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. Author manuscript; available in PMC: 2011 Jan 1.
Published in final edited form as: Psychol Men Masc. 2010 Jan 1;11(1):15–24. doi: 10.1037/a0017874

Masculine Norms, Avoidant Coping, Asian Values and Depression among Asian American Men

Derek Kenji Iwamoto 1, Liang Liao 2, William Ming Liu 3
PMCID: PMC2906828  NIHMSID: NIHMS185800  PMID: 20657794

Abstract

Contrary to the “model minority” myth, growing research indicates that the rates of mental health problems among Asian Americans may be higher than initially assumed. This study seeks to add to the scant knowledge regarding the mental health of Asian American men by examining the role of masculine norms, coping and cultural values in predicting depression among this population (N=149). Results reveal that Asian American men who used avoidant coping strategies and endorsed the masculine norm Dominance reported higher levels of depressive symptoms. In contrast, endorsing Winning masculine norms was associated to lower levels of depressive symptoms. Findings suggest that adherence to masculine norms and avoidant coping strategies play a salient role in the mental health of Asian American men.

Keywords: Asian American men, masculine norms, depression, avoidant coping, Asian values

Asian Americans are often perceived as the “model minority” due to this group’s relatively high academic and economic achievement (Wong, & Hagin, 2006). This stereotype obscures the need to examine mental health problems such as depression among this population. This gap in the knowledge base is especially alarming because emerging research indicates that mental health problems, such as depression and anxiety are increasingly salient problems observed among Asian Americans (Gee, 2004; Okazaki, 1997; Siegel, Aneshensel, Taub, Cantwell, & Driscoll, 1998). In addition, recent studies indicate that mental health problems may be a bigger problem among Asian Americans than what was initially presumed. A study examining a clinical sample of 1,166 college students from various universities across the nation found that Asian Americans reported the highest amount of psychological distress among all racial groups (Kearney et al., 2005). Additionally the Commonwealth Fund survey (1998) reported that Asian American women between the ages of 18–24 had the highest depression and suicide rates of all racial groups. However, little is known about risk and protective factors of depressive symptoms for Asian American men. In particular, there has been a paucity of research investigating how gender mechanisms such as masculinity might be related to depressive symptoms in this group (Liu & Iwamoto, 2006).

Masculinity is an important construct to study because mental health literature indicates that strict adherence to traditional masculine norms has deleterious consequences on the mental health of men (Levant, 1996; Mahalik, Locke, et al., 2003; Pleck, 1995). Similarly men and women’s differences in coping styles may contribute to variances in incidents of maladaptive behaviors. For example, whereas prevalence rates of depression among men might be lower, men are two to four times more likely to commit suicide compared to women (Cochran, 2001; Cochran & Rabinowitz, 2000; Joe & Marcus, 2003; Moller-Leimkuehler, 2003; Murphy, 1998; Vannatta, 1997). The low prevalence rates of depression have been often attributed to men’s unwillingness to seek help and their tendency to under-report symptoms (Angst et al., 2002; Courtenay, 2000) or clinicians’ tendencies to more frequently diagnose depression in women compared to men (Potts, Burnam, & Wells, 1991). This study extends the literature by examining the relationship between conformity to masculine norms, avoidant coping, Asian values and depressive symptoms among Asian American men.

Conformity to Masculine Norms and Depression

One factor that may help explain how men experience depressive symptoms is adherence to masculine norms. Masculine norms are a multidimensional construct that are developed through societal expectations, scripts, norms and beliefs of what it means to be a man (Levant, 1996; Mahalik et al., 2003). Mahalik and colleagues (2003) postulate that traditional masculine norms in America comprise of Winning, Emotional Control, Self-Reliance, Dominance, Risk-Taking, Violence, Playboy, Primacy of Work, Power Over Women, Disdain for Homosexuals, and Pursuit of Status. According to the masculine gender role strain paradigm, adhering and attempting to fulfill these norms create dysfunction-strain or psychological distress, and may result in other negative consequences such as relationship conflict (Levant, 1996; Pleck, 1995). Accordingly, recent studies have documented the negative effects of conforming to traditional masculine norms on the mental health of men. Mahalik et al.’s (2003) validation study on the Conformity to Masculine Norm Inventory (CMNI) detected significant associations between Self-Reliance and depressive symptoms, while Dominance was found to be related to psychological distress. Burns and Mahalik (2006) found that the masculine norms Emotional Control and Self-Reliance were related to negative mental health among men treated for prostate cancer. Among adolescent boys, Jackson (2007) found that masculinity predicted higher levels of depressive symptomatology. In contrast, a few studies have detected an inverse relationship between masculinity and depressive symptoms (Lengua & Stormshak, 2000; Li, 2000; Sanfilipo, 1994). Taken together, it appears that masculine norms are associated with depressive symptoms, though it is unclear whether masculine norms operate similarly for Asian American men.

Coping Strategies

One of the ways by which men manage their depressive symptomatology is through avoidant coping strategies (Magovcevic & Addis, 2008). Avoidant coping strategies are indirect methods of dealing with stressors and can include substance abuse (e.g., alcohol or other drugs), behavioral disengagement, denial, or premature resignation from dealing with the problem. Men who adhere to masculine norms, such as, self-reliance and controlling emotions, may manage their negative affect by using avoidant coping strategies as these may be in concert with their conceptualization of what it means to be a man. This may place these men at elevated risk for mental health problems as several studies have linked avoidant coping strategies with depression among men (Chan 1995; Dunn, Whelton, & Sharpe, 2006; Dyson & Renk, 2006; Wilkinson, Walford, & Espnes, 2000). Langhinrichsen-Rohling and colleagues (2006) reported that men were more likely to engage in less social support seeking and emotional expression compared to women in a college sample. Panayiotou and Papageorgious (2007) also detected significant relationships between avoidant coping strategies and depressive symptoms. Interestingly, avoidant coping strategies were a more robust predictor of depression than endorsement of sex roles (i.e., “women should always take care of their appearance”; Panayiotou & Papageorgious, 2007, p.292). These findings underscore the potentially important role that avoidant coping strategies may have in predicting depression among men.

Asian Values

In addition to understanding the influence of masculinity and avoidant coping strategies with depression, this study also investigates the role of Asian values in mitigating depressive symptoms. Kim and Hong (2004) suggested that factors such as cultural values may influence how individuals manifest and express psychological problems such as depression. Kim and colleagues (2001) found that despite significant within-group differences found among various Asian ethnic groups, there are some common values that are shared among Asians, including: collective worldview, family recognition through achievement, control over emotions, filial piety (i.e., taking care of elders or parents), humility, and hierarchical relationships (Kim, Atkinson, & Yang, 1999).

Adherence to Asian values is an important factor to investigate because it has been found to be associated with self-esteem (Liu & Iwamoto, 2006; Kim & Omizo, 2006). In addition, Asian values have been indicated to alleviate the deleterious effects of race-related stress on psychological well-being (Iwamoto & Liu, in press). It has been postulated that these relationships may exist due to the fact that individuals who have a strong Asian identity may find it fulfilling (thus promoting life satisfaction) to live up to Asian cultural values (Diener, Oishi & Lucus, 2003). Therefore, Asian values may be a protective factor of mental health among this population.

Hypotheses

Based on masculine dysfunction-strain theory (Levant, 1996; Pleck, 1995), it is hypothesized that Asian American men who have higher adherence to masculine norms and use avoidant coping will report higher levels of depressive symptoms. This hypothesis assumes that when Asian American men hold strict adherence to masculine norms, the pressure to conform and live up to these norms may be related to depressive symptoms. We also postulated that avoidant coping will be associated with negative mental health. Specifically, men who have traditional views of masculinity tend to use avoidant coping strategies (Hatzenbuehler, Hilt, & Nolen-Hoeksema, in press; Magovcevic & Addis, 2008), and these avoidant strategies may be associated to poorer mental health. Finally, Asian American men who endorse Asian values will have lower levels of depressive symptomatology when compared to Asian American men who do not endorse Asian values.

Method

Participants

Participants in this study were 149 Asian American men, of which 36 (24.2%) were Chinese American, 31 (20.8%) Vietnamese, 23 (15.4%) Filipino, 14 (9.4%) Korean, 13 (8.7%) Asian Indian, 12 (8.1%) Japanese, and 20 (13.4%) were “other Asian” Americans. Of the participants, 91.3% were undergraduates (n = 136) and 5.4% were graduate students (n = 8) from a large West Coast university, while 3.4% (n = 5) listed “other” (i.e., non-student, graduated, or alumni). The mean age for the participants was 21.64 (SD = 3.68).

Measures

Center of Epidemiological Studies-Depression (Radloff, 1977)

The CES-D is a widely used measure of depressive symptomatology. The CES-D consists of 20 items, and participants respond to each item on a 4-point Likert scale ranging from, “rarely or none of the time” to “most or all of the time.” Higher scores on this instrument indicate greater depressive symptoms. In this study the CES-D reliability estimate was α = .80.

Conformity to Masculine Norms Inventory (CMNI; Mahalik et al., 2003)

The CMNI is designed to assess conformity to a range of traditional masculine norms widespread in the United States. The CMNI consists of 94 items, and each item is rated on a 4-point Likert scale (0 = strongly disagree to 3 = strongly agree). The 94 items group into 11 subscales which include, Winning, Emotional Control, Risk-Taking, Violence, Power Over Women, Dominance, Playboy, Self-Reliance, Primacy of Work, Disdain for Homosexuality, and Pursuit of Status. Higher scores on the total CMNI score and subscales indicate greater endorsement of traditional masculine norms found in the United States. In the present study we only used the CMNI subcales Winning, Emotional Control, Self-Reliance, and Dominance as predictors of depressive symptoms. These items were selected because Emotional Control and Self-Reliance have been found to be associated to negative mental health in prior studies (Burns & Mahalik, 2006; Mahalik et al., 2003); while in the Mahalik and colleagues’ study (2003) Dominance was found to be associated to somatization, which is reflective of depressive symptomatology (Mahalik et al., 2003). Winning was selected because it is believed to be an important component of American masculinity and masculine culture (Brannon, 1976; Levant & Pollack, 1995). The idea of “winning” is predicated on men being in control, as well as ascending to higher status positions and being dominant over others.

There is strong psychometric support for the CMNI. Mahalik et al.’s (2003) validation study on the CMNI identified 11 masculine norms, and the overall instrument displayed strong convergent validity with other masculine measures such as the Gender Role Conflict Scale (O'Neil, Helms, Gable, & Wrightsman, 1986), Masculinity Gender Role Stress Scale (Eisler & Skidmore, 1988), and Brannon Masculinity Scale-Short Form (Brannon & Juni, 1984). There was support of the CMNI’s concurrent validity as evidenced by the associations between the CMNI subscales in relation to aggression, social discomfort, hostility and psychological distress (Mahalik et al., 2003). Mahlik and colleagues report that the internal consistency estimates for the 11 masculine norms subscales ranged from .75 to .91, and the test-retest results for the CMNI total score over a 2–3 week span was α = .95. Among Asian American men, Liu and Iwamoto (2007) reported reliability estimates for the CMNI ranging from .58 (Dominance) to .88 (Disdain for homosexuality). The current study yielded internal consistency estimates of .82 for Winning, .83 Emotional Control, .77 Self-Reliance, and .57 for the Dominance subscale.

Avoidant Coping (Brief Cope; Carver, 1997)

The avoidant coping scale was based on items from the Brief Cope scale (Carver, Scheier, & Weintrub, 1989). Generally this measure is intended to assess how individuals cope with stressful events, and items are answered on a 4-point Likert scale (1 = I haven’t been doing this at all, 4 = I’ve been doing this a lot).

The avoidant coping strategy measure was derived from Liu and Iwamoto’s (2007) exploratory analysis on the Brief Cope. They identified two factors, indirect (avoidant) and direct (active) coping. While Liu and Iwamoto (2007) did not use the two substance use coping items as their outcome was a measure of substance use, these items were included in the present study because we believed that these coping strategies may be used by men when they are experiencing depressive symptoms. Some sample items in the Avoidant Coping measure include, “I've been saying to myself "this isn't real", “I've been using alcohol or other drugs to make myself feel better.” The internal consistency coefficient for the Avoidant Coping instrument in this study was α = .80.

Asian Values Scale-Revised (AVS-R; Kim & Hong, 2004)

The AVS-R is a 25-item instrument designed to measure enculturation or the maintenance of one’s indigenous cultural values and believes. More specifically, the AVS-R assesses dimensions of Asian cultural values that include “collectivism, conformity to norms, deference to authority figures, emotional restraint, filial piety, hierarchical family structure, and humility” (Kim & Hong, 2004, p. 19). Sample items include “One should avoid bringing displeasure to one's ancestors” and “One should consider the needs of others before considering one's own needs.” The instrument uses a 4-point Likert scale (1= strongly disagree to 4 = strongly agree). To obtain the AVS-R score, all 25 items are summed together and divided by 25. Higher scores indicate greater adherence to Asian cultural values. In the current investigation the reliability estimate for the AVS-R was α = .73.

Procedure

Participants were recruited from undergraduate classes at a large public West Coast University and through the use of listserves. For classroom recruitment, the lead investigator contacted professors who had class enrollment of over 20 students. Although, in-class data collection included all students regardless of race or ethnicity, only Asian American men were included in this current study. All potential participants were informed that the study’s purpose was to examine the relationship between social norms, cultural beliefs and values, and mental health. All participants completed the surveys voluntarily and were not provided any compensation for their participation. The survey packets and online questionnaire consisted of the demographics questionnaire, Center of Epidemiological Studies-Depression (Radloff, 1977), Conformity to Masculine Norms Inventory (Mahalik et al., 2003), Avoidant Coping (Carver, 1997), and the Asian Values Scale-Revised (Kim & Hong, 2004).

Prospective online participants were notified of the study via email through the listserves of an Asian American fraternity and other student organizations at the university. Upon completion of the survey, participants were presented with a debriefing page that stated the purpose of the study. No compensation for participating in the study was provided. In order to ensure that we had no duplicate responses, we examined the data, time, and IP addresses of the participant’s response; if there were any conflicts (two of the same IP addresses), these responses were deleted (Mohr & Rochlen, 1999).

Of the 149 participants, 103 completed the paper questionnaires in the classroom, and 46 took the survey online. No differences on the independent and dependent variables between the two groups were detected in the present study. This supports previous research that indicates response patterns on online survey are generally equivalent to pencil-and-paper surveys (Lewis, Watson, & White, 2009; Naus, Philipp, & Samsi, 2009).

Results

A power analysis using G*Power (Erdfelder, Faul, & Buchner, 1996) was conducted prior to the study. The power was set at f2 = .80 and the alpha at .05. Based on the analysis, in order to detect a medium effect size (Cohen, 1988), a sample size of 98 was needed, F (6, 91) = 2.19, λ = 14.7. According to the power analysis, the current study was able to detect medium and large effects.

Correlation Analysis

Pearson correlations were conducted to test the relationships between the variables in the study (See Table 1). Winning was significantly related to Dominance and Self-Reliance, while Emotional Control was associated to Self-Reliance and Asian values. Finally avoidant coping was significantly correlated to depressive symptoms.

Table 1.

Correlations among masculine norms, Asian values, avoidant coping, and depressive symptoms

Measure 1 2 3 4 5 6 7
1. Winning --
2. Emotional Control .01 --
3. Dominance .55** .03 --
4. Self Reliance .20* .19* .15 --
5. Asian values .03 .31* −.04 .06 --
6. Avoidant Coping .04 .07 .07 .13 −.06 --
7. Depressive symptoms −.13 .08 .08 .12 −.08 .47 --
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*

p < .05,

**

p < .01.

Multiple Regression

Regression analysis was performed using Mplus5 (Muthen & Muthen, 2008). The program Mplus has the advantage of using full maximum likelihood to handle missing values. Specifically FIML uses all of the data to estimate standard errors and parameter estimates, a method that has been found to be an effective procedure to deal with missing values (Graham, 2009).

The first research question examined whether the CMNI subscales Winning, Dominance, Self-Reliance, Emotional Restriction, and avoidant coping and AVS-R would predict depressive symptomatology. Before interpreting the results, we checked the collinearity statistics Tolerance and VIF (variance inflation factor). Multicollinearity was suspected due to significant correlations between the CMNI subscales. The criteria of a Tolerance score of less than .20 and a VIF score of greater than 10 were used to detect multicollinearity (Cohen et al., 2003). The results revealed no VIF scores greater than 3.13 and the lowest Tolerance estimate was .32. Thus, there were no multicollinearity problems in the analysis.

The results revealed that avoidant coping (β = .53, p < .001) was a robust predictor of depressive symptoms, followed by Winning (β = −.23, p < .005) and Dominance (β = .17, p < .04), R2 = .34, F (6, 143) = 7.37, p < .001 (Table 2). Self-Reliance, Emotional Control, and Asian values were not significant predictors of depressive symptoms. These findings suggest that individuals who have lower endorsement of Winning and ascribe more to Dominance norms and avoidant coping strategies tend to report higher levels of depressive symptomatology.

Table 2.

Summary of Simultaneous Multiple Regression Results with Center of Epidemiological Studies-Depression as Criterion and Winning, Emotional Control, Self-Reliance, Dominance, Avoidant Coping, and Asian Values as Predictors

Variable B SE B β
Winning −.40 .14 −.25**
Emotion Control .14 .13 .08
Self-Reliance .25 .20 .10
Dominance .75 .35 .17*
Avoidant Coping 7.54 1.01 .53**
Asian Values −.81 2.10 −.03
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Note.

*

p < .05.

**

p < .01.

Discussion

The present investigation contributes to the literature by identifying risk and protective factors of depressive symptoms among Asian American men. The results suggest that the masculine norms Winning and Dominance, and avoidant coping strategy were associated with depressive symptoms among Asian American men, while endorsement of Asian culture values, Self-Reliance, and Emotional Control was not associated with the dependent variable.

The findings build upon on the existing body of research regarding the relationship between masculinity and depressive symptoms. Mahalik et al. (2003) discussed the possible benefits associated with conformity to certain masculine norms, and for Asian American men in this study, subscribing to Winning was found to be a protective factor of mental health. This may be due to the fact that men who value Winning and spend a lot of energy to win, may experience more success and achieve a higher status than their peers. Moreover, since American society tends to value the masculine norm of Winning among men (Mahalik et al., 2003) this attribute may be positively reinforced and validated. Furthermore, men who have Winning beliefs may be able to better self-regulate their negative thoughts (Lengua & Sandler, 1996). For example, if an individual who adheres to Winning norms experiences a draw-back at work or school, the individual may be able to direct their thoughts in a more optimistic direction, thus mitigating feelings of hopelessness and other adverse thoughts.

On the other hand, this current study revealed that Asian American men who endorse Dominance masculine scripts tended to report greater depressive symptomatology. This finding provides support for the masculine dysfunctional-strain theory that contends that even though these men are fulfilling these “male codes” (Levant, 1996), these norms create additional burden and strain on the individual. For example, adhering to Dominance norms may create distress and tension in interpersonal relationships and thus negatively impacting the individual who adheres to these masculine scripts. In addition, it is possible that these men may have less cognitive flexibility or the ability to consider alternative options, such as adapting to the situation or compromising (Martin & Rubin, 1995).

Emotional control did not predict depressive symptoms as hypothesized. This finding is similar to Rude and McCarthy’s (2003) results that found no significant difference in willingness to self-disclose negative emotions between depression-vulnerable and never-depressed undergraduate college students. Contrary to Mahalik et al.’s (2003) findings in a large undergraduate sample, Self-Reliance was not found to be associated with depressive symptoms. This lack of association could be due the inclusion of the Asian values and avoidant coping measures, which might have taken some of the variance away from Self-Reliance in explaining depressive symptoms.

Our results supported our hypothesis that avoidant coping strategies were predictive of depressive symptoms among Asian American men. This is congruent with results from previous research conducted with other men (Chan 1995; Dunn, Whelton, & Sharpe, 2006; Dyson & Renk, 2006; Wilkinson, Walford, & Espnes, 2000). It appears that cognitive strategies, such as, giving up or denying the presence of stressors, contributed to increased depressive symptoms. That is, by avoiding or not dealing with the stressor or issue, the individual creates more distress and problems for himself. These findings lend support to the self-medication theory that postulates that individuals use substances to deal with psychological distress. However, since we did not include a measure that specifically assessed alcohol consumption to cope with stressors (Cooper, 1994), this hypothesis is speculative at best. Future studies with Asian American men should include Cooper’s (1994) assessment along with a depression measure to test this hypothesis.

Contrary to our hypothesis, this study found no relationship between the endorsement of Asian values and depressive symptoms. It is possible that while cultural values are important component of identity (Iwamoto & Liu, in press) and have been found to be related to self-esteem among Asian Americans (Kim & Omizo, 2006), conformity to masculine norms and the use avoidant coping strategies may be more salient factors for this group in predicting depressive symptoms. Another alternative explanation could be that cultural values have an indirect influence on depression through masculinity norms and avoidant coping strategies. Moreover, cultural influences may be more optimally captured using racial identity measures (Iwamoto & Liu, in press). In other words, since Asian American men tend to be racialized and are often negatively depicted in the media (Liu & Chang, 2006), the interaction between racial identity and masculine norms may better account for the cultural/racial specific masculine strain experienced by these men.

While our findings add to the understanding of potential mechanisms contributing to depressive symptoms among Asian American men, there are several limitations to this study. First, only Asian American men were included in the study, therefore it would be interesting to examine if the predictors and the magnitude of the associations to the outcome measure would be comparable with men from other racial/ethnic groups (i.e., Latinos, African Americans, Caucasians). Second, this study is cross-sectional, therefore causality is not assumed. Future studies should consider examining these relationships longitudinally, or investigate how factors such as masculinity changes over time among diverse populations. Third, although a significant relationship between Dominance and depressive symptoms was detected, the Dominance scale’s internal consistency estimate was low. Thus, caution is warranted in interpreting this finding. If this subscale could be improved psychometrically, it is possible that the main effects would be larger. Fourth, given that the majority of the participants were college students, the result cannot be generalized to non-college and older Asian American men. Future studies should include non-college educated or a community sample of men as these groups have been overlooked in the literature. A broad cross-section of the population would yield insights about men from different generations and social-economic background. Finally, our study also did not measure the participants’ degree of acculturation, which can be a mediator between the independent variables of this study and depressive symptoms.

Implications

Despite the limitations, the results of this study highlight the potential benefits of assessing the endorsement of masculine norms such as Winning and Dominance, as well as the use of avoidant coping strategies, among Asian American male clients. This assessment could be approached by integrating motivational interviewing techniques (Miller & Rollnick, 1991), thereby asking Asian American male clients to think about the pros and cons of endorsing specific masculine norms. This technique may assist the client’s reflection regarding the influence of gender scripts and expectations on his psychological functioning. Additionally, if an individual has beliefs related to those measured by the CMNI Winning subscale, the clinician can ask the client to recall how these beliefs helped him during difficult times in the past (using this strength-focused technique can have the effect of providing additional hope to the client) and then ask him how can he apply these same beliefs in his current situation. Since avoidant coping strategies were a robust predictor of depressive symptoms, clinicians need to assess the clients’ non-adaptive emotional regulation strategies. Specifically, the clinician can ask the client to reflect upon his current coping strategies and discuss how these maladaptive coping strategies can be a contributing factor to the depressive symptoms. The clinician can also provide the client with a handout of positive or active coping strategies that are congruent with the client’s lifestyle (i.e., participating in sports or sporting events with friends, identifying friends he feels comfortable talking to about his problems). The handout can serve as a “therapeutic gift” or “gift giving” (Sue & Zane, 1987), which can be an effective technique for Asian American men since the handout can be immediately helpful to the client, and the client “takes away something” tangible from the session. Finally, although Asian values were not associated with depressive symptoms, it may be fruitful to explore with the client what it means to be an Asian American man in America. This might help the client gain insight about how his subscription to certain masculine norms are related to his racial, ethnic, and cultural identities and values (Iwamoto & Liu, 2008). That is, rather than discussing masculinity as a separate experience from his racial and ethnic experiences, clinicians may help clients talk about how these identities and values are interconnected and interdependent.

In summary, Asian Americans represent one of the fastest growing populations in the United States therefore clinicians must be prepared to meet the needs of this group. To this end, it is crucial that researchers identify factors associated with depressive symptoms among Asian Americans in order to inform culturally-responsive services and interventions. This study represents an important step in expanding the literature by elucidating the role of masculine norms and avoidant coping strategies on the mental health of Asian American men.

Acknowledgments

Manuscript preparation for the first author was supported by the National Institute of Health Drug Abuse grant 5T32 019426-04.

Footnotes

Publisher's Disclaimer: The following manuscript is the final accepted manuscript. It has not been subjected to the final copyediting, fact-checking, and proofreading required for formal publication. It is not the definitive, publisher-authenticated version. The American Psychological Association and its Council of Editors disclaim any responsibility or liabilities for errors or omissions of this manuscript version, any version derived from this manuscript by NIH, or other third parties. The published version is available at www.apa.org/pubs/journals/men.

Contributor Information

Derek Kenji Iwamoto, Yale University School of Medicine.

Liang Liao, University of Iowa.

William Ming Liu, University of Iowa.

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