Machismo in Youth Linked to Fewer CVD Diagnoses, Less Treatment in Adulthood

Men who report having a strongly masculine gender identity at a young age are less likely to be diagnosed with or treated for hypertension and diabetes later in life than those who are less stereotypically male, according to an analysis of US data published in JAMA Network Open. Researchers say this presents an opportunity to create targeted public health interventions and improve care.

Nathaniel J. Glasser, MD (University of Chicago, IL), who led the study, said stereotypically male qualities—those that may discourage seeking help, being vulnerable, or showing weakness—might lead to “decreased engagement with primary care and other dimensions of preventive health [as well] rejection of the recommendations of health institutions.”

It’s important to develop ways to get past any societal expectations that make people less inclined to take care of their health and seek help from medical professionals, Glasser suggested. “The specter of embarrassment, of stigma, of shame is oftentimes, I think, more motivating than the prospect of long-term cardiovascular disease morbidity and mortality,” he explained. “A lot of people would rather forego dimensions of care in order to not be embarrassed, [irrespective of their] sociodemographic characteristic or background.”

Sociocultural pressures to convey masculinity, which can take the form of “narratives, norms, values, and expectations” that vary across cultures and eras, have previously “been shown to shape boys’ and men’s behaviors, preferences, and beliefs,” the researchers write in their paper. The pressures, they add, “frequently encourage displays of self-reliance, emotional control, and strength.”

Prior studies have looked at sex, showing that women are more apt to seek out healthcare than men, for instance. Here the focus in on gender expression: in particular, its relationship to cardiovascular disease.

“Previous research has attributed these findings to sex-linked physiologic differences,” said Glasser. “My research does not discount any of that,” he specified, but instead suggests that beyond sex, there could be a “concurrent process going on.”

Despite looking at relatively young individuals—up to age 42—already there were signs in their study suggesting more-macho adolescent males went on, as adults, to be less aware they might have CVD and less apt to receive treatment.

Nationally Representative Data

Glasser et al analyzed data from three waves of the US National Longitudinal Study of Adolescent to Adult Health, also known as Add Health. The approach allowed them to look at 4,230 male adolescents (age 12-18) at the time of their enrollment in Add Health then during the same participants’ young adulthood (age 24-32 years) and adulthood (age 32-42 years). Most were non-Hispanic white (64%) and privately insured (80%). All identified as men throughout the study period.

The researchers used a validated measure, one developed from Add Health data, to quantify each person’s male gender expressivity (MGE) during the adolescent and young adult years. MGE is based on participants’ responses to survey questions that capture societal expectations of masculinity—things like their how often they cry, play an active sport, or get into physical fights, for instance, as well as working habits, markers of mental health, and even how much time they spend playing video games, among many others.

The men with higher-than-average MGE as younger adults in Add Health were significantly less likely than those with below-average MGE to report having diagnoses of hypertension (22% vs 26%), diabetes (5% vs 8%), and hyperlipidemia (19% vs 24%; P < 0.001 for all) during later adulthood. They also were less likely to be undergoing diabetes treatment as adults (3% vs 5%; P = 0.02).

Multivariable analyses showed that every standard deviation (SD) increase in adolescent MGE was linked to lower likelihoods of being treated for hypertension (by 11 percentage points) and diagnosed with diabetes (by 15 percentage points) during adulthood. For younger adults, each SD increase in MGE was tied to lower likelihoods in older adulthood of being diagnosed with hypertension (by 4 percentage points), treated for hypertension (by 7 percentage points), and treated for diabetes (by 10 percentage points).

There were no significant associations for hyperlipidemia or biomarker measurements of blood pressure, HbA1c, or non-HDL cholesterol. This is not to say that gender expression doesn’t have any impacts on these, Glasser told TCTMD. It may just be that the follow-up duration wasn’t long enough to detect them. Add Health is ongoing and continues to gather data as the participants grow older; he predicted that additional differences in CVD will emerge with time.

The specter . . . of shame is oftentimes, I think, more motivating than the prospect of long-term cardiovascular disease morbidity and mortality. Nathaniel J. Glasser

For now, “the findings of this study suggest that sociocultural pressures to convey male gender may be associated with suboptimal cardiovascular disease outcomes through decreased risk diagnosis and treatment,” the investigators conclude, adding that the data also suggest “males with high MGE may bear distinctive risks and correspondingly benefit from tailored public health efforts to prevent downstream CVD.”

Glasser stressed that their results have clinical implications, as well, given that CVD is a modifiable condition. If there are two patients who both have high blood pressure but have different levels of awareness, the person who knows about their hypertension and is actively engaged in addressing it through lifestyle, and medication if needed, will likely have better long-term outcomes.

In his own experience working in primary care, the population he sees tends to skew female, said Glasser, so “one thing we need to do is have more outreach and better outreach to males.” Also, in general, “we need to be a little more attentive, empathetic, and sympathetic to the interior lives” of the boys and men who do make it to the clinic, he added. His point isn’t that boys and men are necessarily different, but “to encourage us to see kind of broader commonalities” that enable clinicians to support each patient, Glasser said.