Editorial

Growing men's health: Broadening the conceptual and practical agenda

John Scott
Department of Sociology, University of New England, Armidale NSW

Gary Dowsett
Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne VIC

Victor Minichiello
Faculty of The Professions, University of New England, Armidale NSW

PP: 403 - 408

Article Text

It still surprises those of us working on men's issues that it has taken so long to realise - and that there is so little real grassroots support and advocacy for - men's health as a legitimate domain in public health. The men's movement - such as it is (see Connell 2005/1995) - goes back to the late 1970s; the gay men's movement started earlier and the gay men's health movement has been better organised and articulated since then (if one understands and concedes the central place that HIV/AIDS has taken during the last 28 years). What men's health will become, what it will include, redefine and incorporate in the next ten years is interesting to consider.

In May 2010, the Australian Government launched a long-awaited national men's health strategy, entitled (somewhat tweely) the National Male Health Strategy: Building on the Strengths of Australian Males (Commonwealth of Australia 2010). It was long awaited because work had first started well over 15 years ago during the Keating Labor Party administration under its then Federal Health Minister Dr Carmen Lawrence. What remains of that initiative emerged in 1998 - a document entitled Men's Health: A Research Agenda and Background Report (Connell et al 1998). Then followed 11 years of frustration under the conservative government of John Howard during which little progress on a policy was made at a national level, although some State governments did move forward on the issue. The Howard years did yield some important initiatives: the establishment of Andrology Australia[1], a national centre of excellence focused on men's reproductive health, based at Monash University in Melbourne; and the establishment of MensLine Australia[2], a national telephone support line.

That period also witnessed the gradual rise of a national, coordinated men's health 'movement', focused largely on biennial conferences, which importantly featured an Indigenous men's health component in various guises. This led to the eventual formation of the Australasian Men's Health Forum (AMHF) in 2006. AMHF has developed a series of activities (newsletters e.g., E-MALE; websites e.g., Men's Health Australia) that continue to build a constituency by bringing together policy makers, researchers, community advocates, health professionals practitioners, and the like. We used inverted commas around the word 'movement' because most of us working in the field would recognise that 'men's health', as a galvanising and mobilising issue, has never gathered the head of steam that 'women's health' produced from the 1970s onwards. That, in part, explains the slowness of progress over the years and the lack of political purchase the issue has achieved.

The Labor Party federal government elected in 2007 did finally move on the issue under its Health Minister Nicola Roxon and her Minister for Indigenous Health, Rural and Regional Health and Regional Services Delivery, Warren Snowdon, someone long involved in Indigenous issues and with a solid 'feel' for men's health as an issue. The policy took some time to develop, and there were certainly some false turns (drafts that were inadequate, an earlier discussion paper that was less than satisfactory, and consultative processes that were poorly done at times); but it finally arrived. The new policy is modest in its scope and ambition. Framed within the notion of the social determinants of health, the policy aims to promote:

• Optimal health outcomes for males
• Health equity between different population groups of males
• Improved health for males at different life stages
• A focus on preventive health for males, particularly regarding chronic disease and injury
• Building a strong evidence base on male health and using it to inform policies, programs and initiatives; and
• Improved access to health care for males through initiatives and tailored healthcare services, particularly for male population groups at risk of poor health.

To achieve this, the Policy aims to: improve male awareness of preventable diseases and injuries; support males to take charge of their health and act to improve their health; and influence health care services to provide better information and access for males.

There is not a lot of new money behind the policy, but it does name the issue, and this is tremendously important in making a claim for certain health issues, in framing the field, and in facilitating the practical politics of improving the situation of men (and boys) in Australia. That naming dampens the long debate over any challenge to women's health and its funding, and now allows particular men's health concerns to gain some air time, e.g., prostate cancer, drug and alcohol misuse, risk behaviours in the workplace, etc. It also has allowed issues relegated to the margins and treated as somewhat dismissive (for some), such as erectile dysfunction, to find a place beyond a smirk or wink. The headway made on this particular issue is, however, undercut by the federal government's refusal to date to add treatments for erectile dysfunction (e.g., Viagra, Cialis, etc.) to the national Pharmaceutical Benefits Scheme, thereby providing more affordable assistance to men with such problems arising from prostate cancer, cardiovascular disease and diabetes.

This lack reflects a somewhat unconcerned approach by government to Australian men's sexuality and sexual health needs. Indeed, the new national strategy barely mentions sexual health at all (reproductive health gets a Guernsey) and sexuality loses out as a problematic through which a number of concerns about men and their sexual behaviour and attitudes might better be addressed. Also, the fact that the strategy makes no links with the five national HIV/AIDS, Hepatitis C, Hepatitis B, Sexually Transmissible Infections, and Indigenous Sexual Health strategies not only reveals poor policy thinking, but a predilection to keep the sexual out of focus. The policy is much the weaker for not recognising how sexuality functions as one of the major social determinants of health - HIV/AIDS should have taught us at least that.

There is middling concern for men from minority communities, with nominated priority groups: Aboriginal and Torres Strait Islander males; males from socioeconomically disadvantaged backgrounds; males living in rural and remote areas of Australia; males with a disability, including mental illness; males from culturally and linguistically diverse backgrounds. Marginalised men are not forgotten: it lists gay, bisexual or transgender, or from intersex groups, veterans, socially isolated males, and males in the criminal justice system (summarised from Commonwealth of Australia 2010: 11-12). Meeting these men's needs will be complex, and one must ask whether the new national policy provides an adequate conceptualisation and understanding of these complexities. For example, the usual listing together of these diverse minorities continues to connote their 'otherness'. Moreover, the policy mentions gay men only seven times, and while bisexual men are mentioned five times, the two terms are usually compressed together. This is better than the NSW Men's Health Plan 2009-2012, which does not mention gay or bisexual men at all; although it does use 'homosexual' twice. Haven't they heard of Mardi Gras? The recent Victorian Men's Health and Wellbeing Strategy Background Paper has 16 references for gay men, 11 for bisexual men, and 5 for homosexual men - it does make one wonder why Victoria has so much to talk about. A real test of the new national policy will be how or if it manages to move the margins to centre stage in men's health.

It is to be hoped that the discursive framing of the field will finally allow specificity in understanding certain health problems as experienced by men and boys. For example, eating disorders among men and boys may finally get the attention they deserve. We use this example to make another point: eating disorders are configured as tremendously gendered when women and girls are concerned. That is, they are recognised as being determined by the gender order and its unequal consequences for those designated female at birth. We might readily understand over-eating and poor nutritional habits, often noted for men, as also determined by the gender order; but how are we to understand increasing incidence of anorexia and bulimia in young men? This literature is growing, and a visit to any 'pro ana' web site for boys (see for example http://anasboi.blogspot.com) soon reveals that something is going on in the gender order that can no longer be understood by the essential 'male/female' binary or a simple belief that inequality only travels in one direction or takes one form.

Similarly, the rise in transgender politics, challenging the man/woman binary, and the ever-widening nomenclature of sexuality politics - GLTTTBBIEQQ (gay, lesbian, transsexual, transgender, transvestite, bisexual, bi-curious, intersex, eunuch, queer, and questioning); now internationally termed in the United Nations system as 'SOGI' (sexual orientation and gender identity) issues - demand a significant theoretical reconfiguring of the intersection of sexuality and gender as a field of inquiry, research and discourse. It is not new to argue that gender ≠ women; it was useful for a time to think that gender = women + men when it suited; it is now clear that gender as a binary logic is outdated and that the biological hook that still theoretically holds gender to sex is increasingly problematic.

The fields of men's studies and masculinity theory now face this very same problem, and the theoretical tools that these fields use must develop faster if they are to handle, encompass, interrogate and understand the phenomena that will need to be addressed within the emerging and enlarging discourse of men's health. A few examples will suffice: how can 'blokey' men's health ambassadors be of much use in assisting transwomen with prostate cancer; how will we deal with the emerging evidence of female- perpetrated domestic violence against men; what are the longer-term health consequences of the increasing commodification of men's bodies by the cosmeceutical industry, the fashion industry (with size 0 young men on catwalks), and the sex and pornography industries; what are we to do with the increasing evidence of the far more widespread and long-term effects of war on men's mental health and their lives after service?

We believe the men's health agenda is not yet ready for all this and more; but as the papers in this special issue of Health Sociology Review reveal, things are moving ahead. We hope that the trend toward policy strategies focused on men's health might open at least some of the way forward for more progress toward producing really useful knowledge about men.

Overview of Papers

The papers in this special issue of Health Sociology Review reveal how men's health is intrinsically interwoven with the concept of masculinity and highlight key issues likely to dominate the research agenda of men's health. Engaging with some of the challenges we have outlined above, these papers link men's health to key social factors such as age, class, status and ethnicity. Notably, a number of papers examine how sexuality and sexual health may function as major social determinants of men's health and how the commodification of the male body, in its various guises, informs health.

Richardson (2010) raises an interesting contradiction for men's health policy. On the one hand, there is a health policy push towards self-regulating and promoting the health-seeking responsibility of citizens; on the other hand, the effects of masculinity on men is that it is likely to produce irresponsible individual health practices. Qualitative interviews with a sample of Irish men document how 'real men' are prone to produce non-responsive health behaviours. It seems that men are experts in 'bad' health. This poses a challenge to the relevance of current policies and intervention for improving men's health.

The topic of fatherhood is the focus of the article by Greaves et al (2010), who interviewed Canadian fathers who smoke, reveal that changing social expectations on men to assume a more balanced view of the 'responsible father' is affecting their lives and lifestyle habits. What is interesting about this study is that discourses used by these men about fatherhood and smoking may be different from those from women talking about motherhood and smoking, highlighting how masculine norms are significant in constructing health outcomes.

Durkheim made the important observation that suicide had distinctive social characteristics. Kalish and Kimmel (2010) extend this analysis to show how masculinity shapes the suicide behaviour of men. By discussing the cases of four young American men who shot fellow students and teachers before killing themselves, Kalish and Kimmel describe how such acts of violence can be interpreted as expressions of power and aggression, and as 'compensation' for the humiliation caused through a perceived emasculation experienced by these young men. The argument is powerful because it forces us to acknowledge several interesting arguments: the 'gender' of aggrieved entitlement, so often a precursor to fatal and public suicide performance, is masculine; and the context of the shooters' school provides a more grounded understanding and explanation for the mass suicide phenomenon. That teasing, bullying, physical violence and ostracisation are a result of the policing of homophobia, having a detrimental effect on the lives of men, is clearly revealed through the stories of the men interviewed by McCann et al (2010). They argue that homophobic humour is used to create and enforce a sense of heterosexual masculinity. This leads the reader to ask the question of whether such humour is an 'orchestrated cruelty' used to create an unwanted maleness that is the 'other' and a failed masculinity.

Barnshaw and Letukas (2010) remind us of the complex relationships between culture, sex and masculinity. While the motivation for their study is guided by an interest to examine whether men who identify as heterosexual, but have sex with other men, are at higher risk for HIV and STIs, it also raises some more general problems associated with the construction of men's sexuality and its relationship to health. Their findings, using the large US Urban Men's Health Study, found significantly higher risk for infection with non-Whites who identify as heterosexual, than whites who identify as heterosexual. While this is an interesting finding, what is of greater interest is the discussion on what they term the 'down low', a concept that has attracted much media attention in the US and refers to men who publicly identify as 'heterosexual', but engage in sex with both men and women while failing to disclose same-sex behaviours to their partners. Such behaviour may result in increased risk for STIs. Worth noting here is the importance of race and ethnicity in shaping the gender and sexuality of men.

One of the more interesting studies in this issue is the interview-based research carried out by Drummond and Drummond (2010), where young boys aged between four to six talked about nutrition, physical activity and health. Key findings worth noting are: the boys identified certain sports, physical activity and foods that 'were more for boys'; the gendered nature of nutrition and how this informed how food consumption is governed within the household. These findings certainly provide evidence for improving the health literacy of boys and men. Perhaps, the popular 'Master Chef' cult phenomenon may challenge the entrenched gender norms associated with food practices?

In more recent times, a preoccupation with body image and 'penis performance' is emerging as an important issue with regard to boys' and men's health. Duncan's (2010) study reveals the significance of achieving a 'hyper-masculine' body image that conforms to dominant masculine norms in a sample of Australian gay men. Paradoxically, like women, gay men strive to create a body prototype acceptable to heterosexual society (read 'straight' men).

Oliffe et al (2010), in interviews with Canadian men who reported suffering from depression, found much to support many of the issues discussed in the other articles, where masculine ideals of, for example, body image, identity, and risky behaviours can have profound effects on the lives of men, including creating a context for depression. The suggestion that depression erodes masculine identities and can, therefore, exacerbate existing health problems is worthy of further research.

Finally, Creighton and Oliffe (2010) provide a useful summary of how the literature has theorised masculinities and how sex and gender theories have been used to explain men's health. Health policy makers and practitioners may find the discussion on the community of practice framework useful, particularly in terms of its utility to identify and introduce intervention programs that may improve men's health by creating some really useful knowledge about men.

Clearly, the research agenda on men's health is on the move as new issues emerge and old problems are recast within the framework and policy settings that men's health provides. The nine new contributions in this special issue herald the way forward.

[1] http://www.andrologyaustralia.org

[2] http://www.menslineaus.org.au/

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