DYING TO BE MEN: Psychosocial, Environmental, and Biobehavioral Directions in Promoting the Health of Men and Boys pptx

DYING TO BE MEN
The Routledge Series on Counseling and
Psychotherapy with Boys and Men
SERIES EDITOR
Mark S. Kiselica
The College of New Jersey
ADVISORY BOARD
Deryl Bailey David Lisak
University of Georgia University of Massachusetts – Boston
Chris Blazina William M. Liu
Tennessee State University University of Iowa
J. Manuel Casas James O’Neil
University of California – University of Connecticut
Santa Barbara
Matt Englar-Carlson Steve Wester
California State University – University of Wisconsin – Milwaukee
Fullerton
Ann Fischer
Southern Illinois University – Carbondale
VOLUMES IN THIS SERIES
Volume 1: Counseling Troubled Boys: A Guidebook for Professionals
Mark S. Kiselica, Matt Englar-Carlson, and Arthur M.
Horne, editors
Volume 2: BAM! Boys Advocacy and Mentoring: A Leader’s Guide
to Facilitating Strengths-Based Groups for Boys – Helping
Boys Make Better Contact by Making Better Contact with
Them
Peter Motorola, Howard Hiton, and Stephen Grant
Volume 3: Counseling Fathers
Chen Z. Oren and Dora Chase Oren, editors

Volume 4: Counseling Boys and Men with ADHD
George Kapalka
Volume 5: Culturally Responsive Counseling with Asian American
Men
William M. Liu, Derek Kenji Iwamoto, and Mark H.
Chae, editors
Volume 6: Therapy with Young Men: 16–24 Year Olds in Treatment
David A. Verhaagen
Volume 7: An International Psychology of Men: Theoretical Advanc-
es, Case Studies, and Clinical Innovations
Chris Blazina and David S. Shen Miller, editors
Volume 8: Psychotherapy with Older Men
Tammi Vacha-Haase, Stephen R. Wester, and Heidi
Fowell Christianson
Volume 9: Engaging Boys in Treatment: Creative Approaches to
Formulating, Initiating, and Sustaining the Therapy
Process
Craig Haen, editor
Volume 10: Dying to Be Men: Psychosocial, Environmental, and
Biobehaviorial Directions in Promoting the Health of Men
and Boys
Will H. Courtenay
FORTHCOMING
Volume 11: Working Successfully with Men in Couples Counseling:
A Gender-Sensitive Approach
David S. Shepard and Michelle Harway, editors
Volume 12: Resiliency, Achievement, and Manhood: Promoting the
Healthy Development of African American Men
Cyrus Marcellus Ellis and Jon Carlson, editors
Volume 13: Substance Abuse Counseling with Adolescent Males and

Adult Men: A Practitioner’s Guide to Gender-Responsive
Prevention and Treatment Practices
Mark S. Woodford
Volume 14: Gender in the Therapy Hour: Voices of Female Clinicians
Working with Men
Holly Sweet, editor
Volume 15: Project Gentlemen on the Move: Nurturing Excellence in
African American Youth
Deryl Bailey and Mary Bradbury-Bailey
Volume 16: Tough Guys and True Believers: Managing Authoritarian
Men in the Psychotherapy Room
John M. Robertson

New York London
Psychosocial, Environmental,
and Biobehavioral Directions
in Promoting the Health
of Men and Boys
DYING TO BE MEN
Will H. Courtenay
Routledge
Taylor & Francis Group
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New York, NY 10016
Routledge
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Hove, East Sussex BN3 2FA
© 2011 by Taylor and Francis Group, LLC
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Library of Congress Cataloging-in-Publication Data
Courtenay, William.
Dying to be men : psychosocial, environmental, and biobehavioral directions in
promoting the health of men and boys / William Courtenay.
p. ; cm.
Includes bibliographical references and index.
Summary: “Men have specific gender-related influences that can affect their health
and psychological well-being, and it is thus necessary for mental health practitioners
to be knowledgeable in effective interventions for working with them. The purpose of
this book is to provide a thorough foundation for understanding men health and risks
and the differences between men. It will discuss effective, evidence-based strategies
for practitioners to improve the health and well being of boys and men by drawing
from a wealth of literature and research in a diverse array of disciplines, as well as
from the authors original research designed specifically to examine gender and men’s
health” Provided by publisher.
ISBN 978-0-415-87875-3 (hardcover : alk. paper) ISBN 978-0-415-87876-0 (pbk.
: alk. paper)
1. Men Health and hygiene. 2. Health behavior. I. Title.
[DNLM: 1. Men’s Health United States. 2. Health Behavior United States.
3. Health Promotion methods United States. 4. Health Status United States. 5.
Masculinity United States. WA 306]
RA564.83.C68 2010

613’.04234 dc22 2010037177
Visit the Taylor & Francis Web site at

and the Routledge Web site at

This edition published in the Taylor & Francis e-Library, 2011.
To
purchase your own copy of this or any of Taylor & Francis or Routledge’s
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To my kids, Justine and Tate
I love you more than words can express.
I hope the world continues to open its
gendered borders, so you can live and
work and play as freely as you like.

ix
Contents
Series Editor’s Foreword xi
Acknowledgments xiii
Introduction xvii
I WHY MEN AND BOYS GET SICK AND DIE YOUNGSECTION
1 Key Determinants of the Health and Well-Being
of Men and Boys: An Overview 3
2 Behavioral Factors Associated With Disease, Injury,
and Death Among Men: Evidence and Implications
for Prevention 43
II WHY MEN AND BOYS DO THE THINGS THAT SECTION
MAKE THEM SICK AND KILL THEM
Introduction: Who Are the “Men” in “Men’s Health”?

3 Engendering Health: The Social Construction of
Gendered Health Beliefs and Behaviors 127
4 Constructions of Masculinity and Their Infl uence on
Men’s Well-Being: A Theory of Gender and Health 141
III SPECIFIC POPULATIONSSECTION
Introduction: Ethnicity Matters
5 Rural Men’s Health: Situating Men’s Risk in the
Negotiation of Masculinity 171
6 College Men’s Health 189
x Contents
7 Preventive Health Strategies for Men in Prison 209
Will H. Courtenay and Don Sabo
IV EMERGING RESEARCH ON MEN, MASCULINITY, SECTION
AND HEALTH
Introduction: Youth Violence? Let’s Call It What It Is
8 Gender and Ethnic Differences in Health Beliefs
and Behaviors 229
Will H. Courtenay, Donald R. McCreary, and Joseph R. Merighi
9 Masculinity and Gender Role Confl ict: How They
Infl uence the Likelihood That Men Will Engage in
Multiple High-Risk Behaviors 241
Will H. Courtenay and Donald R. McCreary
10 Measurement of Men’s Help Seeking: Development
and Evaluation of the Barriers to Help Seeking Scale 251
Abigail K. Mansfi eld, Michael E. Addis, and Will H. Courtenay
11 The Drive for Muscularity and Masculinity: Testing
the Associations Among Gender Role Traits,
Behaviors, Attitudes, and Confl ict 271
Donald R. McCreary, Deborah M. Saucier, and Will H. Courtenay
V REACHING MENSECTION

Introduction: Making Health Manly: Social Marketing
and Men’s Health
12 Counseling Men About Their Health: An Evidence-
Based Practice Guideline 289
13 Designing Effective Programs and Services for
College Men: Applying the Six-Point HEALTH
Plan and Other Evidence-Based Strategies 315
VI LOOKING FORWARDSECTION
Introduction: Teaming Up for the New Men’s Health Movement
14 A Global Perspective on Men’s Health and Future
Directions in Research 337
References 353
Index 485
xi
Series Editor’s Foreword
Although traditional men are socialized to be providers for and pro-
tectors of others, they tend to be poor guardians of their own health.
Compared to women, men are less likely to get routine physicals,
and when they feel sick or are injured, men are more likely to ignore
their symptoms and less likely to seek medical care (Arias, Anderson,
Kung, Murphy, & Kochanek, 2003; Sandman, Simantov, & An, 2000).
Similarly, when faced with emotional distress, men are less likely than
women to seek professional assistance with their mental health con-
cerns (Addis & Mahalik, 2003). Men are also more likely than women
to engage in a host of health risk behaviors (e.g., smoking, substance
abuse, drinking and driving, and poor diets) that are associated with a
variety of diseases, injuries, and death (Courtenay, 2001).
Health experts consider the propensity of men to ignore their health
needs, take risks, and have unhealthy lifestyles to play a key role in
some adverse health outcomes in men. Consider just a few, related,

alarming statistics. Rates of heart disease, cancer, stroke, and HIV/
AIDS are higher for men than women (Men’s Health Network, 2010).
Men are more likely than women to suffer accidental injuries, work-
related and fi reworks-related injuries and deaths, unintentional drown-
ing, motor-vehicle deaths, death by homicide, and suicide (Centers for
Disease Control and Prevention, 2010). Moreover, life expectancy is
5.1 years shorter for men than women (Centers for Disease Control and
Prevention, 2010). Many of these injuries, illnesses, and deaths could be
prevented and the life span of males could be extended if men changed
their attitudes about their lifestyles and about seeking help and talking
with health care professionals.
Over the past 20 years, my attempts to study and understand health-
related diffi culties of men consistently took me to the work of Dr. Will
Courtenay, a dedicated and passionate advocate for men and their health
needs. Recognizing that Dr. Courtenay is also an accomplished scholar
of men’s health issues, I reached out to him, hoping that he would
contribute his impressive expertise on the topic to The Routledge Series
xii Series Editor’s Foreword
on Counseling and Psychotherapy with Boys and Men. Eager to synthesize
his wide body of work on the subject, Dr. Courtenay enthusiastically
agreed to compose Dying to Be Men: Psychosocial, Environmental, and
Biobehavioral Directions in Promoting the Health of Men and Boys for this
series. I am so glad that he did!
In Dying to Be Men, Dr. Courtenay takes us into the world of boys and
men, alerting us to the troubling fact that too many males are killing
themselves, sometimes slowly over the course of a lifetime through a
series of poor lifestyle choices contributing to the development of life-
threatening illnesses, and at other times, abruptly through impulsive risk
taking, violent encounters, and suicide. Dr. Courtenay summarizes what
is known about gender differences in diseases, accidents, and mortality,

and he discusses the attitudes and behaviors that place males at risk for
injury, illness, and death, including the role of masculine ideology in
men’s health. He provides a comprehensive analysis of the medical and
psychological problems experienced by boys and men across the life
span, and he offers gender-sensitive interventions for addressing these
problems. No doubt, the wealth of information provided in this book
can help all health care providers to enhance their efforts to promote
the well-being of boys and men. I am deeply grateful for this informa-
tion, and I am pleased and honored to have Dr. Courtenay’s fi ne work as
a volume in this series.
REFERENCES
Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and the contexts of help-
seeking. American Psychologist, 58, 5–14.
Arias, E., Anderson, R. N., Kung, H. C., Murphy, S. L., & Kochanek, K. D. (2003).
Deaths: Final data for 2001. National Vital Statistics Reports, 52(3). Hyattsville,
MD: National Center for Health Statistics.
Centers for Disease Control and Prevention. (2010). Men’s health at CDC. Retrieved
November 7, 2010, from />Courtenay, W. H. (2001). Counseling men in medical settings: The six-point
HEALTH plan. In G. R. Brooks & G. E. Good (Eds.), The new handbook of
psychotherapy and counseling with men: A comprehensive guide to settings, prob-
lems, and treatment approaches (pp. 59–91). San Francisco, CA: Jossey-Bass.
Men’s Health Network. (2010). Men’s health facts. Retrieved November 7, 2010,
from />Sandman, D., Simantov, E., & An, C. (2000). Out of touch: American men and the
health care system. New York: Commonwealth Fund.
Mark S. Kiselica, Series Editor
The Routledge Series on Counseling and Psychotherapy
with Boys and Men
The College of New Jersey
xiii
Acknowledgments

This book and the ideas it contains have developed over many years.
Consequently, its creation is the result of input and assistance from innu-
merable people. As much as I would like to recognize the contributions
of everyone, most of these people must necessarily remain unnamed:
They approached me after a talk I gave and shared incisive thoughts;
they commented anonymously on a manuscript under peer review and
offered me critical feedback; and they attended my trainings and prof-
fered thoughtful refl ections about their own hands-on experiences
working with men. The fact is, a book of this scope could not be written
without the contributions—in all their various forms—of countless peo-
ple to whom I feel indebted. I will take this opportunity to express my
gratitude to a small number of these people, many of whom supported
my work long before the topic of men’s health sold magazines.
First, I want to recognize those who—most tangibly—made this
book possible. I am much indebted to Mark S. Kiselica, the book series
editor, who graciously invited me to join a long list of esteemed scholars
and authors who have contributed to The Routledge Series on Counseling
and Psychotherapy with Boys and Men. His warmth and grace, and dili-
gence, was welcomed and deeply reassuring throughout the process
of authoring this work. I’m also indebted to my editors at Taylor and
Francis, Dana Bliss and Christopher Tominich, for their guidance in
shepherding this project from its earliest stages all the way through to
its completion.
I am especially grateful to those friends and colleagues who have coau-
thored chapters of this book: Don Sabo, Don McCreary, Michael Addis,
Abigail Mansfi eld, Joseph Merighi, and Deborah Saucier. I am grateful
not only for their contributions to this book but also for their intellects,
energy, enthusiasm, time, and friendship. Each of these coauthors has
deeply infl uenced my thinking and my work in their own unique and
personal way. I am particularly grateful to Don and Don, who are both

long-term friends and collaborators. An enormous debt of gratitude
goes to Don Sabo, who has been my strongest—and fi ercest—mentor,
xiv Acknowledgments
and who is also a great guy. When I was a young researcher, Don was the
fi rst seasoned scholar to take me under his wing, and like a great mentor,
“Sabo” always seemed to be more concerned about my work than his
own. His unwavering support and collaboration throughout the years
have been an incredible boon to both my spirit and my work. I am also
deeply indebted to Don McCreary. Apart from being the consummate
statistician for most of the quantitative research and analysis my work
has required and continues to require—which is enormously valuable
in its own right—he also has been an incredibly important and patient
teacher, an absolutely dedicated and delightful colleague, and a great
buddy. In terms of friends and colleagues, they simply don’t get any bet-
ter than Don and Don.
I am also deeply grateful to my former colleagues at Harvard Medical
School, McLean Hospital, particularly William Pollack. His encourage-
ment throughout the years, as well as his support in the endeavor we
share helping men, has been—and remains—invaluable. I am especially
thankful for his continued collaboration with me through the Center
for Men and Young Men at McLean Hospital, where he is Director.
I am similarly grateful to my former colleagues at the University of
California, San Francisco, especially Bill Shore in the Department of
Family and Community Medicine, who has demonstrated steadfast
support for addressing the health needs of men and boys.
I want to extend my warmest thanks to the members of the Society
for the Psychological Study of Men and Masculinity (Division 51 of
the American Psychological Association), including Ron Levant, past
president of the American Psychological Association, Mark S. Kiselica,
Bill Pollack, Joe Pleck, Glenn Good, Gary Brooks, Jim O’Neil, Michael

Addis, Jim Mahalik, Don McCreary, Chris Kilmartin, Aaron Rochlin,
Dan Quinn, and many others. These men have supported my work and
me personally for over a decade, and are a constant source of intellectual
inspiration.
Like so many other scholars who have studied and written about
masculinity, men, fathers, and boys over the past several decades, I am
deeply indebted to Jim Doyle at Men’s Studies Press, who since 1992
has been independently publishing, disseminating, and promoting our
work (besides being a published scholar on this subject himself). It was
Jim who, in 1999, had the prescience to conceive of the fi rst professional
journal of men’s health and approached me to serve as its fi rst editor.
In his own quiet, determined way, Jim—and his tireless dedication to
men’s studies—has truly transformed the way social scientists and other
professionals understand, study, and help men and boys.
I also want to offer my deepest gratitude to those who enabled me
to develop and apply my work throughout the years; to all the clini-
cians, researchers, scholars, and health professionals who have always
encouraged me and believed in my research on a subject relatively few
scholars examine, particularly at a time when men’s health was not yet
considered a legitimate fi eld of specialization, and when there was little
Acknowledgments xv
cultural or social support for studying the subject. I am especially grate-
ful to the professionals in the fi elds of higher education, family planning,
and public health throughout the United States who had the foresight
to see the value of addressing men’s health. Although there are far too
many health professionals to thank personally, I do want to extend spe-
cial thanks to Richard Keeling and Gar Kellom, who have both provided
extensive support to me in reaching other health professionals in higher
education. I also want to express similar gratitude to Susan Moskosky,
Director for the Federal Offi ce of Family Planning, who invited me to

provide numerous trainings on men’s sexual and reproductive health
to providers nationally, and to Marsha Gelt at the Center for Health
Training in Oakland, who has enlisted me to do similar trainings in
California. In the fi eld of public health, I want to extend my thanks to
Irvienne Goldson at Action for Boston Community Development; John
Rich at the Drexel Universit y School of Public Health; Owen Borda, who
served the New York Public Health Department for decades; and Larry
Cohen at Prevention Institute in Oakland. Each of these individuals has
been a staunch supporter of me throughout the years and has given me
strength in my pursuits. Irvienne Goldson, in particular, enabled me to
put many of my ideas and intervention strategies into action in serving
men of color in Boston for nearly a decade. Irvienne’s undaunted dedica-
tion to her community is extraordinary and I am convinced the men in
Boston are living longer and healthier lives as a result of her efforts.
I want to extend deep and heartfelt thanks to Irene Elmer, who for
nearly 20 years has been and remains my copyeditor. Besides being a
lovely person, she has quite diligently made certain that my modifi ers
are never misplaced and that my participles have not been left dangling.
I am deeply indebted to Irene for her conscientious attention to—quite
literally—my every word. I must also express my deep gratitude to Sally
Douglas Arce, my publicist, who for nearly 20 years has very effectively
helped me to get my messages about men’s health out to the public,
while also being a wonderful person to work with. I also want to extend
special thanks to Kathryn Day, who gratefully appeared during the last
year at the 11
th
hour to help out as my research assistant. Although she
was fi nalizing her dissertation at the time, she enthusiastically embraced
the work of this book as if it were her own. Her assistance during this
time was invaluable.

Because much of this book has been previously published in various
forms, I would also like to extend my thanks to the countless social
scientists, colleagues from various disciplines, reviewers, journal edi-
tors, and book publishers who have provided critical feedback to me
on earlier versions of this work. Over the years, they have all con-
tributed to strengthening my critical thinking, my research, and my
writing. Similarly, I wish to acknowledge my tremendous debt to the
many researchers and scholars who preceded me in the fi eld of women’s
health. Their work was truly foundational for me and also crucial to the
development of my feminist perspectives on men’s health.
xvi Acknowledgments
Of course, no book can be written without the strong support of
family and friends, and this one is no exception. The list of friends who
have supported me and my work throughout the years is—gratefully—
quite extraordinary. I wish I could include every one of you here, but I
trust you know how important you are to me and how I value both your
friendship and the support you have provided to me.
Lucian Burg and Mark Swanson are the best friends a guy could ever
have; they have had my back for decades and I love them both deeply.
Their wives, my dearest friends Marie Pollard and Claudia Sieber, are
family to me and their enduring support and love—and especially their
frank opinions over many years—have been invaluable to me. I am also
deeply indebted and grateful to Lucian, in particular, for his labor of love
in designing the evocative (we might say “haunting”) cover for this book.
Deep and heartfelt thanks also go to my kids Tate and Justine, who,
for the most part, good-naturedly endured my all-too-frequent recent
absences while I was completing this book, and to my wife and partner
of 20 years, Amy Huang, whose love has been a constant in my life.
Amy always keeps me honest, and thankfully never hesitates to point
out when I’m being a “men’s health hypocrite!”

I also want to express deep gratitude to my father and late mother. I
am especially grateful for their enduring unconditional love and stead-
fast commitment to me, despite my innumerable gender transgressions
throughout my life. The foundation they provided for me has remained
my bedrock.
xvii
Introduction
Twenty years ago, when I began researching and writing about men’s
health at the University of California at Berkeley, men in the United
States were dying more than 7 years younger than women. It was a time
when “men’s health” was really nothing more than an oxymoron. The
gender gap in longevity, however, was not new; it had been steadily wid-
ening since 1920, when women and men in the United States lived lives
that were equal in length. But when I conducted training sessions about
improving men’s health, physicians and other health professionals were
consistently shocked to learn of this gap in the life spans of women and
men, as well as other gender differences in health and health-related
attitudes and behaviors. With few exceptions, these gender differences
were also largely unknown to—or ignored by—other health scientists.
The gender gap in longevity has fi nally begun to narrow. Today men
die 5 years younger than women. And today Men’s Health magazine is
the top-selling magazine in the United States—and the largest men’s
magazine in the world, with 10 million readers in 39 countries. The
subject of men’s health has also fi nally captured the attention of medical
communities and health scientists—as well as policy makers and govern-
ments around the world, including in Australia, the United Kingdom,
Austria, and Switzerland. Most of these changes have occurred during
the past decade. In 2000, I served as guest editor for a special issue of the
Journal of American College Health (Courtenay & Keeling, 2000b). This
was the fi rst time a professional or medical journal devoted an entire

issue to the subject of men’s health. Since then, special issues on men’s
health have appeared in journals of other organizations and disciplines,
including public health (Treadwell, 2003) and sociology (Annandale &
Riska, 2009). Similarly, when I became the founding editor of the
International Journal of Men’s Health in 2001, it was the only profes-
sional or academic journal on the subject. Today there are three such
professional journals of men’s health internationally. Men’s sexual and
reproductive health is also increasingly being addressed—and acknowl-
edged as a necessary step in improving the sexual and reproductive
xviii Introduction
health of women. For several years during the past decade, I served as
consultant to the federal government’s Offi ce of Family Planning in its
fi rst attempts to train health educators nationally in providing sexual
and reproductive health and family planning services to men. Similar
efforts are now being made in Africa, Central America, South America,
and parts of Asia.
As a result of these efforts and cultural shifts, men are increasingly
adopting healthy lifestyles and living longer lives. However, gender dif-
ferences in health-related behavior, chronic illness, severe disease, and
death persist, so that women still outpace men in health and longev-
ity. Consequently, I continue to ask myself the same question that fi rst
motivated my work 20 years ago: “Why do men and boys suffer more
disease and disability, and die younger, than women and girls?”
In this book, I propose gender-specifi c approaches for answering
that question, and for improving the physical and mental health of men
and boys, which incorporate sociocultural, psychological, biological,
environmental, behavioral, and structural factors. These approaches
are consistent with the national health promotion and disease preven-
tion initiative in the United States, referred to as Healthy People 2010
(Department of Health and Human Services [DHHS], 2000c). One

of its primary goals is to eliminate health disparities. The National
Institutes of Health defi nes populations with health disparities as “a
population where there is a signifi cant disparity in the overall rate of
disease incidence, prevalence, morbidity, mortality, or survival rates in
the population as compared to the health status of the general popula-
tion” (DHHS, 2002a, p. 7). As I make abundantly clear in this book,
men and boys constitute one such population.
As the title suggests, a central point that I discuss throughout this
book is the powerful impact that masculinity has on the health of men
and boys. There is a large body of both quantitative and qualitative
research—which I review—showing that masculinity, measured in a
variety of ways, is associated with men’s health risks. The evidence I pro-
vide includes my own longitudinal research of young men nationally. As
I demon strate, many of the behaviors men use to “be men” are the same
behaviors that increase their risk of disease, injury, and death. However,
these enactments of masculinity are not simply a matter of personal
choice. On the contrary, they are fostered and reinforced by families,
communities, institutions, and cultures, as well as by individual men.
But there are also new and developing healthy aspects of masculinity—
which is a complex, dynamic, and ever-changing concept enacted dif-
ferently in different contexts. One of the most promising contemporary
approaches to improving men’s health—which I discuss—is tapping into
these new notions of masculinity and correcting men’s misperceptions
that other men hold traditionally unhealthy beliefs about masculinity
and that they are unconcerned about their health.
In Section I of the book, I identify why men and boys get sick and
die young. Chapter 1 is a broad multidisciplinary overview, in which I
Introduction xix
provide a summary of key determinants of the health and well-being
of men and boys in the United States. I identify 31 key determinants

of physical and mental health from an extensive review of literature.
The fi ndings reported in this review indicate that men’s greatest health
risks are the result of modifi able factors, and that efforts to address
these factors through practice, policy, and research would contribute
to enhanced health conditions for men and boys, as well as to healthier
families and communities.
In Chapter 2, I provide an extensive review of research regarding both
gender differences in health-related behaviors and the health conse-
quences of these differences. This is a major update of a previous review
I wrote, which was published in 2000. At that time, it was the fi rst such
review to examine a wide range of health-related behaviors previously
unexamined by health scientists, and available data were relatively lim-
ited. In the ensuing years, epidemiological and medical research seems
to have increased exponentially. An immense amount of sophisticated
research is now available, including data from large prospective stud-
ies, population-based research, meta-analyses, and national surveillance
systems. Consequently, this review is dense in terms of data; it is both
exhaustive and—admittedly—at times exhausting. But these data pro-
vide powerful information for understanding men’s health, as well as
differences between men and women. They also provide overwhelming
evidence that men’s behaviors are the primary reasons for their increased
risks relative to women. This chapter systematically demonstrates that
males of all ages are more likely than females to engage in more than
30 behaviors that increase the risk of disease, injury, and death. These
fi ndings compellingly show that the greatest disparities in men’s health
are preventable.
In 2000, I was invited by the American Psychological Association
to discuss the research of a panel of scholars at the association’s annual
meeting, which was held in Washington, DC. The title of the panel was
“Men’s Health in the New Millennium: Emerging Research, Theory,

and Practice.” My comments serve as the introduction to Section II of
this book. I provide a critique of previous models for understanding
men’s health and propose a new model, as well as new directions for
research, based on emerging approaches to both understanding and
addressing men’s health in the 21st century. In the following two chap-
ters, I provide my own comprehensive approaches for understanding
and conceptualizing men’s health.
I make clear in Section I of the book that men are at greater risk than
women for nearly all key indicators of health, and that men’s attitudes
and behaviors are the biggest contributors to their increased risk for
disease, injury, and death. But this is not to suggest that the problem
is simply a matter of men “behaving badly.” In fact, it is a simplistic
and incorrect reading of my work to suggest that “men are victims of
their own behavior” (Smith, Braunack-Mayer, & Wittert, 2007, p. 81).
As I illustrate in Section II, there are powerful social, environmental,
xx Introduction
institutional, and cultural infl uences that both foster men’s adoption of
unhealthy behaviors and constrain their adoption of healthier ones.
During the past 2 decades, I have frequently voiced the need to exam-
ine and understand the environments and social contexts within which
health behaviors occur. In recent years, other health scientists and orga-
nizations have increasingly joined in this effort, including the American
Cancer Society (Kushi et al., 2006). To help explain why women and
men adopt the health beliefs and behaviors that they do, Chapter 3
reviews research examining gender differences in social experiences,
cultural representations of gender, and additional social and institu-
tional structures, such as the media and the health care system. This
review reveals that North Americans collectively work diligently to
reinforce stereotypically feminine or masculine behavior in themselves
and others, and that the beliefs and behaviors fostered in men and boys,

the resources available to demonstrate masculinity, and the resources
boys and men use to enact gender are largely unhealthy. It illuminates
how cultural dictates, everyday interactions, and social and institutional
structures help to sustain and reproduce men’s risks.
In Chapter 4, I further explain gender differences in health-related
attitudes and behaviors. In doing so, I propose a relational theory of
men’s health from a social constructionist and feminist perspective. In
this theoretical model, I suggest that health-related beliefs and behav-
iors, like other social practices that women and men engage in, are a
means for demonstrating various forms of femininity and masculinity.
In examining constructions of masculinity and health within a relational
context, this theory proposes that health behaviors are used in daily
interactions in the social structuring of gender and power. It further pro-
poses that the social practices that undermine men’s health are often
signifi ers of masculinity and instruments that men use in the negotiation
of social power and status. In this chapter, I explore how factors such
as ethnicity, economic status, educational level, sexual orientation, and
social context infl uence the kind of masculinity that men construct and
contribute to differential health risks among men in the United States.
I also examine how masculinity and health are constructed in relation
to femininities and to institutional structures—such as the health care
system—and how social and institutional structures help to sustain and
reproduce men’s health risks and the social construction of men as “the
stronger sex.”
Throughout the book, I use the term men’s health. This is for the sake
of convenience and not intended to “homogenize” men’s experiences
related to their health. Although I discuss differences among men in
other chapters, in Section III, I more closely examine the health needs of
specifi c populations of men. It opens with “Ethnicity Matters.” Indeed,
ethnicity—along with socioeconomic status—is strongly linked with

health disparities among men. African American men, for example,
die 6 years younger than European American men (DHHS, 2009a).
There are a number of additional factors that infl uence health and
Introduction xxi
that differ among men, which I discuss in the introduction to Section
III and in the following chapters of that section. Chapter 5 focuses
on rural men. Using a social constructionist approach, I examine dif-
ferences in health behaviors and risks by comparing rural men and
women, as well as rural men and other populations of men. I explore
how rural men’s health beliefs and behavior are used as a form of gen-
dered practice, and provide a conceptual and theoretical framework
that suggests the very practices that undermine rural men’s health are
often used to negotiate social power in relation to rural women and
also within hierarchies of men.
In Chapter 6, I examine the health of college men, who are in the age
group with the greatest gender disparities in injury and death. They are
also more likely than college women to engage in unhealthy behaviors,
which research shows frequently continue into adulthood. In this mul-
tidisciplinary overview, I discuss the health risks of college men, college
men’s failure to adopt health-promoting behaviors, their propensity to
engage in risky behaviors, their beliefs about manhood, their attitudes
concerning their own vulnerability, and their limited knowledge about
health. I discuss men’s socialization as boys to provide a framework
for understanding why so many college men have adopted unhealthy
lifestyles. I also briefl y outline how masculinity and stereotypes about
manhood infl uence the health services that are provided to college men,
and stress the importance of providing gender-specifi c interventions
and programs to these men.
As Don Sabo and I explain in Chapter 7, there is a dire need for
preventive health strategies in prisons. However, developing such strat-

egies within the prison context is a complex matter. In this chapter, we
present the insights, observations, and conclusions that were developed
from the experiences of 22 students who participated in a college-level
seminar in the sociology of health and medicine conducted at a north-
eastern U.S. maximum-security prison. To do this, we use standpoint
theory. This theory holds that disadvantaged and less powerful mem-
bers of a society can provide unique and useful knowledge to others.
In this chapter, the male students identify health risks of prisoners, the
effects of masculinity on health, realistic prevention strategies for pris-
oners, and potential obstacles to implementing these strategies.
In 1999, the Columbine High School massacre shook the United
States. Sadly, this was neither the fi rst—nor the last—such incident
on a school campus. However, as disturbing as it is to read or hear
news accounts of these incidents, it is more disturbing to me that these
accounts consistently remain genderless; the fact that it is always boys
who commit these heinous acts is rarely mentioned. After the shootings
at Columbine, I wrote a short opinion piece that was published in the
Journal of American College Health (Courtenay, 1999b), which provides
the introduction to Section IV. In it, I contend that until we as a society
fully recognize that it is boys who kill—and acknowledge the effects of
the confl icting messages we give to boys—we will not be able to prevent
xxii Introduction
these shootings. I argue, in essence, the need for examining and more
deeply understanding masculinity, which is the focus of this section of
the book.
Section IV presents four empirical studies that were conducted by
several of my colleagues and me. In these chapters, we examine associa-
tions between masculinity and various factors related to men’s health,
specifi cally, health beliefs and practices, high-risk behavior, help seek-
ing, and the desire to be muscular. In Chapter 8, my colleagues Donald

R. McCreary, Joseph R. Merighi, and I explore the extent to which
college men and women of various racial and ethnic groups differ in
their health beliefs and behaviors. Exploratory factor analyses of sur-
vey responses from a diverse sample of more than 1,800 undergraduate
students reveal 21 items in six cohesive domains: diet, anger and stress,
preventive care, medical compliance, substance use, and beliefs about
masculinity. Applying analyses of variance, we explore group differ-
ences across these domains. Our fi ndings demonstrate consistent gender
differences, with men engaging in riskier behaviors and holding riskier
beliefs than women. Main effects for ethnicity are also reported. In
conclusion, we discuss the implications of this research for establishing
gender- and ethnicity-based health promotion and disease prevention
interventions.
In the following chapter, Donald R. McCreary and I go on to
examine the relationships between specifi c aspects of masculinity and
young men’s likelihood of engaging in multiple high-risk behaviors.
Self-reported health risks (i.e., alcohol use, sexual activity, safety belt
use) are used to identify low-risk and high-risk men. We carried out
a binary logistic regression analysis to determine the degree to which
beliefs about masculinity and masculine gender role confl ict uniquely
predict the likelihood of engaging in multiple risk behaviors. Our fi nd-
ings reveal that while beliefs about masculinity and gender role confl ict
are both associated with multiple high-risk behaviors at the bivariate
level, two aspects of gender role confl ict more than double the prob-
ability of men engaging in multiple high-risk behaviors when the data
are analyzed using multiple regression. We demonstrate in this chapter
that men who place emphasis on achievement and status, as well as on
gaining authority and control over others, and men who are uncomfort-
able disclosing their feelings to others—especially to other men—are at
increased risk for involvement in multiple high-risk behaviors.

Chapter 10 describes the development and psychometric evaluation
of the Barriers to Help Seeking Scale, which was developed by my col-
leagues Abigail K. Mansfi eld, Michael E. Addis, and me. The measure is
designed to assess reasons that men identify for not seeking professional
help for mental and physical health problems. Exploratory factor analy-
ses in a sample of 537 undergraduate men reveal a 5-factor solution of
internally consistent subscales. An additional study of 58 undergraduate
men included in this chapter confi rms the reliability of the scale and
provides evidence of convergent and criterion validity between the scale
Introduction xxiii
and measures of masculine gender role confl ict and attitudes toward
seeking professional help. In this chapter, we demonstrate that men’s
help seeking is infl uenced not only by norms of masculinity but also by
social psychological processes, as well as practical constraints. A threat
to their sense of autonomy is a primary reason why these men avoid
health care. They also tend to minimize the seriousness of their prob-
lems to avoid care. Practical constraints, such as those related to time
and money, are also cited by these men as important barriers to care.
In the fi nal chapter of Section IV, Donald R. McCreary, Deborah
M. Saucier, and I examine masculinity and men’s body image. Previous
qualitative research suggests that people assume muscular men are
more masculine. This assumption was tested quantitatively in two stud-
ies in this chapter. In the fi rst study, men and women completed mea-
sures of gender role traits and behaviors; in the second, men completed
measures of gender role confl ict and traditional attitudes about men.
We discuss how the fi rst study reveals a correlation between self-rated
male-typed traits and behaviors, with a need to be more muscular for
both men and women. In the second study, men with more traditional
attitudes about men also wanted to be more muscular. Furthermore,
men who wanted to be more muscular experienced confl ict with regard

to society’s expectations that they be successful, powerful, and com-
petitive, and they reported that fi nding a balance between work and
leisure is diffi cult.
Some additional research that I conducted with Donald R. McCreary
also revealed surprising and interesting results: Men are more concerned
about their health than they think other men are concerned about their
health. This may not seem like a particularly important fi nding, but it is.
In fact, it is very important. This is because social norms research shows
that our perceptions of others’ behavior infl uence our own behavior.
These perceptions—and misperceptions—of normative group behavior
often infl uence our behavior by providing information about what is
“normal” (for example, how we should—and should not—act as a man).
In the introduction to Section V, I briefl y discuss this kind of research
and its implications for men’s health and interventions with men—
which is the focus of this section of the book.
In the fi rst chapter of Section V, I outline a practice guideline for
working with men in clinical settings. The recommendations for this
guideline are based on an extensive review of biopsychosocial research
related to men’s gender and health. It identifi es behavioral and psycho-
social factors that affect the onset, progression, and management of
men’s health problems; reviews evidence demonstrating the effective-
ness of various interventions; and outlines specifi c recommendations for
addressing these factors when working with men in clinical practice.
It is organized into six sections—each of which represents one type of
intervention discussed in the guideline—forming an acronym that spells
HEALTH: humanize, educate, assume the worst, locate supports, tai-
lor plan, and harness strengths. In Chapter 13, I go on to provide an
xxiv Introduction
example of applying this guideline—as well as identifying other evi-
dence-based, gender-specifi c strategies—in working with a particular

population, specifi cally college men.
The fi nal section of this book, Section VI, looks to the future of
men’s health. In doing so, I begin by taking a step back. In 1999, the
Philadelphia Department of Public Health sponsored the fi rst national
conference on men’s health, and I was invited to give an opening
address (Courtenay, 2000e). That address provides the introduction
to Section VI, which explores the health concerns of two men viewed
from diverse professional and disciplinary perspectives. How men’s
health is understood, in fact, depends on the lens through which it is
examined. Although it has historically been viewed from biomedical
perspectives, social scientists such as myself have also identifi ed count-
less cultural, psychosocial, and behavioral factors that infl uence men’s
health. I highlight the strengths and limitations of each disciplinary
perspective as I examine the complexity of these men’s lives and well-
being. I conclude by proposing an interdisciplinary biopsychosocial
and behavioral approach to the study of men’s health that unites these
complementary perspectives.
In the fi nal chapter of the book, I provide a global perspective on the
fi eld of men’s health. In doing so, I recommend a variety of precepts for
developing new theoretical paradigms and research models for men’s
health, and offer some direction for social scientists and practitioners in
this nascent fi eld. In particular, I advocate interdisciplinary approaches
that explore how biological, sociocultural, psychological, and behavioral
factors interact to mediate the physical and mental health of men and
boys. I recommend that these approaches apply social structural analy-
ses, examine geographic and cultural contexts, integrate recent theory
and research on masculinity, and develop relational paradigms that rec-
ognize dynamic intersections of various social factors. I also suggest that
new global community health models that can address the convergence
of micro and macro health determinants at international, national,

community, and individual levels are necessary, given the multinational
nature of men’s health.
Much of what is written in this book was previously published and
was read—or heard—in a variety of places designed for health profes-
sionals from diverse disciplines. Consequently, the research I review
derives from a broad array of disciplines, and my style of writing varies
throughout the book. Some chapters are written in a style that is socio-
logical, whereas others are epidemiological. Other chapters are written
for practitioners and provide hands-on advice, and the introductions
to several sections of the book are conversational. All of it, however, is
intended for a large readership. My intention and hope is that a broad
range of readers will fi nd the book easily accessible and readable, and that
you as a reader will be stimulated by and engaged in the per spectives
from other disciplines.