Impacts of Masculinity on Men’s Health in Maseru, Lesotho

Abstract

Masculinity is a health determinant for men and a risk factor for non-communicable diseases. This chapter explores how dominant masculinity influences lifestyle risk factors for non-communicable diseases focusing on adult men. The study conducted eight exploratory focus group discussions with adult men from Maseru, Lesotho. The participants were recruited using purposive sampling. Thematic analysis processes were followed to analyse data. The participants’ rationales and behaviours indicated dependence on women for healthy living even though men claimed taking responsibility as one of the key descriptions for a man. Smoking was perceived as one of the practices used to prove masculinity. Participants were informed about the unfavourable impacts of smoking. Stress, leisure time and peer pressure were reported as contributing factors to harmful alcohol consumption among participants. Many participants understood the benefits from healthy diets, however, they depended on females for healthy meals. Nearly all the men were aware of the health benefits of physical activities. Participants were aware of the undesirable effects of physical inactivity. Participants reported various challenges to effective physical activities and classified some activities as suitable for middle-class individuals. Health education focused on men is critical in order to alleviate the negative impacts of masculinity on men’s health.

1. Introduction

Masculinity is a multifaceted concept which is socially and culturally constructed [1]. Masculinity is a significant socio-cultural determinant of health and health-related behaviours [2]. Masculinity traits are largely created and shaped by life experiences in different settings resulting in sets of behaviours in which men, in particular, are socialised to practice [3]. In many countries, men often lead health defeating behaviours owing to their subscription to toxic masculinity. The two predominant approaches used in the study of masculinity are the trait and the normative approaches to masculinity. The trait perspective is essentially rooted in the differences between male and female genders [4]. Based on normative viewpoint to masculinity, the concept of masculinity is socially constructed and does not necessarily depend on the differences perceived between men and women [4]. Masculinity qualities appear similar across the globe. They include independence, invulnerability, sexual promiscuity, competitiveness, bravery, leadership and control, and physical strength. In most societies, men are socialised as those with high tolerance to pain, are self-reliant, and the sole decision-makers, and fundamentally avoid any feminine behaviours [5, 6].

In addition to power dynamics between genders on dominance and subordination, masculinity may also be described in relation to power relations between different sides of masculinity. Scholars in the field acknowledge hegemonic masculinity, complicit masculinity, marginalised masculinity, and subordinate masculinity as the main facets [2, 7]. Hegemonic masculinity is the dominant type and is characterised by strength, heterosexuality, superiority, being white, suppression of emotions as well as feelings [2]. Complicit masculinity is the passive expression of masculinity which lacks most characteristics observed in hegemonic masculinity. Men in this category do not challenge gender systems, they somehow benefit from being males [2, 7]. Marginalised masculinity refers to the subculture of hegemonic masculinity. Even though men in this group do not have some qualities of hegemonic masculinity like race, individuals in this category demonstrate the same traits as the hegemonic masculinity, for instance, physical strength, suppressing emotions and ferociousness [2, 7]. Subordinate masculinity displays the opposite characteristics from those of hegemonic masculinity. Men in this category demonstrate feminine behaviours comprising physical weakness, and they easily show their emotions [2].

Negative masculinity traits encourage health defeating behaviours [8, 9]. Individuals who subscribe to masculinity are most likely to embrace hazardous behaviours that discourage a healthy lifestyle and long life [8, 10]. Irrespective of their awareness of the negative consequences of unhealthy living, masculine men resist healthy living practices and often engage in risky behaviours generally associated with manliness [11, 12]. The reckless behaviour practised by masculine men shows how dedicated men identifying with dominant masculinity are to proving their masculinity. Different media platforms similarly contribute in different ways to the construction of masculinity. Images depicting hegemonic masculinity showcasing undesired behaviours, for example, reliance on fast-food, excessive alcohol consumption and excess consumption of red meat as cool and attractive influence the construction of hegemonic masculinity [13]. This chapter explores the role played by masculinity in the prevalence of lifestyle risk factors for non-communicable sicknesses.

This chapter draws from a qualitative study that was conducted in Maseru, Lesotho. Data was collected using eight exploratory focus group discussions (FGDs). The FGDs were made up of adult men aged 18 years and older. The FGDs were arranged with different groups of men who devoted their time, efforts and experiences to inform this study. Each group of men was invited to a central place for that specific group. These places included worship buildings, schools and sports facilities. The researcher transported most participants to and from these central places. However, some participants voluntarily transported themselves to and from the places where the FGDs were facilitated. The researcher had planned to recruit more men for FGDs, however, from the sixth group, it was evident that the researchers were not going to get any new information. A total of eight FGDs were held. On average, 60 adult men took part in eight FGDs on risk factors for non-communicable diseases (NCDs). A relaxed atmosphere during the FGDs encouraged open discussion among participants as well as between participants and the facilitator. The FGDs covered questions related to risk factors for NCDs—harmful consumption of alcohol, smoking, unhealthy diet and physical inactivity. Data were collected from November 2016 to February 2017. Verbatim narratives were used in this chapter in order to substantiate participants’ arguments.

Participants were recruited through purposive sampling where the existing men’s social groups such as recreational and sports clubs, business cooperatives and religious groups were targeted. The other strategy was to identify ‘popular men’ comprising local school principals and local business owners from different communities. These men were instrumental in that they assisted in recruiting adult men who showed interest to participate in the study from their communities.

During data analysis processes, thematic analysis was used. This approach was useful in that it assisted the researcher to explore the study participants’ opinions, knowledge and experiences from the qualitative data collected. Six steps practised in thematic analysis were followed, that is, the familiarisation with the data and notes, coding, generation of themes, revision of the generated themes, defining and naming of themes and lastly the writing up of the analysis report emanating from the data.

The names used in the report are not the real names of participants in order to protect their identity. The main study was conducted through the University of KwaZulu-Natal, Durban, South Africa. The ethical clearance was attained from the University of KwaZulu-Natal’s ethics committee (reference number: HSS/0697/015D). The study participants, that is, adult men, were members of society and were not representatives of any organisation during the interviews. Data collection process did not require any approval from any organisation; however, participants were given consent letters which invited them to participate in the study. The consent letter further provided details on what the study was about and highlighted that participation was voluntary and that participants were allowed to pull out from the study at any time they felt uncomfortable. The potential participants who were comfortable participating in the study signed the consent letters and returned them back to the researcher.

2. Who is a man?

In their description of a man, participants used age, sex, marital status, being a father, and taking responsibility with varying emphasis as the key contributing factors to who a man was perceived as. Being born male and aged 18 years and older, a male person was defined as a man by most participants. Alex, a participant in one of the FGDs put it this way:

A man is a male individual who is eighteen years old and can take responsibility, married or not married. As long as he is old enough to be trusted to take responsibility in the family he is a man.

Heterosexuality was an important determinant for one to be referred to as a man. This stereotype led to hegemonic masculinity subscribers disregarding homosexuality irrespective of other characteristics and behaviours related to manliness. Homosexual males were mostly disqualified as men by most study participants. In addition to homophobic views perceived, some of the FGD participants emphasised that some heterosexual males were ignorant:

Being born male does not necessarily mean that we are all men. There are [male] people who are eighteen years old and above and responsible in their families but whose [social] behavior and the way they live does not say they are men. I have an example; gay men were born males but the way they conduct their lives does not reflect the way a man should live. They are ‘women’, they take women’s role even in sexual intercourse. Even their general behavior in public is similar to that of women.

Being married was another determining factor in the definition of a man. Most participants in the FGDs strongly associated manhood with marriage. In most societies, bachelor men are alleged irresponsible and socially deviant. This perception led boys to be taught from a young age by their mothers and shown by their fathers how to become men [14]. Jacob explained this as follows:

A man is a married male person. When he is married, he is now having the responsibility of caring for other people, his wife and children which he did not have before getting married. If you do not get married and start having children, you are still a boy.

In addition to marriage, men who had biological children had a sense of pride and bearing children had resulted in acknowledgement and acceptance of these men in their families. One of the newly married men confirmed:

Just like me, before I got married, in my family, the elders treated me like one of the boys in the family regardless of my age especially for serious family matters. My opinions in any family matters were not taken serious until now. Now I am married and my wife is pregnant. My voice is heard in the family, my elders have started treating me like one of the family men and even listening to me. So, for me, until a male person is married, in my opinion and experience he will always be a boy.

One cannot become a father without bearing a child, at the same time; he cannot become a man unless he gets married. If he is not married, he can only be referred to as a man as praise if he has done some good works associated with men. So, in this case, his good actions can lead to referring to him as a man, but it will be temporary. (Tigger, FGD#3)

Among the older men, graduating from traditional initiation school was one of the determining factors for males to qualify as men. Physical and emotional capabilities similarly dictated the definition of a man. Men who had the ability to protect and provide for their households were defined as men:

I can say a man is somebody who can work and provide for his family, one who can be able to protect the family and somebody who has control and works and protects the family. He can do tough/heavy jobs. He can work in the garden, prune trees. The other thought that comes to mind goes together with a Sesotho saying which says ‘a man is a sheep, he does not cry’. He does not display emotions. (Thabo, FGD #7)

A man is a male person who has gone for our Sesotho traditional initiation school (lebollo). When he gets back to the society, he is now referred to as a real man because we have now taught him how to be a man while he was in the mountain. He can even get married now. (Thabo, FGD #7)

The last part of the previous quotation highlights extreme hegemonic masculinity which usually led to men living risky lifestyles is highlighted in the quote above. Men are socialised as strong even against illnesses resulting in these men shying away from consultation with health professionals. One of the participants alluded:

There is also this statement: ‘Be a man’, drive like a man, man up, etc. for you to be a man you should drive at a certain speed, at high speed basically, for you to be a man you should drink so many quarts [of beer] a day. The risky kind of behaviours one engages in, the man you are. The feminine part of a man who takes a good care of himself, respecting his family and wife is seen as not being man enough. A man is a sheep, he does not cry. Even if you go through hardship, do not cry, do not let people know. A man can be sick, but cannot go to the hospital or clinic because that would be a sign of weakness. A man is expected to be resilient and able to stand the pain in any forms of it. A man should mask his emotions and emotional experiences he goes through and should always come out as strong. (Tsebo, FGD#2)

Young men were acknowledged as men post their graduation from the traditional initiation school. After the initiation process, the older generation in society trusted these initiates and perceived them as ready to take responsibility including getting married. The traditions taught at initiation school were thought to have shaped, equipped young men and capacitated them to become accountable members of society. Some males, particularly those who were born and grown in urban areas did not subscribe to traditional initiation schools and its teachings. These men did not believe that young men’s behaviours could only be transformed through traditional initiation experience:

Those people are not turning into men just because they have gone to the mountain. They are just full of theory of what a man should be like. They are still boys until they get married like everybody else. Some of them practice the worst behavior when they come back to the society. (Tumelo, FGD #6)

3. Masculinity and smoking

Participants in the study knew about the harmful health effects of smoking. Nevertheless, they still reported a high prevalence of cigarette smoking, specifically among the working class and students at institutions of higher learning. Hand-rolled tobacco smoking was a common habit among older men, particularly the unemployed and men with lower formal education while smoking marijuana was common among younger men. Most current smokers during the study reported that the habit of smoking was developed during teenage-hood when they wanted to prove their masculinity owing to peer pressure and too much leisure time:

I was in secondary school when I started smoking and it was out of peer pressure and also wanting to be regarded as cool and as a man. To tell you the truth, I was already convinced that smoking was not right from what we were taught at school. (Mike, FGD #4)

I do not really keep track of how many times I smoke a day but now I think I have decreased my smoking to roughly four times a day. One of the reasons why I have decreased the number of times I smoke is because I am now busy most of the time. Before I came here (college campus) I had nothing to do for almost the whole day so I smoked a lot. Since I came here, I have really decreased my smoking because of being busy throughout the day with my schoolwork. (John, FGD #2)

Once initiated, smoking is addictive:

I have always thought smoking helps me release stress, but honestly speaking, if I go for two or three days without smoking, I feel good. I usually get back to it because of the strong cravings I get, but health wise it is not good to smoke. I tried stopping to smoke, in fact at one point I stopped for six months. I cannot really tell what happened, but today I am back to smoking. I think there is something about smoking; it is not easy to stop smoking once you start. (Pule, FGD #2)

Subscribers to dominant masculinity avoided any feminine behaviour. One man who was a current smoker alleged:

I cannot smell like a woman, smoking gives me that smell, different from a woman. There should be a difference between a man and a woman. We cannot smell the same. (Andre, FGD #5)

A follow-up from a different participant in the same FGD however indicated that the reasoning by the participant above was flawed. There were women who smoked, and the trend was reported growing during the study:

Can I say something about women and smoking? Eish! We are seeing this habit of smoking growing even among our women here. This was not a norm, but it is becoming popular especially here. So, it’s not only men who are smoking my brother. (Morena, FGD#5)

4. Harmful alcohol consumption

Detrimental periodic heavy drinking was the most prevalent among men in this study. This binge drinking often took place on weekends and at social events. Beer, especially the locally brewed ‘Maluti’ was the popular beverage among men. Very few men consumed traditional beer. Similar to smoking, the men who consumed traditional beer were mostly older unemployed men with lower formal education. Participants said social drinking was therapeutic as they got to share life experiences with other male counterparts during these drinking gatherings:

I always hangout with my boys. Mostly on weekends. We drink and talk about life; I mean everything from our hurts and joys maybe from the family or girlfriends. It is funny that when we are sober it is difficult to talk about some stuff. I for one cannot openly talk about family issues to my friends when I am sober, but when I am tipsy anything goes. I do not know why this happens so for me that is one of the reasons why I drink, I become free. (Luke, FGD #3)

Some men in England believe excessive drinking of alcohol makes one to appear masculine [15]. This stereotype contributes to the high and reckless consumption of alcohol by men in comparison to their female counterparts [10, 16]. The masculine standards of being a ‘playboy’, endearing and taking risks are determinants alluded to in literature for heavy consumption of alcohol and high risks of alcohol-related challenges [17]. Subscribers to hegemonic masculinity hide their feelings or emotions when they are abstemious. The avoidance of emotions, the belief that excessive alcohol consumption prevents boredom and that stress caused by female partners caused men to excessively consume alcohol were illustrated as follows:

Men usually cannot stand pain. Not physical pain as such, this emotional pain. For example, a man who has a wife who is always shouting at him would rather be in a bar and get home drunk and care free. Unfortunately, some women do not realise that they are the source of their husbands’ bad drinking habits. (Thato, FGD #8)

For some the reason is family problems faced. They are running away from a nagging wife. They would rather arrive home drunk because they are not respected in their houses anyway. They are treated like children. For some, bars are the only place where they get to socialise with friends and avoid boredom. (Thabang, FGD #2)

I think we are created different from women. Men get stressed when they are just idling, that is when the thought of at least going to the bar comes. Even if there is money in the house that the wife has hidden for some serious housekeeping, a bored man would steal some of that money and go for alcoholic drinks. (Tumelo, FGD #4)

One of the participants differentiated men from women, as seen from other men, he attributed this difference to masculine identities especially the competitive nature of masculine men:

Yeah, there is a huge difference. Men drink more alcohol containing beverages than women. Men like showing off what they can do. Somebody mentioned the issue of competition; that is one of the reasons. Men enjoy competition almost in everything they do. (Lerata, FGD #6)

Different from smoking, participants did not instantly link harmful consumption of alcohol to negative health effects, instead they related excessive alcohol consumption to social issues experienced in society. They pointed out unwanted behaviours that usually lead to more violence and fights between friends and family members, avoidable road accidents and deaths.

5. Masculinity and healthy food consumption

Participants considered cooking as a women’s obligation. This finding concurs with previous studies that reported cooking as a feminine task [18]. The belief that cooking is women’s responsibility has resulted in unhealthy eating behaviours in men [14], particularly in the absence of females who are expected to prepare food for men. Men who endorse traditional masculine identities are therefore at higher risk than women of developing chronic NCDs related to poor diet. Most men in Maseru, Lesotho relied on women for food preparation mainly because food preparation was considered a feminine task. Similarly, other men from different surroundings who do not cook [19], some men in Maseru said they did not cook at all in their households:

I do not know much about food stuff and preparation. The truth is that I am not interested. As long as my stomach is full I am okay. (Molisa, FGD #4)

Masculinity was associated with less attention on food and what to eat. For men having especially dominant masculine characteristics, cooking their own meals is often optional [20]. Finnish men from different working groups define food purchasing and preparation as feminine [20]. Femininity is also used to label food and beverages in most communities. For instance, consuming red meat and alcoholic beverages is an indicator of masculinity in different cultures, whereas eating salads, fruits, and desserts is considered feminine [20]. The femininization of food preparation and cooking is a stereotype that has led to men’s poor eating habits which are health defeating and exposing men to multiple NCDs. Men who were married but were not living with their spouses reported that they only ate healthy meals when their wives visited them. Single men who were not living with their partners but lived with their family members and depended on their female relatives for healthy meal preparation. Men who were single, and not living with their family members and not with their partners failed constantly to cook healthy meals for themselves. Buying fast food was a common alternative for this group of men.

I am not staying with my wife here, so I always go for meals that are easy to get at work and even at home except if my wife is around. If I cook, it’s always eggs or grilled chicken from the oven and prepare some papa and eat without vegetables. The only time when I eat healthy food is when my wife is around. On my own, I always go for fast food. Proper cooking is a mission. (Liketso, FGD #6)

It is my wife who always prepares food for my family. I usually prepare my own meals when there is a need, [that is], when my wife is not around. (Paul, FGD #8)

Cooking was considered a woman’s obligation even though there was an acknowledgement of unfairness to cooking deemed a women’s responsibility, especially in cases where both partners were working:

The fact that women are also working these days, they are doing men a huge favour, they should be staying at home nurturing babies and making sure that there is cooked food for the kids, men and the family at large while men are out at work. Strange enough when we get back home, both from work, I sit down and expect her to give me some food and even start complaining that she is too slow to prepare me some food. (Liketso, FGD #3)

With regards to the unemployed men, there was inclination to sharing responsibilities such as cooking and other household chores previously perceived women’s responsibility:

It is not only women who should cook in the house. We should assist and share whatever house chore we have. Even doing laundry is one of the activities that I personally help with. I really do not mind. (Thulo, FGD #5)

Being intentional about healthy diet consumption was criticised by some participants as feminine. However, there were men who aspired to develop courage and commitment to healthy eating in the future:

I have lately realized that some men, like women, are too careful on the food they eat. They are so picky. It is a very small number of them that I have seen. I think that is a good thing to practice. I am not one of those men but hopefully I will be one day. For now, for me, being so selective on food to eat is too much admin. Maybe as time goes I will be able to change. For now, I eat whatever I lay my hands on. As long as I am full and the food is nice, I am a happy man. (Mohau, FGD #7)

Participants were asked to provide possible and effective strategies that can be used to encourage men to practice healthy dietary habits. The majority of the men alluded to nutritional education and awareness specifically targeting men. Some men thought that there was a general need to empower men to challenge health by defeating cultural beliefs and practices.

6. Masculinity and physical inactivity

Physical strength and competitiveness are among other features previously deemed important to masculinity. Men usually participate in rigorous physical activities to realise these two qualities. Individuals aspiring and subscribing to masculine energy usually participate in rigorous physical activities. Research reports physical activity as more prevalent, especially among men than it is among women [10]. High competition is one of the traits associated with masculinity and participation in competitive physical activity exposes masculine subscribers to a platform for competition with others with similar characteristics.

Majority of the men were aware of the susceptibility to various health challenges and undesirable health effects related to physical inactivity. However, due to a lack of knowledge and awareness for some men, physical activities, especially recreational physical activities were associated with sophisticated community members and sportsmen. This lack of understanding and awareness restricted physical activities to leisure physical activities. Unemployed men and non-office workers were some of the groups that perceived physical activity as a middle-class practice. The blue-collar employees were of the view that their daily jobs were already physical activities, but they did not know of the health benefits attained from physical activities carried out at work:

It [physical activity] is mostly done by the middle-class people who are usually using cars as their mode of transport most of the time so they try and do jogging as a physical activity to keep healthy. From there it would be those people who are actively participating in sports who go jogging to get their bodies ready for games. I am a construction worker, when I get home; all I need is to rest for the next day. My job takes all my energy away. (Mosebi, FGD #6)

Some participants engaged in domestic activities which they correctly perceived as physical activities:

I am a farmer, I am always busy in my garden and I also feed my chickens and pigs and clean their shelters on daily basis. In doing so, I believe I am engaging in physical activities that keep me healthy and active. What do you think? (Tanki, FGD #6)

However, consistency in physical activities was lacking:

There are days when I do not enjoy this thing [farming]. If it was not work I would not be doing it. (Lebo, FGD #4)

Some men in the study reported that they did not participate in any form of physical activities owing to their too busy daily schedules:

To be honest with you, for me there is no sport or games that I play. I do not have the time. The only time I get to do a physical activity is when am at church. The type of music we do there makes us run around and jump up and down. I would therefore say that is the only chance I have for a physical activity in a week. (Tlotli, FGD #5)

Consistent physical activities are associated with healthy body weight. When asked about the societal meaning attached to men’s body mass in Lesotho’s context, most responses alluded to associations between wealth and being obese, especially with the older generations. However, the men reported a shift in perspective where the current generation seems aware that obesity is unhealthy and does not indicate wealth. Some men indicated that they were aware of the health challenges linked to obesity. One participant alluded to the fact that many illnesses that are caused by obesity are avoided. Study participants also shared that obesity constrains physical activities citing particularly men’s sexual performance:

I work with women in the farm. When they see a fat man, they always comment that they doubt that fat [man] is doing well in his sexual life because of the weight he is carrying. So, when women see fat men, they get too curious about their sexual performance in bed. You cannot even satisfy your woman in bed if you are fat my man. These women talk chief. I do not think this relate to sexual life alone. I mean, being fat must be heavy; I am sure any physical work is a challenge for a fat man. So again, I would say for me when I see a fat man, the first thing that comes to mind is laziness. (Jerry, FGD #3)

I do not know, but personally I think a man should be physically fit. That helps him to be admired and respected by other men as well as women. (Theo, FGD #1)

Hegemonic masculinity is protective as seen in the quotation above showcasing that men’s sexual prowess was valued by masculinity subscribers.

7. Conclusion

Masculinity is one of the major determining factors contributing to the risky lifestyle of masculine men. The preventable exposure to NCDs increases particularly in men due to increased risky behaviours masculine men practice. This chapter explored the role of masculinity in the prevalence of lifestyle risk factors for NCDs. Participant’s lifestyle and attitude did not match the men’s awareness and knowledge about the harmful health effects caused by lifestyle risk factors. Not all characteristics of masculinity have negative effects on health, however, identifying with masculinity can be problematic. It contributes to the initiation of smoking, excessive alcohol consumption, and lack of motivation to maintain healthy food consumption. Masculinity can be protective thereby resulting in motivation to maintain a healthy body weight. Key features to the definition of a man included having the knowledge, and the ability to take responsibility for others, however, it was startling that men generally relinquished responsibility for their health to their female counterparts, for example, their wives and female partners. Men can be considered high-risk members of society. They need to commit and adopt lifestyle changes that lessen the negative effects related to lifestyle risk factors for NCDs.