Cover Story

There’s a joke about a man who goes to the doctor complaining that he sees spots. The receptionist asks, “Have you ever seen a doctor?” And he replies, “No. Just the spots.”

The joke gets laughs because it reflects a truth: Men are much less likely than women to look after their health and see physicians. They’re 25 percent less likely to have visited a health-care provider in the past year, and almost 40 percent more likely to have skipped recommended cholesterol screenings, according to the U.S. Agency for Healthcare Research and Quality. As stereotype would have it, nagging from women is the main reason men ever get their health checked out.

But what’s no laughing matter are the statistics on men’s poorer health outcomes: U.S. men are 1.5 times more likely than women to die from heart disease, cancer and respiratory diseases, according to U.S. Centers for Disease Control and Prevention data. And they die, on average, five years earlier than women.

Part of this may be genetics. For example, some variants of the Y chromosome may make men more prone to heart disease. But much of it may be masculine socialization, behavioral scientists theorize. “About the difference in life expectancy, we say that one year is biological, and the rest is cultural,” says Gilles Tremblay, PhD, a social work professor at Laval University in Quebec City. Research by Tremblay and others has uncovered a cluster of traits frequently seen in men — emotional suppression, aggression and risk-taking in particular — that are associated with fewer visits to health-care providers and higher rates of injury and disease.

“Masculine gender socialization is hazardous for men’s health, posing a double whammy of poorer health behaviors and lower use of health care,” says Ronald Levant, EdD, a former president of APA and the originator of one of the primary measures of traditional masculinity, the Male Role Norms Inventory (MRNI).

But now research by Levant and other psychologists has revealed something quite different and intriguing: Some aspects of masculinity might actually protect men’s health. Men high in traits that are often considered masculine ideals — self-reliance, responsibility, emotional maturity and an even-keeled approach — are more prone to visit their physicians and avoid risky behaviors, findings suggest.

Interestingly, some of these findings on healthy masculinity leading to good health behavior come from research on African-American men, even though they often have less access to health care. Buoyed by the results, the researchers behind them hope that they can be used to teach all men to draw on these positives of masculinity — and perhaps even teach women a thing or two.

Self-reliance — and cool heads

One of the researchers pioneering this new work on African-American masculinity and health is Jay Wade, PhD, a psychology professor at Fordham University and president-elect of APA’s Div. 51 (Society for the Psychological Study of Men and Masculinity). In a study published in 2009 in the American Journal of Men’s Health (Vol. 3, No. 2), Wade had 208 low-income African-American men in the New York City area fill out the MRNI and several measures of their health attitudes and behaviors.

After controlling for demographic variables, Wade found that participants who stifled their emotions felt more anxious about and out of control of their health. But those who identified as self-reliant were more likely to think about their health, take steps to take care of it and believe that they could influence their health.

Why might self-reliance exert such power in this group? Wade isn’t sure, but he’s willing to speculate: “The original self-reliance concept as it was developed is, ‘I can do it all on my own. I don’t depend on anybody. I don’t need anybody.’ But it may be that the construct isn’t necessarily the same for African-American men. Because of the history of discrimination, it may be more like, ‘I can’t depend on others in society to take care of me, so I need to rely on myself. And because others — like my family — are depending on me, I really need to take care of myself.’”

Jibing with Wade’s finding is another from the Men’s Health Research Lab at the University of North Carolina at Chapel Hill. In the study, published last year in the Journal of General Internal Medicine (Vol. 25, No. 12) and led by lab director Wizdom Powell Hammond, PhD, researchers recruited 610 African-American men from barbershops nationwide and administered the MRNI, among other measures.

Men who scored highest on self-reliance were least likely to delay blood pressure screenings, and those who strongly embraced traditional masculine role norms as a whole were least likely to delay cholesterol screenings. In comparison, those who reported high mistrust of the medical establishment were more likely to delay blood pressure and cholesterol screenings, as well as routine health checkups.

Like Wade, Hammond believes that the particular way African-American men define self-reliance is what makes the difference. “For African-American men, masculinity is tied to their efforts to overcome oppression and a past that involves medical maltreatment — and to increase their access to health-care resources,” explains Hammond. “Those who endorse standing on their own two feet want to ‘man up’ by seeking out preventive services.”

This isn’t to say that self-reliance is the only positive masculine trait when it comes to health behavior. A new study of 323 college men, led by Levant and published in January in Psychology of Men and Masculinity (Vol. 12, No. 1), reveals that some traditionally male traits may actually propel men to seek psychological help from professionals. The stand-out ones, says Levant, are the ability to focus on important matters and not sweat the small stuff, and emotional maturity, which includes avoiding self-destructive behaviors, such as substance abuse and not always expecting to receive what one wants.

“Men who must always get their way, who can’t ask for help and who can’t ignore the little hassles of life may have the worst health outcomes,” says Levant, who is a professor of psychology at the University of Akron.

Amplified effects

The health hazards of masculinity also loom large for gay men, several studies indicate. Researchers in this area find that gay men who identify with traditional masculinity are more likely to abuse substances and engage in risky sexual behaviors, such as unprotected anal intercourse. Sometimes fueling this risky behavior is “minority stress” — a form of stress that results from oppression of a minority group, in this case, gay men — together with a perception that risky health behaviors are the norm. So finds a study of 315 gay men by counseling psychology graduate student Christopher Hamilton and psychologist James Mahalik, PhD, of Boston College.

The results appeared in 2009 in the Journal of Counseling Psychology (Vol. 56, No. 1). And they’re backed by results of another study led by psychologist Mark Hatzenbuehler, PhD, of Columbia University’s Center for the Study of Social Inequalities and Health, and published in Health Psychology (Vol. 27, No. 4) in 2008. In it, Hatzenbuehler assessed levels of minority stress and risky health behaviors among 74 gay men who had recently lost a partner to HIV/AIDS. He found a strong relationship between depression, substance use and unprotected sex and such minority-stress characteristics as internalized homophobia and experiences of discrimination. In comparison, the men’s risky health behaviors were largely unrelated to their bereavement — and Hatzenbuehler points out that bereavement is typically associated with mental and behavioral health problems.

“The study shows that minority stress was a unique predictor of adverse health outcomes, even in the context of bereavement,” he says.

The results point to a need for large-scale programs to reduce stigma and prejudice, says Hatzenbuehler, as well as individual-level therapy that helps gay men regulate their emotions and tap social support. And that gets back to the core issue of motivating men to look after their health.

Manly conversations

When men finally do come in for care, health-care professionals, particularly psychologists, have a chance to intervene — and help men improve their health, says Levant. The key, he says, is getting them to see how manliness can work for them instead of against them.

“It almost never works to tell a man to stop being masculine,” says Levant. “You need to advise the man to keep up the masculine behaviors that are helpful, but challenge the ones that aren’t.”

Also important, says psychologist Will Courtenay, PhD, is getting the provider-patient relationship off to a good start. It’s all in the health-care provider’s approach, he says (see sidebar): Men generally respond better if they think their health-care providers are teammates.

“If the doctor says, ‘Where do you want to start?’ it immediately enlists the man’s involvement and cues him that we’re standing shoulder to shoulder and working together on this,” says Courtenay, a Berkeley, Calif.-based psychotherapist and masculinity researcher. “And we know that collaborative treatment with active patient involvement is associated with improved outcomes and treatment adherence.”

If a patient leans toward the traditionally masculine tendency of active problem-solving, a health-care provider can harness that by skill pointing him to tools and strategies, says Courtenay. You could, for example, explain to a smoker how quitting will almost immediately begin healing his cardiovascular system. Such appeals to action and problem-solving may be behind the fact that men are more successful at quitting smoking than women, even though more women say they want to quit — a trend documented in a 2009 analysis in Nicotine and Tobacco Research (Vol. 1, Issue Suppl. 2).

Real men, real action

Courtenay attributes men’s greater success at quitting smoking to such stereotypically masculine traits as self-reliance, showing what can happen when they put their minds to health improvement. And this is where behavioral researchers hope to intervene with men on a broader, public health level. Men’s health researcher Hammond wants, for example, to see the self-reliance findings from African-American men used to craft public health messages focused on action and responsibility.

Past men’s health campaigns have been promising, she says, but not focused enough on action. One of them, the National Institute of Mental Health’s 2003 “Real Men, Real Depression” campaign, featured men’s stories of getting help for depression. In one analysis, published in 2006 in Psychology of Men and Masculinity (Vol. 7, No. 1), 209 college men mostly reported finding the materials helpful and educational. But as yet, there is no evidence showing that men sought help as a result of the campaign.

Similarly, the U.S. Agency for Healthcare Research and Quality launched its “Real Men Wear Gowns” campaign in 2008, with an aim to convince men to don hospital gowns and get screened for various cancers and other chronic diseases. Among other recommendations, the campaign offered tips on how to talk to physicians. No evaluation data on the program, however, are available to date. And, says Hammond, the primary message wasn’t a “take control of your destiny” call-to-action.

“We have to frame health-care seeking as an act of self-reliance,” she says. “The message should be that taking charge of your health is what it means to be a real man. It’s about engaging and becoming a partner in your care. You have decision-making power about your health.”

One campaign using an action-oriented approach is in Quebec, where suicide is the leading cause of death among 20- to 40-year-old men. Now in its 20th year and held every February, Quebec’s Suicide Prevention Week refers young men to a suicide-prevention hotline and 33 suicide-prevention centers. While there are no data to suggest that the drop is directly linked to the campaign, the suicide rate among Quebec’s young men has dropped by a third over the past 10 years.

At least one men’s health researcher, Gilles Tremblay, thinks the campaign has played a role in that drop. “The campaign sent a message that asking for help is a strong thing for a man to do,” says Tremblay. “Now, 15 to 20 years later, providers I work with in mental health are saying more men are more prone to asking for help.”

Another benefit of the self-reliance approach is that it appears to work with a variety of ethnic and cultural groups. For instance, nurse and researcher John Lowe, PhD, of the University of Florida, has been using it to train nurses about effectively treating Cherokee men — a group that traditionally values being responsible, disciplined and confident. Lowe describes his approach in a 2002 article in the Journal of Crosscultural Nursing (Vol. 13, No. 4). The self-reliance approach has not yet been tested with Latino men, but recent research on this population’s resistance to prostate cancer screening, published in January in Psychology of Men and Masculinity (Vol. 12, No. 1), suggests the approach might help: In the study of a small sample of 10 middle-aged Latino men — led by Zully A. Rivera-Ramos, an educational psychology graduate student at the University of Illinois at Urbana-Champaign — results indicate that low-income Latino men might respond better to health messages emphasizing that prostate screening does not violate their masculinity. In comparison, high-income Latino men may respond more to messages playing to their role as provider and family protector.

So perhaps — just perhaps — by playing to all men’s interests in control and responsibility, health-care professionals and officials have a chance to help them ward off serious diseases and live longer. If the tactic works, the average man will go and see a physician long before he starts seeing spots. And the joke won’t be funny anymore.


Bridget Murray-Law is a writer in Silver Spring, Md.