“Constrained Choice: A Framework for Understanding the Intersectionality of Social Disparities and Health Outcomes” American Sociological Association Annual Meeting, Atlanta. August 16.

1. Constrained Choice: a Gendered Framework for Understanding Health Disparities Chloe E. Bird, PhD RAND Corporation Martha E. Lang, PhD Guilford College Patricia P. Rieker, PhD Boston University

2. Overview Summary of gendered health disparities Current knowledge gaps in understanding causes of gendered health disparities The uses of the constrained choice model to address these knowledge gaps Ways that the constrained choice model can inform our understanding of health disparities stemming from the intersections of gender, race/ethnicity and sexual orientation

3. Years of life U.S. Life Expectancy at Birth, 1970-2005 0 White female Black female White male Black male 2005 1980 1990 1970 2000 SOURCE: Hoyert, DL, Kung HC, Smith BL, Deaths: Preliminary Data for 2003, National Vital Statistics Report, Volume 53, No. 15, National Center for Health Statistics, Hyattsville MD, February 28, 2005 and Kochanek, KD, Murphy, SL, and Anderson, RN, Deaths: Final Data for 2002, National Vital Statistics Report, Volume 53, No. 5, National Center for Health Statistics, Hyattsville, MD, October 12, 2004. More information on life expectancy is available at: http://www.cdc.gov/nchs/about/major/dvs/mortdata.htm

4. World Map of Gender Gap in Life Expectancies, 2000-2005 Average Number of Years Women Live Longer than Men Source:: UNDP 2005

5. Explanations of Gendered Life Expectancy Gap Biomedical Explanations Hormonal differences Immune function Sex-specific and sex-linked diseases Biological evolution Social Explanations Emphasize Context and Mediating Factors SES affects exposure/risk and vulnerability/resilience Age, education, race/ethnicity, marital status Social relationships Social support Social isolation Personality traits and coping responses

6. What’s Missing? Neither social or biological explanations alone are sufficient Inequality models do not explain paradox Lack of knowledge of pathways and processes Disciplines proceed separately Many questions about gender and little certainty

7. What’s Needed to Gain a Better Understanding of Gender Differences? A comprehensive social framework that incorporates: contextual effects on health individual choice and agency interaction between biological and social processes

8. Decisions and Actions by Families, Communities and Governments Shape men’s and women’s choices and opportunities Impact their stress levels and exposure to risks Create incentives and disincentives for engaging in health behaviors

9. Schematic Framework of Constrained Choice

10. Further Questions for Consideration How are does gender intersect with other social statuses in compounding health disparities? How do these intersected statuses result in unique health disparity experiences for specific populations? How do we frame the role of normative expectations and social policies in shaping intersectional health disparities?

11. Constrained Choice Schematic with Intersection Theory

12. Female HIV/AIDS Cases by Race/Ethnicity U.S. 1981-2002 SOURCE: CDC 2008

13. Male HIV/AIDS Cases by Race/Ethnicity U.S. 1981-2002 SOURCE: CDC 2008

14. 1600 1400 1200 1000 800 Women Men 600 400 200 0 45-54 Black 55-64 65-74 Crude Death Rates for Diseases of the Circulatory System by Age, Gender and Race/Ethnicity in the United States 1999-2005 Deaths per100,000 Adults White Age SOURCE: CDC/NCHS 2008

15. Questions to Ponder Are there gender differences in opportunities to choose health? Does understanding constrained choice make a difference for how we intervene? How do further marginalized statuses shape opportunities to pursue health?

16. Related Publications Bird and Rieker. 2008. Gender and Health: The Effects of Constrained Choice and Social Policies. Cambridge University Press. Bird,Lang, and Rieker. 2010. “Changing Gendered Patterns of Morbidity and Mortality” in Handbook for Gender and Health Care edited by Ellen Kuhlmann and Ellen Annandale. London: Palgrave. Rieker, Bird,and Lang. In Press. “New Directions in Understanding Gender and Health” in The Handbook of Medical Sociology edited by Bird, Conrad, Fremont, and Timmermans. Sixth Edition. Nashville, TN: Vanderbilt University Press.