Handbook of Clinical Gender Medicine. Группа авторов

exists that promotes research for other key groups such as LGBT populations or that requires sex and gender to be considered in the composition of ethic committees or in the review of research proposals. This oversight points to a potential root cause for certain health disparities that undoubtedly have health and healthcare system equity implications.

      Healthcare Utilization

Across the healthcare landscape we see different utilization rates, as well as different barriers and enablers to healthcare access. For example, women in high-income countries are more likely to engage in preventative health activities than are men. They are also more likely to seek treatment for most diseases and to do so early in the course of an illness [1]. In contrast, women within emerging economies, such as those of Ghana and India, have been shown to utilize health systems less than men during their lifespan due to restrictive barriers such as childcare duties and care giving obligations, as well as service cost [2, 3]. Irrespective of country of origin, women in general are less likely to perceive their overall cardiac risk level and therefore are less likely to attribute their symptoms to a possible cardiac related health issue [4].

Men’s lower healthcare utilization rates in high-income countries are linked to the trend that they are fulltime workers, work longer hours, and have less flexible schedules than women do [1, 5]. Additionally, the presence of long wait times (more than 1 week) for a routine care appointment is a strong negative predictor of men accessing the health system within the USA [1]. Although variation may exist across countries, a study conducted in Denmark shows that working-age men have higher rates of hospitalization and mortality than their female counterparts [6]. This is attributed to lower rates of healthcare practitioner contact [6].

Available information from both the USA and Canada provides insights with respect to the LGBT population’s utilization of healthcare systems. Lesbians and gay men are less likely to seek preventive care, such as cancer-screening services, and to have poorer health maintenance behaviors than the general population [1, 7, 8]. This disparity is thought to be attributable to stigma, healthcare professionals’ perceived biases, lack of clinical and cultural knowledge, and lack of gender-sensitive care [1, 7, 8].

      Lesbians are also less likely to have health insurance, to see a healthcare practitioner, or to have a consistent source of care [1, 7, 8]. This population is believed to underutilize health systems and delay health seeking [1, 7, 8]. In contrast, gay men living with a partner are as likely as a male living with a female partner to have a consistent source of care and to have significantly elevated chances of having seen a clinician within the last year [1, 7].

      Transgender, bisexual, and intersex people are less likely to utilize the healthcare system than is the population as a whole [7, 8], while research demonstrates that trans-gender people are less likely to be insured than the general population. The underutilization of the healthcare system by bisexuals and intersex people is reported as being due to their perception that healthcare professionals lack the requisite knowledge to support their unique needs [7, 8].

      The Morbidity and Mortality Paradox

When we look at health status in terms of mortality rates, we see that men’s life expectancy at all ages is less than that of women in most countries around the world (on average around 6-8 years less). This mortality gap is wider in the former Soviet Union countries. In fact, Russia reached an unprecedented 13-year difference between male and female life expectancies in the 1990s; this is primarily attributed to high rates of circulatory disease among the men [9]. Meanwhile, in the USA and other high-income countries the gap is narrowing. The US 2010 census shows that the gender mortality gap is getting smaller, most significantly in the above 65 year range.

In general, the shorter life expectancy in men is thought to be the result of male behaviors including greater risk taking in relation to tobacco and alcohol use [1, 10]. It is also attributed to masculine attitudes towards health, such as not expressing pain or discomfort or acknowledging emotions [1, 10]. In some low-and middle-income countries in Asia, a deviation from this trend is seen; women’s life expectancy at birth is actually lower than or equal to men’s [11]. This is thought to be due to socially mediated causes including maternal mortality, disparities in access to care, female infanticide, and lack of female empowerment [11]. It is worth noting that, irrespective of the gender mortality trends, about 350,000 women die each year, predominantly in low-and middle-income countries, due to pregnancy and childbirth. Neither of these conditions in isolation constitutes an illness or disorder.

While men in most instances are more likely to die earlier than women, epidemiological information points to greater morbidity in women, based on rates of self-reporting and provider reporting [1, 12]. This finding is further supported by research in the USA that reveals that on a per capita basis women’s spending on health care services exceeds that of males [13]. Another study provides additional cultural insights in that women in Canada were shown to be more likely than men to report unmet health needs; this is within a country that provides universal basic care [14]. Women’s spending rates and their likelihood to report unmet health needs may be either a consequence of or a causative factor in the higher rates of morbidity in women.

      Although the medical literature overwhelmingly points to a gender difference, there has been some questioning of the existence and the extent of any gender difference in morbidity. It has