Medical research has demonstrated that seeking medical help early in a disease process, can lead to a greater chance of survival, a less intensive treatment regimen, and reduced cost to the public health system (Dracup, McKinley and Moser 1997, Taplin et al. 1995). However, many people delay consulting their doctor, and men tend to delay more and visit their doctor less often than women. Numerous population-based (Boros et al. 2000, Ladwig et al. 2000, Mustard et al. 1998) longitudinal (Green and Pope 1999) and smaller-scale studies of health care utilisation (Bertakis et al. 2000, Briscoe, 1987) have indicated that men of many different cultures in the Western world tend to delay visiting their doctor for longer and use their services less often than women. However, a growing number of exceptions indicate that the relationship between gender and help-seeking is more complex than once thought (Fernandez et al. 1999, Macintyre, Hunt and Sweeting 1996, Settertobulte and Kolip 1997, Van Wijk, Huisman and Kolk 1999, Wyke, Hunt and Ford 1998).
Addis and Mahalik (2003) suggest that these inconsistencies are partially due to the misguided categorisation of men and women into two homogenous and mutually exclusive biological groups. Categorising by sex does not adequately explain why certain men visit their doctor more often, why some women are reluctant to seek help, or why an individual will visit their doctor in some circumstances but not others. Social theories and analysis of the social construction of gender provide explanations of how social influences, rather than biological differences, constrain men's and women's behaviour.
Social construction of gender and health
Contemporary gender theory goes beyond deterministic understandings of masculinity and femininity to show how, within the limits of existing social discourses, individuals actively construct and reconstruct gender through social relations in a historically situated context (Carr 1998, Connell 1995, West and Zimmerman 1987). Bohan (1993) also argues that appropriate masculine behaviours are constructed in direct opposition to those constructed as feminine behaviours.
Many gender theorists suggest that health care practices are gendered so that ‘doing’ health reflects ‘doing’ gender (Courtenay 2000b, 2000a, Saltonstall 1993, West and Zimmerman 1987). For example, Courtenay (2000a: 10) argues that for a man to do masculinity he must ‘. . . be relatively unconcerned about his health and well-being in general and would place little value on health knowledge. He would see himself as stronger, both physically and emotionally, than most women.’ In these terms, failure to seek medical help originates in a socially constructed agreement that men do not ask for help and do not need to go to the doctor as this denotes feminine vulnerability or weakness. (Addis and Mahalik 2003, Courtenay 2000b, 2000a).
Research has demonstrated how culturally dominant constructions of masculinity and femininity are drawn upon to construct men's and women's health, and how men's help-seeking behaviours are influenced by these dominant forms (Cameron and Bernardes 1998, Chapple and Ziebland 2002, O’Brien, Hunt and Hart 2005, Pitmman 1999, Robertson 2003, Seymour-Smith, Wetherell and Phoenix 2002, Tudiver and Talbot 1999, White and Johnson 2000). Health professionals themselves contribute to the gendered construction of health behaviour. Seymour-Smith et al. (2002) found that health professionals criticised culturally idealised forms of masculinity for their part in men's reluctance to seek help, but valorised or celebrated them at the same time. Women's problems were constructed as more trivial than men's while men's reluctance to visit the doctor was accepted as amusing.
Gendered power imbalances are a central tenet of Connell's (1995) theory of hegemonic masculinity which is defined as, ‘the configuration of gender practice which . . . guarantees . . . the dominant position of men and the subordination of women’ (1995: 77). Connell refrains from identifying hegemonic traits but emphasises how hegemonic forms of masculinity impinge on the ways men can identify as masculine. In terms of health care, the evidence of power dynamics between different groups of men may be found in the discourses of prostate and testicular cancer survivors used to reconstruct alternative masculine identities following surgery-induced impotency (Chapple and Ziebland 2002, Gascoigne, Mason and Roberts 1999, Gray et al. 2002, Oliffe 2005). Connell's theory of hegemonic masculinity has been instrumental in recent gender research including men's health (Courtenay 2000b, 2000a, Gray et al. 2002) and the construction of masculine identities for men ‘online’ and for men who do ‘women's work’ (Kendall 2000, Lupton 2000).
Although the concept of hegemonic masculinity has been used extensively in such research, a growing number of critics argue against the relevance of hegemonic masculinity for contemporary males, or the utility of the concept for examining masculine identities (Demetriou 2001, Jefferson 2002, Wetherell and Edley 1999). First, Wetherell and Edley (1999) argue that because few men embody all the ideals of hegemonic masculinity and because the ideals are themselves unclear, the value of the concept for analysing masculinities is questionable. Second, they argue that there is no single hegemonic masculinity, but rather a multiplicity of hegemonic sense-making or shared ‘intelligibilities’ that maintain male privilege. Following this same argument, Jefferson (2002) conceptualises the negotiable status of dominant masculinity as multiple, context-dependent strategies for doing hegemonic masculinity (see also Phoenix and Frosh 2001). As an example, O’Brien et al. (2005) found that although focus group participants endorsed a masculine identity based on the ability to endure illness whilst implying that women are the ‘weaker’ sex, not all participants identified as reluctant help seekers. A group of firemen highlighted the importance of seeking medical help early because illness might affect their ability to stay fit and work. The authors argue that, in the context of a highly ‘masculinised’ occupation, masculine identities were based on having a strong and healthy body, rather than on negative health behaviours or reluctance to seek help (O’Brien, Hunt and Hart 2005).
In summary, it has been argued that the assumption that ‘men’ and ‘women’ are two homogenous and mutually exclusive groups does not help to explain the complexities of health care utilisation (Addis and Mahalik 2003). Social constructionist theories of gender may explain variations in men and women's help-seeking behaviours and Connell's (1995) ‘hegemonic masculinity’ provides a relativist approach to studying gender. Thus, we aimed to examine the utility of hegemonic masculinity for understanding the ways men construct masculine identities within the context of health. To achieve this aim we conducted a study to identify and describe the discursive resources used by a group of late-mid-aged men to construct health and health care utilisation, and to examine how socially constructed masculine identities may impact on medical help-seeking. This understanding is important as older men are particularly at risk for illnesses such as prostate cancer and heart disease. We also aimed to examine the seldom-studied masculine identities available to rural men. Much of the masculinity research to date has focused on urban males, and as a result a great deal of theorising on help-seeking behaviour is based on masculinities constructed in urban contexts.
To recruit participants, information sheets describing the study and an invitation to ask questions were sent to members of a small rural community via the local mail delivery service. One month later, full details and a formal invitation for men over the age of 50 to participate were sent out to the same households. No further direct or indirect attempts were made to encourage participation. Participants responded to the invitation by post and were then contacted by phone to arrange interviews at their homes.
Seven men from 45 eligible households volunteered to participate. The first author was acquainted with five of these participants because his immediate family are long-term residents of this community. Although he is not personally well known in the community, his shared knowledge of farming and rural life was expected to increase the likelihood of participation and enhance his rapport with the participants. In addition, we knew that health care in general is an issue for this rural community. Access to emergency response and to post-operative care are ongoing issues.
The median age of participants was 59, six were farmers and all were married. To protect their identity, further demographic information has been omitted. The issues of confidentiality and anonymity are vitally important when there is any prior relationship between interviewer and interviewee (Wiles et al. 2006). Our participants were assured that all published material would have any identifying information removed. This is particularly important in a small community where participants are easily identified by personal details.
To begin each interview a computer was used to present approximately 10 minutes of video clips from the movie, Something's Gotta Give, in which Jack Nicholson plays the part of ‘Harry’, a suave 63-year-old businessman who ignores chest pains and suffers a heart attack. The respondents discussed why Harry ignored his symptoms. Then two hypothetical scenarios about men who had experienced other symptoms were discussed, and finally the men were asked about a time when they had not sought, or delayed seeking help, despite experiencing symptoms. Participants also raised issues about their own medical experiences. Excluding the video presentation, the interviews ranged from 30 to 50 minutes with a total of 5.5 hours of interview time.
The interviews were audiotaped and transcribed. Copies of the transcriptions were returned to participants for checking, although no changes were made. All respondents were given pseudonyms and any talk that could potentially identify them was removed from subsequent analysis.
The transcribed data were analysed following Potter and Wetherell (1987). Data were coded by categorising specific speech units based on commonalities, themes, or patterns of talk. The coded data were examined to identify variations or contradictions in the men's accounts of health-seeking. For example, the language respondents used to construct their own help-seeking behaviours was found to be different from the language used to describe the help-seeking behaviours of other men. The codes were then used to categorise the language used. For instance, talk to legitimise either seeking or not seeking help used words specific to medicine, whilst references to other men's help-seeking was characterised by talk that differentiated ‘health’ for men and women. These patterns were then analysed to identify the words and images as constituents of socially available ‘interpretative repertoires’ that the men drew on to construct their own and other men's health care utilisation. Finally, analysis determined the function of the repertoires, or what the men were achieving by constructing men's health in different ways. Potter and Wetherell's approach to analysis was then developed in two ways. First, the interpretative repertoires were conceptualised as ‘discourses’ (see Parker 2005) to take account of their function in the broader social context, and the power relations reproduced in their use. Secondly, the analysis was developed to include the discursive positioning of subjects (Davies and Harré 1990). Positioning theory suggests that actual conversations, past and present construct selves, rather than transcendental concepts like ‘roles’. Accordingly, we examined the subject positions offered by the discourses and taken up by the men according to the function of the talk.
Findings and discussion
Discourses of health
The analysis resulted in the identification of several discourses that were drawn on by the men to talk about health care and help-seeking. To answer our question about how masculine identities may impact on medical help-seeking we focus here on the identification of two widely recognised discourses, which we labelled the ‘biomedical’ discourse and the ‘morality’ discourse. These labels denote the men's use of biomedical and morality discourses within the context of the interview rather than the existence of single and overarching discourses. Previous literature has identified multiple biomedical and morality discourses that are made available to individuals across different social contexts and over time (Burke 2004, de Ras and Grace 1997). The interview context, a discussion about men's health care utilisation with a health researcher, made certain forms of biomedical and morality discourses available for these men to draw upon.
The biomedical discourse
Biomedical discourses have been widely acknowledged in both psychological and sociological research as a dominant way of constructing health, illness, and the body in our society. Linked directly to science and scientific neutrality, biomedical discourses discount social influences by constructing the practice of medicine as rational, objective, and value free (Annandale 1998). Bodily functions are often represented by mechanical images whereby the heart is construed as a ‘pump’, bodies are ‘maintained’, and food becomes the ‘fuel’ for the body (Gray et al. 2002, Saltonstall 1993). Lupton (2005) argues from a Foucauldian perspective that the medical encounter between doctor and patient is a site of disciplinary power in which the biomedical discourse constructs the ways that ‘patients should understand, regulate and experience their bodies’. (2005: 249). In these contexts, biomedical constructions of disease processes, immunity, and medications are more valued than alternative forms of understanding (Keogh 2005, Lyons and Griffin 2003).
Within the interview context, many respondents drew on the biomedical discourse when constructing their own and other men's health. For example, in the excerpt below Kelvin uses the biomedical discourse to construct an account of peritonitis that illustrates his medical knowledge of disease processes, despite not being a doctor:
Peritonitis or something wasn't it at the finish? But, but that is, was brought about by delay really. Peritonitis can, I'm no doctor but, appendicitis can become peritonitis too and obviously pneumonia can as well. But you know, they were talking, he was three or four days in bed or something (Kelvin).
In the passage below, Andy uses medical terms such as ‘observation’ and ‘pills’ to show that he does have an understanding of the effective use of drugs:
If he'd got some help, even if it had only been a week's supply of pills, and that isn't enough as it takes a fortnight. Even if he'd only got those, at least he would have been under observation and the doctor would have listened to his chest (Andy).
As a final illustration, Brian uses descriptors from the biomedical discourse to describe the events leading up to an acquaintance's death:
Well just that he had the flu and he um didn't, didn't actually go to the doctor and then the flu must have just suddenly developed into septicaemia type thing and when you, that there's no going back (mmm). Your blood's poisoned isn't it? It's blood poisoning. I think that's what it was that finished him (Brian).
In these examples the speakers draw on the biomedical discourse to convey authoritative knowledge about health matters and disease and to give weight to their versions of appropriate behaviour in the face of illness.
The morality discourse
Discourses of morality in relation to health have also been widely identified and examined in the literature (e.g. Crossley 2003, Hodgetts and Chamberlain 2002). Lupton (1999) describes how morality discourses function to hold individuals responsible for their ill health especially in relation to lifestyle choices. For instance, smokers are positioned by a morality discourse as ‘weak willed’ and consequently held personally responsible for their deteriorating health later in life. In contrast, those who consult their general practitioner for regular health checks, are active in disease screening programmes, and up to date with their immunisations, are positioned as virtuous citizens. Crawford (1994) argues that the healthy person has come to represent one who is virtuous, responsible, and ultimately good. Robertson (2003) has demonstrated that contemporary health care discourse provides a moral burden for men to identify as a ‘good citizen’ by regularly visiting their doctor and consequently ‘staying healthy’.
The moral connotations of health care utilisation were apparent throughout the interviews, with all of the men positioning themselves as regular health care users at different points. For example, Phil argues below that every time he has been sick he has sought help without delay. The interviewer's comment reinforces this position as a morally virtuous one.
|Interviewer:||Is there a time in your life that there's been something wrong with you, it could be an injury or an illness, that you didn't go to the doctor but deep down you know you should have? Take a couple of minutes to think about that and it may not be something you can share, I'm not sure.|
|Phil:||I think as far as I'm concerned, whether I've had a problem with any health, parts of my health, I have addressed it and I have actually gone and talked about it or been and done something about it.|
|Interviewer:||As a rule, good.|
As another example, Warren simply suggests that men should go to the doctor. Although Warren admits that he is unsure of whether he would seek help or not, his talk reflects a moral pressure that people ought to go, even if they are reluctant or uncertain. This type of talk occurred regularly throughout the interviews:
. . . [A]nd you should, blokes should probably go, but I don't know if that's what I would do or not (Warren).
Jacob suggests that his relative was partially responsible for her own ill health because she did not attend the doctor early or often enough.
. . . . My [relative] should have gone earlier in the first place and she probably should have gone back quicker the second time. I don't know, yeah (Jacob).
At certain points in the interviews, some men admitted to not always seeking prompt medical attention. In the context of the interview this was an uncomfortable position for these men. For example, Brian's problematic positioning is illustrated by his use of laughter:
|Interviewer:||Can you think of a time in your life when you put off going to the doctor when you really know that you should have?|
|Brian:||Oh yeah, um, yeah well I've got [this problem] and I've been putting it off and um, as it's turned out there was a shed full of sheep to crutch and [person's name] yeah and I thought I would get in and give him a hand but it's not very good for me. And I know I should go (mmm) yeah, but it's inconvenient (laughs).|
Brian is uncomfortable in this context because his actions belie his previous positioning as a ‘good’ health care user.
In summary, within each interview the men and the interviewer drew on the morality discourse to support social sanctions to take responsibility for their own health and well-being. The difficulty some men had with admitting they were reluctant to seek help, illustrates the pervasiveness of the morality discourse.
Positioning and masculine dilemmas
Discourses provide positions for subjects (see Davies and Harre 1990). For example, biomedical discourse includes subject positions for doctors and patients or health care users, and the morality discourse positions subjects as virtuous or immoral citizens. In any moment of talk there may be more than one discourse being drawn upon and at each moment the person or subject may be positioned within multiple discourses. In conversations a speaker may be positioned as a consistent subject at the intersection of multiple discourses (Stephens, Carryer and Budge 2004). When the discourses in use together provide inconsistent subject positions, or at moments in which a subject's position is troubled by another speaker (Wetherell 1998), speakers employ skilful linguistic negotiations with only momentary disruption. For analytic purposes, these are the sorts of moments in which we can observe the construction of certain sorts of subjects. Our analysis demonstrated the gendered nature of these subject positions. At the intersection of the biomedical and moral discourses there is a position for virtuous health care users. Because of the feminine character of this subject position, it requires additional work for men to negotiate.
The regular-user of health care – a feminine subject position
Our respondents constructed the ‘regular-user’ as a feminine subject position. The men positioned women as regular-users who were more likely to utilise medical services (and were also responsible for their husbands’ health concerns). The regular-user visits the doctor often, and for reasons that could be considered trivial in nature. She openly discusses her problems with her friends and is involved in preventative health including immunisation and screening for disease. For example, in the passage below, Warren indicates that his wife talks about her problems with her friends who are often going to the doctor:
If they've got a problem they share it with, with a lady friend or I don't know why it is but they talk about their problems to one another in a big way. I know my wife does and she has friends and they all talk about their problems, difficulties and what they are doing about it. And you know they’re invariably going to doctors and having treatment (Warren).
Andy suggests that women go to the doctor more often than men because men's psyches prevent them from seeking help:
|Interviewer:||What if Pat was a woman, do you think she would go see a doctor?|
|Andy:||More likely, much more likely.|
|Interviewer:||Why would that be do you think?|
|Andy:||They don't have problems with their psyche like males do. Um even if she lived on her own she would talk to her niece or her sisters or somebody, from my experience that is. They, yeah, don't seem to have any hang-ups about discussing things like that.|
The seldom-user of health care – a masculine subject position
Because culturally idealised or dominant forms of masculinity construct men as stoic, invulnerable, and reluctant to go to the doctor, the ‘seldom-user’ of health care is a masculine subject position. Many respondents positioned men as seldom-users of health care. For example, Kelvin provides an account of the reasons that a recently deceased resident of the community had not sought help for his illness. Of note is the way Kelvin refers to the ‘hard nosed fella’, which implies that many men belong to this group.
Oh well, that he [the former resident] was obviously bloody sick (mmm) and nobody realised how sick he was but he, like I knew [the former resident] pretty well, he was probably the hard nosed fella, you know ‘I’ll get over it’, couple of Disprins or whatever they are and I’ll come right (Kelvin).
In the following passage, Jacob suggests that men think that they will never have any health problems and therefore do not need to seek help. It is noteworthy that Jacob's careful qualification and repetition of ‘lots of males’ suggests that he does not belong to this group of men:
Lots of males and I don't say them all, but lots of males, um like to think that nothing will ever happen to them. Um, I don't know how exactly you would put it. It's part of the macho male (Jacob).
Robertson (2003) showed how men in focus groups faced a dilemma between demonstrating that they do not care about health, as is culturally appropriate for men, and showing that they should care about their health, as the good citizen must. Hodgetts and Chamberlain (2002) also found that despite voicing traditional notions of masculinity, such as self reliance and fortitude, many of their respondents also endorsed media messages such as the need to seek help regularly, to engage in healthy lifestyles, and be aware of ‘unhealthy’ masculine attitudes. Our analysis showed that hegemonic masculinity's opposition to the feminine adds a further dimension to this dilemma because, not only is the seldom-user of health care a masculine subject position, but the virtuous and regular user of health care is a feminine position. The dilemma arises because to admit that one does not seek medical help, risks being positioned as an immoral member of our society. But to identify as a man who is willing to seek help, risks damaging one's masculine identity, as the regular-user position is one they had constructed for women.
Thus, we identified two opposing and gendered subject positions which arise at the intersection of the biomedical and moral discourses. It is important to note here that the social context of the interview, in which men's poor help-seeking was understood as a societal problem, highlighted this dilemma. The participants’ prior knowledge of men's health issues, and the health researcher's reinforcement of positive help-seeking behaviours, privileged the morality discourse. To solve this dilemma, we suggest that the men were compelled by the ideals of hegemonic masculinity, to construct their positive health behaviours as legitimate and masculine in opposition to trivial or feminine reasons for seeking help. This is evidenced in the following passage where the consequences of going to the doctor, without a legitimate medical problem, are explained by Kelvin:
I think I would feel silly if I went to the doctor thinking I was dying and he told me I only had the flu. I'd think I'd just wasted his time (Kelvin).
Soon afterwards, Kelvin suggests that some women actually enjoy going to the doctor. He implies that when these women seek help, it is for trivial reasons. Again the interviewer's comments reinforce his positioning of older women in this way.
|Kelvin:||But it's yeah, I don't think anyone likes going to the doctor, well some people.|
|Kelvin:||Old ladies do.|
|Interviewer:||A bit lonely?|
|Interviewer:||No it's not something you look forward to obviously.|
For Kelvin to identify as a regular user of health care while maintaining a masculine identity, he must construct his positive health behaviours as legitimate because to do otherwise would risk being positioned as an ‘old lady’.
The legitimate-user position
To solve their difficult positioning, our participants drew on another subject position provided by the biomedical discourse that we have labelled the ‘legitimate-user’. The legitimate user of health care is one who willingly uses health care services when they have a genuine condition. From the legitimate-user position many respondents constructed their positive health behaviours as warranted in opposition to trivial or feminine reasons for seeking help. Taking up this position enabled the men to identify as regular users of health care whilst still maintaining a masculine identity. Below is one example of the negotiation of this position during an interview. Warren initially positions himself as a masculine seldom-user of health care, however, his laughter suggests that this position is problematic and he immediately goes on to construct himself as a help-seeker for ‘everything in general’. However, this is a position that he had previously constructed for women, and, again, laughter suggests that this position is also problematic. He solves this dilemma by repositioning himself as a legitimate-user, one who does not seek help for everything, but goes when it is necessary:
You know I'd be probably a typical male guy and not too ready to run off to doctors (laughs). But you know, I attend my doctor reasonably regularly, not for anything in particular but for everything in general basically (laughs) (sure, yeah). I don't go running to the doctor for everything, but, I’ll go see her now and again (Warren).
In this particular context, Warren has effectively maintained a masculine identity by reconstructing his health behaviours as ‘not feminine’ in nature. Warren then continued with a lengthy account of his past help-seeking behaviours to further validate his position as the legitimate-user of health care. Accordingly, Kelvin does not settle for the seldom-user position, but his talk indicates that his identity as a man hinges on not appearing feminine, or ‘old lady-like’. Thus, the hegemonic masculine ideal, which rejects the feminine, impinged on the way these men could construct themselves as regular health care users whilst still maintaining a masculine identity. Just as men participating in previous research (Cameron and Bernardes 1998, Chapple and Ziebland 2002, White and Johnson 2000) were compelled by hegemonic ideals not to appear weak or effeminate, our respondents were compelled to identify as ‘not feminine’.
Although the theory of hegemonic masculinity has been criticised due to the vagueness surrounding the actual practice of hegemonic, complicit, and resistant masculinities (Wetherell and Edley 1999, Jefferson 2002), the discursive evidence from this study suggests that it is a useful tool for examining the detailed construction of masculine, in opposition to feminine, identities. First, this analysis has described how these men maintained masculine identities despite resisting what has been previously identified as a hegemonic position for men. Secondly, it has described how these men were, at the same time, compelled by hegemonic masculinity to construct their health behaviours as ‘not feminine’. Our discussion now shifts to Wetherell and Edley's (1999) second criticism and a focus on the formation of masculine identities in relationship to other groups of men.
Strategies for doing hegemonic masculinity
The men used the biomedical discourse to skilfully negotiate their way through a moment in which they were in an incompatible subject position, to identify as ‘not feminine’. In the context of these interviews men rejected the morally dubious, seldom-user position despite constructing it as masculine. Some respondents went further to construct seldom-users as ignorant of the medical knowledge needed to be responsible for one's health. In doing so, these men drew on the biomedical and morality discourses to position themselves as powerful lay experts of health, both masculine and morally virtuous, and those men who don't seek help, as ignorant and weak.
The lay expert position
A subject position provided by the biomedical discourse, the lay expert possesses knowledge of medicine and medical issues related to their own health status and health in general. From the lay expert position respondents constructed men who do not seek help as ignorant and weak. These men discussed symptoms and diagnoses and suggested that men should understand these and be able to make decisions about consulting a doctor.
In the following example, Andy argues that other men, the seldom-users of health care, are reluctant to seek help because they are fearful of the consequences. His use of the biomedical discourse here positions him as a lay expert or someone who knows about medical issues like prostate cancer and knows what prevents men from seeking help. From the position of lay expert, his use of the biomedical discourse suggests that he definitely does not belong to this group of men.
|Andy:||Yeah that's right, yeah that wouldn't be covered under prostate cancer, that would be the thing that would worry him about it I would have thought.|
|Interviewer:||For sure, that's really good. So, why in that situation, you've pretty much answered it through the way, but just to get it down, why do you think Doug or Pat would put off going to the doctor? For a week or so, if you had blood in your urine.|
|Andy:||I can't imagine why (laughs) but fear I would imagine. I would think their primary cause would be fear. Not necessarily brought on by knowledge, it can be brought on by ignorance. Could be either.|
|Interviewer:||So do you think that was a reasonable response, to sort of ignore the|
|Andy:||Oh I gather, not really, but I gather that's what happens. I gather that's what people do. Um ignore it. Um, to be fair though to some people I think that they think it's indigestion probably because it can be hard for an unprofessional person to pick the difference between the two.|
Some lay experts used this position to challenge the capabilities of their doctor and the decisions they had made, demonstrating how these relationships are embedded in issues of power and status. In the passage below, Jacob suggests his doctor acted incompetently in not giving him the appropriate medication. He then sought a second opinion. His use of the biomedical discourse positions him as a lay expert who can tell his doctor exactly what medication he needs. At the end of the excerpt he validates this positioning by indicating that the treatment he suggested was successful:
I had an experience once where I a lump [on my body], obviously a wound I had had. He picked it: blood poisoning. I went to doctor [name] in [the local town] and he gave me some bloody um, ointment, drawing paste stuff to put on and told me to go home to bed and rot (oh?) And I thought, yeah that's exactly what I'm going to do. So I didn't even go home, I went straight to doctor [name] in [another town] and told him I needed some antibiotics, I had this infection, this lump . . . and I want to be [working] in four days (yeah). And he gave me the required antibiotics and fixed it (Jacob).
Finally, Joe argues that he knew more about his particular injury than his doctor who simply referred him to a physiotherapist rather than attending to the underlying medical problem:
I've got an [injury] . . . that I knew was worse than what it was but ended up being at the physio instead of the doctors. The doctor had sort of said ‘oh well, physio’ but I knew, just again from experience that I was bleeding . . . but the physios didn't believe it and then once the [injury] had gone down far enough that they could see there was tissue damage and I was going ‘yeah I told you that at the start . . . Yeah [there is this injury] but it's tissue damage here (points to injury)’ (yeah) (Joe).
Jefferson (2002) and Wetherell and Edley (1999) have argued that to understand the influence of the social context on masculine identities, one must conceptualise hegemonic masculinity as plural. These authors suggest that the strategies considered hegemonic are determined by age, socio-economic status, time, and social context so that strategies for doing masculinity will be hegemonic in certain situations but not in others and for only certain groups of men. Here, the use of the biomedical discourse to construct a powerful masculine identity may be seen as one strategy for doing masculinity in a context in which the moral imperative of health care was in the foreground. It is likely that if these men were interviewed in a focus group or observed in a bar, the same patterns would not be found. For example, in a different context these men might have endorsed men's stoicism and reluctance to seek help, rather than identifying as regular health care users and experts of medical matters.
A further important consideration in relation to the interview context concerns the first author's acquaintance with five of the participants. When the participants are known to the interviewer, there is a danger that participants may be unduly influenced into participating or bring their relationship into the interview and this may affect results. There was no apparent effect on the substance of the analysis because the themes that emerged throughout the interviews were consistent across all participants, regardless of whether they were known by the interviewer or not. Therefore, the interviewer's personal associations in this community did not unduly influence the men's participation in this study, nor how they constructed men's health behaviours within the interviews. Instead, the rapport that was generated by this association produced an insight into rural masculinities that may not otherwise been possible.
Based on this discursive evidence, we suggest that hegemonic masculinity, when conceived in its plural sense, is a useful tool for understanding the power inequalities between men and women and between different groups of men. In addition, it is apparent that the construction of masculine identities is best theorised as a process of negotiation in a situated context rather than through the performance of normative roles.
These findings demonstrate that hegemonic masculinity is alive and well. Our older rural men did not focus on any practical difficulties about their access to a doctor. Rather, they drew on widely available discursive resources that have been noted in other studies, to construct masculine identities. In doing so they encountered the same incongruence between virtue and masculinity as the younger urban men in Robertson's (2003) study of health care utilisation. Robertson suggested that the men in his study had to legitimise their health behaviours in order to maintain their masculine identity, and we suggest that this negotiation takes place in the shadow of the ideals of hegemonic masculinity as described by Connell (1995). We further suggest that because gendered identities are constructed in opposition, our respondents were compelled to identify as ‘not feminine’. Hall (1996) points out that identities, including gender identities, are constructed through difference or the relation to the ‘other’. Our respondents demonstrated the discursive work involved in constructing and maintaining a masculine identity in opposition to feminine behaviours. Although many men rejected the masculine position of one who seldom uses health care, a non-immoral position in the interview context, they still orientated their accounts away from frequent consultations which they had constructed as feminine health behaviours. Thus, the ideals of hegemonic masculinity may be seen as ‘slippery’ (Donaldson 1993) in regard to shifting, context-dependent norms of masculinity, but as consistently demanding that a man is positioned as non-feminine.
The talk of our respondents did support Wetherell and Edley's (1999) contention that there are multiple strategies for doing hegemonic masculinity and that these strategies are context dependent (Jefferson 2002). O’Brien et al. (2005) found that, although many of their participants endorsed a masculine reluctance to seek medical attention, within the highly ‘masculinised’ context of fire fighting, men highlighted the importance of help-seeking to preserve more important aspects of masculinity. Similarly, in the current study, a number of respondents additionally positioned themselves as knowledgeable and legitimate health care users who understood the importance of seeking medical advice, while positioning other men, who do not seek help, as ignorant and weak. These findings illustrate the flexibility of doing masculinity in talk; masculine subject positions for regular health care users are available within the dominant discourses. The masculine ideal of power and control may suggest a subject who displays stoic forbearance of pain in opposition to feminine weakness. Our informants suggest that this ideal may also be realised by one who is a knowledgeable and masterful user of medical services.
These findings will assist health care providers to be reflexive about the discursive resources that they make available to men who use their services. Previous research (Seymour-Smith, Wetherell and Phoenix 2002) has shown how health care practitioners may construct male patients as stubborn and unwilling to seek help whilst constructing female patients as the over-users of health care services. The reinforcement of these positions in a medical setting serves only to further discourage men from seeking help. Following on from this, these findings do not support the provision of health promotion programmes that position men as ignorant about the functioning of bodies, about medical services, and about health care. Instead they support the continuing development of serious health care education for men (such as men's health nights focusing on prevention and early detection information) which provides resources for men to be knowledgeable about health issues and active in making health care choices.
In summary, we argue that hegemonic masculinity is a useful concept for exploring the imperatives and power relations inherent in construction of masculine identities. It is however only useful for understanding men's reluctance to seek medical help if we take into account the social context. Suggestions that men delay seeking help simply because they do not want to appear effeminate fail to understand the resources available that enable men to negotiate health care as masculine behaviour, and the ways in which the context of interactions may enable or restrain the availability of certain subject positions.