Health-Seeking, Stoicism, and Illness Behavior in Men’s Health

“Well-being is realized by small steps, but is truly no small thing.” – Zeno

Chuka Nestor Emezue // While the concept of masculinity is socially conferred, its assumed philosophical attribute–stoicism--remains a personalized and guiding ideology practiced by stoical adherents (male and female) – either by omission or commission. My research looks at the foundational causes of interpersonal and intimate partner violence (IPV), situating accountability and intentionality with the perpetrator – who we know from evidence is likely male (1 in 3 women are victim-survivors of IPV). By the same token, peer-reinforcing stoicism may explain the denial, minimization, and non-health seeking behavior of male sexual victims and the hypercritical nature of formal systems in place to help them. As expected, this has turned my attention to illness behavior in men–especially regarding their alternative narratives held up against a master narrative of masculinity, the hegemonic kind. Here I consider the implications of the diligent practice of stoicism in the context of gender identity, and other psychosocial and socioecological factors.

For context, Stoicism is a conflict-ridden branch of Hellenistic philosophy promulgated in Athens by its recognized founder, Zeno of Citium in the 3rd century BCE. Stories of an Asian philosophical genesis are not unheard of; however, having come upon hard times after a disaster–-a capsized freight ship–-Zeno, economically impaired and seeking answers to some of life’s harder questions, articulated this philosophy of Stoicism. He further validated his findings through the works of prominent thinkers of his time (including Socrates and Marcus Aurelius). Etymologically, the notion of Stoicism derives from the infamous Stoa Poikile podium (aka The Painted Porch) from which Zeno edified the minds of lay passersby.

At its crux, stoicism incorporates a meticulous set of personal modules (or topos). Such as Reason or logos, Nature or physis – there is also its prescribed aversion to fear and pleasure in the harmonized daily conduct of emotional suppression. Orthodox stoicism was esteemed as an outlining – but semiotic – peculiarity of masculinely gendered embodiment. This archaic variant of masculinity condoned hypersexuality, aggression, homophobia, and a limited range of emotions. Then came neostoicism in the 17th century which has since evolved into contemporary stoicism. Discussed in detail by distinguished gender theorist and Professor Emerita of Sociology Raewyn Connell [1, 2, 3], hierarchies of contemporary existentialist masculinity describe hegemonic, subordinated, marginalized and complicit forms. These dissimilarities ensure that, at the macrosystemic level, illness behaviors are mislabeled as stoical forbearance, and at the individual level, gender hierarchized men in need of care delay at the boundaries of what qualifies as acceptable masculine-reinforcing norms regarding how, why and when men seek care [4]. Repeatedly, this injunctive reticence is self-prescribed in response to social imposition.

Empirically, we can measure contemporary stoicism–or its proximal formation. Validated and corroborated measures have materialized–counting the Liverpool Stoicism Scale developed by Wagstaff and Rowledge (1995), and the Pathak-Wieten Stoicism Ideology Scale (PW-SIS) which utilizes four domains (stoic taciturnity, stoic endurance, stoic serenity and stoic death indifference) to gauge a respondent’s mean stoicism ideology scores (MIS) [5]. In one study, MIS was rated highest with men (32.8% of men “strongly endorsed stoicism”) compared to women (18.9%); although most respondents tiered as neutral regardless of gender [5]. Could this gendered rationalization explain why even with abysmal mortality rates, men constantly self-report better health and quality of life than women?

Turning to health statistics we find that compared to non-Hispanic whites, communities of color report worse health outcomes and highest underutilization of universal health services [7, 8]. Accordingly, health problems among men of color are discovered too late or after complications arise. Several factors predict this Health Utilization Behavior (HUB) – i.e. differential access to care, psychosocial factors, socioeconomic and sociodemographic issues. A more specific question persists: what is the place of injunctive masculinity and gender schemas in health use and illness behaviors?

Outside of what we know, that men reinforce the same illiberal patriarchial norms among themselves, one answer comes from an arguably rudimentary human conduct: how women select their sexual partners as deterministic of masculine illness behavior. An article in the Journal of Evolutionary Medicine on Health Selection Theory saw women overwhelmingly nominate high-status stoic men with health impediments as long-term partners. The same respondents considered attractiveness and physique (facial regularity and body types) only in short-term partnerships [9], therefore suggesting the likelihood that innate stoicism was anticipated, even fortified, by female choices. Like the authors, I am wary of the limitations of the methodologies employed in this study: slideshows and vignettes. However, I agree, to an extent, masculinity is only as compelling as the femininity that ratifies it. (NB: I caution against the genderization of stoicism as there are no absolutes.)

We can also find answers in socioecology– or the Petri dish in which stoicism flourishes. Arguably, classic stoicism encouraged suffering from chronic pain or delaying use of health essentials in the face of exigent priorities – war, illness, penury, or simply just for honorable masculinity in some cases. Contemporary stoicism fluctuates, however, contradicting itself, mirroring the extant normativity that oversees illness behavior. Does this then govern how men seek and use health care services, where available? Could this illness behavior be different with adolescents/boys in a time of progressively masculine fluidity? The answer might be a categorical yes, if one considers that research on stoicism as an illness behavior has uncovered discrepancies along the lines of socioeconomic classism (Blue-collar vs white), geolocation (rural vs. urban, or global-south vs. global-North), race/ethnicity (e.g. Hispanic Machismo vs. Marianismo), ageism (baby-boomer stringency vs. modern day fluidity), and religious stereotyping (pain-bearing Protestant ‘Old Americans) [4].

Other writers distinguish stoical expressions among ethno-cultures. For example, private indifference in Asian cultures guided by the Confucian philosophy, or in one instance, under-medication of pained patients by Filipino nurses handling limited medicine (see Moore et al, 2012). In the aforementioned study, the author states: “point estimates suggested higher endorsement of stoicism for Blacks, Hispanics and biracial persons compared with Whites, but these results were not statistically significant.” Of note, I caution against formulaic half-truths grounding stoical attributes by ethnoracial subgroups [5].

In the health utilization literature, stoicism describes a configuration of behaviors symptomatic in how one describes illness. Patients who abide by high stoical philosophies are prone to delays and avoidance in utilizing availed healthcare [4]. In fact, health-negative attitudes to seeking help for psychological distress mediate the association between stoicism and lower quality of life [6]. Further, terminologies such as endurance, taciturnity, indifference to death, and reticence; or a ‘stiff upper lip’ have been used to describe those who downplay communicative pain or discomfort [4].

Stoicism remains an emic or personal ideologue even in the face of etic or medical objectivity. Health and biomedical researchers define theoretical framings of stoicism when describing divergent levels of coping and resiliency in pained or chronically ill patients. With these differences in how people express pain, the answer, if not physiological must reside in psychology – even as we stress the other important sociocultural and psychosocial factors that guide illness behavior [4]. Of note, in a video-based qualitative ethology study on pain expressivity in nurse-patient communication, patients reflected the nurses “politeness” and were willing to endure pain and reserve complaint as the nurse kept a stoical demeanor while investigating the limits of their pain [10]. It is not unusual for medical personnel to adapt stoicism in dealing and coping with ever-present maladies in lieu of vicarious trauma [5].

A duality of stoicism exists in healthcare masking further investigation into illness behaviors. There are likely pros and cons of stoicism by the dosage – not so much good or bad stoicism. For example, the health positives of adaptive stoicism demonstrated by patients with “muscular dystrophy desiring a better quality of life”, or the elderly who remain physically – if not emotionally – active, averse to a forced commitment to geriatric care in nursing homes, thereby relinquishing their self-determination and independence. Health negative maladaptive stoicism “[generating] harmful inertia in the face of some medical symptoms” [4, 6] may explain men who are averse to prostate cancer screening, holding in view the real possibility of impotence preceding the peril to their masculinity tied to sexual function [4]. This may explain the underutilization of health care among men of color, and underreporting of sexual assault with victimized men.

Finally, there are critical implications for men’s health linked to the self-perception of health status as a function of gender embodiment. Understanding these gender normative elements of stoicism and pain-bearing mentalities that operate in gendered social contexts and govern illness behaviors is vital and mandates continued investigation.

Work Cited

[1] Connell, R. W. Masculinities. Polity, 2005.

[2] Connell, R. W., and James W. Messerschmidt. “Hegemonic Masculinity.” Gender & Society, vol. 19, no. 6, 2005, pp. 829-859.

[3] Javaid, Aliraza. “Hegemonic Masculinity, Heteronormativity, and Male Rape.” Male Rape, Masculinities, and Sexualities, 2018, pp. 155-193.

[4] Moore, Andrew, et al. “Troubling stoicism: Sociocultural influences and applications to health and illness behaviour.” Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, vol. 17, no. 2, 2012, pp. 159-173.

[5] Pathak, Elizabeth B., et al. “Stoic beliefs and health: development and preliminary validation of the Pathak-Wieten Stoicism Ideology Scale.” BMJ Open, vol. 7, no. 11, 2017, p. e015137.

[6] Murray, Greg, et al. “Big boys don’t cry: An investigation of stoicism and its mental health outcomes.” Personality and Individual Differences, vol. 44, no. 6, 2008, pp. 1369-1381.

[7] Pullen, E., Perry, B., & Oser, C. (2014). African American women’s preventative care usage: the role of social support and racial experiences and attitudes. Sociology of Health & Illness36(7), 1037-1053. doi:10.1111/1467-9566.12141

[8] Wyn R, Ojeda V, Ranji U, Salganicoff A. Report. The Henry J. Kaiser Family Foundation; Menio Park: 2004. Racial and ethnic disparities in women’s health coverage and access to care: findings from the 2001 Kaiser women’s health survey.

[9] Brown, Susan G., et al. “Female Choice and Male Stoicism.” Journal of Evolutionary Medicine, vol. 6, 2018, pp. 1-7.

[10] Spiers, Judith. “Expressing and responding to pain and stoicism in home-care nurse–patient interactions.” Scandinavian Journal of Caring Sciences, vol. 20, no. 3, 2006, pp. 293-301.

Image: mwangi gatheca @thirdworldhippy

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