The Need to Do MORE-vember: Exclusion in a Hu(MAN) Movement – Frantz M. Berthaud

MO-problems

Globally, it is the sixth leading cause of cancer-related death in men, but in the United States, prostate cancer is the most common cancer in men. Perhaps these facts are known to the populace. Less likely realized is that African American men have higher rates of developing prostate cancer that is more aggressive and more advanced than men of other ethnicities. They are dying from it more so than men of other racial groups in the United States.(1) 1 in 5 African American men will be diagnosed with prostate cancer.(2) This is not an insignificant disparity. Recently, the U.S. Senate passed a resolution acknowledging prostate cancer levels in African American men having reached “epidemic proportions.”(3) Perhaps also not known is that Latino men are 41.3% less likely than both African American and White men to not get screened for prostate cancer.(4) An estimated 214,740 men in the United States will be diagnosed with prostate cancer and 28,170 men will die from prostate cancer in 2012.(5) Given the statistics, why is there such an adverse reaction to prostate cancer screening amongst men? Why won’t they (men) do something about it?

MO-screenings

The natural route to take in order to combat these high rates of incidence for the disease is the early detection of prostate cancer. Preventative medicine comes in the form of prostate cancer screening including two current methods being utilized; the prostate-specific antigen (PSA) blood test and the digital rectal exam (DRE). Not only is there controversy in the medical community regarding screening, but there is a general conflict in the psyche of men inhibiting the early detection of such cancers. Screening, specifically PSA testing may have benefits in catching cancers early, but may carry the risks of overdiagnosis and provoking unnecessary treatments.(6) This has split medical professionals and medical societies on whether recommending regular PSA screening is beneficial or not.(7) As recent as November 2012, the United States Prevention Services Task Force reviewed the evidence and recommended against PSA-based screening due to the small potential benefit of screening using PSA and that it does not outweigh expected harms.(8) The report does acknowledge that studies that do not recruit minorities cannot provide definitive answers.

NO MO-macho

There are apparent discrepancies in screening approaches amongst the medical community, equally in the minds of patients of color; for non-medical/scientific reasoning. Lower rates of screening amongst men of color are reinforced by a societal gender construct of the “man’s man.” Many African American men deemed the digital rectal examination to be embarrassing and uncomfortable.(9) This sentiment of embarrassment and emasculation is incredibly subversive in promoting prostate cancer screening to all men and in particular, men of color. In a qualitative study of Latino men and their thought surrounding prostate cancer screenings, Latino men spoke of emasculation in regards to the DRE. They spoke of being in “control” of their health and the attitudes of the procedure being viewed as a homosexual act.(10) This will remain an inhibitor for affective preventative health in men. Elements of the machismo culture of Latin America and the hypermasculinity of American culture directly undermine the provocation of men to seek health-related help.

Gender studies’ principle of “hegemonic masculinity” speaks directly to these elements. The promotion of a dominant version of masculinity is widespread in many societies. Author Patricia Cayo Sexton states, “Male norms stress values such as courage, inner direction, certain forms of aggression, autonomy, mastery, technological skill, group solidarity, adventure and considerable amounts of toughness in mind and body.”(11) If the social norms urge that men act a specific way in relation to their bodies, this will play a significant role in the manner in which they relate to their bodies; in the manner in which they treat their bodies. Men with strong masculinity beliefs are half as likely as men with moderate masculinity beliefs to receive preventative care.(12) There is an emergence of a body of literature delving into the hegemonic constructions of masculinity and their role in perpetuating an image of men that promotes risk-taking behavior and discourages health-positive behavior. How do we get men to see the importance of prostate cancer screening and the benefits of preventative care and how can we simultaneously be cognizant of their cultural and gender beliefs? Can we approach men’s health issues without first approaching the health of men’s issues?

MO-vember

Borne from the combination of “mo” the Australian colloquialism for moustache, and the month of November; Movember is a month-long campaign to raise money and awareness for prostate cancer, testicular cancer, and general men’s health. It consists of participants growing moustaches all month long.(13) There is a fundraising aspect run through the Movember charity. Movember raised $126.3 million and had 854,288 participants (deemed Mo Bros and Mo Sistas) worldwide in 2011.(14) The campaign that started in Australia and New Zealand is now international including countries like the United Kingdom, the United States, Ireland, South Africa, Germany, and Singapore, amongst others.(15) So, the intentions behind the Movember campaign are honorable ones. The moustache is the ribbon, the symbol by which conversations and awareness are generated and funds are raised for men’s health.(16) According to chief operating office of Movember, Jason Hincks:

“The campaign is inspired by breast cancer awareness activities, with their ubiquitous pink ribbons and fundraising efforts that have hammered home the importance of early testing and detection. Nothing like that exists for men.”(17)

This statement alone excludes the approximate 2,190 men newly diagnosed with invasive breast cancer and the 410 men that will die from the disease this year.(18) Once again, the reinforcement of what constitutes masculinity is explicit. The idea of living with a feminized illness is very distressing and stigmatizing for some men. (19) Their mission to “change the face of men’s health” as the Mo Bros become “walking, talking billboards for the 30 days of November” is needed; I agree.(20) Feeling the need to construct a “hairy ribbon” is not necessarily the most honorable motive. But allowing participants to tout their moustaches and clearly demonstrate their involvement in the awareness initiative is an easy and effective way to promote Movember. But does it promote awareness for prostate cancer? The campaign relies on conversations surrounding men’s health being generated from inquiries about a participant’s moustache. As friends, family members, co-workers, and strangers alike ask about the Mo Bro’s facial hair, they can use this to segue into a conversation around prostate cancer and testicular cancer. But does the moustache change attitudes and behavior of men?

MO’s-model

The Movember campaign utilizes the often-used Health Belief Model (HBM). This theory is founded on the basis that people are rational. Decisions about health behaviors are a balancing act where you weigh the perceived benefit of taking action versus their perceived costs. With Movember, there is an assumption that there is a rational chain of events that will occur with the end result being the “change” in men’s health:

You grow a moustache; a (male) friend asks you as to why you’re growing a moustache; you inform him that it is to raise awareness for prostate cancer, and at that moment you take it upon yourself to educate that individual about prostate cancer (screening) and men’s health. You then assume that that individual will start their own conversations among their male counterparts are better yet, go get screened themselves (if they are in any of the risk groups for prostate cancer). And voila...change.

This is an irrational assumption; whereas the HBM relies heavily on rationality. Rationality would dictate men to get screened for prostate cancer. HBM’s rationality framework would further provoke men, particularly African American men, Latino men, men over the age of 50 (risk groups) to get screened for prostate cancer given statistical evidence to support the necessity of the screening. But why does it not work? Why don’t more men; African American men, get screened for prostate cancer? Why don’t more men seek health-related help? The health belief model cannot provide sufficient answers to these questions.

Despite its remaining one of the most widely recognized in the field, hence its presence in numerous public health interventions, the HBM is considerably limited. Its rational decision-making foundation cannot provide adequate support to account for the observed health behavior of men. The health belief model posits that people are ready to take action if they believe that costs of taking action (perceived barriers) are outweighed by the benefits.(21) It also argues that people are exposed to factors that prompt action (i.e. advertisements, a suggestion from their doctor to get a prostate screening).(22) These “cues to action” are arbitrated by dynamics like age, race, and gender. They play a role in dictating whether or not individuals will act upon the cues. The HBM is concentrated on the individual level and cannot account for conditional factors like cultural beliefs, societal constructs/norms and historical context. What does Movember need to do to consider answering the questions that the HBM does not?

MO-redefinition

In order to discuss the health of men, the idea of a “man” must be explored. As aforementioned, the social construct of masculinity drives men’s health. Movember’s website is emblazoned with language like “moustache is king” and has young white men peddling their masculinity above their upper lips. The campaign’s simplicity implicitly equates being a man with the explicit display of a sexual characteristic. What does this say to individuals who identify as men without having a moustache or having the genetic ability to grow one? Society’s constant barrage of “manly man” talk is easily protected by gender-normative displays like Movember. There must be a more profound and inclusive ideology of what masculinity is.

What if there was a woman that too wanted to grow a moustache? Unfortunately, this too is not widely accepted. Women with unwanted facial hair carry psychological burden and it represents a “significant intrusion into their daily lives.” (23) It is imperative that there be a deconstruction and redefinition of societal norms of masculinity prior to promoting a public health campaign aimed at men. A more effective model to use in regard to redefining masculinity and social norms would naturally be the social norms theory, which states that massive change can be created on a mass level, simply by changing social norms.(24) This is a group-level approach in contrast to the HBM’s individualized methodology. The one-size-fits-all criteria of the health belief model sans an understanding of the gender constructs that are constantly in play only perpetuates the ineffectiveness of this awareness campaign. More poignant factors have to be considered.

MO-cultural/historical context

The old-fashioned sexism and exclusion of the Movember campaign is obvious. When a demographic (African American men) are more at risk of having prostate cancer, why would there not be more literal language and visual language ingrained within the campaign to speak to them? For the U.S. branch of the public health campaign, disregarding the disproportionate affect prostate cancer has on African American men is dangerous. Senator John Kerry’s resolution to the U.S. Senate that spoke of bringing attention to the need for additional federal investment in prostate cancer education, awareness, and research specifically its effect on black men, should serve as a catalyst for their overt inclusion in the campaign.(3) Coupled with the gender-driven lack of initiated preventative medicine is the incredibly important racial aspect. Approaching the Movember campaign through the HBM’s rose-colored glasses does not account for the importance of race. The rationality basis of the HBM would inform individuals to act, recognizing the severity of the health issue. A study done by Neighbors and Howard in 1987 discredits this claim. Though understanding the severity of their personal problem, African American men’s help-seeking tendencies were not influenced. (25) Perhaps this is not a surprise.

Medical mistrust amongst African Americans has a history as long as racism in this country. Acknowledging the historical dynamic of African American men and medicine is vital. Much like, not acknowledging the existence of a deformed ideology of masculinity into the HBM, the exclusion of the historical relationship between African American men and medicine is equally detrimental. One cannot just apply the same circumstances for a Caucasian male and an African American male when promoting prostate cancer screening. There is a historical ethos that systematically oppressed African American people. So, though African American men express the same masculinity normalized by society they perhaps have a general desire to maintain power over the dominion of their bodies given the significance of slavery in America.(26)

To gain more of an understanding, we must consider the fact that there are historical incidents and “scientific” theories about Blacks that attribute to African American men’s distrust of the medical community and public health. African American mistrust for public health dates as far back as slavery and the antebellum period where there were instances of slaves and free Black people being used as subjects for dissection and medical experimentation.(27) Conceivably, the most prominent and widely recognized historical occurrence of racism in respect to medical misuse is the Tuskegee Study of Untreated Syphilis in the Negro Male (TSUS), which took place in 1932-1972.(28) This amongst other historical incidents like the unbeknownst cancer injection experiment on debilitated African American patients at the Jewish Chronic Disease Hospital in 1963 serve as plausible evidence to the African American community to distrust public health.(29) The racist philosophies of Blacks’ biological inferiority to Whites by U.S. academic physicians Louis Agassiz, Samuel George Mortion, Samuel Cartwright, and Josiah Clark Nott were at the time widely accepted.(30) Displaying only a fraction of a past consisting of slavery, segregation, and racism, it is understood why fear and distrust is a natural development for African American men. The manifestation of fear and avoidance distinguishes physician’s offices and/or hospitals – and the medical staff present at these places as existing in a metaphysically hostile environment. If black men do not feel safe enough to speak with their doctors about medical issues, to whom do they speak?

MO-forums

James Withey, head of brand insight at the marketing company Precise out of the United Kingdom, in reference to Movember’s message of men’s health possibly getting lost in social media:

“While more and more people are clearly aware of and excited by Movember, the original aim of the movement seems at risk of being overtaken by the excitement around growing moustaches. In order to sustain the phenomenon, the Movember organizers may benefit from going back to their roots and drawing more overt links with its original cause.”(31)

In order for the root cause of Movember to remain relevant and for the campaign to be successful in its inclusiveness, it must venture off of laptops and upper-lips and into the barbershop. How apropos is it that a public health intervention grown around facial hair, find its applicability in African American barbershops? Recent studies have shown that barbershop administered intervention was not only an appropriate mode of communication, but viable and promising in promoting prostate cancer knowledge and awareness in African American men.(32, 33) As current guidelines for prostate cancer screening continues to be controversial, it is ever more important that African American men have adequate information about prostate cancer screening. And barbershops can be that nucleus where that information is provided, outside of doctors’ offices and hospitals.

Barbershops are bastions in Black communities. Trudier Harris describes the barbershop as, "A gathering place – also functioning as a complicated and often contradictory microcosm of the larger world. It is an environment that can bolster egos and be supportive as well as a place where phony men can be destroyed.”(34) During the 1960s, people like James Armstrong opened the doors to his Birmingham barbershop as a hub for the Civil Rights Movement allowing organizers to plan marches and engage in liberating discourse.(35) Today’s barbershops perhaps do not serve the same purpose, but do continue to function as a place where Black men frequent and engross themselves in conversation. This space and the relationship that the barber and barbershop have with the surrounding community is now being leveraged as an avenue to reach African American men about health issues.

The principles of communications theory reflect on likeability, familiarity, similarity, and associations. With this tactic, African American men should be more receptive to the message of prostate cancer screening since all of these criteria would be met at the barbershop. Barbers serve as lay advisers disseminating health information to loyal customers who frequent the shop. It should be noted that hypermasculinity is still performed in the setting of the barbershop, thus the redefinition of masculinity is still pertinent. The Movember campaign should work with barbershops in communities of color in order to affectively reach those particular constituents. An international public health campaign that makes no change on a local level is not a well-groomed idea.

MORE-vember

A public health campaign geared towards men, without any consideration for the ill-effects of social norms, the exclusion of a demographic disproportionately affected by the disease, and the promotion of non-active activism, is weak. Movember’s “cue to action” grounded on the assumption that the non-removal of facial hair follicles is going to do more than just cultivate a competition of facial aesthetics, has no longevity. What can Movember do in order to truly grow awareness and not just moustaches?

They need to be mavens in forging a new identity for masculinity. If they are truly concerned with men’s health, that should encompass emotional and social health. The elements of “man” (as they are currently defined) cannot be incompatible with help-seeking behavior if we are to really take effect on men’s health. Health policy should be informed by social science taking into account the challenge of transforming a school of thought that has been in effect since we were Neanderthals (some might argue that we still are). We should look for a deconstruction of masculinity and not necessarily a destruction as a reliance on generalizations will undermine the efforts.(36) It is about time that a richer, deeper, and more comprehensive story of what it means to be a man is written. And Mo Bros could/should be the authors.

Secondly, a blatant inclusion of men of color, in particular African American and Latino men in the campaign is critical. It is not enough to just find Snoop Dogg on the website. Moustaches come in different colors. Drawing on the voices and visages of men of color will further draw on the principle of inclusiveness. Ensuring that ALL men are becoming aware of the risks of prostate cancer and the benefits of screening should be in line with the campaign’s mission. This will not be easy given the historical context of African American men in the United States; therefore, enlisting the help of ambassadors within African American and Latino communities is important.

Lastly, we have seen that the medium utilized to inform African American men of health issues does not have to come in the form of a primary care physician’s office or on a website. Men’s constructions of masculinity and their approaches to health remain diverse and arguably complex. I urge that public health interventions like Movember should consider how we approach men, when and where we approach them, and the campaigns should reflect these complexities. There is variation across cultures, ethnicities, generations, socioeconomic statuses, and geographical locations. Discarding ineffective health models and a reframing of Movember’s message in order to affectively create awareness surrounding prostate cancer and men’s health in general, across all of these variations, is essential. Until these standards are met, Movember’s shortcomings will only blemish any opportunity to actually “change the face of men’s health.”

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