"Men's bodies, men's selves": men's health self-help books and the promotion of health care.

This paper is a critical analysis of men's health self-help books, focusing on the health care strategies encouraged by this advice literature. It is argued that the genre of men's health self-help overwhelmingly emphasizes the role of the individual in achieving good health and well-being. In presenting this message, men's health self-help reproduces a neo-conservative ideological perspective about public health: good health is primarily an individual concern, and that good health outcomes are largely the product of individual behavior. It is suggested that this emphasis on individuality works best for the genre's target audience of middle-class men, but is of limited use for health-care strategies aimed at achieving better health outcomes for a broader male population.

Key Words: men's physical health, self-help books, health-care strategies, individualism

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Throughout the 20th century, there have been many popular Western health movements (Starker, 1989), which have made a difference to people's health outcomes. For example, in the 1950s, the founding of the La Leche League signaled a turn away from bottle-feeding back to breast-feeding of infants, and subsequently, new forms of women's empowerment in the face of male medical dominance. Beginning in the 1960s, complementary and alternative medicine gained increased public support, and practices such as naturopathy, homoeopathy, and acupuncture have become an accepted part of many people's health regimen.

Fueled in part by concerns about men's higher rates of morbidity and mortality compared to women, the men's health movement has flourished in recent years in Europe, the United States, and Australia. This movement manifests itself in many ways: conferences have been organized by stakeholders to analyze and discuss men's health issues, scholarly explanations have been offered to account for men's poor health outcomes, and dedicated men's health services have been established by health-care providers. At this point in time, it is not yet clear what impact the men's health movement has had on men's health outcomes, especially those men with the poorest health.

In his book Oracle at the Supermarket, Starker (1989) observes that popular health movements of any kind are always supported by self-help literature. The burgeoning concern with men's health is no different. A visit to the local bookstore or on-line bookseller reveals an ever-increasing range of self-help books that present a total program for improving a man's health (as opposed to books covering just one area, like diet). In the first instance, these books offer practical advice for men in the prevention, diagnosis, and treatment of male health issues like testicular cancer and erectile dysfunction. Other areas of "body maintenance" (Saltonstall, 1993) also come under consideration, from general health problems, to lifestyle issues, fitness programs, and even personal grooming. These books share similarities with popular magazines like Men's Health and Men's Fitness, both of which dispense accessible health and lifestyle advice to the mass market. Unlike the magazines, however, men's health self-help books offer the consumer an all-in-one guidebook covering the major areas of men's health and thus ought to be viewed as a kind of do-it-yourself "comprehensive health promotion package" (Sabo, 2000, p. 134).

As a do-it-yourself form of health care, men's health self-help books are an intermediary between the individual and the wider health-care system. It is important, therefore, to understand the messages the reader receives about his health. In this paper, I analyze several men's health self-help books to determine the type of health care these advice books advocate and how this advice is positioned in relation to competing ideologies about health promotion and health care.

I argue that the reader is educated to see that he, the individual, is primarily responsible for his own health, and that good health outcomes are largely the product of individual behavior. In presenting this message about individualization, men's health self-help reproduces a neo-conservative ideological view about public health. (1) That is, good health is primarily an individual concern, rather than a problem for state or government agencies (the implication being that the cost of care should be borne by the consumer rather than the state). Rimke (2000), in her account of psychological self-help literature, suggests that self-help is a medium "which exalts the individual over the social ... [and] is elaborately consistent with the [neo-liberal] political rationalities promoted in advanced liberal democracies" (p. 62). In like manner, men's health self-help, it is argued, is both an instigator and a product of a neo-liberal or neo-conservative view of public health. I conclude the paper with a comment on the role these books might play in a broader movement aimed at improving men's health.

The aim of this paper is not to criticize the utility of men's health self-help books in enabling men to lead healthier lives; rather, it is to question the broader health-care ideology that these books can be interpreted as promoting and, arguably, how this is of limited value in improving men's health across the board. As Western governments continue to favor a free market health system funded by individual consumers, it is important to understand how associated and often inequitable healthcare ideologies are sustained. This paper is part of the evolving "sociology of health promotion" (Bunton et al., 1995), which involves a "critical analysis of the underlying assumptions inherent in health promotion" (Nettleton & Bunton, 1995, p. 42).

To begin, I outline the methodology used to analyze the books and discuss the generic features of these texts. From there, I examine the ways men's health self-help books frame their discussion of heart disease and testicular cancer. In this analysis, I demonstrate how the ideology of individualism is central to the men's health self-help approach.

METHODS

Typically, self-help books discuss personal problems, posit a solution or solutions, and encourage the reader to engage in self-changing behaviors (Simonds, 1996; Starker, 1989). There is an abundance of self-help books for men that are devoted in some way to aspects of health, lifestyle, and well-being. Topics covered include "good sex," psychological well-being, body-building, grooming, and diet. In this paper, I am particularly interested in books that present a total program of men's health. These are pitched at the lay audience, are primarily concerned with men's physical health, and cover more than one men's health issue. Furthermore, I was interested in books written by American authors, as most of the books in this area emerge from the United States. Self-help is extremely popular in the United States; Americans spent $563 million on self-help books in 2000 (Paul, 2001).

In order to find self-help titles of this kind, I accessed the on-line bookstore Amazon.com and conducted a search using the key words "men's health." I found six titles that satisfied the criteria outlined above. These are (authors in parentheses): the Complete Guide to Men's Health (American Medical Association, 2001), The Complete Book of Men's Health (Editors of Men's Health, 1999), How Men Can Live as Long as Women: Seven Steps to a Longer and Better Life (Goldberg, 1993), Men's Health for Dummies (Inlander & The People's Medical Society, 1999), It's in the Male: Everyone's Guide to Men's Health (Pryor & Glass, 2000), and The Male Body: An Owner's Manual (Caine et al., 1996). All six were purchased for this research.

Every book except one contains the phrase "men's health" in the title. The exception--The Male Body: An Owner's Manual--asserts on the back cover that its authors have "put together the most comprehensive guide possible for taking control of a man's health and well-being." All are targeted at a non-health professional audience (unlike some professional source books on men's health, such as Cook's [1998] Men's Health Concerns Sourcebook) and carry disclaimers warning that the books are not suitable substitutes for professional advice. Obviously, the six titles are indicative of the genre and do not constitute all the available books of this type (although a visit to my campus library did not reveal any others). What follows is an indicative analysis of men's health self-help, rather than a comprehensive review.

For the purposes of analysis, each book was read in its entirety. Notes were taken about the key themes, the presentation of material, and the author/s' approach to explaining a medical issue. The books were then compared on each of these criteria in order to identify common patterns. In conducting this review, it became apparent that the philosophy of individualism favored in self-help generally is central to the genre of men's health self-help (Rimke, 2000).

One further point about terminology ought to be added. In this paper, I make extensive use of the concept of "ideology." As the term is used in contemporary literary and social theory, ideologies are the various, usually competing, bodies of knowledge or sets of values "which human beings [and social groups] perceive, and by recourse to which they explain, what they take to be reality" (Abrams, 1993, p. 241). Importantly, all cultural texts are infused with ideologies; as Buchbinder (1998) argues, the "products of culture, whether in the form of works of art or of social institutions [in this case self-help books] ... are produced within and by ideology. Indeed, their task, is to articulate the culture's ideology to us and to affirm its validity" (p. 4). The ensuing analysis considers the various ideological perspectives privileged in the pages of men's health self-help.

GOOD HEALTH FOR MEN? READING MEN'S HEALTH SELF-HELP

THE GENERIC FEATURES OF MEN'S HEALTH SELF-HELP

Prior to examining the type of health care promoted in men's health self-help literature, it is valuable to discuss the salient features of this genre and its key themes. I also highlight differences and similarities between these and other health oriented self-help books.

The books analyzed in this article are more than just source books that men can dip into when they feel sick, much like the traditional family medical encyclopedia. They possess both a writing style and a narrative structure that calls for ordered reading in some measure. For example, each of the six books I examined feature some variation of the same plot structure: taking the reader on a journey towards achieving "good health," and indeed, a "good life." Five of the six books discuss broad lifestyle issues central to achieving "good health" in the first few chapters or sections. This includes advice about diet and nutrition, stress reduction, health insurance, choosing an appropriate doctor, and emotional well-being (including some relationship advice). In these early sections, the books exhort the reader to engage in lifestyle practices that will produce superior health outcomes, typically understood to be a longer life expectancy and reduced risk of morbidity. From there, the focus shifts to a review of common "male" health concerns, or issues in which men have poorer health outcomes compared to women. Areas of discussion include sexual problems (both psychological and physiological), heart and lung disease, and muscular injuries. The one book that omits the review of lifestyle issues in the first few chapters, It's in the Male: Everyone's Guide to Men's Health (Pryor & Glass, 2000), proceeds directly to discussion about men's sexual and reproductive health issues. It concludes, however, with an account of the lifestyle factors which need to be managed in order to achieve "good health."

The contents and concerns of men's health self-help reflect several broader social trends that have transformed contemporary understandings of both the self and health. The first of these is the primacy accorded to the self in late modernity. Giddens (1991) argues that contemporary society is characterized by reflexivity and that the "self is seen as a reflexive project, for which the individual is responsible.... We are, not what we are, but what we make of ourselves" (p. 75). Doing something to address one's situation or circumstances is deeply enmeshed in Western culture. Men's health self-help, which places great emphasis on health as a "personal project," fits well with contemporary concerns about the development of the self (cf. Rimke, 2000), in this case, the healthy self. In addition to concerns with the self and individualization (Giddens, 1991), cultural critics have suggested that contemporary society is increasingly characterized by concerns about "risk" (Beck, 1992; Peterson, 1997). According to Green (1995), contemporary health promotion is crucially concerned with the management of risk. Examples include warnings on cigarette packs, billboards extolling the virtues of applying sunscreen, and health insurance companies encouraging members to join gyms. The topics featured in men's health self-help--advice about health insurance, choosing a doctor, diet and nutrition--are centrally concerned with risk management and risk reduction.

There is widespread recognition that in comparison to women, men are less likely to take advantage of health care services and less likely to undertake self-care practices (Courtenay, 2000b; Luck et al., 2000; Pease, 2002; Ziguras, 1998). This pattern is often explained by the belief that men are socialized to be stoic and brave, thus ignoring signs of ill health (Pease, 2002). Looking after oneself, however, is the precise raison d'etre of men's health self-help. Given this, it is interesting to observe that the books frame, to varying degrees, their discussion of health matters using language that is typically culturally associated with men: matter-of-fact, jocular, and "folksy." The authors appear to accept the idea that men need to be talked to on "men's terms," otherwise the good health message will not be taken seriously. The discussion of erectile dysfunction (ED) and other penis-related problems are a case in point.

For instance, one "masculinizing" strategy used by the books to discuss ED, and the penis generally, is to refer to it as if it were a "machine," or has mechanical workings and functions. (2) How Men Can Live as Long as Women (Goldberg, 1993) has the following text that accompanies a picture of an air compressor:

   You can think of the process of getting an erection as the
   equivalent of filling a tire with an air compressor. (Figure 1) The
   main difference is that the penis fills with blood rather than air.
   To get the job done, you need a good control switch (brain),
   well-insulated wires (nerves), a strong compressor (the heart), an
   adequate supply line (arteries), and a tire (the penis) without
   leaks (veins).... If any of these components are defective, you've
   got a flat tire. (Figure 2) (pp. 142-143)

Men's Health for Dummies (Inlander & The People's Medical Society, 1999) offers a similar understanding in a box with the words "How your body builds an erection":

   You know how an erection feels, but do you know the mechanics
   of an erection? Technically speaking, an erection must complete
   two tasks. Blood must flow like a river into three spongy cavern
   like areas, which suck up the blood to expand. (p. 349)

The Male Body: An Owner's Manual (Caine et al., 1996), also favors the "mechanical approach." A section on the penis, entitled "Mechanical wonder," features phrases like "the bladder's drainpipe," "the launch is aborted," "clamps off the drains," and concludes with the sentence: "[t]hat's how the machine works. There's a lot you can do to keep it working."

To conceive of the body as a "machine" or "mechanical" is not new in Western thought (Jackson et al., 2001; Saltonstall, 1993; Watson, 2000). However, in the pages of men's health self-help, language such as this is of some consolation to the male reader experiencing ED, who may find himself "emasculated" by the fact his penis does not function in a way that he expects. A non-functioning penis is simply treated like any mechanical apparatus that needs repair. In Western culture, men are traditionally and culturally the ones who engage in repair activity, from handy work around the house to fixing the family car. The reader who suffers from ED opens the pages of men's health self-help and is immediately positioned within the context of a "man's world." The solutions to ED also emphasize practicality: how the patient's problem will be measured and assessed, the various treatments that are available, their pros and cons, as well as the cost. This discussion is handled in a matter-of-fact fashion. A visit to the doctor is analogous to a visit to the mechanic (cf. Jackson et al., 2001).

Men's health self-help books that deal with one topic, such as ED, impotence, or prostate cancer also rely on plain language and gendered assumptions in order to communicate their message. For example, in his book Prostate Cancer, Goldenberg (1992) employs a "mechanical" register to describe how a penile implant works:

   By simply squeezing the pump in the scrotum, fluid is transferred
   from the reservoir into the cylinders to create an erection. When a
   release valve on the pump is pressed the fluid returns to the
   reservoir and the penis becomes soft again. (p. 131)

Problem-specific texts are likely to be purchased and used as an adjunct to treatment for an existing, perhaps acute, medical condition. In contrast, general men's health self-help of the kind discussed in this paper places greater emphasis on prevention and lifestyle rather than in demystifying specific treatment programs.

While men's health self-help constructs and addresses men as a collective with their own unique problems, the genre of men's health self-help does not appear, upon examination, as explicitly political as some of the early publications that emerged from the post 1960s women's health movement, including the influential Boston Women's Health Book Collective's Our Bodies Ourselves (1971). Absent in the pages of men's health self-help are political statements or an explicit critique of medical power. This perhaps reflects the differences in the women's and men's health movements; the former is very much the product of a political movement (second-wave feminism), whereas the origins of the men's health movement are far more diffuse (variously the product of consumerism, media discourse, concern from the medical profession, and scholarly advocacy).

One further point about the target audience ought to be added at this point. Self-help is generally targeted at middle class audiences. Men's health self-help is no different. The books assume fairly high levels of literacy, lifestyle preferences, and income. In a chapter from How men can live as long as women titled, "Drafting Dr. Right," Goldberg (1993) tells his readers: "Options always exist. If the treatment you're getting isn't working, it's time to try another" (p. 43).

While this is an important statement, it is advice that works best for a man with adequate medical insurance, the ability to articulate his concerns to his doctor, and a certain level of mobility. It is not necessarily advice that can be acted upon by other groups of men, especially those in lower socio-economic groups. According to the U.S. Department of Health and Human Services [DHHS] (1998, p. 7), in "1994-95 poor men were six to seven times as likely to be uninsured as high-income men, depending on race and ethnicity."

As the foregoing discussion of the generic features of these books demonstrates, men's health self-help offers the male reader a comprehensive and accessible guide to reducing the risk of morbidity, improving one's day-to-day health and lifestyle, and understanding specific men's health problems. While not political in the manner of many women's health self-help books, this genre employs a style and tone to which the male middle class might readily relate. Importantly, the main objective of each men's health book is to take the reader on a journey that teaches him that he may develop health problems, helps him to understand in some way the reasons behind these problems, and encourages him to take personal, self-generated action in order to achieve a good outcome (cf. Rimke, 2000; Simonds, 1996). In emphasizing the primacy of the individual in health management, men's health self-help conflates with a neo-conservative ideological perspective about health care: good health is largely an individual's responsibility.

THE INDIVIDUAL'S RESPONSIBILITY IN ACHIEVING GOOD HEALTH

In this section, I demonstrate the techniques and strategies through which "individual responsibility" (Watson, 2000) is promoted in the pages of men's health self-help, with particular reference to the genre's account of testicular cancer and coronary heart disease. This discussion demonstrates the importance these books place on the individual in achieving good health outcomes. To situate these arguments, however, it is first necessary to outline competing perspectives on health care and health promotion.

Advice, information, and actual screening for cancer and heart disease are all forms of health promotion. In Western nations, there are competing ideological perspectives on how health promotion should be effected. The "traditional approach," founded on a conventional biomedical model (Watson, 2000), emphasizes the importance of the individual in living active, healthy lifestyles in order to minimize the incidence of morbidity or early mortality. From this perspective, health care strategies ought to be directed at the individual, with emphasis on the individual changing his (or her) behavior (Watson, 2000, p. 126). Critics of this approach to health policy assert that an over-emphasis on individual responsibility fails to recognize the broader structural factors which might influence "good health" outcomes, such as class, wealth, gender, and race (Davison & Smith, 1995; Nettleton & Bunton, 1995; Watson, 2000; Ziguras, 1998).

From a men's health perspective, the assertion that good health is not simply the product of individual choice is borne out by the fact that less wealthy men, less educated men, and men of color have some of the poorest health outcomes in Western nations, with a lower life expectancy and higher mortality rates from many diseases. For example, according to the U.S. DHHS (1998, p. 6), "Men with family incomes less than $10,000 were more than twice as likely to die of lung cancer as those earning at least $25,000." Furthermore, in 1996 the life expectancy for white males at birth is 73.9 years, compared to 66.1 years for black males (DHHS, 1998, p. 200).

A popular alternative to the traditional, individually focused model of health care policy is the "New Public Health" (Luck et al., 2000; Petersen & Lupton, 1996; Schofield, 2000). According to Petersen and Lupton (1996), the "new public health takes as its foci the categories of 'population,' and 'the environment,' conceived of in their widest sense to include psychological, social and physical elements" (p. ix). Health promotion ought to focus not just on personal responsibility, but also in making changes to "social, economic and ecological environments" (Burrows et al., 1995, p. 2).

In 1992, both the U.S. and British governments released health care policy statements that emphasized the primacy of individuals in taking responsibility for good health, rather than governments first addressing the broader social, economic, and environmental factors that influence health outcomes (Howell & Ingham, 2001; Luck et al., 2000; Watson, 2000). As Watson (2000, p. 18) observes, policy statements like these "coincided with global concerns about containing the escalating cost of health care." In like manner, Howell and Ingham (2001, p. 331) note that from a U.S. government perspective, "[s]elf-help was preferable to government handouts and entitlements.' Health promotion that emphasizes individual responsibility reinforces "neo-conservative laissez faire ideologies" (Howell & Ingham, 2001) about who should bear the responsibility for health care. From a neo-conservative point of view, health care should be a private, and thus by logical inference, a self-funded, affair (Peterson, 1997; Watson, 2000). (3) As I demonstrate in the ensuing discussion of cancer and heart disease, men's health is both a product and instigator of this ideology (cf. Rimke, 2000). In making such claims, I am not arguing that it is the authors' intention to produce particular ideological messages. They may merely reflect a prevailing ideology about health care.

Men suffer two cancers unique to them: testicular cancer and prostate cancer. Men in their teens through their late thirties are particularly at risk of developing testicular cancer. One way to prevent mortality from testicular cancer is early diagnosis, which is best achieved through screening, either performed by a health professional or the individual. Men, however, are not always successful in achieving early intervention. Indeed, it is axiomatic in the scholarly literature on men's health to observe that "men engage in fewer health-promoting behaviors" (Davies et al., 2000, p. 259), especially when it comes to this type of cancer. These behaviors include men visiting the doctor when they discover something unusual or taking the time to engage in self-screening for cancer. Among the explanations offered for why this is the case is the popular view in scholarly discussions of men's health that "looking after oneself" is a transgression of prevailing masculine codes of behavior (Courtenay, 2000a; Pease, 2002; Sabo, 2000; Sabo & Gordon, 1995).

All six books examined for this paper have sections on testicular cancer. To begin, readers are informed about the prevalence, etiology, risk factors, treatment, and chances of survival. These accounts invariably use direct, non-technical, even "folksy" language: "When cancer is diagnosed, the testicle is usually removed. 'If you lose one, you can still get along pretty well with the other,' says Dr. Nadig" (Caine et al., 1996, p. 325).

The most notable aspect of the discussion about testicular cancer, however, is the primacy placed on the individual taking personal responsibility for early detection, in this case, in the form of self-screening. The Male Body: An Owner's Manual (Caine et al., 1996), for example, instructs the reader that:

   Cure ... depends on early detection. And that's where you come in.
   It's your job to detect testicular cancer. "I don't think I've ever
   discovered a testicular cancer that the patient didn't know about,"
   says Dr. Gleich. (p. 325)

In like manner, How Men Can Live as Long as Women (Goldberg, 1993) notes:

   [The] testicular self-exam is unquestionably the most vital for guys
   under forty. Simply put, you don't see the doctor often enough for
   him to have a decent chance of catching testicular cancer before
   it's too late. It's your responsibility to find it and save your own
   life. (p. 11)

There is little doubt that self-screening is a very useful tool in reducing men's risk of mortality from this type of cancer. The abiding expectation that the individual is accountable for early intervention, however, has the effect of moving responsibility or the onus of responsibility (in terms of costs and labor) away from medical providers and, thus, governments and health organizations. In this sense, exhortations for the individual to be solely responsible "privatizes health" (Watson, 2000).

As is to be expected with self-help literature, the reader is not just told what to do (i.e. self-screen), but also how to do it. All except one book has a picture that depicts how a testicular self-examination is undertaken (the book without the picture does have a similar one captioned "Inside the testicles"). In each case, the picture is accompanied by text explaining the procedure. Again, the language is in the everyday vernacular rather than being excessively medical. For example, The Complete Book of Men's Health (Editors of Men's Health, 1999) says:

   [After a shower or bath] Stand in front of the mirror if one's
   available. Examine each testicle with both hands, rolling it gently
   between your thumbs and finger. Look for any lumps, swelling or
   hardening--anything that seems unusual. Don't panic if you find
   something--not all such changes are cancerous--but do have it
   checked out by a doctor. (p. 247)

The reader is told in accessible language about of the value of self-screening. In addition, he is also equipped with information necessary for the practical achievement of early detection. This is crucial in producing personal responsibility: the gap between the motivation "look after one's self" and the capacity to undertake action is greatly reduced if the reader understands the how of self-screening.

Testicular cancer is a disease unique to men. Coronary heart disease (CHD) is not exclusively a man's problem; however, men are more likely to die as a result of the disease, although the rates do vary from country to country (Courtenay, 2000b; Schofield, 2000; Weidner, 2000). Weidner (2000, p. 291) notes that the female-to-male ratio of death from CHD is one-to-10 in Iceland and six-to-10 in Beijing, China. As is to be expected, information about CHD features prominently in the pages of men's health self-help. Like the previous example of testicular cancer, the discussions about CHD overwhelmingly emphasize the reader's responsibility in minimizing the risk of this disease. In a section titled "Preventing high blood pressure," the reader of the Complete guide to men's health (American Medical Association, 2001) is told: "Anyone, regardless of age, sex, race, or heredity, can lower his or her risk of developing high blood pressure or lower existing blood pressure by taking the steps described here" (p. 219).

These steps are then outlined in great detail: "maintain a healthy weight," "exercise regularly," "choose foods that are lower in salt." For example: "To take in fewer calories, you need to limit your portion sizes. Try especially to take smaller helpings of high-calorie foods such as fatty meats and cheeses. And try not to go back for seconds" (p. 220).

A similar message is put forward by Men's Health for Dummies (Inlander & The People's Medical Society, 1999). It has a section "Using self-care and prevention" to deal with high blood pressure, informing the reader in an unequivocal manner: "Reduce personal stress and anger. As a man, you're especially prone to high blood pressure levels. Lose excess weight. Obesity and high blood pressure go hand-in-hand" (p. 248).

The implication of such statements is clear: if risk is not individually monitored, then it is a man's own fault if he develops CHD. The impression that these books individualize risk is confirmed by the fact that the reader is not alerted to the role factors such as class, race, and occupation play in determining individual lifestyle choices (Watson, 2000, p. 20). Poor diet is as much a product of social class as it is individual choice. Along with the emphasis on individual risk monitoring, the lack of discussion on how structural matters impinge on individual choice-making has the effect of privatizing health responsibility, not just in relation to CHD, but health in general. The abiding message to the reader is that if the individual has both the power and the wherewithal to fix his own problems, then responsibility for all health matters can and ought to be borne by the consumer, rather than by the state.

By its very nature, self-help literature of any kind exhorts individuals to take ownership of their problems and champions both self-modification and self-improvement (Rimke, 2000, p. 62). This is certainly the case in men's health self-help: not simply in accounts of testicular cancer or CHD, but in all aspects of a man's well-being. For this reason, men's health self-help literature can be interpreted as both a product and an instigator of conservative health ideologies that position the individual as primarily responsible for good health outcomes. This impression of the function of men's health self-help is further substantiated by an absence of discussion about how broader structural issues--like class and race--impact on individual health outcomes (cf. Daykin & Naidoo, 1995). In making such assertions, I am subscribing to a critical-structuralist view of health promotion, which argues that any "genuine attempt to promote health must tackle the political economy that produces ill health in the first place; matters such as poverty, bad housing conditions, homelessness, poor working environments and industrial pollution" (Nettleton & Bunton, 1995, p. 44; see also Davison & Smith, 1995).

Significantly, the value of individual responsibility for health is not presented to the reader on the basis that it works well with a free market, neo-conservative approach to health care. Instead, men's health self-help emphasizes how taking individual responsibility will result in the achievement of the "good life."

"GOOD HEALTH" IS THE "GOOD LIFE": PROMOTING INDIVIDUAL RESPONSIBILITY TO THE READER

In the previous section, I examined the way men's health self-help framed the concept of responsibility with respect to testicular cancer and CHD: the individual is given primacy for the maintenance of well-being. In this section, I examine the presentation of lifestyle issues to demonstrate how individual responsibility is presented to the reader. This is done through the creating of a link between the value of practicing "good health" and the "good life" (Howell & Ingham, 2001; Jackson et al., 2001).

Typical of most contemporary approaches to health promotion, issues of lifestyle are very important in the pages of men's health self-help. The reader is clearly warned of the link between excessive, or "risky" lifestyle practices--overworking, excessive drinking--and poor health outcomes. For example, in Men's Health for Dummies (Inlander & The People's Medical Society, 1999), the reader learns the following about smoking:

   Although smoking makes you feel great, you're enjoying that feeling
   at great cost to your health. One dreadful cost may be lung
   cancer.... Smoking clogs your arteries.... Smoking also thickens
   your blood and increases the risk of blood clots, which can result
   in a stroke. (p. 69)

Diet is also targeted. The Complete Guide to Men's Health (American Medical Association, 2001) suggests:

   [M]ost people in developed countries consume too much fat,
   which leads to the development of heart disease, some types of
   cancer, and other chronic diseases. This explains why the Dietary
   Guidelines for Americans ... advises deriving no more than 30
   percent of your total calorie intake from fat. (p. 47)

As indicated in an earlier section, this emphasis on risk has become heightened in late modern society and now characterizes many contemporary approaches to health care.

If one is to engage in risk management good health practices, such as a good lifestyle, then there must be a strong motivating factor. The various reasons why official health policies, like those advocated by governments in the 1990s, overwhelmingly emphasize personal responsibility is not necessarily palatable or even recognized in the production and consumption of men's health self-help. Instead, the motivation to engage in good lifestyle practices is framed "as a passport to the good life" (Jackson et al., 2001, p. 91).

Good health practices are tacitly linked to the maintenance and development of a "good life," which involves not just longevity and absence of disease, but pleasure, prosperity, and even bodily enjoyment. To be sure, the "good life" is not described to the reader in a coherent and sustained way, but is manifested in particular moments. How Men Can Live as Long as Women (Goldberg, 1993) observes:

   Living longer is a fine goal, but you might have noticed that the
   title of this book includes the word "better." Isn't that our real
   goal--to live not just more years, but better years ... you should
   be enjoying yourself. (pp. 137-138)

Often, moderation in consumption is linked with bodily enjoyment, not simply reducing the chances of morbidity. It's in the Male: Everyone's Guide to Men's Health (Pryor & Glass, 2000) tells the reader:

   Smoking can also make it more difficult to get it up. If he cannot
   conceive and cannot have intercourse, well, can he at least smoke
   and kiss? No. Smoking and chewing tobacco can cause throat cancer,
   which could result in the removal of half a man's face just to
   save his life. That would definitely hurt kissing. (p. 132)

The message to readers is clear: individual responsibility is associated with the measurable, material benefits of pleasure and prosperity. Concomitantly, the ideological position promulgated by men's health self-help is obscured.

As I indicated earlier, in making such claims I am not arguing that it was the authors' explicit intention to produce the ideological messages described above. Rather, these books reflect the prevailing cultural conditions within which they were produced. The logic of privatized health dominates the U.S. medical system; all of the books discussed in this paper originate there. Furthermore, the emphasis on the "good life" is typical of a "high-modern" or "post-modern" shift toward pleasure and prosperity. Most contemporary social theorists agree that contemporary Western society, having moved beyond the early capitalism of the industrializing era that required productive bodies to labor in factories, is now a consumer society that places great emphasis on spending the results of labor (Jackson et al., 2001; Jameson, 1991; Lury, 1996; Miles, 1998).

CONCLUSION

In this paper, I have argued that men's health self-help overwhelmingly emphasizes the individual's responsibility for his own health and well-being. Such analysis allowed me to make an argument about the type of health consumer encouraged by the reading of such advice books.

Based on the foregoing review, the ideal consumer envisioned in the pages of men's health self-help is a man who takes active individual responsibility for his health, engages in various forms of self-care and is motivated to do so in pursuit of the "good life." The imperative to act as an "ideal health consumer" is strong. The reader is repeatedly warned of the dangers of a poor lifestyle and reminded of the rewards that accrue from looking after oneself. The "ideal consumer," engaging in personal responsibility, is acting in a way favored by those who champion a free market, laissez faire approach to health care. From this perspective, an ideal health system is one in which responsibility for, and cost of, health care is placed on the individual rather than carried by the state (Peterson, 1997, cited in Watson, 2000, p. 141). Men's health self-help is both an instigator and a product of this ideology.

To conclude, it is appropriate to offer comment on the role these books might play in a broader movement aimed at improving men's health. As noted above, men are often less likely to engage in good health practices or self-examinations. Men's health self-help can usefully play a role in enabling men to take steps in achieving good health, or in demysticizing aspects of treatment. Furthermore, the greater self-knowledge derived from these books might also be empowering, allowing a patient to arrive at his doctor's office much better prepared (Coddington et al., 2001, p. 3) or to subvert a doctor's authority in a clinical setting, especially if the doctor's prognosis does not accord with the patient's own self-assessment. This was certainly the case with the self-help books associated with the women's health movement.

However, the highly individual health care strategy outlined in the pages of men's health self-help is one that, unsurprisingly, is most readily achievable by the middle class target audience of these books. These men are literate and possess the necessary wherewithal, resources, and time to engage in individually driven self-improvement and self-monitoring programs, especially for the sake of "pleasure and prosperity." Making this group healthier, however, will not improve the health of more disadvantaged men, who, as noted earlier, experience poorer health outcomes. Moreover, highly individual programs for improving men's health do not "acknowledge the circumstances of men marginalized by class, race and sexuality and address the discrimination they face in meeting their health-care needs" (Pease, 2002, pp.117-118). Therefore, men's health self-help has a limited utility in any health care promotion strategy aimed at achieving better health outcomes for the broader male population.

The author would like to thank the three anonymous referees and the editor for their very helpful comments on earlier drafts of this article.

NOTES

(1.) My thinking on this point is informed by Rimke (2000) and Watson (2000).

(2.) My thinking on this point is indebted to Jackson et al. (2001).

(3.) To be sure, Western government health policies do not just emphasize individual responsibility. This is simply a feature of some policy statements.

REFERENCES

Abrams, M.H. (1993). A glossary of literary terms. Forth Worth, TX: Harcourt.

American Medical Association. (2001). Complete guide to men's health. New York: John Wiley & Sons.

Beck, U. (1992). Risk society: Towards a new modernity. London: Sage.

Boston Women's Health Book Collective. (1971). Our bodies, ourselves. New York: Simon & Schuster.

Buchbinder, D. (1998). Performance anxieties: Re-producing masculinity. Sydney: Allen & Unwin.

Burrows, R., Nettleton S., & Bunton, R. (1995). Sociology and health promotion: Health, risk and consumption under later modernism. In R. Bunton, S. Nettleton, & R. Burrows (Eds.), The sociology of health promotion (pp. 1-12). London: Routledge.

Bunton, R., Nettleton, S., & Burrows, R. (Eds.). (1995). The sociology of health promotion. London: Routledge.

Caine, K.W., Garfinkel, P., & the Editor's of Men's Health. (1996). The male body: An owner's manual. Emmaus, PA: Rodale.

Coddington, D.C., Fischer, E.A., & Moore, K.D. (2001). Strategies for a new health care marketplace: Managing the convergence of consumerism and technology. San Francisco: Jossey-Bass.

Cook, A.R. (Ed.). (1998). Men's health concerns sourcebook. Detroit, MI: Omnigraphics.

Courtenay, W.H. (2000a). Constructions of masculinity and their influence on men's well-being: A theory of gender and health. Social Science & Medicine, 50, 1385-1401.

Courtenay, W.H. (2000b). Behavioral factors associated with disease, injury and death among men: Evidence and implications for prevention. The Journal of Men's Studies, 9, 81-142.

Davies, J., McCrae, B.P., Frank, J., Dochnahl, A., Pickering, T., Harrison, B., et al. (2000). Identifying male college students' perceived health needs, barriers to seeking help, and recommendations to help men adopt healthier lifestyles. Journal of American College Health, 48, 259-267.

Davison, C., & Smith, G.D. (1995). The baby and the bath water: Examining socio-cultural and free-market critiques of health promotion. In R. Bunton, S. Nettleton, & R. Burrows (Eds.), The sociology of health promotion (pp. 91-99). London: Routledge.

Daykin, N., & Naidoo, J. (1995) Feminist critiques of health promotion. In R. Bunton, S. Nettleton, & R. Burrows (Eds.), The sociology of health promotion (pp. 59-69). London: Routledge.

Department of Health and Human Services. (1998). Health, United States, 1998: Socioeconomic status and health chartbook (DHHS Publication No. [PHS] 98-1232-1). Hyattsville, MD: National Center for Health Statistics.

Editors of Men's Health. (1999). The complete book of men's health. London: Octopus.

Giddens, A. (1991). Modernity and self-identity: Self and society in the late modern age. Oxford: Polity Press.

Green, J. (1995). Accidents and the risk society: Some problems with prevention. In R. Bunton, S. Nettleton, & R. Burrows (Eds.), The sociology of health promotion (pp. 116-144). London: Routledge.

Goldberg, K. (1993). How men can live as long as women: Seven steps to a longer and better life. Fort Worth, TX: The Summit Group.

Goldenberg, S.L. (1992). The intelligent patient's guide to prostate cancer: All you need to know to take an active part in your treatment. Vancouver: Intelligent Patient Guide.

Howell, J., & Ingham, A. (2001). From social problem to personal issue: The language of lifestyle. Cultural Studies, 15, 326-351.

Inlander, C., & The People's Medical Society. (1999). Men's health for dummies. Foster City, CA: IDG Books.

Jackson, M., Stevenson, N., & Brooks, K. (2001). Making sense of men's magazines. Oxford: Polity Press.

Jameson, F. (1991). Postmodernism or the cultural logic of late capitalism. London: Verso.

Lichterman, P. (1992). Self-help reading as a thin culture. Media, Culture and Society, 14, 421-447.

Luck, M., Bamford, M., & Williamson, P. (2000). Men's health: Perspectives, diversity and paradox. Oxford: Blackwell Science.

Lury, C. (1996). Consumer culture. Cambridge: Polity Press.

Miles, S. (1998). Consumerism as a way of life. London: Sage.

Nettleton, S., & Bunton, R. (1995). Sociological critiques of health promotion. In R. Bunton, S. Nettleton, & R. Burrows (Eds.), The sociology of health promotion (pp. 41-58). London: Routledge.

Paul, A.N. (2001). Self-help: Shattering the myths. Psychology Today, 34, 60-68.

Pease, B. (2002). Men and gender relations. Melbourne: Tertiary Press.

Peterson, A. (1997). Risk, governance and the new public health. In A. Peterson & R. Bunton (Eds.), Foucault, health and medicine (pp. 189-206). London: Routledge.

Peterson, A., & Lupton, D. (1996). The new public health: Health and self in the age of risk. Sydney: Allen & Unwin.

Pryor, J.L., & Glass, R.N. (2000). It's in the male: Everyone's guide to men's health. Minneapolis, MN: Appladay Press.

Rimke, H.M. (2000). Governing citizens through self-help literature. Cultural Studies, 14, 61-78.

Sabo, D. (2000). Men's health studies: Origins and trends. Journal of American College Health, 49, 133-142.

Sabo, D., & Gordon, D.F. (1995). Rethinking men's health and illness. In D. Sabo & D.F. Gordon (Eds.), Men's health and illness: Gender, power, and the body (pp. 1-21). Thousand Oaks, CA: Sage.

Saltonstall, R. (1993). Healthy bodies, social bodies: Men's and women's concepts and practices of health in everyday life. Social Science & Medicine, 36, 7-14.

Schofield, T., Connell, R.W., Walker, L., Wood, J.F., & Butland, M. (2000). Understanding men's health and illness: A gender-relations approach to policy, research, and practice. Journal of American College Health, 48, 247-256.

Simonds, W. (1992). Women and self-help culture. New Brunswick, NJ: Rutgers University Press.

Simonds, W. (1996). All consuming selves: Self-help literature and women's identities. In D. Grodin (Ed.), Constructing the self in a mediated world (pp. 15-29). Thousand Oaks, CA: Sage.

Starker, S. (1989). Oracle at the supermarket. New Brunswick, NJ: Transaction Publishers.

Watson, J. (2000). Male bodies: Health, culture, and identity. Buckingham: Open University Press.

Weidner, G. (2000). Why do men get more heart disease than women? An international perspective. Journal of American College Health, 48, 291-294.

Ziguras, C. (1998). Masculinity and self-care. In T. Laws (Ed.), Promoting men's health: An essential book for nurses (pp. 44-59). Melbourne: Ausmed Publications.

Correspondence concerning this article should be addressed to Andrew Singleton, School of Political and Social Inquiry, P.O. Box 11A, Monash University, Victoria 3800, Australia. Electronic mail: Andrew. [e-mail].

ANDREW SINGLETON

Monash University

Melbourne, Australia