In Doing Harm, Maya Dusenbery describes a breast cancer patient “who wanted a mastectomy but whose doctor objected, saying, ‘But you aren’t married.'” Similarly, Abby Norman writes in Ask Me About My Uterus that doctors limited her endometriosis treatment in accord with their belief, which she did not share, that avoiding any possible threat to her (presumed) future marriage and motherhood took precedence over relieving her debilitating pain and sexual dysfunction.
Although these books focus on sexism, they also reveal the stereotyping and stigmatization of uncoupled adults that Bella DePaulo has named singlism. The stories above, for instance, illustrate the outdated belief that almost all single people want to marry and will eventually do so. By contrast, a 2017 survey by the Pew Research Center shows that only 23 percent of previously married adults, and 58 percent of those who never married, expressed a desire to marry. These results are consistent with multiple studies demonstrating that a substantial proportion of never-married adults do not want to marry, and even more divorced and widowed individuals do not want to re-marry.
Like all human decision-makers, even the most dedicated medical professionals are subject to the influence of beliefs that are often repeated, rarely challenged, and factually incorrect. For that reason, unmarried status, especially if a patient lives alone, may evoke a stereotype of isolation and insufficient support, perhaps exacerbated by such factors as depression, poverty, and mental illness. To be sure, that description does fit some unmarried patients — as well as some married patients — and that subset would indeed have exceptional difficulty in handling a serious illness. But that cannot be true of almost half the adult population, and according to the U.S. census bureau, more than 110 million adults are divorced, widowed, or never married, out of 252 million over the age of eighteen. Moreover, the typical adult spends more years unmarried than married, and more than 35 million live alone. As sociologist Eric Klinenberg observes in Going Solo, “For the first time in human history, great numbers of people — at all ages, in all places, of every political persuasion — have begun settling down as singletons,” often as a voluntary and fulfilling choice.
For those single individuals who do enjoy sufficient financial, emotional, and social resources, the cost of being viewed through the lens of an outdated stereotype can be high, particularly when it impedes access to optimal treatment. In the TEDx talk at the sidebar of this article, Joan DelFattore describes an oncologist who, on learning that she has neither a partner nor children, proposed to use only one mild drug rather than more challenging, and effective, combination chemotherapy. When she tried to describe her strong network of friends and extended family, he interrupted and changed the subject. And yet, multiple studies have shown that binaries like married/unmarried reveal little about the implications of social support for health outcomes, compared with the more robust results of multidimensional measures. And far from being isolated, single people on average have more friends than married people do, and they do more to stay in touch with, and to support, friends, neighbors, siblings, and parents.
Unfortunately, the oncologist DelFattore encountered is far from unique. Her review of 59 studies based on the National Cancer Institute’s massive database, SEER, reveals two consistent findings: that currently married patients are more likely to survive cancer, and that they’re more likely to receive surgery or radiotherapy when those are the treatments of choice. To be sure, decisions to withhold treatment are sometimes clinically justified; but the significant disparity in treatment rates associated with marital status, combined with an unrelentingly negative view of unmarried patients, is cause for concern. In particular, despite extensive psychological and sociological research to the contrary, these articles consistently conflate marriage with social support. Since unmarried cancer patients rarely refuse surgery or radiotherapy recommended by physicians, their systematic undertreatment raises the chilling possibility that a narrow understanding of social support may lead to withholding the most effective therapies from patients who could have handled them, and who may die sooner than necessary as a result.
As DePaulo has repeatedly pointed out, cross-sectional comparisons of currently married people to unmarried people, such as those in the SEER-based studies, are often misread to suggest that spouses are doing better because they got married. Perhaps the most obvious flaw in that reasoning is that married people might differ from the unmarried in countless ways, such as financial status, that could contribute to disparities in outcomes. And contrary to the long-standing “get married, get healthy” narrative, longitudinal research shows that people who marry experience no fewer illnesses than when they were single, and are typically no better off or even a bit worse off with respect to overall health.
Not only medical researchers, but also federal lawmakers, overlook the importance of non-spousal connections. Under the Family and Medical Leave Act, for example, employees in eligible workplaces can take unpaid leave to care for a child, parent, or spouse. But unmarried employees cannot take leave to care for their closest connections, such as relatives other than children or intimate friends, and no employee can take leave to care for an unmarried individual except that person’s parent or child. Although state medical leave policies may be more inclusive, close friends, siblings, and extended family members are rarely covered even when they live with the employee and/or have non-sexual relationships just as interdependent as those of conjugal couples. Similar restrictions impede access to affordable healthcare in workplaces where employees can add no one but spouses, domestic partners, and children to an employer-sponsored plan.
Even when federal or state laws do acknowledge the people who matter most to a patient, regardless of marital or family status, deeply ingrained social beliefs may still create difficulties for single patients. The Health Insurance, Portability, and Accountability Act, for instance, upholds the patient’s right to designate who is to receive medical information. But health care workers, either unaware of the law or ignoring it, may nonetheless insist that only immediate family members can be informed.
In some instances, laws and policies that create obstacles for some single patients may also affect married patients whose spouses are unable or unwilling to provide care. Consider, for instance, the legal requirement that patients who may be cognitively impaired after anesthesia must be discharged to a responsible adult, which medical facilities may extend to include some patients who are not impaired. They may also require the companion to remain throughout the visit, and they may exclude paid drivers except for medical transport services which, if available, are often prohibitively expensive. In addition, some medical facilities wait until the evening before a procedure to finalize the arrival time, thus forcing the companion/driver to keep the whole day clear even if needed for only a couple of hours.
Without doubt, such rules, restrictions, and procedures are often necessary, and in the patient’s best interest. But making access to care dependent on having personal caregivers and drivers available on demand ignores not only the growing population of unpartnered individuals, but also the reality that some spouses have health issues of their own, other caregiving responsibilities, or cannot easily take time off from work. Like single adults, some couples, especially those who cannot easily call on adult children or other relatives, would benefit from improvements in the availability and acceptability of friend-based and paid care.
Health psychologists have an important role to play in fostering attitudes and practices that accommodate the way people live today. Among the most important considerations are ensuring that decisions about medical treatment are informed by multiple measures of social support, conducting unbiased research on patients without partners, addressing lifestyle issues in staff training, and promoting equitable policies and services.
Read Dr. DelFattore’s recent article in The Washington Post on singlism in cancer treatment here.
Dr. DelFattore’s TEDx Talk on discrimination experienced by single people in health care.
Dr. DePaulo’s TEDx Talk on the stories that are often told about single people that lead to stereotypes.