The Tip of the Iceberg: Male Suicide and the social determinants of health

Keynote presentation by Professor John Macdonald
President, Australasian Men’s Health Forum. Co-Director MHIRC UWS

The tip of the iceberg theme will be used to suggest that we need to look beneath the surface of things, in many areas of life: often we have preconceived ideas, sometimes formed by the media or prejudices in our culture. In men’s health, there is a particular need to look beneath the surface, especially of received wisdom, as I will suggest.

The tip of the iceberg will be used in this presentation in three ways:

· As an image of the state of research into men’s health in Australia: the focus is on only a little of the reality
· To suggest that the issue of male suicide in our society is a phenomenon which needs to be examined more closely to see more clearly what lies beneath the surface if we wish to help prevent tragic deaths and the anguish they bring to many.
· To suggest that the research into the social determinants of health allows us to look beneath the surface of all population health, in this case, men’s, in order to ask, in a more profound way than is generally the case, what must we do to promote a society which sustains the health of boys and men?

Suicide, the tip of the iceberg

People readily acknowledge the fact that more men than women kill themselves in our country. There are studies which look at how men kill themselves: with guns, hanging themselves, throwing themselves from bridges etc (De Leo et al 2003). There are studies which look for reasons why men don’t seek help. However, there seem to be no studies looking at why men kill themselves. This is surely curious since it is perhaps the only really important question. If we are interested in prevention we must seek to understand not only how this is happening and why men don’t use services (although another, perhaps more useful way of looking at this might mean asking what’s wrong with the men, but rather, more importantly, what’s wrong with the services?). We must also ask the big Why question – what is happening to these men? Can we get some sense of why men are killing themselves?

Epidemiology has the task of casting light on the phenomena of health and ill health in society. Male suicide provides a good example of how inadequate science can fail a society. Science has the task of looking in detail at what is going on. A country which looks at male suicide in terms of the means of suicide, in terms of why men don’t seek help but does not systematically look at why men are killing themselves is, to say the least, seriously flawed.

I suggest that the tip of the iceberg analogy could be helpful here:

The way male suicide is often ‘understood and dealt with’ illustrates how other male health issues are often inadequately and unscientifically addressed. The general approach to men’s and boys’ health is based on pre-judgements and assumptions rather than on anything resembling “evidence”.

In an age when there is a great deal of talk of “evidence-based” practice in health services, it is remarkable that “(m)any non-evidence based assumptions continue to prevail in men’s health. The discourse that has so far influenced policy development has tended to be in the mode of male deficiency : “men don’t take care of themselves’, “men don’t go to the doctor’, “men are not in touch with their feelings..'(Macdonald 2005 p.100). As a society, certainly as a collection of health services with policies and practices concerning men, we have given an enormous amount of credence to “hegemonic masculinity” as a “one size fit all” explanation for almost anything in men’s and boy’s health. Even if this language is not used the ideas behind it often underpin policy. Hegemonic masculinity sees everything in terms of the power which men are seen to wield in, presumably, all significant areas of life. It is understood to mean the social conditioning of men which leads them to abuse their bodies and minds and die young, abuse their partners (and no doubt their children), refuse to seek help from friendly health services etc. You think this is exaggerated? Let me remind you of the Doctors Reform Society of Australia and its policy on men’s health:

8 3 Men’s Health
8 3 1 The DRS recognises that there are particular issues for men which affect their health. These issues can arise from the process of socialisation to compete and dominate in social and political spheres which can foster violence. As a result of this, many men experience a number of psychological difficulties, a reluctance to acknowledge and address their own health issues and diffidence in approaching health services. (see also 15. Violence and Aggression)
8 3 2 The DRS recognises that despite the fact that the majority of health research has been conducted on men and that there are biases towards men in health care teaching (due to the dominance of men in teaching and research positions), men still have poorer health in a number of areas and a lower life expectancy than women.
8 3 3 The DRS believes that increased attention to lifestyle changes (such as exercise, reduction of alcohol consumption, and strategies to reduce violence) are more important in improving the health of men than technological improvements in health care.
8.3.4 The DRS believes all men in Australia must have access to appropriate information and education about health. In particular, men need to be encouraged to make earlier, more appropriate use of primary health services.
8 3 5 The DRS encourages the development of accessible, appropriate services for those who are victims of violence. It is also important to develop preventive and treatment services for those who are at risk of, or have, perpetrated violence. (see also Violence and Aggression 15.1.3 General, 15.3 Domestic Violence and 15.4 Sexual Assault)
8 3 6 The DRS believes in order to improve men’s health, the men’s health movement needs to focus on the above issues, rather than competing with the women’s health movement.
(Doctors’ Reform Society, undated)

It is of note that in a policy of just over 250 words, violence is the most repeated word, mentioned seven times. This is a reflection of a cultural stereotype: men as violent, men as irresponsible seems to be a major preoccupation of some western health systems in their thinking, planning and funding for men’s health. Of course, victims of male abuse and those who support them must inevitably be preoccupied with male violence. But what if I were a mother or father of a man who had killed himself or had threatened as much and visited the website of the Doctors’ Reform Society (DRS) for insights into what was good for the health of my son? Or a young doctor or psychologist looking to help my practice adopt a population health approach to all my clients, including men? Or to try to make a health service male-friendly? I would hardly find much help in such an approach.

In a health culture which focuses on the pathological and the pathogenic rather than on the building and maintenance of health, there is need for what we can call a salutogenic approach, perhaps especially in regard to men. By this is meant a way of looking a people which acknowledges their capacity to deal with even hostile environments and grow through the process of managing these (Antonovsky 1979, 1987, Macdonald 2005 p80-86). I also mean the creation of environments which are health-fostering: salutogenic. These by way of making a difference with pathogenic, the focus on what is wrong and what causes illness.

The above policy of DRS is an excellent example of a non-salutogenic approach to men’s health. A salutogenic approach would involve a radical change of perspective, not to say a sea change. In the first place, the concern would be to encourage the salutogenic in men: their ability to deal with the hostile and absorb the good in their environment. In a world where young men kill themselves with alarming frequency – and our own country leads the world in this domain – we need a cultural shift towards the fostering of the positive inner life force of all men, especially the young. The salutogenic dynamic in the individual, his/her capacity to manage the environment is a personal/spiritual dimension to be fostered as we have indicated. Just as the individual child’s inner force needs positive reinforcement so does the collective boy child and young man, as it were. Specifically in the context of suicide in Australia, our society needs to be saying to boys and young men, “You are valued. You have a real place in our society’. In western society and in our own country in particular it is not clear that this is happening.

“Masculinity”, as I have said , is often mentioned as a social conditioning explaining male behaviour and often, any factors of poor health in men. The fact that this conditioning is seen, inevitably to be negative, should make us cautious. Within this perspective there is no focus on what might be good in the conditioning of the male psyche – the tradition, for example, to put “women and children first”, to protect and provide for their partners and dependents, to take risks to put out fires etc. Even these caring attitudes are reduced to something rather pathetic and to be apologised for under the lens of “hegemonic masculinity”. Lamentable incidents of male violence, especially in the domestic situation have been allowed, even encouraged, to colour much of our professional understanding of men and men’s health.

An illustration of this is the book, The Psychology of men’s health (Lee and Owens 2002). Almost every chapter explains anything that is happening to men in terms of the mantra of hegemonic masculinity. This is so far from evidence based understanding and practice as to beggar belief.

The authors reject the disease focus of medicine so that the attention can be brought to bear on what they see to be the real problem: men’s psycho-social-pathologies: their poor emotional expression, their risk taking, violence and criminality (two of the chapters), their deficit behaviour and attitudes toward sex, their bodies, work and family (four more chapters). The basic premise of the book is that men are in need of saving: the authors see their work as contributing to this liberation by offering “a direction for the development of the psychology of men’s health which has as its fundamental aim the liberation of both men and women from restrictive and unnecessary gender roles” (p.2).

It would seem that the reasons for male suicide are not worthy of research or examination, almost as though we have a “taken for granted” situation: “Well you know what men are like”. Why the reluctance to examine the phenomenon of male suicide? We have a wonderful organisation in Australia, the SPA – Suicide Prevention Australia. It has led the way in making our society more conscious of the tragedy of youth suicide and surely contributed to the reduction of tragic deaths of young people. There is now no possible doubt concerning the demographic killing themselves in Australia more than any other – it is men, notably older old men and men aged 25-44. Yet at the most recent SPA conference (2005) there was not the same attention given to men’s suicide as there was to youth suicide. The tip of the iceberg. It is presumed we understand what is going on. But do we? Or are we hesitant to look?

The lack of attention to the possible causes of male suicide suggests to me that we are far from looking as objectively as we can at men’s health.

THE TIP OF THE ICEBERG- Pathways to despair

When we at MHIRC began to look at male suicide in a little depth we called the study “Pathways to depression and suicide”. As with our study on other forms of violence, we wanted to have some research insight into the road men travel before they take their own lives. But our collaboration with colleagues on the Central Coast helped us, among other things, to widen even the way we frame the issue and therefore the way we see and understand it. The work of the Suicide Safety Network of the Central Coast of NSW has contributed in a marvellous way to our understanding of the importance of grasping the context – the emotional, economic and social environment of men at risk of suicide. It is good to note that Wesley Mission and the Federal Government are seeking to learn from this experience. Maybe the tip of the iceberg.

The tip of the iceberg and the social determinants of men’s health with a salutogenic approach

I think the image of the iceberg is useful again in the context of men’s health to provide us with an image of the social determinants of men’s health in general.

Social determinants of health

A huge amount of evidence now exists to show – in those countries in which the majority of the population are not struggling for the very basics of survival – that health is largely determined by a host of social and economic circumstances which either hold us in life or threaten or health and wellbeing, building the capacity to engage with the total environment or diminishing this capacity. This body of evidence is what we know as the social determinants of health. A straightforward presentation of these determinants is presented by the World Health Organisation’s The Solid Facts, the Social Determinants of health document (WHO 2003). The two prominent researchers in this field who edit this booklet have this to say in the introduction:

We need friends, we need more sociable societies, we need to feel useful, and we need to exercise a significant degree of control over meaningful work. Without these we can become prone to depression, drug use, anxiety, hostility and feelings of hopelessness, which all rebound on physical health (Wilkinson and Marmot, in WHO 2003, Introduction)

I want to suggest that what we need in men’s health is a straightforward commitment to the social determinants of health as a framework for examining men’s and boys’ health in this country and elsewhere. Only men’s and boy’s health? Of course not, but it is an area which needs to be liberated from previous frameworks based, as I have said, on assumptions and what can be seen as ideological approaches rather than evidence. We have to collect the evidence of the social determinants of boys’ and men’s health, both the positive and the negative, and have these built into policy.

This inclusion of the social determinants of health would mean widening the perspective, for example, of the Doctors’ Reform Society and its clones, to create a mindset which looks to see what can be done about creating environments which are genuinely concerned with fostering boys’ and men’s health. Even if one were simply to take the list of determinants of health suggested by WHO in its booklet already mentioned, The Solid Facts, the Social Determinants of Health and applied them to men, one might have the outlines of an approach to men’s health policy rather than a medically-driven disease policy or a psycho-pathology-driven one focusing on men’s violence. In a men’s health policy, the acknowledgement of the impact of the social determinants of health would mean an acceptance of the fact that there are serious factors impacting on the life of men which lie beyond their control: more visits to the doctor and that more exercise and less alcohol, on their own, will not guarantee better health The social determinants of health perspective imposes humility and respect on the part of policy makers and providers.

Some of the social determinants suggested by The Solid Facts are:

The social gradient:
Most diseases and causes of death are more common lower down the social hierarchy. The social gradient in health reflects material disadvantage and the effects of insecurity, anxiety and lack of social integration (WHO 2003 p 7).

This reminds us to acknowledge that men are not a homogenous bundle and social stratification is still a major factor influencing health, including men’s health. Those who use the Titanic as an analogy of social life – Upper, middle and lower classes with stratified access to life boats – are offering us a useful image, but they should not forget those who were even below the third class passengers, those who stoked the boilers in the bowels of the ship and who perished as a result: all of them men. Simplified versions of patriarchy, like all salvation stories, are far from doing justice to the complexities of life and health.

The social determinants of health perspective allows us to address the issue of the lamentable situation of Indigenous men’s health in Australia. The main causal factor in this situation is the historical and current discrimination this population faces. The only way forward is not for exhortations about life style, it is rather to address the contexts of ill health and to improve the social economic environment of Indigenous and all underprivileged men.

Stress
Social and psychological circumstances can cause long-term stress. Continuing anxiety, insecurity, low self-esteem, social isolation and lack of control over work and home life have powerful effects on health. Such psychosocial risks accumulate during life and increase the chances of poor mental health and premature death. Long periods of anxiety and insecurity and the lack of supportive friendships are damaging in whatever area of life they arise (WHO 2003 p 8).

To suggest that there needs to be an acknowledgement of the role of stress in understanding men’s health is not to suggest that women live stress-free lives. Rather, it is to point to the fact that stress is often experienced and dealt with differently by men and women. The role of stress in men’s health profiles is increasingly recognised. Expectations on boys and men, whether social or economic, can be the cause of great stress. For example, in a world of shifting job opportunities, the notion of permanent employment may well be a thing of the past. Recent legislation which erodes collective bargaining under the name of “Industrial Reform” will take a toll on the health of men and their families. Yet, despite the discourse about the importance of men not identifying themselves too closely with their occupation, many men both see themselves and are seen by their families as the main providers (and the state), responsible for the delivery of the basic necessities of life. Permanent insecurity of job tenure in such a context is a recipe for constant stress.

The employment situation is only one example of stress and its impact on men’s health. There are many others which should be acknowledged.

Early life and education
The nurturing of all children can be seen to be the encouragement of their own salutogenic drive, their life force. With the help of the social determinants of health, an image of health emerges as the “successful’ interaction between the self and the environment (Macdonald 2005). The two mentioned determinants, social gradient and education illustrate well the fact that the phenomenon of “health’ is often inextricably linked to the interaction between the person and community and their context(s): one’s experienced position in life and one’s education either “feed’ or “starve’ a person’s well-being and his or her ability to engage with other aspects of “the world’, like the domain of employment and social interaction. Education intervenes: it either increases the child’s self-confidence and purchasing power or else it doesn’t, but either way it impacts on the child’s interaction with its environment. We need to build salutogenic environments for them and the resilience required to deal with the challenges life will present them with. In the case of boys a salutogenic perspective leads us to question a certain pathologising which can be observed, for example in the diagnosis of Attention Deficiency Hyperactive Disorder (ADHD). One can either unquestioningly accept that many children, overwhelmingly boys, have a chemical imbalance which leads to behavioural “abnormalities’ calling for regulation and control through medication, or one can look to a wider explanation of this phenomenon. It is surely legitimate to ask here: is this a classic case of the medicalisation of a social phenomenon? Are we witnessing and sometimes colluding with a harmful pathologising of boys (Grandpre, 1999)?

Social exclusion/social support
The social determinants of health perspective encourages us to see the emotional environment as having an important impact on health. It is fundamental, in the real sense, to human health, to be cared for. Human wellbeing is nourished, not only by food, but by supportive engagement with other people, by the knowledge and experience of being cared for and valued. If the already mentioned link between health and an adequate material economic base seems obvious, so might also the insistence in the same related literature about this matter of the importance for health of social support networks and social cohesion (Macdonald 2005).

Men and boys may have different ways from women of expressing their social nature and their need for contact with others, but connectedness and social support is as important for them as for women. In one study of older men, a respondent said that when he came to his group of supportive “mates’ he didn’t feel “like a load of old rubbish’, like most people he needed some form of validation from other people and he found it with a group of his peers, in an organised group of older men set up and run by themselves to meet just a need (Macdonald, Brown & Buchanan, 2000). In many societies after retirement or especially retrenchment men experience that they are not valued and what this older man was saying was that his group offered him positive affirmation of himself. He wouldn’t have used the words, but the group can be seen to be offering him a salutogenic environment. It offered him a place for his own energies to engage with others and to be supported by them. In most societies men see an important part of their self worth as being related to their employment status. One can challenge the “construction of masculinity’ which brings this about, but a more positive (and health) orientation would be provided by a salutogenic framework which would acknowledge the contribution men make to society and their families and offer supportive environments to men whose job security is threatened or taken away.

Men’s use or non-use of health services
The social determinants of health/salutogenic approach is again a useful outlook here when, in this context, one is faced again with deficit stereotypes about men: It is common to hear in the context of men’s mental health: “Men do not access mental health services because they do not get in touch with their feelings’. This has become like a mantra of many health professionals faced by the non-engagement of their services with their male populations. A non-deficit approach would not start from this blaming view. It would be concerned with encouraging a salutogenic orientation in each individual and in creating environments supportive of their health – in this case access to health services – in ways appropriate and attractive to men. The question should not be, how we can adapt men to the service for example by “deconstructing their masculinity’ or destroying a culture of “hegemonic masculinity, as has been suggested by authors already referred to (Lee & Owens, 2002). We should be asking: How can we ensure that the service is adapted to men and their needs? An evaluation of a phone-in service for people in stress and at risk of suicide recognised the under-utilisation by men. At first the by now standard “explanations’ were offered: men’s reluctance to divulge their innermost thoughts etc. The manager of this service, a woman, questioned this direction. Her approach was rather: If we have a service aimed at men and they do not use it, it may be of limited use to seek to adapt the user to the service, rather it makes sense to see how we adapt the service, in this case, to men. Because women will more often use general counselling services and because more counsellors are women, the service may become sensitised to women’s particular needs. This shift in perspective brought about a more man-friendly approach, involving a “task-oriented’ approach to counselling, and the result? Greater call back by men (Bender, Psychologist, personal communication, 2004).

We have already suggested that much of what passes for “evidence’ in the matter of men’s health is, to say the least, somewhat limited. In the case of the Doctors’ Reform Society and many men’s health policies seem to have been shaped by those who have been dealing with the victims of abuse. All violence, including male violence, needs to be dealt with by society at large and health systems as well, but cannot be the main grounding for a rational health system for one major sub-group of the population.

To sum up:

· Tip of the iceberg: lack of interest in the “But Why”? question concerning male suicide: let’s have the courage to look at possible causes outside the male psyche
· Tip of the iceberg: we need a clear and compassionate view of the pathways to despair of many men
· Tip of the iceberg: let’s make it “normal” that we look at men’s and boys’ health through the lens of the social determinants and not some preconceived and often negative views of males.

Let us continue to build a salutogenic society for men and boys

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MCB:
Although this speech is now a couple of years old, is still appears to be far ahead of NZ suicide research and social programmes.

Our wiser Australian cousins are actively researching and applying the knowledge gained.
The other pages on this website well illustrate men’s frustrations and stresses, what the public see as underneath the iceberg….
Rather than wait for Australian research and social programmes to become fully mature and then copy them, we should be contributing research and working towards developing worthwhile social programmes – right now!
MurrayBacon.