Shalon Irving, PhD, was an accomplished

epidemiologist and lieutenant commander

in the surveillance branch of the CDC. She
died in January 2017 at age 36 due to
pregnancy-related complications after the
birth of her daughter, Soleil.

THE BIG QUESTIONS

How do social contexts affect the

human body?

The Sociology Understand how social, cultural, and structural

contexts shape attitudes toward "ideal"
body forms and give rise to two body-related

of the Body: social problems in the United States: eating

disorders and obesity.

How do sociologists understand

Health, lllness health and illness?

Learn about functionalist and symbolic
interactionist perspectives on physical and

and Sexuality
mental health and illness in contemporary
society. Recognize the ways that disability
challenges theoretical perspectives on health
and illness. Understand the relationship
between traditional medicine and complemen-
tary and alternative medicine (CAM).

How do social factors affect health

and illness?
Recognize that health and illness are shaped
by cultural, social, and economic factors. Learn
about race, class, gender, and geographic
differences in the distribution of disease.

How do social contexts shape

sexual behavior?
Understand the diversity of sexual orientation
today. Learn about the debate over the impor-

Obesity Rates tance of biological versus social and cultural

influences on human sexual behavior. Explore
p. 461
cultural differences in sexual behavior and
patterns of sexual behavior today.
 Friends and family of Dr. Shalon Irving were shocked and saddened when the
36-year-old collapsed and died from pregnancy-related complications just four
months after giving birth to her daughter, Soleil. Such deaths are relatively rare in
the United States, with 26 women dying per every 100,000 births each year. Yet
that ove rail statistic belies a stark racial difference: Black mothers are three to four times as
likely as their White counterparts to die (Martin and Montagne, 2017). Put differently, Black
expectant and new mothers in the United States have death rates similar to those of women
in much poorer nations, including México and Uzbekistán (World Health Organization, 2016).
Dr. Irving's death was particularly shocking because she was a well-respected scientist at
the Centers for Disease Control and Prevention (CDC) who had dedicated her life to studying,
understanding, and, ideally, eradicating racial disparities in health. After earning her PhD in
sociology from Purdue University, Shalon continued on to the nations top public health school,
Johns Hopkins, where she earned a master's degree in public health. She then joined the ranks

The Sociology of the Body: Health. Illness, and Sexuality 455

 at the CDC, conducting important research on race disparities in health, intímate partner vio-
lence, and eider abuse. Dr. Irving lived the comfortable life of a highly educated professional in
Atlanta, one of the nation’s premier cities for health care. She had top-of-the-line health insur-
ance, a lovely home, and a strong and close-knit community of friends and family to help her
through her pregnancy. Yet despite her many accomplishments and rich support networks,
Dr. Irving carried with her the imprints of her lifelong experiences with racism, stress, high
blood pressure, and early-tife obesity, which placed her at high risk during pregnancy. These
rísks were amplified by the fact that some of her doctors failed to recognize that pregnancy-
related health concerns do not end when a person gives birth; rather, postpartum care is also
essential, especially for those who had high-risk pregnancies (Martin and Montagne, 2017).
The untimely deaths of Dr. Irving and others like her are an all-too-common outcome for
African American women, who face múltiple stressors throughout their lives that may cause
"weathering." According to epidemiologist Arline Geronimus, weathering involves the wearing
down of one's body and one's health due to long-standing and far-reaching stressors. It ren-
ders its victims vulnerable to chronic diseases like diabetes and high blood pressure (Villarosa,
2018). Weathering can affect men and women alike, although its physical toll is particularly
acute during and shortly after pregnancy, a physiologically complex period in a person’s life
(Martin and Montagne, 2017).
In general, Americans are living longer lives than ever before. The average American can
expect to live until age 79, with women surviving 81 years on average and men surviving 76.
Yet, as we saw in the tragic case of Dr. Irving, simple statistical snapshots may conceal stark
differences on the basis of race, socioeconomic status, and gender. For instance, although life
expectancy has been rising steadily throughout the late twentieth and early twenty-first cen-
turies, working-class White people have been dying younger and younger. Experts describe
these premature deaths as "deaths of despair," a product of financial stress; obesity; and
reliance on alcohol, smoking, unhealthy foods, or drugs like opioids to cope with financial
difficulties (Case and Deaton, 2017).
Another important reason for the stark socioeconomic divide in health is that not all
Americans have access to health insurance. The proportion of U.S. adults who are unin-
sured decreased dramatically between 2013 and 2016, following the implementation of the
Affordable Care Act (ACA) under President Barack Obama. While fully 20 percent of working-
age Americans lacked health insurance in 2013, by 2016, that figure had dropped to just over
10 percent, although the proportions of uninsured people are considerably higher among Black
and Latino populations (Kaiser Family Foundation, 2017). The future of the ACA is uncer-
tain, but even with the dramatic expansión of health insurance that occurred under President
Obama, the United States still lags behind other wealthy nations, including Cañada, most
European nations, Japan, Israel, New Zealand, Taiwan, and a growing number of nations in
Latín America. In those countries, each and every individual has some form of health insurance
through universal health coverage, which ensures that all people can obtain the health Services
universal health
coverage they need without incurring financial hardship (World Health Organization, 2010).
Health insurance is about more than just providing access to health care for people after
Public health care pro-
grams motivated by the they get sick. Many health insurance plans promote preventive health care, encouraging people
goal of providing afford- to maintain healthy lifestyles and detect health problems early on rather than wait to seek med­
able health Services to all ical care only after their conditions have advanced to a dangerous stage. For example, health
members of a population. insurance may cover Services like depression screening, substance use disorder screening,
blood pressure screening, obesity counseling and screening, assistance with quitting smoking,

456 CHAPTER 14 The Sociology of the Body: Health, lllness, and Sexuality
vaccinations, and counseling for domestic abuse victims (Kaiser Family Foundation, 2013).
These Services are particularly important for low-income and Black Americans, who are at a
greater risk for nearly every major health condition relative to their wealthier White counterparts.
One of the most consistent patterns documented by sociologists of health and illness is
the social class gradient in health, whereby those with higher levels of education, income, social class
and assets are less likely than their disadvantaged counterparts to suffer from heart disease,
gradient in
diabetes, high blood pressure, early onset of dementia, physical disability, sleep problems,
health
The strong inverse
substance use problems, mental illness, and premature death (CDC, 2011). These patterns
association between
are so pronounced that one of the four main goals of Healthy People 2020, the federal gov-
socioeconomic resources
ernment’s health agenda, is to "achieve health equity, elimínate disparities, and improve the and risk of illness or death.
health of all groups,” especially disparities on the basis of socioeconomic resources and race
(Office of Disease Prevention and Health Promotion, 2020).
Judging by the chapter title, you might have expected to read about biology or about the
physical ways that our bodies function. You might have been surprised to read about something
as seemingly far removed from our everyday lives as federal health care policy or something as
pervasive as stress and racism. Yet public policy and macrosocial factors are powerful influ-
ences on our health. The fietd known as sociology of the body investigates how and why our sociology of
bodies are affected by our social experiences and the norms and valúes of the groups to which the body
we belong. The connection between social factors and our health was painfully ¡llustrated, for Field that focuses on how
example, when the COVID-19 crisis devastated populations worldwide, with low-wage work- our bodies are affected by
our social experiences.
ers like grocery store clerks and nursing home aides and those living in overcrowded housing
Health and illness, for
being particularly vulnerable. Using this framework, we begin our chapter by analyzing why ¡nstance, are shaped
obesity and an equally problematic phenomenon, eating disorders, have become so common by social, cultural, and
in the Western world. We then describe how sociologists theorize about health and medicine; economic influences.
discuss social dimensíons of health and illness, with an emphasis on the ways that social class,
race, and gender affect our health; and provide an overview of health issues that affect the
lives of people in low-income nations. We conclude by examining social and cultural influences
on our sexuality; as we will see, sexual orientation and behaviors, like health, are producís of
bíological, cultural, and social forces.

How Do Social Contexts

Affect the Human Body? <
Social contexts affect our bodies in myriad ways. The types of jobs we hold, the neigh- Understand how social,
borhoods in which we live, how much money we earn, our cultural practices, and our cultural, and structural
contexts shape attitudes
personal relationships all shape how long we live, the types of illnesses we suffer from,
toward "ideal” body forms
and even the shapes and sizes of our bodies. Later in this chapter, we delve more fully and give rise to two body-
into how key features of our social lives, including race and social class, affect our phys­ related social problems in
ical and mental health. In this section, we focus on one specific aspect of our bodies to the United States: eating
show the power of social, economic, and cultural contexts: our body weight. Whether disorders and obesity.
we are slender or heavy is not just a consequence of our personal choices (such as what
foods we eat) or our genes; rather, body weight is shaped by powerful social structures
as well as cultural forces.

How Do Social Contexts Affect the Human Body? 457

Take a look at these three
individuáis: The first (from
Let’s consider eating disorders, such as anorexia nervosa or bulimia, and obesity, or
left) is painfully thin as
a result of famine and
excessive body weight. Both are important social problems in wealthy nations. Although
malnutrition, common both are conditions of the body, their causes reflect social factors more than physical or bio-
problems in areas of the logical factors. If both conditions reflected biology alone, we would expect that rates would
world plagued by frequent be fairly constant across history—because human physiology has changed little over time.
drought and crop failure. However, both are very recent social problems. Both conditions are also highly stratified
The middle has become
by social factors, such as gender, social class, race, and ethnicity. Women are far more likely
painfully thin by her own
doing; people with anorexia
than men to have an eating disorder, while economically disadvantaged persons are far
feel compelled by personal more likely than wealthier people to struggle with obesity.
and social pressures to lose Both conditions are also shaped by the cultural context. Fashion magazines regularly
weight. The third (right) is show images of models who are severely underweight yet uphold these women as paragons
severely overweight and
of beauty. The average fashion model today is 23 percent thinner than the average American
is preparing for gastric
woman, yet 25 years ago, that number was 8 percent (Derenne and Beresin, 2006). At the
bypass surgery.
same time, our culture also promotes excessive eating. A Big Mac is less expensive than a
healthy salad in most parts of the country, perpetuating the social class gradient in obesity
rates. By contrast, both eating disorders and obesity are virtually unknown in impover-
ished societies where food is scarce and cherished.
In addition, both obesity and eating disorders ¡Ilústrate how a “personal trouble" (for
example, self-starvation or obesity-related complications, such as diabetes) can reflect
“public issues" (for example, a culture that promotes an unrealistic “thin ideal” for young
women). These conditions also highlight the fact that poverty makes it difficult for
individuáis to buy costly healthful foods or to reach public parks and other spaces for
regular exercise.

458 CHAPTER 14 The Sociology of the Body: Health, lllness, and Sexuality
Eating Disorders
Anorexia is related to the idea of dieting, and it reflects changing views of physical attrac-
tiveness in modern society. In most premodern societies, the ideal female shape was a
plump one. Thinness was not desirable, partly because it was associated with hunger and
poverty. The notion of slimness as the desirable feminine shape originated among some
middle-class groups in the late nineteenth century, but it became generalized as an ideal
for most women only recently. A historical examination of the physiques of Miss America
winners between 1922 and 1999, for example, shows that for much of the twentieth cen­
tury, pageant winners had a body weight that would be classified as “normal.” In recent
years, however, the majority of winners would be classified as “underweight” using medi­
cal guidelines (Rubinstein and Caballero, 2000).
Anorexia was identified as a disorder in France in 1874, but it remained obscure until
the past 30 or 40 years (Brown and Jasper, 1993). Since then, it has become increasingly
common among young women. So has bulimia—bingeing on food, followed by self-
induced vomiting. Anorexia and bulimia often occur in the same individual. A recent study
estimates that 1.3 million women and 450,000 men suffer from anorexia, 2.25 million
women and 750,000 men suffer from bulimia, and 5.25 million women and 3 million men
suffer from binge eating. A total of 30 million Americans, or about 9 percent of the popula-
tion, suffer from one or more forms of eating disorders (Eating Disorders Coalition, 2009;
National Association of Anorexia Nervosa and Associated Disorders, 2020).
Eating disorders have long been considered a health problem exclusive to young
White women, yet recent data suggest that women of color and gay men also are vulnera­
ble. Evidence suggests that boys and young men, especially athletes and gay and bisexual
men, increasingly develop disordered eating habits under pressure to maintain a lean and
muscular physique (Feldman and Meyer, 2007; Field et al., 2014). New evidence also chal-
lenges the assumption that women of color are immune to eating disorders; national data
show that White women are especially susceptible to anorexia nervosa, whereas Black and
Latina women show higher rates of bulimia (Marques et al., 2011).
Once a young person starts to diet and exercise compulsively, they can become locked
into a pattern of refusing food or vomiting up what they have eaten. As the body loses
muscle mass, it loses heart muscle, so the heart gets smaller and weaker, which can ulti-
mately lead to heart failure. About half of all anorexic people also have low white blood cell
counts, and about one-third are anemic. Both conditions can lower the immune system’s
resistance to disease, leaving people with anorexia vulnerable to infections. Anorexia has
the highest mortality rate of any psychological disorder (Arcelus et al., 2011).
Why are rates of eating disorders higher among women (especially young women) and
gay and bisexual men? Sociologists note that social norms stress the importance of physical
attractiveness more for women than for men and that desirable body images of men differ
from those of women. However, men are also less likely to seek treatment for eating dis­
orders because they are considered to be female disorders; as a result, their illnesses are less
likely to be reported and detected (National Association of Anorexia Nervosa and Associated
Disorders, 2010). Emerging research on gay and bisexual men highlights the importance of
a lean, muscular physique for these men’s self-concept but also emphasizes that experiences
of discrimination, social rejection, or fear of rejection may make some young men especially
vulnerable to negative body image and eating disorders (McClain and Peebles, 2016).

How Do Social Contexts Affect the Human Body? 459

 This unhealthy cultural emphasis on a lean physique—and the resulting eating
disorders—extend beyond the United States and Europe. As Western images of feminine
beauty have spread to the rest of the world, so too have associated illnesses. Eating prob-
lems have surfaced among young, primarily affluent women in Hong Kong and Singapore
as well as in urban areas of Taiwan, China, the Philippines, India, and Pakistán (Pike and
Dunne, 2015). One famous study showed that in Fiji, a nation where larger bodies were
long considered the cultural ideal, rates of eating disorders among young women increased
markedly after American televisión shows like Beverly Hills 90210 started to air there
(Becker, 2004).
The rise of eating disorders in Western societies coincides with the globalization of
food production. Since the 1960S, supermarket shelves have been abundant with a variety
of foods from all parts of the world, not just food that happens to be in season locally.
When all foods are available all the time, we must decide what to eat, considering not only
the medical information with which Science bombards us—for instance, that cholesterol
levels contribute to heart disease—but also the calorie content of the foods we choose.
The fací that we have much more control over our own bodies than people had in the past
presents us with positive possibilities as well as new anxieties and problems.

The Obesity Epidemic

Eating disorders are a major social problem in the United States and, increasingly, world-
wide. Yet a very different weight-related health issue, obesity, is considered the top public
obesity health problem facing Americans today. Obesity is defined as a body mass Índex (BMI) of
Excessive body weight 30 or greater (CDC, 2008). Over the past two decades, obesity rates among adults in the
indicated by a body mass United States have risen dramatically. In 2000, 31 percent of adults were obese; by 2019,
índex (BMI) over 30. that proportion had climbed steadily to over 40 percent. This proportion varíes widely by
race; for example, 37 percent of Black women and 44 percent of Hispanic women are now
obese, compared with 40 percent of non-Hispanic White women (Hales et al., 2020). An
even more troubling trend is that nearly 19 percent of children and adolescents are obese
(Hales et al., 2017).
Obesity increases an individual’s risk for a wide range of health problems, including
heart disease, diabetes, sleep apnea, osteoarthritis, and some forms of cáncer (Haslam and
James, 2005; Wang et al., 2011). Excessive body weight may also take a psychological toll.
Overweight and obese Americans are more likely than their thinner peers to experience
depression; strained family relationships; poorer-quality sex and dating Uves; employment
discrimination; discrimination by health care providers; and daily experiences of teasing,
insults, and shame (Carr and Friedman, 2005, 2006; Carr et al., 2007, 2013). Negative atti-
tudes toward overweight and obese persons develop as early as elementary school (Puhl
and Latner, 2007). Sociologists are fascinated with the persistence of negative attitudes
toward overweight and obese persons, especially because these individuáis make up the
statistical majority of all Americans.
The reasons behind the obesity crisis are widely debated. Some argüe that the apparent
increase in the overweight and obese population is a statistical artifact. The proportion of
the U.S. population that is middle-aged has increased rapidly during the past two decades
as the large baby boom cohort has aged. Middle-aged persons, due to their slowing metabo-
lisms, are at greater risk of excessive body weight. Others attribute the pattern—especially w/

460 CHAPTER 14 The Sociology of the Body: Health, lllness, and Sexuality
Globalization
by the Numbers Obesity Rates

Obesity rates worldwide have more than tripled since 19 5. In 2018, more than 650 million people—13 percent
of all adults worldwide—were obese. Once considered a first world" problem, rates of obesity have been rising in
low- and middle-income countries.

Proportion of adults who are obese

United Statesf

Saudi Arabia

United Kingdomft

South Africa

México

Brazil

Russian Federation

China

,cratic Republic of the c0¡

India

Global^^^
prevalence
of obesity

Defined as a body mass Índex (BMI)

of 30 or higher.

Obesity in the United States

By Age By Race*
| | |
mm ... .... "'i1...... U 1111111111111 | I II I | I I I I I | II I II I I I II IIII I I II II IIII

1
'
18.5%
i""""i t 40%

I | 42.2%
i 49.6%

n 111 mi m 11111111111111 ii 111111111111111 I I I

'l i i i i i i i i i i i i i i i i

2 -19 20-39 White Black

Non-Hispanic Non-Hispanic

I1111111111111111 i 11111111111111111
Ll 1111111 II111111 1 1
I (
i 44.8% | 42.8% 17.4% | 44.8%
MI lililí III lili III 11111111111111111 iiiliiimilmm
40-59 60+ Asian
Non-Hispanic Hispanic

Sources: Hales et al., 2020; NHS, 2019. Among adults age 20 and over.
 the rise in childhood obesity—to shifts in the ethnic
makeup of the U.S. population. The proportion of chil-
-ÍAT
fti\C
dren today who are Black or Hispanic is higher than
in earlier decades, and these two ethnic groups are at a
much greater risk for becoming overweight than their
White peers. Still others argüe that the measures used
to count and classify obese persons have shifted, thus
leading to an excessively high number of people. Finally,
some social observers believe that public concern over
obesity is blown out of proportion and reflects more of
a “moral panic” than a “public health crisis” (Campos
et al., 2006; Saguy, 2012).
Americans live in what sociologists cali an "obesogenic environment,
Most public health experts, however, believe
meaning an environment that contributes to weight gain.
that obesity is a very real problem caused by what
psychologist Kelly Brownell calis the “obesogenic
environment"—or a social environment that unwit-
tingly contributes to weight gain (Brownell and
Horgen, 2004). Among adults, sedentary desk jobs have
replaced physical jobs, such as farming. Children are more likely to spend their after-
food deserts school hours sitting in front of a Computer, smartphone, or televisión than playing tag or
riding their bikes around the neighborhood. Parents are pressed for time, given their hec-
Geographic areas in which
residents do not have easy tic work and family schedules, and turn to unhealthy fast food rather than home-cooked
access to high-quality meáis. Restaurants, eager to lure bargain-seeking patrons, provide enormous serving sizes
affordable food. These at low prices. The social forces that promote high fat and sugar consumption and restrict
regions are concentrated the opportunity to exercise are particularly acute for poor persons and people of color.
in rural areas and poor
Small grocery stores in poor neighborhoods rarely sell fresh or low-cost produce. Large
urban neighborhoods.
grocery stores are scarce in poor urban neighborhoods and rural areas as well as in pre-
dominantly African American neighborhoods (Morland et al., 2002). Given the scarcity
of high-quality healthy foods in poor neighborhoods, scholars have dubbed these areas
food deserts (Walker et al., 2010). Additionally, high crime rates and high levels of
CONCEPT CHECKS traffic in urban neighborhoods make exercise in public parks or jogging on city streets
potentially dangerous (Brownell and Horgen, 2004).
1. Why ¡s anorexia more Policy makers and public health professionals have proposed a broad range of Solu­
likely to strike young tions to the obesity crisis. Some have (unsuccessfully) proposed practices that place the
women than heterosexual burden directly on individuáis. For example, some schools have considered “weight report
young men?
cards,” where children and parents would be told the child’s BMI, in an effort to trigger
2. What explanations are healthy behaviors at home. Yet most experts endorse Solutions that attack the problem at a
offered for the recent
large-scale level, such as making healthy low-cost produce more widely available; provid-
increase in obesity
ing safe public places to exercise, free or low-cost fitness classes, and classes in health and
rates?
nutrition to low-income children and their families; and requiring restaurants and food
3. In what ways is
manufacturers to clearly note the fat and calorie content of their products. Only in attack-
the United States
an "obesogenic ing the “public issue” of the obesogenic environment will the “prívate trouble” of excessive
environment"? weight be resolved (Brownell and Horgen, 2004).

462 CHAPTER 14 The Sociology of the Body: Health, lllness, and Sexuality
How Do Sociologists
Understand Health
and lllness? <
Sociologists of health and illness also are concerned with understanding the experience of Learn about functionalist
illness—how individuáis experience being sick, chronically ill, or disabled and how these and symbolic interactionist
perspectives on physical
experiences are shaped by one’s social interactions with others. If you have ever been
and mental health and
ill, even for a short period, you know that illness modifies your patterns of daily life and illness in contemporary
changes your interactions with others. This is because the normal functioning of the body society. Recognize the
is a vital, but often taken-for-granted, part of our lives. For most people, our sense of self is ways that disability
predicated on the expectation that our bodies will facilítate, not impede, our social inter­ challenges theoretical
perspectives on health
actions. One important exception is the experience of persons with a physical, sensory, or
and illness. Understand
cognitive impairment. People with blindness, hearing impairments, or physical disabilities
the relationship between
that may limit their movement adapt to these conditions and even base their identities traditional medicine
and senses of self on their capacity to adapt and thrive (Darling, 2003). and complementary and
Illness has both personal and public dimensions. When we fall ill, others are affected alternative medicine (CAM).
as well. In the case of infectious diseases like COVID-19, we can infecí other people with
whom with live, work, and interact. When we ail from other conditions, our friends, fami-
lies, and coworkers may extend sympathy, care, support, and assistance with practical
tasks. They may struggle to understand our illness and its cause or to adjust the patterns
of their own lives to accommodate it. Others’ reactions to our illness, in turn, shape our
own interpretations of and can pose challenges to our senses of self. For instance, a long-
time smoker who develops lung disease may be made to feel guilty by family members.
Two sociological perspectives on the experience of illness have been particularly
influential. The first, associated with the functionalist school, proposes that “being sick”
is a social role, just as “worker" or “mother” is a social role. As such, unhealthy persons are
expected to comply with a widely agreed-upon set of behavioral expectations. The sec-
ond view, favored by symbolic interactionists, explores how the meanings of illness are
socially constructed and how these meanings influence people's behavior.

The Sick Role

The functionalist thinker Talcott Parsons (1951) developed the notion of the sick role to describe sick role
the patterns of behavior that a sick person adopts to minimize the disruptive impact of illness A term Talcott Parsons
or injury. Functionalist thought holds that society usually operates in a smooth and consensual used to describe the
manner. Illness is, therefore, seen as a dysfunction that can disrupt the flow of this normal State. patterns of behavior that a
sick person adopts to mini­
An individual who has fallen ill, for example, might be unable to perform standard responsibil-
mize the disruptive impact
ities or be less reliable and efficient than usual. Because sick people cannot carry out their nor­ of their illness on others.
mal roles, the lives of people around them are disrupted: Assignments at work go unfinished
and cause stress for coworkers, responsibilities at home are not fulfilled, and so forth.
According to Parsons, people learn the sick role through socialization and enact it—
with the cooperation of others—when they fall ill or suffer an injury. Sick persons face

How Do Sociologists Understand Health and lllness? 463

 societal expectations for how to behave; at the same time, other members of society abide
by a generally agreed-upon set of expectations for how they will treat the sick individual.
The sick role is distinguished by three sets of normative expectations:

1. The sick person is not held personally responsible for his or her poor health.
2. The sick person is entitled to certain rights and privileges, including a release from
normal responsibilities.
3. The sick person is expected to take sensible steps to regain their health, such as
Consulting a medical expert and agreeing to become a patient.

EVALUATION
Although the sick-role model reveáis how the ill person is an integral part of a larger social
context, a number of criticisms can be levied against it. Some argüe that the sick-role for­
mula does not adequately capture the “lived experience” of illness. Others point out that it
cannot be applied across all contexts, cultures, and historical periods. For example, it does
not account for instances in which doctors and patients disagree about a diagnosis or have
opposing interests. It also fails to explain illnesses that do not necessarily lead to a suspen­
sión of normal activity, such as alcoholism, certain disabilities, and some chronic diseases.
It also presumes a short-term condition and that people will return to normal functioning
when the illness passes. This scenario does not apply to persons who have permanent or
long-lasting disabilities yet adapt and thrive in their environments through the use, for
example, of hearing aids or wheelchairs (Thomas, 2007).
Furthermore, taking on the sick role is not always a straightforward process. Some
individuáis who suffer for years from chronic pain or from misdiagnosed symptoms are
denied the sick role until they get a clear diagnosis. Other sick people, such as young adults
with autoimmune diseases, often appear physically healthy despite constant physical pain
and exhaustion; because of their “healthy" outward appearance, they may not be readily
granted sick-role status. In other cases, social factors like race, class, and gender can affect
whether and how readily the sick role is granted. Single parents or people caring for ailing
relatives may fail to acknowledge their own symptoms for fear that shirking their social
roles will hurt their loved ones. The sick role cannot be divorced from the social, cultural,
and economic influences that surround it.
The realities of life and illness are more complex than the sick role suggests. The lead-
ing causes of death in the twenty-first century are heart disease and cáncer, two diseases
that are associated with unhealthy behaviors such as smoking, a high-fat diet, and a seden-
tary lifestyle. Given society’s emphasis on taking control of one’s health and lifestyle, indi­
viduáis bear ever-greater responsibility for their own well-being. This contradicts the first
premise of the sick role—that sick individuáis are not to blame for their illness. Moreover,
sick-role theory is less useful for understanding chronic illness (versus infectious disease)
because there is no single formula for chronically ill or disabled people to follow.

Illness as “Lived Experience”

Symbolic interactionists study how people interpret the social world and the meanings
they ascribe to it. Many sociologists have applied this approach to health and illness and
view this perspective as a partial corrective to the limitations of functionalist approaches.

464 CHAPTER 14 The Sociology of the Body: Health, Illness, and Sexuality
Symbolic interactionists are not concerned with identifying risk factors for specific illnesses
or conditions; rather, they address questions about the personal experience of illness:
How do people react and adjust to news about a serious illness? How does illness shape
individuáis’ daily lives? How does a chronic illness affect an individual’s self-identity?
One theme that sociologists address is how chronically ill individuáis cope with the
practical and emotional implications of their illness. Certain illnesses require regular treat-
ments that can affect daily routines. Undergoing dialysis, injecting insulin, or taking large
numbers of pills requires individuáis to adjust their schedules. Other illnesses have unpre-
dictable effects, such as sudden loss of bowel or bladder control or violent nausea. People
suffering from such conditions often develop strategies for managing their illness in daily
life. These inelude practical considerations—such as noting the location of the restrooms
when in an unfamiliar place—as well as skills for managing interpersonal relations, both
intimate and commonplace. Although symptoms can be embarrassing and disruptive,
people develop coping strategies to live as normally as possible (Kelly, 1992).
At the same time, it can be challenging for individuáis to manage their illnesses within
the overall contexts of their lives (Jobling, 1988; Williams, 1993). Corbin and Strauss (1985)
identified three types of “work” incorporated into the everyday strategies of the chron­
ically ill. Illness work refers to activities involved in managing a condition, such as treat-
ing pain, doing diagnostic tests, or undergoing physical therapy. Everyday work pertains to Symbolic interactionists
are ¡nterested in how
the management of daily life—maintaining relationships with others, running household
illnesses shape individuáis'
affairs, and pursuing professional or personal interests. Biographical work involves the pro-
daily lives. For example,
cess of incorporating the illness into one’s life, making sense of it, and developing ways of people with diabetes must
explaining it to others. Such a process can help people with mental and physical illnesses constantly monitor their
restore meaning and order to their lives. blood sugar levels.
This is especially the case for those who have long-lasting or permanent physical dis-
abilities. A flourishing body of research shows that persons with deafness and blindness,
for instance, view these experiences as critical to their identity and belong to cultural
communities with their own languages and practices. Rather than viewing their bodies
as deficient or “disordered,” persons with disabilities view their bodies as simply another
source of personal and cultural difference, just as race, ethnicity, and gender are sources
of difference. For instance, many persons with deafness do not want to be “fixed" with
hearing aids or cochlear implants and instead embrace their own culture and means of
communication (Tucker, 1998).
The process of adaptation may be particularly difficult for those who suffer from a
stigmatized health condition, such as extreme obesity, alcoholism, schizophrenia, or HIV/
AIDS. Sociologist Erving Goffman (1963) developed the concept of stigma, which refers stigma
to any personal characteristic that is labeled as undesirable in a particular social context. Any physical or social
Stigmatized individuáis and groups are often treated with suspicion, hostility, or discrim- characteristic that is
ination. Stigmas are rarely based on valid understandings or scientific data; they spring labeled by society as
undesirable.
from stereotypes or perceptions that may be false or only partially correct. Furthermore,
stigmatized conditions vary widely across sociocultural contexts. The extent to which a
trait is devalued depends on the valúes and beliefs of those who do the stigmatizing. For
instance, in the United States, obese persons are much more likely to be stigmatized by
White upper-middle-class persons than they are to be stigmatized by African Americans
or working-class White people (Carr and Friedman, 2005). By contrast, other health con­
ditions, including major mental illnesses and HIV/AIDS (as we discuss later), are much

How Do Sociologists Understand Health and Illness? 465

TABLE 14.1

Applying Sociology to the Body

Functionalist perspectives argüe Sick role theory describes how sick persons When an employee takes a sick day from
that society operates ¡n a smooth work to minimize the disruptive impact of work, they are expected to stay home and
and consensual manner. Illness is, illness on institutions like work and family. focus on healing. to facilitate their return
therefore, seen as a dysfunction to work.
that can disrupt the flow of this
normal State.

Symbolic interactionists study the Symbolic interactionists focus on meaning- A person who is diagnosed with a health
ways people interpret the social making and everyday experiences of heatth, condition like autoimmune disease may
world and the meanings they like how living with a chronic illness affects consider that a major part of their identity, talk
ascribe to it. one's identity. behavior. and interactions about regularly, join Facebook support groups,
with others. and adjust their daily activities accordingly.

Stigma theory holds that some Physical visible health conditions may Medical and public health experts emphasize
personal traits are devalued in a be stigmatized because they are visually that substance use disorders like opioid
particular social context, and elicit appealing to others, while other conditions addiction are diseases rather than matters
unkind or discriminatory treatment are stigmatized because others incorrectly of choice or personal character, to fight the
from others. view them as indicative of a character flaw. stigmatization of persons with such conditions.

more widely stigmatized. One recent study of 16 countries found that even in the most
liberal, tolerant countries, the majority of the public held stigmatizing attitudes toward
and a willingness to exelude people with schizophrenia from cióse, personal relation-
ships and positions of authority, seeing them as unpredictable and potentially dangerous
(Pescosolido et al., 2013).

Changing Conceptions of Health and Illness

A key theme in the sociological study of health is that cultures and societies differ in terms
of what they consider healthy and normal. All cultures have known concepts of physical
health and illness, but most of what we now recognize as medicine is a consequence of
developments in Western society over the past three centuries. In premodern cultures, the
family was the main institution for coping with sickness or affliction. There have always
been individuáis skilled in both physical and spiritual remedies who have specialized as
healers, and many such traditional systems survive today. For instance, traditional Chinese
medicine aims to restore harmony among aspeets of the personality and bodily systems,
and many treatments involve the use of herbs and acupuncture.
Modern medicine sees disease as physical and explicable in scientific terms. The
application of Science to medical diagnostics and treatment underlies the development
of modern health care systems. Sociologists have argued that in contemporary Western
societies, conditions that were previously viewed as having social, cultural, or religious
causes are now “medicalized." Medicalization, according to sociologist Peter Conrad

466 CHAPTER 14 The Sociology of the Body: Health, Illness, and Sexuality
 (2007), is the process by which some variations in human traits, behaviors, or conditions
become defined as medical conditions that require treatment. For example, sociologist
Alian Horwitz has argued that in the United States, the emotion of “sadness”—a normal
w response to stressors like loss, failure, and disappointment—has now been transformed
into the medical disorder of “depression," which is believed to have its roots in biologi-
cal causes, such as brain chemistry or genetics (Horwitz and Wakefield, 2007). As such,
depressed persons today are much more likely to be treated with medications, such as
antidepressants, than “talk therapy,” in which a therapist would focus on the social or
emotional roots of the sad feelings.
Disability rights activists have critiqued and contested this process through which
human variation is medicalized and deviations from the norm are labeled “medical disor-
ders” to be treated (Beaudry, 2016). In response to the medicalization of disability, scholars
and activists have called for a more critical perspective that views disability as a social
phenomenon caused by social oppression and prejudice rather than by individual “impair-
ments." The daily challenges that persons with disabilities often face are a function not of
their eyes or ears or limbs but of social exclusión and society’s failure to provide physical
and social environments that foster inclusiveness (Oliver, 2009).
In addition to medicalization, another important feature of modern medicine is the
acceptance of the hospital as the setting within which to treat serious illnesses and the
development of the medical profession as a body with codes of ethics and significant social
power. The scientific view of disease is linked to the requirement that medical training be
systematic and long term; self-taught healers are typically excluded. Although professional
medical practice is not limited to hospitals, the hospital provides an environment in which
doctors can treat and study large numbers of patients in circumstances permitting the
concentration of medical technology.
Just as cultural beliefs about health and illness change across time and place, the very ill­
nesses from which individuáis suffer, and the causes and cures of these illnesses, vary widely
by sociohistorical context. In medieval times, the major illnesses were infectious diseases
such as tuberculosis, cholera, malaria, and the bubonic plague. In the fourteenth century,
the epidemic of the plague, also referred to as the Black Death, killed a quarter of the pop-
ulation of England and devastated large areas of Europe. Since that time, rates of infectious
disease have declined dramatically overall and have been a relatively minor cause of death
in industrialized countries, accounting for just 6 percent of deaths annually in the 2010S
(Xu et al., 2020). Infectious diseases gave way to noninfectious diseases such as cáncer and
heart disease as the leading causes of death. However, the assumption that infectious diseases
were a thing of the past was challenged in early 2020, when the novel coronavirus struck
China, Italy, and the United States shortly thereafter. As of December 2020, over 270,000 per­
sons in the United States and over 1,500,000 worldwide had died of the virus (WHO, 2020b).
Although in premodern societies the highest rates of death were among infants and
young children, death rates today (the proportion of the population who die each year) rise
with increasing age. The leading causes of death, heart disease and cáncer, disproportion-
ately affect persons age 65 and older. While infectious diseases can strike anyone today, just
as they did during past centuries, older adults are especially vulnerable to the novel coro­
navirus. According to estimates from the Centers for Disease Control, roughly 80 percent
of all people who died of COVID-19 in early 2020 were age 65 and older (CDC COVID-19
Response Team, 2020).

How Do Sociologists Understand Health and Illness? 467

 Taking a long-term view of health, sociologists have found that improvements in medi­
cal care accounted for only a minor part of the decline in death rates before the twentieth
century. Effective sanitation, better nutrition, water purification, milk pasteurization, control
of sewage, and improved hygiene were more consequential (Dowling, 1977). Drugs, advances
in surgery, and antibiotics did not significantly decrease death rates until well into the twen­
tieth century. Antibiotics used to treat bacterial infections first became available in the
1930S and 1940S; most immunizations (against diseases such as polio) were developed later.

complementary COMPLEMENTARY AND ALTERNATIVE MEDICINE

and alternative Alternative therapies, such as herbal remedies, acupuncture, and chiropractic treatments, are
medicine (CAM) being explored by a record number of adults in the United States today and are slowly gain-
A diverse set of ing acceptance by the mainstream medical community. Medical sociologists refer to such
approaches and therapies
healing and therapeutic practices as complementary and alternative medicine (CAM).
for treating ¡llness and
promoting well-being CAM encompasses a diverse set of approaches and therapies for treating illness and pro­
that generally fall outside moting well-being that generally fall outside of standard medical practices. Alternative
of standard medical medicine is meant to be used in place of standard medical procedures, whereas complemen­
practices. tary therapies are meant to be used in conjunction with medical procedures to increase their
efñcacy or reduce side effects (Saks, 1992).
Industrialized countries have some of the best-developed, best-resourced medical facili-
biomedical model
of health ties in the world. Why, then, are a growing number of people exploring treatments that have
not yet proven effective in controlled clinical triáis, such as aromatherapy and hypnother-
The set of principies
underpinning Western
apy? A 2012 survey conducted by the CDC found that 33 percent of American adults had
medical systems and used some form of CAM in the past year. CAM is used more frequently among women and
practices that defines individuáis with higher levels of educational attainment (Figure 14.1). Furthermore, White
diseases objectively and people are more likely to use CAM than Black and Asían Americans (Clarke et al., 2015).
holds that the healthy body
There are many reasons for pursuing CAM regimens or seeking the Services of an
can be restored through
alternative medicine practitioner. Some people perceive orthodox medicine to be deficient
scientifically based medical
treatment. or ineffective in relieving chronic pain or symptoms of stress and anxiety. Others are dis-
satisfied with features of modern health care systems, such as long waits, referrals through
chains of specialists, and financial restrictions. Connected
to this are concerns about the harmful side effects of
FIGURE 14.1 medication and the intrusiveness of surgery, both Sta­
ples of modern Western medicine. The asymmetrical
Use of Complementary Medicine power relationship between doctors and patients also
drives some people to seek alternative medicine; they feel
50
that the role of the passive patient does not grant them
enough input into their own treatment. Finally, some
individuáis profess religious or philosophical objections
to orthodox medicine, which treats the mind and body
separately. These people believe that orthodox medicine
often overlooks the spiritual and psychological dimen-
sions of health and illness. All these concerns are cri­
tiques of the biomedical model of health, which defines
Less than High School Some College Degree disease in objective terms and believes that scientifically
High School Diploma College or Higher based medical treatment can restore the body to health
Source: Clarke et al.. 2015. (Beyerstein, 1999).
DIGITAL LIFE

Can Wearable Tech Keep You Healthy?

Until fairly recently, when a person felt sick, they would monitoring blood pressure, heart rate, and ovulation cycles
cali a doctor to make an appointment. During this visit, and even assessing hearing and visión. For example, ECG
the doctor would likely diagnose the patient’s symptoms Check allows patients to analyze their own heart rhythms,
and perhaps prescribe medication to help treat the patient. while apps like Glooko and Glucose Buddy help diabetics
Although many Americans, especially those with health monitor their blood sugar levels. Fertility Friend helps
insurance and access to providers, still see a health care pro- women who are hoping to conceive by monitoring their
fessional on a regular basis, more and more Americans are menstrual cycles (Edney, 2013). Psych Drugs helps people
trying to diagnose themselves, often with the assistance of determine which antidepressant or antianxiety medication
health-related smartphone apps and fitness trackers. For the will best treat their symptoms.
past decade or two, people have been visiting websites like It’s not just patients who use apps to enhance their
WebMD to determine whether their headache is due to a health; health care providers also rely on apps to help them
head coid or is a sign of something more dire. More recently, deliver care. Apps like Epocrates help doctors review drug
smartphone users have relied on apps and fitness trackers prescription recommendations and safety information,
to do everything from take their pulses to chart their ovu- research potentially harmful drug interactions, and per-
lation cycles to identify the best medication for depression. form calculations like BMI and glomerular filtration rate,
Health-related apps and fitness trackers range from the an indication of how well one’s kidneys are functioning
very simple to the very complex. Basic fitness trackers keep (Glenn, 2013).
users informed of steps taken and calories burned, while Many health care providers and patients are enthu-
more expensive trackers keep tabs on users’ heart rates and siastic about the role of technology in helping to enhance
sleep patterns, even detailing how much time a user spends medical care. Doctors believe that symptom-monitoring
in light sleep versus deep sleep. apps and fitness trackers encourage patients to be proac­
Smartphones are particularly helpful in guiding us to tive and knowledgeable about their own health (Edney,
make healthy food choices. For instance, with Fooducate, 2013). However, others counter that even the best
users sean the bar codes of food ítems they're considering app or activity tracker is not a substitute for a regular
buying at the grocery store and are then given detailed checkup. What do you think? Are health and wellness
information on the producís’ ingredients and nutritional apps and fitness trackers a cost-effective and efficient
valué (Summers, 2013). way for people to look after their own health, or do
Yet activity trackers and smartphones are increasingly they keep people from receiving potentially valuable
being used for more serious health-related issues, like professional care?
 The growth of alternative medicine is a fascinating reflection of the transformations
occurring within modern societies. We are living in an age where much more informa-
tion is available. Health-related websites such as WebMD and MedicineNet provide instant
CONCEPT CHECKS access to information on health symptoms and treatments, while some fitness trackers
allow users to monitor their activity levels as well as their heart rates and sleep patterns
1. How do functionalist
(see the Digital Life box). Thus, individuáis are increasingly becoming health consumers,
theorists and symbolic
interactionists differ ¡n
adopting an active stance toward their own health and well-being. Not only are people
their perspectives on choosing the types of practitioners to consult but they are also demanding more involve-
health and ¡llness? ment in their own care and treatment.
2. What is stigma. and how Physicians increasingly believe that such unorthodox therapies may be an important
does it pertain to health complement to (although not a substitute for) traditional Western medicine, provided they
and illness? are held up to the same level of scientific scrutiny and rigorous evaluation. Debates about
3. What is the biomedical CAM also shed light on how the nature of health and illness has changed over the past two
model of health? centuries. Many conditions and illnesses for which individuáis seek alternative medical
4 How does disability treatment seem to be producís of the modern age itself. Rates of insomnia, anxiety, stress,
pose a challenge to depression, fatigue, and chronic pain (caused by arthritis, cáncer, and other diseases) are
both functionalist and increasing in industrialized societies (Kessler and Üstün, 2008). Although these conditions
biomedical models
have long existed, they are causing greater distress and disruption to people’s health than
of health?
ever before. Ironically, these consequences of modernity are ones that orthodox medicine
5 Compare complementary
has difficulty addressing. Alternative medicine is unlikely to overtake mainstream health
medicine with alternative
care altogether, but indications are that its role will continué to grow.
medicine.

How Do Social Factors

> Affect Health and Illness?
Recognize that health For people in most parts of the world, life expectancy has increased steadily over the twen-
and ¡llness are shaped tieth and twenty-first centuries. Infectious diseases such as polio, scarlet fever, and diph-
by cultural, social, and
theria have been largely eradicated. In wealthy and industrialized nations infant mortality
economic factors. Learn
rates have dropped precipitously, leading to an increase in the average life span. Compared
about race, class, gender,
and geographic differences with other parts of the world, standards of health and well-being in developed countries
¡n the distribution of disease. are high, and many advances in public health have been attributed to the power of modern
medicine. It is commonly assumed that medical research has been—and will continué to
be—successful in uncovering the biological causes of disease and in developing effective
treatments. At the same time, the proportion of people reporting mental health conditions,
including depression and anxiety disorders, has increased steeply through the twentieth
and twenty-first centuries, raising new questions about how we define, detect, and diag-
nose mental health conditions (Greenberg, 2010; Horwitz, 2013).
From 2017 to 2019, the United States witnessed three consecutive years of declining
life expectancy, a stunning development after a half-century of improvements. A cióse
look at the data shows that the downward trend can be attributed to health conditions
that devastated economically disadvantaged adults; most notably, middle-aged high school

470 CHAPTER 14 The Sociology of the Body: Health, Illness, and Sexuality
dropouts suffered high rates of “deaths of despair,” including suicides and deaths related
to opioid addiction (Case and Deaton, 2020).
Deaths from COVID-19 also follow stark social patterns. As of November 2020, it was
too soon to tell how the pandemic would affect overall life expectancy in the United States,
but one fact is clear: COVID-19 deaths, like deaths of despair, disproportionately strike
economically disadvantaged persons who work in jobs that place them at risk, like bus
drivers or grocery store clerks, and who live in crowded housing. One examination of New
York City found that the Bronx—the borough with the highest proportion of people of
color, the most persons living in poverty, and the lowest levels of educational attainment—
had higher rates of hospitalization and death related to COVID-19 than the other boroughs
(Wadhera et al., 2020). These health inequalities reflect larger systems of social stratifica-
tion, including those based on race, gender, and social class.

Social Class-Based Inequalities in Health

In Chapter 7, we defined social class as a concept that encompasses education, income,
occupation, and assets. In U.S. society, people with better educations, higher incomes, and
more prestigious occupations have better health. What is fascinating is that each of these
dimensions of social class may be related to health and mortality for different reasons.
Income is the most obvious factor. In countries such as the United States, where medi­
cal care is expensive and the ACA is still in its infancy, those with more financial resources
have better access to physicians and medicine. But inequalities in health also persist in coun­
tries such as Great Britain that have a long history of national health insurance. Differences
in occupational status may lead to inequalities in health and illness even when medical
care is fairly evenly distributed. One highly influential study of health inequalities in Great
Britain, the Black Report (Townsend and Davidson, 1982), found that manual workers had
substantially higher mortality rates than professional workers did, even though Britain had
made great strides in equalizing the distribution of health care. Those who work in offices or
in domestic settings face less risk of injury and exposure to hazardous materials.
Education is also a powerful predictor of health; those with higher levels of education
have longer life spans than people with fewer years of schooling do. A recent study found
that life expectancy increased for college-educated people and declined for persons without
a four-year college degree. Closer inspection of these differences found that rates of “deaths
of despair" from suicide and drug abuse are particularly high among those with less edu­
cation (Case and Deaton, 2020; Sasson and Hayward, 2019). Numerous studies have found
a positive correlation between education and a broad array of preventive health behaviors.
Better-educated people are significantly more likely to engage in aerobic exercise and to
know their blood pressure (Shea et al., 1991) and are less likely to smoke (Kenkel et al., 2006)
or to be overweight (Himes, 1999). Highly educated smokers are also much more likely to
quit smoking when faced with a new health threat, such as a heart attack (Wray et al., 1998).
Poorly educated people engage in more cigarette smoking; they also have more problems
with cholesterol and body weight (Winkleby et al., 1992). Lest we jump to the conclusión that
persons with less education make “bad choices,” sociologists have acknowledged that access
to safe places to exercise, grocery stores with healthy foods, and other heath-enhancing
amenities are more common in higher-income neighborhoods (Altschuler et al., 2004).
Mental health is similarly affected by social class-based inequalities. In general, persons
with lower levels of education and income fare worse along most mental health outcomes,

How Do Social Factors Affect Health and Illness? 471

 including risk of depression, anxiety, and suicidal ideation. The stressors related to eco-
nomic adversity, including unsatisfying jobs, strained marriages, and worries about money
and personal safety, may overwhelm one’s ability to cope. The COVID-19 crisis is a case in
point; stay-at-home orders, rampant business shutdowns, and job losses are stressful for
everyone, but they are most overwhelming for low-income persons who Uve paycheck
to paycheck and don’t have ampie savings to sustain them during periods of layoff or fur-
lough. Depressive symptoms (feelings of profound sadness and hopelessness) and anxiety
(nervousness about one’s daily experiences) are emotional consequences of living under
persistently stressful circumstances (Carr, 2014).
Mental health and physical health can be closely intertwined. Where poor physical
health compromises one's emotional well-being, one’s mental health can undermine one’s
physical health, especially for those who try to soothe their feelings of sadness, anxiety,
or alienation through behaviors like excessive drinking, smoking, or using drugs such as
opioids. As we saw earlier in this chapter, growing numbers of Americans with low levels
of education are dying in middle age rather than oíd age. Many are grappling with precar-
ious employment, financial strain, and other stressors that may make them vulnerable to
alcohol and drug abuse and, in the worst-case scenario, deaths from suicide or chronic liver
disease. Health researchers describe these “deaths of despair" as a dramatic example of
social class-based disparities in health (Case and Deaton, 2017).

Race-Based Inequalities in Health

Black Americans fare worse than White Americans on nearly all health indicators, ranging
from body weight to mortality rates to risk of major illnesses like diabetes and cáncer. In
the United States, Ufe expectancy at birth in 2015 was 84 for Hispanic females and
about 81 for White females but 78.5 for Black females. Likewise, Ufe expectancy at birth in
2015 was 79 for Hispanic males and 76 for White males
yet 72 for Black males (CDC, 2017a). An even more
startling gap emerges when early-life mortality is con-
sidered: Black infants have more than twice the mor­
tality rate of White infants, and as we saw earlier in this
chapter, Black expectant and new mothers are nearly
four times as likely as White mothers to die of pregnancy-
related complications, as Irving’s death revealed.
Racial differences in health reveal the complex
interrelations among ethnicity, race, social class,
and culture. A powerful example of the múltiple
ways that race affects health is the Hispanic health
paradox: Although Hispanics in the United States
have poorer socioeconomic resources than White
Americans, on average, their health—and especially
the health of their infants—is just as good as, if not
Many Black people living in poor urban neighborhoods lack access to better than, that of White people. Black Americans, by
high-quality grocery stores and instead rely on cheap fast-food options. contrast, face economic disadvantages that are similar
to those of Hispanics, yet Black people do not enjoy the
same health benefits. Experts attribute Hispanics’ rela-
tive health advantage not only to cultural factors such

472 CHAPTER 14 The Sociology of the Body: Health, lllness, and Sexuality
as social cohesión but also to methodological factors. Studies of Hispanic health in the
United States focus on those who successfully migrated to the United States; individuáis
who are able to migrate are often younger and healthier than those Latinos who remained
in their native countries (Perea, 2012).
A cióse inspection of African Americans’ health and mortality disadvantages fur-
ther reveáis the múltiple ways that race matters for health. One of the main reasons for
this health disadvantage is that Black people as a group have fewer economic resources
than White people do due to a history of systemic racism in the United States, as noted in
Chapter 7. Yet Black-White disparities in health go beyond economic causes and reflect
other important aspects of the social and cultural landscape. Recall that Irving was a highly
educated doctor who earned a good living, yet she remained vulnerable to stressors that
are pervasive for African Americans, including exposure to racism. To take another exam-
ple, consider racial gaps in mortality due to homicide. The homicide rate for Black men is
10 times higher than it is for White men (Widra, 2018). Blacks are also three times as likely
as Whites to be killed by pólice officers, an inequity that fueled many of the Black Lives
Matter (BLM) protests in 2020 (Schwartz and Jahn, 2020). Sociologists have recently rec-
ognized that high rates of mortality from many causes, including tragic and violent causes
like homicide, have a further consequence for Blacks’ health and longevity. The stress and
strain of surviving the deaths of loved ones can take a toll on bereaved people’s health.
Sociologist Debra Umberson and her colleagues have found that Blacks are much more
likely than Whites to have experienced the death of a mother, a father, and a sibling during
their youth or young adult years. They also are more likely to have experienced the death
of a child or a spouse in middle- and oíd age. These losses can take a profound physical and
emotional toll on their loved ones.
Other race-based inequalities in health status, health behaviors, and health care are
similarly stark. There is a higher prevalence of hypertension among Black people than
White people, especially among Black men (41 percent of Black men vs. 30 percent of White
men in 2016)—a difference that may be partly biological (Fryar et al., 2017). The pattern
may also reflect Black Americans’ tendency to eat high-fat foods, a pattern encouraged
by the fast-food industry’s targeting of African Americans as a market (Henderson and
Kelly, 2005). Black women are also far less likely than White women to exercise regularly, a
pattern that most social scientists attribute to their hectic schedules of juggling work and
family and to the high costs of fitness programs and gym memberships (August and Sorkin,
2010). Early evidence also suggests that Black people are more likely than White people to
contract and die from COVID-19. There are several reasons why, a number of which stem
from the generally lower socioeconomic status of Black Americans: Many work in Service
jobs, rely to a greater degree on public transit, have less reliable access to health care and
higher rates of underlying health conditions, live in crowded housing, and are dispropor-
tionately incarcerated in prisons, where infection rates are very high. (CDC, 2020).
Cumulative exposure to racism, whether institutional discrimination from employers
or everyday microaggressions and unkind treatment, also get “under the skin” of people of
color via the process of weathering. As we learned earlier, cumulative exposure to stress
can lead to wear and tear on one’s cardiovascular, metabolic, and immune systems, render-
ing the body vulnerable to disease and even to premature death (Villarosa, 2018).
Racial differences in mental health are far less well understood than racial differences
in physical health. Until recently, most studies have shown that Black people report fewer

How Do Social Factors Affect Health and lllness? 473

symptoms of depression than White people do, and when socioeconomic factors are con-
trolled for, Black people actually report lower rates of depression (Dunlop et al., 2003).
While studies indicate that depression among Black people is prevalent at 10.4 percent
(compared to Whites at 17.9 percent) Black people experience chronic depression at a much
higher rate than White people do (56 percent vs. 38.6 percent, respectively). Although rates
of depression are lower among Black people than they are among White people (partially
due to religious and community support as well as strong racial identity), Black people
with depression are often underdiagnosed or misdiagnosed (Bailey et al., 2019; Oates
and Goode, 2012).

COUNTERING RACIAL INEQUALITIES IN HEALTH

Despite the persistence of inequalities in the health of Black and White Americans, some
progress has been made in eradicating them. According to the CDC, racial differences in
cigarette smoking have decreased. In 1963, half of White men and 60 percent of Black men
age 18 and older smoked cigarettes. By 2016, only 18 percent of White men and 20 percent
of Black men smoked (Jamal et al., 2018). Hypertension among Black people has also greatly
reduced. In the early 1970S, half of Black adults between the ages of 20 and 74 suffered from
hypertension. By 2016, the proportion of Black adults over age 18 suffering from hyper­
tension had dropped to 40 percent (Fryar et al., 2017).
Patterns of physician visitation, hospitalization, and preventive medicine have also
improved, yet racial equity still remains elusive. For example, Black women historically
have been less likely than White women to receive mammograms. This gap has narrowed
in recent years. Still, some studies suggest that Black women delay receiving mammo­
grams and thus those with breast cáncer have their condition detected at a later—and
more dangerous—stage of the disease’s progression (Smith-Bindman et al., 2006). Studies
show that while the rates of cáncer are about the same in Black women and White women,
the likelihood of death for Black women is 19 percent higher than it is for White women
(Monticciolo et al., 2018).

Gender-Based Inequalities in Health

Women in the United States generally live longer than men, and this gender gap increased
steadily throughout the twentieth century. In 1900, there was only a two-year differ-
ence in female and male life expectancies. By 1940, this gap had increased to 4.4 years,
and by 1970, to 7.7 years. Since reaching its peak in the 1970S, however, the gap has been
decreasing. By 2016, the gender gap had fallen to slightly less than five years (Cleary, 1987;
Kochanek et al., 2017).
The main reason for the gender gap in life expectancy is that the leading causes of death
have changed since the turn of the century—and today they disproportionately strike men.
In 1900, the leading cause of death was infectious disease, which affected men, women, and
children equally. However, emerging evidence suggests that COVID-19 is distinct among
infectious diseases for disproportionately affecting men, although scientists do not fully
understand why (Gupta, 2020). Heart disease and cáncer, the leading causes of death today,
also disproportionately strike men. These chronic conditions are heavily influenced by life-
style, diet, and behavior—all of which are shaped by the distinctive experiences of women
and men in contemporary society. The World Health Organization also notes that newborn
girls are more likely than newborn boys to survive to their first birthday. This inherent

CHAPTER 14 The Sociology of the Body: Health, lllness, and Sexuality

biological advantage continúes through life and women are expected to live six to eight
years longer than men in many regions of the world (WHO, 2020a).
One of the apparent ironies of health research is that women have an advantage in
mortality, yet they appear to fare worse than men on nearly every indicator of self-reported
health problems. For instance, women report higher rates of illness from acute conditions
and nonfatal chronic conditions, including arthritis and osteoporosis. They are slightly
more likely to report their health as fair or poor and spend about 57 percent more days
sick in bed each year. Women also report that their physical activities are either restricted
or impossible about 50 percent more than men do. In addition, they make more physician
visits each year and undergo twice the number of surgical procedures as men (CDC, 2013;
National Center for Health Statistics, 2003, 2011). Women are also twice as likely as men
to report symptoms of depression and to be diagnosed with a major depressive disorder
(Van de Velde et al., 2010).
What would explain the paradox that men die younger but women report more health
problems? Sociologists offer two main explanations: (1) Advancing age brings poorer
health, and women are older than men on average due to their greater life expectancy, and
(2) women make greater use of medical Services, including preventive care, and thus are

more cognizant of their overall health and any symptoms of illness (National Center for
Health Statistics, 2008). Men may experience as many, or more, symptoms as women, but
they may ignore the symptoms, underestimate the extent of their illness, or use preven­
tive Services less often (Waldron, 1986). Furthermore, men who are socialized to believe
that men should be “traditionally masculine," strong, and self-sufñcient are less likely to
seek out annual checkups (Springer and Mouzon, 2011).
A major question for sociologists is whether the gender gap in mortality will continué
to decline in coming years. Many researchers believe that it will, yet for an unfortunate
reason: Women’s life expectancies may erode and thus become more similar to men’s. As
men’s and women’s gender roles have converged over the past several decades, women
have increasingly taken on unhealthy “male-typed” behaviors, such as smoking and alco­
hol use, as well as emotional and physical stress in the workplace. These patterns are par-
ticularly pronounced for women of low socioeconomic status. One recent study found
that American women have lost ground with respect to life expectancy compared with
women from other nations. In the early 1980S, the life expectancy of women in the
United States ranked i4th in the world, yet by 2010, American women had fallen to 4ist
place (Karas-Montez and Zajacova, 2013). Currently, the United States is ranked last in
life expectancy for both men and women among comparable large and wealthy countries
(Gonzales et al., 2019). These disheartening findings reveal that gender differences in health
and mortality are not a function of biology alone but of the social advantages and adversi-
ties experienced by men and women in particular sociohistorical contexts.

Disparities in Infectious Diseases Worldwide

Socioeconomic disparities in health exist not only in the United States but also world­
wide. Lower-income nations have higher rates of illness from infectious disease, higher
mortality rates, and lower life expectancies than wealthier nations do. We briefly describe
why and how infectious diseases, HIV/AIDS in particular, pose a threat to low-income
nations and what public health practitioners and policy makers are doing to help fight
these devastating diseases.

How Do Social Factors Affect Health and Illness? 475

 INFECTIOUS DISEASES TODAY
Young ctiildren and Pregnant Although major strides have occurred in reducing, and in some cases eliminating, infec­
women are at greater
risk of malaria tious diseases worldwide, these strides have stalled in the era of the COVID-19 pandemic.
While Italy, China, and the United States have received the most media coverage, there is
Protect them
hardly a country untouched by the virus. Lower-income countries also face greater strug-
with insecticidc
gles in providing medical care to those infected.
treated bed net
The health threats posed by infectious disease in low-income nations have a long his-
tory. Colonialism spread diseases previously known only in the Western world. Smallpox,
measles, and typhus, among other major maladies, were foreign to the indigenous popu-
lations of Central and South America before the Spanish conquest in the early sixteenth
century. The English and French colonists brought the same diseases to North America
(Dubos, 1959). Some of these illnesses developed into epidemics that ravaged or completely
eradicated native populations, which had little or no resistance to them.
In Africa and subtropical parts of Asia, infectious diseases have been rife for a
long time. Tropical and subtropical conditions are especially conducive to diseases
such as malaria, carried by mosquitoes, and sleeping sickness, carried by the tsetse fly.
Infectious diseases such Historians believe that risks from infectious diseases were lower in Africa and Asia prior
as malaria are far more to European colonization—as Europeans often brought with them practices that nega-
common in low-income tively affected the health of indigenous populations. The most significant consequence
countries than they are in
of the colonial system was its effect on nutrition and, therefore, on levels of resis­
wealthier nations. Fully
tance to illness; in many parts of Africa, the nutritional quality of native diets became
91 percent of malaria deaths
occur in Africa. substantially depressed as cash-crop production for world markets supplanted the
production of native foods.

HUMAN IMMUNODEFICIENCY VIRUS (HIV) AND ACQUIRED

IMMUNE DEFICIENCY SYNDROME (AIDS)

COVID-19 is not the only infectious disease to ravage populations in the United States
and worldwide in contemporary times: HIV/AIDS is a devastating global epidemic.
Approximately 38 million people were living with HIV in 2019. In 2019 alone, 1.7 million
people became newly infected with HIV, and another 690,000 people died from AIDS-
related illnesses. The majority of people affected in the world today are heterosexuals;
about half are women (UNAIDS, 2020).
In high-income countries, though the rate of new infections has declined, the demo-
graphics of infected people are striking. In the United States, approximately 38,500 peo­
ple become infected with HIV each year, and roughly 1.1 million people are living with
HIV. The incidence of infection, however, is not proportionately represented throughout
the United States. Despite representing just 12 percent of the U.S. population, African
Americans accounted for 43 percent of all new HIV diagnoses in 2017. Hispanics are also
disproportionately affected: They account for about 18 percent of the population but com-
posed 26 percent of HIV diagnoses in 2017 (CDC, 2017b; Avert, 2019). Although there
was a steep drop in AIDS-related deaths after the introduction of antiretroviral therapy,
African Americans are less likely than White people to benefit from such life-prolonging
treatments. African Americans have the highest death rate of people with HIV, seven times
higher than that of their White counterparts and nearly three times the rate for Hispanics
(CDC, 2017c).

476 CHAPTER 14 The Sociology of the Body: Health, Illness, and Sexuality
 The stigma that associates HlV-positive status with sexual promiscuity, men who have
sex with men, and intravenous drug use results in many individuáis avoiding HIV/AIDS
prevention and treatment programs. In the United States, one in every seven people living
w with HIV/AIDS does not know that they have it (CDC, 20i7d), partly because the high
level of fear and denial associated with being diagnosed as HIV positive discourages
people from being tested for it. The stigma of having HIV and the discrimination against
people living with infections are major barriers to treatment worldwide. A recent study of CONCEPT CHECKS
1,450 HlV-positive patients seeking care in India found that two-thirds of them reported
1. How do social class and
authoritarian behavior from doctors, and 55 percent felt they were not treated in a dignified
race affect health?
manner (Mehta, 2013).
2. Ñame at teast two
Although the spread of AIDS has slowed in many low-income nations, the illness
explanations for the
is still a source of crisis. Besides the devastation to individuáis who suffer from it, the gender gap in health.
AIDS epidemic is creating severe social consequences, including sharply rising numbers
3. Identify at least two
of orphaned children. Frail older adults are increasingly called on to provide physical care
reasons why the gender
to their adult children who suffer from AIDS or to care for their grandchildren who were gap in life expectancy
orphaned by their parents’ deaths from AIDS (Knodel, 2006). The decimated population of may narrow in the future.
working adults combined with the surging population of orphans set the stage for massive 4. What are three social
social instability; economies break down, and governments cannot provide for the social consequences of the
needs of orphans, who become targets for recruitment into gangs and armies. AIDS epidemic in
developing nations?

How Do Social Contexts

Shape Sexual Behavior? <
As with the study of health and illness, scholars disagree as to the importance of biological Understand the diversity of
versus social and cultural influences on human sexual orientations and behaviors, import- sexual orientation today.
Learn about the debate
ant facets of the sociology of the body.
over the importance of
biological versus social
The Diversity of Human Sexuality and cultural influences
Human sexuality is fascinating, diverse, and dynamic. In Chapter 9, we discussed gender on human sexual
identity in great detail and emphasized that while most people are cisgender and identify behavior. Explore cultural
differences in sexual
with the sex they were assigned at birth, growing numbers of people are identifying as
behavior and patterns of
noncisgender. Noncisgender persons challenge the gender binary of male-female, mov- sexual behavior today.
ing fluidly between the categories of male and female or rejecting the binary altogether
(Padawer, 2014; Schulman, 2013). Similarly, growing numbers of persons are challeng-
ing the cultural norm of heteronormativity. Heteronormativity is the pervasive cultural
belief that heterosexuality is the only normal and natural expression of human sexuality.
heteronormativity
Heterosexuality, or being sexually attracted to persons of the opposite sex (i.e., straight), The pervasive cultural
belief that heterosexuality
historically has been considered the cultural norm.
is the only normal and
Homosexuality is the term historically used to describe a sexual or romantic attraction natural expression of
to persons of one's own sex. However, because of past stigma associated with it, that term human sexuality.
is now considered offensive and new terms are widely used to describe those attracted

How Do Social Contexts Shape Sexual Behavior? 477

 to persons of the same sex. The term gay is used to refer to men who experience sexual
desire toward other men, lesbian describes women who experience sexual desire for other
women, and bi—shorthand for bisexual—describes people who are sexually attracted to
both men and women. People increasingly use the term queer to describe people whose
sexual orientation is not exclusively heterosexual, as the gender-specific terms gay and
lesbian may be too limiting for some individuáis (GLAAD, 2020).
All of the above are examples of sexual orientation, or the direction of one’s sexual or
romantic attraction. It is important to note that sexual orientation is a more appropriate term
when describing human sexuality than sexual preference. The latter is misleading because it
implies that one's sexual or romantic attraction is entirely a matter of personal choice. As
we discuss, sexual orientation results from a complex interplay of biological and social fac-
tors not yet fully understood. It is difficult to document sexual orientation because of the
lingering stigma attached to same-sex relationships, which may result in the underreport-
ing of sexuality in demographic surveys. However, most estimates suggest that from 2 to
5 percent of all women and from 3 to 10 percent of all men in the United States are attracted
to same-sex partners (Smith, 2003; Stephens-Davidowitz, 2013).
Early writings viewed sexual orientation, like gender identity, as a binary, where peo­
ple could be categorized as either heterosexual (straight) or homosexual (gay). Yet, in recent
decades, scholars have recognized that these two categories are far too simplistic to cap­
ture the nuances of human sexuality. Sociologist Judith Lorber (1994) identified as many
as 10 different sexual identities, including straight (heterosexual) women, straight men,
lesbian women, gay men, bisexual women, and bisexual men. More contemporary studies
of human sexuality use the acronym LGBTQ to capture even greater complexity. LGBTQ
refers to lesbian, gay, bisexual, transgender, and queer persons. You may notice that some
of these terms reflect one’s gender identity, such as transgender, whereas others refer
specifically to sexual orientation.
The specific language we use to talk about sexual behavior has changed dramatically
over time, yet the notion that human sexuality is complex and constrained by societal
norms has existed for centuries. In the late nineteenth and early twentieth centuries,
Sigmund Freud argued that human beings are born with a wide range of sexual tastes
that are ordinarily curbed through socialization—although some adults may follow these
desires even when, in a given society, they are regarded as immoral or illegal. Freud began
his research during the Victorian period, when many people were sexually prudish, yet his
patients still revealed an amazing diversity of sexual pursuits.
In most societies, sexual norms encourage some practices and discourage or condemn
others. Such norms, however, vary among cultures and often challenge the notion of
heteronormativity. For example, the anthropologist Gilbert Herdt (1981, 1984, 1986)
reported that among more than 20 tribes in Melanesia and New Guinea, ritually prescribed
same-sex encounters among young men and boys were considered necessary for subse-
quent masculine virility (Herdt and Davidson, 1988). Ritualized male-male sexual encoun­
ters also occurred among the Azande of Africa’s Sudan and Congo (Evans-Pritchard, 1970),
Japanese samurai warriors in the nineteenth century (Leupp, 1995), and highly educated
Greek men and boys at the time of Plato (Rousselle, 1999). These examples underscore the
importance of social and historical contexts in shaping sexuality.
Cross-cultural variations have been detected among myriad aspects of human sexu­
ality, including precisely what is included and valued in a sexual encounter and the traits

478 CHAPTER 14 The Sociology of the Body: Health, Itlness, and Sexuality
that one views as attractive in a potential sexual partner. The most comprehensive
cross-cultural study of sexual practices was carried out by Clellan Ford and Frank Beach
(1951), using anthropological evidence from more than 200 societies. Striking variations
were found in what different societies regarded as “natural” sexual behavior and in norms
of sexual attractiveness. For example, in some cultures, extended foreplay is desirable and
even necessary before intercourse; in others, foreplay is nonexistent. In some societies, it is
believed that overly frequent intercourse leads to physical debilitation or illness.
In most cultures, norms of sexual attractiveness (held by both cisgender females and cis-
gender males) focus more on physical looks for women than for men, a situation that may be
changing worldwide as women become active in spheres outside the home. The traits seen as
most important in female beauty, however, differ greatly. In wealthy industrialized nations, a
slim, small physique is admired, while in other cultures, a more generous shape is attractive.
Sometimes the breasts are not considered a source of sexual stimulus, whereas some soci­
eties attach erotic significance to them. Some societies valué the shape of the face, whereas
others emphasize the shape and color of the eyes or the size and form of the nose and lips.

Sexuality in Western Culture:

A Historical OverView
Western attitudes toward sexual behavior were for nearly 2,000 years molded primarily by
Christianity, whose dominant view was that all sexual behavior was suspect except that
needed for reproduction. During some periods, this view produced an extreme prudish-
ness, but at other times, many people ignored the church’s teachings and engaged in prac­
tices such as adultery. The idea that sexual fulfillment can and should be sought through
marriage was rare.
In the nineteenth century, religious presumptions about sexuality were partly replaced
by medical ones. Most early writings by doctors about sexual behavior, however, were as
stern as the views of the church. Some argued that any type of sexual activity unrelated
to reproduction would cause serious physical harm. Masturbation was said to cause blind-
ness, insanity, and heart disease, while oral sex was claimed to cause cáncer. In Victorian
times, sexual hypocrisy abounded. Many Victorian men—who appeared to be sober,
well-behaved citizens devoted to their wives—regularly visited prostitutes or kept mis-
tresses. Such behavior was accepted, whereas “respectable" women who took lovers were
regarded as scandalous and were shunned in polite society. The differing attitudes toward
the sexual activities of men and women formed a double standard that persists today.
Currently, traditional attitudes exist alongside much more permissive attitudes, which
developed widely in the 1960S. Some people, particularly those influenced by Christian
teachings, believe that premarital sex is wrong, and they frown on all forms of sexual
behavior except heterosexual activity within marriage—although it is now more com-
monly accepted that sexual pleasure is an important feature of marriage. Sexual attitudes
have undoubtedly become more permissive over recent decades in most parts of the world,
but some behaviors remain consistently more acceptable than others. For example, the
proportion of Americans saying that premarital sex is “always wrong” dropped from
34 percent in 1972 to 26 percent in 2016 (Bowman, 2018). However, attitudes toward

premarital sex among young teens are far less permissive; more than three-quarters
of Americans disapprove of sexual relations between unmarried teens ages 14 to 16.

How Do Social Contexts Shape Sexual Behavior? 479

 Disapproval of extramarital sex also has remained
consistently high and has even increased: The pro-
portion of Americans saying that extramarital sex
is “always wrong" increased from 71 to 81 percent
between 1972 and 2016 (Labrecque and Whisman,
2017; Smith and Son, 2013).
Despite increasingly open-minded attitudes,
sexual behavior—especially among young women—
is still highly regulated, monitored, and judged.
Scholars, activists, and even celebrities like Lady
Gaga and Amber Rose have called attention to
practices like “slut-shaming,” which maligns young
women for being sexually active, and “prude-
shaming,” whereby young women are shamed or
embarrassed for not being sexually active. Activists
underscore how dangerous these judgments can
be, pointing out that some young women who
have been the victims of sexual assault are blamed
or shamed for wearing miniskirts or low-cut tops,
drinking, flirting, or kissing their assailants prior
to being attacked (Nguyen, 2013).
These public condemnations are part of a larger movement called “sex positivity”: a
philosophy and a social movement that encourages and embraces diverse forms of sexual-
ity and sexual expression, emphasizing the importance of safe, healthy, and consensual sex
(Ivanski and Kohut, 2017). Although the sex-positive movement has flourished in recent
years, facilitated by social media and public events like SlutWalk protest marches, its core
idea dates back to early-twentieth-century doctor and psychoanalyst Wilhelm Reich. Both
Reich and current-day advocates of the sex-positive movement view sexuality as a matter
of personal choice and avoid making moral judgments or distinctions. All forms of healthy,
consensual sex, whether same-sex or opposite-sex relations, masturbation, polyamory,
asexuality, or voluntary sadomasochism, should be respected and spared judgment. The
movement’s larger goal is to advócate for comprehensive sex education for all.

SEXUAL BEHAVIOR: KINSEY'S STUDY

We can speak more confidently about public valúes and attitudes concerning sexuality
than we can about actual sexual behavior, because these deeply prívate practices have gone
undocumented for much of history. Alfred Kinsey broke major ground when he initiated
the first major investigation of sexual behavior in the United States in the 1940S and 1950S.
Kinsey and his collaborators (1948,1953) faced condemnation from religious organizations,
and his work was denounced as immoral in newspapers and in Congress. But he persisted,
thus making his research the largest rigorous study of sexuality at that time, although his
sample was not representative of the overall American population.
Kinsey’s results were surprising because they revealed a tremendous discrepancy
between prevailing public expectations of sexual behavior and actual sexual conduct. The
gap between publicly accepted attitudes and actual behavior was probably especially pro-
nounced just after World War II, the time of Kinsey’s study. A phase of sexual liberalization

480 CHAPTER 14 The Sociology of the Body: Health, lllness, and Sexuality
had begun in the 1920S, when many younger people felt freed from the strict moral codes
that had governed earlier generations. Sexual behavior probably changed, but issues con-
cerning sexuality were not openly discussed. People participating in sexual activities that
were still widely denounced concealed them, not realizing that others were engaging in
similar practices behind closed doors. The more permissive 1960S brought openly declared
altitudes more into line with the realities of behavior.

SEXUAL BEHAVIOR SINCE KINSEY

In the 1960S, social movements that challenged the existing order, such as those associ-
ated with countercultural lifestyles, also broke with existing sexual norms. These move­
ments preached sexual freedom, and the introduction of the contraceptive pill allowed
sexual pleasure to be separated from reproduction. Women’s groups also started pressing
for greater independence from male sexual valúes, rejection of the double standard, and the
need for women to achieve greater sexual satisfaction in their relationships—efforts that
persist today as part of the sex-positive movement. Even so, until recently, it was unclear to
what extent sexual behavior had changed since the time of Kinsey’s research.
In the late 1980S, sociologist Lillian Rubin (1990) interviewed 1,000 Americans
between the ages of 13 and 48 to identify changes in sexual behavior and attitudes that
had occurred over the previous 30 years or so. Her findings indicated significant changes.
Sexual activity begins at a younger age; moreover, teenagers’ sexual practices are as varied
and comprehensive as those of adults. There is still a double standard that divides perception
of the sexual behavior of men and women, but it is not as powerful. Contemporary scholar-
ship confirms this. Studies of high school-age students find that sexual permissiveness is
much greater today than it was in the 1970S. According to the CDC in 2017,40 percent of all
high school students reported having ever had sexual intercourse, and 10 percent reported
having had four or more partners (Kann et al., 2018). Both figures represent declines from
1991, when more than 54 percent of high school students had had sex and nearly 19 percent

had had four or more partners (Tang and Zuo, 2000; Toufexis, 1993).
Recent research on the sexual lives of college students shows that a “hookup culture”
is alive and well on campus, where both male and female students will have one-night
stands, short-lived sexual relationships, or “friends with benefits” relationships in which
friends will have sexual relations without the expectation that their friendship will trans-
form into a full-blown romance (García et al., 2012; Hamilton and Armstrong, 2009; Wade,
2017). However, when a team of sociologists delved more closely into the sexual lives of
college students, they found that while casual sexual encounters were relatively common,
men and women were fairly selective in such encounters. Sociologist Paula England and
colleagues interviewed more than 14,000 undergraduate students at 19 universities and
colleges about their romantic and sexual lives. Nearly three-quarters (72 percent) of both
women and men said that they’d had at least one “hookup” during their sénior year. But for
most, hookups were relatively rare. Of those students who said that they had ever hooked
up, equal proportions said that they had fewer than three (40 percent) or between four and
nine (40 percent) hookups. Just one in five reported 10 or more hookups in their lifetimes.
Moreover, not all of these hookups involved sexual intercourse. Fully 20 percent of college
seniors reported never having had sexual intercourse (England et al., 2012).
Studies of the sexual lives of adults beyond college age also reveal that Americans
report relatively few sexual partners throughout their lives and less frequent sex than their

How Do Social Contexts Shape Sexual Behavior? 481

EMPLOYING Health Care Provider
YOUR
SOCIOLOGICA!. Medicine is commonly lauded as a "noble profession.” Doctors, nurses, and other health
care providers dedícate their lives to diagnosing and treating health problems and helping
IMAGINATION their patients live long and comfortable lives. A deep knowledge of biology, chemistry,
and anatomy is critical to the medical professions, but a sociological imagination is also
necessary. The study of sociology helps physicians understand why some people may
not have access to the health care they need, how power dynamics in the clinician-
patient encounter may affect the quality of care, why some patients ignore sound medical
advice, why social and environmental factors like stress make people sick, and so on.
In fact, a strong grasp of human behavior is so important to health care providers that
in 2015 the Medical College Admission Test (MCAT) introduced a new required mod­
ule on Psychologicat, Social, and Biological Foundations of Behavior. The Association of
American Medical Colteges (AAMC) has also underscored the importance of sociology to
medical education, noting that "medicine now faces complex societal problems like addic-
tion, obesity, violence, and end-of-life care, which require behavioral and social Science
research and interventions” (AAMC, 2011).
One area of particular concern to health care providers is cultural competence, or the
skills and ability to interact effectively with patients from cultural backgrounds different
from one's own. "Culture" refers to more than a patients race, ethnicity, or national origin;
it also encompasses characteristics such as age, gender, gender identity, sexual orien-
tation, disability, religión, income level, education, geographical location, or profession
(Substance Abuse and Mental Health Services Administration, 2016). An understanding
> of sociology helps practitioners to be respectful, responsive, and sensitive to the cultural

counterparts in other nations. For example, in 1994, a team of researchers led by Edward
Laumann published The Social Organization ofSexuality: Sexual Practices in the United States,
the most comprehensive study of sexual behavior since Kinsey. Their findings reflect an
essential sexual conservatism among Americans. For instance, 83 percent of their subjects
had had only one partner (or no partner at all) in the preceding year, and among mar-
ried people, the figure was fully 96 percent, suggesting that only a tiny share of surveyed
married people had been unfaithful to their spouse in the previous year. Fidelity to one’s
spouse was also quite common: Only 10 percent of women and less than 23 percent of men
reported having an extramarital affair during their lifetimes. More recent data reveal that
little has changed; according to the CDC (2017c), in 2015, men reported an average of 6.1
sexual partners in their lives, while women reported just 4.2 partners.

IS SEXUAL ORIENTATION INBORN OR LEARNED?

Most sociologists believe that sexual orientation—whether LGBTQ, heterosexual, bisex­
ual, or asexual—results from a complex interplay between biological factors and social
learning. Since heterosexuality is the norm for most people in U.S. culture, considerable
research has focused on why some people prefer same-sex partners. Some scholars argüe
that biological influences predispose certain people to become gay (Bell et al., 1981; Green,

482 CHAPTER 14 The Sociology of the Body: Health, lllness, and Sexuality
and linguistic needs as well as the health beliefs and practices of their patients. The
classic book The Spirit Catches You and Yon Fall Down vividly portrayed the difficulties a
Hmong famity faced when trying to get medical treatment for their daughter Lia Lee, who
suffered a rare and severe form of epilepsy. Lias parents believed in spiritual approaches
to medicine and refused to give their daughter certain medications, while their doctors
didn't understand Hmong culture, couldn't establish a rapport or empathy with their
patients, and created a context of distrust that impeded Lias treatment and prognosis
(Fadiman, 1997).
Health care providers also need to recognize their own unconscious biases, which may
affect how they internet with and treat their patients. Several studies have found that Black
and Latino emergeney room patients are much less likely than White patients with similar
injuries to be prescribed the painkillers they need. A meta-analysis of 14 studies and about
12,000 White, Black, and Hispanic patients found that Black patients were 40 percent less
likely to receive painkillers for acute pain, while Hispanic patients were 25 percent less
likely as compared to White patients. One explanation is that health care providers hold
assumptions that ethnic minorities are more likely to abuse drugs, or they may believe that
the patients are misrepresenting their conditions simply to secure drugs. Other explanations Understanding the nuances of a
inelude implicit bias, cultural differences, language barriers, and whether patients report diverse body of patients can
pain and the amount they experience (Pletcher et al., 2008; Lee et al., 2019). Other studies help health care workers
have found that health care providers who do not understand the needs and experiences provide care that considers

of gender-nonconforming and transgender patients may treat them insensitively, referring many different experiences.

to them by the wrong gender, and may even neglect particular symptoms or fail to offer
tests the patient might have needed (Sallans, 2016). Medical practitioners who understand
social, cultural, and interpersonal influences on health and health care will be especially well
equipped to provide respectful and high-quality care to their increasingly diverse patients. /\

1987). Biological explanations have included differences in brain characteristics of gay and
straight men (LeVay, 2011) and the effect on fetal development of the mother’s in útero
hormone production during pregnaney (Blanchard and Bogaert, 1996; Manning et al., 1997;
McFadden and Champlin, 2000). Such studies, which are based on small numbers of cases,
give highly inconclusive (and highly controversial) results (Healy, 2001). It is virtually
impossible to sepárate biological from early social influences in determining a person’s
sexual orientation (LeVay, 2011).
Studies of twins may shed light on any genetic basis for homosexuality, since identical
twins share identical genes. In two related studies, Bailey and Pillard (1991; Bailey et al.,
1993) examined 167 pairs of brothers and 143 pairs of sisters, with each pair of siblings
raised in the same family, in which at least one sibling defined themself as gay or lesbian.
Some of these pairs were identical twins (who share all genes), some were fraternal twins
(who share some genes), and some were adoptive brothers or sisters (who share no genes).
The results offer some support that same-sex attraction, like opposite-sex sexual
attraction, results from a combination of biological and social factors. Among the men and
women studied, when one twin was gay, there was about a 50 percent chance that the
other twin was gay. In other words, a person is five times as likely to be gay or lesbian if
their identical twin is gay than if their sibling is gay but related only through adoption.

How Do Social Contexts Shape Sexual Behavior? 483

 These results offer some support for the importance of biological factors, since the higher
the percentage of shared genes, the greater the percentage of cases in which both siblings
were gay. However, because approximately half of the identical twin brothers and sisters
of individuáis who identified as gay were not themselves gay, social learning must also
be involved.
Even studies of identical twins cannot fully isolate biological from social factors. It
is often the case that even in infancy, identical twins are treated more like each other by
parents, peers, and teachers than are fraternal twins, who in turn are treated more like
each other than are adoptive siblings. Thus, identical twins may have more than genes
in common: They may also share a higher proportion of similar socializing experiences.
Sociologist Peter Bearman (2002) has shown the intricate ways that genetics and social
experience are intertwined. Bearman found that males with a female twin are twice as
likely to report same-sex attractions. He theorized that parents of opposite-sex twins
are more likely to give them unisex treatment, leading to a less traditionally masculine
influence on the males. Having an older brother, however, decreases the rate of same-sex
attraction. Bearman hypothesized that an older brother establishes gender-socializing
mechanisms for the younger brother to follow, which allows him to compénsate for uni­
sex treatment. Bearman’s work is consistent with the statements offered by professional
organizations such as the American Academy of Pediatrics (2004), which concludes that
“sexual orientation probably is not determined by any one factor but by a combination of
genetic, hormonal, and environmental influences.”

HOMOPHOBIA AND HETEROSEXISM

The research we have reviewed so far reveáis that Americans’ attitudes toward human
sexuality have grown increasingly expansive and open-minded throughout much of the
twentieth and twenty-first centuries. Yet does this open-mindedness extend to all groups?
heterosexism Some contend that anti-gay prejudice persists and that gay, lesbian, bisexual, transgen­
An ideological System that der, and queer (LGBTQ) Americans still do not enjoy the same rights and privileges as
denies, denigrates, and their heterosexual and cisgender peers. The greater status, prestige, and benefits afforded
stigmatizes any nonhetero-
to heterosexual people is called heterosexism. It is closely related to the concept of
sexual form of behavior,
homophobia, a term coined in the late 1960S, which refers to attitudes and behaviors
identity, relationship. or
community. marked by an aversión to, or hatred of, LGBTQ persons and their practices. It is a form
of prejudice reflected not only in overt acts of hostility and violence toward sexual
minorities but also in forms of verbal abuse that are widespread in American culture—for
homophobia example, using words such as fag or homo to insult heterosexual males or using female-
An ¡rrational fear or gendered offensive terms such as sissy or pansy to insult gay men (Pascoe, 2011). Similarly,
disdain of homosexuality. transphobia refers to negative attitudes, feelings, or actions toward transgender and
gender-nonconforming people, their lifestyles, and their practices.
Heterosexism may take a profound toll on the health, well-being, and personal safety
transphobia
of LGBTQ persons. A 2017 survey found that in the United States, 33 percent of stu-
Negative attitudes, feel-
dents who self-identified as gay, lesbian, or bisexual had been bullied on school property.
ings, or actions toward
transgender and gender- Another 27 percent experienced cyberbullying. Comparatively, heterosexual peers expe-
nonconforming people, rienced bullying at rates of 17.1 percent and 13.3 percent, respectively (Kann et al., 2018).
their lifestyles, and their Another national study from 2015 found that 85 percent of LGBTQ youth reported that
practices. they had been verbally harassed at school, 27 percent had been physically harassed, and 49
percent had been victims of cyberbullying. More than half of LGBTQ students (58 percent)

484 CHAPTER 14 The Sociology of the Body: Health, lllness, and Sexuality
felt “unsafe" at school (Kosciw et al., 2016). Mistreatment of
transgender youth is even more devastating, epitomized by
the violent 2017 murders of 17-year-old Ally Lee Steinfeld in
Missouri and 18-year-old Jaquarrius Holland in Louisiana.
This pervasive culture of fear, intimidation, and harass-
ment can have dire consequences: LGBTQ youth have much
higher rates of suicide, suicidal thoughts, depression, and
substance use than straight youth, due in large part to the
victimization and teasing they suffer at the hands of their
classmates and to the failure, at times, of their families
and teachers to protect them (Espelage et al., 2008; Russell
and Joyner, 2001; Ryan et al., 2009). For many, families are
a source of cruelty and victimization rather than support.
An estimated 20 to 40 percent of all homeless youth iden- The Stonewall Inn nightclub raid in 1969 ¡s regarded as the
tify as LGBTQ, many of whom have been put out on the first shot fired in the battle for gay rights in the United States.
The 25th anniversary of the event was commemorated in New
streets by homophobic or transphobic parents (Durso and
York City with a variety of celebrations as well as discussions
Gates, 2012).
on the evolution and future of gay rights.
Despite the devastating statistics on bullying and home-
lessness among LGBTQ youth, data suggest that homophobia
and transphobia in the United States are slowly starting to
erode. The majority of Americans today view same-sex rela-
tionships as morally acceptable, signifying a marked increase
from 2001, when just 40 percent of Americans agreed with the practice (Gallup, 2013a). In
May 2011, for the first time in its history, a Gallup poli found that the majority of Americans
(53 percent) supported gay marriage (Gallup, 2013b); by 2019, that proportion had risen to
61 percent (Pew Research Center, 2019a). Public policies both reflect and shape prívate
attitudes; as we saw in Chapter 11, in June 2015, the U.S. Supreme Court legalized gay
marriage in Obergefell v. Hodges, guaranteeing same-sex married couples the same rights as
opposite-sex married couples.

THE MOVEMENT FOR LGBTQ CIVIL RIGHTS

Until recently, most gay, lesbian, and queer persons hid their sexual orientation for fear that
“coming out of the closet”—publicly revealing one’s sexual orientation—would cost them
their jobs, families, and friends and leave them open to verbal and physical abuse. Yet, since
the late 1960S, many LGBTQ persons have openly acknowledged their sexual orientation,
and in some cities, the lives of sexual and gender minorities have become quite normalized
(Saguy, 2020). New York City, San Francisco, London, and other large metropolitan areas
worldwide have thriving LGBTQ communities.
LGBTQ activists have achieved important milestones in fighting heterosexism and
forging institutional changes, ranging from changing medical notions of sexual orienta­
tion to legalizing same-sex marriage. The movement for LGBTQ civil rights in the United
States arguably began with the Stonewall riots in June 1969, when New York City’s gay
community—angered by continual pólice harassment—fought the New York Pólice
Department for two days (D’Emilio, 1983; Weeks, 1977). The Stonewall riots became a Sym­
bol of gay pride. In May 2005, the International Day against Homophobia was first cele-
brated, with events held in more than 40 countries.

How Do Social Contexts Shape Sexual Behavior? 485

 Activists and advocates have had a profound impact on the policies and practices that
affect LGBTQ persons. For example, the term homosexuality has a troubled history. It was
first used by the medical community in 1869 to characterize what was then regarded as a
personality disorder. Same-sex attraction was medicalized and viewed as a pathology that
required medical or psychiatric treatment. The American Psychiatric Association did not
remove homosexuality from its list of mental illnesses until 1973 or from its influential
Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1980. These long-overdue
steps were taken only after prolonged lobbying and pressure by LGBTQ advocacy orga-
nizations. The medical community was belatedly torced to acknowledge that no scientific
research had ever found gays and lesbians as a group to be psychologically unhealthier
than heterosexuals (Burr, 1993). However, the DSM-5 continúes to classify other aspects
of sexuality as “disorders,” medicalizing fairly common sexual problems such as disorders
of sexual arousal (for instance, lubrication and erectile problems) and orgasmic disorders
(American Psychiatric Association, 2013).
In addition to policy changes, social movements and cultural shifts have contrib-
uted to the slow and gradual erosión of heterosexism. One such shift is the public
coming-out of LGBTQ persons in the public eye. Corning out may be important not
only for the person who does so but also for others in the larger society: LGBTQ per­
sons discover that they are not alone, while heterosexuals recognize that people whom
they admire and respect are LGBTQ. Famous actors, singers, and performers, such as
Ellen DeGeneres and Elton John, have been out publicly for many years. And in 2018,
Daniela Vega, the Oscar-nominated star of the Chilean film A Fantastic Woman, achieved
a major milestone when she became the first openly transgender person to present at
the Academy Awards.
LGBTQ persons in other professions, especially professional sports, have been more
reticent about acknowledging their sexual orientation, perhaps out of fear of persecu-
tion. NBA basketball player Jason Collins made national news in April 2013 when he
told reporters that he was gay. With his announcement, Collins became the first active
player in one of the four major American professional sports leagues to announce that
he was gay (ESPN, 2013a). The next year, Michael Sam, who was drafted by the NFL’s
St. Louis Rams in 2014, carne out as gay. Since that time, literally dozens of pro athletes
have publicly identified as LGBTQ. The 2018 U.S. Winter Olympic Team boasted more
than 14 “out” athletes, including freestyle skier Gus Kenworthy and outspoken figure
skater Adam Rippon.
Social change is occurring globally, slowly but steadily, even in countries that his-
torically have had cruel and oppressive policies toward gays and lesbians. For example, in
2014, the Constitutional Court in Uganda invalidated a previously passed “antigay” bilí,
which provided jail terms up to life for persons convicted of having gay sex and stipulating
lengthy jail terms for persons convicted of “attempted homosexuality” or the “promotion
of homosexuality” (Gettleman, 2014). This marked a significant change in a nation where,
just three years earlier, the outspoken gay rights activist David Kato was beaten to death
with a hammer.

CHAPTER 14 The Sociology of the Body: Health, lllness, and Sexuality

How Does the Social Context of Bodies,
Sexuality, and Health Affect Your Life?
As we have seen in this chapter, our bodies, health, health behaviors, and sexual orienta-
tions and practices reflect a complex set of biological, social, cultural, and historical influ-
ences. For example, although most American young adults believe they have the freedom
to choose whomever they like as their romantic partners (and turn up their noses at the
idea of arranged marriage), the gender of the people we choose, what we deem attractive,
and when and under what circumstances we engage in sexual relationships are powerfully
shaped by laws, norms, and cultural practices.
Similarly, although most people believe that their body size and shape reflect their
own personal efforts, such as going to the gym four times a week and counting calories, or
biological factors (for example, “good genes”), sociologists have documented that social fac-
tors such as race, class, gender, and región affect one’s access to health-enhancing resources
like healthy food, safe walking and running paths, and high-quality health care. Solutions
to sweeping public health crises, like the obesity epidemic, often require strategies that
alter both individual-level choices and behaviors and macrosocial structures. Public pro-
grams that target both micro levels—encouraging healthier food choices and exercise
among individuáis—and macro levels—bringing grocery stores to urban neighborhoods
and ensuring that major corporations that supply food to public schools abide by healthier CONCEPT CHECKS
food production guidelines—are likely to be more effective.
1. Describe several
Yet further and dramatic social changes are still needed to eradicate persistent racial
changes in sexual
and socioeconomic disparities in health. The life and premature death of Dr. Irving under- practices over the past
scores just how powerfully social inequalities affect our bodies. Persistent stressors like two centuries.
racism get under one’s skin, wearing down one’s body and one’s health and thus rendering 2. What are the most
its victims vulnerable to chronic diseases like diabetes and high blood pressure. Economic important contributions
strains and precarious employment may make some vulnerable to substance use, includ- of Alfred Kinsey’s
ing use of opioids or excessive drinking, which have contributed to “deaths of despair” research on sexuality?
from suicide or chronic liver disease. Support for programs like early screening for high 3. Ñame at least three
blood pressure, obesity, substance use, and depression may help to ensure that health important findings
problems are detected in their earliest stages and that timely treatment is sought. Through about sexual behavior
discovered since Kinsey.
the use of these strategies, it is possible that the United States may ultimately reach
the goal articulated by the federal government to “achieve health equity, elimínate dis­ 4. What are several of
the most important
parities, and improve the health of all groups" (Office of Disease Prevention and Health
achievements of LGBTQ
Promotion, 2020). rights movements?

How Do Social Contexts Shape Sexual Behavior? 487

CHAPTER 14 Learning Objectives

The How Do Social

Understand how social, cultural, and
structural contexts shape attitudes toward

Big Picture Contexts Affect the

Human Body?
"ideal" body forms and give rise to two body-
related social problems in the United States:
eating disorders and obesity.

The Sociology of the p. 457

Body: Health, Illness,

and Sexuality
Learn about functionalist and symbolic
interactionist perspectives on physical and
How Do Sociologists mental health and illness in contemporary
Understand Health society. Recognize the ways that
and Illness? disability challenges theoretical perspectives
Thinking Sociologically on health and illness. Understand the

1. Obesity is a major health concern in

the United States, especially among
p. 463

\| relationship between traditional medicine and

complementary and alternative medicine (CAM).

poor, Black, and Latino Americans.

What types of public programs do
you believe will be most effective in
How Do Social
Factors Affect Health Recognize that health and illness are
fighting the obesity epidemic? Why
and Illness? shaped by cultural, social, and economic
do you think the programs you've
factors. Learn about race, class,
proposed are necessary? gender, and geographic differences in
p. 470
the distribution of disease.
2. Statistical studies of our national health
show a gap in life expectancies between
the rich and the poor. Review all the
major factors that would explain why
rich people live longer than poor people. How Do Social
Understand the diversity of sexual
Contexts Shape
orientation today. Learn about the debate
3. This chapter discusses the biological Sexual Behavior?
over the importance of biological versus
and sociocultural factors associated
social and cultural ¡nfluences on human
with sexual orientation. Why are twin p. 477
sexual behavior. Explore cultural differences
studies the most promising type in sexual behavior and patterns of sexual
of research on the genetic basis of behavior today.
sexual orientation? Summarize the
analysis of these studies, and show
whether it presently appears that
sexual orientation results from genetic
differences, sociocultural practices
and experiences, or both.
 Terms to Know Concept Checks

universal health coverage • social class

gradient in health • sociology of the body

obesity • food deserts

Á 1. Why is anorexia more likely to strike young women than heterosexual
young men?
2. What explanations are offered for the recent increase in obesity rates?
3. In what ways is the United States an "obesogenic environment"?

1. How do functionalist theorists and symbolic interactionists differ in

their perspectives on health and illness?
2. What is stigma, and how does it pertain to health and illness?
sick role • stigma • complementary and 3. What is the biomedical model of health?
alternative medicine (CAM) • biomedical model 4. How does disability pose a challenge to both functionalist and biomedical
of health models of health?
5. Compare complementary medicine with alternative medicine.

1. How do social class and race affect health?

2. Ñame at least two explanations for the gender gap in health.
3. Identify at least two reasons why the gender gap in life expectancy
may narrow in the future.
4. What are three social consequences of the AIDS epidemic in
developing nations?

heteronormativity • heterosexism • homophobia

• transphobia
1. Describe several changes in sexual practices over the past two centuries.
2. What are the most important contributions of Alfred Kinsey's research
on sexuality?
3. Ñame at least three important findings about sexual behavior discovered
since Kinsey.
4. What are several of the most important achievements of LGBTQ rights
movements?