“I AM a Man”: Manhood, Minority Men’s Health and Health Equity

Abstract

Objective

To consider how manhood is a key social determinant of minority men’s health.

Design

This commentary explicates how manhood intersects with other determinants of health to shape minority men’s stress responses, health behaviors and health outcomes across the life course.

Results

Manhood, which perpetually needs to be proven, is an aspirational identity that is defined by the intersection of age, race/ethnicity and other identities. Minority men seek to and successfully embody US-cultural and ethnic-specific aspects of manhood in their daily lives by engaging in behaviors that constantly reaffirm their gender identity through a complex internal and social calculus that varies by intra-personal characteristics and context. Manhood and health are relational constructs that highlight how the salience of masculinities are shaped by perceived and actual social norms and expectations. A life course perspective adds a framework for considering how some gendered beliefs, goals and behaviors change over time while others remain static. Three life course frameworks highlight different mechanisms through which minority men’s life experiences and physiological and behavioral responses to gendered social norms, beliefs and expectations become embodied as premature mortality and other health outcomes over the life course.

Conclusion

Manhood represents an important lens to understand how minority men’s identities, goals and priorities affect their health, yet the role of manhood in minority men’s health is understudied and underdeveloped. To achieve health equity, it is critical to consider how manhood shapes minority men’s lives and health across the life course, and to address how manhood affects gendered and non-gendered mechanisms and pathways that explain minority men’s health over time.

Introduction

In March 1968, Rev. Dr. Martin Luther King, Jr. led the Memphis Sanitation Workers Strike to protest the salary inequities between Black and White sanitation workers.1 One of the most iconic images from this demonstration was the sea of signs that proclaimed, “I AM A MAN.” For these minority men, defining manhood was intertwined with being paid equal wages. The token desegregation that replaced de-jure segregation fused an economic dispute over wages with a gendered clash over what it meant to be a man. This brief example highlights that segregation and other forms of institutional racism not only impeded economic mobility but threatened minority men’s gender identities.2 Restricting or creating obstacles to minority men’s ability to define themselves as men through fulfilling the patriarchal role of an economic provider3-5 has been an important and unique aspect of how racism is gendered. While it is critical to help minority men develop more progressive notions of manhood4,6 and move beyond patriarchal and heterosexist notions of masculinity,7-10 it is critical to recognize that the issue of defining manhood is not just a problem rooted in the ideals of minority men. These problematic aspects of manhood reflect US cultural values and expectations of adult males and often the way men are defined by their communities.11 Yet much of the research has treated minority men, not gendered racism or social norms and expectations, as the problems.2,3,12,13 In this article, I discuss the intrapersonal, behavioral, interpersonal and cultural factors that help explain how manhood is a social determinant of health across minority men’s life course.

Manhood is a determinant of men’s health disparities and minority men’s health and a key to explaining and improving the health of minority men across adult phases of life. This year marks the 30th anniversary of the publication of the 10-volume Secretary’s Task Force on Black and Minority Health that provided critical details on the poor health profile of African American and other minority men across the adult life course.14-16 During the last three decades, the difference in life expectancy among minority men and between minority men and women has increased.17,18 Men have higher death rates than women for 14 of the top 15 leading causes of death,19 and there are persistent racial and ethnic disparities in health among men.20-22 Research on masculinity and health has primarily explored the role of gendered influences on men’s lives, yet we still know relatively little about specific pathways through which gender norms, roles and expectations become embodied as sex differences in health, men’s health disparities or minority men’s health profiles.23,24 In this commentary, I define manhood, distinguish it from masculinity, and discuss its relationship to health. Next, I use an intersectional lens to discuss the gendered and non-gendered factors that shape manhood and minority men’s health. And finally, I conclude with a discussion of key life course frameworks for understanding minority men’s health.

What Is Manhood?

Simply, manhood is the state of being a man. While the specific ideals of manhood change over time, the need for men to prove their manhood remains constant.25 Womanhood is often viewed as a status that is attained by biological changes and that remains secure once reached. Manhood, however, is a social status that is difficult to attain yet easily lost, and requires continual public demonstrations.26 Men are more constrained than women by gender ideologies and stigma, and are subject to greater scrutiny and penalty if they deviate from behaviors that approximate a masculine ideal.27

While there is overlap and some important similarities between the two, masculinity and manhood are distinct. Hegemonic masculinity is an idealized form of masculinity that exists in a specific time, place and culture; it sets the ideal of what it means to be a man and the standard by which all men are judged.4,6,33 Masculinity represents the over-arching beliefs, goals and values that pattern and configure relations among men and between men and women.4,6 But masculinity does not capture how gendered expectations are qualitatively different for males across the adult life course or how masculinities change over time.6 What distinguishes manhood from masculinity is that manhood is a relational construct that highlights how age shapes the meaning of masculinity, and the way men prioritize performing or demonstrating that they are indeed men (eg, not boys, not feminine). Manhood also implicitly offers a set of characteristics and virtues that adult males use to demonstrate and embody key gendered, racialized and class-bound values and goals.3,34-36 Consequently, one of the most enduring qualities characterizing manhood is not its contents – stereotypical male qualities, behaviors, preferences, or tendencies – but the constant anxiety of its precariousness.26

Some studies have explored how notions of manhood and masculinity relate to sexual health behaviors and HIV risk,9,28 substance use and mental health,13,29 and help-seeking30 and chronic disease risk behaviors.31,32 These studies have offered some important insights into minority men’s health yet they tend to look broadly across masculinities instead of narrowing to consider the phase of life factors and concepts that are essential to linking manhood and minority men’s health.

The more masculine behaviors men enact, the greater likelihood that they will be respected.37-39 Whitehead’s Big Man Little Man Complex argues that minority men try to achieve a level of respectability through economic success, educational attainment and social class status.40 But, the opportunities to achieve respectability through these means are often blocked.21,22,41,42 Minority men’s efforts to overcome these obstacles increase their stress levels and psychological strain; these struggles may also trigger a behavioral response that may reduce the physiological and psychological effects of stress but increase their chronic disease risk, morbidity and mortality.43,44 Given the challenges minority men face in achieving respectability and defining manhood, in part by economic success, can create significant stress in minority men’s lives.7,41 These challenges may help explain why socioeconomic status is inversely related to stress for African American women but as African American men’s socioeconomic status improves, they tend to endure more stress.41,45,46

In addition to pursing success along the respectability dimension, minority men use health behaviors to demonstrate prowess along a reputational dimension – the social and cultural dimensions of traditional masculinity (ie, virility, sexual prowess, risk-taking, physical strength, hardiness, alcohol/ substance use/ abuse) – that may increase their risk of morbidity and mortality.40 What is critical to recognize in this conceptualization of masculinity is that minority men are expected to balance gendered expectations and achieve success along both respectable and reputational dimensions across the life course.40 Pursuing success along each of these dimensions confers physiological, psychological and behavioral risks for minority men’s health.

Minority men negotiate masculinity by piecing together aspects of hegemonic masculinity that they have the capacity to perform to establish their own standards and meanings of manhood.33 The notion of “masculine capital” suggests that men are able to engage in behaviors that accommodate or compensate for non-hegemonic masculine behavior within an overall masculine identity.37 The calculus used to assess manhood is complex because each masculine and non-masculine behavior has a different value, and the value ascribed to each may vary by identity group. For example, while some young adult men in college settings value heavy drinking, sexual promiscuity, or risky recreational activities, minority men who do not engage in these behaviors because they are not consistent with their beliefs or peer social norms may experience less of an effect on their masculine capital than those who define masculinity in these ways.37 Performances of masculinity and manhood, therefore, are shaped by the structural and institutional context, economic and social resources, and opportunities available to demonstrate manhood.43,44,47-50 These behaviors help men feel that their masculine identities are valid in the context of their everyday lives and social networks, though they also can affect their health.33

An Intersectional Approach to Manhood and Minority Men’s Health

Manhood has been identified as an important aspect of minority men’s lives and identities.34,51-54 While it is a key contributor to the poor social and economic outcomes of minority men,40,55-59 theories explaining how manhood is a determinant of minority men’s health are underdeveloped. Definitions and practices of manhood vary by time, location and person, but notions of manhood and social determinants of men’s health have not adequately considered men’s social status, economic position, or relations among men as determinants of health.27,60

Being an adult male triggers a variety of social expectations, relations and practices that highlight how identities and health are shaped by gendered environmental and experiential factors.24,27,61 Intersectionality is a useful tool to examine manhood in minority men’s health as it provides a way to explore how socially defined and socially meaningful characteristics derive meaning from one another, and cannot be fully appreciated as factors that operate independently or additively.35,62,63 While a key element of performing masculinities is distinguishing them from feminities,27 minority men also are trying to distinguish themselves from boys, from members of a different social class and from men of other ethnic groups. This highlights that a key element of manhood is not just that they are males, but that they are not women, boys, of another social class, of a different racial or ethnic group or of any other identity group that they do not see as positive.27,28

Minority men’s social location in the stratification hierarchy shapes how they construct meaning,64 and the social, political and economic resources that minority men may develop and use to cope with stressors.21,65-67 For example, minority men’s inability to achieve middle-class status by economic or occupational means has led to class identity and manhood being defined more by material possessions, social networks, and positions in faith-based and other institutions.2,3,7 While an intersectional approach provides an important lens to explore the diversity of determinants of minority men’s health, adding a life course approach to the study of manhood and minority men’s health provides a tool to incorporate a causal chain of these explanations.18,27,68-70

A Life Course Approach to Manhood and Minority Men’s Health

Not only are men’s notions of manhood shaped by the intersection with other identities, but manhood, by definition, is learned, reinforced and reproduced over the life course.71 Men’s demonstrations of manhood vary over the course of their lives in response to life experiences, aging and social context.27,72 Notions of masculinity and manhood are important lenses through which men make health-related decisions, and, therefore, are the strongest predictor of individual risk behavior over men’s life course.27,73 The aspects of masculinity and manhood that minority men prioritize change over time as men think differently about themselves; their families, friends and community change their expectations of minority men as they age.27,74 Taking a life course approach provides minority men’s health a developmental perspective that helps to identify social determinants of minority men’s health that otherwise would remain unidentified and unexplored.27,72

According to Lohan, there are three models that are important for identifying developmental pathways across the life course of men: the critical periods model, the pathway model and the accumulation model.68 The critical periods model suggests that early life adversity and key developmental points from conception to death are major influences on disease risk; these factors can help identify how key transition points across the life course can positively or negatively affect minority men’s health at specific points in their lives.68 Concerns about how men are embodying notions of manhood may be heightened during key transitions and life changes across the life course (eg, achieving age milestones; developing a chronic disease; losing sexual functioning).37,75

The pathway model focuses on how seminal early life events set men on a trajectory that builds on later events to adversely affect life chances, notions of manhood and minority men’s health outcomes.68 These life events can affect health through the challenges that minority men face in trying to be successful in respectability aspects of masculinity and manhood (eg, educational attainment, career stability and success). The pathway model highlights how lower educational success in childhood may leave minority males unprepared to compete for and maintain gainful employment,76 which shapes higher rates of stress and obesogenic behavior-related chronic disease in middle-age and late life.69,77

Finally, the cumulative effects model highlights that the number, clustering and duration of exposure to unhealthy and stressful environmental circumstances at different phases of minority men’s lives has a cumulative effect on their health over time.68 Both gendered social determinants of manhood and health shape minority men’s lives and experiences through economic, social and environmental factors.20,65,78 Minority men are more likely than White men to live in poverty, work in low-paying and dangerous occupations, reside in close proximity to polluted environments, be exposed to toxic substances, experience threats and realities of crime, and live with cumulative worries about meeting basic needs and material representations of class status. These experiences affect gendered and non-gendered aspects of minority men’s environments, identities and experiences and health over the life course.42,65,66,79

Discussion

Minority men’s health is a problem for the nation, not just minority populations. Males in the United States have the lowest life expectancy among men in peer, high-income countries (eg, Australia, Canada, Japan, Sweden, the United Kingdom, etc.),80 and these bleak numbers are driven largely by the poor health profile of minority men. Despite minority men accounting for much of the reported sex difference in mortality globally and domestically,81,82 there is a critical need to use a gendered lens to better understand policy and programmatic strategies to improve US minority men’s health because of the social and economic costs to the nation.83 Focusing on gendered norms and expectations and the role that manhood plays in minority men’s health are essential to understanding the health of men who are structurally advantaged because of their sex yet structurally disadvantaged because of their race, ethnicity and other identities (eg, sexual orientation, disability status).

Despite the importance of these constructs for men’s identities, the literature on how minority men’s masculinities and notions of manhood differ from traditional notions of masculinity is limited.10,84,85 And, little research has explored the relationship between age-congruent notions of manhood and health.22,35,74 Future research should utilize life course models to identify and test the pathways that link manhood and health; there is an urgent need to conduct research that examines the relationship between manhood and health among key phases of life across the adult life course.74 The belief in, and adherence to, some hegemonic masculine norms appear to be intractable and unaffected by social experience, while others appear to be malleable over time.7,8 It is, therefore, critical to explore what aspects of manhood remain consistent over time and which are subject to change if we are to design and implement strategies to improve minority men’s health and eliminate men’s health disparities. Minority men’s health outcomes are the result of dynamic notions of manhood and gendered and non-gendered determinants of health. The field of minority men’s health would benefit from critical examination of the contributions of critical periods and life transitions,86 educational and other pathways,68 and the cumulative effect of disadvantage and gendered racism13 over time. Research and policies to improve minority men’s health should recognize and address the psychological, health and social consequences of not being able to marshal the material resources necessary to express normative or hegemonic masculinities while we help men develop more progressive notions of manhood.4,6