Theories and methods in research on

Gender aspects in sickness absence

Gunnel Hensing and co workers in GendiQ

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Participants

Anne Hammarström, Umeå, SwedenP-O Östergren, Lund, SwedenPetra Verdonk, Maastricht, The NetherlandsArne Mastekaasa, Oslo, NorwayCarin Staland Nyman, Gothenburg, SwedenThe Pre-Conference Participants

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Why a gender analysis?

Sex differencesMore women than men are sick-listed

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

0

50000

100000

150000

200000

250000

300000

350000

1974

1977

1980

1983

1986

1989

1992

1995

1998

2001

2004

No. sick-listed at the end of each year

www.forsakringskassan.se

http://www.forsakringskassan.se/

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Why a gender analysis?Sex differences

More women than men are sick-listed• Women have higher risk for long sick-leave spells

and disability pension with back and neckproblems

• Women have higher incidence of sicknessabsence with psychiatric disorders

• Inconcistent findings regarding length of absence

• Variation over diagnostic groups (injuries), countries (population at risk) and age groups

• Inoncistency regarding length of absence• Other determinants influence

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Why a gender analysis?

Sex differencesMore women than men are sick-listedThe divisions of the labour markets

• Labour force participation• Proportion and degree

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Women 25-44 87%, 45-64 78% Men 25-44 94%, 45-64 84%

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Why a gender analysis?

Sex differencesMore women than men are sick-listedThe divisions of the labour markets

• Labour force participation• The horizontal segregation

• Health, Care, Education, Cleaning• Construction, Engineering, Bureacracy, Craftsmen

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

The divided labour market, 2007 (%)

25

42

1814

12

1115

42

30

05

1015202530354045

90-100% w 60-90% w 40-60% w 10-40% w 0-10% w

WomenMen

Total: 2 038 000 women and 2 260 000 men

Source: Women and men in Sweden. Facts and figures 2008

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Why a gender analysis?

Sex differencesMore women than men are sick-listedThe divisions of the labour markets

• Labour force participation: paid work• The horizontal segregation• The vertical segregation

• ”Men at the top”

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Managers in different sectors, 2006

0

10

20

30

40

50

60

70

80

90

Women Men

PrivatePublicStateMunicipalityCounty councilPrivate and public

Source: Women and men in Sweden. Facts and figures 2008

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Why a gender analysis?

Sex differencesMore women than men are sick-listedThe divisions of the labour markets

• Labour force participation: paid work• The horizontal segregation• The vertical segregation• Unpaid work

• Time spent• Level of responsibility• Type of unpaid work performed

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Why a gender analysis?

Sex differencesMore women than men are sick-listedThe divisions of the labour markets

Gender constructions and gender relationsSickness absence is involved in ”doinggender”

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Why a gender analysis?

Sex differencesMore women than men are sick-listedThe divisions of the labour markets

Gender constructions and gender relationsSickness absence is involved in ”doinggender”

Men as the norm (andronormativity)?diagnostics, treatment, communication, rehabilitation and prevention

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

FamilyWork

Social network

StressRest, sleep,Recreation Health

Ill healthDisability

SA

DP/SA

RTW

EBF

Bio

Life Events

Recove

ry

Rehab

Loweredfunctionaland workcapacity

Pers

SA

Somaticillness

Coping

Ind

Prereq.

Selec-tion

”The context”

Model developed by Gunnel Hensing

A gender perspective can be applied at all stages of the sick-leave process

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Today’s agenda

Gender theories and their application in sickness absence researchPaid work (and combining) Unpaid work (and combining)Stress in young womenThe overall aim:

To understand more and discuss possibleways to move our research area forward

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Biologic constitution

Behaviour, life styleEnvironment, living conditions

A comprehensive view of health

Gender theories and models relevant for research on sickness absence and return to work

-A model of gender dynamics-Basic concepts-Possible applications

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Gender theories

SeveralDifferent disciplinesDifferent basic assumption

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Materialst view-How a society is organisedaround production influencehow individuals behave, think,and make decisions-Women and men are classifiedby biological sex whichinfluence opportunities and socialorganisation

Social construction-Important parts of societyare socially constructed; productsof human interaction and commonactions-Gender is a social construction

Economy Identity

Nature

Culture

Power analysis

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Is this a woman or a man?

Relevant or irrelevant question?

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Individual level:Identity

RationalityBehaviour

Social and institutional level:Divison of activities and paid and unpaid work

Institutional policy and practice

Symbolic level:Ideas regarding women and men

femininity and masculinity.

Biologic sex

Social practice

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Gender, difference and bodies

”…gender…. understood as the cultural differenceof women from men, based on the biological division between male and female.”

• Connell, 2002, p 8

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Objection to such a definition (Connell, 2002)

The images might be dichotomous butreality is notGender can only be seen where thereis differenceDifferences among men and amongwomen are hiddenProcesses behind personal characteristics are ignored

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Gender relations

”Gender is, aboveall, a matter of the social relations within whichindividuals and groups act.”

• Connell, 2002, p 9

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Gender can be defined as

”…the ways in which the ”reproductive arena”, whichincludes ”bodily structures and processesof human reproduction”, organizespractice at all levels of social organization from identities, to symbolic rituals, to large-scaleinstitutions.”

• Connell, 1995, p71 and Schippers, 2007, p86

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

The bodyis the classifying principle

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Individual level:Identity

RationalityBehaviour

Social and institutional level:Divison of activities and paid and unpaid work

Institutional policy and practice

Symbolic level:Ideas regarding women and men

femininity and masculinity.

Biologic sex

Social practice

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Gender constructions: masculinities and femininities

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Different perspectives

PsychologicalGender identityA set of ratherstablecharacteristicsAttached to the individualNormative

SociologicalGender as discourses and practicesChangingAttached to culturePower analysis

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Masculinity (and femininity)have three components (Schippers, 2007)

A social locationwomen and men can move in and outof this location through practice

A set of practices and characteristicsunderstood to be masculine

• Interpretation, Symbolic level

Widespread cultural and social effectsdiffers by embodiement

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

In summary

Gender is a relation at the individual, social/institutional and symbolic levelsSocial practice of women and men reproduce or change genderMasculinities and femininities are social locations that can be enteredand left by women and menThe embodiment of social practice is not indifferent

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Vad är psykisk sjukdom?Vad är psykisk hälsa?

Questions or comments?

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Is there a gender order?

Order as inSystem or structurePatterns or coherenceOrder of precedence or hierachyThe normal state of things

Yes

….?…..

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Hegemonic masculinityBased in feminist theory

patriarchyCritique of sex roleconcepts and theories

Separate behaviorand normAvoid homogenizingand essentialismAccount for power

Take the social natureand changes of masculinity intoaccount

Connell, ”Masculinities”, 2005

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Hegemonic masculinity…

”…was understood as the pattern of practice(i.e. things done, not just a set of roleexpectations or an identity) that allowedmen’s dominance over women to continue”

• Connell and Messerschmidt, 2005, p832

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Hegemony

LeadershipPowerConsent through cultural valuesStatus quoThe power relations are seen as ”natural”

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

”Hegemonic ideologies preserve, legitimate and naturalise the interestsof the powerful – marginalising and subordinating the claims of othergroups. Hegemony is not automatic, however, but involves contest and constant struggle.”

• Wetherell M, Edley N, Feminism and Psychology, 1999,p 337

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

In summary

Gender theories focus onHuman relations and interactionThe importance of labour and how it is organisedThe construction of masculinities and femininitiesThe distribution of power over womenand men, and over identitiesEmbodiment

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Vad är psykisk sjukdom?Vad är psykisk hälsa?

Questions or comments?

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Sickness absence research

Genderrelation

• divisions, negotiationssocial location

• constructionssystem or order

• subordinationwomen and men

• distribution

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Research related to power issues or the gender order (exposure)Women’s overall subordination comparedto men

Access to health care and rehabilitation Quality of care and money spentRelationships, violenceInfluence at home and at workEthnicity and Intersectionality

• Not all women are white, middle class

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Gender order and health(Theory)

Women’s general subordinationPovertyResponsibility for childrenResponsibility for household workCharacter of and wages in femaledominated occupationsViolence against women

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Do we ask the right questions?Aim

• How do hegemonic masculinity influence healthand sickness absence in men and women workingin the health care?

The design• Do we take selection processes into account?

The methods• Questionnaire/register methods promote simplistic

perspectivesThe interpretation

• Men and women as complementary and dichotomous categories?

Research on differences

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Another perspective

The social construction of gender(masculinities and femininities) in the sickness absence and return to workprocesses

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Individual level:Identity

RationalityBehaviour

Social and institutional level:Divison of activities and paid and unpaid work

Institutional policy and practice

Symbolic level:Ideas regarding women and men

femininity and masculinity.

Biologic sex

Social practice

The construction of femininity in medicine

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

The hysteric woman…..

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Women and medicine

CharcotHysteric women on stage

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Women and medicine

CharcotHysteric women on stage

FreudNeurotic women on the couch

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Women and medicine

CharcotHysteric women on stage

FreudNeurotic women on the couch

ProzacDepressive women at the counter

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Sales of psychotropic drugs, DDD per 1000 inhabitants per day

Källa: Läkemedelsregistret, EpC, Socialstyrelsen. Figur 5:38

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Women and medicine

CharcotHysteric women on stage

FreudNeurotic women on the couch

ProzacDepressed women at the counter

Sickness absenceWorn-out women with a sick note

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

The hysteric woman…..

Medicine-Biological explanations

-Hormones-Mental diseases-……..

-Care and cure-She has the problem-She needs help

-Victimization processes-Identity as patient-Passive and out of control

Feminist critique-Social explanations

-Living conditions-Over commitment

-Take action-Change the ”exposure”

-Be responsible-Avoid vicitimization-Support activeprocesses

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Andronormativity

”….signifies a stateof affairs wheremale values are regarded as normal to the extent that female valuesdisappear or needto be blatantlyhighlighted in order to be recognized.”Hölge-Hazelton B, Malterud K, Scand J of Public Health, 2009, p4

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

-Studies on difference between women and men+Questions neutrality, objectivity and fairness of medicine- Dichotomous view on gender, sociobiological explanations

-Studies identifying women’s subordination and denied access to health care+Identify inequalities-Risk to provide images of women as victims

-Studies on the cultural construction of medicine and medical practice+Move the perspective to the system, institution and discourse-Narrow cultural explanations not taking power, politics and economyinto account

Challenges to andronormativity in medicine

Hölge-Hazelton B, Malterud K, Scand J of Public Health, 2009, p4

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

The invisibility of genderThe everyday accumulation of disadvantage

Women and men of the same height?Communication analyses – time used?

• ”The 30% rule”Women and men presenting the same symptoms?

• Valian V, ”Why so slow?”, 1998, Cambridge, MA: M.I.T. Press

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

In summaryResearch on differences is still needed

Identify inequalities and differences in exposureNew questions need to be put and developed

The role of hegemonic masculinity for health in women and men

The role andronormativity in medicine plays in SAP and RTWFemininity needs to be better definedThe role femininities play in SAP and RTW

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

Vad är psykisk sjukdom?Vad är psykisk hälsa?

Questions or comments?

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

GROUP DISCUSSIONSSex differences in sickness absence– what else do weneed to know to move explanationsfurther

2009-12-02Gunnel Hensing, Social Medicine, The Sahlgrenska Academy at University of

Gothenburg, Sweden

GROUP DISCUSSIONS

How can gender theories contribute?To your own research areaTo interventions to reduce sex differences in sickness absence

Theories and methods in research on Gender aspects in sickness absenceParticipantsWhy a gender analysis?Why a gender analysis?Why a gender analysis?Why a gender analysis?The divided labour market, 2007 (%)Why a gender analysis?Managers in different sectors, 2006Why a gender analysis?Why a gender analysis?Why a gender analysis?Today’s agendaGender theories and models relevant for research on sickness absence and return to workGender theoriesIs this a woman or a man?Gender, difference and bodiesObjection to such a definition (Connell, 2002)Gender relationsGender can be defined asThe body�is the classifying principleGender constructions: masculinities and femininitiesDifferent perspectivesMasculinity (and femininity)�have three components (Schippers, 2007)In summaryIs there a gender order?Hegemonic masculinityHegemonic masculinity…HegemonyIn summarySickness absence researchResearch related to power issues or the gender order (exposure)Gender order and health�(Theory)Research on differencesAnother perspectiveThe construction of femininity in medicineWomen and medicineWomen and medicineWomen and medicineSales of psychotropic drugs, DDD �per 1000 inhabitants per dayWomen and medicineAndronormativityThe invisibility of genderIn summaryGROUP DISCUSSIONS