Stereotypes About Single People Can Influence Cancer Treatment

A new report highlights how physician’s assumptions can impede care

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Is being single hazardous to your health? When it comes to having cancer, it certainly seems to be: Unmarried people are more likely to die of the disease than their married counterparts, for reasons that have never been clearly understood.

For decades, medical researchers attempting to account for this phenomenon have resorted to harsh clichés. Some have argued that singles, on the whole, have less to live for. Others opined that they lacked the required “fighting spirit,” a curious phrase that crops up in several studies.

But a new peer-reviewed article in The New England Journal of Medicine offers a very different explanation. It reports that unmarried people are less likely than people who are married to receive aggressive cancer treatments that are proven most effective, like surgery and radiation therapy. One major reason for this, according to the paper, is that doctors assume single people don’t have the necessary social support to endure the often -debilitating side effects that come from such treatments.

“We live in a culture that is very couples-centered,” says Joan DelFattore, the author of the study and a professor emerita of English and legal studies at the University of Delaware. DelFattore experienced singleton discrimination firsthand when she underwent cancer treatment in 2011.

“He got totally hung up on my not having a husband and children. He kept asking, ‘How will you manage?’ In his mind, a woman without a husband and children didn’t have support.”

The never-married professor was diagnosed with Stage 4 gallbladder cancer that had spread to her liver. DelFattore’s surgeon agreed to operate despite her low odds of survival. “I knew he was pushing the envelope regarding whether surgery was warranted,” she says.

But the oncologist she saw for follow-up treatment after her successful surgery had a different attitude. “He got totally hung up on my not having a husband and children,” she says. “He kept harping on it, asking, ‘How will you manage?’ In his mind, a woman without a husband and children didn’t have support.”

DelFattore says the oncologist advised her against the aggressive approach to battling the disease, offering a milder but less-effective regimen. DelFattore instead went to another oncologist, who felt her support system was perfectly adequate and prescribed her the more aggressive treatment she desired.

Once DelFattore recovered from surgery, her original oncologist’s stubbornness “started to nag” on her, which inspired her to do some research. She found 84 articles dating back to 1987 that looked at the relationship between marital status and cancer, and she picked up on a pernicious pattern. As DelFattore writes in her journal article, unmarried patients “are significantly less likely to undergo surgery or radiotherapy when those are the treatments of choice.”

She further found that while this tendency “is often attributed to patient preference,” a large study of more than 925,000 people by researchers at Harvard, M.D. Anderson, the Mayo Clinic, and elsewhere reported that less than 1% of unmarried people with cancer declined physician-recommended surgery, and less than 2% declined physician-recommended radiation therapy. Based on those low numbers, it’s then reasonable, DelFattore argues, that single people with cancer are following doctor’s advice and physicians’ implicit beliefs influence what they are recommending to unmarried people.

The effect this bias has on medical decision-making was shown in another recent study. Tufts University researchers Satia Marotta and Keren Ladin report that when 1,200 people were asked to provide their opinion of whether an accident victim needed a kidney transplant, “divorced patients were perceived as having less durable and adequate social support than those who were married to their caregivers.”

Tellingly, divorced people “were also perceived as less deserving of a transplant, and were less likely to be recommended for transplant wait-listing,” the researchers report in the journal Group Processes and Intergroup Relations. These results suggest that the bias DelFattore experienced may not solely be limited to people with cancer.

Dr. Jonathan Metzl, MD, PhD, director of the Center for Medicine, Health, and Society at Vanderbilt University, says he is unsurprised by the findings. “There is a tradition in medicine going back to the 1950s, which is this assumption that a married, heterosexual person is the norm — the healthy ideal,” he says. “That’s a societal bias. There’s an assumption that single people don’t have the same social support, when very often that’s not the case.”

The stereotype permeates our culture as well, says Bella DePaulo, PhD, a research psychologist affiliated with the University of California, Santa Barbara, who has studied bias against single people. “[The bias] is in popular culture, including TV shows, movies, novels, song lyrics, and even children’s books,” she says. “Single people are depicted as lonely and sad; protagonists aspire to become coupled and then married. That’s what’s valued and celebrated.”

“The irony of the assumption that single people don’t have anyone is that dozens of studies show that, in important ways, just the opposite is true,” DePaulo adds. “Single people have more friends and bigger social networks than most married people do.”

DePaulo says this puts them at an advantage over seriously ill people who are totally dependent upon a spouse. “With a network of potential helpers, different people can help at different times,” she says. “Any one person is less likely to feel burned out.”

DelFattore argues that medical institutions can and should do a better job in making the next generation of doctors aware of these unconscious assumptions. “Medical schools already have courses on bias, which tend to focus on race, sex, and sexual orientation,” she says. “I’m arguing that bias about marital arrangements needs to be in there.”

Her original oncologist “honestly thought he was doing me the right thing by sparing me this treatment he thought I couldn’t handle,” DelFattore says. But if good intentions are founded on unexamined prejudices, they could be deadly.