Why Learning About Masculine Norms Can Improve MS Care

June 13, 2020

In Part 1 of this interview, the clinical health psychology fellow at Cleveland Clinic’s Mellen Center for MS Treatment and Research provides in-depth insight on his study evaluating masculinity norms in patients with multiple sclerosis.

Bryan Davis, PsyD, MS

A new study lead by Bryan Davis, PsyD, MS, will be 1 of the first research projects that aim to understand the association between conformity to masculine norms and its effects on coping, health behaviors, and quality of life in men with multiple sclerosis (MS). As of now, there have been few studies that specifically look at the impact of gender norms affecting men with MS.

The clinical health psychology fellow at Cleveland Clinic’s Mellen Center for MS Treatment and Research will use the Conformity of Masculinity Inventory-46, a shorter version of the Conformity to Masculine Norms Inventory (CMNI) tool, to assess conformity to 9 masculine norms, while also using the PROMIS Global Health assessment to examine health-related quality of life.

Davis and his team hope that exploring gender roles will provide long-term benefits and potentially change how clinicians care for men with MS. In a conversation with NeurologyLive, Davis discusses the reasons behind diving into this specific population, as well as the importance of behavioral health assessments and interventions.

NeurologyLive: What propelled you to explore this specific population in MS and the challenges they face?

Bryan Davis, PsyD, MS: What sparked my interest was being within health psychology. I had a background with interest looking at traditional masculinity norms and had done dissertation research where I looked at masculinity in the development in men from different cultures. Being in the health psychology side of things and working different populations such as chronic disease or ecology or substance abuse, I kept seeing this consistency of men having challenges in terms of health behaviors due to the conflict of gender norms. With my extensive background in that area anyway, when I started at the Mellen Center, I immediately began to take interest and look into how men are dealing with a disease such as MS.

When I dove into the research, the first thing I noticed was the prevalence rates. Women with MS are almost 3 times as more common than men, and with that, you didn’t see a lot of resources, interventions, or even just discussion about men dealing with MS. That was 1 area where I wanted to explore more and felt there was a void in the research in terms of the rigid adhering to gender roles. Before I even got started, I thought about the premise of it. I thought about how us, as men, trying to adhere to gender norms based on societal pressures is difficult in general. I looked at the literature of gender roles, strain, and gender role conflict. Men, just on a societal level, have a difficulty in terms of living up to gendered expectations, whether it’s being a provider, being a strong man, being independent, being restricted. It’s hard to do all of those things.

It’s also hard to do all those things in many different situations. That’s where men find a lot of strain. For example, maybe being emotionally restrictive doesn’t really work, or being the provider doesn’t really work. When I think about MS, I think about men dealing with physical disability, cognitive disability, increased levels of anxiety, stress, depression. That as a layer can create even more difficulty. When you think about that, you are remembering that there are men who are rigidly adhering to gender norms of being the provider, being the breadwinner, being the independent, strong person, maybe athletic—but then they are diagnosed with MS. At that point it gets completely flipped right there, and their identity can potentially be flipped as well. Navigating this process of self-identification, trying to get back to old performance of gender can be difficult and they may not be able to do it as well. That turmoil is something that I was really interested in and didn’t really find that anywhere else. In my head, I was thinking that we need to look at this and conceptualize men in terms of their experience and how they are navigating this process. We also want to illuminate this idea of finding the best support for them and being there for them throughout this process. I was really happy to get started and we do have some results that are hot off the press. It has been a very exciting experience so far and I’m really happy with some of the attention it has gotten.

What is the importance of behavioral health in MS and why is this especially relevant for men with this disease?

Here at the Mellen Center, I’m very proud to say we’re the only housed behavioral medicine department within an MS clinic in the nation. At the same time, it is a bit frustrating because this is something that needs to be within the integrative model, just as physical therapy, social work, and occupational therapy are. I think we all play an important role because this is such a complex disease and touching coming at it in an integrative way in terms of care is just another avenue for us to contribute, not only in overall patient populations, but for men too.

I think when we’re able to have these discussions about gender and include more resources, we’re seeing the potential increased levels of treatment. We are also seeing men be more open to coming and talking about their experiences in terms of support groups and individual sessions. It is more of men participating within their treatment rather than rejecting this conflict with it. Everything you think about when discussing masculinity, coming in, seeking treatment and what not, goes against everything we previously talked about. Us having this integrative model that includes behavioral medicine is so important rounds out the overall model for these patients.

Do you feel that assessments such as the CMNI tool should be incorporated more frequently into patient visits?

I think right now they’re not included whatsoever. Everything in the assessment world is getting smaller and smaller and more efficient at the same time. So potentially, I think that would be great. I think there’s other models too, such as the male role norms inventory by Dr. Ronald Levant. That assessment is relatively brief and uses 21 questions. There are opportunities here that we can screen for. The results of my study so far have shown that adherence to traditional masculinity norms had associations with higher disability status, increased risky health behaviors, lower levels of physical health scores, health promotion, seeking social support. These are a really big deal. I don’t want to quote that all traditional masculinity is all bad, but what we’re seeing is that there’s a nuanced relationship here where certain gender roles don’t jive well in terms of treatment adherence. We want to identify an increase in risky health behaviors, seeking social support, health promotion, and ultimately support the individual patient and steer intervention that can be effective, just like with do with depression and anxiety.

What are the recommended interventions for patients who may be struggling with these specific challenges?

In terms of specific intervention, there isn’t necessarily a protocol or standardized way. What I found to be most effective is when men are given the opportunity to take the “mask off,” and discuss some of the difficulties they’re having—whether that be with a provider, a neurologist, a psychologist, or even social worker—it allows the men to, from a fundamental sense, really talk more about what the struggle is and that it is okay to talk about. As providers, we have to be able to take that shield away and help the conflict by the way we are coming at men in the conversation. Once we do that, men are able to identify themselves instead to sticking to traditional gender norms that polarize their experiences further. Flexibly having these discussions allow men to re-evaluate how they’re providing. It may not be the same way but at least it is happening. We want to be self-compassionate and really give them the opportunity to get rid of these gender norms but also helping them navigate their process.

Transcript edited for clarity. For more coverage of CMSC 2020, click here.

REFERENCE

Davis B. The conformity of masculine norms and the effects on coping, health behaviors, and quality of life in men with multiple sclerosis. Int J MS Care. 2020;22(Suppl 2). PSF10.