Men die younger. Women live longer in poorer health.
Women and girls experience more disability in every region of the world, but men and boys bear a greater share of the global mortality burden. The 2016 Global Burden of Disease data show age-standardised death rates per 100 000 population of 1002 for men and 690 for women. If we understand why, then maybe we can address the causes.
A recent report in the Lancet talks about why men might be dying younger than necessary, whether it’s an innate physical cause or something else. It concludes that “Many of the drivers of men’s ill-health are linked to perceptions and attitudes about manhood and the overall structural organisation of men’s lives and relationships.”
It concludes that our attitudes to what being male means rather than the biological reality, is the problem. And the report goes further to add that the problem is made worse because around the globe, these attitudes are largely ignored, largely invisible. Across the globe, we pay ” insufficient attention to the intersections between masculine norms and men’s health within public health systems”.
An abundance of evidence shows health outcomes and experiences to be different for women and men, and this is true across time, space, and culture. The impact of biological sex accounts for a fraction of these differences; gender explains the rest.
Gender refers to the social phenomena and relationships of males and females in terms of their roles, attributes, and opportunities. In health and otherwise, advantage and privilege are largely the domain of maleness and men. That gender is socially constructed; it lies on top of human biology.
Decades of global research has provided a foundation to continue deepening our understanding of masculinity and masculine norms. Theories of hegemonic masculinity and precarious manhood have established a common set of norms, attitudes, and behaviours related to what it means to be a man in today’s society.5, 6
As the recent Lancet Series on gender equality, norms, and health and other publications have recently highlighted, adherence to these specific masculine norms is associated with unhealthy behaviours. Norms are those often unconscious definitions and expectations of being a woman or a man. They guide and exert pressure to conform to certain behaviours.
Norms do not just exist on an individual or interpersonal level but are powerfully embedded in our cultures, institutions, economies, and ways of being. As the recent lancet series articulates across five papers, rigid gender norms undermine the health and wellbeing of all people—girls and women, boys and men, and gender minorities
The Lancet series lays out extensive empirical analyses and literature reviews to document how norms can be either protective or harmful to health: through gender operating as a determinant of health, by influencing health behaviours, and via expression in health systems, policies, and programmes. It shows how rigid gender systems that perpetuate injustices towards girls and women also disadvantage boys and men.
Highlighting and recognising the importance of gender norms provides an opening to understanding how to create needed change. Ultimately, as the Series concludes, the transformation of gender inequality and norms is a political act. Is the world ready to act?
Gender is a slippery thing. On the one hand, it’s everywhere—#MeToo, pay gap reporting, high-profile sexual misconduct cases, and the campaigns to advance women in science, medicine, and global health. WHO consistently states gender equality to be a cross-cutting feature of its work. Gender is ubiquitous in the UN system: UN Women, UNFPA, UNICEF, and the sustainable development agenda.
On the other hand, it’s nowhere. Not in the universal health coverage plans, not among WHO’s ten priority global health threats, and not tied to governance or the accountability of organisational and government leaders. Despite decades of funder and journal policies, sex and gender are not routinely reported in research. Increasingly prevalent gender mainstreaming programmes have proved largely ineffective.
Gender now runs the risk of being treated like motherhood and apple pie—a common good no one would disparage, but neutered of its radical political nature. Or as “everyone’s problem but no one’s responsibility”, as Geeta Rao Gupta and colleagues argue in their Lancet series paper. An uncomfortable truth is that the shift in global health thinking from women and girls to gender has depoliticised the agenda intended to transform lives and wellbeing. Despite the good intentions of broadening child, adolescent, and maternal health to their larger social context, the gender equality aspiration hasn’t translated into a meaningful action and accountability agenda for women or men.
It hasn’t resulted in men exercising their political prominence and power to drive equity. And it hasn’t sufficiently overcome the brutal reality for millions of women and gender minorities in the world who suffer sexual and domestic violence, lack access to essential prerequisites for health and safety, or are denied basic human rights and control over their own bodies. Gender analyses that simply reaffirm the value placed on traditional masculinity over femininity, rather than link this to broader relations and patterns of economic and political power, will only ensure the status quo
Promundo Global’s 2019 report, Masculine Norms and Men’s Health: Making the Connections, shows that seven key male health behaviours—poor diet, tobacco use, alcohol use, occupational hazards, unsafe sex, drug use, and limited health-seeking behaviour—account for more than half of all premature male deaths and about 70% of men’s illnesses.
All seven behaviours are partly related to masculine social norms that reinforce the notion that manhood is associated with self-sufficiency, stoicism, risk-taking, and hypersexuality. These norms, individually and collectively, encourage a specific set of health behaviours across the globe that are among the drivers of men’s poor health outcomes and have implications for both men and women.
Research has also called attention to the social determinants of men’s poor health, particularly how restrictive ideas about manhood intersect with poverty, ethnicity, gendered employment patterns, and other factors. Recognising the importance of these issues, the WHO Regional Office for Europe released a strategy in 2018 for addressing men’s health and a similar document from the Pan American Health Organization is expected to be released later in 2019.
Public health experts and researchers need to expand the understanding of men’s physical and psychosocial health to build an evidence base for programming and policy. Presently, much research on masculinity and men’s health draws on a deficit-based approach, whereby men are pathologised or masculinity is framed as inherently problematic or toxic.
It is important to recognise and leverage the fact that many men take care of their individual health and wellbeing and often access health care through their support for the health and wellbeing of their partners or children. Being male needs to be seen as the solution to the problem.
Efforts to address men’s health should build on men’s positive health practices, experiences, and desire for health care, and the importance of taking care of themselves for their own wellbeing and those around them including women, who often bear the social and economic costs of men’s poor health.
Some men seek preventive care, support their partners and children in accessing health care, and use health services adequately. Moreover, many men around the world engage in health promoting behaviours such as regular exercise, healthy diets, and practising safe sex.
Academics and researchers should research healthy masculine norms that could promote healthy behaviour, such as responsibility and self-control, alongside men’s positive involvement as fathers, partners, caregivers, and community members.
Through an asset-based approach, the public health community can help pivot and amplify the conversation to be more constructive and begin to incentivise healthier behaviours among men through embracing positive and health-conscious masculine norms.
Additionally, academics, in partnership with health-care professionals, should evaluate the effectiveness of different health-promotion approaches for male engagement, norm and behaviour change, and health-care service provision throughout the life course, taking account of dynamics of power and poverty.
Rather than blaming men, or presenting masculinity as inherently toxic or damaging, we need to articulate a positive masculine approach, a gendered and intersectional lens that articulates evidence-based concepts of healthy masculinities and men’s wellbeing. The public health community must capitalise on the growing momentum of attention to gender and to men’s health within a framework of universal health coverage.
Men’s health matters for everyone; by adopting a gendered, asset-based approach that embraces social determinants of health, we will be able to improve the health and wellbeing of countless men, women, and families around the world.
