Facets of Medicine (7)
By William Wetherall
A Japanese version of this article appeared in
Kokutai, 16(9), October 1995, pages 160-161
Bureaucrats classify populations according to four sub-categories of "marital status": never married, married, divorced, and widowed. These sub-categories reflect the legal concerns of governments in their efforts to regulate family relationships. They do not, unfortunately, shed light on the physical or emotional content of these relationships.
In the Japan, the Ministry of Health and Welfare compiles annual statistics on morbidity and mortality by marital status, sex, and age group. However, it publishes such data only for national census years, or every five years.
Before looking closer at the limitations of "marital status" data, let's look at how death rates vary by marital status. In general, rates of illness, and rates of death due to illness, are higher for the never married, and even for the divorced and widowed, than for the married. So married people live longer, basically because they are less lonely and suffer less stress. Though suicide is not an illness, differences in suicide mortality by marital status exemplify these patterns. In general, for adults of both sexes, suicide rates are very low for people who are married, and are two, three, five, ten, twenty times higher for people who never marry, or are divorced or widowed. But the risks are comparatively higher for men, than for women, who never marry, or have lost their spouse through divorce or death.
For young adults in their twenties and thirties, having never married, or being divorced or widowed, increases the risk of suicide, compared with those who are married, by multiples of four to fifteen, depending on sex and age group. The multiples are generally much higher for men. However, for young adults, unlike older adults, being divorced or widowed are bigger factors in suicide risk than having never married.
Suicide rates increase with age for both sexes, and the increase accelerates in the older age groups. And with increasing age, the relationship between the suicide risks for the four categories of "marital status" somewhat change.
For older adults, in their forties and above, having never married overtakes being divorced or widowed as the greatest contributor to suicide risk. And the relative increase in the suicide risk for never married middle-aged and elderly men, compared to the increase in the risk for married men, is generally much greater than the corresponding increase for women. In other words, the risk of suicide among never married older people accelerates faster with age for men than it does for women.
Older women are not married are roughly twice as vulnerable to suicide than older women who are married. But older men who are not married are roughly four times the suicide risk of married older men.
Comparing just the experience of being divorced or widowed, older men tend to be more suicidal when widowed, while older women are more inclined to kill themselves when divorced. But for both sexes of older people, having never been married is from two to three times as risky as either separation through divorce or death.
Boys and girls in their teens show slightly different patterns. Teenage boys, like adult men, are also less likely to commit suicide if they are married. But marriage may slightly increase the risk of suicide among teenage girls. Suicide associated with teen divorce is rare, but widowed teenage girls are five times more likely to kill themselves than girls in other categories of marital status.
In summary, the above profiles of suicide risk by marital status clearly show that being married helps stabilize adult life for both men and women. However, they also suggest that men are more dependent on marriage than women.
At certain stages in their life cycle most married women may be more economically dependent on their husbands. At the same time, women are probably less socially or emotionally dependent on marriage, and hence they may suffer more stress in marriage.
While separation through divorce or death increases suicide risk for both men and women, more women than men may benefit from divorce or widowhood. Once divorcee or widow copes with the trauma of her loss, she may find that her loss is actually a gain of independence from the stress of caring for a dependent husband. Whereas life for a dependent married man becomes more stressful after divorce or death of his wife because he is unable to care for himself, or for small children.
The above observations concern suicide, but similar correlations are found between a person's marital and other social relationships and vulnerability to illness and even accidents. This raises all kinds of chicken-and-egg questions.
For example, do people who never marry have higher morbidity and mortality rates because they never marry? Or do they remain unmarried because they are physically and mentally less healthy, hence socially less desirable?
Such questions have no simple answer, because some very healthy people remain unmarried by choice, while some very unhealthy people manage to find someone who is willing to marry them. Obviously, all kinds of selective factors determine who marries whom, from class and caste to wealth and status, not to mention appearance and personality.
More important to studies of the connection between health and social relationships, however, are the "alternatives" to marriage that are rapidly evolving. The chicken-and-egg problems remain, but our focus here is on correlations of illness and death with the content of one's relationships, not how one came into these relationships.
The word "relationship" implies some connection between two or more people. There are many kinds of relationships--parent-child, teacher-student, ruler-subject, friend-enemy, and such, ad infinitum. But here I would like to focus on the kinds of relationships that may have an impact on the patterns of illness and death.
The observations made possible by "marital status" statistics are useful enough, if all we want to know is the connection between physical and mental health and "marriage" as a bureaucratic legal phenomenon. But such "official" data is difficult to interpret for two reasons.
One, the four conventional sub-categories of "marital status" say little about the physical, social, and emotional content of the actual relationships in the lives of the people being classified. A marriage could be an emotionally nurturing relationship. Or it could be a living hell involving "emotional divorce" or "domestic violence".
Two, actual relationships are changing in many ways that are challenging the meanings of the legal institution of marriage. Men and women are marrying later, but they are also dating more freely, having sex, and cohabiting before marriage. At the same time, more men and women are choosing to remain legally single. And more of these "single" people are living together out of marriage and even having children. And in doing so they are enjoying the same benefits (or suffering the same hazards) of married life as couples who are legally married.
There is a lot of concern about people who live alone. But even people who live alone may have healthier relationships than people who live with others. The main factor in health may be the amount and quality of contact that a person has with others.
A study at Yale by Berman and Saim showed that regardless of sex, age, status, or wealth, the fewer friends and social contacts people had, the higher their death rates. They also found that people with fewer social contacts smoked more and were more obese.