"Go Now": a popular film showing the potential for "masculinity" to facilitate health-promoting behaviours.
Multiple sclerosis (Social aspects)
Multiple sclerosis (Care and treatment)
Help-seeking behavior (Portrayals)
Health behavior (Portrayals)
Krahn, Timothy Mark
|Publication:||Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 Men's Studies Press ISSN: 1532-6306|
|Issue:||Date: Summer, 2012 Source Volume: 11 Source Issue: 2|
|Topic:||NamedWork: Go Now (Motion picture) Event Code: 290 Public affairs Canadian Subject Form: Help seeking behaviour; Health behaviour|
|Geographic:||Geographic Scope: Australia Geographic Code: 8AUST Australia|
The film Go Now explores three key themes relevant to the way in
which many men have been socialized to manage their health, including:
1. men's access to healthcare services and lack of awareness of
their health needs; 2. men's (seeming) inability to express
emotions and communicate their health needs; and 3. men's lack of
social networks. As a story of how masculine identity in the face of
Multiple sclerosis can be negotiated and re-negotiated to propel
positive help-seeking and help-providing health behaviours in males, Go
Now cultivates awareness of the role of social constructions in
men's health behaviours. Rather than blaming masculity as mostly a
liability for health, the film instead works as a public health
education piece showing the potential for positive health behaviours
across diverse performances of masculinity within the featured social
Keywords: men's health, masculinity, multiple sclerosis, illness behaviour, social networks, gender identity, popular film, lay narratives, public health education
"... it is the norms of masculine behaviour that form the backdrop against which men must constantly negotiate their health-related behaviour." (Saunders & Peerson, 2009, p. 96)
Multiple sclerosis (MS), a chronic degenerative disorder of the central nervous system, is the leading cause of non-traumatic disability among young adults in the developed world (Fox, Bethoux, Goldman, & Cohen, 2006). The clinical course (and tempo) of the disease varies tremendously: normally this includes episodes of worsening neurologic symptoms. gradual progressive deterioration with eventual fixed neurologic deficits (Buchanan, Radin, Chakravorty, & Tyry, 2010). Despite the resulting challenges, some patients are able to regain a certain balance in their lives, while others find the experience devastating, suffering "insuperable discontinuity in their lives" (Boeije, Duijnstee, Grypdonck, & Pool, 2002, p. 881 ). Commonly, MS is a predictor of loss of income, employment, and social status, as well as withdrawal from social and leisure activities for patients and sometimes their families (Green & Todd, 2008). MS is a strong indicator of stress amongst relatives and caregiver burnout in families. As a fluctuating condition, MS brings with it what Khan, Pallant, and Brand (2007) describe as a "constant moving target of deficits and disability that require constant adjustment" (p. 1247). By making the lives of patients (and their families) very unpredictable, difficult to control, and creating a future that is hard to plan for (Steck, Amsler, Kappos, & Burgin, 2001), persons with MS often experience an accompanying sense of powerlessness and pronounced vulnerability (White, White, & Russell, 2008). In this regard, Riessman (2003) has described MS as "a disease that challenges capacities usually associated with [hegemonic] masculinity" (p. 8), including physical strength, competitiveness, self-reliance, self-control, sexual prowess, and general ability (Gerschick & Miller, 1995, pp. 183, 191-192).
Go Now (set in Bristol) tells the story of Nick Cameron (Robert Carlyle) who endures challenges to his male self-identity with the onset of MS. It was co-written by Jimmy McGovern and Paul Henry Powell: the drama is based on Powell's own experiences as a male with MS. Carlyle claims he did more research for this role than any other before in his acting career, spending much time "just watching and looking," as well as conversing with patients at MS centres in Bristol and Glasgow (Anonymous, 2011). The film was broadcast in 1995 as part of a BBC2 drama series called Love Bites, which included Loved Up (an "Ecstasy romance") and Ruffian Hearts: in 1996 it won the Royal Television Society's Best Writer award and enjoyed a limited theatrical release in the UK and abroad.
In this paper, we evaluate Go Now's positive potential as a public health education piece on men's health as portrayed in the case of the protagonist's experiences of living through the onset of the chronic condition, MS. In Section I, we briefly: (1) outline our approach to gender identity and men's health; (2) explain how films are especially well suited to communicate the valuable and often needed perspective of lay knowledge: and (3) delineate our methods for analyzing the film. In Section II, we analyze how Go Now explores three key (1) themes relevant to men's health: (1) "men's access to health services" and "lack of awareness of their health needs"; (2) "men's seeming inability to express emotions"; and (3) "men's lack of social networks" (White, 2010, p. 3). Doing so will demonstrate that the movie illustrates how masculine identity in the face of MS can be negotiated and re-negotiated to propel positive help-seeking and help-providing health behaviours in males. In this way, Go Now has potential to cultivate awareness of the role of social constructions in men's health behaviours with respect to MS. We conclude that, rather than blaming masculinity as mostly a liability for health--as suggested by the "male deficit model" and its dependence on hegemonic masculine stereotypes (Smith, 2007a; Smith, 2007b: Smith & Robertson, 2008)--the film presses its viewers to look closer at the potential for positive health behaviours spanning diverse performances on how to be "male" within the featured social structures of the narrative.
APPROACHING THE MATERIAL
Gender and Men's Health
Doing health can be a form of doing gender and vice versa (Saltonstall, 1993: Williams, 2000). In the "developed" world, over the past two decades, men's health has emerged as a growing concern for health policy and promotion (Kierans, Robertson, & Mair, 2007; White, 2006). Amongst various foci, emphasis has been placed on removing barriers to accessing health services, including constricting role expectations or psychological difficulties that either follow men into the consulting room or deter them from getting medical assistance (O'Brien, Hunt, & Hart, 2005). Proponents of this view believe that finding the means to challenge and redress some of the on-point, prevalent stereotypes of masculinity should be a public health priority (Coles, Watkins, Swami, Jones, Woolf, & Stanistreet, 2010; Smith, 2007b; White, 2010; Williams, Robertson, & Hewison, 2009). After all, as White (2001) explains, "[m]en's health is not [just] a medical issue: it is societal" (p. 7). "'It's about what it means to be a man: about lifestyles and social pressures'" (White quoted in Roberts, 2008, n.p.).
Campaigns addressing men's health issues have until relatively recently been dominated by simplistic interpretations of "masculinity" that tend to equate it with "a set of (usually negative) characteristics that all men share or a set of common values that all men subscribe to" (Smith & Robertson, 2008, p. 284). This is problematic insofar as it looks at men's health outcomes as a function of individual behaviours that are treated as blameworthy and cause for social disapprobation: the "men behaving badly" stance (Macdonald, 2006). This has also meant, as Smith and Robertson (2008) explain, a certain neglect of the way men "embody gender, experientially and pragmatically," placing an overly narrow focus on personality factors, without due regard for the social, political, and environmental determinants impacting how men perform their gender identities in context (Macdonald). Thus, an alternative framework--one that can focus attention on men's everyday lived experiences--is warranted to move beyond the "male deficit model" of men's health (Robertson, 2007; Smith & Robertson).
Popular Films and Communicating Lay Knowledge
The medium is of course critical, not only to the reach of a public health campaign message, but also to making that message compelling for the audience. Popular films resonate with broad audiences. They can act as powerful vehicles for stories, and as Thomas (1999) explains, "lay knowledge is contained in, and told through, stories" (pp. 10-11). Cinematic portrayals of a narrative, by exploring relationships between individuals and the wider social context within which they live, have the potential to give an insider's perspective on issues and to provide insight into questions of structure and agency (cf. Robertson, 2007, p. 5; Williams, 2003). Gender theorists have long been concerned with analyzing how films (and other image-driven media) have the capacity to both reflect and shape (or, re-shape) within a given culture what are considered appropriate feminine and masculine behaviours (Holtzman, 2000). Insofar as the featured gender practices in Go Now are relevant to men's health, there is a potential for this popular film to be used to promote public health on a widespread scale.
In terms of methodology, we reviewed the film on multiple occasions: the above-mentioned themes were established and then used to structure our analysis of Go Now as a men's public health piece. To be clear, the objective was to develop themes generated from the film, rather than apply existing theories to the film. In doing so, the methodology conforms to a process of data-driven thematic analysis. Although this terminology is generally applied to text (Boyatzis, 1998; Braun & Clarke, 2006), we hold it to be equally appropriate for the analysis of film. Themes and sub-themes were created and modified through continuous discussion between the authors, until the major elements of the narrative were decided upon, with the objective of examining a given male's health experiences with MS in the featured social context. Our approach to the material treats the film like a case study, providing a "chronological account of the evolution of the phenomenon from the perspective of the central character" (Marks, Murray, Evans, Willig, Woodall, & Sykes, 2011, p. 87). Background discussions from the relevant literature are discussed, in order to see the general in the particular, thus providing insight into different ways through which men define and re-define their gender identity to respond to the realities they face in living with the chronic condition of MS. Doing so makes plain some of the structural limits on, as well as multiple options of agency for, men living, or supporting others, with MS.
Accessing Medical Healthcare Services and Awareness of Health Needs
The film opens with the aftermath of a football game. Nick's team-mates are yelling at him and blame their loss on the fact that he missed what should have been a sure goal. Nick's excuse is that it "bobbled" but his team-mates will brook no excuses. This is definitely a group of men who measure one another's worth according to certain stereotypical ideals of contemporary hegemonic masculinity: (2) men who are self-reliant; appear physically able, strong, and robust; remain physically and emotionally independent and "in control"; are competitive; interested, and "successful" in sex: and aspire to dominate (Courtenay, 2000b; Gerschick & Miller, 1995; Rogers-Clark, Kyle, & Wilson, 2005; Williams, 2000). The film focuses variously on the sub-plot depicting the social gatherings of the team: this includes mainly drinking beer together in a bar, playing football--with a great deal of frustration expressed at one another when individuals fail to perform--as well as further drinking, dancing, and story-telling at Nick's eventual wedding. The main plot, however, tells the story of Tony (James Nesbitt) and Nick, who work together in the construction trade and court two young women whom they meet while out drinking at a nightclub. Shortly after his romance begins, though, Nick's ability to perform physically is compromised by the onset of MS. We turn now to an analysis of various healthcare crises faced by Nick, which provide insight into the film's narrative perspective on men's behaviours, in terms of their accessing of healthcare services, as well as becoming aware of their health needs.
Crisis: The hammer drop. Health-related beliefs and behaviours that are typically used to demonstrate hegemonic masculinity include the denial of weakness and vulnerability, with the experience of pain and sickness often resulting in healthcare needs being ignored (Coles et al., 2010; Courtenay, 2000b). That men utilize general practitioners' services less often than women is a widespread finding across various health studies (Schofield, Connell, Walker, Wood, & Butland, 2000). Men's reluctance to seek medical help is especially acute during their early and middle years. Evidence from the relevant literature reveals that, in facing most chronic conditions, men tend to delay seeking healthcare (Jarrett, Bellamy, & Adeyemi, 2007, p. 89). Taking time off work to obtain a medical assessment can be seen as a sign of weakness. Other negative emotions include feelings of fear and embarrassment when using healthcare services (Coles et al., 2010, p. 930).
In Go Now, besides general under-performance in his football play, the first introduction of MS symptomatology for Nick is when he drops a hammer at work, for no apparent reason except a sudden numbness in his hands. Perhaps surprisingly, given the temporary nature of the incident, Nick takes himself to hospital. In analyzing this scene, it is clear that the film reflects the literature, in that the early onset of MS is characterized by sporadic symptomatology that often evades notice (Koopman & Schweitzer, 1999). Nick's response to the first signs of his illness, though an example of health conscientiousness, seems somewhat suspect since it runs counter to evidence for most men within his general occupational and socio-economic profile (Galdas, Cheater, & Marshall, 2005: O'Brien et al., 2005; Richards, Reid, & Watt, 2002).
When Nick's girlfriend Karen arrives at the hospital to collect him, she finds Nick seated alone in a corridor. Asked what's wrong, he replies: "Well, my hand went numb. It was weird. Don't know." Nick claims to have been waiting for an hour and he makes no mention of having received medical attention. Nick and Karen leave without any diagnosis or medical explanation: admittedly, at this point Nick is not much concerned about his failing health, especially in contrast with Karen's somewhat anxious attitude. In summary, the film is perhaps slightly unrealistic in its depiction of Nick as seeking (though in this case failing to obtain) medical advice early in the course of his disease, although, to be fair, his hands are very important for his work. However, Nick's apparent lack of concern with the health implications of this attack is quite realistically portrayed. In the early phases of the most common form of MS (relapsing-remitting MS), symptoms appear and then subsequently resolve, and because of this intermittent presentation, patients may initially neglect or delay bringing their symptoms forward for medical consideration (Campagnolo & Vollmer, 2010).
Crisis: Double vision. Nick's second health crisis is signalled by a case of double vision (diplopia) while shopping at a local market in Bristol. Again, contact with the medical profession is initiated quickly--more quickly than might be expected, given some of the literature on men's help-seeking behaviours (Galdas et al., 2005; Tudiver & Talbot, 1999). Nick is then given a Brainstem Evoked Potentials test, which reveals definite visual problems. Crucially, Nick is asked by his doctor if he has experienced numbness, indicating that his general practitioner (Dave Schneider) already suspects MS. Nick responds by asking in return, "What, numbness in my eye?," clearly demonstrating that he is confused by the phrasing of the question. The doctor tries again, asking about numbness anywhere, which Nick affirms the experience of in his areas. When asked if it's like "pins and needles" Nick replies in the affirmative: "Ah, the kind everybody gets, kind of thing." The doctor then gives a vague explanation of a trapped nerve (with the other eye compensating) and he recommends glasses for Nick. Passively, Nick asks no further questions: it would almost seem that he does not imagine that anything could be seriously wrong with his health.
On the one hand, Nick normalizes and minimizes his symptoms when faced with his doctor's questioning. On the other hand, his initiative to seek medical care represents a positive exception to an otherwise stereotypical male resistance to help-seeking. Several reports do show that, as compared with women in general, men's health consultations tend to be shorter in duration (Malcher, 2005); men also appear less predisposed to discuss their health problems, and when they do. it is generally with less detail (Jarrett et al., 2007). Correspondingly, at this stage, Nick seems more representative of these tendencies as he is somewhat reticent to communicate any more than the minimum with his doctor.
Crisis: Burning hand accident. The next health crisis shows Nick bunting his hand on a pot, which he has failed to recognize as dangerously hot, owing to the lack of nerve sensation in his fingers. Though the burn is quite severe, Nick is satisfied to simply have Karen bandage the affected area, and he does not seek medical attention this time. Perhaps owing to dissatisfaction with the prior diagnosis, it is Karen (rather than Nick) who goes to a public library, where she researches information that leads her to suspect MS. On her own, she then confronts Nick's physician about what is happening to Nick and asks what can be done.
In this context, several studies have shown that care initiation is quite commonly spearheaded by female partners (relatives, or friends), rather than the affected male (O'Brien et al., 2005; Seymour-Smith, Wetherell, & Phoenix, 2002). Discursive analysis of men's contact with the medical profession has shown evidence of system-wide factors that contribute to a re-enforcement of the role of female as primary family health navigator and default care provider (Seymour-Smith et al.). Gillon (2007) points to further complicating structural issues (in the UK context), in that: "the associations between masculinity and strength, non-emotionality and detachment not only prevent men from seeking help, but also erect subtle barriers to its being made available" (online version, n.p.). Indeed, there is evidence that medical professionals play into and entrench stereotypical male-female role constructions for access to healthcare services. Accordingly, Seymour-Smith and colleagues report on a qualitative study of healthcare practitioners from the Midlands area of the UK, concluding that: "In common with the general ideological climate forming around masculinity in recent years ..., the status quo was preserved through the construction of men [who are patients] as hapless and helpless but this 'hopelessness' was celebrated and deferred to, positively tolerated and welcomed" (Seymour-Smith et al., 2002, p. 265).
To return to the story: Nick appears to be rapidly losing control of his health. At this point, he is portrayed as not completely unaware of his health needs, but his approach is still relatively passive, while Karen takes the lead in securing more definite information from the doctor about Nick's medical situation. Furthermore, she pro-actively begins to adjust her own work schedule (and her life in general) to respond to his changing needs.
Crisis: Automobile accident. Shortly after Karen's private visit to the doctor, Nick's loss of motor skills leaves him unable to move his loot sufficiently to apply the brakes of his truck while driving down a hill. The result: Nick crashes into a skip and ends up in hospital. Viewers of the film are left to surmise that Nick's general practitioner, adopting a "wait and see" (passive) approach to communication, has been insufficiently responsive to Nick's needs and his situation as a patient. In this regard, the literature shows that a more pro-active approach aimed at getting patients more involved in their own health care, achieving shared understanding and shared decision making (through collaborative input from both parties), is more likely to reduce errors, adverse events, and non-adherence to treatment (Lovell, Lee, & Brotheridge, 2010). As viewers, we are left with the ominous recognition that Nick's accident could have been much worse than it was: i.e., it is merely lucky that he was not injured more severely and that he did not inadvertently harm any other persons. We as viewers might further surmise that it would have been prudent for Nick to seek medical attention himself for the serious injuries suffered as a result of his previous health crisis. Finally and most notably, the viewer is left wondering why Nick's physician did not at least attempt more frank communication with his patient (see Krahn, 2011) to make Nick aware of the range of risks that might be associated with his evolving condition.
Self-care: The example of seeking medical help for urinary incontinence. At this point Nick is hospitalized. He receives a battery of tests (spine puncture; MRI; blood test; and further eye tests) and his doctor puts him on a course of steroids as treatment. Nick is, to all appearances, completely compliant throughout this process. After returning home, he next proves incontinent and wakes up having wet himself. When Karen inquires what's wrong, it is obvious from the tone of Nick's response that he is embarrassed and understandably distressed. The stigma associated with urinary incontinence for adults often prevents those affected from seeking medical assistance (Goldstein, Hawthorne, Engeberg, McDowell, & Burgio, 1992) and early treatment (Garcia, Crocker, Wyman, & Krissovich, 2005). Koch, Kralik, and Kelly (2000) report that: "[f]or people with MS, urinary incontinence can become central to their experiences of managing the consequences of the disease" (p. 254). The men interviewed in this study "perceived that living with MS and urinary incontinence meant they no longer had control of their body" (Koch et al., p. 257). One male interviewee reported that he "'learnt to lie and cheat a lot'" in order to hide his frequent visits to washrooms when in public; he also employed various means to disguise "wet marks" while in others' company. In contrast, another male interviewee reported that "catheterization ... enabled him to gain control over his incontinence and, for this reason, catheterization was liberating for him" (Koch et al., p. 257).
In the next scene of Go Now, Nick and Karen attend an appointment with a nurse, who advises them on how to use a catheter and urine collection bag. The nurse asks what size catheter Nick requires: "small, medium, or large?" Nick looks at Karen, they both laugh and Nick requests "medium." The scene is instructively light: Nick is shown to be only very slightly embarrassed, open to receiving advice, and obviously frank with both the medical personnel and his girlfriend about his needs. As a result, by seeking help and getting a catheter, Nick is able to continue to socialize outside his home.
In one scene, while out with his family at a local pub, Nick is forced to excuse himself (in order to empty his urostomy bag) and tries (unsuccessfully) to do so without being noticed. He rebuffs an offer of assistance from his brother Chris (Tony Curran) who asks if he needs any help getting to the washroom. Nonetheless his father (Tom Watson) and brother follow him, and we see them next standing outside the bathroom stall, pestering Nick with questions. When opening the collection bag it proves to be mostly full of gas and so the urine bursts out as spray. Nick mishandles the device at first, but regains control only to direct the spray away from himself over the bathroom stall, showering his brother and father. Nick makes no apology but instead laughs triumphantly at hearing the two men shriek in disgust; he shows no shame, thus revealing a growing acceptance of his condition and the resulting limitations for himself.
The director uses the above-mentioned scene for light-hearted comic relief, as with a later scene in which Tony gives Nick "a bit of stick" in the locker room. The latter scene features Tony teasing Nick about his purported loss of masculinity and his diminishing abilities to perform as a male "lover," due to the progress of the MS (which we shall give more detail on below). At one point, Tony stops himself: he suspects Nick is ignoring him, and so he asks with an edge of condescension: "Are you [Nick] pissing in that bag?" Nick retorts with a wry smile of satisfaction: "Ay!" This game of competitive male, "one-up-manship" becomes Nick's way of resisting Tony's insults and attempts to embarrass him. In this way, the movie communicates a point echoed in the literature regarding the positive use of humour to cope with the embarrassment or stigma of living with an in-dwelling urinary catheter (Wilde, 2003). In sum, Nick's humorous "comebacks" prove an effective means of resisting embarrassment in the face of his male peers.
Further examples of self-care and compliance with medical healthcare advice. Certain men's health studies have highlighted how hegemonic definitions of "masculinity" require men to resist revealing their problems in order to maintain a "tough front" and conceal vulnerability (Schofield et al., 2000, p. 253). However, this does not remain the case for Nick. As a rule, Nick does not try to hide his symptoms, even if he battles to overcome them. Although he resists some offers of assistance, he usually seeks help when he really needs it. O'Brien and colleagues (2005) have noted that some accounts in the literature attribute men's reluctance to seek help with either poor health awareness or resistance to take responsibility for personal health. But Nick is presented as quite aware of his health needs, at least most (though not all) of the time. Although he smokes cigarettes and drinks beer--and although he also proves resistant to Karen's proposal of a non-fatty acid diet because it sounds "a little bit too much like hard work"--post-diagnosis. Nick is not shown smoking. When out with his family, he is shown drinking non-alcoholic beer in compliance with medical advice. (3) Furthermore, despite (at this stage) being symptomatic with MS, Nick continues jogging with Karen, an activity he began upon first meeting her. According to some research, this would be atypical for someone of his income bracket and level of physical disability (Taylor. Kralik, & Kelly, 1998). Post-diagnosis, Nick also follows a physiotherapeutic regimen--a practice that has been shown to improve fitness, lower depression and anger, reduce fatigue, and improve overall quality of life in MS patients (Dalgas et al., 2010). In the scenes which feature him exercising at his physiotherapy appointment, Nick exerts himself with great determination, a man obviously concerned to do what he can to uphold his health and identity as fit and physically capable.
As Robertson and Williams (2009) point out, "[w]e should not assume that all men are always reluctant to engage with health care" (p. 34). One qualitative study by O'Brien, Hunt, and Hart (2009) found that certain men feel pressure to present themselves, in conversation with other men, as caring little about their health. But, as Robertson argues, how men present themselves or say they behave in response to their health needs, may be quite different from how they actually behave (O'Brien citing Robertson, 2003). Indeed, several recent studies are challenging the formerly received view that women are more likely than men to consult a general practitioner for a variety of disease conditions (Robertson & Williams, 2009). Galdas and colleagues point to countervailing evidence that shows cases of men seeking medical help more so than women, or with no significant difference across gender. Instead, they maintain the "evidence suggests that occupational and socio-economic status, among others, as more important variables than gender alone" (Galdas et al., 2005, p. 620; see Robertson & Williams, 2009, p. 34).
Demanding and receiving further help: Reliance on female partner as default care provider. With the increasing onset of MS symptoms, Nick at times resents the reality of his changing bodily condition and his growing inability to cope both physically and mentally. Eventually, unable to work, with no financial income, no apparent provisions for professional social support or services in the home, and faced with navigating an apartment with many stairs and no lift, his situation becomes truly dire. These limiting factors are pointed out to him by Karen, who suggests that they move to Glasgow, where Nick's parents live and presumably will be better able to provide some assistance and relief. Nick responds by lashing out in anger at Karen, accusing her of wanting to off-load him onto his family. Presumably, out of wounded pride, Nick claims to no longer need or want Karen: he demands that she "go now" and says that he will survive with the help of his mates. When Karen refuses to leave, he becomes both verbally and, eventually, physically abusive towards her. Nick next threatens suicide if she doesn't leave. Karen then exits the apartment, only to stand waiting in the rain across the street open to Nick's view from inside their flat. After some time, Nick finally relents and takes her back.
The overall societal presumption that a female partner will serve as default care provider (Tronto, 1993) is in many respects quite common for the general time period in the featured cultural context. Elian and Dean noted in a 1983 English study that many more persons with MS were eligible for, than received, home-help services. Of those not receiving such services, all were men whose wives still worked outside the home but nonetheless provided much of their husbands' required care (Elian & Dean). The film does little to question the gender stereotype of female partners' presumed obligations (reinforced by societal pressures) to provide unpaid care for husbands or male partners. Instead, Go Now, without compromising its realism as a public health piece, could have afforded to develop Karen's character more fully, to show more of the effects and costs of Nick's changed condition for her life (see Buhse, 2008). In this way, the film might have done more to "examine the intersections between men's and women's health (and other social) practices, and the impact they have on one another" (Smith & Robertson, 2008, p. 284).
Admittedly, Go Now involves evidence of only very limited attempts at reformulating hegemonic masculine stereotypes of male resistance to seeking help. Most instances where Nick is shown seeking assistance are, expectedly, not in his interactions with his male peers, but rather, with Karen. For example, when Nick is picked up by Karen after his first stay in hospital, he is dependent upon a cane to ambulate. He initially rejects her offer to carry his duffel bag, but yields to her second attempt, and responds with thanks and affection by taking her hand and giving her a kiss. The movie ends with their wedding. The closing scenes feature Nick standing with two canes, watching his father dance with his bride. The final scene shows Nick draped with his arms around Karen--who is both taller and by now much fitter than Nick--letting her lead, as they dance together. In all these scenes, Nick relinquishes his tendency to try to project to others a man who is "fully" self-reliant, invulnerable to disability, and unaffected by MS. Rather than conveying a sense of personal defeat or victory in response to the onset of disability, the film instead portrays Nick as more or less capable of accepting his changed condition and doing what he can to adapt to the changes necessary to living with MS. The movie thus presents some (potentially) very positive behavioural responses to chronic illness as borne out in the literature (Evers, Kraaimaat, van Lankveld, Jongen, Jacobs, & Bijlsma, 2001).
Communicating Health Status and Emotions
Many of the challenges faced by Nick in trying to process the changes brought on by MS raise the issue of the communication barriers commonly experienced by men dealing with chronic health problems. Theories prevalent among international men's health studies hold variously that men are not allowed (or become "unable") to be expressive in their illness behaviour (Robertson, 1995) due to the negative effects of hegemonic masculinities that may compel them to conceal emotion(s) and states of physical fragility, opting instead lot "stoic" attitudes (Coles et al., 2010; Courtenay, 2000b; Galdas et al., 2005). Voicing emotional distress, especially to other men, can be seen to flout conventional practices of masculinity (O'Brien, Hart, & Hunt, 2007). The reluctance to communicate a need for help, to seek help, or to be seen to be seeking help, tend to be more pronounced for younger, rather than older, males who experience "serious" conditions (O'Brien et al., 2005).
As a young male in his journey to MS diagnosis, Nick at times appears to "close down", producing only half explanations for Karen, as in one scene where she fruitlessly inquires about what the doctors are saying when visiting him in the hospital alter his accident. At one point, Nick tries to push her away by claiming that his doctors might be worried that he has AIDS--purportedly, the result of Nick's sexual escapades while on holiday in Africa. Nick retreats from a lull explanation, only later to throw it in Karen's face, as a way to drive her away from him, when he feels himself becoming an object of pity. We as the viewing audience can see from this that Nick is probably propelled by certain insecurities brought on by the process of being diagnosed with MS (Pfaffenberger et al., 2010) as well as the growing sense of losing control over his life (see Koch et al., 2000). Nonetheless, it is apparent that his lack of communication in these matters is only temporary and not the product of having been socialized to be "stoic".
Prioritizing family relationships, as well as increased emotional expressiveness, are both features that have been observed as emotional responses to various chronic conditions, raising questions about gendered identity as relevantly affected males re-evaluate their previous patterns of gendered behaviour (Charmaz, 1995). Robertson has observed that in fact, "the negotiation of a disabled (male) identity may result in an increased need and/or desire to communicate, challenging previous hegemonic male patterns of emotional passivity" (2007, p. 108). Robertson further points out that intimate relationships are commonly acknowledged as a priority, when men are queried as to what contributes "both (positively and negatively) to their health and well-being" (2007, p. 95). Indeed, Robertson has found that "emotions represent one medium through which intimate relationship experiences are transformed into health outcomes" (2007. p. 95).
Nick is emotionally expressive, though perhaps not always in touch with the sources of his emotion. His insecurity with respect to his changing male identity, for instance, arguably propels him to become jealous of Karen's attention--a problem for him throughout the narrative--and to (at first) falsely accuse her of infidelity. This same pattern of exerting control over one's female partner as a response to loss of control in one's own life is reiterated in a qualitative study of males with MS by Riessman (2003). The challenge of understanding and learning how to deal productively with emotions has been discussed in the literature in terms of "emotional literacy", commonly referenced as especially relevant to young men who may find it difficult to claim their feelings, and in turn, to articulate their problems. This phenomenon is considered a major contributing factor in both men's mental health difficulties and differential suicide rates in both young and old populations (White, 2001). These problems are especially endemic to males with MS (Stenager. Koch-Henriksen, & Stenager, 1996) and to MS patients without adequate social supports (Siegert & Abernethy, 2005). As mentioned previously, Nick threatens to commit suicide while trying to drive Karen away. It seems that his doing so reflects his feeling that, due to his MS. he is a compromised man, who is not worthy of love. Had his efforts succeeded, Karen's leaving might have appeared to confirm Nick's anxieties (and depressed state) about his worth as a partner. In this way, the movie illustrates how certain hegemonic models of masculinity can "militate against rather than for men's mental health" (White, 2001, p. 13).
Having been, until recently, a young, otherwise robust male, Nick is not likely to be a regular user of health services and as such unlikely to have significant experience as a consumer who would be able to navigate the medical system well enough to negotiate for better service. After a battery of further tests, Nick attends an appointment with his neurologist, only' to find out that his results have gone missing. The specialist asks to re-schedule his appointment in a month's time. Revealing a growing assertiveness over his own health care, Nick asks if more cannot be done. But, aggravating the situation further, the doctor informs Nick that he won't be available in the next while: he's going on holidays. In response, Nick, though frustrated, does not let his anger get the better of him: he also does not revert to his former passivity. Instead, at this point in the film, he remains determined to find out his health status asking the neurologist, with reserved irritation, to "please" have the results communicated to him as soon as possible by telephone.
Nick's neurologist seems inadequately motivated, almost negligent in his attitude. In a commentary on doctor-patient communication. Waitzkin (1984) has admonished physicians to disabuse themselves of certain assumptions saying. "lower-class patients want more information than we [doctors] may think, and their diffidence reinforces a structural barrier to communication in doctor-patient encounters" (pp. 2442-2443). Perhaps barriers to communication, such as those experienced by Nick with his neurologist, also have some parallel with the findings of Richards and colleagues (2002), in their review of how increased social distance (defined through occupation/class) may negatively affect the doctor-patient relationship. In his insistence with the neurologist. Nick (as presented at this juncture in the film) counts as a counter-example to a trend reported by researchers where "... the wide gap in educational background and socioeconomic status between most patients and their physicians ... contributes to the deference of lower-social class patients and their adoption of a passive and dependent role in the doctor-patient relationship" (Roter & Hall, 2006, p. 29).
When Nick finally receives a positive diagnosis of MS (over the telephone) he has progressed to the point of acceptance where he no longer evades Karen's questions. Instead, he relays the news to her directly. Once done, he asks her what is for dinner and she tries to put a cheerful face on the situation while describing the three-course meal she has prepared. Nick then states in response: "You spoil me." Admittedly this can be read as a statement that communicates that he does not deserve such good treatment--perhaps a slightly condescending assertion of stereotypical "male" ego, a passive resistance to affection, and a presumption that he should be self-reliant. These are not words that patently communicate an intention to henceforth be more responsive for Karen's sake. Nevertheless, Nick's admission that Karen spoils him might also be read as an acknowledgement of her significant efforts on his behalf, as well as a sign of self-awareness that she would be justified in doing much less than she does for him.
Nick's willingness and capacity to communicate his health situation are also evidenced in the immediate aftermath of his diagnosis. As stated above, he sometimes fails to admit or even denies the limitations of his condition. All in all though, he does not attempt to hide the fact that he is ill: not from himself, not from his family, not from his male friends, not from his partner. He at no point appears to avoid socializing with his male friends and team mates, even when his symptoms become visibly pronounced. He presumably invites his family to visit him--or at least accepts their coming over--as soon as the diagnosis is confirmed, the meaning of which he communicates to them very openly. Though his parents (Tom Watson and Barbara Rafferty) and brother (Tony Curran) are overwhelmed by the news--so much so that they withdraw into their own coping mechanisms by being quite non-communicative--Nick responds by describing in an empathetic, tender tone both the possibility of a mildly debilitating, and then the possibility of a severely debilitating, prognosis. When his younger sister (Erin McMahon) asks him very. pointed and direct questions about what to expect with this prognosis, Nick--by way of contrast to his mother's and brother's attempts to silence the child--responds by insisting that her questions are reasonable and he does his best to answer them directly. Nick hereby demonstrates a preference for open communication: he is not concerned to be or appear "stoic". In fact, he resists silence, and thus shows that there are other ways to be a man and courageous than resisting talk of one's vulnerabilities and potential for physical weakness (Jarrett et al., 2007). In doing so, Nick defies certain hegemonic male stereotypes concerning barriers to communication as stated in the literature. (4)
Go Now is a film very focussed on Nick's relationships as providing him with that which is important for preserving his sense of well-being and as a support network helping him to meet the health challenges presented with the onset of MS. In this regard, Kierans and colleagues (2007) have noted that many men's access and utilization of health services is "refracted" through structures of family, friends, and community: indeed, the presence or absence of these relations can have critical repercussions for men's health. Several studies have shown that men have fewer social networks and are less able to mobilize social support than women (Courtenay. 2000a)--factors especially critical when facing a sudden onset of illness (White, 2001), as seen in Nick's case. White (2001) and Kierans, Robertson, and Mair (2007) have signaled that a significant issue in men's health is isolation and lack of social integration, often leading to depression. In a qualitative study by Coles and colleagues, male research participants "spoke about how problems of stress and isolation were exacerbated by men's tendency to 'keep things bottled up' ..., instead of 'getting together and have [sic] a natter' ..." (2010, p. 927).
According to Jarrett and colleagues, "[g]endered health socialization contributes to men being less apt than women to discuss health problems" (Jarrett et al., 2007, p. 90). Tudiver and Talbot have reported that women garner support for help-seeking through discussion, while men rarely seek social support for healthcare: if doing so, men are more likely to seek support from a female partner, and rarely from male friends (cited in Jarrett et al., p. 90). However. other research has shown that some of these stereotypes of men's and women's ways of relating to one another are in need of further nuance and appreciation (Walker, 1994). Sherrod, for instance, has pointed out that even though the men she studied rated their friendships as less intimate than women did, with respect to measures of self-disclosure and emotional expressiveness, men's friendships "nevertheless serve to buffer stress and reduce depression in the same way that women's friendships do" (cited in Traustadottir, 2010). Sherrod has also noted that men's path to intimacy may be different, placing more emphasis on shared activities and companionship (see Robertson, 2007) as opposed to self-disclosure and emotional expressiveness (Traustadottir, 2010). Furthermore, Swain (1989) has argued that accounts which blame men for a lack of intimacy, as measured by verbal communication, overlook the place of non-verbal intimacy that can play a significant role in men's social interactions. For instance, Robertson, in a qualitative research study, has detailed how one man claimed to provide support and care to male friends in distress, not by talking "about it very often," but "by being a mate and involving them again" in group activities (2007, p. 110).
Walker has argued that, contrary to the belief that men share activities and women share intimate feelings through verbal exchange in their friendships, much of these observable gender differences in behaviour are a function of cultural ideologies, class, and various kinds of mobility. Accordingly, geographical, occupational, and social mobility in both men and women decrease the likelihood of intimacy in the experience of friendship (Walker, 1994, p. 247). Walker has found that "[e]mployed middle-class women indicate[d] they are sometimes averse to sharing feelings with friends. Working-class men, on the other hand, report[ed] regularly sharing feelings and discussing personal problems" (Walker, p. 247). Working-class respondents from this study also had more financial as well as health problems, and hence these somewhat "intimate" subjects tended to predominate in topics of conversation with these research participants more than with the professional-class respondents (Walker). As Walker concludes: "[t]o the extent that discussing problems is a mark of intimacy for many individuals, working-class men appeared to have more intimate friendships than professional men and women" (p. 261).
Returning to the movie, social solidarity and socilaizing together as a group matter a great deal to Nick's mates. Although their jokes and attitudes to persons with disabilities are sometimes disrespectful and callous, there is no question that these men's behaviour towards Nick assures him of his membership in their group regardless of his MS diagnosis and level of disability. Even prior to diagnosis, these men show up en masse at the hospital, making quite a humorous scene, teasing the nurses and Nick, and drawing him into joking conversation, which visibly seems to put Nick at ease. This can be interpreted as evidence of male peer support to Nick, a social network he has depended upon in the past and continues to do so through the periods of relapse and remission of MS.
The film's demonstrations of humour involving Nick's male social network also show how the performance of male gender roles can provide resilience by normalizing certain changes of functionality accompanying MS. Hilton and colleagues (2009) have reported from their study of men being diagnosed with cancer that the affected individuals "were relatively open about their diagnosis [and] often explicitly linked disclosing or discussing cancer with their identity as a man who could 'take a joke'" (p. 751). As Hilton and colleagues further explain: "Humor is one of the ways in which men are positioned within dominant and subordinate groups, so it is perhaps not surprising that many men preferred to be the target of jokes, and have the chance to answer back, rather than be excluded from banter entirely, given the consequences for the construction and consolidation of their gendered identities" (pp. 751-752).
In the movie, humor works in certain ways to normalize disability in how Tony and Nick "carry on" post-diagnosis. For instance, once, while playing pool together at a local pub, Nick tries to offset attention from his losing by asking Tony in a mocking tone of voice whether he has "had any luck" with their server Bridget (Sara Stockbridge), who routinely refuses Tony's romantic advances throughout the film. Arguably, Nick hereby attempts to draw attention to Tony's own inability to "perform successfully." Near the end of the game. Tony senses Nick's visceral frustration at the loss of motor control in his hands and arms. Realizing his own unfair advantage, Tony (perhaps out of pity) deliberately misses what could have been the winning shot. Nick lashes out, telling Tony not to patronize him. The camera then cuts to a close-up on Nick as he is wracked with tremors. Nick stutters with a sense of wounded bitterness: "I want to be told to get my round done. I want a bit of stick. And I want a pasting on there.... "Cause I'm still the fucking same, up here [pointing at his head]. Still the same."
Later on Tony gives Nick more than just "a bit of stick" as part of post-game, locker-room conversation. Tony begins by pointing out Nick's presumed loss of sexual capacity (impotence). Tony jokingly suggests the team will "help" Nick out by taking turns "'coming "round" to satisfy Karen's sexual "needs" now that Nick can no longer sexually perform ("as a man"). In response, not one team member voices a word of disagreement, but the moral repugnance on their faces is unmistakable--even from George (Sean MacKenzie), a character responsible for some of the most insensitive, asinine humour in the film-thus putting Tony on the defensive. While his attempt at humour is in this case inappropriate, Tony's motivation to challenge Nick can be seen to start from a place of camaraderie. Although his attempts to give Nick "a pasting" (as requested) turn out to cross a line of decency tacitly accepted by all members of the men's group, Tony's actions can still be interpreted as a gesture aimed at communicating to Nick a continued sense of equality: why else would Tony remain so verbally competitive with Nick? By risking humour that would adequately convey to Nick that he did not consider him too vulnerable to tease, Tony shows a closeness in his friendship with Nick that could not evade this very personal (perhaps, even moral) demand to be treated as an equal- as a steadfast friend and peer of tile football club. More specifically, Tony actually delivers oil Nick's request to be treated according to the particular norms of masculinity of his social group, which include being humorously "roughed up."
Tony in the end feels disciplined through the response of silence from his team mates. These, indeed, are very expressive men, whose roughness and toughness sometimes disguises caring attitudes that extend to individual members and to the group as a whole. The positive effects of this cam for Nick show the value of "relational solidarity" for meeting health challenges (Baylis, Kenny. & Sherwin, 2008). This support, evident with all group members present at Karen and Nick's wedding at the end of the film, is a sign of hope. In this regard, ensuring social support as a means to building hope has been shown to be an effective strategy for patients coping with chronic conditions in general (Raleigh, 1992). and is important for the functioning and overall wellbeing of persons with MS in particular (Foote, Piazza, Holcombe, Paul, & Daffin, 1990).
SUMMARY AND CONCLUSIONS
In summary, Go Now is a film that has the potential to promote public health messages about men's health. In particular, it seeks to disabuse its viewing public of overly rigid masculine stereotypes which suggest that: (1) men are unaware of their health needs and are disinclined to access healthcare services; (2) men are resistant to communicating their health needs or to being emotionally expressive about matters related to their health; and (3) men do not support and care for themselves or one another when facing health challenges. Masculinities--and femininities, for that matter--are constantly under construction. The movie reveals how certain structures underlying the relationships between men's health and gender identity are not fixed. On the contrary, the movie teaches that men's ways of "doing health" can be positively related to their ways of "doing gender." As such, the film presents gender as containing multiple (and sometimes oppositional) forces that present definite possibilities for change, as demonstrated through the capacities for agency given in the examples of the protagonist Nick Cameron and his supportive network of male friends. The film (as a narrative account) provides a lay perspective and an insider's viewpoint into how men can resist stereotypes of masculinity as mostly a liability for health and instead use their gender identity to care for their health and for one another. As Coles and colleagues (2010) have suggested, "... if it were more widely known that most men really are concerned about their health, this knowledge might make men more comfortable addressing their own health issues" (p. 934). In providing a compelling story of how masculinity can underwrite and assist men being concerned about and taking care of their health, Go Now has definite potential as a public health piece addressing critical issues in men's health.
Rather than suggesting that the relationship between masculinity and men's health is endogenous to men and their adoption of unhealthy stereotypes, the film illustrates that "the common perception that men are being stubborn, or in denial, about their health is clearly simplistic and, if it is true, may be as much a product of socialization" as it is about individual agency or choice (White. Fawkner, & Holmes, 2006, pp. 454-455). As such, the movie pushes its audience(s) to consider the underlying determinants of men's health rather than apportioning blame (cf. Australian Medical Association [AMA], 2005; NSW Department of Health, 1999; Smith. 2007a). As Smith aptly explains:
Generic stereotypes of men are likely to exclude significant attributes and to include inaccurate attributes. It is paramount to recognise that men enact and embody a range of masculinities, sometimes simultaneously, which are fluid and situationally dependent. In turn, these influence the choices men make with respect to their health at both a personal and relational level. (Smith, 2007b, p. 23)
The film's public and critical appeal owes much to its third person perspective on the subject matter, not as a personalized or emotive drama documentary, but as a situational comedy centred on a community of young adult, male friends and how they, as a football club, do and do not change their way of relating to one of their members as he goes through the protracted and involving process of being diagnosed and living with MS. This is not a "feel good" movie; there is no personal triumph, no medical breakthrough, and no community action that somehow boosts this group of friends above the normal. The film is focused more on what these men are able to achieve within the limits of their particular working-class, "masculine" ideals. It is not concerned to openly challenge or show characters capable of revolutionizing or defeating these ideals (cf. Gerschick & Miller, 1995). but instead shows windows of agency with which these men seek to help and socially support a valued member of their group who undergoes the challenges to identity and health associated with MS. As the viewing public, we are not asked to have sympathy with someone who has either lost a special talent due to illness, or is raised to a higher plane due to the actions of his friends. Instead, there is an unrelenting realism to this movie, represented both by the gradual physical and social "decline" in the main character's life. and in how his friends behave towards him. Through this lens we see the potential for "masculinity" to facilitate health-promoting (as well as health-defeating) behaviours. Go Now thus seeks to engage public concern for men's health without moralizing or enlisting pity.
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(1) These themes have been recently declared by A.K. White (2010) to be "the most relevant in understanding men's health problems" in the UK (p. 3).
(2) Smith and Bollen (2009) have noted that: "While it is unproductive to use simplistic definitions of hegemonic masculinity to suggest that 'men behave badly with respect to their health' it is equally dangerous to ignore the influence of gender, particularly with respect to men's health promotion and illness prevention" (p. 99).
(3) Admittedly, though, even post-diagnosis, Nick continues to drink regular beer when out with his mates in the pub.
(4) With respect to another chronic disease population, Hilton, Emslie, Hunt, Chapple, and Ziebland (2009) have observed a "diversity among men (and among women) in the way that they respond to and chose to communicate about a cancer diagnosis." In turn, they recommend that "[h]ealth professionals should be aware of this diversity and be wary of stereotypes about 'expressive' women and 'stoical' men" (pp. 752-753).
TIMOTHY MARK KRAHN, MA (CAND.) * and SIMON OUTRAM. PH.D. **
* Dalhousie University, Halifax, Nova Scotia, Canada.
** Victoria University, Melbourne, Australia.
The authors wish to thank Francoise Baylis. Jacqueline Shaw and the Novel Tech Ethics research team for critical feedback on earlier drafts of this paper. Research for this project has been funded by Canadian Institutes of Health Research, MOP 77670. "Therapeutic Hopes and Ethical Concerns: Clinical Research in the Neurosciences." and NNF 80045. "States of Mind: Emerging Issues in Neuroethics."
Correspondence concerning this article should be sent to Timothy Mark Krahn, Novel Tech Ethics, Faculty of Medicine, Dalhousie University, 1379 Seymour Street, Halifax. Nova Scotia, B3H 3M6. Canada. Email: firstname.lastname@example.org
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