Diabetes and Masculinity

Recently I have been working on a research study on women's lived experiences with diabetes. We interviewed several women to understand their experiences of navigating diabetes. Hopefully the findings of the study will come out in the form of a publication soon. This blog is not about that. It is about the impact of the social construct of masculinity on diabetes management. 

One of the first things I do before starting the clinic is to visit the tiny hut near our clinic in which a couple run an idly shop. They make really good idly and when combined with the piping hot sambar (which must be pardoned for its watery consistency), pudina chutney and crispy lentil vada, it is a really wholesome breakfast to get the day started. My routine is 3 idlies and one vada. But getting the shopkeepers to limit the number of idlies to 3 and vadas to 1 was an uphill task. "How will 3 idlies be enough sir? you should have at least 3-4 more. Will you also have 2 poories in addition?" This would be their question every day. It took me weeks to get them to give me 3 + 1. The other day one of our patients was also there in the shop. We were having our breakfast sitting side by side. She was keenly looking at my plate throughout the time. When I finished and got up to wash my hands she let out a loud yelp of shock "What??? Is that all? I am a woman and I eat at least 5 idlies. How are 3 idlies sufficient for a man like you?", along with shock, she was quite upset and angry. I smiled at her and got up and left. The shopkeeper couple were explaining to her how I routinely have only 3 and my "un-manly" appetite for idlies was the matter of discussion that continued even after I left the hut. There is a masculine social construct on the portion size of the meals and being chided for the number of idlies that I eat has taught me this from long time ago. This is a challenge when it comes to helping men restrict the intake of carbohydrates and portion sizes when treating them for diabetes. Eating small portion sizes makes them feel emasculated and leads to poor compliance. 

Last Sunday a 40 year old man came to the clinic for the first time to take treatment for diabetes. He had been diagnosed about 2 years ago. But has not been on regular treatment. He has struggled with accepting the diagnosis for many months. He has visited several doctors and laboratories to test repeatedly, desperate to find someone would pronounce him non-diabetic. But that did not happen. He had started taking medicines from the local primary health centre (PHC). He would send his wife to get the tablets on his behalf. But when the PHC doctor refused to give medicines without seeing him even once, he switched over to a private doctor in the nearby town. The PHC functioned during day time and if he had to go there, he had to skip work. This is the explanation he gave for not being able to go to the PHC. However on close observation one can see that a PHC is a feminine health care space. It is the headquarters for maternal and child health care at the community level. Therefore, unless absolutely necessary, visiting a PHC to get medicines gives a blow to the masculinity of men with diabetes. This could be one of the reasons why he preferred to switch over to the private doctor in the nearby town. It is common to find in many rural households the wives taking treatment from the PHC, but husbands going to the town to private doctors and spending almost 10 times more money on their treatment. 

As the clinical encounter with this man was coming to a close, the man said, "Diabetes has completely destroyed my life" The comment lacked any affect. One of the challenges of working in a small clinical space with a huge crowd of patients waiting outside is that anything we talk inside the clinic, can be heard by patients waiting outside and by the persons in the clinic functioning in the adjacent room. The man suddenly started whispering and asked me, "I know whatever we talk hear can be heard by doctor madam in the next room and patients outside. is there anywhere we can talk separately without being heard?" I suggested that we shut the door and also block the other door that accesses the room from behind and keep our voices low. The man then said, "For the past 2 months I am unable to do the most important duty of a man" and his voice started quivering. The tense look on his face and the rigid expression, all started melting and he broke down into a silent cry. I understood that he was talking about erectile dysfunction. "Is there any treatment for this? They say diabetes can completely take away my manhood. Have I completely lost it?" he asked. Erectile dysfunction is quite common among men over 40 years of age. Some epidemiological studies report that about 50% of men above 40 years experience it at some point. One of the most important reasons for this condition is psychological. Diabetes can lead to erectile dysfunction, but even among men with diabetes, one of the common reasons is psychological and emotional. I then took some time to talk to him about his state of mind, stress levels, diabetes and his sexual health. The erectile dysfunction that this man experienced made him call it "failure to do the most important duty of a man". It challenged his identity and his masculinity. The shame and stigma associated with sexual dysfunction leads to under-reporting of this problem and seeking health care among secret unregistered practitioners in the nooks and corners of villages and cities who promise miracle cures. 

The other huge challenge in treatment of diabetes is making men quit smoking and alcohol. Smoking and alcohol are an integral part of the social life of many working class men in the villages. Just adjacent to the government subsidised alcohol outlet in the village is a vast open space. In this space men who return from manual labour in the nearby town get together, hang out and drink. In most villages such 'open air bars' have become the only social outlet for men. Many men feel left out and excluded from their friend circles if they stop drinking and smoking. They become isolated and feel lonely and some even report feeling 'un manly' if they do not hang out and drink. While the alcohol may actually worsen their diabetes and erectile dysfunction, stopping the alcohol makes them feel excluded from the masculine circles. This is a difficult situation. Recently I saw a man with diabetes, who developed severe postural hypotension. As soon as he got up from lying posture he felt light headed and fainted and fell. This was because the alcohol and diabetes were worsening his blood pressure regulation. When I was talking to him about stopping alcohol he said, "I have no problems stopping alcohol. If I want I can completely stop. But my only problem is that all my friends drink. So when I go to meet my friends, they force me. How can I live without any friends?" It was a fair question, with no good answers. 

Diabetes is a leveller of a very different kind. The social construct of masculinity imposes wild, risk taking, aggressive behaviours on men. Diabetes requires moderation and risk reduction for its effective control. In some ways, diabetes levels the aggression and wildness that masculinity imposes on men. The initial stages of adjusting to diabetes can be difficult to men because it challenges their masculinity. Those who adopt to these changes and allow themselves to be levelled out, manage their diabetes well. Those who fail to adopt go through a traumatic experience of poor control and complications of diabetes. One of the important public health strategies to address this challenge that masculine social norms pose to diabetes control is to implement social messages that make moderation in life sound cool and masculine. We need masculine role models who prioritise fitness and good health in movies, media and social media.