of their abilities (stevenson et al.
1996). they may also ind the jobs dificult to do, since they have often been
designed as a function of the anthropometric measurements of the majority
(male) populations (Courville et al. 1991, 1992). they may ind it dificult to
ask for changes in the jobs, because they are afraid to appear less qualiied.
thus, it is possible that working in a non-traditional job may pose a risk of
musculoskeletal disorders.
extensive research is in progress in sweden documenting differential physi-
cal and psychosocial risks for women and men in similar or gender-segregated
tasks (härenstam, personal communication). In fact, by increasing the level
of monotony and limiting variety of tasks for each sex, the sexual division
of labour may be injurious to the health of both women and men (messing
212
1998, see also chapter 11). however, in the past, research has usually been
oriented by the kinds of risks incurred in traditional male jobs.
in the last 10–15 years, researchers have concentrated on two common
risks found in women’s traditional work: repetition and static effort. it has
been demonstrated that repetitive movements are associated with various
musculoskeletal problems, among women and men (Bernard 1997; kilbom
1994). however, the literature does not yet allow good characterisation of
the relative effects of force and simple repetition. Women’s jobs are often
very highly repetitive, while relatively little force is deployed (silverstein et
al. 1986). the extreme example is that of data entry, which can involve over
15 000 keystrokes an hour (Billette and Piché 1987). Most studies have not
clearly distinguished between those exposed to very high levels of repetition,
from those with somewhat longer cycles.
static work of the upper limb has been studied extensively in the last
decade, and many papers have found an association with shoulder/neck com-
plaints (hägg and Åström 1997; Jonsson et al. 1988; Winkel and Westgaard
1992). some researchers have examined the effects of static standing on
lower limb problems in such female-dominated professions as that of shop
clerk (stvrtinová et al. 1991) and (in some countries) bank teller (seifert et
al. 1997) and grocery cashier (ryan 1989).
Work still needs to be done in order to ind ways to describe the relevant
parameters of static work, and there is no consensus on maximum levels of
acceptability. recently, interview techniques have been developed permitting
relatively accurate estimates of time spent in static postures, especially for-
ward bending and work with raised arms (wiktorin et al. 1996). the results
agreed well with thorough measurements performed at the workplace, and
the interview method thereby offers a more cost-effective method of assessing
postural workloads. questionnaires are used in many studies and have shown
reasonably good reliability, even in retrospective assessments (torgén et al.
1997). self-reports by questionnaire only permit a crude estimate of work
loads, however, and work still needs to be done to develop better phrasing
of the questions.
the effects on musculoskeletal disorders of combined exposures, e.g.
static or repetitive work in combination with cold or heat exposure, toxic
chemicals, etc., are hardly known. since the pattern of combined exposures
213
among women and men differs considerably, gender differences in muscu-

loskeletal disorders may be further emphasized.
Domestic roles of women and men

another reason why women’s problems can be different from those of their
male colleagues has to do with the domestic roles of women and men, which
can combine differently with paid work even when the two sexes do the
same paid tasks (hall 1992). Women report feeling tired more than men,
for example, and this could be attributed to a longer combined domestic and
paid workday (tierney et al. 1990).
in 1990 and 1991, swedish women spent on the average 27 hours per
week at their work and 33 hours doing domestic work, while men spent
about 41 and 12 hours, respectively (Lagerlöf 1993). the gender difference
in domestic work is, in comparison to most other countries, relatively small
before the irst child is born. thereafter, women take a larger share of the
planning of family life, e.g. the planning of meals, children’s clothing, contacts
with friends and relatives. their domestic chores are more conined in time,
whereas men appear to have a larger freedom of choice about when and how
to do their share (lagerlöf 1993). women with very small children who also
have jobs that require them to lift weights, may be lifting more weight in a
day than their male colleagues. other tasks such as cooking, cleaning and
sewing, may be done by women as part of their paid work and then extended
into the unpaid workday.
In conclusion, both the physical and the mental demands on women in
domestic life, are heavier than those on men, which is likely to add to the
total amount of risk factors for musculoskeletal disorders.
Psychosocial conditions and musculoskeletal disorders

— methodological aspects relevant in a gender perspective
as laura Punnett explains (Punnett and Bergqvist 1997), the effects of work
organisation on health are mediated through their interactions with the emo-
tions and understanding, as well as the physiology of the individual. thus,
parameters of work organisation can become psychosocial factors impacting
on health. unfortunately, it can be very hard to document these effects and,
more particularly, to distinguish between psychosocial and physical impacts
214
of parameters of work organisation. repetitive work, for example, has both a

physical and a psychological aspect. if a person exposed to a repetitive work
organisation feels pain in her shoulders, is this to be attributed entirely to the
sustained lexion or abduction at the shoulder joint, or does the monotony
or time pressure of her work contribute to the damage?
In many practical contexts this question is not very important. what
does it matter how a worker suffers from repetitive work – if she suffers,
the repetition should be diminished. however, for women, the question of
psychological mechanisms may be important, because of the reluctance of
many to treat psychological effects as “real”. we know that women’s problems
are often wrongly attributed to their psychology, for four reasons:
• women’s credibility is not as good as men’s.
• since women’s physiology is less well understood, their problems may
not be diagnosed as readily, and a psychosomatic origin may be postulated
as a diagnosis of exclusion (see chapter 5).
• women workers express more psychological distress than men, often
attributed to their multiple responsibilities (messing et al. 1998).
• women’s working conditions do not appear to be physically taxing and
a psychological explanation may be more believable (reid et al. 1991).
therefore, scientiic confusion about the relative contribution of biology
and psychology to the determination of musculoskeletal problems could
lead to a propensity to disbelieve in the occupational origin of women’s
musculoskeletal problems. this is particularly true in studies where occupa-
tional factors are not well-deined and “gender” is treated as a confounding
variable; such a study design leaves the reader with the notion that gender
rather than women’s or men’s speciic working conditions is responsible for
an effect (see chapter 1).
such a propensity exists. In sweden, men’s claims for occupational in-
juries due to musculoskeletal problems are accepted almost twice as often
as women’s (38 percent cf. 22 percent) (arbetarskyddsstyrelsen 1998). the
refusal of women’s claims is often supported with reference to family or
personal factors, as well as to the relative banality of the women’s working
conditions (lippel 1995). thus, in examining psychosocial contributions to
musculoskeletal problems, care must be taken to deine carefully the exact
215
parameters of work organisation involved and the mechanisms postulated

for their effects.
in the comprehensive review by niosh on “Musculoskeletal disorders
and Workplace factors”, psychosocial factors are looked upon as generalized
risk factors which seem to exert their effect independently of physical factors.
While these factors are statistically signiicant in some studies, they generally
have only modest strength. the mechanisms whereby adverse psychosocial
conditions, such as poor control over work conditions, high demands on
productivity and precision, and lack of support, exert their effects, have been
discussed by theorell (1996). a review of the relationship between muscu-
loskeletal disorders and psychosocial factors has also been given by Bongers
et al. (1993). several studies in the nordic countries have conirmed both
the existence and weakness of the relationship (ekberg 1994; estlander et al.
1998; leino and magni 1993; linton 1990; mäkelä et al. 1991; theorell et
al. 1991; toomingas et al. 1997). many of these studies use the questionnaires
developed by karasek and colleagues to measure job control, job demands
and social support (karasek and theorell 1991; theorell et al. 1991).
one problem with many previous studies is that physical and psychosocial
factors have not been assessed together. In a study of medical secretaries,
over 60 percent said they had neck and/or shoulder pain. they illed out a
questionnaire on physical discomfort and on the psychological work environ-
ment. those with a “poor” psychological work environment had more pain
than others, so the researchers inferred that the pain reports were related
to psychosocial stress. no information was gathered on the physical work
environment, so we do not learn whether those in a poor psychological en-
vironment also had a poor physical environment. In fact, physical aspects of
the work environment were not covered in any way (linton and kamwendo
1989). a similar study of neck, shoulder and back pain, concluded that pain
was greater when the environment is perceived as unmanageable, but did
not consider whether this might be because of uncomfortable environments
which the worker was unable to modify (Viikari-Juntura et al. 1991).
of special interest are some longitudinal studies in the scandinavian
countries, identifying psychosocial factors as causally related to subsequent
development of musculskeletal disorders, both in the low back and in the
shoulder-neck area (leino 1989; Viikari-Juntura et al. 1991).
216
newspaper employees have been found to have musculoskeletal pain related

to work environment and posture as rated by observers. there was more pain
among those subjected to poor work organisation, such as low control over their
job content. the two kinds of circumstances interacted, that is, workers with
better scores on work organisation reacted less to uncomfortable keyboard
positions or seat back heights (faucett and rempel 1994). these and other
such studies conclude that Msds are related to both physical and psychologi-
cal factors, although both the niosh review and a recent review by frank,
support the view that physical work load factors yield higher risk estimates
than psychosocial factors (frank et al. 1996). in the MusiC-norrtälje study,
which is a large (approx. 700 cases and 1 400 referents) case-control study of
low back pain, psychosocial factors seemed to be of some importance, but
less than that of physical risk factors (Vingård et al. 1998).
Complementary possible mechanisms have also been proposed, such
as insuficient “sense of coherence”, i.e. your conditions in life can not be
understood or controlled (antonovsky 1987).
yet another psychological risk factor has been proposed, i.e. the “type a”
personality characterized by impatience and high demands on own achieve-
ments. Few studies have been presented, two of them suggesting that this
personality type is related to musculoskeletal disorders (Flodmark and aase
1992; hägg et al. 1990). In the irst study, however, physical work load was not
controlled for, and the type a behaviour may have been required by the job.
hypotheses such as malingering, neurosis, or hysteria, explaining non-speciic
musculoskeletal disorders, have usually been rejected, at least in cases of acute
or sub-acute musculoskeletal disorders (Faucett and rempel 1994).
Psychosocial conditions as risk factors for musculoskeletal

disorders — gender effects
hall and colleagues (1993) have found differences in the psychosocial work-
ing conditions of men and women in swedish populations. although there
may be a relationship between psychosocial factors and muscular tension for
both sexes, the speciic relationships between stress and work organisation
may not hold for women (Johnson and hall 1996). one group of researchers,
who separated their analysis of msDs by gender, found differing relation-
ships between pain and psychological symptoms. musculoskeletal disorders
217
were more common among male factory workers with depression and stress
symptoms, than among men with no such symptoms. the researchers men-
tioned that the inding did not hold for women factory workers, but did not
try to explain this discrepancy (leino and magni 1993).
In a recent study, work and non-work related factors were studied as risk
factors for shoulder-neck and low back disorders up to 24 years later. It was
found that the risk factors differed between men and women. For low back
disorders, strong interactions between work and leisure time factors were
found, especially for women, probably supporting the importance of the role
played by domestic work (Bildt thorbjörnsson et al. 1998). high mental load
at work was a fairly weak risk factor for shoulder-neck disorders for women
as well as for men, but in combination with overtime work and unsatisfactory
leisure time it caused a considerable increase in risk among women. having
a high domestic work load was much more common among women than
among men, but it was a risk factor for both genders. as was the case for
low back disorders, interactions between domestic, leisure and work factors
occurred more commonly as strong risk factors for shoulder-neck disorders
among women than among men (Fredriksson et al. 1998). thus a gender
differential effect of interactions between work and non-work factors seems
to exist, but needs more studies in the future.
one problem has already been discussed above. the measures usually used
to assess psychological job demands almost always include variables that can
also measure physical demands, such as “repetition”, or “work speed”. It is
therefore not clear that psychological demands are what is being measured.
when designing questionnaires, or interview protocols, it is important to
distinguish between repetitive motion and monotony, for example. one
possible avenue is to design questionnaire items to distinguish more clearly
between the facts of work (e.g. “how many times/for how long do you ...”)
as against how these are perceived (“do you perceive this work task to be
...”). another problem is that information about psychosocial conditions are
always obtained via self-reports, whereas physical workloads can be observed
or measured. thus there is an element of subjectivity in psychosocial reports
which may be relevant, but makes these factors dificult to compare with
physical loads. It is hard to think of a solution to this problem, since both
repetition and work speed have both physical and psychological effects. more
218
attention to the design of research instruments and better knowledge about

possible gender differences in expressing aspects of work is needed.
in the previous two sections the methodological problems in assess-
ing psychosocial conditions, possible gender bias in the weight attributed
to psychosocial and physical risk factors, and the lack of gender sensitive
epidemiological data have been described. obviously the role played by
psychosocial conditions, for women and for men, need more study with a
gender sensitive approach and including conditions both at work and in the
domestic setting, and interactions between them.
Care-seeking behavior, chronic musculoskeletal disorders,

coping and rehabilitation
in the MusiC-norrtälje study, women tended to seek traditional care-giv-
ers (physicians, physiotherapists) to a larger extent than men, who preferred
experts like chiropractors and osteopaths (Vingård et al. 1998).
so far, the distinction between acute, subacute and chronic musculoskeletal
disorders have not been well described in the scientiic literature (see also
chapter 3). as musculoskeletal disorders develop from acute to chronic state,
the relationship between workplace factors and disorders seems to become
less apparent, depression often sets in, and the quality of life is lowered.
while a review by unruh (1996) suggests relatively large gender differ-
ences in coping with responses to acute pain, these differences appear to be
much smaller in response to chronic pain. Information on the response to
treatment of musculoskeletal disorders is conlicting, however; in two dif-
ferent studies, women and men, respectively, have been found to respond
better to cognitive behavioral rehabilitation (Jensen et al. 1993; lindström
1994). however, much more knowledge is needed before it is possible to
give speciic recommendations on gender-speciic treatments in the acute
and chronic state.
as discussed above, recent statistics from the swedish Board of occu-
pational safety and health indicate that women are discriminated against
when reporting occupational musculoskeletal injuries. similar discrimina-
tory actions have been observed when rehabilitation and early retirement
due to musculoskeletal injuries are considered. women are usually offered
less expensive rehabilitation, and recent statistics suggests that they are,
219
more often than men, granted only part-time retirement (Marklund 1997;
riksförsäkringsverket 1997).
Proposed research priorities
General research goals:

• research should be done in support of the political goal of allowing
women to enter into the workforce on an equal basis without sacriicing
their health or welfare.
• research should try to establish the link between musculoskeletal disor-
ders among women and the mechanisms that maintain gender segregation
at the workplace and assign certain work tasks (monotonous and repetitive)
to women rather than distributing them equally between genders.
Research methodology:
Continued research should be done on the characterisation and more precise
deinitions of exposures known to be typical of women’s work: static effort
and high degrees of repetition.
research instruments that semantically have a common understanding
among women and men, need to be developed.
Channels should be set up between women workers and researchers so as
to make researchers aware of emerging problems. an alternative approach is
to contact populations of retired women and ask them about their working
conditions and health problems.
Research related to biological, psychological and social specificities:

• the expression and description of discomfort and pain among men and
women. Do women behave differently when they feel pain?
• the prevalence of osteoporosis in working populations and the rela-
tionship, if any, to conditions during working life.
• the relationships between menstrual pain, pregnancy and estrogen
therapy and work performance, musculoskeletal symptom reporting and
disorders.
220
• are there certain behaviours (exercise, safety-related behaviours) which

are related to an increased/reduced risk of musculoskeletal problems
among women?
• how can life-style factors (training, diet, smoking) that reduce the risk
of musculoskeletal disorders be supported among women?
• dificulties women may have in obtaining recognition for their work-
related musculoskeletal disorders.
Research on physical and psychosocial conditions

and musculoskeletal problems:
• Gender differences in physical and psychosocial risk factor patterns. are
the interactions between speciic risk factors and their relative strength
different in women and men?
• are there physical exposures in work done by women and not already
studied, that are associated with musculoskeletal disorders?
• Characterisation of aspects of the domestic workload that may interact
with workplace variables to inluence the probability of women getting
musculoskeletal disorders.
• Interaction between musculoskeletal risk factors and other environ-
mental aggressors, such as cold, heat and chemical substances, in the
production of disorders, among women and men.
• Coping strategies used by women and men when musculoskeletal
disorders start to appear.
• are women’s jobs less adjustable in terms of job control and author-
ity?
• the evolution of women’s exposure to musculoskeletal risks, with age
and seniority.
• the reasons for women’s lower accident rate and the relative roles of
gender-based job or task assignments and risk-avoiding behaviour.
221
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227
228
Chapter 9
JoB strEss
aMonG WoMEn
230
job stress among women
Psychiatric ill health

and conditions at work
by Carina Bildt Thorbjörnsson and Malin Lindelöw
strong connections between gender and psychiatric health, and similarly

between working conditions and psychiatric health, have been established.
this chapter seeks to provide an overview of how these two areas are inter-
related. the chapter focuses on the signiicance of work related stress and
its effects on the psychiatric health of women.
Gender and psychiatric ill health

the connection between gender and psychiatric health has been debated for
several decades, sometimes very heatedly due to the stigma that is associ-
ated with psychiatric problems and distress. many of the earlier scientiic
studies were mainly based on hospital journals concerning the treatment of
psychiatric illnesses. these have indicated that women have been treated for
psychiatric illnesses more often than men (Chester 1972).
Despite the fact that much of the discussion surrounding the above-named
studies concerns the scale, time period and context in which this difference
in prevalence of psychiatric illness was observed, there is no pressing reason
to spend time considering this research if the prime aim is to understand the
differences between the genders in terms of psychiatric health. the reason
for this is the extremely serious objections to the way in which the treatment
of psychiatric illnesses has been equated with such illness itself. In numerous
studies it has been emphasised that many individuals who have been treated
for psychiatric illnesses were not suffering from such illness, according to the
true deinition of the condition (Gove 1978; Gove and tudor 1973, Gove
and tudor 1977). another problem linked to the use of hospital journals
as indicators of psychiatric ill health is that most psychiatric problems and
231
illnesses in society are never diagnosed. More likely, these hospital journals
indicate a cry for help in individuals and how accessible treatment is in the
society in which they live, rather than the incidence of psychiatric illness in
the population. a behavioural difference between the genders in “crying for
help” has been established, and this can be an explanation for the noticeable
differences between the genders in the incidences of psychiatric illness (see
chapter 3). this can be illustrated by a study undertaken in stockholm in
the late 1960s, which had the principal aim of identifying unmet demands
for medical and social help in subgroups of the population (Bygren 1974).
the genders differed in terms of unmet psychiatric clinical care, where more
men than women failed to get their needs satisied. thus, women were more
able to receive or obtain clinical treatment for their psychiatric problems
than men. this difference was more pronounced in middle-aged people
than in younger age groups. social class also affected the level of unsatisied
need, with working-class women and men less likely to have their needs met,
compared with middle-class men and women. with the study based solely
on the number of men and women who received clinical care, the difference
in prevalence of psychiatric problems amongst the genders would have ap-
peared larger than it actually was.
the criticism levelled at the use of hospital journals as indicators of psy-
chiatric dicease has led to greater attention being paid to investigating the
incidence of psychiatric problems and illnesses in the population in general.
many such efforts have been made and today we have quite reliable data on
the incidences of the most common psychiatric illnesses, at least in europe
and north america (hällström 1996). there are big differences between
illnesses which are more common in women and those more common in
men. the question of which gender suffers the most psychiatric illness in
general is of lesser interest. In terms of inding a way of preventing psychi-
atric problems it is of greater interest to undertake more detailed studies
of speciic illnesses. these studies can provide more information on how
genetic and biological factors, various stress factors in life notwithstanding,
can affect women and men.
one of the more solid observations is that women exhibit more emotional
problems and men more outward signs and anti-social problems. the differ-
ence is particularly marked in relation to clinical unipolar depression (clinical
232
depression, which often leads to admission to a psychiatric clinic), the most

common psychiatric illness. the life-time risk of clinical unipolar depression
has been estimated at between 10 and 25 per cent for women, and 5 to 12 per
cent for men (Boyd and Weissman 1981), whilst over 6 per cent of women
and 3 per cent of men are assumed to suffer from clinical depression at any
one time (Paykel 1989). the difference between the genders in the incidence
of depression is well documented today (Boyd and Weissman 1981), even if
there are signs of a certain levelling out as more young males are becoming
depressed than previously (Weissman and klerman 1989). different studies
have led to different lifetime risk assessments of depression, partly because
depression of different degrees of severity has been studied and different
methods employed, but also because the prevalence of depression varies
between different geographical areas and over time. Certain other psychiatric
illnesses also occur to a greater extent in women than in men, such as eating
disorders, anorexia nervosa and bulimia nervosa, panic syndrome, and certain
forms of bipolar syndrome (manic depression) (fombonne 1995). other
psychiatric problems are approximately equally prevalent in both genders,
or with only slight differences. these include generalised anxiety syndromes
and compulsion syndrome. the disorders more common in men include
exhibitionism, anti-social personality disorders and paranoid schizophrenia.
But male adjustment dificulties manifest themselves primarily in anti-social
behaviour, such as violence, criminality and drug abuse, factors which are
also discussed in chapter 3.
several studies which considered a lack of psychiatric well-being rather
than psychiatric ill health have indicated a major difference between the
genders, with over twice as many women as men reporting reduced psychi-
atric well-being (Folkhälsorapport 1994). In a prospective swedish study of
psychiatric health in the population, the risk of individuals suffering some
form of psychiatric problem during the course of their working life, was
found to be 73 per cent for women and 43 per cent for men (hagnell 1970).
the same survey found that the risk of suffering some form of depression
of varying severity (including sub-clinical depression that does not require
treatment at a psychiatric clinic) is 25 per cent for women and 12 per cent
for men. For both women and men, the same proportional difference in
prevalence can be observed for clinical unipolar depression (Forsell et al.
233
1997). it must therefore be emphasised that psychiatric illness is a genuine

problem in the population, both in terms of the cost to society and reduced
quality of life for the individuals concerned.
Psychiatric ill health, e.g. depression, is diagnosed through the manifes-
tation of reported symptoms of social isolation, lack of initiative, inirmity,
thoughts of suicide etc. If a suficient number of symptoms are present, a
psychiatric diagnosis is conirmed, e.g. clinical unipolar depression. absence
of psychiatric well-being is conirmed by reports of a lower than normal
initiative capacity, more indecisiveness than usual, more sleeping problems
than usual, greater problems in relationships with others, etc. If many such
problems are reported, a lack of psychiatric well-being is diagnosed. effec-
tively, most people can suffer a lack of psychiatric well-being at some stage
in their lives.
Work and psychiatric health

there are probably several reasons for the proven differences in the psy-
chiatric health of men and women, such as the effects of work, social status
and line of work. the general effect of work on the psychiatric health of
women has been investigated in a number of studies (Dennerstein 1995; Parry
1986). several of these studies found that the psychiatric health of working
women, and their health in general, was better than that of non-working
women (Dennerstein 1995; Parry 1986). this is not, or at least not solely, a
product of selection. working and non-working women who have similar
health at the beginning of a study, display differences on follow ups, so it
would appear to be the case that paid work is a contributory factor to better
psychiatric health, especially if people have a positive attitude to their job
(Gore and mangione 1983; romito 1994). the explanation given as to why
working women enjoy sounder psychiatric health is that they have access to
many different roles (Barnett et al. 1992; Pietromonaco and Frohardt-lane
1986; Puglesiesi 1992). the performance of many different roles offers plenty
of potential sources of satisfaction with life and makes women less sensitive
to disturbances and disharmony within a speciic area. the performance
of many different roles can naturally also lead to greater overall stress, and
consideration must also be given to the alternatives available to paid work,
for the women studied.
234
however, paid work has more than just emotional and social implications,
it also affects standard of living. if the alternative is to be unemployed and
more or less an involuntary housewife and mother, and with this having a
signiicantly lower standard of living, this could have a fundamental effect
on psychiatric well-being.
this does not prevent there being decisive factors in the working environment
which cause psychiatric problems and lowered psychiatric well-being in women.
Various studies have revealed differences in the prevalence of poor psychiatric
health between women in different social strata, between women of different ethnic
origin (Dennerstein 1995; waldron and Jacobs 1988), and between women in
different occupational sectors (Jenkins et al. 1996). several studies have revealed
that female doctors in particular have a high incidence of psychiatric ill health
(north and ryall 1997). they have also shown to be less inclined to seek help
for their problems than other women, possibly for fear of being stigmatised.
Differences in the incidence of psychiatric ill health in female nurses in various
clinical departments has also been established, with nurses on geriatric wards
having a higher incidence than others (Petterson et al. 1995).
a 1994 study of working conditions and ill health in stockholm indicated
that the prevalence of reduced psychological well-being differed largely be-
tween men and women in different sectors (Ågren et al. 1995). the sectors
where most women reported impaired psychiatric well-being were journalism
(43 per cent), restaurant personnel (33 per cent), teachers in science (32 per
cent), and caregivers (29 per cent). the equivalent sectors for men were bus
and taxi drivers (31 per cent), psychiatric nurses (29 per cent), doctors (26 per
cent) and delivery or lorry drivers (22 per cent). the sectors where few women
reported impaired psychiatric well-being were company administrators (8
per cent), personnel administrators (15 per cent), infant school teachers (16
per cent) and systems programmers (18 per cent). the equivalent sectors
for men were restaurant personnel (5 per cent), advertising (10 per cent),
business advisers (11 per cent) and journalists (12 per cent). the large dif-
ferences between the genders probably relects the fact that men and women
in the same sector tend to have different types of work, and thus different
work related stresses (see chapters 2 and 11).
the aim of the following survey of literature was to ascertain the current
level of understanding of what kinds of working conditions cause psychiatric
235
problems for women. this is a prerequisite for where further research is

needed in order to be better able to prevent work-related psychiatric ill-
nesses in women. an account of risk factors related to home life and leisure
activities and the grey area between work and home investigated in studies
of working conditions and psychiatric ill health has also been given.
Literature research
a comprehensive database search of literature on women, work and psy-
chiatric health was made, mainly in the following databases: nioshtiC,
MEdLinE (MEd94) and PsYChLit. Many of the articles found within
these subjects could not be included in the analysis because the data were
not structured or presented in a way that enabled the risks to women to be
identiied. some studies had included both women and men in the survey
group but had made all the association analyses on the group as a whole, and
other studies had speciied the gender but then presented the results of the
analysis for the whole group and were therefore excluded from the review.
another problem was that results were not always well deined, sometimes
not at all. these articles were also excluded from the review.
outcomes studied were: depression symptoms (sub-clinical depression), anxi-
ety and phobias, physical stress reactions, lowered psychological well-being and
minor psychiatric illnesses. the most common indings studied in connection
with the demands of the workplace were depression symptoms and lowered
psychological well being. Different instruments were used for collating data
on the state of psychiatric health in individuals. In studies of depression and/or
anxiety, the Center For epidemiologic studies — Depression scale (ses-D)
was mainly used, together with sCl-90-r, hodkins symptom Checklist,
Crown-Crisp experimental Index (CCeI), Beck Depression Inventory (BDI),
Proile of mood states (Poms), Composite International Diagnostic Interview
(CIDI) and the state-trait anxiety Inventory. a General health questionnaire
(Ghq, 12 or 30 questions) was principally used to measure lowered psycho-
logical well-being. the Derenwendt 27-question questionnaire and 20-item
Guring scale, were also employed. In several studies, special questionnaires
were formulated to measure depression and anxiety.
In this particular review of literature,the results were categorised accord-
ing to a hypothetical scale of severity. Psychiatric illness covered depression
236
symptoms, anxiety and phobias. reduced psychological well-being included

a lack of psychological well-being, physiological stress reactions and minor
psychiatric illness.
Bipolar syndrome, schizophrenia and psychoses were not studied in
relation to the demands of working life as factors affecting this were as-
sumed to have little signiicance in the origins of these illnesses, compared
with genetic/biological causes and family factors. the presence of certain
of these patient groups in working life are also only found to an extremely
limited degree. sub-clinical depression and certain anxiety symptoms can be
expected to have biological origins to a lesser extent. studying the effect of
stress factors in work and family life in relation to these problems is therefore
of greater importance for preventive reasons.
there is no self-evident categorisation of non-physical work factors. the
categorisation of the factors in this chapter are based on a further reinement
of the deinition of psychosocial factors given in a reference book from 1995
which focuses on musculoskeletal disorders, where psychosocial factors are
deined as the individual’s interpretation of organisational factors (hagberg
et al. 1995). this reinement, which differentiates between experienced and
construed psychosocial factors, was made and presented by a Dutch researcher
at a conference in montreal in 1995 (Bongers 1995). In this system, factors
experienced stand for the more subjective aspects in the non-physical work-
ing environment, and factors construed for the more descriptive elements.
what is included in the psychosocial working environment as experienced
is very similar to that which is deined as work organisation factors on an
individual level. In order to clarify the difference between the psychosocial
factors experienced and those construed in the literature searched, we have
named them psychosocial and organisational factors, respectively. the former
correspond to the more subjective, and the latter the more descriptive factors
in the working environment.
the potential risk factors studied can be summarised in six separate sec-
tions, of which the irst three are physical, psychosocial and organisational
factors of the work. they are directly focused on work-related demands and
conditions. we have tried to make these sections as comprehensive as pos-
sible. the last three sections are individual factors, factors related to family
life, and factors from the cross-over area between work and family life. they
237
are illustrated to the extent of having being investigated in studies of the con-
nection between work-related demands and conditions, and the psychiatric
health of women. studies including these factors were reviewed only when
they focused on the connection between work-related demands and condi-
tions, and psychiatric health among women. a certain overlapping between
different factors within the sections was unavoidable, which must be taken
into consideration when conclusions are drawn on the connections found.
Literature review
the survey of the various studies focuses on risk factors for psychiatric illness
and reduced psychological well-being in women. in those instances when the
surveyed study group included both women and men, comments has been
given in the text on the possible differences and similarities in the risk factors
for each gender. the tables present the factors which were studied and the
risk factors which were identiied for women in different studies.
the risk factors which have been studied are, as mentioned earlier, set
out and categorised in tabular form. Cross-sectional studies and prospective
studies have been individually presented to facilitate discussion of the pos-
sible causality in the connections reported in different studies. this can be
of particular value for psychiatric illness as it is easy to dismiss connections
found in work conditions in cross-sectional studies, on the grounds that
reports on poor working conditions and poor working environment are a
manifestation of psychiatric ill health.
the indings in each section are discussed and areas for further research
identiied and summarised at the end of each chapter.
with one exception (Braun and hollander 1988), the studies are either
performed on one or several sectors, or on a subgroup of the population (e.g.
female directors with small children).
Physical working conditions

there has been little research into the relationship between physical demands
in the work environment — e.g. heavy lifting, piece-work or unsuitable or
demanding working positions — and the psychiatric health of women. how-
ever, some studies have investigated the signiicance of such work related
demands. these indings are summarised in table 1.
238
Physically demanding tasks and piece-work were risk factors for both
psychiatric illness and lowered psychiatric well-being (amick et al. 1998;
Eskelinen et al. 1991; Estryn-Behar et al. 1990). Piece-work was also a risk
factor for psychiatric illness in men (Eskelinen et al. 1991). the combination
of high physical load and little scope to inluence events in the workplace,
increased the risk of psychiatric illness (eskelinen et al. 1991), which indi-
cates that it is in combination with other work factors that physical working
conditions cause psychiatric illness. nurses who worked on wards where
there were more physically and psychologically demanding tasks compared
to other wards, had a higher incidence of psychiatric illness (Petterson et al.
1995), which can also be an indication of an interactive effect between the
physical and psychosocial/organisational work relationship.
only a few physical factors have been investigated in cross-sectional stud-
ies. Poor hygiene in the workplace and exposure to solvents, was a risk factor
for psychiatric illness (Bromet et al. 1992; Goldberg et al. 1996). women
have only to a limited extent been included in studies of the health effects
Table 1. Associations between physical working conditions and psychiatric illness and
reduced psychological well-being among women.
Psychiatric illness Reduced psychological well being
Physical Prospective Cross-sectional Prospective Cross-sectional
factors studies studies studies studies
High physical (Eskelinen (Estryn-Behar (Amick
load et al. 1991a) et al. 1990) et al. 1998)
(Estryn-Behar (Makowska
et al. 1990) 1995)
Piece-work (Eskelinen
et al. 1991a)
Poor hygiene (Goldberg
at work et al. 1996)
Large accident (Goldenhar
risks et al 1998)
Exposure to (Bromet
solvents et al. 1992)
Bold= associations have been found, Italic= associations have not been found.
239
of exposure to solvents, hence an understanding of the long-term effects on

women is limited.
the indings in this section indicate that the physical working environ-
ment, the aspect of the working environment which to date has been most
extensively researched in relation to musculoskeletal illnesses, is a signiicant
factor in the psychiatric health of women. Further research is needed into
how heavy lifting, piece-work and other physical factors in the working en-
vironment, in combination with other demanding factors in work and home
life, cause psychiatric illness in women. Prospective research into the effect
of solvents on psychiatric health of women is also needed.
Psychosocial working conditions

the psychosocial aspects of working conditions is perhaps the most individual
and experience-oriented part of work demands and working conditions. It is
also the most researched dimension of the signiicance of working conditions
to the psychiatric health of women. work-related stress — investigated in
almost half the studies performed — and different forms of social support at
work are psychosocial factors which have proved to be of particular interest.
the indings are summarised in table 2.
a high level of job stress and unclear, negative or unbalanced job demands
were risk factors for both psychiatric illness and reduced psychological well-
being (Barnett and Baruch 1987; Bromet et al. 1992; Cooper and melhuish
1984; Cooper et al. 1987; Davidson et al. 1995; estryn-Behar et al. 1990;
Iwata et al. 1988, 1989; kandel et al. 1985; kandolin 1993; lam et al. 1985;
lundberg et al. 1994; o’neill and zeichner 1985; reifman et al. 1991;
schonfeld and ruan 1991; schonfeld 1992; shigemi et al. 1997; stansfeld
et al. 1995).
work-related stress has been gauged in a variety of different ways, some-
times with a few questions, at other times with comprehensive questionnaires.
Despite the differences in methodology, many studies have still managed to
capture some degree of the dimension of work-related stress which leads to
psychiatric illness and reduced psychological well-being in women.
For instance, work-related stress amongst dentists was surveyed with
a 40-question questionnaire (Cooper et al. 1987). the study group were
240
asked to answer all the questions on various incidents, and to rank them
according to how much stress each induced. this ranking of stresses in
the study of psychiatric illness and work-related demands (ibid.) amongst
dentists differed only slightly between the genders. Work-related stress
is related to job status (noborisaka and Yamada 1995). the work-related
stress is higher, especially among women, the lower the status of the work
performed. Many “typically” women’s jobs are low-status and can therefore
also be expected to be characterised by high work-related stress (see chapter
2). they may thereby be harmful to women’s psychiatric health. high mental
demands and time pressure were also risk factors for psychiatric illness, or
lower psychiatric well-being (amick et al. 1998; Braun and hollander 1988;
Eskelinen et al. 1991; Estryn-Behar et al. 1990; kandolin 1993; Makowska
1995; noor 1995).
several of the psychosocial factors were only studied in the cross-sectional
studies. Low job satisfaction, poor social support, previous work-related dif-
iculties, dificult clients/patients, a poor emotional atmosphere at work, the
fear of making mistakes, conlicts between individual assessments and those
of the company, in addition to sexual harassment and sex discrimination,
were risk factors for psychiatric illness and reduced psychiatric well-being,
even if the results were not totally consistent (Bromet et al. 1992; Chevalier
1996; Cooper and melhuish 1984; Davidson et al. 1995; Goldberg et al. 1996,
Goldenhar et al. 1998; Gutek and koss 1993; kandolin 1993; makowska
1995; Piotrkowski 1998; reifman et al. 1991; shigemi et al. 1997; stansfeld
et al. 1995, 1997). Further research is therefore required into the long-term
consequences of these factors.
there are also important questions surrounding the deinition of these
concepts and the extent to which the instruments developed for men can also
be applied to women, in a meaningful way. For instance, surveys have been
done on the signiicance women and men place on the concept of job satisfac-
tion (Barnett and Baruch 1987; miller 1980). what was most important for
women was that they were able to use their abilities and skills and that they
could help others. men stressed that they needed control over what they did.
as many questionnaires are tailored to a male audience and male working
conditions, there is an apparent risk that crucial information which could
be able to explain ill health in women is missed. the problem of deinition
241
Table 2. Associations between psychosocial working conditions and psychiatric illness and
Psychiatric illness Reduced psychological well-being
Phychosocial Prospective Cross-sectional Prospective Cross-sectional
Time pressure (Eskelinen (Reifman (Kandolin 1993)
et al. 1991a) et al. 1991)
(Reifman
et al. 1991)
Poor social (Bromet (Stansfeld (Davidson
support et al. 1992) et al. 1997) et al. 1995)
(Goldberg (Makowska
et al. 1996) 1995)
(Goldenhar (Shigemi
et al. 1998) et al. 1997)
(Lennon & Rosen- (Stansfeld
field 1992) et al. 1995)
(Snapp 1992)
Previous work- (Goldberg
related dificulties et al. 1996)
Low job (Cooper & Melhuish (Davidson
satisfaction 1984) et al. 1995)
(Goldberg (Lam et al.
et al. 1996) 1985)
(Stansfeld
et al. 1995)
Low consideration (Goldberg (Piotrowski
at work et al. 1996) 1998)
High mental (Estryn-Behar (Braun & Holl- (Estryn-Behar (Amick et al.
demands et al. 1990) ander 1988) et al. 1990) 1998)
(Bromet et al. (Noor, 1995) (Makowska
1992) 1995)
(Goldenhar (Noor, 1995)
et al., 1998),
(Snapp, 1992)
Unclear, negative (Reifman (Reifman (Barnett (Davidson
or unbalanced et al. 1991) et al. 1991) et al.1992) et al. 1995)
role demands (Stansfeld
et al. 1995)
242

Phychosocial Prospective Cross-sectional Prospective Cross-sectional
High job stress (Estryn-Behar (Bromet (Estryn-Behar (Davidson
et al. 1990) et al. 1992) et al. 1990) et al. 1995)
(Kandolin (Cooper & Mel- (Iwata et al.
1993) huish, 1984) 1988)
(Lundberg (Cooper (Lam et al.
et al. 1994) et al. 1987) 1985)
(Schonfeld & (Iwata et al. (Shigemi
Ruan 1991) 1989) et al. 1997)
(Schonfeld (Kandel
1992) et al. 1985)
(O’Neill &
Zeichner 1985)
Lack of (Reifman (Reifman (Davidson
motivation et al. 1991) et al. 1991) et al. 1995)
Dificult clients/ (Kandolin
patients 1993)
Poor emotional (Kandolin
atmosphere 1993)
Fear of making (Shigemi
mistakes et al. 1997)
Sexual harass- (Reifman (Cooper & Mel- (Davidson
ment and sex et al. 1991) huish 1984) et al. 1995)
discrimination (Goldenhar (Piotrkowski
et al. 1998) 1998)
(Reifman et al. 1991)
Conlicts between (Chevalier (Davidson
individual assess- et al. 1996) et al. 1995)
ments and those
of the company
Conlicts with (Reifman (Bromet
colleagues or et al. 1991) et al. 1992)
superiors (Reifman
et al. 1991)
(Snapp 1992)
243
recurs in the question of social support. this is often deined as the number of
social contacts a person has, rather than the quality of these contacts. Cardio-
vascular research has shown that a high level of social contact outside work
is a risk factor for heart attacks amongst women (Jung 1984; rook 1984).
the explanation given is that women feel a tremendous responsibility for
individuals in their social network, and that they give more than they take.
having a wide network can therefore be a burden rather than a blessing.
In their place of work women can also assume responsibility — and also be
expected to do so — for supporting and consoling colleagues in distress. this
can certainly be partly explained by socialisation in the adult world where
girls are brought up to take responsibility for others, appreciate the needs
of others, and wherever possible, satisfy them (see chapter 3). studying the
quality of social relationships rather than the number of social contacts would
therefore provide more relevant information on the conditions which could
conceivably be stressful for women, and as such, affect their mental health.
sexual harassment and sex discrimination seem to go together, i.e. they
often occur at the same time in a work environment and are probably due to
the culture within the company, rather than the behaviour of one or several
colleagues (Bursten 1985). this has also been reinforced in a later survey of
the health consequences to women of sexual harassment (Decker and Barling
1998). Data on both individuals and the company were gathered and revealed
that companies/organisations which had few sanctions against sexual harass-
ment, and where women had a lower status than men (e.g. lower pay) had a
signiicantly higher incidence of sexual harassment than companies which had
clearly-stated sanctions against this type of behaviour. studies on the health
consequences of sexual harassment should therefore collate information at
individual and organisation levels. a review from 1993 on published studies
of sexual harassment revealed that it is relatively common that women in the
usa who suffer sexual harassment, subsequently leave the company (Gutek
and koss 1993). the experience of women who decide to stay is often that
their social relationships at the workplace are as a whole negatively affected
by the harassment, as is, naturally, also their job satisfaction and commit-
ment. In various surveys between 21 and 82 per cent of women sexually
harassed have reported that their psychiatric health was adversely affected
as a result of the harassment. a number of more or less scientiic surveys
244
have been done in sweden on the extent of sexual harassment at work and
within the educational system. as the questions have been posed in widely
different ways, the prevalence of sexual harassment has luctuated sharply.
as a rule, the focus of these studies was not on the effects on health. there
is an urgent need for further research on the effects of sexual harassment on
the psychiatric health of women, to get an idea of how widespread such pos-
sible effects are, and which other work environment and work organisation
factors they may interact with. attempts have been made to deine sexual
harassment, both in terms of the degree of severity, and whether it occurs
on a speciic occasion, or continuously (Bursten 1985). qualitative research
may be required to be able to formulate suitable questions.
the conclusions drawn from the indings in this section, are that a number
of psychosocial factors are closely related to the psychiatric health of women.
the long term effect is in many cases unclear, hence the need for research
to be done in the future. It would be of great value to study the subjective
experience and objective organisational conditions in relation to women’s
psychiatric health at the same time. Further, both quantitative and qualitative
aspects of social support should be investigated in relation to women’s psy-
chiatric health to be able to identify and compare stress and support factors.
Finally, there is an urgent need to research the effects of sexual harassment
on women’s psychiatric health, based on information at both individual and
organisational level, to gain an understanding of the extent of such possible
effects, and to understand which other working environment and work or-
ganisation factors they possibly interact with.
Organizational working conditions

another area where valuable conclusions on the relation between the de-
mands of working life and the psychiatric health of women were drawn, is
the organizational component of working conditions, i.e. the perceived con-
sequences of the way the work is structured and organised for the individual.
these indings are summarised in table 3.
where there are few opportunities to inluence one’s working situation or
the working pace, there is a risk of both psychiatric illness and reduced well-
being in both the cross-sectional and prospective studies for women and men
(amick et al. 1998; eskelinen et al. 1991; Goldenhar et al. 1998; makowska
245
1995; reifman et al. 1991; stansfeld et al 1995, 1997), and there are certain
indications that these variables interact with family circumstances (Barnett
and Baruch 1987). interactions between occupational factors could be seen
between high physical load and the lack of opportunities to inluence the
working conditions. the latter was, as previously mentioned, a risk factor for
women but not for men, and the reverse applied for the combination of the
lack of opportunities to inluence the working conditions and a demand to
work fast (eskelinen et al. 1991). shift work has also proved positively related
to psychiatric illness, as has reduced psychological well-being (eskelinen
et al. 1991; estryn-Behar et al. 1990; kandolin 1993). shift work has been
considered more stressful for women, in addition to biological and hormonal
reasons, because women also face greater home and family burdens (Costa
1997). In addition, a poor accord between an individual’s ability and the de-
mands of the work has proved to be a risk factor for reduced psychological
well-being and/or psychiatric illness (estryn-Behar et al. 1990; shigemi et al.
1997). stress due to ixed time schedules was also positively related, both to
psychiatric illness and reduced well-being in prospective studies (estryn-Behar
et al. 1990), while less consistent conclusions have been drawn in relation to
uncertainly over an individual’s own future within the organisation (amick
et al. 1998; Goldenhar et al. 1998; makowska 1995; noor 1995).
several organizational factors have only been studied in cross-sectional
studies. having a supervisory position and considerable responsibility, be-
ing transferred frequent and working for a large company, have all proved
to be related either to reduced well-being or illness in the psychiatric sense
(Cooper and melhuish 1984; snapp 1992; Goldenhar et al. 1998; shigemi
et al. 1997). Conversely, having considerable responsibility and a supervi-
sory position were not linked to psychiatric ill health in men (Cooper and
melhuish 1984).
many organisational factors studied were linked to psychiatric illness and
reduced psychiatric well-being, sometimes in both prospective studies and
in cross-sectional studies, which indicates a causal link. the conclusions that
can be drawn from the indings in this section, are that certain organizational
factors should be further investigated with a prospective design and that
organizational factors — for example, information on how the working time
is structured, what, if any, control workers have and the demands of the job
246
Table 3. Associations between organizational working conditions and psychiatric illness and
Organizational Prospective Cross-sectional Prospective Cross-sectional
Shift work (Estryn-Behar (Goldberg (Kandolin 1993)
et al. 1990) et al. 1996)
Stress due to ixed (Estryn-Behar (Estryn-Behar
time schedules et al. 1990) et al. 1990)
Poor accord be- (Estryn-Behar (Estryn-Behar (Shigemi
tween own ability et al. 1990) et al. 1990) et al. 1997)
and demands of work
Low skill discretion (Goldberg (Stansfeld (Davidson
et al. 1996) et al. 1997) et al. 1995)
(Stansfeld
et al. 1995)
Few opportunities (Eskelinen (Goldenhar (Stansfeld (Amick et al.
to inluence the et al. 1991) et al. 1998) et al. 1997) 1998)
working situation (Reifman (Lennon & Rosen- (Noor, 1995) (Davidson
et al. 1991) field 1992) et al. 1995)
(Reifman (Makowska
et al. 1991), 1995)
(Noor 1995)
Having a Cooper & Mel-
superior position (huish, 1984)
(Lennon & Rosen-
field 1992)
Few opportunities (Eskelinen (Reifman (Stansfeld
to inluence the et al. 1991a) et al. 1991) et al. 1995)
work pace (Reifman
et al. 1991)
Great of work re- (Goldenhar (Shigemi
lated responsibility et al. 1998) et al. 1997)
(Snapp, 1992)
Frequent transfers (Cooper &
Melhuish, 1984)
Uncertain future with- (Goldenhar (Noor 1995) (Amick et al.
in the organization et al. 1998) 1998)
(Makowska 1995)
(Noor 1995)
Working for a (Cooper & Mel-
large company huish 1984)
(Snapp 1992)
247
— should be included in research into working conditions and psychiatric

illness in women.
Individual factors
individual factors include both factors such as level of education and other
personality-related factors, for instance, coping strategies (problem-solving
ability), negative affectivity (negative attitude to life) and type a behaviour
(impetuosity and hectic life style). these indings are summarised in table 4.
Personality factors have mainly been investigated in cross-sectional
studies of psychiatric illness and reduced psychiatric well-being. weak
coping strategies were compared with both psychiatric illness and reduced
psychological well-being in cross-sectional studies (Davidson et al. 1995;
kandolin 1993; o’neill and zeichner 1985). women and men differed in a
study of reduced psychological well-being with regard to the use of coping
strategies (Davidson et al. 1995). women exercised more often than men to
lower their stress level, or conided in a close friend or relative, while men
consumed more alcohol to achieve the same result. this might reduce their
stress level in the short term, but could be expected to have a harmful effect
on their psychiatric well-being in the longer term.
type a behaviour was compared with reduced psychological well-being
but not with psychiatric illness (Cooper and melhuish 1984; Davidson et
al. 1995). negative affectivity was analysed both in cross sectional and pro-
spective analyses in a 1995 study of lowered psychiatric well being, but was
only a risk factor in the cross-sectional analyses. this indicates that lowered
psychological well-being can have inluenced the expression of negative
feelings, rather than that negative affectivity inluenced well-being (noor
1995). a study indicated that type a behaviour in relation to psychiatric
illness was not a signiicant risk factor for women but was for men (Cooper
and melhuish 1984).
of the other individual factors studied — ethnic origin, having blue collar
work, level of education (both for women and men ), being the main provider
in the family, or having had previous psychiatric symptoms — none were
identiied by anyone as being risk factors in the prospective studies.
several of the individual factors which were studied were related to psy-
chiatric ill health in women. Personality factors ought to be expected to play a
248
Table 4. Associations between individual factors and psychiatric illness and reduced psycho-
logical well-being among women.
Individual Prospective Cross-sectional Prospective Cross-sectional
Being the main (Lennon & Rosen-
provider in the family field 1992)
Level of (Goldberg (Noor 1995) (Lam et al. 1985)
education et al. 1996) (Noor 1995)
Ethnicity (Schonfeld & (Snapp 1992)
Ruan 1991)
(Schonfeld 1992)
Having blue (Schonfeld & (Snapp 1992) (Piotrkowski
collar work Ruan 1991) 1998)
Weak coping (O’Neill & Zeich- (Davidson
strategies ner 1985) et al. 1995)
(Kandolin 1993)
(Lam et al. 1985)
Type A (Cooper & Mel- (Davidson
behaviour huish 1984) et al. 1995)
Negative affectivity (Noor 1995) (Noor 1995)
Previous psychi-
atric symptoms (Schonfeld 1992)
role in how women and men describe their work and home circumstances. in
order to obtain a greater understanding of the long-term effects, personality
factors, in interaction with different work factors, coping strategies, type a
behaviour and negative attitudes, etc., should be the subject of prospective
research, together with work life factors in relation to both psychiatric illness
and reduced psychological well-being.
Family life
in studies into the signiicance of work demands and conditions on the psy-
chiatric health of women, various dimensions of their home life have also
been of interest. research here includes both social relationships, conlicts,
249
the presence of children, division of housework and stressful family events.

these indings are summarised in table 5.
living without a partner was a risk factor for psychiatric illness in the
cross-sectional studies, but not in the prospective studies, (schonfeld and
ruan 1991; schonfeld 1992). this may indicate that women with psychiatric
ill health tend to live alone, but that their problems have not been caused
by their single life style (Iwata et al. 1989; kandel et al. 1985; snapp 1992).
there are indications that it is related to psychiatric illness in men to a greater
degree (ibid.). single life style was not related to reduced psychological well-
being in women (Davidson et al. 1995; Iwata et al. 1988; kandolin 1993;
noor 1995). the presence of small children at home, has proven to be an
important risk factor for depression in women. however, in studies which
also investigates the effects of working conditions, small children at home has
not convincingly proven to be a risk factor for psychiatric illness, or reduced
psychological well being (Beatty 1996; Iwata et al. 1988, 1989; kandel et
al. 1985; kandolin 1993; lennon and rosenield 1992; noor 1995; snapp
1992). It is possible that the interaction between work life and home life, or
the individual’s overall living conditions, has been studied to a too limited
degree, while researchers ever increasingly have focused on individual risk
factors, or risk factors within a limited area. the effect of social support from
family and friends has also been studied, similarly with little convincing results,
despite informative conclusions within epidemiological research (Bromet et
al. 1992; Davidson et al. 1995; makowska 1995; schonfeld and ruan 1991;
schonfeld 1992; snapp 1992). the explanation for this can partly be that
the research has focused on the frequency of social contact, rather than on
its quality, according to the same rational as applied above with reference to
social support in the work place (see also chapter 3).
other factors from home life have solely or principally been studied in
cross-sectional studies. having the main responsibility for the home and
children, marriage problems and little time for one’s own interests, have all
proved positively related to psychiatric illness to a certain extent (Iwata et
al 1988; Iwata et al. 1989; kandel et al. 1985; lennon and rosenield 1992;
reifman et al. 1991). serious life events have also been shown to be related
to both outcomes in the cross-sectional studies, but not in the prospective
studies (Bromet et al. 1992; Cooper and melhuish 1984; makowska 1995;
250
Table 5. Association with conditions in family life and psychiatric illness and reduced psycho-
logical well-being among women.
Factors from Prospective Cross-sectional Prospective Cross-sectional
family life studies studies studies studies
Living without (Schonfeld & (Iwata et al. (Noor 1995) (Davidson
a partner Ruan 1991) 1989) et al. 1995)
(Schonfeld (Kandel et (Iwata et al.
1992) al. 1985) 1988)
(Snapp 1992) (Kandolin 1993)
Small children (Beatty 1996) (Estryn-Behar (Kandolin 1993)
at home (Iwata et al. 1989) et al. 1990) (Iwata 1988)
(Kandel et al. 1985) (Noor 1995)
(Lennon & Rosen-
field 1992)
(Snapp 1992)
Poor social (Schonfeld & (Bromet (Davidson
support from Ruan 1991) et al. 1992) et al. 1995)
family and friends (Schonfeld (Snapp 1992) (Makowska
1992) 1995)
Having the main (Kandel et al. 1985)
responsibility for (Lennon & Rosen-
children and home field 1992)
Marriage problems (Kandel et al. 1985) (Iwata et al. 1989)
(Iwata et al. 1988)
Little time for (Reifman (Kandel et al. 1985)
own interests et al. 1991) (Reifman et al. 1991)
High level of (Iwata et al. 1989) (Iwata et al. 1988)
stress in family life
Serious life (Schonfeld & (Bromet (Noor 1995) (Makowska
events Ruan 1991) et al. 1992) 1995)
(Schonfeld (Cooper &
1992) Melhuish 1984)
251
noor 1995; schonfeld and ruan 1991; schonfeld 1992). on the other hand,
when it comes to a high level of stress in home life it has not been possible
to prove a connection to the psychiatric health of women, even though it
was related to that of men (iwata et al. 1988, iwata et al. 1989).
Many of the risk factors in home life and leisure pursuits which have
been studied can conceivably interact with both physical, psychosocial and
organisational risk factors at work, despite the fact that it is not altogether
clear that these occupy the borderland between work and home life/leisure
activities. for instance, it has been proposed that women react more strongly
than men to monotonous work as they do not shut themselves off from their
problems at home (roxburgh 1996).
Monotonous work offers plenty of opportunity to think about problems
that need solving, things that must be put right, etc. this would entail that
monotonous work would be more damaging to women than men if they
had problems at home. the role women take in the family as initiator and
responsibility taker, rather than the number of hours women spend on
housework, has also been mentioned in other contexts as a risk to health
(Lundberg et al. 1994).
Consequently the image of the effect of home life on the psychiatric
health of women is, to say the least, mixed. the long-term consequences of
the interactive effects of relationships and stresses in home life and work life
leading to psychiatric illness and reduced psychological well-being should
be investigated in prospective design studies. it is also important that indica-
tors from different sub-systems such as work, home life and leisure, be also
included in future studies in order to increase our understanding of what
is most determining for psychiatric health and of how the above interact.
such studies can give information about possible buffer effects from different
subsystems. this has also been mentioned in other contexts, where it has
been said that the analysis should focus on the individual, not on individual
factors (Magnusson 1998).
Borderland between work and family life

another area that has been of certain interest is the borderland between work,
home and leisure time, although only for women and principally in relation
to psychiatric illness. these indings are summarised in table 6.
252
Table 6. Associations between factors from the borderland between work and family life and
psychiatric illness and reduced psychological well-being among women.
Factors from Prospective Cross-sectional Prospective Cross-sectional
work — family studies studies studies studies
Children nega- (Reifman (Reifman
tively affected by et al. 1991) et al. 1991)
a woman’s work out-
side the home
Work intrudes (Reifman (Beatty 1996)
on family life et al. 1991) (Reifman et al. 1991)
Family intrudes (Reifman (Beatty 1996)
on work et al. 1991) (Reifman et al. 1991)
Role conlict
work — family (Noor 1995)
three factors — that children are negatively affected by their mothers work
outside the home, that the work intrudes on family life, and that family life
intrudes on work have proved to be positively related to psychiatric illness,
but mostly in cross-sectional studies (Beatty 1996; reifman et al. 1991).
there have been no signiicant indings in relation to the conlict between
work and family roles, i.e. that work and the family have opposing demands
which are dificult to live up to (noor 1995).
Generally speaking, we counsel caution in the interpretation of these ind-
ings. only a very limited number of studies have been performed, and there
is a great deal of uncertainty over whether the questions have been put in the
right way to properly grasp the conlicts women themselves experience most
strongly in their lives. a qualitative study has revealed that it is common for
women to feel inadequate in relation to their family and feel that work takes
up too much of their time, and that such feelings may in the long run cause
reduced psychological well-being (thomsson 1996). as such, we return to
the conclusion we drew above: that investigations should be structured so
that they look at the total stress from work and family life, starting from the
individual’s actual situation, rather than from individual variables.
253
Prevention
Proposals for preventative measures to reduce psychiatric ill health depend-
ing on factors at work have been presented in several studies (akabas 1988;
stansfeld et al. 1997). these proposals are mostly at an organisational level,
including the structure of work and production (greater division of work,
more lexible working hours, better career opportunities, etc.) and ways
in which management can offer better social support and provide more
adequate information.
But there are also examples of preventative measures focused on the
individual, rather than on how the work is structured (spilman 1988). For
instance both women and men have been taught to handle stress and build
up self-awareness to reduce psychiatric ill health. But, interestingly enough,
when both genders were given the opportunity to participate in various
preventative programmes, there was much greater interest amongst women
than men. women also had a better understanding of how various life style
factors affected health and were signiicantly more motivated than men to
do something about circumstances that were unsatisfactory in their life style.
when it comes to sexual harassment the focus has been on the speciic indi-
vidual, not on the structures that allow scope for such behaviour (hamilton
et al. 1987). supportive and self-belief-developing discussions are one of the
methods recommended.
other preventative measures based on the indings of an appraisal of the
literature, should also be implemented (e.g. to reduce work-related stress),
even if further research is needed to clarify additional dimensions signiicant
to work-related stress in the psychiatric health of women.
Discussion and conclusions

a large number of psychosocial factors, a somewhat smaller number of
organisational factors, a small number of physical factors, and a few factors
from home life and from the borderland between work and home life, have
been identiied in the studies undertaken.
only small differences between women and men in terms of risk factors
in the work place were identiied in the studies. Further studies of a qualita-
tive nature can, however, be undertaken to shed more light on the possible
differences between the genders in terms of risk factor patterns including
254
work-related factors. there were certain indications that such differences

exist, e.g. in heavy lifting work combined with the lack of opportunities to
inluence such work, was a risk factor for women, but not for men. the op-
posite was the case for a combination of demands to work fast with a lack
of opportunities to inluence the work. the interaction between different
work-related factors and between home and work related factors can be
expected to be different for women and men, depending on the different
expectations and demands on the genders. Very few studies where informa-
tion from both home life and work had been investigated included both
genders, and therefore assumptions of differences cannot be supported by
existing studies. In studies of musculoskeletal problems where information
from both spheres have been investigated it has been possible to show that
interaction effects between work and home life occur and that they differed
between the genders (Bildt thorbjörnsson et al. 1998). Certain interactions
were common to both genders while others occurred only in women, or
only in men, which has been interpreted to relect the differing conditions
in work and life for women and men. It is therefore important to undertake
population studies where both genders are included and where information
from both work and home life are studied. the genders differed in a study
which looked at coping strategies. other studies which focused speciically
on coping strategies have shown that the context has a decisive bearing on
the strategy an individual chooses, that is, what it is possible to choose (see
chapter 3). women and men in similar work environments tended to solve
problems in the same way.
an explanation for the higher incidence of psychiatric diagnoses in women
mentioned in the literature is that the psychiatrists who have determined
the diagnoses, were inluenced by the gender of the subject. In 1997, a
very accomplished study was published in this ield (redman et al. 1991).
Psychiatric diagnoses were determined by the responses given in completed
questionnaires on psychiatric health (Ghq). the principal inding was that
women were more often incorrectly given a psychiatric diagnosis than men.
Despite the fact that the proportion of female to male subjects who had a
high Ghq score (= reduced psychiatric well being) were similiar, 34 per
cent of the women were diagnosed as psychiatrically disturbed, compared
to only 20 per cent of the men. the conclusion drawn was that gender had
255
a signiicant inluence on the risk of being given a psychiatric diagnosis. the

same study also investigated the propensity of female and male psychiatrists
to diagnose women as psychiatrically disturbed. male psychiatrists diagnosed
the case study women as psychiatrically disturbed twice as often as female
psychiatrists. the errors in diagnoses in the study were effectively dependent
on the gender of both the psychiatrist and the test subject.
such errors ought to explain some of the differences in the incidence
of various psychiatric illnesses. on the other hand they can not explain the
differences in self-proclaimed psychiatric well-being. If there are gender-
dependent errors in these reports, this is more likely to be due to the way
the questionnaire is formulated. It is not particularly far-fetched to believe
that the roles women and men are allocated in society inluence the way they
answer questions. women are more likely to place a lower value on ques-
tions about assertiveness and self-belief, which can be explained by their own
expectations on how women should act. assertiveness and career-minded-
ness is not something that has previously been encouraged in women, but
it has in men. the construction of questionnaires used to ascertain lowered
psychiatric well-being and psychiatric disturbances can relect prejudices
about genders and may simply be formulated so that women, more or less
automatically, appear to be more disturbed (see chapter 5). In other words,
it is important to recognise that the same instrument, or questionnaire, can
be interpreted differently by women and men. If psychiatric illness among
women has been overestimated in the studies reviewed for this survey, the
consequenses would be that risks that actually exist in the workplace envi-
ronment were not identiied, and that the risks were under-estimated for
the associations found.
apart from the gender-dependent effects, the cultural context and ethnic
background play a decisive role in how psychiatric health is experienced and
expressed, as are job market conditions (walters 1993). qualitative studies
need to be done of the symptoms of ill health which women from differ-
ent sub-groups in the population experience as inhibiting and as having a
negative effect on their quality of life — and of how these women express
such symptoms.
In a survey of the current understanding of psychosocial overload and
work-related psychiatric illness, it emerged that only 3 per cent of all work-
256
related illnesses reported were due to psychiatric causes (Westerholm 1996).

this was considered to be low, as the proportion of women in high-stress
professions has gone up from 15 to 21 per cent in the last ten years, a six-
fold increase compared to men in the same period (ibid). fifteen per cent
of the female workforce has moved from a low- to a high-stress profession
since the 1980s, mainly into health care and education. the greatest number
of reports come from women in precisely these areas. Many of the risk fac-
tors for psychiatric illness and lowered psychiatric well-being identiied in
the studies performed, occur to a large extent in professions dominated by
women (see chapter 2).
In studies of psychiatric ill health in women, as in studies of other forms
of illness in women, it should be noted that many of the instruments used to
ascertain stresses in the working environment have been developed to deal
with men and their typical working conditions. this can lead to the risk that
female problems are missed, which was pointed out as early as 1982 in a
survey of literature on work-related stress and ill health in women by haw
(1982). he drew the conclusion that studies on women were not suficiently
speciic to properly chart the working environment and family relation-
ships/attitudes.
It is worth noting that no labour market factors have been studied in the
studies undertaken. Interaction between labour market factors, psychosocial
factors and organisation factors, have most probably had a signiicant inlu-
ence on the psychiatric health of women and should therefore be studied in
parallel. By implementing measures at different levels — at individual, or-
ganisational and social levels — to improve the working conditions of women,
the psychiatric health of women would probably be positively affected.
Summary of proposals for further research

studies with a prospective design need to be done on: the interaction effects
between physical and psychosocial factors in work and home life/leisure time;
the psychosocial and work organisation factors in the work environment,
which in cross-sectional studies have been shown to have a connection with
psychiatric illness and/or reduced psychiatric well being; qualitative and
quantitative aspects of poor social support in the work place, sexual harass-
ment, and the interactions between sexual harassment and other factors in
257
the work place; individual coping strategies and personality traits in women
in different positions and different stress factors in the working environment
and in home life, in relation to psychiatric illness and reduced psychiatric
well-being.
studies where information from every level is linked together, can be
done by collating and analysing information on psychosocial and physical
stresses in the work place and in home life, at the level of the individual and
the organisational and labor market factors which can conceivably affect the
psychiatric health of women. Qualitative studies need to be done on:
• which circumstances in paid work and home life, is perceived to be the
most demanding, for women from different social backgrounds and with
different positions in the working environment;
• what symptoms of ill health women experience as restricting and which
negatively affect their quality of life;
• heavy work responsibilities, for instance, what do women and men
include in the deinition of this?
when choosing the method of data collection, in the cases where it is known
that women and men put a different emphasis on concepts, (e.g. job satisfac-
tion) and experience different aspects of this phenomenon as particularly
stressful, data should be assembled which truly covers the aspects relevant
to women.
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264
Chapter 10
WoMEn rECEiVE LEss

ProtECtion
266
women receive less protection
the neglect of women

in occupational toxicology
by Sven Ove Hansson
in many countries, the irst factory legislation in the 19th century protected
only women and children, leaving the work conditions of men unregulated.
It was assumed that men were capable of taking care of themselves. a man
who accepted a job entered a voluntary agreement, and the contents of such
voluntary agreements should, according to 19th century legislators, be left
unattended by the (liberal) state. women received (albeit insuficient) pro-
tection, not primarily because their bodies were weaker but because their
minds were believed to be weaker.
today, it is almost universally accepted that women and men have an
equal right to protection by government against workplace hazards. there
are strong reasons to believe, however, that women receive less protection
than men. as compared to the 19th century, the pendulum has swung away
to the opposite side.
Three reasons to pay attention to sexual differences

there are at least three major reasons why close attention should be paid
to differences between women and men in studies of workplace hazards.
First, although most adverse health effects affect both women and men, the
frequencies of these effects may differ between the sexes. aggregate statistics
that pay no attention to such differences may severely underestimate the risks
that the minority sex is exposed to. In most cases, women are the minority
endangered by such practices.
secondly, some health effects affect only one of the sexes. this applies
primarily to diseases of the reproductive systems.
267
thirdly, in order to detect effects on children of exposed workers, we

need to treat separately the different mechanisms through which exposures
of men and women may have such effects.
Frequency differences
the irst of these reasons is an instance of a more general argument that ap-
plies also to other subdivisions of the working population: Any subpopulation
that may have above-average sensitivity to a workplace hazard should, as far as
possible, be treated separately in an analysis of that hazard. there are many
such subpopulations besides women and men: elderly workers, workers with
cardiovascular disease, smokers, etc. By taking such subpopulations into
account we can increase our chances of discovering hazardous substances
and processes.
unfortunately, it is often very dificult to discover connections between
work factors, or other environmental factors, and impairments to health.
effects on health typically come as excess frequencies of diseases that are
also present among unexposed individuals. For statistical reasons, such ex-
cess frequencies have to be rather large in order to be distinguishable from
random variations. as a rough rule of thumb, epidemiological studies cannot
detect excessive relative risks unless they are about ten percent or greater.
For the more common types of cancer, such as leukemia and lung cancer,
lifetime risks are between one and ten percent. therefore, even in the most
sensitive studies, lifetime risks smaller than 0.01 or 0.001 cannot be observed
(Vainio and tomatis 1985).
animal experiments have the same statistical problems. to some extent,
they can be compensated for by extrapolation from high-dose experiments.
on the other hand, inter-species differences complicate the use of animal
experiments in human toxicology.
this statistical problem is severely aggravated if an oversensitive subpopu-
lation is not treated separately. as an example, suppose that 10 percent of
the workers subject to a certain exposure are women. Furthermore, suppose
that this exposure increases the lifetime incidence of leukemia from 1.0 to
2.0 percent among female workers, whereas the incidence of leukemia is 1.0
percent among both exposed and unexposed males. then the total effect of
exposure in this group of workers will be an increase of the lifetime incidence
268
from 1.0 to 1.1 percent. the chances of discovering such an effect are in most
practical cases quite small unless women and men are studied separately.
as already mentioned, the same argument applies to any other identii-
able subpopulation that can reasonably be supposed to differ in sensitivity
to toxic substances from the rest of the exposed population. however, its
relevance in relation to the male/female distinction is corroborated by the
available evidence of systematic differences between women and men in the
susceptibility to toxic inluences. Cadmium absorption in the gastro-intestinal
tract is larger in women than in men, probably due to smaller supplies of iron
(Flanagan et al. 1978). women exposed to lead have higher protoporphyrin
levels in erythrocytes than men, which has been interpreted as a sign of higher
sensitivity to lead exposure (stuik 1974; alessio et al. 1977). a simulation
study indicates that the elimination of solvents such as trichloroethylene
is, on average, slower in women than in men, due to a higher retention in
adipose tissue (sato et al. 1991).
In general, sex-speciic averages provide better estimates of individual
risks than averages for the whole working population. however, it must be
warned that both women and men also belong to groups that may have a
higher or lower susceptibility to toxic inluence than their sex has in general.
In such cases, averages for women or men may be misleading. this can be
seen from the following hypothetical example.
suppose that in a certain exposed population, the frequency of a certain
disease is as follows:
• Female smokers, 10 percent
• Female non-smokers, 2 percent
• all females, 4 percent
• male smokers, 20 percent
• male non-smokers, 4 percent
• all males, 8 percent
• the whole population, 6 percent
to begin with, we only know the frequency in the total population. at that
stage, we might tell an exposed woman that her risk of catching this disease
269
is six percent. next, we obtain the additional information that the disease
frequency is eight percent among men and four percent among women.
this will probably lead us to tell her that the actual risk was smaller than
what we had said earlier, namely only four percent. however, this would be
misleading if she is a smoker. in that case, it would have been more accurate
to upgrade our estimate from six to ten percent. if there is no information
available about the risks to smokers and non-smokers, respectively, then we
have no means of knowing that our adjustment of the risk estimate from six
to four percent went in the wrong direction. (smoking is usually taken into
account in epidemiological studies, but other, less well-known factors that
inluence risks may be unknown.)
the best available estimate of the risk to an individual is normally equal
to the best available estimate of the risk to the smallest subpopulation to
which she belongs and for which a reasonably accurate estimate can be
made. however, such a best estimate is always provisional, and may have to
be adjusted whenever information about a more speciic subpopulation is
obtained. since we can never in practice know which are the relevant sub-
populations, reliable risk estimates can only be obtained for groups, not for
individuals. more speciically, differences between the sexes need not be the
“last word”, but may have to be supplemented with additional subdivisions
of the exposed population.
Exclusively female or male diseases

the second argument given above refers more speciically to differences be-
tween the sexes: some diseases affect only women, or only men. this applies,
of course, primarily to diseases of the reproductive system. on the male side,
1,2-dibromo-3-chloropropane (DBCP) gives rise to testicular damage and
male sterility. there are indications that some industrial chemicals, including
carbon disulphide, boric acid, and lead may affect potency or libido. on the
female side, several substances have been reported to give rise to sterility or
subfertility, including ethylene oxide, arsenic, lead, aniline, formaldehyde,
and benzene. there are also reports of gynaecological disorders such as
menstrual irregularities associated with exposure to several substances, includ-
ing formaldehyde, toluene, and inorganic mercury (for details and further
references, see Barlow and sullivan 1982 and ratcliffe et al. 1993.)
270
in view of the delicate mechanisms involved in the menstrual cycle, it is a

reasonable hypothesis that gynaecological disorders may often be one of the
adverse effects detectable at the lowest levels of exposure. therefore, one
should expect such disorders to have been at the focus of many epidemiologi-
cal studies. however, as shown by Messing and kilbom (see chapter 1), only
few epidemiologists or practitioners of occupational medicine seem to have
looked systematically for gynaecological diseases. one possible reason for
this may be that a picture of workers as being male prevails in occupational
medicine.
the Criteria Group preparing the scientiic basis for swedish occupational
exposure limits has assigned critical effects to 165 substances. the critical effect
of a substance is the adverse effect that appears at the lowest exposure level.
For none of these substances was the critical effect a gynaecological disorder
(hansson 1997). this is not surprising, since exposure-related information
on gynaecological effects is extremely rare in the toxicological literature.
Effects on children
the third reason to pay attention to differences between women and men is
that this is often necessary in order to detect effects on children of the exposed.
It is extremely dificult to discover such effects, and in order to succeed we
need to deal separately with the different mechanisms by which exposures of
men and women may affect their children. For obvious biological reasons,
there are more such mechanisms for mothers than for fathers.
teratological and embryotoxic effects are much more dificult to discover
than effects on the workers themselves. as was noted by hunt (1979, p. 118):
“If an expected incidence of an event is 1 in 1000 and the risk is increased
to 2 in 1000, that is, the risk is doubled in exposed individuals, 10 100
exposed individuals are required in order to have a 75 % probability of
showing a difference signiicant at the 5 % level, using a two-tailed test.
there are few if any industrial settings where such a number of pregnan-
cies could be observed to establish the presence of teratogenic effects for
a suspected agent” (Cf. also ratcliffe et al. 1993, pp. 995–996).
If the effect on foetuses is mediated by toxic effects on the semen of male
workers, then detection is rendered dificult by the fact that pregnancies of
271
wives are not typically included in occupational health studies. if the effect is
instead mediated by some toxic effect on the mother, then the small proportion
of women in most heavily exposed populations makes discovery dificult.
several substances have been reported to cause decreased semen quality,
including carbon disulphide (WHO 1979), ethylene dibromide (ratcliffe et
al. 1987), 2-ethoxyethanol (ratcliffe et al. 1989), and chloroprene (sanotskii
1976). substances that reportedly give rise to spontaneous abortion after
exposure of the mother include carbon disulphide, dimethylformamide,
and ethylene oxide.
A case study: German occupational exposure limits

In a recent study of the oficial German occupational exposure limits (maks),
I found a surprising example of how women’s health was openly neglected
(hansson 1998).
In its report on lead (1977), the mak commission referred to a German
law of 1976, according to which women younger than 45 years of age are not
allowed in employment which leads to “an increase of lead in blood to values
above 40 μg/100 ml”. according to the commission, “this restriction applies not
only to the protection of the unborn children but also to the women themselves,
since their sensitivity to lead is higher than that of men”. Detailed biochemical
arguments were given for women’s higher susceptibility to lead. For workers
not covered by the law of 1976 (i.e. women of at least 45 years and all men),
a mak value was determined in order to avoid a lead concentration in blood
above 60 μg/100 ml. the commission argued as follows:
“since there is no suficiently grounded suspicion that chronic exposure
of male employees impairs health at levels below this concentration in
blood, the commission does not at present see any reason to consider a
lower value.”
hence, women of all ages were said to be in medical need of stricter protec-
tion against lead than men, but the adopted regulations provide such stricter
protection only for women not above 45 years of age. this discrepancy is
not explained in the report; indeed there is no indication that the commis-
sion paid any attention to it. neither has there been any rectiication at any
later point in time.
272
the Maks are oficially claimed not to be the outcome of a compromise

between health protection and economic considerations; they are explicitly
said to be based exclusively on scientiic information on health effects, and
thus to be unaffected by economic, political, or technological considerations.
(see hansson 1998 pp. 35–39 for a documentation of that claim.) against
that background, it is dificult to make sense of the commission’s approach
to effects on unborn children of pregnant workers.
Particularly in the last few years, the commission has put much work into
the documentation of such effects. however, to deal with them they have not
chosen the most straightforward regulatory method, which is, of course, to
reduce the maks whenever that is necessary to protect the unborn. Instead,
separate warnings against embryotoxic effects are printed in the list of maks.
the preamble of this warns that the “observance [of these values] does not
guarantee, in every case, that the unborn child is reliably protected from the
prenatal toxicity of these substances” (senatskommission 1996a, p. 16; 1996b,
p. 16). methyl mercury is assigned a warning (“Group a”) to wit: “exposure
of pregnant women can lead to damage to the developing organism even when
mak and Bat [biological exposure limit] values are observed” (senatskom-
mission 1996a, pp. 16 and 74; 1996b, pp. 16 and 69). sixteen substances are
assigned a somewhat weaker warning (“Group B”), to wit: “Damage to the
developing organism cannot be excluded when pregnant women are exposed,
even when mak and Bat values are observed” (senatskommission 1996a,
pp.16 and 20–100; 1996b, pp. 16 and 20–95).
one of the sixteen “group B” substances is dimethylformamide (DmF). In
its report on this substance (1992), the commission said that 150 ppm gives
rise to embryotoxic effects in rabbits. the “no effect level” was reported to
be 50 ppm. the mak value assigned to the substance was 10 ppm, with the
following comment:
“the safety margin to the mak value is too small to make it possible to
rule out, in practice, embryotoxic effects even when the mak value is
complied with. therefore DmF is included in Group B.”
hence, the commission has chosen to issue warnings to the effect that certain
mak values do not protect the unborn, rather than to reduce these values to
levels that offer such protection. no risks that emanate from the exposure of
273
male workers are treated in the same way. it is dificult to see how this choice
of a different regulatory strategy could be based on considerations of health
alone. economic and/or political considerations seem to be at play here, de-
spite the commission’s assurances that it never takes such factors into account.
Presumably, the removal of pregnant women from workplaces with exposures
dangerous to the foetus is subject to less resistance than the reduction of all
workplace exposures to levels at which these dangers have been eliminated.
unfortunately, due to the time lag between conception and the recognition
of pregnancy, the chosen method does not protect against effects in the sensitive
early part of pregnancy. Birth defects due to disturbances of organogenesis occur
during the 4th to 9th weeks, when the pregnancy is often unknown (weeks et
al. 1991, pp. 489–501; Peters and Garbis-Berkvens 1996, pp. 935–936).
another possible strategy to deal with the differences between men and
women in susceptibility to toxic inluences is to adopt different exposure limits
for the two sexes. In my view, this is not a viable strategy, for the following
two reasons. First, it may lead to discrimination on the labour market. If,
for example, the exposure limit for a certain substance is lower for women
than for men, and compliance with the lower limit is more costly, then an
effective economic barrier against hiring women has been created.
the second reason is based on the precautionary principle. For concrete-
ness, suppose that a certain substance gives rise to disturbances in sperma-
togenesis at 10 ppm, whereas in females the lowest exposure known to have
adverse effects is 100 ppm. this does not mean that exposures below 100
ppm are known to be safe for women. to the contrary, the effect dem-
onstrated in males at 10 ppm shows that the substance interferes with the
human body at that exposure level. this can be taken as an indication that
possibly other human organs, in both females and males, may be affected at
about the same level. therefore, according to the precautionary principle,
an exposure limit that protects the most sensitive sex should be chosen, and
should then be applied to both sexes.
It also follows from the same principle that exposure limits should be
accompanied by information about their inherent uncertainty, which is due
to our ignorance about toxic effects and dose-response relationships. such
warnings can be used as a basis for additional precautionary measures in
workplace practice.
274
Conclusions
We have found two neglect mechanisms, mechanisms that lead to the neglect
of women’s health problems in occupational toxicology:
the irst neglect mechanism depends on the fact that women are in
many cases a rather small minority in exposed groups. therefore, if women
are more sensitive than men to a certain exposure, then this will often go
undetected for statistical reasons — the groups of women included in many
studies are too small for effects on their health to be detected.
the second neglect mechanism is that health problems that only affect
women, such as gynaeological diseases, have seldom been studied at all.
the combined effect of the two neglect mechanisms is that too little is
known about toxic effects on women’s bodies. as a consequence of this, we
have reasons to fear that occupational exposure limits and other standards and
regulations protect women to a signiicantly lower degree than men.
to correct this bias in occupational toxicology is no easy matter. supple-
mentary studies of women’s health can — realistically speaking — only cover
a small fraction of the thousands of exposures that have been studied in the
past, with insuficient attention to women’s health. however, the following
types of studies could contribute to a partial rectiication of the bias:
1. studies of the health of women in highly exposed occupations (such as
female welders, women working in the chemical industry, etc.). Due to the
small proportion of women in most such occupations, samples from many
workplaces, often from several countries, will be required in order to obtain
suficiently large groups for statistical evaluation.
2. epidemiological studies of relationships between women’s diseases and
occupational exposure.
3. the construction of standardized laboratory tests to identify substances
that may give rise to gynaecological disorders. recent developments in en-
docrine toxicology open up new opportunities for work in this area.
275
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sato a et al (1991) a simulation study of physiological factors affecting pharmaco-
kinetic behaviour of organic solvent vapours. British J Indust Med 48 342–347.
senatskommission zur Prüfung gesundheitsschädlicher arbeitsstoffe (1996a) MAK-
und BAT-Werte-Liste 1996. weinheim, Deutsche Forschungsgemeinschaft.
senatskommission zur Prüfung gesundheitsschädlicher arbeitsstoffe (1996b) List of
MAK and BAT Values 1996. weinheim, Deutsche Forschungsgemeinschaft.
stuik e J (1974) Biological response of male and female volunteers to inorganic lead.
Internationales Archiv für Arbeitsmedizin 33 83–97.
Vainio h & tomatis l (1985) exposure to carcinogens: scientiic and regulatory
aspects. Annals of the American Conference of Governmental Industrial Hygienists
12 135–143.
weeks J l, levy B s & wagner G r (1991) Preventing Occupational Disease and Injury.
washington DC, american Public health association.
who (1979) Carbon Disulfide, environmental health Criteria 10.
276
Chapter 11
MEn aLso arE GEndErEd

278
men also are gendered
Men, work and health

by Anders Kjellberg
it is clear from earlier chapters that gender segregation on the swedish

labour market is both extensive and highly resistant to change. it is just
as evident that this segregation has in many ways worked against women.
the gender sorting processes active on the labour market have resulted in
women being over-represented in positions that are unfavourable in terms
of economics and power. however, it is not reasonable to assert that women
have been “wronged in every area” of working life (robertsson 1993), and
that it is therefore only natural that the focus has been almost entirely on the
female situation in analysing working conditions from a gender and equal-
ity perspective. such a concentration on the woman’s situation is especially
misleading when discussing the health consequences of the working envi-
ronment. there are more men than women in professions which are almost
completely single-sexed, and many of these involve health risks which are far
less common in occupations dominated by women. one of the aims of this
chapter is to illustrate this, and indicate several other areas of importance in
working environment studies from a male gender perspective.
the purpose of the chapter is not to provide an overall summary of re-
search in this area. it is rather an illustration using empirical data on selected
issues which have been brought to the fore while reading literature relating
to the area, and some thoughts on these issues.
Working environment studies

from a male gender perspective are uncommon
Both behavioural science and biological research have justiiably been criti-
cised for basing a disproportionate amount of their conclusions on studies of
279
men. this applies to research into the working environment as well as other
ields of research. this sexual imbalance does not necessarily mean that the
phenomenon under study has been treated from a male gender perspective.
the fact that male research subjects have so often been chosen has not been
due to an interest in what it means to be a man in the context under discussion.
on the contrary, men usually appear to have been considered representatives
of mankind, and their sex has not been treated as an important factor when
interpreting results. For this reason, working environment studies from a
male gender perspective are rare, even though so many have been based on
groups of male subjects.
the greatly increased emphasis on gender perspective in working life
research in recent years has therefore in practice given rise to more research
from a female perspective. these studies have analysed the woman’s situa-
tion, and any male subjects have only served as comparison groups, used to
demonstrate women’s unfavourable position: this type of analysis has less
often been based on men’s conditions.
Sex-typed occupational health risks

— background and outline of the chapter
traditional male values and lifestyles involve health risks. this has been
studied in many contexts (helgeson 1995; levant and kopecky 1995; sabo
and Gordon 1995), but the focus has rarely been on the role of the work and
work conditions. this discussion has instead focused on violence, accidents,
alcohol, tobacco and other abuse, sexual habits, doping and other sports-
related practices, all of which concentrate on life outside work. such factors
do at least constitute part of the explanation as to why certain diseases and
causes of death, e.g. lung cancer, hIV, ischaemic heart disease and cirrhosis
of the liver, are more common among men than women.
Differences in values and life styles may also lead to sexually differenti-
ated health effects of work. traditionally, work has a more central position
in men’s lives and morgan (1992) even regards work as the primary basis
for the masculine identity. the centrality of work, together with a male life
style characterised by aggressiveness, competitiveness and a striving for
independence and emotional control, probably mean that men and women
do not carry out their work in the same ways, which might be of importance
280
for the health consequences of their work. these questions are touched upon
in several of the sections of this chapter.
Work-related health differences between the sexes are, however, primarily
an effect of selection, one result of which is that more men than women can
be found in, and apply for, jobs in working environments which involve a
higher degree of exposure to certain serious health risks, including accidents.
one conceivable basis for this sexual segregation may be that men’s and
women’s physical and intellectual abilities are different in various essential
respects; the following section argues that this only explains a small part of
the segregation.
however, this sexual segregation towards different occupational areas
is not the only conceivable reason behind work-related health differences
between men and women. More men than women hold senior positions
within each ield, and allocation of work duties according to sex also often
occurs in other ways. For these reasons, men’s and women’s psycho-social
work situations differ in ways that may be of signiicance to their health, be
it to the detriment of one sex or the other.
By tradition, work, career, social relations, the home and the family do
not play the same roles in men’s and women’s lives. the consequences of
the uneven distribution of responsibility for the home and family as a pro-
portion of total workload for each sex are discussed later. this issue is usu-
ally discussed in the context of equality and justice, with the woman as the
wronged party. From a health and quality of life perspective, it is not always
as obvious whether the man or the woman is disfavoured.
our image of the differences in men’s and women’s health is partly due
to the fact that men and women do not seem to experience, describe and
react to the symptoms of ill health in the same way. these differences and
the differences in views on health are also discussed.
Finally, we deal with one aspect of the extremely sex-segregated labour
market: what are the consequences of belonging to the majority or minority
sex in workplaces which are almost completely single-sexed?
another possible basis for special male health problems at work might
be that men biologically are more vulnerable than women to some exposure
factors. thus, it has, for example, been claimed that female hormones provide
a certain protection against some diseases (hemström 1996a). these ques-
281
tions are not dealt with in this chapter, but are discussed by Westerholm in
relation to cardiovascular diseases, in chapter 6.
Differences between men’s and women’s physical and cognitive

ability explain only a minor part of gender segregation on the
labour market
one possible reason for gender-based selection in different occupations may
be that men’s and women’s physical and cognitive abilities are different in
various essential respects. the only ability variable that bears any relevance in
this context is probably physical strength, although there is reason to question
what bearing traditional parameters for measuring physical strength actually
have on the physical demands of the job (Messing and stevenson 1996). in
a limited number of professions which place extreme demands on physical
strength, this difference could in any case result in a very low proportion of
female personnel, and may create problems for the women who, neverthe-
less, work in these occupations. note that this applies to the present work
design, which is usually based on the premise that men will do the work;
tools, machinery, etc., could in many cases be adapted so as to render it more
realistic for women to perform the same work tasks.
But regardless of the validity of this argument, differences in physical
strength have certainly also been used as a pretext for male domination in
contexts where physical strength ought not to preclude women. it is also
apparent that women are in the overwhelming majority in certain physically
demanding occupations, primarily within the health care sector.
Women are not more intelligent than men, and men are not more intelligent
than women. however, sex differences have been demonstrated in some speciic
cognitive abilities; women tend to be slightly better than men as regards certain
memory functions and verbal abilities, whilst the average performance in some
spatial and mathematical tasks is slightly better among men (for references
see chapter 3). however, in each of these cases the sex difference is much
smaller than the variation within each sex. a person’s sex therefore has no
real informational value in evaluating the individual, nor could the sex differ-
ences have anything but a marginal effect on the distribution of sexes within
a given occupation. even if this is true, it is possible that also a rather small
mean difference may lead to a disproportionately large number of men or
282
women among persons with an extremely low ability in some critical respect.
this is probably only rarely the case. one possible example, is that women’s
slightly better average verbal ability is also evident in that the occurrence of
dyslexia and other reading dificulties is three times higher among boys than
among girls (DeFries 1989). thus men could be particularly affected by the
increasingly widespread and more stringent demands on reading, writing
and language ability, partly due to computerisation.
other alleged sex differences, such as the superior ability of men to con-
centrate their efforts on one task at a time, and that of women to deal with
several tasks at once, seem to ind little or no empirical support. Conclusions
relating to such differences seem to be grounded on the possibly correct
supposition that demands on men and women, both in and outside the work-
place, differ in corresponding ways. we therefore suppose that women have
more experience of dealing with several tasks simultaneously, and that this
has made them generally better able to handle this kind of work situation.
this is in itself a reasonable hypothesis, but seems to be void of all empirical
substantiation. moreover, such a difference would much sooner constitute
an effect of the sexually segregated labour market, than something which
would motivate such a segregation.
Differences in physical and cognitive ability do not therefore provide
any rational explanation as to why many occupational groups consist almost
entirely of men. however, certain preconceived ideas regarding the differ-
ences in cognitive ability between men and women seem hard to get rid of,
despite the lack of empirical support, and may therefore have an inluence
on people’s actions in any case, thus contributing to sex differentiation on
the labour market.
sexual segregation therefore seems to depend on differences in male and
female values, ambitions in life and priorities, rather than on differences in
ability. the segregation particularly seems to relect the less central role
played by social relations in men’s lives, and men’s stronger emphasis on the
occupational role. the fact that certain professions are almost completely
single-sexed could therefore be said to relect men’s and women’s own values
to a certain extent.
the fact that sexual segregation is founded to some extent on differences in
values does not of course mean it is not problematic for either sex. In the irst
283
place, segregation exists not only within every occupational sphere, but also at
each individual workplace. a much higher proportion of men than women
hold management positions, and this is of course not only due to the fact that
women prioritise their careers less than men. there are also many examples of
work-task segregation between the sexes within narrowly deined occupational
groups, segregation that cannot be put down to men’s and women’s differing
interests, but rather to factors such as sex-role stereotyping in the allocation
of work duties (see e.g. study of train cleaners, messing et al. 1993).
secondly, the differences in values are hardly great enough to explain
the extreme sex segregation in such professions as nursing and mechanics.
hagström (1998), for instance, found that female nurses considered social
relations to be a slightly more important aspect of work than male engineers
did, but also that both groups considered social relations more important
than material beneits. a parallel study of swedish youths produced similar
results (Gamberale et al. 1996). the only tangible difference between male
and female value prioritisation in these two studies was that women considered
the potential of being helpful to other people in their work more important
than material beneits, whilst men thought the opposite. tolbert and moen
(1998) found similar, small but stable sex differences in an american longi-
tudinal study. moreover, these differences narrowed with age.
the current extreme sexual segregation can therefore be seen more as a
caricature than a true representation of the actual differences in values be-
tween men and women. this is a problem, since sexual segregation in itself
probably prevents large groups of people, whose values do not correspond
to the sex stereotype, from realising their career ambitions.
thirdly, almost completely single-sexed environments also create prob-
lems for those that break through the sex barriers in spite of the obstacles,
and it is also possible that a more evenly balanced sex distribution leads to
a better social working environment for both sexes. moreover, a better bal-
ance between the sexes can in some cases promote the achievement of an
organisation’s goals. this is most evident in child-care and education, where
an absence of men might possibly have undesired consequences.
In this context, the important question is whether the sexual segregation
has involved any particular risks to the men’s health, well-being and quality
of life.
284
It is men who die at work — differences in men’s and women’s

exposure to conventional risks in the working environment
it is almost solely men who are killed at work, and the accidents occur primarily
in extensively male-dominated occupations; only six percent of fatal accidents
in sweden between 1987 and 1995 affected women, and the igure probably
should drop even further if accidents suffered on the way to and from work
are disregarded. the difference in the proportion of men and women is not
so pronounced in less serious accidents: in 1995, men reported approximately
twice the number of accidents to the central Isa industrial accident register
(national Board of occupational safety and health and statistics sweden
1997). the difference in accident frequency among men and women has
decreased dramatically since the 1980s, primarily as a result of the reduced
number of occupational accidents suffered by men. this change, in turn, is
probably primarily an effect of the restructured labour market.
more men than women are also killed in accidents outside work, though
these igures are much more even than for work accidents. For example,
women accounted for 42 percent of all people killed in fatal accidents in
sweden in 1991–1995 (statistics sweden 1998).
the statistics thus seem to indicate that the difference in accident fre-
quency between men and women is almost entirely due to the fact that men
work in environments with a greater risk exposure; men are subjected to
more and greater risks in their work. men are also exposed to these risks for
a longer period of time than women, as more women work part time, but
the difference in exposure time could only explain a small part of the sex
difference in accident frequency. It is, of course, also possible that the way
men work exposes them to greater risks than women with the same work
duties. however, a higher accident frequency among men than women in
the same occupational group cannot simply be supposed to support this,
since studies have shown that men and women often have different work
duties even within quite narrowly deined occupational groups (messing et
al. 1994a, 1994b).
more men than women are also exposed to noise, vibrations, unfavourable
climate, organic solvents and most other types of conventional physical and
chemical risk in their working environments. heavy physical work is also
285
slightly more common among men, although large groups of women also
carry out such duties, and unfavourable working positions seem to affect
both men and women to a roughly equal extent. Women have repetitive
work duties to a greater extent than men, and in some female-dominated
groups, the great majority of women perform such work duties (Järvholm
1996; statistics sweden 1991). however, such work duties are also appallingly
common among men: 32 per cent of men (39 percent of women) indicate
that they repeat simple tasks many times an hour, and 37 percent say they
can only determine the rate at which they work for half their working time
at the most (51 percent of women), (Järvholm 1996).
Women accounted for a slightly larger proportion (around 55 percent) of
occupational illnesses reported in 1995. the differences in terms of types of
illness between the sexes show that musculo-skeletal disorders are by far the
most common type of illness for both men and women, but also that these
disorders are more common among women (national Board of occupational
safety and health and statistics sweden 1997). sixty-eight percent of illnesses
reported by women in 1995 were musculo-skeletal disorders, while the cor-
responding igure for men was 60 percent. a total of 9 995 musculo-skeletal
diseases were reported and 42 percent of these reports were made by men.
the sex difference is largely the result of neck and shoulder disorders being
much more common among women. the sex difference is small for back
disorders, and disorders of the hip joint and legs are even more frequent
among men. the mean sick leave is also somewhat longer for men.
the study of living conditions made by statistics sweden shows much
the same distribution between men and women of complaints; this study
indicated that 20 per cent of women and 15 per cent of men were troubled
by musculo-skeletal problems in 1988–1989 ( statistics sweden, 1991a). the
sex difference is more pronounced for neck and shoulder problems, which are
considerably more common among women than men. Back problems are the
most common complaints among men, but even these problems are slightly
more common among women. more detailed data are given in chapter 8.
Illness caused by exposure to hazards in the chemical and physical environ-
ment, such as solvents-related illnesses and hearing and vibration injuries,
are more common among men. one important exception, however, is that
of skin diseases (see chapter 7).
286
the sexual segregation processes active on the labour market therefore

lead to men being exposed to most of the conventional working environ-
ment risks to a greater extent than women, and they therefore also suffer
from occupational illnesses related to these factors more often. the one
major important exception is musculo-skeletal disorders, although it would
be directly misleading to describe this as a female problem. While they are
more common among women, they are also by far the most common type
of occupational disorders among men.
to put this section more clearly into its context, it is clear that while
men may be somewhat better equipped to handle some of the work duties
in question, this does not provide any real explanation as to why men end
up in professions which entail these health risks.
Psycho-social working environment, stress and health

Demands, control and social support
a far larger proportion of women than men consider that they have unquali-
ied work duties. a study from statistics sweden (1991) shows that two thirds
of women with a post-sixth form education consider that their work duties
require at most a few month’s education over and above the level reached
during mandatory education, while only half as many men with the same
degree of education consider this to be the case. of the whole group of
women studied, 78 percent considered that they currently performed work
duties of this kind, while the corresponding igure for men was 47 percent.
the difference was accentuated in that the women in several totally female-
dominated occupational spheres such as cleaning and pre-school teaching
had this opinion of their work, but the difference was true within almost
all occupational areas. Female modesty may have had some bearing on the
judgement of qualiication levels, though the opinions shown certainly also
relect some real differences.
the same study from statistic sweden also showed that more men considered
that they had some inluence on how their work was laid out. however, the
difference between the sexes was nowhere near as marked in this respect. It was
therefore often possible to determine the rate and layout of work, and decide
when to take breaks, even in those jobs considered to be unqualiied.
287
in terms of constant attention and concentration, the difference was only

minor and worked in the other direction. one effect of the difference in work
position, is that men indicate they are forced to deal with crisis situations on
their own at work more often than women. this same difference probably
also explains why men in all occupational spheres more often have to work
outside normal working hours.
a book edited by Järvholm (1996) enlarges on 1992–1993 data from sta-
tistic sweden by analysing jobs according to the demand/control model, in
order to identify how common jobs involving negative stress (high demands
— low control) and active jobs (high demands — high control) are for men and
women in different occupational areas. these analyses indicated that twelve
percent of women and eight percent of men were in jobs characterised by
negative stress. this difference between the sexes seems primarily to depend
on the fact that fewer women have good control opportunity (i.e. decision
latitude) in their jobs, rather than that more women have high demands
placed on them. the discrepancy was also generally explained by the spread
of men and women across occupational areas, and could not therefore be
observed within occupational groups (in this case the distinction was made
between qualiied and unqualiied workers and junior and senior salaried
personnel). the proportion of active jobs was practically the same for men
as for women. resulting igures were also compared to a 1979 study, which
showed that the number of employees who described their jobs as both
stressful and psychologically arduous had increased slightly, particularly in
such female-dominated areas as care, nursing and education.
however, men appear to have an unfavourable work situation in one
important respect; women more often feel they can obtain help and support
in their jobs, while men consider themselves forced to deal with their work
tasks themselves (statistics sweden 1991).
It has also been shown that men receive less social support outside the
workplace. For men, the wife often provides all the crucial social support,
while women generally enjoy a broader social network (antonnuci 1990).
the critical importance of the wife is also indicated by the fact that it is
positive for men from a health point of view to be married or cohabiting,
while this connection is much weaker for women (umberson and Chen
1996). Furthermore, mortality is slightly higher among newly widowed men
288
than newly widowed women, while the higher mortality among single and
divorced men than single and divorced women would appear rather to be a
selection-related phenomenon (hemström 1996b).
Generally speaking then, it would not be true to say that any systematic
sex difference exists in terms of the level of demands at work. on the other
hand, a higher proportion of men than women have jobs which give them
good control (decision latitude), while women often receive better social
support both in and outside the workplace. however, this type of comparison
risks being very misleading, since the labour market is so segregated. this
segregation means that control, demands and social support can represent
very different conditions for men and women, in a way that could be of
great signiicance to health consequences. For instance, having little scope
for decision-making means totally different things on the factory produc-
tion line and in emergency health care, and the difference in the nature of
controlability may be of signiicance to the risk of ill health. theorell (1996)
suggests that this could be one of the reasons why the connection between
these conditions and the risk of heart attack are not as clear among women
as among men.
Effects of unemployment
there are several possible reasons for suspecting sex differences in the health
consequences of unemployment. If the professional role is more important
for men’s than for women’s identity, the effect of job loss should be more
severe for men. It is also possible that unemployment has different economic
consequences for men and women, and that sex differences in social support
might affect the vulnerability to the effects of job loss. unemployed men and
women may also be met with different attitudes and responses by their social
environment; to be unemployed may, for example, be more shameful for men
than for women, and the husband’s response to his wife’s unemployment may
differ from the wife’s response to an unemployed husband. sex differences
may also arise as a result of differences between men’s and women’s ways of
coping with the situation. Comparisons between the effects of unemployment
on men and women involve further complications as a result of the sexually
segregated labour market; it is rather likely that the effects differ between
occupational ields and positions.
289
thus, many factors may lead to differential effects of unemployment

among men and women, and it is obvious that one could expect different
effects depending on where, when and in what occupational groups the sex
differences are studied. the possibility to generalize between countries, widely
different points in time and occupational groups therefore is limited.
furthermore, it is methodologically very dificult to show that unemploy-
ment causes ill health, and that this effect is different for men and women
(hallsten 1998). Poorer health among the unemployed might mean that
unemployment causes ill health, but also that ill health increases the risk of
unemployment; the health in the unemployed group might have been worse
also before they lost their jobs. If unemployed women appear less healthy
than men, this does not necessarily mean that they are more affected by
unemployment; it might just relect a general tendency among women to
report more symptoms. It might also be an effect of a stronger tendency
to health-related selection in unemployment among women or in typical
female occupations.
against this background it is not surprising that the research on unem-
ployment does not give a clear-cut picture of sex differences in the effects
of unemployment. however, research reviews indicate that, typically, no sex
differences have been found (Perrucci and Perrucci 1990; wineield 1995).
neither did hallsten (1998) in his meta-analysis ind any support for gender
differentiated effects.
one swedish study has focused on sex differences in the effects of unem-
ployment (hammarström 1994). hammarström followed a group from the
last year at elementary school (16-year-olds) and ive years ahead. the only
clear difference found between boys and girls, was that unemployed boys
increased their alcohol consumption more than unemployed girls during this
period. she also found a similar tendency to a larger deterioration regard-
ing psychological symptoms among unemployed boys. however, selection
effects might at least partly explain these effects; the alcohol consumption
was, for example, very much higher already at school among the boys who
later became unemployed.
If the female identity is less dependent on the professional role, one
should expect unemployed women to be more willing than men to enter new
types of jobs and to attend courses in new ields. this was supported by, for
290
example, a study by Gonäs (1991) of men’s and women’s conditions on the

labour market accompanying structural changes of industries on the other
hand, there seems to be no clearcut support for the notion that unemployed
women generally are more active than men.
a general conclusion often drawn in discussions of research on unemploy-
ment and health is that this research too seldom has been guided by theories
about how effects due to health could arise. theoretically based hypotheses
about the factors critical for the effects of unemployment have rarely deter-
mined the choice of groups that are compared. this is true also of comparisons
made between men and women. it is quite possible that gender is a critical
factor in this context. Men or women are likely to be overrepresented in
some of the groups where the risk for health effects due to unemployment
is especially high. it is also possible, or even probable, that the effects of
unemployment differ between men and women in some groups. however,
unemployment research has seldom provided a basis for such conclusions; as
a result of the sexually differentiated labour market, the compared groups of
unemployed men and women have usually differed in so many other respects
that differences in health status are dificult to interpret.
Men more often hold management positions

one reason why certain working environment and health problems affect
women to a particularly high degree, is that women are over-represented in
lower-ranking positions and less qualiied work duties in almost all occupa-
tional spheres. thus, for example in 1992, 91 percent of salaried employees
in senior positions in the private sector were men, while 75 percent of those
with routine work tasks were women (statistics sweden 1992).
a higher service position may be advantageous in most respects, but
management can also be associated with working conditions which entail
risks to health and well-being. the fact that more men than women hold
management positions may, for example, provide one explanation as to why
men do not consider they receive social support at the workplace (statistics
sweden 1991b).
another issue is whether management can be seen as more or less of a
burden for men than for women. several factors which may make leadership
more of a strain for women than for men were shown in a 1988 study of male
291
and female employees in various positions, conducted by frankenhaeuser and

others (1988). Women managers often feel they need to out-perform their
male colleagues in order to be looked upon as equals. frankenhaeuser (1996)
saw this as an explanation as to why women managers in dentistry displayed
a more typically male style of leadership, centring on the work duties, than
did male managers. they also felt that they experienced far more dificulty
in communicating with senior management, than did their male colleagues.
women in management positions took greater responsibility for the home
and family, and experienced more of a conlict between this responsibility
and the demands of the job (see also the next section). In all likelihood as
a consequence of this, studies of physiological stress reactions showed that
female managers’ stress levels increased soon after inishing work, while
stress levels among men decreased dramatically. a similar pattern has also
been observed in other studies.
management is often therefore a greater burden for women than for men.
Is there then anything to indicate that it may entail any particular problems
for men? one factor which may have such consequences is the prevailing
masculine ideal which places higher expectations on men to strive for man-
agement positions. a probable consequence of this ideal is that men more
often achieve such positions without the necessary qualiications, and pos-
sibly without even wanting the work duties these positions involve. It may
also be more dificult for a man not at home with managerial tasks to leave
them for a more junior position.
another side of expectations on men to strive for management positions
is that it also creates problems for those who do not fulil this expectation. a
man not achieving a management position may be looked upon as a failure,
and a man not even striving for this goal probably runs a higher risk of being
criticised as unambitious than a woman in a similar situation.
Men’s and women’s stress reactions

In a recent outline article, marianne Frankenhaeuser (1996) has summarised
her long series of studies into the stress reactions of men and women, both in
the laboratory and at the place of work. the most reasonable conclusion of
these studies is that involvement in a work task bears a cost, and that the sex
differences which have been observed relect the fact that men and women
292
tend to be involved in different work tasks, rather than a general difference

between the way men and women react in stress situations. this would also
practically rule out the conclusion that the stress reactions generally have
different health consequences for men and women, unless based on the
premise that there exists a general difference in degree of involvement in
the work between the sexes.
Paid work and housework — a double burden

Total work time
in terms of responsibility for the home and family, traditional sex-role pat-
terns still very much remain. the difference between how much time each
sex devotes to unpaid work in the home has decreased slightly in sweden
(nermo 1994), but men still spend signiicantly less time on such tasks. since
a great majority of women also have paid jobs, it would not seem improb-
able that women have a much greater total work load than men. lundberg,
mårdberg and Frankenhaeuser (1994) have presented data interpreted to
support this. they also observed that the difference increased even further,
the higher the number of children. however, the interpretation of these
results is complicated by the selection of groups for the study. In this case,
they were chosen to be as comparable as possible in terms of work time
and career advancement level. this meant that all study subjects worked at
least 35 hours a week, and that an uncommonly large proportion of women
held management positions. there were probably also a larger proportion
of single parents among the women, which would serve to increase the dif-
ference between the sexes. what the igures therefore show is that female
full-time salaried employees on average have a greater total work load than
male full-time salaried employees. It is also extremely likely that the women
studied had a greater total work load than the men they may have lived with.
(however, strictly interpreted, the results do not permit this conclusion, since
we do not know how representative the male group was of these men.)
on the other hand, it is not at all as clear that the total work load of the
men studied was less than the women they may have lived with. the selection
principles exclude anyone working part time, thereby practically eliminat-
ing the effects of what may be the most signiicant means of regulating the
293
total work load. the signiicance of this is shown in a 1990–1991 study from
statistics sweden of how men and women use their time. the study showed
that women spent far more time than men on work in the home, but also that
this was completely compensated for in the reduced time they spent in paid
employment (rydenstam 1992). this diary study showed that men’s total
work time averaged just over 61 hours, and women’s, 60 hours 40 minutes.
not even the single mothers in the study reported a much greater work load
than attached men with children.
similar results have been presented by nermo (1994), who also indicated
that the difference in total weekly work time between men and women de-
creased by six hours between 1974 and 1991. this change was primarily due
to the fact that women were spending less and less time on housework, but
also partly that men were devoting more time to such work. women more
often work part time than men on all professional levels. even among those
with independent qualiied jobs in the private sector, as many as 24 percent
of the women worked part time, while the corresponding igure for men was
3 percent (rydenstam 1992).
the issue of uneven distribution of work time cannot, of course, simply
be resolved by referring to the fact that the total average work time does
not seem to differ greatly between men and women. In the irst place, it is
important to identify the groups in which the work load is very unevenly
distributed. Frankenhaeuser (1996), for instance, reports that women work
a total of eight hours longer per week than men in families, where both
partners focus on their careers. another issue is to what extent the uneven
distribution of work time between the sexes is forced, and to what extent
this distribution corresponds to the wishes of each individual partner. the
great majority of part-time workers seem to prefer this to full-time work,
but about a fourth of them would prefer to work full-time (Persson 1997).
this percentage is about the same for men and women. surveys as to which
men take advantage of paternity leave (statistics sweden 1996) can be inter-
preted to support the idea that women have a crucial inluence on whether
the man takes paternity leave or not. thus, the likelihood of this increases,
the higher the woman’s income and professional position, and decreases,
the less personal gain the woman considers that the work offers. the man’s
salary alone does not have a bearing on whether leave is taken or not, any
294
more than the woman’s salary does, and no connection exists between the
man’s personal gains and whether or not he takes paternity leave.
Lundberg and others (1994) also found that however much they worked
(in the limited variation of work time available in the base material), women
experienced more of a conlict between work and other commitments than
did men. It is evident that men in general place lower demands on themselves
in terms of contributing to home and family work tasks. thus, this difference
in perceived conlict between the sexes perhaps relects what is primarily a
difference in values, and would therefore not automatically be eliminated
if the man and woman devoted an equal amount of time to paid work, and
also shared domestic duties equally. the current differences between men’s
and women’s distribution of time in paid employment and housework might
therefore partly be seen as a result of an endeavour to place the man’s and
the woman’s subjective conlict between work and home on an equal level.
however, in families where both partners work full time and want to make
a career, the woman usually has to devote more time than the man to house-
work in order to attain a tolerable level of conlict.
Parental leave
extensive resources have been invested in campaigns in sweden to encourage
more men to take greater responsibility as fathers. still, only a small minority
of men use their statutory right to paternity leave, but the increasing number
of men who do so does indicate a change in attitude among swedish men
(Bekkengen 1996). there is therefore reason to believe that the subjective
conlict between home and work is set to become stronger among men.
women have tried to settle this conlict in two main ways: by reducing their
time at work and by declining to apply for higher positions. these means
of reducing the conlict have been seen as less legitimate for men, and it is
not in any way evident that this legitimacy increases as demands for efforts
in the home increase. the question posed by Gunnela westlander (1979),
is still therefore very topical:
“equality problems, which on the other hand are not discussed, are the
real consequences for men of taking increased practical responsibility
within the family. how can they be relieved from their career-related and
295
social commitments, or how can they compromise them without feeling

that they are losing some of their dignity?”
Health consequences
the uneven distribution between men and women as regards parental leave
and work time in employment or unpaid work at home, can and often has, been
treated as a justice and equality issue (though it can of course also be seen as
an issue regarding the right of the child to receive care from both parents). it
is, however, unclear as to which partner should be seen as the wronged party.
seeing the woman as the aggrieved party means emphasising the character
of the parental leave in terms of a sacriice; a sacriice which is made despite
the potential negative effects on the professional career. But it may of course
be argued, on just as sound a basis, that the man is the aggrieved party. Close
contact with the child during the time off work is in itself something worth
striving for, and something which could have positive effects even after the
leave period. this contact with the child is also the factor which the men
who have taken paternity leave name as the principal motive for taking leave
in the irst place (Idégruppen för manrollsfrågor 1992).
the short- and long-term health consequences of parental leave, of total
work time and of the balance of paid and unpaid work, have not been fully
investigated and are far from obvious. It is, for example, quite credible that
long breaks from their careers in the form of maternity leave could have
positive health consequences for women. neither does the interruption
necessarily have a totally negative long-term effect on a career itself; it may,
for example, reduce the risk of becoming burnt out. It is also possible that
part-time work makes for a better balance between career and private life,
which is better from a health and quality of life perspective. the woman’s
stronger connection with home and family life may also provide extra support
in emergency situations at work and outside the workplace. In conclusion, it
is not at all obvious which party is favoured by the current division between
paid employment and work in the home, in terms of short and long-term
health consequences.
Continued research in this area ought more closely to analyse the con-
sequences of the total work load and its distribution between home and the
workplace, for example from the point of view of health, quality of life and
296
perceived conlict between family duties and paid employment, and how
these consequences differ between men and women.
Men and women do not express symptoms of ill health

in the same way
women live longer than men, yet they almost always report a higher number
of — and more serious — symptoms in health surveys, consult their doctors
more often, and display more ill health symptoms than men in several other
respects. this apparent contrast can be interpreted in various ways. one may
be that men do not actually experience fewer and less serious symptoms than
women, but that women complain about and seek medical help for triling
problems which would not concern a man. this sex difference could there-
fore be said to stem from women over-reporting minor symptoms. another
interpretation is that women do in fact suffer from a higher number of com-
plaints, and more serious ones. the difference in length of life would then
be due to the fact that women are biologically better suited to a longer life,
or that the problems and illnesses women suffer are not life-threatening to
as great an extent as for men.
a third possible interpretation worth considering is that men’s reporting
of symptoms is unreliable, and that the sex difference is due to men reporting
too few symptoms. a research review by Verbrugge (1985) indicates that this
hypothesis has empirical support. under-reporting can be seen as an aspect of
a male ideal which involves men not showing their vulnerability and showing
that they can manage on their own. It is also possible that as a result of this
ideal, men have not developed the same level of body awareness as women,
or the same ability to receive and understand ill-health signals from the body.
For a study of conditions which could contribute to this difference between
the sexes, see Gijbers van wink and kolk (1997). regardless of the causes,
one result of this sex difference may be that comparing men’s and women’s
symptom frequency in survey studies can be misleading, and normally leads
to an underestimation of the men’s problems.
however, under-reporting is not a general phenomenon among men.
the difference in question comes to the fore primarily in general surveys of
symptom frequency. In studies of groups of people who have already deined
themselves as being ill, men have been found to report as many or more, and
297
more serious, symptoms. such results can, for instance, be seen both in a
study of people suffering from the common cold (Macintyre 1993), and in an
investigation of patients with cancer of the colon (Marshall and funch 1986).
it may be easier for men to afirm their symptoms when they are actually ill,
as it does not pose the same threat to their masculinity. moreover, the higher
occurrence of symptoms among women in one study (Pennebaker 1982), only
became evident in retrospective evaluations; there was no difference between
men and women in describing current symptoms. however, this effect does
not appear to have been followed up in subsequent studies.
Perhaps the most important lesson to be learned from these studies of symp-
tom reporting is not the fact that men under-report to a great extent. It is more
vital to realise that great care is needed when interpreting differences between
groups in descriptions of problems and working environment. the greater the
differences in linguistic habits and in any respect which might affect the criteria
or deinition levels of the phenomena in question, the higher the risk that direct
comparison may become misleading. therefore, the more crucial the gender
categorisation is deemed to be, the more sceptically we should be regarding
such simplistic comparisons between men and women.
In order to better understand the particular conditions of men and women
in working life, we need to know more about how men and women describe
the working environment, symptoms and other possible effects resulting from
it. linguistic differences can not only cloud real differences between the sexes,
but also give rise to false differences in survey and interview studies.
Men in female-dominated occupations

Financially speaking, men have less to gain by entering traditionally female
occupations, than women do, in seeking traditionally male occupations. this
probably explains why efforts to break sexual barriers have been far more
manifest among women than among men, whose entry into female profes-
sions is increasing only slowly, and in some cases is even decreasing. there
are also far fewer studies of men in women’s occupations, than there are of
women in male-dominated occupations.
as a group, men in women’s professions distinguish themselves from
their female colleagues, and often ind a male niche within the traditionally
female occupation. In sweden, for example, there is a disproportionately
298
high number of male nurses within psychiatry, and among those with ad-
ministrative and educational duties (Carlsson and Bergknut 1988). Male
nurses are also far more involved in trade union work, research and the use
of technologically advanced equipment. also in the area of child care, male
pre-school teachers have been observed to strive more for a professionalisa-
tion of the occupational role, and a stronger emphasis on the pedagogic role
(Lantz and Pingel 1988).
Men seem inclined to take the opportunity to redeine the occupational
role to bring it more in line with the male role, thereby also endeavouring to
create a “male” career within the traditionally female occupation. men are
also often encouraged in different ways to apply for new jobs and to undergo
more occupational training. one important question to study is whether these
male niches and careers only occur as a result of the men’s endeavour, or if
expulsion mechanisms are also a contributory factor to this development.
the fact that more men enter women’s professions does not therefore
necessarily mean that segregation has weakened: segregation can be kept at
prevailing levels when men ind male enclaves within traditionally female
occupations.
men are often encouraged and supported by their female colleagues and
are met with positive expectations. recruiting men to a female profession
may have positive effects on its status, whereas the opposite effect may be
attained by increasing the number of women. nevertheless men often feel
alienated from the female work place culture and not as an integrated part of
the working group (kauppinen et al. 1993). erngren, Birath and lindberg,
as quoted by kauppinen et al. (1993), found, for example, that problems met
with when co-operating with female nurses was one important reason for
the men to consider changing to another job.
kanter (1977) discusses the problems resulting from the fact that women
in traditionally male professions attract attention, and assumes that men in
female occupations encounter the same problems. others have indicated
that these situations are not completely comparable, and that men often
get much more positive attention in groups of women than women in male
groups (kvande 1998). the man is often encouraged and supported by his
female colleagues, and is met with positive expectations. Increased recruit-
ment of men into a women’s profession might also have a positive impact on
299
the status of that profession, while the opposite may be true of an increased
proportion of women in a male workforce. nevertheless, men often feel like
outsiders in the female work culture, and do not feel as if they are as much
an integrated part of the working group as are the women (kauppinen et
al. 1993). Erngren, Birath and Lindberg, referred to by kauppinen et al.
(1993), found for example that dificulty in working together with female
nurses was an important reason for men considering a change of career.
expectations on men to fulil male stereotype roles at the female workplace
can also be perceived as a problem. In the case of pre-school teachers, for
instance, demands may be placed on the man to act as a male role model
and take initiatives to play male games and conduct male activities, while his
female colleagues retain their function as carers of the youngest children,
(see review by kauppinen et al. 1993). one reason why women hesitate to
let men carry out the traditionally female tasks may be a prejudiced view of
what men can actually manage (westerståhl 1998).
the attention men receive in female occupations, and the favourable
treatment they might be perceived as being given, may of course also give
rise to conlict in the workplace. one Finnish study (kauppinenet al. 1993)
showed that many male pre-school teachers reported such problems, while
male nurses did so more rarely.
women who work in male-dominated situations often indicate that they
seem to be expected to carry out their work duties better than their male
colleagues. this in all likelihood springs from a well-founded fear that
problems and failures at work will be seen as a consequence of gender by the
male world around her. It would seem to be likely that men can encounter
similar problems in female-dominated occupations.
men’s previously discussed tendency to redeine the occupational role in
care work towards something more professional, may well also incite conlict
with female colleagues, who might see this as a threat.
another problem, which is perhaps equally important, might be the way
other men look upon those men who have chosen a traditionally female oc-
cupation. In a study of male pre-school teachers in norway (kauppinen et
al.1993), 40 percent of men indicated that this was a problem for them.
In a study of the frequency of sickness absence among men and women
in different occupations (alexanderson et al. 1994), the highest occurrence
300
was found among women in male occupations (less than 10 percent women).
a later study (hensing et al. 1995), which dealt only with sickness absence
as a result of minor psychiatric disorders, conirmed this, but also showed
that the men in these male-dominated occupations also took sick leave more
often than in professions with a more even sexual distribution. Correspond-
ing results were obtained in female-dominated occupations. sick leaves
were more frequent among men than in occupations with a more balanced
distribution of men and women; the occurrence was in fact higher for the
men, than for the women in these jobs. analogous to the results shown in
the male-dominated occupations, women also took sick leave more often in
these occupational groups than in those with an even sexual distribution.
these studies do not clarify the causes of these differences, and the
mechanisms require further investigation. Part of the explanation may be that
working conditions in occupations with an uneven sexual distribution could
be generally unfavourable, and particularly ill-suited to the minority gender.
they may also to some extent relect selection processes. however, it is not
entirely improbable that a single-sex environment in itself might constitute
a form of strain, especially of course for the minority gender.
Concluding comments
sex differences in work-related health seem primarily to be a result of the
fact that men and women work in different occupational spheres. however,
it may also depend on the fact that men and women hold different positions
within these spheres, do not spend the same amount of time in these posi-
tions, and are allocated different work duties within the same occupational
sphere. the consequences of certain occupations being dominated by men
are obvious; the consequences of segregation within occupational spheres
for men are much less clear, and demand further investigation.
similar values regarding male and female seem to determine sexual segre-
gation on every level, but the mechanisms behind the segregation evidently
differ. Different kinds of remedial measures are therefore called for, if a change
in the current situation is to be brought about. sexual segregation within a
workplace or occupational sphere may be a result of actively favouring the
one sex and expulsion of the other. however, such processes do not explain
why certain occupations are completely dominated by women, which seems
301
almost entirely to be a result of the fact that few men seek employment in
these occupations. the immediate solution to this problem is therefore, of
course, an improvement in wages, career opportunities and other working
conditions in order to attract more men. this does however presuppose that
such conditions are far more important to men than women, since women
have clearly not been tempted into male-dominated jobs by the same beneits
to any great extent. these circumstances made Bradley (1993) conclude that
men will not choose female professions until they are radically changed in
a direction which makes them more attractive to men.
there may be several reasons why women do not apply for the highest-paid
jobs in the male-dominated areas. men’s and women’s interests differ in such
a way that we can expect women to be predominant in certain occupations.
since there is no reasonable argument for striving to efface the differences in
values between men and women, this imbalance in values would not represent
a problem in itself, given that the segregated occupational groups were not
treated particularly unfairly in various respects. the differences in values do
not however explain the fact that certain occupations are almost completely
single-sexed, and it would be desirable in these cases to strive for a more
even sexual distribution. It would therefore be important to develop and test
strategies for change in order to reduce such extreme sexual selection.
Feminist research has often highlighted the consequences in many areas
of gender hierarchy, which gives the man dominance over the woman. such
an analysis often seems to neglect the fact that the hierarchical structure,
which is seen as a relection of patriarchy, also involves a small group of men
dominating over the great majority of other men. the health implications
of this are surely at least as signiicant as those of the gender order. It can
therefore be dangerous to let the gender perspective cloud the class perspec-
tive in analyses of health and of the relationship between work and health.
the class perspective is not important in itself: however, it does seem likely
that gender ranking can express itself in different ways and have different
consequences on health in different classes. For this reason, other perspec-
tives, such as the generation perspective, may be equally important.
the fact that structure can be described as a manifestation of male values
and interests does not therefore necessarily mean that the men within the
302
system control it: more often than not, it is just as reasonable to perceive the
man as being controlled by the system as well. this can also apply to men who
hold positions of power, who in many situations might be seen as prisoners
of the system. if analyses are based on the premise that women are victims
of the system, it is important to examine whether men’s attitudes can also
be perceived as a result of the same system, rather than directly looking for
explanations on another level, such as in terms of personal characteristics.
intellectually speaking, this is as unsatisfactory as corresponding interpreta-
tions of women’s behaviour.
When the male situation in working life has been examined from a gender
perspective, this has almost always been against a background of the problems
and obstacles encountered by women. When dealt with in this way, being a
man will always be associated with privileges, unwarranted favour, etc. one
result of this is that the expression “men’s problems” hardly ever comes up
in discussions relating to health and the working environment. for instance,
very few people, if any, have ever used the term “men’s problems” in connec-
tion with fatal accidents, or the neurotoxic effects of solvents. however, it
goes without saying, that musculo-skeletal disorders are women’s problems,
despite the fact that the proportion of men who suffer such disorders is far
higher than the proportion of women who die in fatal occupational accidents.
furthermore, it is unlikely that anyone would claim sexual discrimination
against men if resources for preventing accidents were cut back, while such
a reduction in spending to prevent strain injuries would, without a doubt,
be described as a blow to the female cause.
the fact that one seldom speaks of problems in the work environment
as male problems does not mean that men have been treated unfairly in this
context. it is rather a result of the fact that men have determined the agenda
for discussions on the working environment, and that the male perspective
has been the prevailing one. Men’s problems have therefore often been
prioritised, but not been identiied as male problems.
the result has been that gender has not been deemed relevant in analysing
the health risks at the workplace which present a particular problem for men,
whilst it is regarded as a main explanation of women’s problems. this is of
course an unreasonable standpoint, and research therefore needs to be more
open to testing alternative hypotheses and theories about how conditions in
303
working life affect men and women and sub-groups of these. as it is now,
research into the working environment from a gender perspective risks limit-
ing, to too great an extent, the overall goal of conirming injustices which a
priori, and often justiiably, are presumed to affect women. the occupational
health problems associated with being a man are, of course, just as important
as highlighting the problems encountered by women.
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naden 1991:1). statistics sweden, stockholm.
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privat och offentlig sektor. stockholm. statistics sweden.
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om familj och arbete. Del 4. Sammanfattning (demograiska rapporter 1995:2.4).
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theorell t (1996) arbete och hjärtkärlsjukdomar hos män och kvinnor. in: Östlin
P, danielsson M, diderichsen f, härenstam a & Lindberg G (Eds.) Kön och
ohälsa – en antologi om könsskillnader ur ett folkhälsoperspektiv. (pp. 186–205). Lund:
studentlitteratur.
tolbert P s & Moen P (1998) Men’s and women’s deinitions of “good” jobs. Work
and Occupations, 25, 168–194.
umberson D & Chen . D (1996) effect of social relationships on psychological
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Verbrugge l m (1985) Gender and health: an update on hypotheses and evidence.
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westerståhl a (1998) läkarstudenter ick inblick i könsperspektiv. Läkartidningen,
95, 1817–1819.
westlander G (1979) Forskning för jämställdhet – några framtida utvecklingslinjer.
In: Johansson G (ed.) Forskning för jämställdhet. (pp. 47–61). stockholm. riks-
bankens jubileumsfond.
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307
308
Chapter 12
and thE futurE?

310
and the future?
Conclusions
by Åsa Kilbom, Karen Messing
and Carina Bildt Thorbjörnsson
Previous chapters of this book have described the main sources of gender-
related ill-health in working life, with the main focus on ill-health among
women. Physiological and psychological characteristics of women and men
that may be relevant to differences in health outcomes have also been outlined.
the analysis of gender-related ill-health must also consider the conditions
under which women and men live; at work, in their family setting and during
leisure time. While the gender differences in psychological and biological
characteristics are small to moderate, with large overlaps between female
and male groups (see chapters 3 and 4), the gender differences in living and
working conditions are larger, with relatively little overlap. this context
was described in chapter 2, where women’s place in today’s swedish labour
market, including vertical and horizontal segregation and the gender marking
of jobs and tasks, was discussed. speciic risk factors for the most common
outcomes in health among women are described in subsequent chapters. In
all these aspects the differences between women and men in working con-
ditions are considerable. For other aspects of living conditions, i.e. leisure
time and family, other sources of statistical information indicating gender
differences are available (lagerlöf 1993; Vogel et al. 1992).
the three main factors, believed to cause gender-related outcomes in
health, are living conditions, biological/physiological characteristics and
psychological characteristics (igure 1). Both biological/physiological and
psychological characteristics can be either inborn or acquired. observe that
these three causative factors are interlinked; thus a woman’s physical strength
and body size may inluence her choice of occupation, whereas leisure time
physical training will inluence her physical capacity. In a similar way per-
311
sonal characteristics like motivation and cognitive capacity will inluence

choice of career, and the selection of a certain occupation will inluence the
development of coping strategies. It is thus possible that small, in themselves
rather insigniicant, gender differences may be accentuated by interactions
between the three factors.
living conditions as well as biological and psychological characteristics
of women and men are not static. they develop by interaction and they de-
pend to a large extent on the conditions in our society. If sexual stereotypes
expect a man to be competitive and seeking economic and technical goals
and a woman is expected to be caring and less competitive, this creates a
strong impetus to conform to expectations. If legislation, child and health
care give poor support to women’s participation in working life, then work-
ing women will be more heavily exposed to physical as well as psychological
stressors. thus the macro-level of our society, as expressed by national and
local regulations, media, and the general public’s expectations, exert strong
inluences on risk factors for ill health.
so far this chapter has discussed factors that may lead to gender-related
health outcomes, especially ill-health among women. we cannot asses
the relative importance of these factors, the extent of interaction between
them, or whether small gender differences are accentuated through these
interactions. moreover, we are not sure whether all potential risk factors
(and combinations of them) for gender-speciic health outcomes have been
properly described or even identiied.
when selecting which health issues to discuss in this book, we have in-
cluded not only “work-related” disorders according to the who deinition,
i.e. disorders in part caused by or aggravated by work, but also ill-health as
expressed at work, whether caused by work or by factors completely outside
work. For example, pregnancy and cardiovascular disease can have serious
impact on work and require adjustments of working conditions. not even
fatigue is necessarily work-related; it can be caused entirely by factors outside
work, but it affects work and it may require other adjustments.
Ill-health (or morbidity), as discussed in chapter 5 is a complex state that
can be expressed and/or measured either as illness, disease or sickness. as
pointed out, caution must be exerted when choosing which measures to
use, as their interrelationships differ between women and men. In chapters
312
and the future?
Figure 1. Factors interacting with gender-related ill-health.
Conditions in society:
Legislation, labour market, education, child care,
health care, rehabilitation, cultural norms, stereotypes,
segregation, gendermarkings of jobs and tasks
Biological/physio- Living conditions: Psychological

logical characteristics Occupations characteristics
inborn or aquired: Income
Job tasks inborn or aquired:
Anatomy Women in men’s jobs Motivation
Anthropometry Men in women’s jobs Risk taking
Physical capacity Home work Body consciousness
Metabolism Leisure time activities Coping strategies
Hormones Parenthood
Cognitive capacities
Gender different outcome in health:

Incidence, natural course, treatment
on outcomes speciic to certain tissues and organs, especially cardiovascular

and skin, morbidity has usually been expressed as disease incidence and/or
prevalence; while for other outcomes a mixture of illness, disease and sickness
data have been used. women more often than men undergo the experience
that their symptoms at work are not given a diagnosis, and thus are not
recognised as diseases or are ascribed to psychological causes. this is partly
due to a male model in traditional medicine, partly to less dramatic and well
circumscribed symptoms among women, and partly to women’s relatively
recent entry into the labour force.
these deiciencies in diagnosis should not be accepted. large efforts
are needed in order to deine and develop concepts of ill-health relevant
for women as well as for men. this may imply the development and expan-
sion of morbidity to include so-called “vague” symptoms, common among
313
women, like fatigue, reduced vitality, unspeciic feelings of insuficiency,

feelings of pain and discomfort etc. risk factors behind these states have
not been well identiied. It has been suggested that they are warning signals
enabling women to avoid exposure and therefore constitute useful coping
mechanism to which men do not seem to have access. they may also be
responses to over-load or even to existential anguish. there is also a great
deal of uncertainty about the consequences of these symptoms; it is conceiv-
able that they lead to a reduced quality of life and may affect the ability to
inluence one’s environment and living conditions. Clearly we need more
research into the neurophysiological and psychological gender differences in
response to discomfort and pain. neurophysiological differences in response
to experimentally induced pain do exist, but their relevance to discomfort
experienced in everyday life is obscure. moreover, gender differences in
semantic expressions of discomfort have also been discussed (Gijsber van
wijk and kolk 1997) and needs more study.
so far, gender-related differences in ill-health have been discussed as
endpoints of a whole range of causal factors in working and living conditions.
however, ill-health can also have consequences that relect back onto these
factors and modify them. Chronic pain or fatigue, for example, may reduce
productivity and hamper the wish to seek promotion and more challenging
work tasks. societal reactions to illness may also be gender-speciic and inlu-
ence women’s health and place in working life. For example, degenerative
cardiovascular disease expresses itself somewhat differently among women
compared with men, and, partly as a consequence, less attention is given to
medical care and rehabilitation of women. women with such diseases may
therefore ind it more dificult to work at their usual jobs than men. simi-
larly, as discussed in several chapters, symptoms perceived by women are not
acknowledged to the same extent as men’s, and society’s response to female
symptoms may be discriminatory, for example when sick building syndrome
or work-related upper limb disorders are not taken seriously.
Gender comparisons of ill-health must be performed and interpreted
with great caution. not only do women and men express symptoms differ-
ently; there also seems to be gender differences in the importance ascribed
to certain risk factors. the methodological problems of developing gender
314
and the future?
sensitive measures are large and have been discussed in previous chapters.
Probably more importance should be attached to comparisons between
women in different settings, in order to identify high risk situations speciic
to women — at least until better methods for gender comparisons have
been developed.
Gender-related ill-health in the future

In chapter 2 an attempt was made to predict women’s conditions at work in
the future. It is thought that the improvements seen in women’s working
conditions during the last decades in sweden may not continue but stagnate
and even deteriorate. In particular, these fears are linked with an increase in
the proportion of temporary employment which affects young female groups
more than others. women in swedish working life report more psychological
stress than men and there are signs of a “low trust” syndrome, expressed as a
reduced conidence in society’s and employers’ ability to provide reasonable
working conditions. women are said to be more “lexible” than men under
rapidly changing conditions, such as exist in today’s working life (sou 1996).
If so — and this hypothesis has not been suficiently tested — lexibility may
be an advantage, conferring grater adaptability to a changing work situation,
or a disadvantage, allowing women to be forced into poor work situations.
Despite the problems associated with the new global economy, it is likely
to be easier to inluence conditions in working life in a period of rapid change
than during a stagnant period. During the present period of rapid change it
is of vital interest to monitor both working and living conditions, women’s
as well as men’s, together with their health status. thus the future may have
both positive and negative prospect for women in working life.
yet another factor encourages close monitoring of women’s health in the
coming years. It is only 30–40 years ago that a large proportion of women
entered the employed work force in sweden. no other country in the west-
ern world is able to explore the consequences of such a profound changes in
societal structure (see also chapter 5). In spite of the development of child
care services outside the home during this period, women have continued
to assume a larger share of family responsibilities. will these changes in
women’s workload have an impact on female morbidity and mortality in the
315
future? the increase in long-term sick leave, seen at the end of the 1980s
in sweden, was almost entirely due to increased morbidity among middle-
aged and elderly women (diderichsen et al. 1993; socialstyrelsen 1994).
the consequences of these changes, and of other life-style changes among
women (more smoking, more alcohol consumption), may become evident
both in morbidity and mortality statistics over the next 10–20 years. it is
true that some studies demonstrate a lower mortality among occupationally
active women. however, we also know that some occupational groups have
poor health.
this question links to an ongoing discussion about the causes of female
ill health (härenstam et al. 1996). is women’s health supported if they have
access to several roles in life, e.g. through the stimulus of occupational work?
or is the total burden of work and family too high? it is likely that both ex-
planations may hold true, but for different groups of women and in different
settings of work environments, family conditions and social classes.
nothing indicates that labour force participation among women will
be reduced in the future. on the contrary, as traditional family structures
and economic dependencies are weakened the demands for an independent
income increases. Especially among young women this is so apparent that
occupational work is not considered a matter of choice. it is rather a question
of what education and which occupation to choose. apart from the economic
independence acquired through employment, access to an adequate income
is also an important determinant of health. therefore, women’s access to
the labour market must be safeguarded but at the same time their health in
working life must be supported. to enable effective prevention of ill health
at work it is necessary to clarify mechanisms at work and in the family-work
interface that inluence women’s health.
In conclusion, gender-related differences in ill-health in working life
requires the development of new research methods and concepts and a close
monitoring of risk factors, their interactions and their consequences for
health. this research must be performed as a multidisciplinary effort, so that
preventive actions can be taken where they have their largest impact.
316
and the future?
references
diderichsen f, kindlund h & Vogel J (1993) kvinnans sjukfrånvaro. Läkartidningen
90 289–292.
Gijsberg van Wijk CMt & kolk aM (1997) sex differences in physical symptoms:
the contribution of symptom perception theory. Soc Sci Med 45 231–246.
härenstam a, aronsson G & hammarström a (1996) kön och ohälsa i ett framtids-
perspektiv. in: Östlin P, danielsson M, diderichsen f, härenstam a & Lindberg G
Kön och ohälsa – en antologi om könsskillnader ur ett folkhälsoperspektiv. Chapter 12,
pp 281–310 Lund; studentlitteratur.
Lagerlöf E (1993) Women, work and health. national report sweden, stockholm;
Ministry of health and social affairs, ds 1993:98.
socialstyrelsen (1994) Folkhälsorapport 1994. stockholm; socialstyrelsen.
sou (1996) Hälften vore nog. statens offentliga utredningar 1996:56. stockholm:
regeringskansliet.
Vogel J, kindlund h & diderichsen f (1992) Arbetsförhållanden, ohälsa och sjukfrånvaro
1975–1989. stockholm; statistiska Centralbyrån.
317
318
and the future?
the authors
Kristina Alexanderson
Ph.d., senior lecturer at the division of social Medicine and Public health,
the department of health and Environment, faculty of health sciences at
the Linköping university. she is a trained social worker and lectures at the
Medical faculty since 1985. in 1995 she completed her Ph.d. with a thesis
on variations of sickness absence with gender, occupation, pregnancy, and
parenthood. in her research she combines a social-medical perspective with a
gender and a salutogenic perspective using both quantitative and qualitative
methods. focus has been on gender aspects of sickness absence, health, and
life circumstances.
Carina Bildt Thorbjörnsson

is a registered psychologist, with a degree from the department of applied
Psychology at uppsala university, and has been working at the national
institute for Working Life in sweden since 1993. her dissertation is planned
to take place during the earlier part of 1999. she has mainly been interested
in psychosocial factors in relation to low back pain among women and men,
but is also interested in the mechanisms in occurrence of health problems in
general. Within her Ph.d. work she has been working with the development of
methods to collect information about psychosocial working conditions, as well
as conditions in family life. since a year back she has been involved in develop-
ing the research program “Gender, work and health” at the institute.
Sven Ove Hansson

Ph.d., is associate Professor of theoretical Philosophy at uppsala university.
his research is devoted to epistemology, value theory, decision theory, and
the philosophy of risk. his latest book is Setting the Limit. Occupational Health
Standards and the Limits of Science (oxford university Press, 1998).
Åsa Kilbom
M.d., is professor of work physiology at the national institute for Working
Life. for many years, her research has centred on work-related musculoskel-
319
etal disorders, especially among female workers, and on prevention using

ergonomic measures. she has also coordinated a multi-disciplinary research
program focusing on the ageing of the workforce, and she is very active in
teaching, especially in a new Masters program in ergonomics, organized jointly
between the institute and the universities of Linköping and Lund. together
with associate professor Lena Gonäs, Åsa kilbom has been planning a new
multi-disciplinary research and development program at the institute; “Gender,
work and health”. the present publication is a starting point for the institute’s
research activities on gender-related issues in working life.
Anders Kjellberg
is professor of work psychology at the national institute for Working Life.
his research has mostly dealt with psychological effects of noise and other
aspects of the physical work environment.
Malin Lindelöw
earned her irst degree in social Psychology from the london school of
economics and Political sciences and her Ph.D. from the Institute of Psy-
chiatry. she has been active as a researcher, previously at the mrX national
survey of health and Development, university College medical school,
and currently at the Division of Forensic Psychiatry, karolinska Institute
in stockholm. she is also active as a lecturer at uppsala university. her
research is focused on sex differences in psychological health, both in terms
of aetiology and implications for other areas of functioning. these issues are
studied in a life term perspective, where the importance of a holistic approach
is underlined. she also has a speciic interest in methodology.
Birgitta Meding
associate Professor, m.D., Ph.D., active at the Department of occupational
medicine at the national Institute for working life, and the Department of
occupational and environmental Dermatology, stockholm County Council.
Birgitta is a dermatologist with experience from clinical work as well as from
research in the area of occupational dermatology. her thesis from 1990 is an
epidemiologic study on hand eczema, where she estimated the occurrence
of hand eczema in the general population of Gothenburg and studied risk
320
and the future?
factors and consequences of the hand eczema disease. Later research has also
focused on epidemiology of work-related skin disease with an interest in risk
exposures and risk occupations, prognosis and prevention.
Karen Messing
is a professor of biology at the university of Québec at Montréal and a
researcher at CinBiosE (the Centre for the study of Biological interac-
tions in Environmental health.) she has published many articles on various
aspects of occupational health in jobs occupied by women, research done
in partnership with Québec unions, and her most recent book is One Eyed
Science: Occupational Health and Women Workers, (temple university Press,
1998). she has recently prepared a report on equality and occupational health
for the European union trades union technical Bureau.
Hanna Westberg (maiden name Wohlgemuth)

Ph. d. Educational Psychology researcher at national institute for Working
Life (formerly the swedish Centre for Working Life). during the past decade
hanna has actively been involved in different research projects trying to create
new possibilities for women and men in working life. the object of the studies
is to increase the knowledge about different mechanisms in order to ind ways
and means to reach a real equality between the sexes in the labour market.
the research is emphasizing the transmission of representations of sex-marked
work-tasks and work trough hidden inluence and unconscious learning and
how this is related to work organisation and work environment.
Peter Westerholm
m.D. and professor in occupational epidemiology at the national Institute
for working life. he was previously medical adviser to the swedish Con-
federation of trade unions. his primary interests are epidemiological re-
search on occupational cancer, occupationally related reproductive disorders,
musculoskeletal disorders and cardiovascular disease. Peter westerholm is
responsible for the postgraduate vocational training of occupational health
physicians in sweden. among international commitments can be mentioned
chairmanship of the scientiic committee on health services research and
evaluation in occupational health within the International Commission on
occupational health (ICoh).
321
322

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women’s

Graphic design & lay-out: lena karlsson and eric elgemyr

© national Institute for working life & authors 1998

solna, august 1998

why study women separately?

In view of these changes, and the statistical data presented above, it is

discussed. the main section of the book presents dermatological, mental,

the third type of missing information is that on prevention efforts in

we calculate the workday of a nursery school teacher who is the mother of

Characterisation of aggressors is particularly dificult when the exposures

Women and men are not so different

Considering women raises questions relevant to men

Gender-sensitive data are better data

Pickering t G, James G D, schnall P l, schlussel y r, Pieper C F, Gerin w &

zahm s h, Pottern l m, riedel lewis D, ward m h & white D w (1994) Inclu-

where are women

to make visible and upgrade women’s working conditions is an important

Industrial society grew, and production increased even as it changed. these

The notion of “employee”

• he/she is subject to certain directives or control, concerning how,

Sweden — a strictly gender segregated labour market

examples of the most typical male occupations are (percent):

Changes in the labour market

and short-term contractual jobs is steadily increasing. this weakens com-

plies especially to those working short part-time ((ministry of labour 1997a;

Table 5. Percentage distribution 1996 of temporary employees aged 20–64.

Table 8. Proportion of temporary employees in each confederation divided by gender in

Trends and prospects in the labour market

employers consider the existing legislation which regulates the relationship

Segmented labour market

working conditions. In sweden, by comparision with other countries, the

Technical/economical versus responsible rationality

Conclusions and commentary

the qualiication proile for temporary jobs is highly polarised, in that

another problem resulting from temporary employment is that these

How do working conditions correspond with the notion

• Decentralised decision-making systems

a comparison between hierarchy and network organisations shows that a

What characterises good work organisation?

• work should contain some variation. the employee herself/himself or

What does it look like in reality?

most true of mid-level white-collar workers such as nurses, or bank admin-

Just over 8 percent of all workers suffered harassment from co-employees

Consequences of the new labour market — summary

be identiied here — “the lost trust syndrome” — ill-health caused when

information about working conditions in the census 1990 (westberg-wohlgemuth

ressner u (1985) Den dolda hierarkin; om demokrati och jämställdhet i statsförvaltningen.

FaCts anD PreJuDICes

cross-culturally, they have been thought to represent complementary domains

different strands of literature are drawn together in an attempt to provide

The sources of sex differences

The early years: Sex typing within the family

another dimension which has received considerable attention is the

Play, peer relationships and their consequences

years or older, to use the ‘multi-action control to knock (their) opponent’s

Schooling and the educational system

Socialising agents: Concluding comments

by females, which essentially represent an extension of their nurturing role,