Three studies suggest that, although men live shorter lives than women, their health receives little attention in health policies

This series of articles published in The Lancet analyses, on the one hand, global patterns of morbidity and mortality among men and, on the other, the extent to which health policies have addressed their health. The authors conclude that men exhibit specific patterns of disease and mortality, in which the intersection of various axes of inequality creates particularly vulnerable groups; yet these issues have received little attention in the political sphere.
 
This premise is, however, open to debate. Rather than having been rendered invisible, issues relating to men’s health have traditionally occupied a central place on the scientific and health agenda, precisely because the masculine model has been regarded as the universal norm in the field of health. However, this opens up a possibility that has been little explored to date in gender studies: namely, that a gender-based approach to research and the development of health policies can also benefit men. 

Thus, incorporating a gender perspective into research benefits both men and women, as it enables the identification of those factors derived from the social construction of gender that are associated with poorer health outcomes. In the case of men, this approach would facilitate the development of policies addressing issues such as the commercial determinants of health – that is, the systems through which commercial interests impact people’s health and health equity – or the influence of the ‘manosphere’, issues that are particularly relevant to men’s health.

The fact that a journal as prestigious as The Lancet is devoting a series to men’s health strikes me, without a doubt, as good news, because it helps to raise the profile of an issue that deserves greater attention in the field of public health. However, we cannot say that this is a new topic, as for decades we have had research showing how gender norms and models of masculinity influence men’s health. But it is no less true that this series represents an opportunity to place the debate more prominently on the scientific agenda and within health policy. So, overall, I would say that one of its main contributions is that it brings together complementary evidence and perspectives that allow for a better understanding of health inequalities, focusing not only on the differences between men and women, but also on the social, economic and cultural conditions that help to explain them. In this respect, these are well-founded studies, combining the analysis of epidemiological data from established sources with a comprehensive review of the available scientific evidence.

Indeed, one of the aspects I find most noteworthy about this series is that it highlights the need to look beyond the health differences we observe between men and women. Some of the epidemiological measures used, such as life expectancy or disability-adjusted life years, provide us with valuable information on the magnitude of certain health differences and inequalities; however, on their own, these measures do not enable us to understand what lies behind them. That is why those of us who work in this field emphasise that disaggregating data by sex is, of course, a necessary first step, but it is not the same as incorporating a gender perspective. Nor should we forget – and I believe this is another of the series’ most noteworthy contributions – that there are also significant inequalities amongst men themselves, which can be obscured by population averages.

For example, we knew that the hegemonic traits of masculinity – defined by attitudes and ideals related to strength, control and a reluctance to show vulnerability, such as emotional repression – can encourage the adoption of risky behaviours that negatively affect men’s health. The series highlights issues such as cardiovascular health, suicide, injuries and the consequences of violence; not to mention a lower commitment to preventive and self-care practices, as well as the adoption of unhealthy lifestyles, such as a sedentary lifestyle and the excessive consumption of certain substances, such as alcohol. These patterns are associated with higher rates of premature mortality in men. In other words, we have solid evidence that a large proportion of premature deaths among men are due to non-communicable diseases and injuries. In this regard, the articles remind us that, whilst there are biological factors that we certainly cannot ignore, a significant part of the increased risk of premature death among men is due to social factors, over which there is scope for intervention.

Previous studies had already shown how certain ideals of masculinity are associated, for example, with men’s reluctance to express their health concerns; this is partly due to the internalisation of social expectations that link masculinity with self-sufficiency and strength. Consequently, acknowledging a health problem can be perceived as a sign of weakness, which conflicts with the norms of hegemonic masculinity. This need to project invulnerability not only affects their self-image and public perception, but may also limit their willingness to seek help and adhere to treatment. However, when discussing health from a gender perspective, it is also important to consider other structural and psychosocial factors. For example, the impact of unemployment on mental health tends to be greater among men, partly due to the frustration they may experience if they feel they are failing to fulfil the traditional role of being the main provider for the family unit.

In this regard, these articles help to ensure we do not fall into the trap of thinking that discussing a gender perspective means focusing solely on women. These publications in health-related journals reinforce the idea that, in societies such as ours, which have undergone significant socio-demographic changes in a short space of time, the analysis of gender identities is particularly relevant. And this is because it allows us to gain a more nuanced understanding of the differences and similarities in the behaviours and experiences that affect people’s health. In the case of the study of masculinities, this line of research highlights the health risks and problems that men often face as a result of how they interpret their identity and maintain their social position. In other words, certain social codes of masculinity may help to maintain positions of privilege, but at the same time pose health risks to men themselves. This phenomenon is precisely what our research group has conceptualised as ‘the dark side of privilege’.

This becomes evident when we observe that health disparities amongst men from different ethnic groups, social classes or geographical regions cannot be attributed solely to biological causes. Hence, throughout this series of articles, we have also highlighted the need to take gender analysis a step further by incorporating an intersectional approach.

The series also highlights that some countries have already developed specific health strategies or policies for men, which would also represent a significant step forward for Spain. The aim would be to develop a strategy that challenges harmful gender norms and promotes men’s active participation in looking after their own health and that of others. To this end, greater attention must be paid to policies and interventions that encourage men to share responsibility for informal care, child-rearing, the prevention of violence, and sexual and reproductive health. Furthermore, integrating a gender perspective into healthcare training and health services is key not only to eliminating gender bias in healthcare provision, but also to breaking down communication barriers and improving adherence to treatment.

On the other hand, although a significant proportion of research on men’s health has traditionally focused on analysing behavioural differences, I believe that designing policies, programmes and interventions exclusively around men’s risk behaviours reinforces a restrictive approach to gender. Furthermore – and the series is very illustrative in this regard – making progress in this area requires recognition of the health inequalities that exist amongst men themselves. Furthermore, acknowledging the consequences of hegemonic forms of masculinity for men’s health should not simply become a means of assigning blame, but rather an aspect that should guide the development of more comprehensive health policies that are sensitive to the incorporation of a gender perspective.

The three papers in The Lancet are of high scientific quality and adopt a socio-ecological approach that allows for the integration of the various factors explaining how men’s health is linked to masculinity – that is, to the way in which sociocultural constructs define what it means to be a man, with all the behaviours, habits and attitudes associated with it – and how this relationship results in poorer health.

What is surprising is that such an objective impact – reflected in indicators such as disability-adjusted life years (DALYs), which are 16 per cent higher for men than for women, a lower life expectancy, and an age-standardised mortality rate 38 per cent higher than that of women – has not been the focus of attention or policy by those men who have historically held positions of institutional power, from which the necessary measures to improve men’s health could have been developed.

The analysis of the situation takes the socio-ecological model as its conceptual framework, in which three main axes are interrelated: the first consists of social, structural and economic determinants; the second comprises the intersection of elements within the power system, such as class, gender, ethnicity, sociocultural factors, etc.; and the third, syndemic theory, which enables social and environmental factors to be directly linked to those associated with disease, and how this relationship produces a synergistic effect.

Reading the studies raises questions about the reasons for this ‘passivity’ in responding to such a serious problem with such far-reaching and profound consequences; for, as noted, the negative impact on men’s health leads to more severe social problems, which in turn further affect men’s health and, more broadly, that of society as a whole. And the reasons can be deduced from the very relationship described in the studies between sociocultural factors and the deterioration of men’s health – a relationship that has a dual impact, at both the social and individual levels.

At the social level, the idea of a virile, provider and stoic masculinity facilitates the emergence of psychosocial stress in various circumstances, and leads to habits that are harmful to health, such as the use of toxic substances, engaging in risky behaviour in different contexts, or resorting to violence. And at the individual level, once a health problem has arisen, behaviour is characterised by a tendency to seek clinical care later, as well as lower adherence to treatment or discontinuation of it.

The central role of sociocultural constructs in the factors leading to poorer men’s health is reinforced by the observation that those who have held institutional positions to develop a response to men’s health issues—who have themselves been men—have failed to do so. The response can also be deduced from the socio-ecological model and revolves around three key points. On the one hand, men’s health problems are associated with those who engage in a range of harmful habits under the concept of ‘toxic masculinities’; on the other hand, it is understood that men’s health problems represent a kind of ‘price’ to be paid for the social benefits and privileges that the model itself makes available to them through the very behaviours that cause these health problems; and thirdly, the intersectionality of factors that increase vulnerability in certain groups of men or in men in specific circumstances – such as when poverty, ethnicity, unemployment, etc., coincide – is interpreted in such a way that, rather than seeing the health problem as exacerbated by these intersecting factors, it is understood to be an individual problem of those men, not a social one. This idea justifies the invisibility of health problems associated with masculinity and reinforces the social model of inequality by leading people to believe that certain men are ‘inferior’ by nature.

Neither in Spain nor in most other countries are there specific strategies to address men’s health problems and their relationship with social determinants, which are not merely reduced to the individual level within a clinical framework. It is therefore essential to address these issues in health policies and plans, particularly at a historic moment when factors such as social uncertainty, job insecurity, psychosocial stress and isolation—exacerbated by the use of social media—are converging, all of which have a direct impact on men’s health.

The picture becomes even bleaker when we consider that two critical factors are currently converging: firstly, the promotion of an idea of masculinity based on traditional notions of virility, male stoicism, and the glorification of high testosterone levels – expressed both behaviourally and physically through a muscular physique. And, secondly, proposals that reject the use of gender as a framework for developing health policies – positions which are even calling into question all existing initiatives addressing women’s health, and which will make it more difficult to incorporate a gender perspective into health policies centred on masculinity.