A SALUTOGENIC APPROACH TO MEN’S HEALTH: CHALLENGING THE STEREOTYPES
J
J Macdonald, D McDermott, M Woods, A Brown, G Sliwka
Presentation
at 12th Australian National Health Promotion Conference,
Melbourne
30th October – 2nd November 2000
Summary
This paper argues that men’s health is a seriously neglected area of
organised health care systems. It presents a challenge to Health Promotion in
that it calls for the issue of men’s health to be addressed on the basis of
logic and justice, calling for a truly health promoting approach rather than a
pathology-focused one. This involves questioning some of the stereotypes around
men’s health issues.
In
this paper it will be argued that men’s health is a seriously neglected area of
organised health care systems which demands to be addressed on the basis of
logic and justice and that it is an area which calls for a truly health promoting approach rather than a
pathology-focused one.
The
argument utilized in describing men’s health as a “seriously neglected area” is
not a compensatory one as in “women’s health has received some attention, so
men’s health should as well.” It is rather that in a population health approach
one looks at the needs of different groups in their own right: children, women,
older people, men. An objective view of the health needs and status of any
population will lead to the inclusion of men’s health issues as a matter of
course. This has not always happened and even when it has, as will be argued,
we tend to find what we are looking for: our view of men’s health is to a large
extent determined by our cultural perspectives on men. Some of these can be
seen as having degenerated into the category of stereotypes and need to be
challenged.
A second point regarding health promotion and men is that we need a genuinely health promoting approach to men’s health. It is a truism that medicine in general has had a focus on the pathological and the pathogenic. Illich’s old claim that we have disease and not health services is, unfortunately, as true today as it was when he made it in the 1970’s (Illich 1975). The best of health promotion has been an attempt to reorient the health services away from an orientation toward disease and pathology and to switch the focus onto prevention, health and wellness. A simple vocabulary check can be useful here: if we want to complement the clinical preoccupation with disease and pathologies, we need a vocabulary that will convey this, a vehicle for the enormous cultural shift involved. The fact is that the vocabulary in health care circles in general has largely to do with disease and other pathogenic concerns: “at risk conditions” and diseases of every kind. At a recent international conference on innovative medical education in South America it was heartening to be presented with a paper, not on ways of dealing with what is broken and ill, but on putting on the medical curriculum courses on understanding family resilience; how to build families’ health (Macdonald, 2000). Whether this preoccupation with health will actually result in significant changes in medical curricula remains to be seen. If we wish to talk health and not just disease, we need to enlarge our vocabulary: what is the opposite of pathologies and pathogenic? The words do not spring too easily to our lips. We see what we are trained to look for, what our so-called “health” culture disposes us to look for: illness, disease, the pathological and how to prevent or avoid it. Antonovosky has a go at the creation of another vocabulary, in the context of human resilience in the face of enormous adversity: he spoke of salutogenesis (Antonovsky 1987). The initial point here is a general one: we need to see salutogenically, to question our overwhelmingly preoccupation with the pathological if we are to think and act accordingly.
This salutogenic approach is of particular relevance in the context of men’s health. The literature shows a concern, laudable in itself, with testicular and prostate cancer, or with CVD (Coronary Vascular Disease): pathologies all. But, more worryingly, the literature on initiatives on men’s health, even so-called “health promotion’, has another major strand of concern: the social pathologies of men: men’s violence, the prevention of abuse, the need to address men’s inadequacies in “talking about their emotions”, men’s failure to use health services and so forth. Even the Australian Doctors’ Reform Society, seen by many as the progressive wing of the medical establishment, in its men’s health policy of just over two hundred and fifty words, uses the term “violence” 8 times (Doctors’Reform Society of Australia, undated). It is hard not to see this as a worrying cultural mindset. This deficiency syndrome is often what we are conditioned to see, are being paid to look for in the area of men’s health.
It is time to put things in balance,, a truly health promotion approach that lives up to its name, and adopts a salutogenic approach to men’s health. How can we focus on the positive in men and build on it? What fosters men’s health? What is good for men? How can we make health services more men-friendly?
The
NSW Department of Health, in its recent directions document, Moving Forward In Men’s Health
highlights how differently a gendered approach to health has developed in
relation to male as compared to female health:
“The
development of women’s health as a separate health care issue was firmly
grounded in the women’s public dissatisfaction with existing health care
services and the strong sense (and later evidence) that health services were
not meeting the specific needs of women.
In contrast, calls for action in men’s health have largely been made by
others on the basis of epidemiological evidence of health inequality,
particularly with regard to mortality rates” (NSW Health Department 2000).
This
acknowledgment of a real difference in the way which calls for change have
arisen in the two cases has, unfortunately, given rise to a misperception, an
untested assumption. It has been
assumed that if health services were not meeting women’s specific health requirements
then, surely, they must be meeting those of men (Fletcher 2000).
Yet,
the fact is that men do access all health services less than women. The 1999
NSW Chief Health Officer’s Report makes the situation in that State clear: men
are not utilising health services – services ranging from hospitals and GPs to
community health services, naturopaths and telephone counselling - at the same
rate as women (NSW Health 1999). The NSW
situation is echoed in reports from other states and other countries. When we
seek to answer this question we should be open to the possibility that our
answer is informed by stereotype rather than informed opinion.
Emerging
research here and in the USA contradicts the assumption that the manner in
which health services are currently configured and the kinds of programmes
offered and the therapeutic or interpersonal styles adopted by health services
really do service the health needs of men.
When actually asked, men are saying loud and clear that existing
services do not meet their needs.
American Medical News, a publication of the American Medical association, reported on one of the largest polls yet conducted on Men’s Health, a telephone survey of 1,500 men and 2,850 women. It summarized one of the key findings as a shortfall in health provider/consumer communication:
“When a man finally makes it to a physician’s office, the quality of the interaction is not all it should be…Men generally liked and trusted their doctors…9 out of 10 rated (them) as excellent or good…(but)…men viewed their doctors as reluctant communicators” (italics added).
The findings of this research, Out of Touch: American Men and the Health Care System, prompted Dr. Jean Bonhomme, a public health physician and president of the (U.S.) National Black Men’s Health Network, to comment on how communication and prevention messages raise issues of cultural sensitivity and linguistic specificity: “Men and women” he says, “really do speak different languages. We need to speak men’s language in health care.”
There is a paucity of good Australian research on the issue. Men, as consumers, have rarely been consulted as to their explanations for the disparity in service utilization. When they are so consulted, the findings sometimes challenge the stereotypes. A pilot study by Henley, surveying men in Eurobodalla Shire on the South Coast of NSW, noted that: “(counter to)…a traditional male stereotype of self-reliance and denial of their problems…this study found (that) there are legitimate reasons for men not addressing their health needs that include:
q A realistic assessment that the needs will not be met
q Practical (transport) and financial obstacles
q Problems with the entry points to such services that have much to do with trust and sense of discomfort with these services as ‘not for men (Henley 2000).
Anecdotally, some men report a lack of sensitivity or respect – even anti-male bias – from some service providers, a lack of “male-friendly” factors in service design and presentation, inappropriate opening hours, “hectoring” or “blaming” health messages and inappropriate language, models and communication style in both the medical and the psychotherapeutic setting. At the Men’s Health Information and Resource Centre, we have commenced a program of research into the twinned aspects of men’s perceptions of their health needs and how well the health system is meeting those needs, to try and collect this emerging body of evidence (see, for example: Woods, Macdonald, Gardner and Campbell 2000). Yet this consumer perspective has, as yet, had little impact on longstanding attitudes around male utilization of health services. In short, conventional wisdom holds that differential rates are mostly explained by deficiencies in male behaviour, the male psyche or male culture.
The majority of writers attempting to explain difference in the health-seeking behaviour of women and men adopt an explanatory framework for making sense of the data that is clearly based on a deficiency model of men. At times the language of supposedly value-free researchers or analysts is patronising, at times judgemental, even hostile. In a major Review of Men’s Health Literature for Queensland Health, prepared by the School of Social and Preventive Medicine at the University of Queensland, Esben Stroll summarizes the conclusions of scores of studies into male utilization of health services thus:
“Put simply, when the morbidity is perceived to be mild then men don’t want to be cry babies and seek medical help. However, once the morbidity is perceived to be serious then it is O.K. for them to seek medical help.” (Stroll 1996)
The problem is assumed to be lie within men themselves, some form of internal deficiency. Yet, if I throw a party and nobody comes should I blame the no-shows? Health services could gain from a change of focus - away from blame to a search for how to make themselves more attractive to men.
In the area of men’s health policy, until very recently, the Deficiency Model has had a privileged place. Much of the thinking around men’s health – and, consequently, much of the planning – may have been informed more by stereotype than unbiased research. Current models focus on a deficiency story about men: men’s psychological, social and, of course, physical pathologies. In this context the discourse includes such statements as “men are not able to talk”. It emphasises male violence, men as perpetrators.
Contrast this with Henley’s conclusions from his survey of NSW South Coast men:
“Efforts to deal with men’s ‘denial’ have so far failed to improve take-up of services by men. This (Eurobodalla) study suggests that a new approach to designing the entry points into the social health system based on what men say may be more productive” (italics added) (Henley).
At MHIRC we have adopted just such a “new approach”, a salutogenic approach. A salutogenic view of men’s health would acknowledge that all people have a darker side, but start the debate on men’s health by focussing on men’s health and health-enhancing behaviour, on what is salutogenic as opposed to what is pathogenic.
Antonovsky coined the phrase, “salutogenesis” in the context of survivors of the Holocaust: he was fascinated by the phenomenon of survival: some people came through the horrors of the holocaust seemingly unscathed as human beings. For him, salutogenesis is an interior phenomenon, linked to what others call resilience. Macdonald (2001) extends the term beyond the psychological to the environmental, to encompass an interest in what is salutogenic, health enhancing in the contexts of people’s lives: their physical, emotional, economic and cultural environments. There is need for a mindset which counters the medical concern with the pathological with a salutogenic vision of populations, be it adolescents, older people, or in this instance, men.
The pathogenic gaze is dominant in mental health work: The focus is on dealing with what is dysfunctional, pathological, on repairing the damages of past experiences - of childhood rearing or what have you - and of controlling the pathologies. All this is a necessary part of any mental health system, but it is unmistakably biased in the sense that there is much less emphasis on understanding what is salutogenic, healthy and wholesome. Neither time nor resources are spent on fostering these.
The Men’s Health Information and Resource Centre sets out to build a truly health-promoting, salutogenic approach to men and men’s health. In the context of dreadful statistics on male suicide – the Australian Institute of Health and Welfare has reappraised Australian Bureau of Statistics figures to show that: “Since the mid-1970s…Australian men aged 20-39 have increased their rate of suicide by 93%, and 18.5% in the past two years alone.” (Costello 2000)- there is urgent need to affirm the positive in boys and men and to orientate the health services – and perhaps society at large - away from a narrow pathological gaze.
We suggest that it is imperative that we find a positive way of seeing maleness and our male culture, both in their historical manifestations and as they are now. We cannot build an approach to men’s health around apologies for what is masculine. We need to find a positive language around maleness, male energy, male sexual drive. We must move away from the images of “caging the beast”. It’s also vital for men not to see themselves only through others’ eyes, especially those eyes that, perhaps for their own good reasons, focus almost exclusively on the experience of male violence and “perpetration”. This is often the tone of the discourse around “masculinities”. Men, including young men, must be encouraged to see themselves as being of value, as being “OK”.
From the aboriginal culture we may find a “walk the walk and a talk the talk”. Without in any way colonising the aboriginal men’s health movement, we suggest that we can find in it a way forward, to build a new language of men’s health. In this way we can build a language of “men’s business” in health, a language which is respectful of “women’s business”, but claims, without any need for aggression, the right to talk of men’s health as something complementary to women’s health. A talk, or discourse, which is ready to address contradictions but from the outset, and throughout, is based on the foundation that being male is what we are and it is good.
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