Y. Benyamini: Stress and Co ping with Womens Health Issues European Psychologist 2009; Vol.

14(1):6371 2009 Hogrefe & Huber Publishers

Stress and Coping with Womens Health Issues

A Review from a Self-Regulation Perspective
Yael Benyamini
Tel Aviv University, Israel
Abstract. The goals of this review are: (1) to present the Leventhal common-sense model (CSM) of self-regulation of stress and coping with health threats as well as new directions and questions arising from this model, and (2) to apply this theoretical perspective to womens health issues in order to highlight concerns that are unique to women. Examples from research on womens health are reviewed to show: (a) how women apply decision rules to the internal and external information available to them in order to interpret their symptoms, in an attempt to reach a coherent representation of the health threat; (b) how these representations are related to womens choices of coping strategies and why they are often unrelated to actual coping; and (c) how women appraise their situation and in what ways this internal appraisal could differ from objective outcomes. Viewing coping with womens health issues through the lens of the CSM highlights the ways in which biological and social gender differences in the experience of illness and the interactions between them affect each stage of the self-regulation process (i.e., womens experience of the stressor and the representations they form, how these representations guide coping, and womens appraisal of their situation). This review helps identify principles and general conclusions derived from the CSM and generalizes them across various threats to womens health, which should be taken into account when planning theoretically-based interventions to support women coping with health threats, as well as questions that should be investigated in future research. Keywords: self-regulation, womens health, gender differences, stress, coping

People often encounter adverse conditions, which we intuitively refer to as stressful. One definition of stressors refers to threats, demands, or structural constraints that, by the very fact of their occurrence or existence, call into question the operating integrity of the organism (Wheaton, 1997). This definition acknowledges that stressors have personal and social facets that go beyond biological stress, even when the source is a health problem. The process of coping with such stressors can be viewed from a self-regulation perspective. Self-regulation models view people as active problem-solvers, motivated by goals, constantly gathering goal-relevant information and integrating it with their prior knowledge to form subjective assessments of their status. These assessments then serve to guide their coping efforts. Additional information is gathered and updated assessments are appraised in relation to ones goals. This dynamic self-regulation process becomes more intensive when we encounter a stressor such as a health threat. The current review focuses on a prominent theory of selfregulation, which was developed specifically for the study of coping with health-related stressors: The Leventhal common-sense model (CSM) of self-regulation (Leventhal, Meyer, & Nerenz, 1980). This review aims to: (1) present the CSM of self-regulation of stress and coping with health threats as well as new directions in this model; and (2) to apply this theoretical perspective to womens health issues in order to highlight concerns that are unique to women.
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A General Overview of the CommonSense Model of Self-Regulation

The CSM delineates a process that begins when one encounters a health problem (Leventhal et al., 1997). The process includes three stages that occur at the cognitive and emotional levels in parallel: (1) Forming illness representations, (2) implementing coping procedures, and (3) appraising ones status. At the first stage, one attempts to understand the health problem by checking the current somatic experience against preexisting prototypes of illness. These prototypes are based on ones past illness history as well as on external information. Comparing this preexisting information to the current symptoms serves to form the prototypes, commonly referred to as illness representations. Research has identified several main components of these representations, including the identity of the health threat, its causes, timeline, and consequences, and the degree of controllability/curability. In the second stage of the self-regulation process, illness representations guide ones coping strategies. These include strategies aimed at coping with the stressor, as it is perceived by the person, and strategies addressing its emotional representation. The third stage involves ones appraisal of the outcomes of these coping efforts. The results of the appraisal guide
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future actions. If the outcomes are as expected, this serves to confirm the initial representations and the choice of coping strategies based on them. If the outcome is unsatisfactory, this can lead one to change ones initial representations and correspondingly ones coping strategies, or, alternatively, to retain the initial representation but change the way of coping. Thus, the model delineates a dynamic process and the initial representation is more of a working cognition that is reevaluated over time. Another proposition of the CSM is related to its hierarchical nature. The model argues that there are higher-level, abstract representations and corresponding coping strategies, and lower-level, concrete representations as well as specific coping tactics. For example, at the abstract level, cancer worries can lead to greater attention to bodily changes while at the concrete level, the identification of a specific symptom can lead one to seek care (Benyamini, McClain, Leventhal, & Leventhal, 2003). A general coping strategy (vigilance about health) could further translate into different coping procedures (checking your body, contacting the doctor). In sum, the self-regulation process takes place over time and between levels, in both top-down and bottom-up directions. The CSM was proposed as a universal, generic model of the self-regulation of health threats: The self-regulation process should be similar for all individuals, only the content differs among individuals. For example, the same general process should be evident for an older man coping with an enlarged prostate or a middle-aged woman coping with menstrual irregularities. The content would differ at three levels: first, at the level of the stressor itself. Perceptions of an enlarged prostate would differ from those of menstrual irregularities. Second, the self-regulation process is embedded within the self and, thus, is affected by personality dispositions and interacts with ones self-system and selfidentity. Third, the self-regulation process, similar to the wider self-system, is embedded in a social and cultural context. Societal values and cultural meanings ascribed to menopause, for example, would also affect the representations and coping procedures shown by different persons. The theoretical CSM acknowledges these wider circles in which the self-regulation process takes place (Leventhal, Weinman, Leventhal, & Phillips, 2008). However, in practice, the personal and the social-cultural levels, and their effects on the self-regulation process, have not been investigated with the same frequency and depth as the intraindividual process leading from representations to coping to outcomes. This review will focus on the role of personal and social characteristics that are specific to coping with womens health issues. Understanding how gender impacts on each component of the CSM and on the relationships between them can help identify questions that are specific to womens self-regulation. Such questions involve the types of information that serve as a basis for womens illness representations and the rules women use to evaluate this information and incorporate it into their representations. Another expected outcome of a gendered view of self-regulation is uncovering the assumptions women and
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healthcare providers use, often without awareness, when engaging in self-regulation and in the understanding of the self-regulation of womens health. Gender has not been altogether ignored in studies of the representation of, and coping with, health threats. However, studies have varied in the extent to which they attended to issues that are specific to women. There are studies that acknowledge the potential effect of gender by reporting gender differences or controlling for gender in multivariate models (e.g., Fortune, Richards, Griffiths, & Main, 2002). This is insufficient as a way to uncover unique aspects of womens experience of stress and coping because it overlooks the possibility that gender interacts with some of the factors in the model. On the other hand, there are studies that have focused on deep understanding of the stressors involved in coping with specific womens health problems (e.g., Huntington & Gilmour, 2005). These studies provide a wealth of information but principles regarding coping with womens health, which could be generalized beyond the specific stressors, are not always highlighted. Both types of studies provide evidence suggesting that a special focus on womens health issues is needed. The current review aims to provide such focus within a wide theoretical framework that extends beyond specific health threats.

Why Do We Need a Gendered View of Self-Regulation?

There are two main types of gender differences, which call for a gendered view of the self-regulation process: biological and social differences. First, women cope with a variety of gynecological problems that are unique to them; women are more likely to cope with invisible or unexplained diseases and symptoms; and even for diseases that are common in both genders, women often experience them differently (e.g., heart disease). These differences result in unique needs of women compared to men coping with similar stressors (Vazquez, Gibson, & Kustra, 2007). Second, social norms and gender roles prescribe different expectations from women and men and, thus, provide a different context for the self-regulation process (e.g., OLeary, 1999). More women than men are poor and uneducated and these differences result in a qualitatively, not only quantitatively, different context for coping (Walters & Charles, 1997), which cannot be sufficiently understood by simply adjusting for indicators of socioeconomic status. Womens coping with stressful health events could differ from mens because of each of these types of factors biological and social as well as the interaction between them: Different symptoms or diseases experienced within a different social context, which yields gender-based expectations, could lead to greater differences than are accounted for by the biological or social factors separately (Hader, Smith, Moore, & Holmberg, 2001).
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What Is the Stressor?

The CSM can be useful only if one understands its focus on situation-specific characteristics. This focus begins with the subjective definition of the stressor itself, even before one attends to specific components of its representation. For example, many studies have investigated how women cope with involuntary infertility. This implies that there is a common stressor, the inability to conceive, and a variety of ways of coping with it. However, a closer look at the difficulties with which these women are coping showed great interindividual variability in the nature of the stressor, at the abstract and the concrete levels. At the abstract level, even within the same culture, the common stressor can be perceived very differently by different women (Haelyon, 2006). At the concrete daily-life level, the general common stressor breaks down into a large number of specific stressors (e.g., lack of control over the future, social and family pressures) that greatly vary among women (Benyamini, Gozlan, & Kokia, 2005). Thus, one cannot assume that coping with infertility involves a single main stressor or even a list of common stressors. This is probably just as true of other health threats (including mens) but is especially salient with infertility because it is a complex stressor that involves personal, couple, family, social, and ethical issues. Another example of assumptions about a stressor was highlighted by Meyerowitz and Hart (1996) in their analysis of research about women and cancer. They argued that women with breast cancer have been especially targeted for research, as compared with women with cancers in other sites, and that this bias cannot be fully explained by differences in survival and incidence rates among different types of cancer. They proposed that the bias results from an assumption that the breast is so central to womanhood that any assault to the breast will destroy womens psychological integrity. This is in contrast with evidence that breast cancer is no more devastating to women than other cancers (Mendelsohn, 1990). In terms of the CSM, this again emphasizes that we should not make general assumptions about the nature of the specific stressor, for example, loss of a breast with its impact on self and feminine identity versus uncertainty about the future and its impact on life in the present. Such assumptions about the meaning of cancer in the breast may have contributed to the rapid developments in breast reconstructive surgery that are being followed by much slower recognition that this solution is satisfactory for many but not for all eligible breast cancer patients. A recent review found overall good levels of satisfaction with breast reconstruction (Guyomard, Leinster, & Wilkinson, 2007) yet recent studies (not included in that review) have provided evidence that such surgery does not always stand up to womens expectations of it (e.g., Crompvoets, 2006). Thus, clinicians and researchers should be careful not to base their definitions of a stressor on untested generalized assumptions but rather to recognize the extent of variability among patients in these definitions and strive for an under 2009 Hogrefe & Huber Publishers

standing of each patients definition of the specific stressor with which s/he is coping.

How Do Individuals Represent the Health Threat?

The CSM proposes that individuals form cognitive representations of the stressor (the first stage of the self-regulation process). The definition of the stressor, discussed above, could be construed as part of the cognitive representation but it is at a more general level compared to specific components of the representation, i.e., the identity, causes, timeline, consequences, and controllability of the health threat (Leventhal et al., 1997). Understanding the identity and causes of symptoms is crucial to patients seeking appropriate care and to the provision of such care. Examples from four disease categories that are important from a womens health perspective will be discussed: (a) interpreting cardiac symptoms, (b) diagnosing diseases with apparently psychiatric symptoms, (c) making sense of invisible and unexplained symptoms, and (d) medical barriers to becoming a parent.

Interpreting Cardiac Symptoms

The evidence on gender differences in the self-regulation of seeking cardiac health care has been reviewed by Martin and Suls (2003), who showed that gender stereotypes of cardiac disease might be an important factor in explaining the greater delay in seeking care among women, compared to men. The prototypical heart disease patient is a middleaged man, with several risk factors (sedentary, smoking, obese), who is experiencing acute chest pain. Many women judge their experience to be quite different and, therefore, are late in realizing that they may be having a heart attack (Schoenberg, Peters, & Drew, 2003). Similarly, healthcare providers are also affected by their prototypes of diseases and gender stereotypes, which may be one reason that women are less likely to be referred to cardiac procedures (Shaw et al., 2004). Previous research based on the CSM has identified several heuristics that people use as rules to determine the nature of a symptom (Leventhal et al., 1997). These rules can explain womens misperception of cardiac symptoms: (1) the symmetry rule people attempt to connect somatic experiences with labels. Women do not ignore their symptoms but because they often experience heart disease not with severe chest pain but with vague pains and discomfort, their first tentative label is indigestion or other noncardiac labels (Albarran, Clarke, & Crawford, 2007); (2) the ageillness rule as people age, they tend to attribute milder symptoms to aging processes. Since women are afflicted with heart disease on average at a higher age than men, they
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are more likely to experience cardiac symptoms along with other bodily changes. It may be more difficult to discern these symptoms from other changes and, therefore, easier to attribute them to age; and (3) the stress-illness rule in the presence of a recent stressor, new symptoms are often attributed to stress (Cameron, Leventhal, & Leventhal, 1995). Women with heart disease are likely to be older and, therefore, are less likely to be experiencing work stress; however, they are more likely to be coping with family caregiving demands, which could continuously provide new stressors. This makes it easier to attribute symptoms to the stressor and not seek care.

Diagnosing Diseases with Apparently Psychiatric Symptoms

A second type of misperception results from the higher prevalence of mental health problems among women. It relates to physical disorders with symptoms that could be mistaken as psychiatric (e.g., endocrinological disorder, lupus). Not surprisingly, a psychological misattribution is more often made by both female patients with symptoms of these diseases and by their physicians (Klonoff & Landrine, 1997).

Making Sense of Invisible and Unexplained Symptoms

Invisible diseases, such as pain and unexplained symptoms, tend to be more prevalent among women. In these diseases, the subjective experience often does not correspond with objective examinations (e.g., back pain; Lillrank, 2003). Moreover, the main explanation for gender differences in pain is not biological but in terms of gender disparities in life circumstances (Bingefors & Isacson, 2004). All this makes diagnosis difficult and often leaves women feeling misunderstood and disrespected because healthcare providers discount the seriousness of their symptoms or blame the victim. Such attitudes prolong the time to diagnosis and exacerbate womens distress (e.g., Huntington & Gilmour, 2005; Lillrank, 2003). Many of these chronic conditions change from day to day and, thus, make it difficult to form a coherent illness representation, another core issue in the CSM (Leventhal et al., 2008). Though men strive just as much to make sense of their illnesses, class and female gender are especially likely to combine with unpredictable ill health to create a sense of powerlessness (Walters & Charles, 1997).

threats to life or to independent functioning, threats to the attainment of parenthood seem to be more serious among women (van Balen & Trimbos-Kemper, 1995). Therefore, not surprisingly, women perceive infertility more negatively than their partners (Benyamini, Gozlan, & Kokia, 2009). This can reflect the social norms of pronatalist societies (societies in which childbearing is highly valued), where womens self and feminine identity is much more dependent on their becoming mothers, compared with the importance of fatherhood for mens self and masculine identity. In sum, womens representations of their symptoms and medical conditions, as well as healthcare providers representations, could differ from representations of mens conditions in the content on which they could be based (e.g., different somatic experiences) or in the content on which they are actually based (e.g., because of the salience of certain experiences and interpretations, because of the priming effect of prior knowledge and experience). The latter type reflects differences in the decision rules applied to the content or in the cut-off points used for these rules (e.g., is attribution to agerelated changes performed more easily by women in midlife because of the prominence of the menopause in their perceptions of bodily changes? Do women more readily attribute symptoms to stress?). The decision rules and cut-off points applied are influenced by gender stereotypes of diseases and patients. These stereotypes stem from biological differences in the expression of diseases, from social norms and gender stereotypes, and from the interactions between them. Therefore, research in this area should strive to ensure that the assessment of illness representations is sensitive to womens experiences of medical conditions.

Coping with Health Threats

The CSM proposes that the second stage of the self-regulation process involves coping with the health threat. A review of the literature on gender differences in coping is beyond the current focus and has been dealt with elsewhere (e.g., Matud, 2004). The self-regulation perspective focuses on the relationships between illness representations and coping, which have been documented in many patient populations (see meta-analysis by Hagger & Orbell, 2003). For the purpose of the current review, the most important issue is whether gender moderates these relationships and this has rarely been studied (for an exception, see Kelly, Sereika, Battista, & Brown, 2007). Specifically for womens health issues, it is important: (1) to highlight unique aspects of the relationships between representations and coping procedures and (2) where such relationships were not found, to discuss possible reasons for their absence. The simplest, most obvious, gendered view of the relationship between representations and coping procedures would be that where representations differ between women and men, coping would also differ. For example, womens greater tendency to attribute cardiovascular disease to
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Barriers to Becoming a Parent

Similar to other medical conditions, infertility and miscarriages pose a serious threat to ones ability to achieve life goals. However, in contrast with other threats, such as
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causes beyond their control (Grace et al., 2005), may be one explanation for their lower attendance at cardiac rehabilitation programs (Scott, Ben-Or, & Allen, 2002). Similarly, if mass media leads women to feel vulnerable to breast cancer (Clarke, 2004), they would be more likely to take measures for early detection of this type of cancer while ignoring the detection of more prevalent causes of death. However, different representations or attitudes could still lead to similar ways of coping: For example, womens self-regulation of hypertension was more strongly affected by perceived social norms whereas mens was affected by their attitudes (Taylor, Bagozzi, & Gaither, 2001). A fuller understanding of the relationship between representations and coping with womens health issues requires attention to the CSM hierarchical view of self-regulation. For example, women undergoing infertility treatments reported stressors related to their identity and life goals as well as concrete stressors related to work relationships and technical aspects of treatment (Benyamini et al., 2005). Correspondingly, a study of womens coping with infertility identified a cluster of strategies related to accepting and understanding the problem as well as a cluster of strategies related to its practical daily management (Benyamini, Gefen-Bardarian et al., 2008). Each cluster further breaks down into specific strategies and tactics. This hierarchical structure of representations and coping would be expected regardless of gender. However, women also react to the threat to their self and gender identity in unique ways, such as self-nurturing or the opposite strategy of self-neglect (Benyamini, Gefen-Bardarian et al., 2008). This is in line with arguments that generic approaches of coping do not sufficiently attend to the context (Coyne & Gottlieb, 1996). The importance of the fit between coping and context has been emphasized by the goodness-of-fit principle. It proposes that problem-focused coping fits controllable situations and emotion-focused coping fits uncontrollable ones (Folkman, Schaefer, & Lazarus, 1979). This general principle does not cover the entire range of strategies that could be effective for coping with uncontrollable stressors, as shown by Terry and Hynes (1998), who studied women coping with infertility treatments and found that one needs to further break down these two general coping approaches. A meta-analysis showed gender differences in the use of coping strategies that fall within these broad categories for coping with infertility, and explained this mainly in terms of womens and mens different construals and experiences of infertility (Jordan & Revenson, 1999).

The Lack of a Relationship Between Representations and Coping

We often find evidence that contradicts the expectation for a simple logical relationship between representations and coping procedures. First, women are generally poorer and poverty restricts the range of actions available to people
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and often leads women to ignore their own health needs (Givaudan, Pick, Poortinga, Fuertes, & Gold, 2005; ONeill & Morrow, 2001). Moreover, in many traditional cultures, women are more likely to be subjected to strict societal regulations that deprive them of full control over their own bodies and, thus, hamper their ability to protect themselves from sexually transmitted diseases (OLeary, 1999). This also decreases the likelihood that they will attend regular gynecological check-ups or cervical cancer screening, possibly because they do not have access to female healthcare providers (e.g., Benyamini, Blumstein, Boyko, & Lerner-Geva, 2008) or because their husbands disapprove of such procedures (Givaudan et al., 2005). Thus, forming representations that logically lead to effective coping strategies does not ensure that all women can exercise these behaviors. Second, many women are supposedly free to carry out the coping strategies that would be most effective in preserving their health, yet choose not to do so because of perceived social pressures. Is it possible that women find it harder to disengage from various goals, such as caregiving, even when the price for their health and well-being becomes excessive, because these goals are set by social expectations? This possibility is supported by evidence showing that women caregivers tend to provide more personal, intensive care (Navaie-Waliser, Spriggs, & Feldman, 2002) whereas men are more likely to serve as care-managers who incorporate extra-household assistance in caregiving (Stoller, 1992). Another example can be seen among individuals recovering from coronary bypass surgery: Women tend to return to their domestic chores faster than men do because they use their symptoms as a guide for their activity level whereas men are more likely to adhere to medical recommendations to disengage from certain tasks (Hawthorne, 1993). Third, the medicalization of many obstetric and gynecological issues has placed more power in the hands of physicians in what used to be female-dominated areas (e.g., birth, menopause). This creates problems, particularly in cultures where most physicians are male and womens behaviors are governed by strict cultural norms (Uskul & Ahmad, 2003). Women who do not adhere to medical recommendations are likely to be perceived by healthcare providers as needing monitoring and sanctioning (Todorova, Baban, Balabanova, Panayotova, & Bradley, 2006). Therefore, women often give up their right to fully informed and active choice and instead choose compliance out of social pressure (Nicol, 2007) or as a pragmatic strategy to ensure a more positive treatment outcome (Tanassi, 2004). Fourth, women are better at recruiting social support (Antonucci, 1990) and benefiting from their social environment (Blumstein et al., 2004). Although this places women at an advantage in terms of their ability to cope with stress, it is not without cost: Women are also more sensitive than men to stressors affecting members of their network, which affect their psychological well-being and their general perceptions of health (Benyamini, Leventhal, & Leventhal,
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2000) and women are subjected to social control that can undermine attempts to refrain from harmful health behaviors (Westmaas, Wild, & Ferrence, 2002). Even when ill, such as after a heart attack, they attempt to minimize the severity of their symptoms, possibly as a way to cope and to protect others, and they seem to support others more than they receive support (Kristofferzon, Lofmark, & Carlsson, 2003; White, Hunter, & Holttum, 2007). Women seem to help their husbands change lifestyle habits but receive much less support, or do not demand it, when they need to manage a chronic disease (e.g., Emslie, 2005). In sum, womens and mens illness representations guide their choice of coping procedures. Different representations of the same health threat could lead women and men to choose different coping strategies. In addition, their ability to carry out the most effective coping strategies may be differentially affected by social and cultural constraints, leading to even greater differences in coping, which could only be identified and understood within the relevant context.

and progress? To what extent is this choice affected by social norms and expectations, which would then lead to gender differences? For example, are women more likely than men to use external criteria, or, alternatively, to appraise their situation in relation to multiple standards, such as the effect of illness on themselves as well as on their family? Future research may identify the heuristics underlying the appraisal process and investigate possible gender differences in these heuristics and their application.

What About the Self-Regulation of Stress and Coping with Mens Health Issues?
Paradoxically, there is even less knowledge about self-regulation processes that is specific to men. Much of the research on self-regulation of health threats was conducted on male samples or has implicitly assumed that findings from mixed-gender samples apply to men and women alike. Since the 1990s, a rising emphasis on womens health problems has resulted in many studies on female samples. However, stereotypes of men and masculinity could interact with actual experiences of health problems to create unique ways of representing a health threat, coping with it, and appraising the outcome, similar to the examples discussed above for women. Many illnesses have different manifestations among men (e.g., depression) and have gender-biased stereotypes (e.g., migraine; Kempner, 2006) that could lead to different rates of care-seeking and diagnosis. Men with breast cancer tend to be diagnosed at an older age than women and with later stage disease (Giordano, 2005). This is the mirror image of the findings on heart disease among women, since breast cancer in men is relatively rare and goes largely unnoticed. Mens ways of coping are no less constrained by social pressures; it is the type of pressures that go with expectations from masculinity that differs from those for femininity (Lee & Owens, 2002). Most prominent is mens difficulty in help-seeking (Addis & Mahalik, 2003). Finally, men also cope with losses that could have an impact on self and gender identity, such as prostatectomy-induced impotence (Oliffe, 2005).

The Final Stage of the Self-Regulation Process: Appraisal of the Outcomes

The appraisal stage is the most understudied part of the self-regulation model. Appraisal is an intraindividual process, in which physical and emotional outcomes are assessed against a reference value. In practice, most studies have operationalized this final stage of the CSM by assessing outcomes (Hagger & Orbell, 2003) and have, thus, measured the outcomes of the coping efforts and not peoples evaluation of these outcomes. The distinction between observed outcomes and ones appraisal of the outcomes could be important. For example, a study of teenagers with chronic diseases suggests that womens seemingly greater adaptability to disease could sometimes result from their greater ability to incorporate the disease into their lives and identities, at the cost of feeling less control and having lower expectations of themselves (Williams, 2000). Additionally, women sometimes encounter external social pressures to appraise their situation more favorably even though this does not correspond with their feelings. This is likely to occur with womens health issues that involve loss (e.g., of a fetus, a breast, or a uterus). Recovery could be a prolonged process, which is in contrast with the social expectations from women to bounce back quickly to their usual existence (Gerber-Epstein, Leichtentritt, & Benyamini, 2009). In sum, appraisal processes also take place in the context of ones life circumstances but research to date has yielded very little knowledge of this stage. The main challenge is to identify the rules people use: How do they choose the reference level? What are the rules they use to determine whether they are doing better or worse than expected? Do they use internal or external criteria to judge their status
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Conclusions and Implications

The Importance of a Focus on Coping with Womens Health From a Wide Theoretical Perspective
Research on womens health in the last two decades has been greatly influenced by womens movements. However, in many instances this has not widened our focus but, rath 2009 Hogrefe & Huber Publishers

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er, has resulted in the substitution of one narrow perspective for another and/or in much deeper understanding of the self-regulation of specific health issues, without further theoretical conceptualization. Even for heart disease, where it is clear that there are gender differences in the presentation of the illness and in its prototype, there is still insufficient gender focus in the literature (Emslie, 2005).

Is it Gender or Gender Roles?

In a general population cohort, men with higher femininity scores were at lower risk of death from coronary heart disease in the next 17 years (Hunt, Lewars, Emslie, & Batty, 2007). In a sample of women and men who had suffered a heart attack 6 months earlier, higher levels of masculinity were associated with better health status for both women and men (Radley, Grove, Wright, & Thurston, 2000). Such findings raise the intriguing possibility that it is not gender but rather gender-role and its interactions with biological differences that affect coping and health outcomes. Future research should explore this possibility.

Questions for Future Research

The current review emphasized the ways in which the CSM could guide future research on the self-regulation of coping with womens health issues: How do women define the stressor and how much variability is there among women in their definitions? Do differences between women and men in their judgment of stressors and the cognitive and emotional representations they form arise from differences in their actual experience or in the heuristics and decision rules applied to these experiences? Do womens and mens coping strategies differ because of initially different representations, which lead to different ways of coping, or because the relationships between representations and coping differ for the two genders? Finally, after taking various measures to cope with a stressful health condition, what rules and context do women use to appraise their current status (and are they different, or applied differently, in comparison to men)?

What Are the Implications for Interventions?

The CSM has already proven to be a fruitful basis for planning effective interventions (Petrie, Cameron, Ellis, Buick, & Weinman, 2002). Answers to the questions above could enable us to construct even more effective interventions, which take into account specific issues that concern women (or men) as they cope with stressful health conditions (e.g., Clark et al., 2007). The CSM argues that the more we plan our interventions to fit peoples representations of the health threat, the greater the chances that they will be effective. Though in large-scale interventions it is not always feasible to tailor interventions to persons, we should at least aim to adapt them to major distinctions such as gender. In sum, from a self-regulatory approach, our interest should be how to enable women, men, and healthcare providers to form accurate representations of health threats that would serve as adequate guides to coping with these threats and lead to optimal outcomes. Any gender-related factor that biases the formation of these representations, distorts their relationship with coping, or limits the ability to cope in optimal ways, should be identified and measures should be taken to diminish its effects.

Does a Focus on Gender Result in an Oversimplified View?

It is important to note that in order to present existing evidence on the self-regulation of womens health issues and the open issues on which future research could focus, this review has at times presented an oversimplified picture of the differences between women and men. The full picture includes many similarities between women and men as well as many differences within each gender group in their self-regulation of health threats. Gender is only one aspect of the great diversity among people and their life circumstances, which affects their ways of coping with stress. Studying it alone in a decontextualized way would deprive us of the ability to understand the interactions between gender and a variety of additional characteristics, such as age, cohort, culture, class, and more. However, it is also clear that studying womens health within their context poses practical challenges regarding how to operationalize and study the many factors that could affect womens coping with health threats (Hunt, 2002). Thus, one must find the optimal path between an overly simplistic view of gender differences and a highly contextualized and personalized view of the diversity among individuals in their experiences of the self-regulation of stressful health threats. Gender could be a starting point to which one could add factors that possibly interact with it or explain the diversity within gender groups.
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About the author Yael Benyamini, PhD, is a health psychologist and senior lecturer at the Bob Shapell School of Social Work at the Tel Aviv University, Israel. Her research interests lie in global perceptions of health as well as perceptions of specific health threats, with a special focus on womens health issues.

Yael Benyamini Bob Shapell School of Social Work Tel Aviv University Tel Aviv 69978 Israel Tel. +972 3 640-9075 Fax +972 3 640-9182 E-mail benyael@post.tau.ac.il

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European Psychologist 2009; Vol. 14(1):6371