‘Rules’ for boys, ‘guidelines’ for girls: Gender differences in symptom reporting during childhood and adolescence

Abstract

The emergence of higher reported morbidity in females compared with males is a feature of adolescent health in a large proportion of the world's industrialised countries. In this paper, qualitative data from twenty-five single-sex focus groups (90 participants in total) conducted with 10-, 13-, and 15-year olds in two Scottish schools is used to explore whether symptom reporting is influenced by perceived societal gender- and age-related expectations and the social context of symptom experiences. The degree to which these factors can help explain quantitative evidence of increases in gender differences in symptom reporting during adolescence is also examined. Accounts suggested gender-related expectations act as strict ‘rules’ for boys and less prohibitive ‘guidelines’ for girls. An unexpected finding was the extent of similarity between these ‘rules’ and ‘guidelines’. Both boys and girls presented themselves as pressured to react to symptoms in stoic, controlled and independent ways, particularly when in the company of their peers, and both perceived that boys and girls could incur negative consequences if seen to have physical (e.g. stomach ache) or, especially, psychological symptoms (e.g. feeling like crying). These qualitative findings do not suggest that girls are simply more willing than boys to report their symptoms as they get older, which is one potential explanation for the quantitative evidence of increasing gender differences in symptom reporting in adolescence. Rather, the findings suggest a need to highlight both the potentially damaging effects of gender stereotypes which make boys reluctant to seek help for physical and, particularly, psychological symptoms, and the misconception that girls are not similarly reluctant to report illness.

Introduction

The emergence of higher reported morbidity in females compared with males is increasingly recognised as a feature of adolescent health in “a large proportion of the world's industrialised countries” (Torsheim et al., 2006, p. 823). For example, when completing self-report symptom checklists at age 11, 56% of boys and 66% of girls reported having “stomach ache or sickness” in the past month in a longitudinal study of Scottish schoolchildren (n = 2063). However, at age 15 the prevalence was substantially higher in girls (78%) but little changed in boys (52%). Similarly, whilst comparable proportions (33% for males; 37% for females) reported “feeling sad, unhappy or low” in the past month at age 11, many more girls (56%) than boys (32%) reported this symptom at 15 years (Sweeting & West, 2003). Evidence from 29 European and North American countries (n = 125,732) demonstrates a similar pattern: the reporting of at least one symptom from a list of eight common health complaints was very similar for boys at age 11 (47%) and 15 (46%), whereas in girls it was higher at age 15 (63%) than at 11 (53%) (Torsheim et al., 2006). These figures demonstrate not only emerging female excess morbidity, but also the generally high rates of symptom reporting in adolescence (West, 2009), at least in the context of self-complete questionnaire surveys.

Although gender differences in adult health have been widely reported and discussed (Annandale, 2009, Barsky et al., 2001, Gijsbers van Wijk and Kolk, 1997, Gove and Hughes, 1979, Macintyre et al., 1996, Verbrugge and Wingard, 1987), comparatively little research has focused on the gender patterning of ill-health during childhood and adolescence (Sweeting, 1995, Sweeting et al., 2007). As at all ages (Bird & Rieker, 2008), it is likely that both biological factors and social influences underlie observed patterns, but societal gender- and age-related expectations of illness behaviours may be particularly important at this age (Angold et al., 1999, Barsky et al., 2001, Prout, 1989, Simpson, 2000, Sweeting and West, 2003, Sweeting et al., 2007, Williams, 2000). A better understanding of the emergence of higher symptom reporting by females during adolescence may help explain gender differences in adult health (Hetland et al., 2002, Sweeting, 1995).

Throughout their childhood, children are exposed to societal expectations for gender- and age-appropriate illness behaviours. In respect of gender, these processes may be at work from infancy (Hoffman & Hurst, 1990). Sociological understandings of gender have placed increasing emphasis on performative gender, i.e. on gender as something which consciously or unconsciously is ‘achieved’, demonstrated or, indeed, parodied in social interactions (Butler, 1990, Goffman, 1977, West and Zimmerman, 1987) throughout the lifecourse. In line with this, children and young people are commonly conceptualised as active agents in the construction of their gender identities (Connell, 2000, Frosh et al., 2002, Morrow, 2006, Thorne, 1993). The ability to report feelings about the self may be a function of culturally prescribed stereotypes of gender, with males' tendency to be less expressive in disclosing feelings (Gijsbers van Wijk & Kolk, 1997) reflecting a need to conform to hegemonic stereotypes of masculinity (Connell, 2000, Courtenay, 2000), whereas similarly dominant stereotypes of femininity may encourage girls to partake in ‘girl talk’, whereby they share their feelings and concerns with other females (Polce-Lynch, Myers, Kilmartin, Forsmann-Falck, & Kliewer, 1998). Studies have suggested that adolescent boys perceive ill-health as something which can threaten their masculinity and which should thus be hidden, particularly in the public, peer-based context of school (Prout, 1989, Williams, 1999, Williams, 2000, Williams, 2002).

Research, albeit from a different, more psychological theoretical tradition, also generally concludes that socialisation processes work to mould the illness behaviours of children towards the self-discipline displayed by most adults, with reductions in both emotional displays and help-seeking (Fearon et al., 1996, Fuchs and Thelen, 1988, Mechanic, 1964, Prout, 1986). With age, children's understandings of the causes of ill-health increase and they also become more aware of age- and gender-appropriate illness behaviours. In addition, their ideas about gender become more sophisticated, and understandings begin to incorporate flexibility and allow for similarities between, as well as differences within, the categories of male and female (Martin and Ruble, 2004, Montgomery, 2005). Although gender identities are constructed from an early age, it has been suggested that adolescence may be a particularly important time for their development because of the occurrence of the physical and physiological changes of puberty at the same time as boys and girls become increasingly distinguished by differing social expectations (Burke & Weir, 1978) and their lives dominated by their peer environments and focussed around issues of status, identity and conformity (Brown et al., 1986, Giordano, 2003).

Boys' peer groups have been described as competitive and unsupportive environments (Adler and Adler, 1998, Gilbert and Gilbert, 1998, Harris, 1998, Leaper, 1994). Membership is seen as a social ‘must’, with entry into a popular group often relying on evidence of typically ‘masculine’ attributes, such as ‘hardness’ and sporting prowess, which serve to boost boys' constructions of themselves as occupying higher positions in masculine hierarchies (Askew and Ross, 1988, Frosh et al., 2002). Projection of the body as physically superior and athletic is viewed as a crucial resource for successful performances of masculinity. Admissions of pain or displays of weakness, such as crying or losing a fight, are seen as reflecting inadequate or failed masculinities (Connell, 2000, Swain, 2003, Swain, 2004). Boys' ritualised forms of humour are important in regulating masculinities and constructing hierarchies, confirming the high position of the story-tellers or name-callers, whilst policing and punishing any boys who stray too far from dominant masculine ideals (Kehily and Nayak, 1997, Mac an Ghaill, 1994).

Studies of girls' peer groups depict them as more likely to invest time in talking and emotional work, with friendships characterised by physical closeness, ‘having a laugh’ and reciprocal loyalty and support (Frosh et al., 2002, Griffiths, 1995, Hey, 1997, Rose, 2002). Nevertheless, girls' groups also have ‘rules’ and power relationships which serve to include some while excluding others, depending on the performance of “appropriate forms of femininity” (Hey, 1997, p. 130). However, the literature suggests less clarity in the behaviours deemed (in)appropriate for adolescent girls and contradictions and ambiguities between a more traditional passive, regulated ‘femininity’ versus a restless ‘adolescence’ and girls' increasing physiological sexualisation. To some degree these reflect changes in girls' expectations following secular changes in the social and economic positions of women in recent decades (Duncan, 1999, Frosh et al., 2002, Griffiths, 1995, Holstein-Beck, 1995, Hudson, 1984, Mac an Ghaill, 1994, McRobbie, 2000). It has been argued that these have resulted in a divide between how young women “feel they ought to identify themselves and how they actually identify themselves” (Bjerrum Nielsen, 2004, p. 21).

Taken together, this literature suggests that, with age, boys will become less likely than girls to report symptoms of illness because of the detrimental impact this may have on their own and others' perception of their masculinity. In contrast, dominant stereotypes of femininity would suggest that it is generally easier for girls to report and seek help for illness. This paper presents qualitative data generated within focus group discussions with 10-, 13- and 15-year old males and females. The main aim of the paper is to explore whether symptom reporting is influenced by perceived societal gender and age-related expectations and the social context of symptom experiences. A secondary aim is to assess whether these factors help to explain quantitative evidence of age-related increases in gender differences in symptom reporting.