Analyzing any bio-psycho-social paradigm is complex and requires a comprehensive, integrative approach. Parsing the health picture of individuals, as well as whole populations, is no exception. Considering masculinity as a factor may shed light on health status, especially since traditional ideas of ‘manhood’ work against health promotion and prevention, as revealed in studies worldwide. In fact, these studies show a direct association between traditional understandings of masculinity and risks, vulnerabilities and the construction of health. In the last decade, such observations have received a bit more attention from international agencies.

This column addresses what it means to be a man in Cuba today and the implications for men’s health—and furthermore, what changes might lead to improvements in the situation.

Globally, strides have been made in terms of research and intersectoral policies and practices incorporating a gender perspective. These provide deeper insight into the differing realities of men and women, the effects of inequality and what might be done about it. But gender as a category and its possible associated effects have yet to be fully realized, in part because thus far, it has suffered from a limited and general focus, as well as multicausal resistance to its effective application.

The problem is real and the data sobering: women’s life expectancy in the Americas is 5.8 years more than men and 1 in 5 men die before they turn 50. Furthermore, many male deaths are preventable, including those related to violence (7 men for every woman); accidents and suicide (3 times the rates of women); and unsafe sex contributing to HIV/AIDS prevalence (more than double that of women). Drug, alcohol and tobacco addiction are more prevalent among men and contribute to a larger share of male deaths: 719 per 100,000 men as compared to 615 per 100,000 women. Data also show that men are much less likely to access health services and follow doctor’s orders. Compounding the problem is the fact that health services designed for men are often short term, narrowly focused and absent from public policies.[¹1. Pan American Health Organization. Masculinidades y salud en la Región de las Américas. Washington, D.C.: Pan American Health Organization; 2019. 15 p. Spanish.]

Data confirm that male gender socialization is more deadly in Cuba as well. Excess mortality is the case for more than 90% of causes of death. Mortality for cirrhosis and other chronic liver diseases is 4 times that of women and intentionally inflicted injury (suicide) almost 4 times as well; men die 1.4, 1.2 and 1.1 times more often than women due to malignant tumors, heart disease and cerebrovascular disease respectively. Figures for influenza and pneumonia, accidents, and chronic lower respiratory disease are similar.

Morbidity data are just as sobering: incidence of gonorrhea among men is double that of women, tuberculosis three times, and HIV/AIDS five times. Years of potential life lost (YPLL) to main causes of death for men between ages 1 and 74 is almost double that of women.[²2. National Health Statistics and Medical Records Division (CU). Anuario Estadístico de Salud 2018 [Internet]. Havana: Ministry of Public Health (CU); 2019 [cited 2020 Jun 5]. 206 p. Available at: http://files.sld.cu/bvscuba/files/2019/04/Anuario-Electr%C3%B3nico-Espa%C3%B1ol-2018-ed-2019-compressed.pdf. Spanish.] This gender health gulf is particularly striking considering that the Cuban public health system has the world’s highest doctor-patient ratio (84.8 per 10,000 population), low infant mortality rate (4 per 1,000 live births; 28th globally) and high life expectancy (78 years, average for both sexes, 34th globally).[²2. National Health Statistics and Medical Records Division (CU). Anuario Estadístico de Salud 2018 [Internet]. Havana: Ministry of Public Health (CU); 2019 [cited 2020 Jun 5]. 206 p. Available at: http://files.sld.cu/bvscuba/files/2019/04/Anuario-Electr%C3%B3nico-Espa%C3%B1ol-2018-ed-2019-compressed.pdf. Spanish.]

I believe the problem of Cuban men and their health can be best framed by considering three elements: 1) the effects of hegemonic masculinity on men’s health; 2) social representation of masculinity; and 3) health system approaches to men’s health.

Hegemonic masculinity refers to traditional roles Cuban men learn and replicate, whose alienating attributes lead them to abdicate responsibility for their own health. We are taught that as providers, our bodies are instruments of labor, that working them to the bone is only natural, minimizing attention to our health. This message is reinforced by society through insufficient criticism to the contrary, resulting in harmful effects on our health and the health of others as well.

This model of masculinity in Cuba manifests itself in several ways, including: attraction to power and drive for leadership; violence; suppressing emotions; scant attention to basic necessities; relegating paternity to a secondary role; homo- and transphobia; misogyny; insufficient participation in household chores; role of “the provider”; promiscuity; self-esteem based on work success; work-related stress; addiction; poor nutrition; sedentary lifestyle; exposure to toxic substances; lack of life skills related to family/married life; and little awareness of necessary lifestyle changes.[³3. Rivero Pino R, Hernández de Armas Y. Lo masculino. ¿Nocivo para la salud? Rev Cubana Genética Comun. 2018;12(1). Spanish.] These manifestations are reinforced throughout our lives, typically first emerging in adolescence when we become irresponsible with our health, deny being sick, find it difficult to seek help (medical or otherwise) and if we do, we don’t follow through. We simply don’t care for our health.

In terms of social representations of masculinity, although Cuban society is known for its humanism, cooperative participation and equitable gender policies, it hasn’t been able to rid itself of negative influences on promotion of healthy lifestyles. These include: insufficient intersectoral policies, services and programs focusing on masculinity; unequal resource distribution which aggravate gender inequities among different social groups, including men; a binary gender construct, heteronormativity, and machismo which translate into violence, accidents, homicide, addiction and suicide; inadequate media coverage of problems particular to men, thereby depriving society of health-promoting images; educational institutions ignoring examples of new approaches to masculinity; statements and decisions by lawyers and judges that devalue paternity and sexual diversity; and limited social mechanisms for recognizing best masculine practices such as greater attention to Father’s Day and lauding healthy behavior among men.

How the Cuban health system approaches men’s health is similar to other countries meaning that health policies with a gender focus lack a relational approach—that is, they don’t sufficiently incorporate male or gender-diverse perspectives. While some institutions stand out in this regard including the National Sex Education Center (CENESEX) and the Center for Health Promotion (PROSALUD), their inroads have not been institutionalized, nor incorporated transversally throughout different layers of society. Progress is also slow to incorporate scientific findings about masculinity into university curricula and to implement male-specific health promotion and prevention actions by health institutions. Exerting stronger political will and sparking a transformative process within the health system would help address this, as would learning from civil society, which offers experiences around men’s health and wellbeing. Examples include the Men Against Violence Platform of the Oscar Arnulfo Romero Center and Masculinities of the Cuban Multidisciplinary Sexual Studies Society (SOCUMES).

The link between masculinity and health is almost non-existent in health research and medical training; men’s participation in health services is undervalued by health professionals, society-at-large and men themselves; and treatment directed specifically at men focuses principally on HIV/AIDS, violence and addiction. Health programs around sexual health and reproduction are largely directed at women and the national prostate cancer program hasn’t had the same impact as the cervical cancer program. Men’s mental health is also under-attended due to societal taboos and a lack of targeted services.

In conclusion, I make the following recommendations: 1) implement diagnoses and proposals based on epidemiological factors specific to men’s health, with an emphasis on those related to premature death and non-communicable diseases; 2) given the mortality/morbidity evidence, strengthen health policies, programs and services through a more intersectoral and relational gender approach that incorporates men’s health; 3) incorporate a more comprehensive focus on gender in all health professional curricula that includes men’s health and specific health care needs; and 4) incentivize primary health care actions that deconstruct belief systems related to hegemonic masculinity, underscoring the health costs and consequences of those beliefs. In this way, we can move towards solutions to better controlling mortality and morbidity among men, improve quality of health services delivery and contribute to better population and individual health.

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