Current Psychiatry Reports (2022) 24:831–840

https://doi.org/10.1007/s11920-022-01393-6

SEX AND GENDER ISSUES IN BEHAVIORAL HEALTH (L HANTSOO AND S NAGLE-

YANG, SECTION EDITORS)

Socio‑Ecological Context of Sleep: Gender Differences and Couples’

Relationships as Exemplars
Andrea N. Decker1 · Alexandra R. Fischer1 · Heather E. Gunn1

Accepted: 28 October 2022 / Published online: 19 November 2022

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
Purpose of Review We summarized recent findings on insufficient sleep and insomnia, two prominent sleep issues that impact
public health. We demonstrate the socio-ecologial impact of sleep health with findings on gender and couples’ relationships
as exemplars.
Recent Findings Robust gender differences in sleep duration and insomnia are due to biological and socio-ecological factors.
Gender differences in insufficient sleep vary by country of origin and age whereas gender differences in insomnia reflect
minoritized identities (e.g., sexual, gender). Co-sleeping with a partner is associated with longer sleep and more awaken-
ings. Gender differences and couples’ sleep were affected by intersecting social and societal influences, which supports a
socio-ecological approach to sleep.
Summary Recent and seminal contributions to sleep health highlight the importance of observing individual sleep outcomes
in a socio-ecological context. Novel methodology, such as global measures of sleep health, can inform efforts to improve
sleep and, ultimately, public health.

Keywords Sleep · Health · Gender · Couples · Insomnia

Introduction Observing sleep health through this socio-ecological frame-

work clarifies associations within and among individual and
Sleep health is a key health indicator across affective, car- micro/macro levels of influence. For example, gender differ-
diovascular, endocrinal, immune, and neurodegenerative ences (individual) in sleep health are influenced by family roles
aspects of health [1••, 2]. Several parameters comprise (interpersonal) and policies such as family leave and health
sleep health (e.g., satisfaction, duration, timing). Parameters care (societal). Much of sleep research focuses on the indi-
are independently and collectively associated with physi- vidual level; however, recent work focused on gender, cou-
cal, mental, and neurobehavioral health outcomes [3, 4••, ples, and community and policy highlights the importance of
5]. Poor sleep health is a public health concern [1••, 6, 7]. observing sleep within a socio-ecological framework.
However, dimensions of sleep health are modifiable, which The aim of this article is to review new developments
makes improving sleep health an excellent mechanism for in sleep health research. We limit our review to the adult
improving public health. [1••, 7, 8]. population and to new developments in insufficient sleep
Sleep health is influenced by several factors across indi- and insomnia as these two domains cut across many compo-
vidual, interpersonal, and social/societal domains [1••, 9••]. nents of sleep health and have high public health relevance.
We provide a brief overview of prevalence rates followed
by recent research on individual differences, with a focus
This article is part of the Topical Collection on Sex and Gender
Issues in Behavioral Health on gender, because gender differences in sleep outcomes
begin as early as adolescence [10] and may be influenced by
* Heather E. Gunn social contexts across the lifespan. We then highlight recent
hegunn@ua.edu research that demonstrates how individual differences are
1
Department of Psychology, The University of Alabama, 505
mitigated by social context. In particular, close social con-
Hackberry Lane, Tuscaloosa, AL 35401, USA texts, such as co-sleeping with a partner and relationship

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832 Current Psychiatry Reports (2022) 24:831–840

functioning, are increasingly important to consider in the is associated with increased psychological and behavioral
context of insufficient sleep and insomnia. As such, our over- demands for women, many of which impact sleep [27, 28].
view on insufficient sleep and insomnia includes emergent However, parenting status alone did not explain the gen-
and novel findings on the role of romantic relationships in der difference in nighttime awakenings, indicating multi-
mitigating or exacerbating good sleep health. ple factors of sleep duration. Furthermore, mid-life women
may experience hormonal and physiological symptoms
associated with menopause that contribute to sleep distur-
Insufficient Sleep Duration bances, such as nighttime vasomotor symptoms (e.g., night
sweats) [29]. It is also important to note that these studies
Sleep experts recommend that adults obtain 7–9 h of sleep not only suggest different findings regarding sex differences
per night (7–8 for older adults). About 30–35% of adults in sleep duration, but they also employed different meth-
have insufficient sleep (i.e., less than 7 h; [11, 12]). Preva- ods of assessing sleep duration. While ECG characterizes
lence rates of short or insufficient sleep appear to be rising sleep/wake states using on cardiorespiratory signals, smart
[13]. Insufficient sleep is not itself a diagnosable disorder; wristbands determine sleep/wake states based on movement.
however, the high prevalence highlights a critical target for These measurements therefore reflect different mechanisms
improving the health of the population. Insufficient sleep is that underly sleep. These differential findings emphasize
associated with poorer self-rated health [14], heightened risk the importance for integrated global assessments of gender-
of depression [15], type 2 diabetes [16], cardiovascular dis- based disparities in insufficient sleep duration.
ease [17, 18], and early mortality [19–21]. Cross-sectional Gender differences in sleep duration also vary by coun-
associations are further strengthened by robust evidence try of origin. Seminal works have found that women report
that insufficient sleep precedes health outcomes. For exam- longer sleep duration in most OECD countries (i.e., Organ-
ple, a meta-analysis of 15 prospective studies revealed that ization for Economic Cooperation and Development; an
short sleep duration (< 7 h) increased the risk for coronary intergovernmental organization that consists of democratic
artery disease morbidity and mortality compared to normal countries with free-market economies). Exclusions to this
sleep duration (7–9 h; 22]. Importantly, these relationships finding include Japan, India, Mexico, and Estonia [30–33].
between insufficient sleep and mental and physical health Country of origin impacts gender differences in sleep dura-
outcomes do not seem to be due to sex, age, or other fac- tion because of differences in traditional gender expecta-
tors known to be associated with the aforementioned health tions, such as division of housework or child-rearing [34,
outcomes, such as smoking, body mass index, education, 35]. Seminal works on geography-based gender differences
exercise, and alcohol use [14–22]. Sleep duration is also facilitate understanding of recent findings on gender differ-
influenced by multiple individual, social, and societal fac- ences in sleep duration.
tors. As highlighted below, the prevalence of insufficient Finally, individual gender differences in sleep duration are
sleep varies across gender, race, and other demographics. linked to differential downstream consequences. Recent findings
suggest that women with same-sex partners felt less rested when
Gender Differences sleeping less than 7 h than women with different-sex partners
who slept the same amount. There were no differences in the
Race, marital status, number of children in the household, relationship between sleep duration and feeling rested between
residing region, and level of education predict sleep dura- men with different-sex partners and men with same-sex partners.
tion, with Black Americans being at higher risk of short These findings were not due to differences in sleep duration.
sleep duration than White Americans [23]. Women tend to Rather, not feeling rested was attributable to larger societal fac-
report needing longer sleep [24], but sex-based disparities in tors; women with same-sex partners felt less rested in states with
sleep duration may be age-dependent. A recent electrocardi- less sexual minority support. [36•] Thus, consideration of gen-
ogram (ECG) study on a large Japanese cohort (n = 68,604) der disparities in a close social context, and broader state-level
found that women get less sleep than men of similar ages and values and policy, clarifies one potential mechanism for gender
demonstrated that this difference is more substantial after differences in sleep outcomes.
the age of 30 [25].
However, a global study of nearly 70,000 adults who wore Sleep Duration and Couples
smart wristbands found that women may sleep longer than
men across the lifespan. This study also found that women As indicated above, expanding beyond the individual level
experience more nighttime awakenings, particularly from reveals multiple influences on sleep duration. Considera-
young to middle adulthood, which was moderated by par- tion of couples’ sleep habits is one way the sleep field is
enting status in women but not in men [26•]. Importantly, contextualizing individual sleep. Simply sharing a bed with
this time period is often marked by child-rearing, which a partner contributes to higher levels of sleep fragmentation

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(arousals after sleep onset; 34), which in turn decreases total affect an individual’s sleep duration. Dyadic approaches
sleep duration. This phenomenon is likely more prominent in (e.g., actor-partner modeling) in unique socio-ecological con-
female partners [38]. On the other hand, people who share a texts highlight additional partner characteristics that impact
bed with their partner report total sleep time increases when sleep duration. For example, when examining advanced can-
co-sleeping [39, 40]. Similarly, a study of Hispanic/Latino cer patients and their spousal caretakers, a spouse’s anxiety
adults found that living with a partner predicted better sleep predicted their own, and their partner’s sleep duration [47].
health in general, including sleeping 7–9 h per night. These Similarly, employment status (i.e., employed vs. unem-
associations were strongest among women [41•]. However, ployed) can affect an individual’s sleep and their partner’s
individual-level sleep is also affected by the emotional sleep, but there were gender differences in these relation-
health of the relationship. Co-sleeping may not affect all ships. A male partner’s employment status predicted longer
relationships equally. A seminal review on couples’ sleep actigraphy-assessed sleep duration for women, but a female
indicates that relationship functioning (e.g., marital satisfac- partner’s employment status was associated with increased
tion) influences chronobiological (i.e., one’s sleep timing), sleep problems for men [48].
behavioral, psychological, and physiological processes that
underly sleep, such that individuals in higher functioning Sleep Duration Summary
relationships report better sleep outcomes compared to those
in poorer functioning relationships [42]. Thus, the physical Sleep duration is strongly linked to physical and mental
presence of a partner and relationship characteristics (e.g., health. Individual differences (e.g., sex, race, age) in sleep
satisfaction, conflict) can impact sleep duration at the indi- duration vary depending on the social context, such as coun-
vidual level. try of origin, perceived support from government regula-
Identifying the most robust couple-level influences on tions, relationship status, and relationship functioning. Co-
individual-level sleep involves objective (e.g., polysom- sleeping with a partner is linked to increased sleep duration,
nography) and subjective (e.g., daily diaries, questionnaires) but characteristics such as a partner’s anxiety may diminish
sleep assessments in both partners. Until recently, most stud- such benefits. Additionally, social context (e.g., sexual orien-
ies relied on individual, subjective assessments. A recent tation and living in a state with less sexual minority support)
study of sleep architecture (i.e., sleep stages 1–2, 3–4, and may affect the amount of sleep needed to feel rested. Overall,
rapid eye movement (REM)), assessed via polysomnogra- recent research on gender differences further clarifies how
phy, in young heterosexual couples showed differences in age and gender roles impact sleep duration, highlighting the
sleep when co-sleeping [43]. Co-sleeping was associated importance of social context when examining gender dif-
with more REM sleep in bed partners, despite increased ferences. Studies on couples’ sleep are less common, but
movements and awakenings compared to when the indi- emerging research provides further support that an individ-
vidual slept alone. Individuals who had less social support ual’s sleep duration varies depending on co-sleeping status
received the most benefits to REM sleep from co-sleeping. and characteristics of the close partnership.
Because more REM sleep predicts better subjective sleep
quality, the benefits of sleeping with a partner may outweigh
potential sleep loss, particularly for those with less support Insomnia
from their network [44].
Assessment of couple-level sleep reveals parallel find- Insufficient sleep duration can originate due to dimin-
ings with other couple-level health outcomes. That is, cou- ished opportunities for sleep; however, it can also emerge
ples tend to have similar (or concordant) health behaviors despite sufficient opportunity—a hallmark characteristic of
[45]. Indeed, a recent daily diary study of heterosexual cou- insomnia [49]. Insomnia, which is classified as a disorder,
ples showed positive covariation in sleep duration [46]. One is defined by deficits across multiple parameters: dissatis-
partner’s total sleep time corresponded to the other partner’s faction with sleep quality or quantity, difficulty initiating
total sleep time. Also consistent with the broader literature or maintaining sleep, or early morning awakenings. It is
on couples and social control, when a female partner’s sleep commonly associated with pre-sleep cognitive and somatic
was longer or shorter than usual, their male partner’s sleep arousal at bedtime [50], excessive daytime sleepiness, and
was also longer or shorter than usual. Changes in the male impaired daytime functioning [51, 52•]. Insomnia symptoms
partner’s sleep duration did not significantly predict the are considered clinically significant when the sleep distur-
female partner’s sleep. bance causes significant distress or impairment in important
Taken together, emergent findings on couples’ sleep dem- areas of functioning and the difficulty occurs for three nights
onstrate that sleep duration covaries within partners and that per week for at least 3 months [53]. Insomnia is a prevalent
individual differences such as gender and social support and costly sleep disorder [54, 55], with 8–10% of the popula-
influence the extent to which couple-level sleep patterns tion suffering from chronic insomnia [56, 57]. Additionally,

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insomnia is associated with heightened risk for adverse men- The gender disparity in insomnia may be amplified in pop-
tal health outcomes (i.e., depression, anxiety), irrespective ulations with intersectional identities, exemplifying, again,
of sleep duration. the influence of socio-ecological factors of sleep health [75].
When insomnia is paired with insufficient/short sleep For example, female active US military service members
duration, the health consequences of insomnia are more report higher rates of insomnia than male counterparts [76],
severe [58]. Compared to individuals with insomnia who and female combat veterans utilize more sleep aids than men
report sufficient sleep duration, individuals with insomnia [77]. In Black, middle-aged women in the USA, higher lev-
who report short sleep duration are at higher risk of hyper- els of perceived racism were associated with increased odds
tension [59, 60], diabetes [61], and mortality [62]. More of clinically significant insomnia [78]. Indeed, sexual and
specifically, a multi-ethnic study of atherosclerosis found gender minority populations are two times more likely to be
that women with insomnia were at an 18% increased risk diagnosed with insomnia than their cisgender counterparts
for subclinical atherosclerotic disease compared to men with [79]—although there are gaps in this literature [80]. These
insomnia [63•]. Thus, like insufficient sleep duration, insom- findings speak to the importance of investigating sleep health
nia is increasingly understood as a systemic health problem across intersecting socio-ecological domains (i.e., societal
[2] that affects cardiometabolic, immune, and neurodegen- and social levels factors) and the importance of assessing
erative aspects of health [64]. intersectional identity across those domains in the context of
health outcomes [81].
Gender Differences The global COVID-19 pandemic has highlighted exist-
ing socio-economic, gender, and ethno-racial inequities
Across the lifespan, women report higher rates of insom- in sleep health [82, 83]). Prevalence of reported insomnia
nia symptoms compared to men [65]: during adolescence, symptoms during the pandemic ranges from 25 to 37%,
female individuals experience a 3.6 × increase in insom- with particularly high rates of insomnia symptoms among
nia versus a 2.1 × increase in male individuals [66]. In the female health care workers [84, 85]. Furthermore, gender
general adult population, women have 1.58 higher odds of differences of insomnia among front-line health care work-
receiving a diagnosis of insomnia [67], and gender remains a ers were accounted for by family responsibilities and work
significant predictor of insomnia in older adults [68]. conditions [86•].
Advances in neuroscience inform our understanding of The COVID-19 pandemic has also highlighted moderat-
how sex differences in the brain contribute to the high preva- ing effects across gender that contradict the established rela-
lence of insomnia among women. Fluctuation of the female tionship between insomnia and gender: a longitudinal study
sex hormone, estradiol, is associated with poor sleep qual- of the Italian population during lockdown conditions found
ity during the midluteal phase of the menstrual cycle and that women reported higher distress and insomnia symptoms
may contribute to increased vulnerability to sleep problems early during the lockdown, but demonstrated resilience at
in women of child-bearing age [69]. Similar sex hormone seven weeks, whereas men’s scores declined over time [87].
fluctuations in the brain structures related to circadian regu- Likewise, a meta-analysis of sleep problems in COVID-19
lation may contribute to increased vulnerability to insomnia patients in affected countries found that male sex moder-
during pregnancy, postpartum, [70] and menopause [68]. ated the relationship between COVID-19 and insomnia [88].
Furthermore, recent studies identified sex differences in neu- Outside the context of a pandemic, a similar moderating
roendocrinal, circadian, and emotional regulation processes effect has been found in insomnia associated with tinnitus
associated with restless REM sleep [71], which may contrib- [89], indicating that gender plays a role in the comorbidity
ute to the gender disparity of insomnia in women. of insomnia with medical conditions.
Neurobiological factors alone cannot explain the gender
disparity in insomnia [72]. For example, perpetuating factors Insomnia and Couples
of insomnia differ by gender: men are more likely to hold
false beliefs about the origin and management of insomnia, Studies on insomnia within a couples’ context are sparse;
cope with poor health behaviors (e.g., smoking), and nap however, limited findings suggest that the effects of insomnia
during the day; women reported higher pre-sleep arousal, go beyond the sleep of the insomnia patient. For example,
higher perception of severity, more emotional dysregula- within romantic dyads, an insomnia patient’s partner is at risk
tion, and more use of sleep hygiene strategies [52•, 66, 67]). for disrupted sleep, ostensibly due to their partner’s insomnia.
Furthermore, increased parity (i.e., number of children) has Although insomnia patients are sensitive sleepers, patients
been associated with decreased insomnia in Chinese older cause 25% more partner awakenings than they experience from
adult women [73], but with increased insomnia in middle- their partner [90••]. These findings highlight another way in
aged women in the USA [74], indicating a familial-level which the social context (having a partner with insomnia) can
influence on sleep health. affect individual sleep health.

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Emerging research on insomnia treatment suggests that much of the past literature has indicated that women obtain
considering the social context can also inform treatment more sleep than men [26•], new findings suggest that the
choices. A study of pregnant women experiencing insomnia opposite may be true in countries where women typically
found high concordance of preferred treatment between part- take on more housework or child-rearing responsibilities
ners, with partner preference significantly predicting women’s [34, 35]. Similarly, insomnia is most commonly diagnosed
choices. Majority of women and partners indicated that they in women [65, 67], and this disparity is augmented by mar-
would prefer cognitive behavior therapy for insomnia over ginalized identities [76–80]. Age also provides important
pharmacotherapy [91]. These findings support the large lit- context for gender differences in sleep duration and insom-
erature that suggests concordance in partners’ health behav- nia, with the transition to adolescence [66], child-rearing
iors and demonstrates the importance in incorporating partner years [27, 28], and menopause [68] representing vulnerable
input into the treatment plan [45]. Results from an ongoing periods for women due to biological (e.g., hormonal, neuro-
randomized trial will demonstrate how integrating partners logical) and socioecological (e.g., interpersonal problems,
into treatment influences patient and partner outcomes [92]. division of labor) factors.
Consistent with trends in the field of sleep medicine, Co-sleeping with a romantic partner may benefit some
improving sleep health involves focus on improving multiple aspects of sleep [37•, 38–40, 43] while interfering with
sleep parameters. This is true for insomnia and sleep apnea others. Couples are particularly vulnerable to experiencing
[93–95]. Although beyond the scope of the current study, interruptions to their sleep if at least one partner has a sleep
work on sleep apnea (a condition characterized by repeated disorder [90••]. Thus, the relative benefits of having a co-
stopping and starting of breathing during sleep) is briefly partner should be considered in the context of sleep disor-
highlighted because it is relevant for gender, couples, and ders. Nevertheless, because of recent work on couples’ sleep,
presents with comorbid insomnia [96, 97]. Including part- ongoing clinical trials [92, 101] are incorporating partners
ners in apnea treatment is beneficial [98–100] and increas- into their treatment paradigm, not only to improve patient
ingly common [101]. At least one clinical trial is already sleep but also to improve partner sleep.
examining whether CPAP usage improves a partner’s sleep
health, including symptoms of insomnia [101].
Limitations and Future Directions
Insomnia Summary
This review focused on two sleep domains, sleep
Heterogenous presentations of insomnia with differing health duration and insomnia, that have high public relevance and
consequences demonstrate the importance of identifying mul- specific, behaviorally modifiable targets. Sleep quality was
tiple factors contributing to the development and perpetua- not discussed, but it also has high public health relevance.
tion of insomnia and promotion of sleep health. While there Indeed, much of public health research focuses on this
is evidence from the neuroscience paradigm of gender differ- parameter because it can be assessed with a single ques-
ences in the brain that may contribute to the gender disparity, tion and has high predictive utility [102]. Sleep quality is
there is also evidence that factors across the socio-ecological associated with insomnia, insufficient sleep, and other sleep
model of health affect insomnia, such as the intersection of disorders [54, 102, 103]. Future research that will ben-
work environment and family responsibilities in female health efit from large-scale, population studies will want to con-
care workers and comorbid conditions in male patients. Novel sider this generalizable assessment. In contrast, areas that
research in couples demonstrates that insomnia is disruptive to need greater specificity for identifying targets will want to
the sleep of both patient and partner. Emerging literature sug- consider more nuanced assessments (e.g., sleep duration,
gests that partners should be incorporated into the treatment diagnostic interviews). For example, couples research will
of insomnia, reflecting seminal works that have demonstrated benefit from both large-scale assessments of couples’ sleep
concordance in partners’ sleep habits. and controlled studies that can parse out minute-to-minute
changes based on dyadic patterns.
Findings on disparities in the amount of sleep needed to
Summary feel rested highlight the importance of incorporating mul-
tidimensional assessments of sleep [24, 36•], because fac-
This review of new developments in sleep health demon- tors other than duration (e.g., sleep timing and efficiency)
strate robust gender differences in sleep duration and insom- can affect feeling rested upon awakening. The RU SATED
nia [23, 25, 65, 67]. Importantly, individual, interpersonal, questionnaire is a recent and innovative six-item measure of
and social determinants of sleep health emphasize the global sleep health [3]. Such global measures, and assess-
importance of investigating these gender differences using ments of sleep health, align with proposed paradigm shifts
a socio-ecological framework [1••, 9••]. For example, while in the field that align with overall well-being rather than

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focusing on individual deficits (e.g., insufficient sleep, poor intersectional influences on sleep at the individual level, it
sleep quality) [1••, 3]. In clinical settings, RU SATED can will be important to consider couples’ sleep in the context of
promote sleep health discussions with patients, as demon- other societal influences. For example, low SES is linked to
strated by a recent pilot sleep health promotion study that shorter sleep at the couple level [48]. Improving sleep at the
provided tailored sleep health recommendations using RU public health level will entail modifications across family,
SATED as a framework [104]. Moreover, conceptualizations organizational, and policy domains [1••].
of sleep health include individual, social, and environmen-
tal demands that may impact sleep [3]. Thus, using global
measures of sleep health to assess sleep outcomes can bridge Conclusion
the gap between our understanding of sleep at an individual
level and sleep in the larger socio-ecological context. Recent developments in inadequate sleep and insomnia
Emerging research on gender-based disparities in sleep using a socio-ecological framework were reviewed. Findings
duration and insomnia consistently highlights social and soci- affirm the importance of the social context when examining
etal influences (e.g., social roles and norms, societal support). individual sleep. In particular, gender disparities in sleep
Increased identification and attention to broader societal con- duration are influenced by age and gender role expectations.
textual factors will clarify how intersecting socio-ecological Individual-level factors, such as anxiety, and larger socio-
identities may confer risk for poor sleep health [1••]. In par- ecological factors, such as socio-economic status, influence
ticular, it is important for future research to address dispari- sleep at the couple level. Advances in sleep equity will likely
ties in insomnia diagnoses among sexual and gender minor- need to consider the multiple and intersectional influences
ity populations, considering the finding that they are twice as on sleep. As such, future research will benefit from clarify-
likely to be diagnosed with insomnia as their cisgender coun- ing associations within and among individual, social, and
terparts [79]. Similarly, socio-demographic and racial dispari- societal domains.
ties increase the risk for poor sleep health, particularly in rural
communities [105–107], but socio-economic status and ethno-
racial diversity are rarely accounted for in sleep research [107]. Declarations
Furthermore, large-scale studies could provide a more nuanced
Conflict of Interest The authors declare no competing interests.
understanding of sleep across the lifespan by including parity
(number of children) in analyses of young and middle adult- Human and Animal Rights and Informed Consent This article does not
hood, which may impact sleep and related health outcomes contain any studies with human or animal subjects performed by any
differently across gender and culture [73, 108–112]. of the authors.
To that end, while research has highlighted important
dyadic processes that underlie domains of sleep health, much
of this literature reflects cis-gendered, white, heterosexual
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