Australia's National Men's Health Policy ... - CSIRO Publishing

Perspectives

Australia’s National Men’s Health Policy: Masculinity Matters Margo Saunders and Anita Peerson

Introduction A national men’s health policy has been a long time coming. Australian activity since the early 1990s stems from men shaping the agenda around men’s health and women advocating for a men’s health policy from the context of women’s health and gender equity.1,2 While reports in the 1980s documented gender differences largely due to preventable factors, there was little recognition of men as a population group with distinct health needs.1 During the 1990s, national health goals and targets identified men as a priority group in relation to particular diseases and conditions, the first national Australian men’s health conference was held (1995), and a draft national men’s health policy was prepared (1996). Since then, federal initiatives have been intermittent, with little action and draft policy documents failing to achieve formal endorsement and implementation despite position statements and strategic frameworks on men’s health,3-5 a special issue of the Medical Journal of Australia in 2006 devoted to men’s health, and increasing calls for a national men’s health policy.6 Recent interest in men’s health has been prompted by evidence

of men’s higher mortality rates, men’s apparent reluctance to seek help and use health services7 and a wider focus on behavioural factors for preventable disease and injury,8 with these issues finding a place within a context of rising concerns about health costs and economic productivity.9 The process of developing a national men’s health policy for Australia commenced with the release of background papers in late 200810 and continues with consultations occurring in 2009. The papers indicate that the policy will commit to gender equity, a focus on prevention (including raising men’s awareness of preventable health problems), reducing barriers in accessing health services, addressing needs across the life course, acknowledging groups with specific needs, and building on the existing evidence base. These are all excellent intentions. The extent to which they are honoured in a meaningful and effective national men’s health policy will depend crucially on whether a robust and comprehensive approach is used to frame the key issues. Our analysis of the various background papers, from the perspective of evidence-based policy, suggests there is some way to go before such an approach is achieved.

Abstract

Issue addressed: The development of Australia’s first national men’s health policy provides an important opportunity for informed discussions of health and gender. It is therefore a concern that the stated policy appears to deliberately exclude hegemonic masculinity and other masculinities, despite evidence of their major influence on men’s health-related values, beliefs, perspectives, attitudes, motivations and behaviour. Methods: We provide an evidence-based critique of the proposed approach to a national men’s health policy which raises important questions about whether the new policy can achieve its aims if it fails to acknowledge ‘masculinity’ as a key factor in Australian men’s health. Conclusions: The national men’s health policy should be a means to encourage gender analysis in health. This will require recognition of the influence of hegemonic masculinity, and other masculinities, on men’s health. Recognising the influence of ‘masculinity’ on men’s health is not about ‘blaming’ men for ‘behaving badly’, but is crucial to the development of a robust, meaningful and comprehensive national men’s health policy. Key words: men’s health, health policy, gender masculinity. Health Promotion Journal of Australia 2009; 20:92-7

So What?

The new national men’s health policy provides an opportunity to improve health outcomes for men and boys by advocating greater gender sensitivity in the areas of disease prevention and management, health education, health promotion and health services. Ensuring that this opportunity is fully realised will be difficult without acknowledging the values, beliefs and attitudes associated with men’s gender identity, including those associated with hegemonic masculinity. 92

Health Promotion Journal of Australia 2009: 20 (2)

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What the papers say – and don’t say The suite of papers forming the backdrop to the development of the men’s health policy reveals various omissions and limitations. These are potentially serious, as the papers guide the shape, content and direction of the national policy. Despite the background papers’ introductory remarks about prevention, there is no consistent or coherent focus on prevention as an issue in its own right. This is surprising, given the emphasis on prevention in the Government’s healthcare reform agenda.11 ‘Gender’ is mentioned as a determinant of health but is not considered a social determinant (in Development of a National Men’s Health Policy: An Information Paper); and the suggestion that the health system and men themselves are responsible for improving men’s health (in Developing a Men’s Health Policy for Australia: Setting the Scene) fails to acknowledge how governments and the private sector can influence behaviour.8 Rather than leaving ‘men’s health’ undefined, it would have been helpful to refer to the widely accepted definition: “any issue, condition or determinant that affects the quality of life of men and/or for which different responses are required in order for men (and boys) to experience optimal social, emotional and physical health.”12 Particularly significant is the dismissal of men’s gender identity, and notably traditional concepts of ‘masculinity’, as a significant factor in men’s health. This is a concern, given the extent to which characteristics of ‘masculinity’ have been found to be relevant to, if not at the core of, men’s healthrelated attitudes and behaviours.13-20 There is an acknowledgement, in the principles for the men’s health policy and a new women’s health policy, that ‘gender is a key determinant of health, and that the experience of being male or female in our society affects our health and how we manage it.’ Each policy is to incorporate a gender-specific action plan identifying practical activities to improve health outcomes across the life span (Setting the Scene, p. 2).12 The problem is that the papers seem at best hesitant, and at worst deliberately evasive, when it comes to recognising the role of masculinity in discussions of health and gender.

Gender sensitivity without masculinity? By ‘gender’, we mean, “a dynamic set of socially constructed relationships embedded in everyday interaction.”19 The process of gender analysis – or viewing health initiatives through a ‘gender lens’ – involves identifying, analysing and informing action to address inequalities between men and women arising from their roles and power relationships. This process reveals health risks and problems that men face as a result of the social construction of their roles. Gender mainstreaming involves the integration of men’s and women’s

National men’s health policy

health concerns in the design, development, implementation and evaluation of policies and programs. Internationally, ‘gender analysis’ and ‘gender mainstreaming’ are increasingly being adopted as a means of ensuring that policies and programs respond appropriately and effectively to gender differences.21-25 Based on the results of a large international study, however, there is still a long way to go (and a need for more research and evaluation) in providing interventions which are gender-sensitive, rather than just sex-specific.26 While an Australian Government commitment to a muchneeded ‘gender lens’ is welcome, it is of concern that the awareness of gender, and specifically the ‘experience of being male’, does not extend to an acknowledgement of the central role of ‘masculinity’ in men’s health in relation to either the prevention or management of ill health. Evidence (from a disparate and multi-disciplinary literature) indicates that stereotypical masculine traits do influence men’s health and that these traits continue to be relevant to men’s health in Australia.7-15,17,27-29 Men’s stoicism, commitment to self-reliance when it comes to managing problems, and belief that help-seeking is a sign of weakness were recently cited by Mensline Australia as reasons that men are reluctant to seek help when they need it.30 It has also been suggested that appreciating the role of hegemonic masculinity in the form of the ‘hypermasculine swagger of rural masculinity’ is a prerequisite for improving the health of rural Australian men.17 Research strongly suggests that men’s greatest health risks are the result of modifiable risk factors and that efforts to address these will be crucial in enhancing the lives of men, their families and communities.31,32 Applying a ‘gender lens’ to new preventive health initiatives so that they are viewed from the perspective of men’s needs and circumstances can only improve outcomes. Casting a gender lens over current or revamped programs, such as the national bowel cancer screening program, would provide an important opportunity to improve men’s responses.33 In relation to healthcare access, Development of a National Men’s Health Policy: An Information Paper specifically rejects as misleading the suggestion that the lower levels of healthcare access by men are linked to ‘masculine identity’. It is suggested in the paper that the ‘conjecture’ regarding the importance of ‘masculinities’ has developed in the absence of other evidence, and emphasis is given to the finding that, “no research has explicitly investigated whether men’s perceptions of masculinity influence their decision-making processes with regard to seeking help when they experience ill health.”34 One would have to ask what such research would look like, given the plethora of multi-disciplinary research documenting


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the impact of distinctive and consistent health-related values, beliefs, attitudes and behaviours voiced and demonstrated by men in Western (and some non-Western) cultures.13,16,20,27,29 Rather than disproving the claim that ‘masculinity’ creates barriers to access, the alleged success of ‘men friendly’ services illustrates how some ‘masculine’ values and priorities can be successfully addressed in service provision.7,36,37 Indeed, isn’t making health services (and prevention messages) ‘menfriendly’ what it is all about? We do not suggest that men will fail to utilise healthcare services in any circumstances – only that meaningful changes must consider men’s needs and perspectives. The literature on men’s health suggests that, even taking into account a range of views about masculinity and health, there is widespread support for the notion that ‘culturally appropriate, gender-specific health promotion and disease prevention interventions are needed for men and boys’, including those addressing the needs of various populations of men.38 We would argue that a similar approach is needed for health information and health promotion initiatives with a specific ‘male’ focus. An understanding of gendered aspects of occupational and other settings is also crucial, as interventions designed to support health-promoting practices can be undermined by a masculine culture in which such practices are ridiculed.15,18,27,39

Facing the reality of hegemonic masculinity The use of health-related beliefs and behaviours to define oneself as a man or a woman can have profound impacts on one’s health.13 The active construction of masculinities has been highlighted as central to the understanding of men’s health.14,18,40 The rejection of hegemonic masculinity as integral to a national men’s health policy is therefore a serious concern. By ‘hegemonic masculinity’ we mean the traditional and most influential and culturally accepted notion of ‘manliness’, which includes an expectation of independence, self-reliance, strength, assertiveness, emotional control, competitiveness and aggressive and physical competence and dominance.13,29 Detailed discussions of hegemonic masculinity have been provided elsewhere13,35,41 and are beyond the scope of this paper. However, it should be noted that issues of power and authority are integral to health-related practices and behaviours. The demonstration of hegemonic ideals through health behaviour, for example, serves as a vehicle for men to reinforce strongly held cultural beliefs about power and vulnerability.13 Accepting the relevance of dominant forms of masculinity as integral to men’s understanding of health is not to resort to ‘victim-blaming’ or to relegate men’s health to discussions of ‘men behaving badly’ – rather, it is about fully

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acknowledging that gender, in its various manifestations, is a social determinant of health.32 If the uncomfortable reality is that hegemonic masculinity is a powerful force in Australian men’s health, then it is a reality that must be faced, rather than denied, in a national men’s health policy. The reluctance in the policy papers to address ‘masculinity’ as a key factor in men’s health implies a false distinction between men’s beliefs and the social institutions that perpetuate them. It would be more helpful to acknowledge that these are closely intertwined and to encourage more research into their inter-relationships.18,34,38 As the Australian Medical Association observes: “Beliefs about masculinity and manhood are deeply rooted in our culture. Often they are supported by social institutions and play a role in shaping the behaviour patterns of men in ways that have negative consequences for their health.”4 More research into how gender interacts with factors such as social class, education, age, employment status, geographical location and community, occupation, marital status, race, ethnicity, sexual orientation and disability would be helpful in understanding and addressing barriers to help-seeking and prevention by men.35,42 Being honest about the influence of hegemonic masculinity on men’s health does not imply a denial of the importance of other factors, the inter-relationships between these and various constructs of masculinity, or the existence of systemic barriers to health services. We acknowledge that there are multiple (and sometimes competing) ‘masculinities’ and that gender identities are in a state of change. It is important, however, to consider the continued existence of a hegemonic masculinity among a significant proportion of Australian heterosexual men, especially given that the associated attitudes and behaviours have impacts beyond the men themselves, with implications for their families, workplaces, and community.38,43,44 To acknowledge this is not to apportion blame and is not to allege that change is not occurring, but to simply recognise, as other analyses and policy papers have done, that these influences do affect the way men think about their health, relate to health services, and engage in disease prevention.18,19,29,45 The Setting the Scene background paper refers to ‘prevailing images of masculinity’ (p. 5) as influences on behaviour and health outcomes – as if it were the images, rather than the reality, of masculinity that constitute the issue. Even if we accept that prevailing images of masculinity (quite independent from the reality) influence men’s health, the policy documents ignore the opportunity to discuss the potential for re-defining concepts of masculinity to embrace health as an intrinsic aspect of what it means ‘to be a man’. This is in stark contrast to observations such as those by

Perspectives

the Australian Medical Association, which has noted that, “the detrimental effects of men’s risk taking behaviours can only be addressed if society supports alternative notions of manhood and acceptable male behaviour.”4 It is also a significant departure from the men’s health policy for Ireland and the evidence on which it is based.18,45 The Irish policy explicitly acknowledges that masculinity is a significant factor influencing men’s health. It also proposes that social marketing campaigns addressing health concerns relevant to men need to clearly show that taking charge of their health and seeking help in a timely fashion are allied with masculine attributes such as productivity, vitality and strength (p. 50). When commercial marketing has, within an amazingly short period of time, persuaded men (at least some of them) to use cologne, hair dye and facial moisturisers as part of ‘new interpretations of masculinity’46 it is difficult to see what is so abhorrent about the idea that social marketing might persuade men to use health services.

Research issues and evidence-based policy In the same way that masculinities research has informed the policy recommendations and action plan in Ireland’s national policy, such research should be considered intrinsic to the development of the gender-specific action plan foreshadowed in the Australian background papers. An understanding of how ‘masculinity’ influences men’s health should be pivotal in considerations of how and what needs to happen to improve men’s health outcomes. It also needs to be reflected in the guidance that the forthcoming Australian policy provides on fundamental questions, including those relating to health promotion and healthcare access. For example, there are current debates about whether the goal of improving men’s health can be most appropriately and effectively achieved by trying to change masculine paradigms (as Bonhomme suggests44); by embracing and utilising these paradigms (as exemplified by programs such as PitStop37, by Men’s Health magazine and the media’s ‘consumerist focus’18,47); or by circumventing them and changing the environment to make ‘healthy choices’ the ‘easy choices’ or the default option (as recommended by some public health documents and recently highlighted by proponents of ‘libertarian paternalism’.8,48,49) In contrast to the Government’s men’s health policy background papers, the recent report by Senate Select Committee on Men’s Health notes the increasing attention being given to social and cultural constructions of masculinity.50 The report also supports the view that engaging with men about health issues requires an appreciation of men’s perspectives and emphasises the need for policies, programs and services to be based on sound research about male attitudes and behaviour.51,52


There is a need for more focused research on lay perspectives – on how men define and understand health.53,54 A proposed longitudinal study of men’s health, which has been given strong support from the Senate Select Committee, could play an important role in such research by exploring the contribution of attitudes and behaviour to men’s health outcomes, as well as their linkages with other factors. We have not yet had a clear indication of how Australia’s men’s health policy will distinguish between sex (being biologically male) and gender (living as masculine in a particular culture), or will engage with the discourse around masculinities and health. With the active construction of masculinities, both individually and collectively, central to the understanding of men’s health,14 the efficacy of policy initiatives and of specific programs would benefit from further research into how diverse masculinities relate to different types of ill health, protective behaviours, risk-taking and mortality.45 Australian and international research indicates that attempts to target specific aspects of men’s health (particularly prevention but also treatment) will be of limited success and sustainability without recognising and understanding the health-related attitudes and beliefs that form the ‘backdrop’ to men’s health behaviours.29,45,55 Guidance on improving men’s health outcomes through health promotion, healthcare access and health literacy initiatives, for example, must acknowledge such research.42

The way forward While the Government’s background policy papers indicate that the Australian Government (or at least the Department of Health and Ageing) accepts the need for gender sensitivity in health, the reluctance to discuss ‘masculinity’ is worrying. It is difficult to conceive of a useful discussion about improving men’s health without understanding the role of hegemonic masculinity and multiple masculinities in how men perceive their bodies and their health, engage with the health system, access and process health-related information, and respond to ‘lifestyle choices’ affecting health. Australia’s national men’s health policy needs to be informed by a sound understanding of how ‘masculinity’ affects men’s attitudes and approaches to health, both individually and in specific groups. It could be argued that it is precisely the lack of attention to masculinity in areas such as health service access and health promotion that has helped to stall improvements in men’s health outcomes. There is a need for increasingly sophisticated discussions of health and gender, and calls for a more nuanced approach to the analysis of gender and health,56,57 including an updated understanding of hegemonic masculinity.41 To illustrate the changing and complex relationship between health and gender, Broom suggests that anti-health lifestyles have been adopted by


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working class white men as a way to re-assert their heterosexual masculine authority in the face of alienation and assaults on their masculinity from corporatism and feminism.56 Men’s health as a field of study has generally been characterised by the lack of both a coherent evidence base and a theoretical framework.2,35,52 A major factor in the ad hoc development of policies, programs and services intended to influence men’s health has been the limited and scattered evidence about ‘what works’.35,54 An opportunity to add to the evidence base may be missed if potentially valuable qualitative research (including that relating to lay perspectives) is interpreted to fit limited and predetermined beliefs. Understanding men’s health will involve mining a range of distinct literatures, including studies of men and masculinities, health inequalities and gender inequalities. These need to be linked to the rich literature on the social determinants of health and combined with findings from Australian men’s own experiences and perspectives.43,53,58 It is unclear how the opportunities presented by a national men’s health policy will be maximised if the policy ignores the major socio-cultural drivers of men’s health – the factors that influence how men relate to and interact with others, and the societies, cultures and networks to which they belong. An honest way forward is to stop pretending that masculinity does not promote health-damaging behaviours, while at the same time to be critically aware that health status is a result of the complex interplay of a wide range of factors associated with peoples’ lives. There is no disagreement that greater gender sensitivity is required in health promotion, disease prevention, and the broader health system.

Conclusion Twenty years after the development of Australia’s first national women’s health policy, the Australian Government has taken an important step by responding positively to calls for a national men’s health policy. Such a policy should work to further the integration of gender awareness into the development and evaluation of policies and services, ultimately leading to the best possible health status for men and for women.18,35,45,56 A sustained and adequately resourced effort is required to amalgamate the currently dispersed research evidence into a coherent and accessible form to help guide health promotion and health services for men. 3,35,52,54 From a public health standpoint, moves to improve men’s health outcomes not only concern individuals’ ability to lead healthier lives by making ‘healthy choices’ and accessing healthcare, but are also about creating the environments that enable them to live the healthiest life possible. Reducing inequalities in health will ideally involve addressing the social, economic and environmental conditions that impact on gender in particular ways, with consequent effects on health.59

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None of these issues diminishes the reality that it is the norms of masculine behaviour that form the backdrop against which men must constantly negotiate their healthrelated behaviour.18 Failing to openly acknowledge and discuss the influence of hegemonic masculinity and other masculinities on men’s health will increase the risks that the rate of change will continue to be painfully slow and that the long-awaited commitment to men’s health will fall short of its true potential.

Acknowledgements We acknowledge constructive comments from an anonymous reviewer, and helpful discussions with Bob Pease and Teresa Capetola on an earlier version of this paper.

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Authors

Margo Saunders, Public Health Policy Consultant, Canberra, ACT and Affiliate Member, Freemasons Foundation Centre for Men’s Health, University of Adelaide, South Australia. Anita Peerson, School of Health and Social Development, Faculty of Health, Medicine, Nursing and Behavioural Sciences, Deakin University, Geelong, Victoria and Affiliate Member, Freemasons Foundation Centre for Men’s Health, University of Adelaide, South Australia Correspondence Margo Saunders, Canberra, ACT, Australia. E-mail: [email protected]


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