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The complexities of nursing research with men
NURSING
STUDIES
PERGAMON
International
Journal of Nursing Studies 35 (1998) 4148
The complexities of nursing research with men’ A. White”,*, M. Johnsonb ,’ School of Health and Community, Care. Leeds Metropolitan Uniorrsit.v. Calwrlq Street, Leeds LSI 3HE. C’.K h Unirlersity of’central Lancashire. Preston PRI 2HE, U.K. Received 29 July 1997: accepted 2 December 1997
Abstract There has been a proliferation of nursing and other research on women’s health over the last thirty years but a similar interest in men’s health has not materialised. Within this paper we seek to explore the issues that need to be taken into consideration when conducting research with (or on) men. It outlines the current thinking on men and masculinity and the social development of stereotypes of men. The position of men with regard to the development of feminist thinking is also explored. The paper develops the argument by an examination of the different stages of the research process in nursing. The effect of gender on the setting of the research question; the choice of methodology; obtaining the data; analysis; discussion and dissemination of the findings of research conducted upon men are considered. We suggest that there is a requirement to consider the gender of both researched and researcher during the research process. 1~~1998 Elsevier Science Ltd. All rights reserved. K~~~~~wrds;Men: Men’s health: Masculinity:
Stereotypes: Research; Methodology:
1. Introduction How do men respond to illness? Is there a difference between men’s and women’s perception of health and well being‘? Is a person’s recovery from a period of ill health dependent not only on the nature of their illness but also on their gender? In this paper we will start from the premise that since the inception of the feminist movement in the 1960s there has been a growth in research done on women and women’s health, but that a similar interest in men’s health is less evident. Having men as part of the sample for research is not new, neither is having only men as the sample. What does tend to be missing from the accounts of this research is clarification of the concept of what has been rather clumsily called ‘manliness’ and how this may
*Corresponding author. Tel.: 0113 283 2600; fax: 0113 283 592 I; e-mail: A.White(n lmu.ac.uk ‘This is a developed version of a paper gtven at the RCN Research Society Conference. University of Swansea. 1997. 0020-7489:9X Sl9.00 (’ 1998 Elsevier Science Ltd. All rights reserved. P11:s0020-7489(98)00010 8
Feminist research
affect both the research process and the research outcome. The idea of having men as a focus of health research opens up many controversial and sensitive areas. It suggests that there may be a difference in their health experience and that men may have to be seen as a separate entity within health care provision. A feminist might also reasonably argue that men are trying to displace the new ground that has been broken in identifying the specific concerns of women. Central to this debate are the notions of ‘men’ and ‘masculinity’ and whether men justify the scarce resources of health and nursing researchers. Men as biological entities separate from women do have their own unique health difficulties. Some of these stem from the different anatomy and physiology of the the sexes and certain sexlinked disorders, such as haemophilia. But apart from these, research has not demonstrated that men have other health risks unique to the male sex when other body systems are considered. Evidence suggests that men tend to die younger and that they are more prone to certain diseases (Kings Fund, 1995). These facts alone motivate
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A. White, M. Johnson;‘Int. J. Nurs. Stud. 35
us to be interested in questions of men’s health. Unfortunately, these statistics speak only of Regional and National trends and give no account of the individual’s personal experience of ill health and nursing care. A question of greater interest for us is: how do particular men react to the health and illness they experience, and is this reaction important? Little nursing research of this type has been accomplished. Notions of being strong, not crying and being a ‘good patient’ are lay beliefs about men and how they should live their lives and how they should respond to illness. These however, are myths and mere stereotypes, which may be contradicted by evidence of the way in which social relations are negotiated and flexible rather than fixed (Johnson and Webb, 1995). When looking at research on illness, men occur in the statistics, but very little appears in the texts or articles relating to men’s specific illness trajectories. Textbooks on general nursing bear similar weaknesses (e.g. Faulkner 1996 and others)-the care suggested is virtually gender neutral (it also tends to be race and age neutral as well). Even now, after two decades of ‘individuahsed care’, physical care predominates and the psychological care, being too complicated, is minimal. When gender is mentioned, it tends to be with regard to sex and sexuality and how these are affected by the various conditions as opposed to that gender’s reaction to the condition itself. One reason for these problems may be the difficulty in separating out the issues arising out of gender as opposed to those of sex and sexuality. At present, gender studies marginalised as a genuine domain of research-a point reinforced by Coltrane (1994) who reports: “In the tradition of patriarchal dominance, some colleagues (mostly men) find gender studies superfluous and suggest that conventional academic subjects are more worthy of scholarly attention”.
2. Men’s reality If there is a difference between the subjective experience of being a man and the image of ‘manliness’, why has this materiahsed? Mangan and Walvin (1987) draw together accounts of how, in the nineteenth and early twentieth ‘manliness’ was socially this concept century, constructed. The Victorians’ manipulation of the image of men and women created an ideal male type of ‘stoicism, hardiness and endurance’ and the ideal female type of ‘docility, commitment to domesticity and subservience’. This was perpetuated through all social systems: “ In literature, education, and politics, the vocabulary of the ethic was forcefully promulgated.. Through school textbooks, children’s literature, philan-
(l!%?J
41-48
thropic organisations and the churches, both the image and associated symbolic activities of both Christian and Darwinian ‘manliness’ filtered down to the proletariat through an unrelenting and self assured process of social osmosis”. This image was rightly castigated by the women’s suffrage and more recently feminist movements, who found the social belittling of women both offensive and unjust. This concept of manliness was also not universally acceptable to all men. Those who did not approximate to the hegemonic ideal of masculinity became the victims of abuse and domination (Connell, 1995). Of those who did meet up to the image, many were often unhappy with its implications. Some change occurred through the 1960s and 70s with activity resulting in the Sex Discrimination Act and equal rights for women. These challenged male-only domains both at work and in social settings. Men’s reaction to this change is hard to pinpoint. Clatterbaugh (1997) considers there to be eight different perspectives that men have adopted:
(1) the Conservative perspective which strives for the (4
(3)
(4)
(5)
(6) (7) (8)
retention of the male hierarchy and masculine role in the workplace; the Profeminist perspective, which supported the anti-sexist approach and sought ways to de-masculinise men through consciousness raising groups and publications; a Men’s Rights perspective, which had agreed with the feminist argument but became concerned over a new sexism against men; the Mythopoetic perspective, with its refocusing on men through the writers such as Robert Bly and his work Iron John (1990) trying to identify the supposed deep hidden masculinity within all men; the Socialist perspective, with its view that masculinity, and therefore man’s relation with women, is grounded in economically determined class structures; the Gay Men’s perspective and their challenge to dominant forms of masculinity; the Africa Caribbean men’s perspective, examining the issues of race, ethnicity and structural racism; the Evangelical Christianity perspective which suggested a return to the image of men presented in the bible.
Though Clatterbaugh discusses the American man, it can be seen how these variations demonstrate wide-ranging reactions to the challenge of the changing role of women in society. Clatterbaugh’s (1997) work suggests that men have taken many different interpretations oftheir own position and created a view that will affect the manner in which
A. White,. M. Johsontlnt.
they deal with the challenges met within their lives. Hearn and Collinson (1994) offer a detailed sociological critique of the constructs ‘men’ and ‘masculinity’ but they complicate the picture further. They highlight how each category of men or masculinity may be further deconstrutted to yield such diversity that commonalties cannot be easily found (p. 140). However, they move on from this to suggest that although many differences exist, there are also many similarities. If we relate these complexities to a nursing or health context. it can be seen that the importance ascribed by individuals to health, and the reaction to illness, may be as different between the various forms of masculinity as it is between men and women. This complexity is intimidating. both for the positivist because of the difficulty of controlling variables and for the qualitative researcher because of the conceptual and analytic difficulties which are posed. We will proceed, however, by arguing that knowledge of these difficuties should not preclude good nursing research with, on, and for men, but may help to inform and enable greater validity. rigour and where relevant, reflexivity. We will now identify key areas of the research process and discuss the implications for taking a ‘men orientated’ viewpoint. We will examine the posing of the research question. the choice of method, how the data is collected, analysed and discussed and finally how it may be disseminated (to use a masculine gendered term for want of a better). We will aim to illustrate the potential impact of having men as the focus of health research and whether the gender of the researcher may have an effect on the outcome.
3. Gender and the research question The question posed for a research project can be seen as a political and ideological statement by the researcher. It can (or should) make clear the values and interests of those undertaking the work (O’Connell, Davidson and Layder 1994). There is a difference in studies that have men as part of the study and those which have men central to it and include them in the title. There has been a call over the last few years for more research on men as men; a quest to ‘problematize’ men, to study men yua men (Caplan 1988). Having the gender aspect as part of the question allows the nature of the study to become more apparent and ‘sets the scene’ for the researchers. Feminists have used this strategy well and have helped to draw attention to the gender specific aspects of otherwise general questions, The identification of the female agenda within everyday issues enabled a counter to the prevailing tendency to have a patriarchal and therefore female-invisible approach to social science. Research had frequently been undertaken on men by men and then generalised to the wider population, or research was done
J. Nurs. Stud. 35 (1998) 41-4X
43
by men on women with the feeling being generated of ‘yet another discourse in which men speak to men about women’ (Webb 1993). The stating of a research question alone raises the subject matter to a political level. Asking for an answer means that a problem exists which warrants investigation, Asking about men means that some aspect of men or the way they experience their lives may be problematic. It cannot be assumed that merely having men as part of the sample or by having men doing the research will in itself address deeper concerns. The research has to be open to the possibility of alternative viewpoints and the initial question can create the environment for this debate. Questions such as: what is the impact of illness on their earning potential, their power base within the workplace or family, their sporting/sexual prowess-may not be politically correct but may be of fundamental concern to the ill man.
4. Gender and methodology Feminist research methods were developed as a response by women to the fact that research was malefriendly and female-unfriendly. ‘New paradigm’ and qualitative research were adopted by female researchers who identified within these and other ‘soft’ methods, feminine characteristics of holism and participation. Following this logic to a conclusion, positivist sciencebased research methods should be appropriate for investigating men. However, the research much criticised by the feminist movement as inapplicable to women may be just as impenetrable or inappropriate to the male population. The limitations that writers such as Oakley (198 I, 1990), Greenwood (I 984) and Webb (1993) see, relate to the blindness of the research to the real issues of women--namely the oppression, unmet needs and the everyday experiences of being a woman. They see the positivistic research that is done by men for the sake of ‘mankind’ as being exploitative and dishonest. This view, that much research was designed by men for the sake of men, has much to commend it-but it fails to recognise that the research done by the academic community may not be sensitive to the everyday issues that are relevant to everyday men ‘on the street’. If the critique was aimed at the researchers and their suppositions as opposed to the gender ‘men’ in general, then the case would be fairer (Morgan 1981/1990). It is worth noting that ethnography has encountered criticism for the highly ‘scientific’ detached approach it adopted as a result of the influence of Malinowski and Radchff Brown. There was a feeling that the research was oppressive with the “basso of the ethnographer still speak[ing] for the falsetto of the native“ (Tyler 1985). Caplan (1988) argues against classic ethnography because of its lack of appreciation of the
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A. White, M. JohnsonlInt. J. Nurs. Stud. 35 (1998) 41-48
power of the researcher; a naivete regarding the politics of the interactions; a lack of reflexivity; and an overindulgence in the ideology of academia with objectivity being seen as an absolute rather than a relative concept. Here then, qualitative methods too, can fall within the tradition of patriarchal and exploitative, not only of women but of men, an accusation easily levelled, for example, at Laud Humphreys’ (1970) covert study of gay men’s sexual lives The Tearoom Trade. Despite the possibilities for exploitation within them, for some time it was suggested that only qualitative methods were sensitive to women’s concerns. Kvales (1996) noted the feminist viewpoint on interviewing: “though the linear talk of men can be captured by questionnaires, the way women make connections among areas of their lives is better approached through qualitative in-depth interviews”. Whilst it may be so that in many ways quantitative methods are insensitive to women’s needs and that qualitative and participative methods allow for true expression, this assumes that men’s needs are most easily examined by inferential statistical analysis, something we rather doubt. Indeed, we would go further to argue that the ‘in depth interview’ is hardly the most emancipatory or participative of methods which nurse researchers. women or men, may adopt. It is important to distinquish between method and methodology. In drawing this distinction, Harding (1987) considers method as the way the data is collected and the methodology as the theory and analysis of how the research should proceed. This suggests that if the epistemology is sensitive to the demands of the question and population under study, then the practical and ideological separation between quantitative and qualitative methods is less important. With the full spectrum of methods to choose from, those that address the research question can be chosen. However, this does not mean that choices from extreme ends of the continuum will make practical or theoretical sense unless well justified in the context, and we remain unconvinced that most researchers choose freely from alternatives in relation to the question posed. Rather, in our experience, students choose freely from research questions which will enable them to use a method they fancy or to avoid one they do not! Coltrane (1994) acknowledging the difficulty of choosing a method to study men, does note that to those researchers who avoid the issue of power and dominance there is less of a debate than for those that do. It is quite possible to research men as objects along with other objects such as women, however the quest to delve deeper into these people’s experiences and offer a deconstructed and decentered viewpoint of men (or women) requires more sensitive methods.
Difficulties also arise when we are confronted with such a wide array of varying types of masculinity, or as we would rather see it, strategies for dealing with being masculine in a social context, Connell (1995) makes this point well: “If we spoke only of men as a bloc and women as a bloc, we would not need the terms ‘masculine’ and ‘feminine’ at all. We could just speak of ‘men’s’ and ‘women’s’, or ‘male’ and ‘female’. The terms ‘masculine’ and ‘feminine’ point beyond categorical sex difference to the ways men differ among themselves, in matters of gender”. He goes on to discuss a selection of the different groups he found in his research-the first group were poor working class young men with their protest masculinity; the second group are middle class men who have adopted a New Age philosophy on life and become aware of the benefits of a feminist perspective on their lives; the third group were men in the gay community with the need to be part of two cultures: the dominant hegemonic heterosexual culture and the homosexual culture; a fourth group was the ‘new middle class’ working within the ‘culture of professional and technical work’, Each of the presented groups had very different ways of looking at life and its pressures. Can one method suit the needs of all the groups even if the same research question was being asked? We cannot conclude this section without acknowledging the importance of the notion that men cannot do feminist research. Webb (I 993) reflects the view of many feminists that while men may use the same methods as feminists in some technical sense, feminist methods are done by women, with (or on) women, for women. Whilst we would agree with the intention of this sentiment, that men have a habit of invading and controlling the legitimate concerns of women to achieve equality and emancipation, we would suggest that some men (and we would like to qualify ourselves in this group) share enough genuine interest in the concerns of women to participate in the egalitarian enterprise, of which one aspect is feminism and its research methods. The implication of this for our position in this paper, is that where men use methods developed by feminists they should be cautious about describing them in these terms; and perhaps ‘humanistic’ methods may go some way to an acceptable term. Where we here suggest that men use feminist methods (in order appropriately to acknowledge their history), it is with this qualification.
5. Collecting the data Once the question has been posed and the method chosen then the collection of data can itself become an
issue for debate. In feminist research there is a strong belief that interviews are most sensitive to the needs of women and that only women can be the interviewers (see for instance Oakley 198 l/ 1990). We might conclude from this that men would be confined by the same restrictions to paternalist methods such as the Likert, Thurstone or other scales. As we have suggested, the choice of method appears to be more dependent upon the question, than the sex of the informant. With the assumption that the more sensitive the issue, the more intimate will be the data required from the informant, the question is then how best to obtain the confidence of the participant to allow the necessary degree of self disclosure. Lee (1993) offers some general observations on the use of diaries and logs with the feeling that they may have some use but are an onerous task for the respondent. The area we will discuss will be the use of the interview which tends rightly or wrongly to be the method of choice for most qualitative work. The use of the interview with men has not come under the same degree of scrutiny as it has with women. Oakley’s (198111990) work on the interviewing of women has been developed by other writers and researchers such as Finch (1984) and Webb (1993). The main thrust of their argument was that women should interview women and that the structured survey was inimical to the open dialogue which is required to allow women to share their life experiences. What seems important is whether or not such open dialogue can, or should, be the goal of the qualitative interview of a man. The question is therefore: does a male participant want this same degree of involvement with the researcher? Would the man prefer to converse with a stranger rather than with someone who is willing to share aspects of their own life with them? The relationship between female interviewer and female participant has become of interest with concern being raised over the ease with which very intimate data is obtained through having the ‘cosy chat’ approach (Finch 1984). Would this same degree of self disclosure be possible if it was a female researcher with a male participant or a male researcher with a male participant? Lee’s ( 1993) review of the literature pertaining to interviewer effects suggests that a complex set of factors is at play which is as much linked to the social class and ethnicity of the researcher as to the gender. Padfield and Procter (I 996) found very little difference between the data they obtained from having same sex, as opposed to cross sexed, interviewing. They did notice that there was a significant increase in the amount of unsolicited information when the same sex researchers were used but this research was based on interviewing women, Rubin and Rubin (1995) note that the way men and women use language may cause misinterpretation through the interview itself. Tannen’s (1996) discourse analysis of conversations between men and women warns against overemphasising superficial differences in style between men and women.
It appears that the style and ability of the researcher play as much a part as the gender of the researcher. The more able the researcher is at getting the informant to feel at ease and willing to participate in the interview, the greater the degree of disclosure. Rubin and Rubin (1995) suggest that it may even be of benefit to have interviewers of both genders as there is less likelihood of assumed knowledge, and therefore greater clarity may emerge from the process. They also consider that although different data may be generated, this in itself may be advantageous. The nature of the interviewing style adopted may permit a greater degree of frankness from the participant than they had anticipated. An alternative construction of the view of men is that far from the power figures portrayed in feminist literature, the majority of men are in a powerless position, with strong feelings of vulnerability. This may be seen as a weakness in relation to the hegemonic view of masculinity promoted in the media. If this fdcade is broken down and the ‘true’ feelings emerge. then the researcher will need special skills in supporting the respondent through potentially painful experiences. Though it can be argued that this may be a therapeutic event for the individual concerned, it does raise the issue that the primary function of research is not to enter into a long-term therapeutic relationship with the researcher as a psychoanalyst;‘counsellor. It may also be problematic for the informants. If the natural reaction is to close down and put up defences then the research may inadvertently break down their protection and leave them more vulnerable to fears and anxieties. The image is of the researcher rushing in, grabbing a recorder full of emotions then leaving the ‘victim’ to come to terms with having shared long held secrets or their deepest fears. when such behaviour does not normally conform to the stereotypical behaviour of the male. Davies (1995) sums up the complexity of taking feminist research methods to research men:
“femininity-with its stress on dealing with dependency, acknowledging emotions and intimacy and nurturing others-comes to represent qualities that are feared and denied in masculinity, qualities that are at best seen to be contained and allocated to a different sphere, and at worst, are repressed or treated with contempt.”
Though used in a different context to this paper, the sentiments of Davies appear to be relevant as to how we delve into the emotions of these men when the impression is that this is a protected, even denied area, for some of them. In some respects this concerns the sampling procedure for the study. If informed consent is sought,
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A. White, M. Johnson~Int. J. Nurs. Stud. 35 (1998) 41-48
then a process of self selection will take place, with those willing and perhaps able to discuss more intimate detailsof their lives coming forward; with those less able or willing staying away. This leads to the problem of only having access to those who are potentially at one with themselves and therefore would be quite at ease with the usual ‘softer’ exploratory approaches. If the researcher wants to gather data from the wider male population-from those who may not be willing to give informed consent to participate in the study, then ethically complex areas are entered into. On the one hand, we can see a need to gather data relating to the more emotive areas of men’s lives. But to gather this data will cause us difficulties in deciding the ethical and practical boundaries of what data we can conceive of as legitimate for our research report.
6. Gender and the analysis/interpretation
of the results
To what extent should the gender of the analyst and interpreter of data be taken into account? This question can be expanded to consider the researcher’s role in discussing the validity of the study when cross gender research is undertaken. It seems of concern to know whether the gender of the researcher can have an impact on the way the data from the research is analysed and interpreted. Would the same data be seen in a different light if researchers were from the same gender group as their participants rather than not‘? There is an increasing realisation of how prior assumptions can affect the research process with the notion of ‘Bracketing Off of one’s prior assumptions to allow for an openness to the emerging data being a common feature in phenomenological research (Hycner 1985; Colaizzi 1978). Glaser (1978) expanded this idea further: “The first step in gaining theoretical sensitivity is to enter the research setting with as few pre-determined ideas as possible-especially logically deducted, a priori hypotheses. In this posture, the analyst is able to remain sensitive to the data by being able to record events and detect happenings without first having them filtered through and squared with pre-existing hypotheses and biases, His [sic] mandate is to remain open to what is actually happening.” The question. however, is can one remove the years of socialisation that went into becoming one gender or another? How does one identify when one is making a gender influenced observation or missing a vital aspect of the data presented because its relevance is not identified? The answer may be that both genders need to be involved.
7. Gender, discussion and dissemination Here we may return to the political and ideological framework adopted by the researcher and the academic community in general. The researcher having analysed the data must then locate the work within a debate or describe the work to the wider audience. The perspective that is chosen is as much a property of the values and beliefs of the person who is the researcher as it is to the material on offer. By the time the discussion is reached, the researcher is steeped in the work and has invested a large quantity of energy and emotion in the work. The data collected has been analysed in a certain way and now the nature of the work is to be displayed and explained. It is inevitable that the specific individual’s or group’s beliefs become apparent: “Even when confronted with the same qualitative task no two researchers will produce the same result; there will inevitably be differences in their philosophical and theoretical commitments and styles”. (Sandelowski, 1993) The feminist movement has seen this occur with alternative interpretations being put onto data to frame it within the differing perspectives. Mies (1983) outlines this in the double standing of women who are scholars. She argues that women scholars have been told to look at their contradictory existence, and to see that their subjective existence as women has become an obstacle to ‘pure’ and ‘objective’ research. Even while studying women’s questions, they were advised to suppress their emotions, their subjective feelings of involvement and identification with other women in order to produce ‘objective data”. The implication, therefore, is that the emotive and ‘human’ side of the researcher should emerge and their personal experiences should be allowed to help in the interpretation of the data. The dissemination of the work that is gender invisible can have the effect that has been seen previously of work being given an inappropriate external validity or generalizability. An example of this would be the conflict Gilligan had with Kohlberg’s concept of moral development until the all male nature of his sample was identified. When Gilligan conducted similar research but with a female sample she came up with an alternative model (Millar, 1983). Relatively ‘reflexive’ writing, whether by men or women, may find difficulty in being published in the more ‘scientific’ or arguably patriarchal journals. It is only recently that some nursing journals have become more sensitive to the different styles of research that feminists defend. Webb (1992) perceived a need to argue against compulsory third person ‘objective’ writing in nursing
il. Whire, M. Johnsonilnt. J. Nurs. Stud. 35 ( IVYXi 41-48
journals, despite a long tradition of first person writing in sociology and philosophy at the highest levels of academic distinction.
8. Conclusion Our argument is that the gender ‘man’ consists of a diverse and disparate group which, nevertheless, is different from the gender ‘woman’. This difference is much more than the biological appearance of the two sexes. The difference may also be inferred by the strong feminist argument that women are different from men. and women need to be looked at in a different light to men when it comes to research and political discussion. If the assertion is accepted that men are different from Women. and that therefore men have different life ways and interpretations of the world they inhabit, there needs to be an alternative research strategy adopted when looking at issues from the man’s perspective. At the present time there seems to be lack of nursing research on health and ill health and its impact on a man’s self perception of his masculinity. The impression gained is one of a neglected area that may have much relevance to the health experience of the male population. The epidemiological evidence suggests that men’s health is becoming more problematic-at the same time as medical advances are being made into physical recovery. We suggest that there is a need to problematize men within the context of their gender. to identify how health and illness modify men’s constructions of themselves and those of others. What is important is that men do not ignore the issue of their gender in designing and interpreting nursing research. and that collaboration between the genders is developed, in the wider interests of both.
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STUDIES
PERGAMON
International
Journal of Nursing Studies 35 (1998) 4148
The complexities of nursing research with men’ A. White”,*, M. Johnsonb ,’ School of Health and Community, Care. Leeds Metropolitan Uniorrsit.v. Calwrlq Street, Leeds LSI 3HE. C’.K h Unirlersity of’central Lancashire. Preston PRI 2HE, U.K. Received 29 July 1997: accepted 2 December 1997
Abstract There has been a proliferation of nursing and other research on women’s health over the last thirty years but a similar interest in men’s health has not materialised. Within this paper we seek to explore the issues that need to be taken into consideration when conducting research with (or on) men. It outlines the current thinking on men and masculinity and the social development of stereotypes of men. The position of men with regard to the development of feminist thinking is also explored. The paper develops the argument by an examination of the different stages of the research process in nursing. The effect of gender on the setting of the research question; the choice of methodology; obtaining the data; analysis; discussion and dissemination of the findings of research conducted upon men are considered. We suggest that there is a requirement to consider the gender of both researched and researcher during the research process. 1~~1998 Elsevier Science Ltd. All rights reserved. K~~~~~wrds;Men: Men’s health: Masculinity:
Stereotypes: Research; Methodology:
1. Introduction How do men respond to illness? Is there a difference between men’s and women’s perception of health and well being‘? Is a person’s recovery from a period of ill health dependent not only on the nature of their illness but also on their gender? In this paper we will start from the premise that since the inception of the feminist movement in the 1960s there has been a growth in research done on women and women’s health, but that a similar interest in men’s health is less evident. Having men as part of the sample for research is not new, neither is having only men as the sample. What does tend to be missing from the accounts of this research is clarification of the concept of what has been rather clumsily called ‘manliness’ and how this may
*Corresponding author. Tel.: 0113 283 2600; fax: 0113 283 592 I; e-mail: A.White(n lmu.ac.uk ‘This is a developed version of a paper gtven at the RCN Research Society Conference. University of Swansea. 1997. 0020-7489:9X Sl9.00 (’ 1998 Elsevier Science Ltd. All rights reserved. P11:s0020-7489(98)00010 8
Feminist research
affect both the research process and the research outcome. The idea of having men as a focus of health research opens up many controversial and sensitive areas. It suggests that there may be a difference in their health experience and that men may have to be seen as a separate entity within health care provision. A feminist might also reasonably argue that men are trying to displace the new ground that has been broken in identifying the specific concerns of women. Central to this debate are the notions of ‘men’ and ‘masculinity’ and whether men justify the scarce resources of health and nursing researchers. Men as biological entities separate from women do have their own unique health difficulties. Some of these stem from the different anatomy and physiology of the the sexes and certain sexlinked disorders, such as haemophilia. But apart from these, research has not demonstrated that men have other health risks unique to the male sex when other body systems are considered. Evidence suggests that men tend to die younger and that they are more prone to certain diseases (Kings Fund, 1995). These facts alone motivate
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A. White, M. Johnson;‘Int. J. Nurs. Stud. 35
us to be interested in questions of men’s health. Unfortunately, these statistics speak only of Regional and National trends and give no account of the individual’s personal experience of ill health and nursing care. A question of greater interest for us is: how do particular men react to the health and illness they experience, and is this reaction important? Little nursing research of this type has been accomplished. Notions of being strong, not crying and being a ‘good patient’ are lay beliefs about men and how they should live their lives and how they should respond to illness. These however, are myths and mere stereotypes, which may be contradicted by evidence of the way in which social relations are negotiated and flexible rather than fixed (Johnson and Webb, 1995). When looking at research on illness, men occur in the statistics, but very little appears in the texts or articles relating to men’s specific illness trajectories. Textbooks on general nursing bear similar weaknesses (e.g. Faulkner 1996 and others)-the care suggested is virtually gender neutral (it also tends to be race and age neutral as well). Even now, after two decades of ‘individuahsed care’, physical care predominates and the psychological care, being too complicated, is minimal. When gender is mentioned, it tends to be with regard to sex and sexuality and how these are affected by the various conditions as opposed to that gender’s reaction to the condition itself. One reason for these problems may be the difficulty in separating out the issues arising out of gender as opposed to those of sex and sexuality. At present, gender studies marginalised as a genuine domain of research-a point reinforced by Coltrane (1994) who reports: “In the tradition of patriarchal dominance, some colleagues (mostly men) find gender studies superfluous and suggest that conventional academic subjects are more worthy of scholarly attention”.
2. Men’s reality If there is a difference between the subjective experience of being a man and the image of ‘manliness’, why has this materiahsed? Mangan and Walvin (1987) draw together accounts of how, in the nineteenth and early twentieth ‘manliness’ was socially this concept century, constructed. The Victorians’ manipulation of the image of men and women created an ideal male type of ‘stoicism, hardiness and endurance’ and the ideal female type of ‘docility, commitment to domesticity and subservience’. This was perpetuated through all social systems: “ In literature, education, and politics, the vocabulary of the ethic was forcefully promulgated.. Through school textbooks, children’s literature, philan-
(l!%?J
41-48
thropic organisations and the churches, both the image and associated symbolic activities of both Christian and Darwinian ‘manliness’ filtered down to the proletariat through an unrelenting and self assured process of social osmosis”. This image was rightly castigated by the women’s suffrage and more recently feminist movements, who found the social belittling of women both offensive and unjust. This concept of manliness was also not universally acceptable to all men. Those who did not approximate to the hegemonic ideal of masculinity became the victims of abuse and domination (Connell, 1995). Of those who did meet up to the image, many were often unhappy with its implications. Some change occurred through the 1960s and 70s with activity resulting in the Sex Discrimination Act and equal rights for women. These challenged male-only domains both at work and in social settings. Men’s reaction to this change is hard to pinpoint. Clatterbaugh (1997) considers there to be eight different perspectives that men have adopted:
(1) the Conservative perspective which strives for the (4
(3)
(4)
(5)
(6) (7) (8)
retention of the male hierarchy and masculine role in the workplace; the Profeminist perspective, which supported the anti-sexist approach and sought ways to de-masculinise men through consciousness raising groups and publications; a Men’s Rights perspective, which had agreed with the feminist argument but became concerned over a new sexism against men; the Mythopoetic perspective, with its refocusing on men through the writers such as Robert Bly and his work Iron John (1990) trying to identify the supposed deep hidden masculinity within all men; the Socialist perspective, with its view that masculinity, and therefore man’s relation with women, is grounded in economically determined class structures; the Gay Men’s perspective and their challenge to dominant forms of masculinity; the Africa Caribbean men’s perspective, examining the issues of race, ethnicity and structural racism; the Evangelical Christianity perspective which suggested a return to the image of men presented in the bible.
Though Clatterbaugh discusses the American man, it can be seen how these variations demonstrate wide-ranging reactions to the challenge of the changing role of women in society. Clatterbaugh’s (1997) work suggests that men have taken many different interpretations oftheir own position and created a view that will affect the manner in which
A. White,. M. Johsontlnt.
they deal with the challenges met within their lives. Hearn and Collinson (1994) offer a detailed sociological critique of the constructs ‘men’ and ‘masculinity’ but they complicate the picture further. They highlight how each category of men or masculinity may be further deconstrutted to yield such diversity that commonalties cannot be easily found (p. 140). However, they move on from this to suggest that although many differences exist, there are also many similarities. If we relate these complexities to a nursing or health context. it can be seen that the importance ascribed by individuals to health, and the reaction to illness, may be as different between the various forms of masculinity as it is between men and women. This complexity is intimidating. both for the positivist because of the difficulty of controlling variables and for the qualitative researcher because of the conceptual and analytic difficulties which are posed. We will proceed, however, by arguing that knowledge of these difficuties should not preclude good nursing research with, on, and for men, but may help to inform and enable greater validity. rigour and where relevant, reflexivity. We will now identify key areas of the research process and discuss the implications for taking a ‘men orientated’ viewpoint. We will examine the posing of the research question. the choice of method, how the data is collected, analysed and discussed and finally how it may be disseminated (to use a masculine gendered term for want of a better). We will aim to illustrate the potential impact of having men as the focus of health research and whether the gender of the researcher may have an effect on the outcome.
3. Gender and the research question The question posed for a research project can be seen as a political and ideological statement by the researcher. It can (or should) make clear the values and interests of those undertaking the work (O’Connell, Davidson and Layder 1994). There is a difference in studies that have men as part of the study and those which have men central to it and include them in the title. There has been a call over the last few years for more research on men as men; a quest to ‘problematize’ men, to study men yua men (Caplan 1988). Having the gender aspect as part of the question allows the nature of the study to become more apparent and ‘sets the scene’ for the researchers. Feminists have used this strategy well and have helped to draw attention to the gender specific aspects of otherwise general questions, The identification of the female agenda within everyday issues enabled a counter to the prevailing tendency to have a patriarchal and therefore female-invisible approach to social science. Research had frequently been undertaken on men by men and then generalised to the wider population, or research was done
J. Nurs. Stud. 35 (1998) 41-4X
43
by men on women with the feeling being generated of ‘yet another discourse in which men speak to men about women’ (Webb 1993). The stating of a research question alone raises the subject matter to a political level. Asking for an answer means that a problem exists which warrants investigation, Asking about men means that some aspect of men or the way they experience their lives may be problematic. It cannot be assumed that merely having men as part of the sample or by having men doing the research will in itself address deeper concerns. The research has to be open to the possibility of alternative viewpoints and the initial question can create the environment for this debate. Questions such as: what is the impact of illness on their earning potential, their power base within the workplace or family, their sporting/sexual prowess-may not be politically correct but may be of fundamental concern to the ill man.
4. Gender and methodology Feminist research methods were developed as a response by women to the fact that research was malefriendly and female-unfriendly. ‘New paradigm’ and qualitative research were adopted by female researchers who identified within these and other ‘soft’ methods, feminine characteristics of holism and participation. Following this logic to a conclusion, positivist sciencebased research methods should be appropriate for investigating men. However, the research much criticised by the feminist movement as inapplicable to women may be just as impenetrable or inappropriate to the male population. The limitations that writers such as Oakley (198 I, 1990), Greenwood (I 984) and Webb (1993) see, relate to the blindness of the research to the real issues of women--namely the oppression, unmet needs and the everyday experiences of being a woman. They see the positivistic research that is done by men for the sake of ‘mankind’ as being exploitative and dishonest. This view, that much research was designed by men for the sake of men, has much to commend it-but it fails to recognise that the research done by the academic community may not be sensitive to the everyday issues that are relevant to everyday men ‘on the street’. If the critique was aimed at the researchers and their suppositions as opposed to the gender ‘men’ in general, then the case would be fairer (Morgan 1981/1990). It is worth noting that ethnography has encountered criticism for the highly ‘scientific’ detached approach it adopted as a result of the influence of Malinowski and Radchff Brown. There was a feeling that the research was oppressive with the “basso of the ethnographer still speak[ing] for the falsetto of the native“ (Tyler 1985). Caplan (1988) argues against classic ethnography because of its lack of appreciation of the
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A. White, M. JohnsonlInt. J. Nurs. Stud. 35 (1998) 41-48
power of the researcher; a naivete regarding the politics of the interactions; a lack of reflexivity; and an overindulgence in the ideology of academia with objectivity being seen as an absolute rather than a relative concept. Here then, qualitative methods too, can fall within the tradition of patriarchal and exploitative, not only of women but of men, an accusation easily levelled, for example, at Laud Humphreys’ (1970) covert study of gay men’s sexual lives The Tearoom Trade. Despite the possibilities for exploitation within them, for some time it was suggested that only qualitative methods were sensitive to women’s concerns. Kvales (1996) noted the feminist viewpoint on interviewing: “though the linear talk of men can be captured by questionnaires, the way women make connections among areas of their lives is better approached through qualitative in-depth interviews”. Whilst it may be so that in many ways quantitative methods are insensitive to women’s needs and that qualitative and participative methods allow for true expression, this assumes that men’s needs are most easily examined by inferential statistical analysis, something we rather doubt. Indeed, we would go further to argue that the ‘in depth interview’ is hardly the most emancipatory or participative of methods which nurse researchers. women or men, may adopt. It is important to distinquish between method and methodology. In drawing this distinction, Harding (1987) considers method as the way the data is collected and the methodology as the theory and analysis of how the research should proceed. This suggests that if the epistemology is sensitive to the demands of the question and population under study, then the practical and ideological separation between quantitative and qualitative methods is less important. With the full spectrum of methods to choose from, those that address the research question can be chosen. However, this does not mean that choices from extreme ends of the continuum will make practical or theoretical sense unless well justified in the context, and we remain unconvinced that most researchers choose freely from alternatives in relation to the question posed. Rather, in our experience, students choose freely from research questions which will enable them to use a method they fancy or to avoid one they do not! Coltrane (1994) acknowledging the difficulty of choosing a method to study men, does note that to those researchers who avoid the issue of power and dominance there is less of a debate than for those that do. It is quite possible to research men as objects along with other objects such as women, however the quest to delve deeper into these people’s experiences and offer a deconstructed and decentered viewpoint of men (or women) requires more sensitive methods.
Difficulties also arise when we are confronted with such a wide array of varying types of masculinity, or as we would rather see it, strategies for dealing with being masculine in a social context, Connell (1995) makes this point well: “If we spoke only of men as a bloc and women as a bloc, we would not need the terms ‘masculine’ and ‘feminine’ at all. We could just speak of ‘men’s’ and ‘women’s’, or ‘male’ and ‘female’. The terms ‘masculine’ and ‘feminine’ point beyond categorical sex difference to the ways men differ among themselves, in matters of gender”. He goes on to discuss a selection of the different groups he found in his research-the first group were poor working class young men with their protest masculinity; the second group are middle class men who have adopted a New Age philosophy on life and become aware of the benefits of a feminist perspective on their lives; the third group were men in the gay community with the need to be part of two cultures: the dominant hegemonic heterosexual culture and the homosexual culture; a fourth group was the ‘new middle class’ working within the ‘culture of professional and technical work’, Each of the presented groups had very different ways of looking at life and its pressures. Can one method suit the needs of all the groups even if the same research question was being asked? We cannot conclude this section without acknowledging the importance of the notion that men cannot do feminist research. Webb (I 993) reflects the view of many feminists that while men may use the same methods as feminists in some technical sense, feminist methods are done by women, with (or on) women, for women. Whilst we would agree with the intention of this sentiment, that men have a habit of invading and controlling the legitimate concerns of women to achieve equality and emancipation, we would suggest that some men (and we would like to qualify ourselves in this group) share enough genuine interest in the concerns of women to participate in the egalitarian enterprise, of which one aspect is feminism and its research methods. The implication of this for our position in this paper, is that where men use methods developed by feminists they should be cautious about describing them in these terms; and perhaps ‘humanistic’ methods may go some way to an acceptable term. Where we here suggest that men use feminist methods (in order appropriately to acknowledge their history), it is with this qualification.
5. Collecting the data Once the question has been posed and the method chosen then the collection of data can itself become an
issue for debate. In feminist research there is a strong belief that interviews are most sensitive to the needs of women and that only women can be the interviewers (see for instance Oakley 198 l/ 1990). We might conclude from this that men would be confined by the same restrictions to paternalist methods such as the Likert, Thurstone or other scales. As we have suggested, the choice of method appears to be more dependent upon the question, than the sex of the informant. With the assumption that the more sensitive the issue, the more intimate will be the data required from the informant, the question is then how best to obtain the confidence of the participant to allow the necessary degree of self disclosure. Lee (1993) offers some general observations on the use of diaries and logs with the feeling that they may have some use but are an onerous task for the respondent. The area we will discuss will be the use of the interview which tends rightly or wrongly to be the method of choice for most qualitative work. The use of the interview with men has not come under the same degree of scrutiny as it has with women. Oakley’s (198111990) work on the interviewing of women has been developed by other writers and researchers such as Finch (1984) and Webb (1993). The main thrust of their argument was that women should interview women and that the structured survey was inimical to the open dialogue which is required to allow women to share their life experiences. What seems important is whether or not such open dialogue can, or should, be the goal of the qualitative interview of a man. The question is therefore: does a male participant want this same degree of involvement with the researcher? Would the man prefer to converse with a stranger rather than with someone who is willing to share aspects of their own life with them? The relationship between female interviewer and female participant has become of interest with concern being raised over the ease with which very intimate data is obtained through having the ‘cosy chat’ approach (Finch 1984). Would this same degree of self disclosure be possible if it was a female researcher with a male participant or a male researcher with a male participant? Lee’s ( 1993) review of the literature pertaining to interviewer effects suggests that a complex set of factors is at play which is as much linked to the social class and ethnicity of the researcher as to the gender. Padfield and Procter (I 996) found very little difference between the data they obtained from having same sex, as opposed to cross sexed, interviewing. They did notice that there was a significant increase in the amount of unsolicited information when the same sex researchers were used but this research was based on interviewing women, Rubin and Rubin (1995) note that the way men and women use language may cause misinterpretation through the interview itself. Tannen’s (1996) discourse analysis of conversations between men and women warns against overemphasising superficial differences in style between men and women.
It appears that the style and ability of the researcher play as much a part as the gender of the researcher. The more able the researcher is at getting the informant to feel at ease and willing to participate in the interview, the greater the degree of disclosure. Rubin and Rubin (1995) suggest that it may even be of benefit to have interviewers of both genders as there is less likelihood of assumed knowledge, and therefore greater clarity may emerge from the process. They also consider that although different data may be generated, this in itself may be advantageous. The nature of the interviewing style adopted may permit a greater degree of frankness from the participant than they had anticipated. An alternative construction of the view of men is that far from the power figures portrayed in feminist literature, the majority of men are in a powerless position, with strong feelings of vulnerability. This may be seen as a weakness in relation to the hegemonic view of masculinity promoted in the media. If this fdcade is broken down and the ‘true’ feelings emerge. then the researcher will need special skills in supporting the respondent through potentially painful experiences. Though it can be argued that this may be a therapeutic event for the individual concerned, it does raise the issue that the primary function of research is not to enter into a long-term therapeutic relationship with the researcher as a psychoanalyst;‘counsellor. It may also be problematic for the informants. If the natural reaction is to close down and put up defences then the research may inadvertently break down their protection and leave them more vulnerable to fears and anxieties. The image is of the researcher rushing in, grabbing a recorder full of emotions then leaving the ‘victim’ to come to terms with having shared long held secrets or their deepest fears. when such behaviour does not normally conform to the stereotypical behaviour of the male. Davies (1995) sums up the complexity of taking feminist research methods to research men:
“femininity-with its stress on dealing with dependency, acknowledging emotions and intimacy and nurturing others-comes to represent qualities that are feared and denied in masculinity, qualities that are at best seen to be contained and allocated to a different sphere, and at worst, are repressed or treated with contempt.”
Though used in a different context to this paper, the sentiments of Davies appear to be relevant as to how we delve into the emotions of these men when the impression is that this is a protected, even denied area, for some of them. In some respects this concerns the sampling procedure for the study. If informed consent is sought,
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A. White, M. Johnson~Int. J. Nurs. Stud. 35 (1998) 41-48
then a process of self selection will take place, with those willing and perhaps able to discuss more intimate detailsof their lives coming forward; with those less able or willing staying away. This leads to the problem of only having access to those who are potentially at one with themselves and therefore would be quite at ease with the usual ‘softer’ exploratory approaches. If the researcher wants to gather data from the wider male population-from those who may not be willing to give informed consent to participate in the study, then ethically complex areas are entered into. On the one hand, we can see a need to gather data relating to the more emotive areas of men’s lives. But to gather this data will cause us difficulties in deciding the ethical and practical boundaries of what data we can conceive of as legitimate for our research report.
6. Gender and the analysis/interpretation
of the results
To what extent should the gender of the analyst and interpreter of data be taken into account? This question can be expanded to consider the researcher’s role in discussing the validity of the study when cross gender research is undertaken. It seems of concern to know whether the gender of the researcher can have an impact on the way the data from the research is analysed and interpreted. Would the same data be seen in a different light if researchers were from the same gender group as their participants rather than not‘? There is an increasing realisation of how prior assumptions can affect the research process with the notion of ‘Bracketing Off of one’s prior assumptions to allow for an openness to the emerging data being a common feature in phenomenological research (Hycner 1985; Colaizzi 1978). Glaser (1978) expanded this idea further: “The first step in gaining theoretical sensitivity is to enter the research setting with as few pre-determined ideas as possible-especially logically deducted, a priori hypotheses. In this posture, the analyst is able to remain sensitive to the data by being able to record events and detect happenings without first having them filtered through and squared with pre-existing hypotheses and biases, His [sic] mandate is to remain open to what is actually happening.” The question. however, is can one remove the years of socialisation that went into becoming one gender or another? How does one identify when one is making a gender influenced observation or missing a vital aspect of the data presented because its relevance is not identified? The answer may be that both genders need to be involved.
7. Gender, discussion and dissemination Here we may return to the political and ideological framework adopted by the researcher and the academic community in general. The researcher having analysed the data must then locate the work within a debate or describe the work to the wider audience. The perspective that is chosen is as much a property of the values and beliefs of the person who is the researcher as it is to the material on offer. By the time the discussion is reached, the researcher is steeped in the work and has invested a large quantity of energy and emotion in the work. The data collected has been analysed in a certain way and now the nature of the work is to be displayed and explained. It is inevitable that the specific individual’s or group’s beliefs become apparent: “Even when confronted with the same qualitative task no two researchers will produce the same result; there will inevitably be differences in their philosophical and theoretical commitments and styles”. (Sandelowski, 1993) The feminist movement has seen this occur with alternative interpretations being put onto data to frame it within the differing perspectives. Mies (1983) outlines this in the double standing of women who are scholars. She argues that women scholars have been told to look at their contradictory existence, and to see that their subjective existence as women has become an obstacle to ‘pure’ and ‘objective’ research. Even while studying women’s questions, they were advised to suppress their emotions, their subjective feelings of involvement and identification with other women in order to produce ‘objective data”. The implication, therefore, is that the emotive and ‘human’ side of the researcher should emerge and their personal experiences should be allowed to help in the interpretation of the data. The dissemination of the work that is gender invisible can have the effect that has been seen previously of work being given an inappropriate external validity or generalizability. An example of this would be the conflict Gilligan had with Kohlberg’s concept of moral development until the all male nature of his sample was identified. When Gilligan conducted similar research but with a female sample she came up with an alternative model (Millar, 1983). Relatively ‘reflexive’ writing, whether by men or women, may find difficulty in being published in the more ‘scientific’ or arguably patriarchal journals. It is only recently that some nursing journals have become more sensitive to the different styles of research that feminists defend. Webb (1992) perceived a need to argue against compulsory third person ‘objective’ writing in nursing
il. Whire, M. Johnsonilnt. J. Nurs. Stud. 35 ( IVYXi 41-48
journals, despite a long tradition of first person writing in sociology and philosophy at the highest levels of academic distinction.
8. Conclusion Our argument is that the gender ‘man’ consists of a diverse and disparate group which, nevertheless, is different from the gender ‘woman’. This difference is much more than the biological appearance of the two sexes. The difference may also be inferred by the strong feminist argument that women are different from men. and women need to be looked at in a different light to men when it comes to research and political discussion. If the assertion is accepted that men are different from Women. and that therefore men have different life ways and interpretations of the world they inhabit, there needs to be an alternative research strategy adopted when looking at issues from the man’s perspective. At the present time there seems to be lack of nursing research on health and ill health and its impact on a man’s self perception of his masculinity. The impression gained is one of a neglected area that may have much relevance to the health experience of the male population. The epidemiological evidence suggests that men’s health is becoming more problematic-at the same time as medical advances are being made into physical recovery. We suggest that there is a need to problematize men within the context of their gender. to identify how health and illness modify men’s constructions of themselves and those of others. What is important is that men do not ignore the issue of their gender in designing and interpreting nursing research. and that collaboration between the genders is developed, in the wider interests of both.
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