The belief that “real men” must be strong, tough and independent may be a detriment to their social needs later in life.
A study co-authored by a Michigan State University sociologist found that men who endorse hegemonic ideals of masculinity – or “toxic masculinity” – can become socially isolated as they age, impacting their health, well-being and overall happiness.
“When we age, there are certain ways that we can ensure we maintain our health and well-being,” said stef shuster, MSU assistant professor in Lyman Briggs College and the Department of Sociology.
“Having people with whom we can talk about personal matters is a form of social support. If people only have one person that they can share information with, or sometimes even no people, they don’t really have an opportunity to reflect and share.”
Shuster said that when issues arise, like health or financial problems, it puts individuals in an incredibly disadvantaged position if they don’t have anyone to share this with, which also might have negative consequences for their mental health.
“Social isolation is common among aging adults. Changes such as retirement, widowhood or moving to a new home can disrupt their existing friendships,” said Celeste Campos-Castillo, one of shuster’s co-authors and an associate professor in the Department of Sociology at the University of Wisconsin-Milwaukee.
“Older men who endorse the ideals of toxic masculinity can become siloed off as they age,” shuster said.
“Not all older men are at risk – just those who favor a particular set of ideals.”
The researchers analyzed nearly 5,500 U.S. older women and men from the Wisconsin Longitudinal Survey, which administered the Hegemonic Masculinity for Older Men Scale.
The study – published in the journal Sex Roles – is one of the first to treat masculinity as a spectrum rather than a simple yes-or-no binary category.
“A lot of gender research is based on simplistic binaries of women or men, feminine or masculine, either you’re hegemonically masculine or you’re not,” shuster said.
“Because of the data set that we’re using, our study actually looks at masculinity on a spectrum.”
The study also found that embracing toxic masculinity is self-harming.
“Often, toxic masculinity is a term that we use to describe how masculinity affects other people, especially women,” shuster said.
“But our study shows how toxic masculinity also has detrimental consequences for the men who subscribe to these ideals.
The very premise of hegemonic masculinity in some ways is based on the idea of isolation because it’s about being autonomous and not showing a lot of emotion. It’s hard to develop friendships living this way.”
As baby boomers prepare to retire from the workforce, they face challenges in finding and sustaining healthy friendships.
The researchers suggest social isolation may be alleviated by embracing an alternative understanding of masculinity that doesn’t rely on independence and toughness as the only way to be “real men,” or at least easing up on the principles of hegemonic masculinity.
Still, shuster recognizes that the higher men score on the scale of hegemonic masculinity, the less likely they are to change their views or seek help.
“Can you change someone’s ideological principles? I think that’s a harder sell than trying to get people to believe that social isolation is incredibly detrimental to their health,” shuster said.
“It’s about learning how to offer tools for people not to be socially isolated and helping them develop the capacity to recognize that all of the ways they have upheld being so-called ‘real men’ is not going to work for them as they age.”
Young men exhibit distinct health and service engagement profiles from that of their female and adult male counterparts . It is widely known that young men are at elevated risk of perpetrating and experiencing aggression or violence, and have higher rates of conduct disorder, accidental death, and suicide comparative to young women and adult males [2–4], yet targeted programs supporting young men’s access to, and engagement with services to support their health and adaptive behaviour are lacking . Differences in the needs of young males are also evident through the inconsistency between self-reported wellbeing and health statistics. It is common for young men to report better subjective wellbeing and satisfaction with life [6, 7], despite indicators of ill-health being higher in young men than young women [3, 8, 9]. Over the past 20 years, the number of deaths from intentional self-harm in youth aged 15–24 has been frequently estimated as two–three times higher in males compared to females [10–12].
Social determinants of health, in particular masculinity , are important in understanding young men’s health status and health-related behaviours. Masculinity is shaped by societal expectations, values, and behaviours deemed essential of a ‘man’ ; as boys develop into young men these social pressures of ‘being a man’ can assert both positive and negative influences on their self-development . The usefulness and broader societal value of adherence to inflexible notions of masculinity among boys and young men has been widely critiqued, especially from an educational perspective [16, 17]. Extremely gender-typed boys and girls have reported lower levels of school engagement than their less gender-typed peers , and there is evidence that boys emotional stoicism behaviours in friendships are associated with lower academic achievement . For adolescent males, denial of vulnerability and emotional or physical control, in addition to risk-taking activities are key gendered norms that shape behaviours and attitudes . As the extant literature highlights the association between conformity to certain male role norms and men’s health related problems and help-seeking , it is imperative that health promotion programs can effectively engage boys and young men. Due to differing health profiles and social influences, interventions and health promotion programs may resonate differently according to gender. It stands to reason then, that interventions specifically addressing, or incorporating masculinity-based factors, may have greater acceptability, engagement, and impact with populations of boys and young men . Such approaches include community-based rite of passage experiences that seek to foster healthy identity development and maturity [23, 24], and sports-based approaches leveraging aspects of masculinity, as well as key role models and influencers .
In the health promotion field, previous systematic reviews have investigated mental health and intimate partner violence prevention programs in mixed-gender adolescent and young-adult samples, reporting improved outcomes from group-based and experiential programs that focus on health promotion across both community and school settings [26, 27]. Reviews that have examined males in particular have generally focussed on related health behaviours and help-seeking [28, 29], or interventions for sexual and reproductive health behaviours [30, 31]. These male-specific reviews conclude that common barriers to help-seeking are aligned with themes of masculinity (e.g., difficulties showing vulnerability), and masculine-focussed health interventions were identified as more effective than programs without a male approach [28–30]. Further, a recent scoping review for mental health promotion programs with adult male samples (or mixed-gender samples with disaggregated data) found that 22 of 25 studies reported significant positive changes in men’s mental wellbeing .
There are currently no published systematic reviews that have specifically investigated engagement with health and positive identity promotion programs for young males that are community and/or school-based. Given schools are increasingly viewed as venues for such initiatives , especially for externalising problems such as aggression that are experienced primarily by males , this focus was seen as important. Moreover, the broader inclusion of community programs allows investigation of ‘at-risk’ or underserved young men who may have disengaged from school. The primary aim of this review was to identify community and school-based programs in young male samples (or gender-disaggregated samples), with an intent to appraise potential effectiveness of gender-focussed and non-gender focussed programming.
The aim of this review was to identify and appraise the potential effectiveness of school and community-based health and wellbeing programs in young men. The articles identified in this review evaluated a range of intervention types, durations, and intensities.
On average, interventions were implemented for 18 weeks, typically through 1–2 hour weekly sessions. Overall, findings support the effectiveness of health promotion programming for boys and young men, especially in gender-focussed interventions and school-based environments, which comprised the most frequently used intervention setting.
The percentage of programs reporting positive effects in young men is encouraging (100% of gender-sensitive and gender-transformative programs, 69% of gender-neutral programs), suggesting that participation in these programs, despite the varying aims and activities, is likely to be valuable.
Nonetheless, a need remains to determine which approaches work best. While heterogeneity in intervention types, foci, and outcomes of studies included in the present review prohibited meta-analysis, this should be considered as a priority as the field develops, and randomised trials and replication studies are undertaken.
It was also clear from results that there is growing interest in the health promotion field for boys and young men, as 55% of included studies were published from 2014 onwards.
Despite this growing interest, further investigation is needed for the development of a robust evidence base, critical for well-informed recommendations regarding program development and implementation.
This review synthesised findings from a high quality pool of literature (62.5% high methodological quality), with a majority of articles reporting controlled methods with multiple assessment points.
An important aspect of this review involved identifying those approaches that incorporated a specific focus on masculinity, a key social determinant of the health of boys and men .
Previously, systematic reviews have focussed on understanding the health-behaviours of men and how they relate to help-seeking, finding that poorer mental health literacy and adherence to rigid male norms prevented help-seeking and increased self-stigma [28, 29].
We were not able to locate any reviews that focussed on young male samples, though for adult men, effective programs were typically gender-transformative and based on theoretic models [30–32]. Extending upon these findings, this review has explored masculine and non-masculine focussed approaches, and existing theoretical frameworks in programs supporting the health of young men.
Incorporating a masculinity focus
In this review, 10 of the 14 articles that incorporated a masculinity focus evaluated gender-sensitive programs, and four evaluated gender-transformative programs. Encouragingly, all four of the gender-transformative programs reported beneficial outcomes in young men across a range of outcomes, including self-efficacy, anger, and perceptions of manhood.
The overarching aim of these four programs however was to help young males develop their own healthy masculine identity, and the relative success of these programs in achieving this aim is less clear.
Indeed, there is a need to identify and define the determinants of what actually constitutes (and does not constitute) a healthy masculine identity. While this work is beyond the scope of the present study, it is likely essential to furthering research rigour and scholarship in the domains of young men’s health .
Participants of ‘The Council’ did not show any quantitative changes in masculine ideology, and an equal number of TRJ participants reported experiencing, and not experiencing, changes to their perceptions of being a man.
Nevertheless, these programs reported reduced anger and improved self-efficacy [37, 40], which are likely important aspects of a healthy masculine identity.
Similarly, all ten articles evaluating gender-sensitive interventions also reported positive outcomes in young males.
The aims of these interventions were focussed on improving self-esteem, school engagement, physical activity and mental health awareness in young men. The effectiveness of these programs are evidenced by improvements in the outcomes related to intervention aims.
For instance, the OBBC had a focus on school engagement and reported increased academic self-esteem in participants. Moreover, the body-image and physical activity interventions found improvements in self-esteem, negative affect, quality of life enjoyment, and psychological wellbeing, all of which are constructs that have been repeatedly linked with positive body-image and physical activity [83, 84].
Lastly, ROC and Incolink both delivered psychoeducational components, and reported high psychological help-seeking intentions in participants post-program.
A number of gender-neutral programs were also effective for health promotion in boys and young men. Notable improvements were found for measures of self-efficacy, competence, negative affect, and depressive symptoms.
These benefits were commonly identified following programs with a focus on experiential learning and shared-activity, for instance outdoor adventure, sporting, and exercise interventions. This aligns with men’s preferences for group interaction and informal spaces as facilitators to engaging with mental health services .
Despite this, there were also a number of gender-neutral programs that were more effective in young women than young men. Females repeatedly showed stronger program engagement, mental health literacy, and lower mental health stigma compared to males.
These findings suggest that young men may be more likely to value programs that incorporate male-specific components, especially in relation to program engagement, rather than gender-neutral interventions.
Male-targeted messaging has been identified by young men themselves as a strategy to improve engagement with community mental health services [86, 87]. This extends from delivering information about men’s mental health, to utilizing spaces frequented by young men, such as sporting clubs and specific social media avenues, as locations to deliver tailored health information and intervention .
The reported lack of improvement in young men’s mental health stigma may be associated with low program engagement. Stigma has been repeatedly recognised as a key barrier to access and engagement with mental health services for boys and young men [3, 88–91].
Disengagement, or lack of engagement, with services may perpetuate negative attitudes that young men and boys typically hold regarding mental ill-health, such as associated feelings of perceived weakness or shame [3, 92].
If young men do not perceive an intervention as worthwhile, they may generalise this view to other health behaviours such as help-seeking. It is imperative to therefore extend program engagement as this may help to reduce mental health stigma in young men.
Nonetheless, synthesis of interventions by gender-transformative, gender-sensitive, and gender-neutral approaches indicates that incorporation of some male-specific approach, whether it is in the core aim of the program or in tailored content information, can have a positive impact on the health and psychological functioning of boys and young men.
Theoretical frameworks supporting the interventions were diverse, with 22 different theories implemented across areas of learning, cognition, motivation, socialisation, and culture. However, common themes of socialisation and connectedness emerged when assessing program frameworks associated with positive outcomes in young men, especially in gender-transformative and gender-sensitive interventions.
The health benefit of social support in young men is associated with enhanced wellbeing . Socialisation may also impact masculinity as young men frequently evaluate their male identity against their peers [94, 95], and it is suggested that friendships can provide space for young men to ‘try out’ masculine identities .
Programs that integrate social activities may give young men the space to acknowledge the existence of different masculinities amongst those around them, and to feel comfortable in expressing their own male identities.
Unfortunately, the frequency of articles that did not mention any theoretical frameworks (n = 7; 17.5%), is problematic for program evaluation and understanding theorised mechanisms of change, and hinders the development and refinement of future health promotion programs for boys and young men.
Moreover, none of the male-focussed interventions incorporated masculine-based frameworks, instead citing general psychological frameworks including cognitive behaviour therapy or self-determination theory [64, 71, 75].
This in itself is not necessarily a limitation, though integrating masculinity frameworks could further improve outcomes in young men through focussed targeting of potential mechanisms of change , and by extension result in improved societal health.
Relevant masculinity frameworks include Kiselica and Englar-Carlson’s Positive Psychology Positive Masculinity (PPPM) framework , and the Health, Illness, Men and Masculinities (HIMM) model .
The PPPM framework aligns with health promotion in young men as the model focuses on endorsing male strengths rather than ‘fixing’ problematic behaviours and beliefs. For example, promoting courage through sensible risk-taking rather than reckless behaviour .
The model is flexible as it recognises how ideologies are endorsed differently in men of different cultures and ages. Similarly, the HIMM model explores the interaction between socialised masculine ideologies and other social determinants of health, namely: race, status, sexuality, socio-economic status, education, and community among others . The youth specific focus in the HIMM framework targets the socialised celebration of physi
cal risk tasking and the ‘take it like a man’ attitude in young men . Both models recognise that there is no single standard for masculinity and understand the influence of social constructions in the overall endorsement of masculine norms.
Future health promotion programs for young men should consider how their programs could incorporate relevant theoretical frameworks and whether this positively influences masculinity and health outcomes.
This review found a high percentage of studies evaluating programs in secondary-school settings (n = 28, 70%). Schools are unique environments for program implementation given students experience connection in an established community with corresponding social values. Moreover, secondary students are at a developmental stage where social and self-identity is in a state of rapid development .
However, secondary schools also may perpetuate or favour particular aspects of masculine identity via the perceived importance of popularity, being gifted in (hyper-masculine) sports, and acceptance within male peer-groups [99, 100].
It is important to help young males identify that at times, these norms can be restrictive and problematic, reinforcing patterns of dominant male socialisation . Schools may be optimal settings therefore to implement early intervention programs for healthy identity development in young males, at a time where their masculine identity is forming [101, 102].
Schools are also ideal settings for programming around health-related attitudes, as they embrace an interconnected community system including parents, staff, and alumni . Programs for adolescent boys could include these broader support systems in the framework or program activities to increase social support, connectedness, and respect for all.
The role and potential impacts of the broader community was seemingly overlooked in reporting of the development and implementation of school-based programs included this review, which may have reflected time-limited programs that were implemented without full support of the school community.
For example, school-based programs included in the present review typically invited outsourced groups or research personnel to administer the programs (n = 12), with only a handful of trained school staff delivering the program (n = 4).
Building the capacity and experience of internal school staff to facilitate school-based programs is likely to be an important aspect of program sustainability. Future research should look to identify any barriers and facilitators of program delivery by internal staff.
From this review, it is apparent that there are health promotion programs being delivered to a large number of secondary students without extensive research evaluation. For example, the RWP intervention cited delivery to over 2 million students worldwide , though only one evaluation study of RWP fit our inclusion criteria, where authors noted previous assessments of the program were typically anecdotal .
Smith  commented that TRJ has been applied in Australia for a number of years, though no additional evaluation literature was found in this review. This alerts us to the possibility that other worthy and innovative programs may be widely used, but rarely evaluated.
Without proper evaluation, it cannot be determined if such programs are demonstrably effective, or whether they may inadvertently be hindering wellbeing, or perpetuating traditional masculine stereotypes in young men, as opposed to reconstructing or reconfiguring masculine norms [104, 105]. Moreover, without such program evaluation researchers and school bodies will be unable to develop or improve programs to tailor to the needs of their target audience.
Limitations and future directions
Due to the broad approach taken in this review, the resulting heterogeneity of study characteristics prevented a meta-analysis or assessing publication bias. The possibility of publication bias is considered as most of the 40 included studies reported at least one significant effect, suggesting that studies failing to report an effect may be less likely to be published. Heterogeneity additionally hindered the ability to draw statistical comparisons for specific outcomes, settings, and designs.
This review was also limited by the inclusion of studies reported in English only. Review of non-English articles is critical to obtain a comprehensive understanding of the literature, unfortunately we were unable to do so in the scope of this review.
Despite the potential effectiveness of masculine-focussed programming, evaluation of young men’s conformity to traditional masculine norms was limited in this review by the small number of studies incorporating a direct measure of masculinity.
It is noteworthy that so few studies seeking to engage boys and young men in attitudes related to masculinity actually sought to measure the construct . There are now at least 16 validated scales to assess masculine ideology, and the Conformity to Masculine Norms Inventory is one of the most widely used measures available in a brief format , including use in national population health studies for men .
There is a need for further investigation of valid and reliable masculinity-based outcomes in the present research studies. The established link between strict adherence to traditional masculine norms and poorer mental health or related behaviours suggests that altering maladaptive masculine attitudes may improve general wellbeing in young men [4, 28, 108].
It is imperative to better understand how gender-sensitive and gender-transformative programs influence masculine ideologies. Measuring these constructs will additionally allow for deeper analysis between related measures of wellbeing, physical or mental health, or identity development.
Limitations of the included articles and therefore of this review include a lack of long-term intervention, follow-up, and program refinement. The majority of evaluations were conducted for relatively short-term programs that would run once a week for 4–12 weeks.
Moreover, it is noteworthy that none of the gender-transformative interventions reported follow-up data. Future studies should collect this data to evaluate sustained or long-term intervention effects. There were also no instances of study replication, though one program was suspected to have been developed from an earlier iteration of the same program [69, 73].
There was also a small subsection of cross-sectional studies that assessed participants up to 12 months after completing very brief programs [55, 70]. The reliability of the outcome measures is reduced if participants are not able to recall the details of the intervention, or when initial effects may have subsided.
This pattern of short-term, one-off intervention evaluation results in a lack of effect replication and no evidence of program enhancement. Without repeating evaluations it cannot be determined whether programs are reliably effective.
From this review, we can determine that there is still a large amount of research and program development that needs to occur before researchers have the capacity for translating beneficial outcomes into best-practice policy.
Specifically, there is scope for the development of programs directed to young men founded in masculinity frameworks and further quantitative assessment of masculinity variables, such as male-norm adherence and masculine identity-distress, in male-targeted interventions. Alongside this need, documentation of program development should also increase in order to assist future development of similar health promotion programs in young men.
Michigan State University