Effects of Conformity to Masculine Norms and Coping on Health Behaviors in Men With Multiple Sclerosis

Although men have lower prevalence rates of multiple sclerosis (MS) than women,¹  it is still important to understand their experience with an MS diagnosis. Previous research has demonstrated sex differences in a variety of relevant psychological domains: higher self-efficacy in women,²  higher levels of depression in men with MS,³  typically worse prognosis in men with MS, and more of an effect of disability on health-related quality of life in men.⁴ 

Given these findings, some data cite evidence that men differ from women in how they experience MS, but this difference is not overwhelming. Male socialized gender norms, such as Western culture gender roles, may be a contributor to such discrepancies. These socialized gender norms are established at a young age and guide young men in how to be masculine, which is socially reinforced by peers, caregivers, and society at large.⁵  Although such gender norms do not seem to be inherently detrimental and can also teach helpful behaviors (eg, independence, toughness, provision), some behaviors may contribute to differences in health behaviors and disease management.

Previous research suggests that the difficulty men have utilizing health care services is an effect of gender norm socialization.⁶  Traditionally dominant masculine ideals often include toughness, resiliency, independency, and stoicism.⁷  Specifically, young men may not practice help-seeking behaviors due to the contradictions to gender norms (vulnerability, weakness, and dependence).¹  It has been found that men also allocate less time towards their personal health and practice less preventative health behaviors when compared to women (eg, increased substance/nicotine use and poorer diets).⁸  Furthermore, Robertson and Williams found that men within the age range of 16 to 44 years perceive the medical setting as more feminine and therefore underutilize health services.⁹ 

Levant and Wimer¹⁰  examined the relationship of male gender norms and male health behaviors in a sample of college- and community-dwelling men. They found that certain subscale scores of the Conformity to Masculine Norms Inventory-46 (CMNI-46)¹¹  seemed to act as protective buffers of health-promoting behaviors, whereas others were risk factors. Specifically, men who self-reported higher levels of masculinity related to Emotional Control were also better at Avoiding Anger and Stress and Avoiding Substance Use. However, men who reported a stronger belief in a drive to win in life as an important component of masculinity showed a poorer ability to avoid stress and anxiety. These men also reported lower use of health care resources and less focus on diet as a health-promoting strategy. Men who endorse risk-taking and being a “playboy” as important components of masculinity were also less likely to avoid substance abuse. Risk-taking was also associated with lower health care use. However, men viewing success in life as an important aspect of masculinity were more likely to use health care properly and to see diet as an important component of health. Finally, men who viewed violence as being key to masculinity, as well as men who emphasized self-reliance, were less likely to report diet as a focus.

Although findings such as these have contributed to additional research on men’s health and other chronic conditions have been highlighted, no studies have focused exclusively on MS.¹  Given this, the relationship between masculinity and health behaviors in men with MS may also be nuanced and deserves exploration. If socialized gender norms are particularly important in health behaviors and support seeking, they warrant focus to understand the relationship between how men with MS conceptualize their own masculinity and the behaviors they engage in to promote their health.

The present study explored the relationship between socialized gender norms and health behaviors in a cross-sectional survey study of men with MS receiving treatment at a large academic hospital. Specifically, the association between conformity to masculinity and health-promoting behaviors was examined. We predicted that higher levels of conformity to masculinity would be related to more negative health behaviors (anger/stress, lack of self-care, improper use of health care, poor diet, increased substance use).

In addition to exploring masculinity and health behaviors, we were interested in measuring the effect that such relationships may have on the coping styles of men with MS. Previous research suggests that differences may exist between men and women in terms of adjustment and ways of coping.⁴  Specifically, men with MS were found to be less likely than women with MS to seek support, practice coping skills/acceptance, or attend a support goup.^12,13  We predicted that higher levels of conformity to masculinity would also be related to limited/rigid coping styles (nonsupport seeking, distancing, confrontive, avoidant, etc).

The institutional review board–approved study took place from January 1 through May 31, 2020, at the Cleveland Clinic Mellen Center for MS. The study protocol involved patients completing a series of survey measures at a single time point. Potential participants were contacted based on their completion of a previous survey regarding their research interest. Inclusion criteria for the study included being a man older than 18 years, being diagnosed as having MS, and receiving treatment for MS at the Mellen Center. Approximately 500 men qualified as potential participants and were sent a message via a web-based patient portal (MyChart; Epic Systems Corp) inviting them to participate in the study. Interested patients were sent an email to access the electronic surveys in a REDCap (Research Electronic Data Capture) database. Completion of the surveys qualified them for a $25 stipend.

The CMNI-46¹²  was used to assess conformity to 9 masculine norms: Emotional Control (6 items) (ie, emotional restriction and suppression), Winning (6 items) (ie, drive to win), Playboy (4 items) (ie, desire for multiple non-committed sexual relationships), Violence (6 items) (ie, penchant for violence), Self-reliance (5 items) (ie, desire to solve problems on one’s own), Risk-Taking (5 items) (ie, inclination toward risky behaviors), Power Over Women (4 items) (ie, perceived control over women), Primacy of Work (4 items) (ie, viewing work as the primary focus in life), and Heterosexual Self-presentation (6 items) (ie, importance of presenting oneself as heterosexual). Items are indicated on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). Higher scores reflect greater conformity to masculine norms.

In the Ways of Coping Questionnaire (WCQ),¹⁴  respondents are asked to rate how much they used a particular strategy in response to a stressor. Items are scored on a 4-point Likert scale (0 = does not apply or not used, 1 = used somewhat, 2 = used quite a bit, 3 = used a great deal) and measure 8 coping styles: Confrontive Coping (6 items) (ie, aggressive efforts to alter the situation, suggesting some degree of hostility and risk-taking), Distancing (6 items) (ie, cognitive efforts to detach oneself and to minimize the significance of the situation), Self-controlling (7 items) (ie, efforts to regulate one’s feelings and actions), Seeking Social Support (6 items) (ie, efforts to seek informational support, tangible support, and emotional support), Accepting Responsibility (4 items) (ie, acknowledges one’s own role in the problem with a concomitant theme of trying to put things right), Escape-Avoidance (8 items) (ie, wishful thinking and behavioral efforts to escape or avoid the problem), Planful Problem-Solving (6 items) (ie, deliberate problem-focused efforts to alter the situation, coupled with an analytic approach to solving the problem), and Positive Reappraisal (7 items) (ie, efforts to create positive meaning by focusing on personal growth, includes a religious dimension). Higher scores reflect a greater reliance on a coping style.

The Health Behavior Inventory-20 (HBI-20)¹⁵  was used to measure health behaviors and consists of 20 items and 5 subscales. Three subscales reflect health-promoting behaviors: Diet (5 items), Preventive Self-care (7 items), and Proper Use of Health Care Resources (2 items). Two subscales reflect health risk behaviors: Avoiding Anger and Stress (3 items) and Avoiding Substance Use (3 items). Participants were asked to rate the extent to which each item describes themselves using a 7-point Likert scale (1 = always to 7 = never). Higher scores reflect greater efforts at health promotion.

Subscale scores are obtained by averaging response scores. A total scale score is obtained by averaging the scores of all the items. Levant et al¹⁵  reported Cronbach α values for the subscales and the full scale ranging from 0.68 to 0.79.

Disease impact was evaluated using the Patient-Determined Disease Steps (PDDS) scale,¹⁶  a self-assessment that subjectively scales personal MS disease status. Higher scores reflect higher perceived disability related to MS (normal = 0, mild disability = 1, moderate disability = 2, gait disability = 3, early cane = 4, late cane = 5, bilateral support = 6, wheelchair/scooter = 7, bedridden = 8).

The following patient demographic and clinical characteristics were collected: age, race, marital status, educational status, and years since MS diagnosis.

Descriptive statistics are used to summarize demographic and clinical characteristics (including the PDDS scale score) and subscale scores on the CMNI-46, WCQ, and HBI-20. Frequency counts with percentages are used to present categorical data, and mean ± SD is used to present continuous variables.

To examine the relationships among demographic and clinical characteristics, conformity to masculinity, and coping, Pearson correlation coefficients were generated for all variables. The associations between these variables and each of the HBI-20 subscale scores were determined using univariate linear regression models. Conformity to masculinity and coping sub-scale scores that were associated with the outcome at least at the P < .10 level were added to multivariate linear regression models, controlling for age, race, marital status, educational status, PDDS scale score, and years since MS diagnosis. Additional interaction effects were also evaluated between masculinity conformity and coping variables in the model.

Given the exploratory nature of the study, there was no correction for multiple testing. Missing data were handled using complete case analysis. Computations were performed in R, version 3.6.3.

Eighty-one patients completed the study protocol. Descriptive statistics are provided in TABLE 1. Race lacked variability and was, therefore, eliminated from future analyses. Also, PDDS scale scores were highly variable, with some categories showing low frequency. Therefore, this variable was dichotomized to reflect whether a patient had a score higher than 3 (gait disability). Finally, 2 subscale scores, WCQ Self-controlling and HBI-20 Avoiding Substance Use, were not found to be internally consistent (Cronbach α < 0.60) and were eliminated from further analyses.

Correlation coefficients between demographic and clinical characteristics, as well as conformity to masculinity and coping subscale scores, are presented in TABLE S1, which is published in the online version of this article at IJMSC.org. Age was related to lower levels of Self-reliance, as well as to Distancing and Escape-Avoidance as coping strategies. Being married was related to lower scores on the Confrontive Coping, Distancing, Accepting Responsibility, and Escape-Avoidance subscales. Length of diagnosis, PDDS scale score, and educational level were not related to subscale scores for conformity to masculinity or coping. For adherence to masculine norms, respondents high on Emotional Control were lower on Seeking Social Support and Accepting Responsibility. Winning was correlated with more Confrontive Coping. Men reporting higher Self-reliance reported lower levels of Seeking Social Support, as did those with higher levels of Power Over Women.

Univariate linear regression models on Diet identified the Planful Problem-Solving and Positive Reappraisal coping styles for further analyses in multivariable models. For modeling on the Preventive Self-care subscale, Emotional Control, Heterosexual Self-presentation, Planful Problem-solving, and Positive Reappraisal were retained (TABLE S2). For modeling on the Proper Use of Health Care Resources subscale, Primacy of Work, Seeking Social Support, Planful Problem-solving, and Positive Reappraisal met the threshold to remain in the multivariable model. Finally, for the Avoiding Anger and Stress subscale, conformity to the masculine norms of Winning, Violence, and Heterosexual Self-presentation as well as Confrontive Coping were retained as multivariable predictors (TABLE S3).

For the multivariable linear regression model for each of the 4 previously mentioned HBI-20 subscale scores, the following patient demographic and clinical characteristics were controlled for: age, race, marital status, educational status, and years since MS diagnosis. In addition, all CMNI-46 and WCQ subscale scores identified as predictors in the univariate analyses were added to the models. Because Planful Problem-solving and Positive Reappraisal were strongly correlated, the potential for multicollinearity was evident. Therefore, after initial examination of the impact of each subscale score on the first 3 outcomes, Positive Reappraisal was retained.

No significant model could be fit for the Diet or Proper Use of Health Care Resources subscale scores. For Preventive Self-care, only Emotional Control and Heterosexual Self-presentation were significant predictors. However, after adding an interaction between Heterosexual Self-presentation and Positive Reappraisal, a main effect for the latter also emerged. The interaction effect was also significant (TABLE 2). Men reporting higher levels of Emotional Control reported worse efforts at Preventive Self-care. In contrast, men endorsing stronger beliefs in Heterosexual Self-presentation reported more efforts. In addition, engaging in Positive Reappraisal as a coping strategy was also positively associated with self-care efforts., With high and low Positive Reappraisal levels split at the median, the interaction is presented in FIGURE 1. For men with low levels of Positive Reappraisal, increasing Heterosexual Self-presentation was associated with higher levels of Preventive Self-care. For those with low levels of Positive Reappraisal, increased Heterosexual Self-presentation was associated with declines in Preventive Self-care.

For the Avoiding Anger and Stress subscale score, having a PDDS scale score greater than 3 was associated with greater efforts to control negative emotions (TABLE 3). In addition, CMNI-46 subscale scores for Violence and Heterosexual Self-presentation were negatively associated with controlling stress and anger. No interaction effect was found.

The present study investigated the relationship between adherence to traditional gender norms in men with MS and their health behaviors. After examining correlation coefficients and univariate regression analyses, candidate predictors in the areas of coping and conformity to masculinity were identified for multivariable models of health behaviors. Of the 5 domains of the HBI-20, 3 could not be successfully modeled. Avoiding Substance Use exhibited very poor reliability (α = 0.50) and was, therefore, eliminated from further analyses. In addition, models for Diet and Proper Use of Health Care Resources were not significant.

For Preventive Self-care, controlling for demographic and clinical characteristics, aspects of masculinity conformity related to Emotional Control and Heterosexual Self-presentation were significant predictors, as was the Positive Reappraisal coping strategy. Men reporting stronger adherence to the masculine norm of Emotional Control reported poorer Preventive Self-care. Men endorsing Heterosexual Self-presentation as a key aspect of masculinity reported greater efforts in self-care. Positive Reappraisal was also associated with higher reported self-care. In addition, the interaction between Heterosexual Self-presentation and Positive Reappraisal was significant. For men reporting low levels of Positive Reappraisal as a coping strategy, increasing Heterosexual Self-presentation was associated with higher levels of Preventive Self-care. For those with high levels of coping with Positive Reappraisals, increased Heterosexual Self-presentation was associated with modest declines in self-care.

For the Avoiding Anger and Stress subscale, having a PDDS scale score greater than 3 positively predicted efforts to control negative emotions. Related to conformity to masculine gender norms, men endorsing Violence or Heterosexual Self-presentation as important aspects of masculinity also reported less effort in controlling stress and anger. No interaction was found between conformity to masculinity and coping.

Previous research^12,13  found that the coping strategies of women with MS may differ from the coping strategies of men with MS (eg, men are less likely to accept the condition, adopt productive coping strategies, and seek social support). The present study showed that men with MS are in fact coping but may be doing so in a way that is influenced by their gender norms. Specifically, men who endorsed the gender norm of Heterosexual Self-presentation (importance of presenting oneself as heterosexual) reported greater efforts in self-care. In contrast, men with MS who endorsed the gender norm of Emotional Control (emotional restriction and suppression) reported poorer Preventive Self-care. Specific to coping, men with MS who used the strategy of positive appraisal (create positive meaning by focusing on personal growth) also reported greater effort in self-care.

The present study showed commonalities with and differences to the findings of Levant and Wimer.¹⁰  For Avoiding Anger and Stress, they found that Emotional Control was a positive predictor, as did the present study. However, they also found that Winning and Risk-Taking were predictive. For Preventive Self-care, no aspects of conformity to masculine norms were significant predictors, whereas the present study identified Emotional Control and Heterosexual Self-presentation. They also found a variety of predictive relationships between aspects of conformity to masculine norms and the subscale scores of Avoiding Substance Use, Diet, and Proper Use of Health Care Resources. A variety of factors may have contributed to these differences. First, their sample consisted of both college students and community members, with an average age of 23 years. In contrast, the sample for the present study was significantly older at nearly 52 years on average. Issues related to masculinity may have differed greatly between these 2 groups due to this difference. Perhaps also related to this, more respondents in the present study reported being married (21%) compared with only 12% reporting being married, partnered, or engaged in the sample from Levant and Wimer. Finally, approximately 13% of respondents in the sample from Levant and Wimer reported having a college degree or higher compared with nearly 50% in the present study.

Overall, the results of the present study show that aspects of conformity to masculine gender norms are associated with health behaviors in men with MS. In the case of Preventive Self-care, there was also evidence of interaction between masculinity conformity and coping strategies. However, contrary to expectations, several demographic and clinical characteristics were not found to be predictive of health behaviors at a univariate or multivariable level (ie, age, educational level, marital status, PDDS scale score, and years since diagnosis). This may be due to a restricted range of patients in terms of age and disease duration. Having a larger portion of younger men with MS in a sample may allow examination of age differences in some of these issues.¹⁷  Furthermore, the present sample consisted largely of patients with long-term disease duration (mean ± SD time since diagnosis of 12.24 ± 8.47 years). It may be that the earlier years of disease duration are critical to the examination of these issues. In addition, we did not look at sexual orientation or gender identification, which would have enhanced the study. This study population identified as 93% White, and recent studies have focused on the underrepresentation of ethnic minorities in MS.¹⁸  It is well-known that racial and ethnic diversity can play a significant role in how people with chronic disease, specifically MS, cope with their health and how health care disparities play a role in disease and progression. Finally, the cross-sectional nature of this study limits the strength of inferences that can be made about the interrelationships among conformity to masculinity, coping strategies, and health behaviors. Longitudinal data analyses would allow a clearer examination of whether and how adherence to traditional male gender norms is related to health behaviors and the mediating role that coping strategies may play.

In future research, it may be helpful to look at how men with MS differ from men living with other chronic illnesses. Also of particular interest would be an assessment of gender norms and their correlation with predicting male-identifying patients and a study of treatment approaches.