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Constructions of marginalised masculinities among young men who die through opiate use.

To date there has been limited research examining constructs of masculinities among marginalised men and how this relates to health experience. This paper aims to contribute to the literature in this field by exploring the biographies of young men who died through opiate use as seen through the eyes of those closest to them. The paper reports the narratives of family and friends of the deceased and examines how their accounts describe the role of risk-taking behaviours and how these behaviours can be interpreted in relation to marginalised forms of masculinities. Themes identified include risk taking, emotional expression, unemployment, fatherhood, and peer identity. The impact of hegemonic masculinity on marginalised men appears to be integral to constructing and sustaining risk-taking and self-destructive masculinities. This implies that risk taking motivated by "protest masculinity" may only be reduced if population health promotion measures are taken to reduce the inequalities that exist between men.

Keywords: masculinities, opiate use, mortality, young men, psychological autopsy

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Until recently, men, or at least men and masculinity, remained relatively invisible as an explicit focus in research and sociological theory (Hearn & Morgan, 1990). Since the '70s, however, social scientists have begun to theorise about gender and men's health (Sabo & Gordon, 1995) and over the past 30 years there has been a considerable increase in literature on masculinities. Nevertheless, for many, the term "gender and health" remains synonymous with women's health; there is still some way to go before it is widely accepted that gender is as significant an influence on the health of men as it is on the health of women.

Development of the gender and men's health literature has been accompanied by rapid social change in Britain. The decline in manual occupations and the growth of more flexible employment contracts has brought greater job insecurity and unemployment. At the same time, men and women are reshaping their domestic lives with more moving into and out of cohabitation and marriage (Graham, 2000), but this does not imply that inequalities in health between men and women are declining. On the contrary, Popay and Groves (2002) argue that, despite this social change, patriarchal ideologies and structures continue to mould women's and men's lives differently, and as a consequence, these processes are continuing to generate gendered inequalities in health. Thus, the relatively more fluid movement between male and female dominated spheres in recent years has not necessarily made things more equal. In addition, change is unlikely to have impacted equally on different subgroups of women and men (Annandale 8,: Hunt, 2000). Men benefit in varying degrees from patriarchy, and the most marginalised probably do not benefit at all. In fact, it is likely that the most marginalised are oppressed by patriarchy, albeit in a different way from women. Marginalisation in this context refers to the relations between the masculinities in dominant and subordinated classes or ethnic groups. Marginalisation is always relative to the authorisation of hegemonic masculinity of the dominant group (Connell, 1999).

This paper reports on a study of biographies of 11 young men who died through opiate use as seen through the eyes of family and friends. In particular, it examines accounts of risk-taking behaviours, how these behaviours relate to marginalized masculinities, and how they may have contributed to the deaths of the men concerned.

THEORIES OF MASCULINITIES

More recent work on masculinity has no settled paradigm, but some common themes are now emerging: the construction of masculinity in everyday life, the importance of economic and institutional structures, the significance of differences among masculinities, and the contradictory and dynamic nature of gender (Connell, 1999). Contemporary theorists now suggest that there are a variety of masculinities, (Annandale, 1998; Connell, 1999; Hearn & Morgan, 1990; Messerschmidt, 2000; Sabo & Gordon, 1995). Conceptualising masculinity in plural terms provides a theoretical context within which to explore health inequalities among men. Thus, such an exploration should attend not only to differences but also to actual relations of dominance and subordination (Annandale, 1998).

The most advanced theoretical framework on masculinities is the work of Robert Connell (1987, 1999), which takes a critical feminist stance. Critical feminist thinkers argue power differences shape relations between men and women, women and women, and men and men. Gender identity is not simply imposed on individuals by socialisation, but individuals actively construct their gender identity and behaviour (Sabo, 1999). Connell argues that masculinities are socially constructed and that patterns of gender and sex are not just an important feature of human life but are specifically social (for example, inequalities of income, the distribution of power, and the division of labour). Masculinities are not isolated; rather, they are an aspect of a larger structure of gender.

Connell defines four aspects of masculinities: hegemony, subordination, complicity, and marginalisation. These aspects reflect the practices and relations that construct the main patterns of masculinity in the current Western gender order. Within this framework there are specific relations of dominance and subordination between groups of men. Hegemony refers to the cultural dynamic by which a group (in this case, men) sustains a leading position in social life. Subordination, on the other hand, refers to the position of those men who are denied access to the hegemonic position. Hegemonic and subordinated masculinities are thus defined in relation to each other. The interplay between hegemonic and subordinate masculinities is a complex one but underlines the fact that the experience of being a man is not uniform. Complicity refers to the way in which the majority of men gain from hegemonic masculinity since they benefit from the patriarchal dividend, and marginalisation refers to the relations between masculinities in dominant and subordinated groups. It is always relative to the authorisation of the hegemonic masculinity of the dominant group. Therefore, certain groups of men, such as gay men and ethnic minorities, for example, may experience subordination, stigmatisation, and marginalisation.

The concept of marginalised masculinities has received particular attention in relation to young men. Connell (1999) describes the oppositional masculinity of marginalised young men as "protest masculinity," which has much in common with Adler's concept of masculine protest (Adler, 1956). Protest masculinity is a marginalised masculinity that picks up themes in hegemonic masculinity and reworks them in the context of poverty. That is, the most powerful men within the marginalised group dominate over the less powerful and do so by overemphasising masculine behaviours such as risk taking. It arises from the childhood experience of powerlessness and results in an exaggerated claim to the potency of masculinity. Messerschmidt (2000) terms this type of masculinity "oppositional masculinity."

MASCULINITIES AND HEALTH

Recent literature has contributed considerably to our understanding of how masculinities may impact on health and health experience (for example, see Annandale & Hunt, 2000; Banks, 2001; Cameron & Bernardes, 1998; Connell, 1999; Courtenay, 2000; Courtenay & Keeling, 2000; Doyal, 2001; Hearn & Morgan, 1990; Hunt & Annandale, 1998; Kimmel, 1987; Lee & Glynn Owens, 2002; Luck et al., 1999; Ostlin et al., 2001; Sabo & Gordon, 1995; Waldron, 1993). Courtenay (2000) suggests that factors that undermine men's health are often signifiers of masculinities and instruments that men use in the pursuit of social power and status. He also states that, like crime, health behaviour may be "invoked" as a practice through which masculinities (and men and women) are differentiated from one another. Among marginalised men, Waldron (1993) suggests that subordinated forms of masculinity and the coping behaviours associated with them, including greater risk taking, are linked to structural position and may reinforce the higher mortality associated with it. While hegemonic masculinity significantly benefits dominant male groups, it also results in incredibly high death rates of young men as they seek to make the transition out of adolescence and into adulthood, adopting hazardous lifestyles resulting in violent death, drug abuse, and suicide (White, 2002). It is this form of masculinity that is as dangerous to some men as it is to women.

One of the possible ways in which marginalised men may choose to take risks in order to express cultural ideas of machismo is through the medium of drug use (Quintero & Estrada, 2000). Drug addiction is clearly more common among men than women. In 1995, 28,097 male drug addicts were notified to the Home Office compared to 9,067 women and Merseyside was reported to have a particularly acute problem with the highest rate of drug addicts reported to the Home Office in the United Kingdom (1,650 per million population) (Home Office, 1996). To date, however, there have been very few studies examining how masculinities are constructed through the medium of drug use.

This study aims to examine how friends and relatives of young opiate-using men who have died in Liverpool (U.K.) describe the lives of the men concerned, and interpret and understand the reasons for their deaths. The analysis examines how these accounts describe the role of risk-taking behaviours, how these behaviours can be interpreted in relation to marginalised forms of masculinities, and how they contributed to the deaths of the men concerned.

METHODS

The following study of interviews with friends, relatives, and other contacts of 11 Liverpool men who died from opiate use was part of a larger study of men who died violently in Liverpool. The aim of the study was to examine whether relatives and friends of young men who died through opiate use identified common pathways leading to death and how these pathways related to constructs of masculinities.

NARRATIVE RESEARCH
 At the very least, "life itself" is a selective achievement of memory
 recall; beyond that recounting one's life is an interpretive feat.
 (Bruner, 1987, p. 13)


Life narratives, generated through qualitative research, can point to new ways of understanding and interpreting gendered patterns of health and illness. This is because they have the potential to illuminate the relationship between gender and health experiences in ways which other forms of "knowing" the social world cannot provide (Popay & Groves, 2002). Life narratives offer a means of exploring how individual experience can he perceived as gendered. From a sociological point of view, individual lives should he understood not merely in terms of their uniqueness, recognising individuality, but also within a social context. Individual accounts thereby help to chart the major societal changes that are underway (Roberts, 2002).

Narratives, likes other forms of presentation, include subjective and social constructions. The goal of analysing the data is to disclose constructive processes offered by the culture rather than to reconstruct factual processes (Bruner, 1987). Flick (2002) states that life as narrative is a new reality, different from the experiences of reality of the individual involved. Narratives cannot be treated as empirical data; rather, they are constructions or stories that should be treated as such, not as a representation of some external reality. Narratives are always edited versions of reality, not objective and impartial descriptions of it, and interviewees always make choices about what to divulge (Riessman, 1990).

In this study, it was not possible to interview the young men themselves, and therefore relatives and friends of those who died provided their biographies. Thus, while it was not possible to elicit how these young men constructed their experiences and their realities, it was possible to elicit how their relatives and friends constructed their understanding of why individuals died. More than one informant was used, where possible, to elicit differing constructions of life stories for each individual.

Interviews with relatives and friends incorporated both structured and semi-structured approaches. The first part of the interview was structured and sought responses to specific questions related to specific life events. The variables examined in the structured part of the questionnaire included sociodemographic information and factors associated with suicide and self-destructive behaviour identified from the literature. The second part was semi-structured, allowing the respondent to expand on the subject topics to identify additional factors pertinent to the death of the individual in question and to explore the interrelationships between identified factors.

Clearly an ex post facto design, common in biographical research, has an influence on data collection. Due to the nature of the study, respondents will probably have thought through and shaped events over and over again and may have told the story or discussed the issues many times prior to the interview in order for it to make sense to them. The narratives provided then are probably a reflection of their own processes of coming to terms with events. Nevertheless, the stories also reflect the culture in which these young men lived and how gender was represented within that culture.

ETHICAL ISSUES

Interviewing the family and friends of someone who has died originated as a research method in the U.S.A. in the late '60s to augment coroners' investigations and was originally termed psychological autopsy. This type of research raises a number of practical and ethical issues including the therapeutic role that may arise. Beskow et al. (1990) suggest that two aspects in particular deserve ethical consideration, the integrity of the individual who has died and the integrity and the health of the respondent. Confidentiality must be maintained, and facts that the deceased has chosen not to disclose to his family must be respected. Further, it is vital to maintain confidentiality by ensuring that individuals cannot be recognised when results are disseminated. Previous studies indicate that a researcher who is responsive to the needs of the respondent can offer a chance to communicate; a chance to talk about the guilt, the shame, and the anger; and a chance for catharsis (Sanborn & Sanborn, 1976). In addition, the process of telling a life story can actually have a "therapeutic effect" on the "giver." Powerful feelings may be released when someone, for example, describes the loss of a relative, and usually a sympathetic response is all that is required (Thompson, 1988).

Ethical approval was obtained from the Local Research Ethics Committee prior to carrying out the study.

SAMPLING AND DATA COLLECTION

In terms of typicality, the aim of narrative research is not to provide representative samples from which to draw generalisations. Rather it is to look in detail at a number of individual cases. Therefore large numbers of cases are not required. This study aimed to identify opiate-related deaths that occurred within a particular area (Liverpool) and during a particular year. The young men in this study probably represent the extremes of risk taking in relation to drug use and other gendered actions identified, and it is unlikely that such extreme representations would be typical of all male drug users. However, researching marginalised men who die as a result of risk taking and sell-destructive behaviour may provide a means for understanding the link between structural position, subordinated forms of masculinities, risk taking, and sell-destructive behaviour.

The names and addresses of relatives and other contacts of all men aged 15 to 39 years who died in Liverpool during a particular year and who tested positive for opiate use following toxicology at the time of death were provided by the coroner. Eighteen individuals were identified. A letter was sent to all listed contacts explaining the nature of the study and inviting the individual to take part. Each respondent in the study was given an opportunity to exercise his or her right of informed consent, following both a letter explaining the purpose of the study and an opportunity to ask the researcher further questions prior to signing a consent form. It was also explained that the interview would be treated in the strictest of confidence. Those friends and relatives who agreed to take part were subsequently interviewed by the researcher. If the respondent did not consent to take part in the study, the researcher provided information on available bereavement services in the area, and another contact was sought where possible. In some instances there was only one contact name and address provided in the inquest notes, whereas in others, there were up to three listed. Where only one contact name was supplied, the informant was asked to furnish the names and addresses of other relatives or friends who could be contacted.

The timing of access to the inquest data was dependent on the manner of death. If there was considered to be any suspicious circumstances surrounding the death, names and addresses were not made available until the inquest had been closed, whereas if the cause of death was considered to be uncomplicated, names and addresses were released immediately after the inquest was opened. In practice, timing of the interview was therefore dependent on external circumstances but was usually within 2-6 months of a death. This was in order to provide a balance between interviewing too soon after the death in the acute stages of grief and interviewing too long after when recall of events might be unreliable (Brent et al., 1988).

The majority of interviews took place in the respondents' own home, although in two cases the respondents requested to be interviewed at the university due to lack of privacy at home. The interview took approximately one hour, and on completion the respondent was provided with information on available bereavement services in the area. Interviews were taped and transcribed for the purposes of analysis.

RESEARCH QUESTION

Do relatives and friend of young men who have died through opiate use identify common pathways leading to death, and how do these pathways relate to constructs of masculinities?

ANALYSIS

Data were analysed using an analytic inductive approach to test the following hypothesis:
 Relatives and friends of young men who have died through opiate
 use identify common pathways leading to death, and these pathways
 relate to constructs of masculinities.


The analysis focused on the respondents' versions and accounts of how they made sense of social phenomena as well as the researcher's own interpretation. Initially, a life narrative was developed from the data for each individual. Each case was then examined, and data were coded according to the themes identified, based on Fielding's approach (1993). A cross-case analysis was then carried out to identify common themes between cases. The data were interpreted in terms of narrative themes of significant others talking m retrospect about the young men, not as empirical measures of the character of young men's lives. In relation to measures of validity, life accounts, which use a multiplicity of perspectives, see the interview as a subjective encounter. The accuracy of the record of a person's life is therefore not the issue; it is whether the stow is trustworthy. Internal consistency can therefore be used as the primary quality check (Atkinson, 1998). The qualitative software programme "NUDIST" was used for storing data, for categorising themes, and for cross-referencing data.

RESULTS

Eighteen young men aged 15 to 39 years who died of opiate use were identified from coroners' records. In five cases no relatives or friends could be contacted, and in two cases the relatives declined to take part. The families and friends of the 11 remaining men were subsequently interviewed. For each individual included in the study, there were between one and three informants. The narratives suggest that these young men constructed a common pathway of risk-taking and self-destructive behaviour that is described in detail below. In particular, risk-taking behaviours appeared to be closely related to the ways that these men developed constructs of marginalised masculinities.

BACKGROUND FINDINGS

Respondents described strikingly similar explanations of the pathways to early death. All of the men in the study were reported to have been in conflict with the law, and most of them had been to prison on at least one occasion. The majority had no skills or qualifications and, consequently, no status or power in terms of hegemonic masculinity. Their lives had been fraught with conflict with all forms of school authority throughout their educational years and with state authority as adults, illustrating the structural exclusion experienced by these young men from an early stage of their lives. Exclusion from school, the labour market, and eventually the family were evident from the reported life experiences.

For many of these cases, the childhood picture was mostly one of instability, and often the chaotic nature of their lives began during childhood. Eight of the cases did not live with both parents throughout their childhood. In five cases this was the result of divorce, and in three cases the death of their fathers. Often, there was no male role model in the home and in some instances, relatives directly attributed later behaviours and experiences to childhood instability, particularly where it was extreme due to the loss of both parents.

It was common for respondents to cite examples of unusual behaviour during childhood such as truanting at a very young age. Nonconformity and rebellion against authority were common features. In two cases, the individuals were taken out of mainstream school and attended specialist schools, but these experiences did not appear to be positive in any way for the individuals concerned. It was apparent that, by the time these young men reached school-leaving age, they were already marginalised in terms of employment opportunities. Only three of the cases left school with any CSE or GCSE qualifications.

RISK-TAKING BEHAVIOUR

Courtenay (2000) suggests that, when men are denied access to the resources necessary for constructing hegemonic masculinity, they must seek other accessible resources such as traditional masculine beliefs or health-risk behaviours in order to validate their masculinity. From the respondents' point of view, these young men did not conform to typical childhood behaviour but were likely to take significant risks at a young age. Rebellion against authority, including the school and parents, were common features identified. Messerchmidt (2000) describes this type of masculinity as "oppositional masculinity" that is extrinsic to and represents significant breaks from hegemonic masculinity.
 He used to go walkabout from the age of two or three, and we
 would have to go looking for him. He was a pain as a child,
 always fighting, always skiving off school. (Case 1, sister) (1)

 He always wanted, you know, adventure and things like that. He'd
 be the first there to do something, whatever it was. He was always
 the first to try new and dangerous adventures; there was no adult
 to provide boundaries for him. (Case 2, cousin)

 He regularly took physical risks as a child, more so than his
 brothers did. He was always boisterous when he was young; he had
 no fear about anything. Completely different from his brother, he
 was. (Case 8, sister)

 He was always taking risks, even as a kid. He had five car
 accidents in all, and one of these was when he got the serious
 injury to his head. There was someone else driving, mind. The
 other driver was killed, and X's friend got a prison sentence. He
 just got the bad head injury, and his behaviour changed a
 lot--completely, actually. (Case 6, mother)

 From the age of 14, he just stopped going to school refused to go
 outright and my mother couldn't do nothing with him. The guy used
 to come from the education department and say that she [my
 mother] had to go to court but he just refused to go outright.
 (Case 7, brother)


Connell (1999) suggests that state power seems repeatedly to provide an object against which a violent, resistant masculinity can be defined. This happens in relation to power as realised in the school as much as it does in relation to the police. The respondents suggested that by the time these young men reached school-leaving age, they were already marginalised in terms of employment opportunities. Only three of them were reported to have left school with any qualifications.

Among these young men, truanting appeared to offer an important means of negotiating masculinity. Connell (1987) suggests that school does not merely adapt to masculinity among boys. Rather, it provides an environment in which to construct various forms of masculinity and to negotiate relations among them. Thus, truancy can be used to define a marginalised oppositional masculinity. It is only one form of risk taking, however. The narratives reported a constellation of other risk-taking behaviours.
 He was a risk taker in every sense. Everything he did seemed to be
 about taking risks. He always had to go to extremes, and there was
 always something else. (Case 5, mother)


Men of all ages are reported to be significantly more likely to engage in risky behaviours (for a detailed review of the literature in this area, see Courtenay, 2002). Conrtenay and Keeling (2000) assert that men construct masculinities by embracing risk, and the dominance of masculinity is dependent on men being able to weigh up risk and to successfully take risks to reach goals.
 He made a living out of stealing cars, and he was always writing
 them off. He'd been banned from driving as well. Quite often he
 would go down on to the railway lines at night as well, to steal and
 things. (Case 1, friend)

 I found him on the second floor from the top, and there were 11
 lads all lying there just passing one needle around, and when they
 weren't injecting they were smoking cannabis. One of them
 opened the window and started hanging out. I had to leave him
 there. I just couldn't drag him out. He wouldn't come. (Case 7,
 brother)


To friends and relatives, there was an inevitability about such destructive drug use.
 If he didn't have AIDS, he was going to get it. He already had
 hepatitis B. The Coroner said his liver was fucked. He was going
 to die of AIDS or get killed. (Case 7, friend)

 Even the bad junkies said, when it comes to X, he's got a habit.
 They felt healthy alter they'd been with X. His drug intake was
 phenomenal. (Case 8, brother)

 They never ever think they're going to die. One thing I have
 noticed is, if somebody dies through a drug overdose, then everyone
 gets worse over the next month. They take more, and they go
 a bit nuts with it, and then they calm down. (Case 8, brother)


The latter vignette implies the need to believe that drug use does not lead to death, and that this need becomes greatest when someone close has died as a result of drug use. The most effective way of dealing with such a contradiction may be to increase risk taking by increasing consumption and yet still survive.

No respondent believed that death of any of the men had been intentional. Emphasis was placed on the accidental nature of the death, occurring due to a poorly judged risk strategy.
 I think all it was was that he had been out of prison for a
 month ... and he just wasn't used to it after being away from it
 for so long, so he had taken a bit too much. (Case 10, counsellor)

 He just injected himself. It was only 10 [pounds sterling] worth.
 It doesn't sound like a great deal for him, but he's done it, and
 it's just been an accident, and he's died. It could have been
 dodgy gear. l think that they're pushed these days with that many
 people doing it. It's just the turnover now. It's just yeah, yeah,
 roll her out. (Case 7, brother)


Respondents felt that prison played an important part in the lives of these young men, only one reportedly never having been imprisoned. Some respondents felt that, when the men were in prison, it was the only time that their drug use was under control. A number of studies have identified the prison system as confirming constructs of masculinities (Carrabine & Longhurst, 1998; Newton, 1994; Toch, 1998). Newton suggests that the hierarchies among men in prison are directly related to, and perhaps a function of, the power relations of hegemonic masculinity. Such a structure would therefore confirm marginalised modes of protest masculinity, such as violence. It would also appear to allow the defendant to recover somewhat from his self abuse.
 A couple of times he went into prison, and he came out looking a
 different lad altogether, because he wouldn't have been able to get
 whatever he had. For about three months he'd look great, and then
 he'd go back into his old way of his face being all drawn. (Case
 11, father)


EMOTIONAL EXPRESSION

Respondents, reflecting on the men's behaviour, suggested that the men did not discuss or disclose their feelings about their health or drug problems to their friends or their families. In much dominant discourse about emotional disclosure, Hearn (1993) reports that men are constructed as unemotional relative to women. The gender stereotype of the strong, silent man and the weak, emotional woman is indeed well documented. Thus, for men who assume complicity with hegemonic masculinity, it is important that they perceive their responses as rational (masculine) as opposed to emotional (feminine). However, numerous studies have reported that there is in fact no difference in the quantity or type of emotions experienced by women and men, only in the way that men and women express them (Prior, 1999). Brownhill et al. (2002) suggest that this is because of the entrenched notion that expressing emotional pain is a sign of weakness in men, perpetuating the keeping, locking in, or bottling up of problems, compartmentalising, or letting problems smoulder. They also suggest that when men do express emotion, there is a risk of being victimised or ostracised by other men. Thus, when men do (or are forced to) seek help, presentations of physical illness, such as chest pain, or behaviour such as deliberate self-harm or drug and alcohol abuse may mask emotional distress (Brownhill et al., 2002).

However, the reality may be a little more complex than this. Hearn (1993) argues that emotions are usually defined within discourses of gender and therefore are context specific. Among these young men, already subordinated and marginalised, the risk of increasing vulnerability may be particularly threatening. The more vulnerable a man feels, the more he may therefore need to "prove" his masculinity and avoid expressing what he perceives as vulnerability such as pain or fear, for example. The most marginalized may therefore need to construct specific acting-out behaviours in response to stress and distress in their lives as a means of expressing emotion. Indeed, these data suggest that the men were not perceived as emotionally inexpressive. Aggression and violence were commonly reported as means of expressing anger and agitation. This suggests that these men may have had a shared meaning of prevailing patriarchal ideology in relation to emotional expression, aggression, and violence being acceptable forms of emotional expression and help seeking being seen as unacceptable. As the following quotes illustrate, the respondents held similar views regarding the emotional state of the participants.
 He had problems with drugs and with his health. The problems
 with his health came from the drugs, so he didn't want to
 distinguish one from the other, so he wouldn't tell you about
 either. (Case 1, friend)

 You know drug addicts; they never really tell you very much
 about themselves. He never used to tell you about it even though it
 was an obsession. (Case 11, father)


In addition, asking for advice and sharing weaknesses inevitably places a male lower in the hierarchical order than the person they are asking. Hence, it is never appropriate to share problems. Among these young men, it is possible that to ask for advice would have been to devalue themselves further, since they were already subordinated by nature of their poverty and lack of education. Men may therefore use other emotions such as anger to express their distress.
 He always seemed to want to be somewhere else. He always
 seemed to want to go someplace else, even in his own flat at times.
 (Case 3, father)

 X was one of those people, no matter what he had; he always had
 to have that bit more. Even when he was younger, if there was a
 new shirt out and everyone was wearing it, he wouldn't be happy
 with one; he'd have to have two or three. It didn't matter what it
 was; he always wanted more. (Case 8, sister)

 He was restless. He wasn't happy. He had to be out doing something
 like he was searching for something. It was as if he hadn't
 got that much time left. He was just spending every hour for
 today. (Case 9, sister)

 In fact there was a change of attitude towards life. You know, he
 would have sort of thought, "Oh, I've got some money; I'll put it
 in the bank," but no, if he wanted anything, he had to have it at
 that moment. Everything for today ... He never sort of looked to
 the future. Everything was for today. He just tried to spend his
 way and enjoy himself. (Case 9, sister)


The descriptions above also suggest a sense of agitation. This could be viewed as a product of marginalisation in relation to how this group was perceived in the hierarchy of hegemonic masculinity. As a result, frustration with their position and possible recognition that they were disempowered could be expected to lead to agitation. The other element apparent in these quotes is a philosophy of being concerned only for the moment rather than behaving in a way that optimises opportunity in the future. For men who do not have the resources to compete with those higher in the hierarchy, deferred gratification offers no rewards. (2) This could also result in a susceptibility to becoming involved in the immediate gratification offered by opiate use.

Some of these men were described as regularly being involved in physical violence, including assault and domestic violence. It was also suggested that those individuals with a reputation for violence appeared to attract violence. Adler (1956) sees protest masculinity as an overcompensation in the direction of aggression and restless striving for triumphs. Aggression is an important and destructive working out of masculinities, especially among marginalised groups. Violence is a masculine resource, a contextually available practice that can be drawn upon so that men and boys can demonstrate to others that they are manly (Messerschmidt, 2000). Certainly the vast majority of criminal perpetrators are men. In 1999 in England and Wales, 417,800 offences were committed by men and 93,400 by women (Office of National Statistics, 2001). Fasteau (1995) points out that violence can be thought of as the crucible of masculinity, the acid test. Thus, violence becomes a means of increasing status and position, drawing boundaries and making exclusions (Connell, 1999). Physical violence may therefore act as an important way of maintaining one's position in the hierarchy.
 He'd come home and start getting aggressive and throwing his
 weight around. If he couldn't get his own way, if he wanted
 money and we didn't have it, he'd smash windows and throw cups
 at her [his mother]. (Case 4, father)

 And like, if someone was getting bullied, then he'd go over and
 have the fight for them, do anything for anyone. He did have a bad
 temper and fly off the handle. He'd always go and knock someone
 about for someone. He got hidings himself loads of times. He was
 the one the bouncers jumped on and that type of thing. (Case 1,
 friend)

 He was really angry all the time and thought everyone was
 talking about him. Then he became quite violent, and his
 girlfriend had a terrible time with him. (Case 6, mother)


UNEMPLOYMENT

The men in this study were reported to have been predominantly unqualified with no specific skills to offer to an already oversaturated employment market. Without exception, respondents described the young men as either unemployed or claiming long-term sickness benefit. The data suggest that they appeared to accept that they could not compete for employment, so generally they did not try. More recent studies of unemployment show that it is part of a process of accumulation of disadvantage that may begin in childhood (Bartley, 1999), and the narratives of these young men provide support for such a view.

During the lives of the young men in this study, traditional manual labour in contemporary Liverpool all but disappeared. Unfortunately, of all the regions in England, the North West had particular difficulty in adjusting to the decline in the traditional manufacturing industry (Hutton, 1995). In Western culture, masculinities are commonly defined by the ability to provide for a family. However, in Liverpool, a generation has grown up with little expectation of stable employment around which familiar models of working class masculinity have been organised.

The men in this study were reported to have no or few saleable skills, no qualifications, no positional power, and no leverage within the labour market. For those living in an area of high unemployment who left school without qualifications, it would seem reasonable to look for alternative avenues for status and success. Mac an Ghaill and Haywood (1997) suggest that unemployment restricts access to the dominant image of masculinity among young men based on economic responsibility within a heterosexual relationship. Thus, marginalised young men may need to undertake new strategies to create masculine identities. Drug dealing could provide an income to support a family and a drug habit as well as providing risk and adventure. Collison (1996) states that groups such as this one, having been excluded or by excluding themselves, lead an itinerant lifestyle in the spaces between family and state, periodically interrupted by intervention of the latter.

It is possible that drug use initially provided status in terms of the risks that they were taking, and in addition it may have been possible to obtain resources through means other than employment.
 The work was really the turning point for him. I mean, he had
 nothing to do all day and started hanging around the drug scene.
 Lots of people have phases (with drugs), but some continue. He
 carried on because of unemployment and depression.... He never
 had much luck with work, either. I mean he wasn't well enough
 educated to go out there and find work. (Case 1, sister)

 He was working on the YTS as a labourer, then when he was 17
 he got meningitis, and that left him blind in one eye and epileptic.
 That changed everything for him, and he never worked again....
 Then these lads would come round because he could spell and
 write properly and say, "Fiddle these forms for us, and we'll get
 over to Germany for nothing," and he'd order all the tickets for
 them. It was only as it went along. He must have got led into it
 slowly but surely. Gradually from there he went on to the cheque
 cards.... Once he got into that lifestyle, you know, easy money
 just sitting about and the money he used to get. (Case 9, sister)


Respondents also claimed that they were often successful in making money through criminal activities and therefore were not motivated to seek conventional work. Messerchmidt (2000) suggests that crime is a resource that may be summoned when men lack other resources to accomplish gender. As Thorne (1993) notes, individuals and groups develop varied forms of accommodation, reinterpretation, and resistance to ideological hegemonic patterns. In fact, it could be argued that these young men worked hard to obtain money by illegitimate means to fund their drug habit while at the same time reconstructing their own form of "poor man's hegemonic masculinity" through taking part in criminal activities. That is, where they were denied the status of hegemonic masculinity through legitimate means, they were able to construct their own version among their peer group, thus subordinating those peers who were unable to successfully obtain drugs through illegitimate means.
 X always made plenty of money, so work never bothered him.
 (Case 1, friend)

 He got this part-time job in a Chinese restaurant washing dishes.
 He packed it in, because he didn't need it because he was selling
 drugs. He used to moan when he had to go to work because it was
 costing him money to go to work. (Case 10, brother)

 He had pure heroin and pure cocaine, the pharmaceutical stuff in
 vials, and he'd keep that for himself and sell everything else, and
 even at them times I never saw him off his head, stoned out of his
 mind. I'd seen him more stoned off his head with stuff from the
 clinic then the stuff he took from the chemist. When I went round
 to his house, it was just a chemist's. We were all spraying perfume
 on each other, nuts. (Case 8, brother)


Pragmatism is another possible interpretation of the criminal careers of these young men. Criminal activity may have been viewed as the only way to provide the resources to fund a drug habit, and in addition it possibly allowed them to increase their drug use. Work, it could be suggested, was an unnecessary nuisance, particularly when there was an option to make money through other means. Crime can quickly become a type of work, allowing the state to take over as the authority against which men define their masculinity. This type of philosophy may be acted out during the "honeymoon period" of drug use. However, later on in a drug career, the story changes. For instance, one respondent suggested that poor health, prison sentences, and desperation for money to fund one young man's habit may eventually have led him into male prostitution to supplement his other forms of income. At this point, drug use no longer acts as an outlet for risk-taking behaviour but becomes debilitating and self destructive. Also, one respondent suggested that making more money than usual allowed a user to indulge more recklessly than at other times. In the following narrative, this was said to have contributed to the death of the individual concerned.
 He was just still himself up to the point where he started selling
 The Big Issue, which was just too much money. He was getting
 money in off that, he had free drugs from the clinic, and he had
 the drugs he was still getting off the street and extra money to
 buy even more, and that was his downfall. Loads of money and a drug
 habit. They are not going to spend the money on anything else,
 just gear. (Case 8, sister)


FATHERHOOD

Four of the young men were reported to have children. Only one of these cases was reported never to have had contact with his child. In the other three cases, respondents asserted that fathers did have contact with their children, and anxiety about their relationship with their children, particularly the tact that they were living apart from them, was viewed as a cause of a great deal of distress. The perspectives of the respondents suggest that these men were not uncaring fathers. In fact, the impact that the end of a relationship had on contact with their children may have been a major source of ongoing concern that possibly contributed to an increase in their drug habit.
 I don't think he was bothered at splitting up with his girlfriend
 but bothered about not being with the baby. Although he always had
 the baby a lot, you know he always had her. I think he would have
 wanted things differently. (Case 1, sister)

 The kids loved him when he came round; they were all over him
 because he was never really down, apart from when he talked
 about his son and his ex-girlfriend, because they'd split up. That
 was the only thing that really got him down. He always had it in
 his head that he was going to get his son back ... the inevitable
 that never happened. (Case 8, brother)


Drug use was also thought to have affected the quality of relationship that this man had with his son and dictated the extent to which he could function as a caregiver.
 He'd take X out for the day, and he must have shot tip somewhere,
 and X used to say "I hate waiting at the bus stop with my dad
 when we go out because he starts to howl." X was embarrassed.
 He thought it was because he was drunk, he'd had a can of lager or
 something. (Case 8, brother)


PEER IDENTITY

Peer pressure was suggested to be one of the main barriers to moving away from a drug-using lifestyle. There is evidence that peer use of drugs is particularly influential in relation to commencing and continuing drug use among men (Binion, 1982; Henderson et al., 1994), and in addition, Binion suggests that men are more likely to use alcohol and illegal drugs for peer acceptance.
 I left the city. You've got to get away from the circle of people
 and "kill them off." It doesn't matter stopping taking the drug,
 it's stopping seeing the people, that's the main one. That's the
 killer. If you can get rid of them, you're okay. It's like having
 someone on your back all the time, the minute you say you're
 packing in anything, it's like smoking. The minute you say you're
 packing it in, everyone is offering them to you. It's amazing how
 much free stuff comes out. (Case 8, brother)


Connell (1999) describes protest masculinity as being built on the principle of working-class solidarity, and drug use provides a perfect medium for creating solidarity among a marginalised group of young men. Masculine practices have to be contextually appropriate, and it is significant therefore that these young men chose to do this through the medium of drug use. This type of lifestyle offers a level of trust and security that obviates some of the uncertainties and insecurities of being a male on the margins of civil society (Collison, 1996). Anderson (1998) suggests that drug abuse may become a means of cultural identity. The masculinities that were constructed could be interpreted then as contextually appropriate to their cultural identity in relation to the position and resources open to them. Messerchmidt (2000) describes this kind of lifestyle as a collective practice that typically includes shared consumption of alcohol and other drugs through which young men can celebrate and affirm their independence, a much admired attribute in hegemonic masculinity. It seems then that it would have been necessary to avoid contact with peers if there was going to be any possibility of reducing drug use. Losing the sense of masculine identity an individual shares with his peers would be extremely hard where there was no other obvious means of masculine identity available. Also, drug use is an unacceptable practice among many societal groups. This means that, as an individual's drug use increases, he becomes more and more marginalised from nondrug users by his behaviour.

Finally, one respondent implied that drug use had become the norm among his peers--an acceptable part of life within his community. He paints a picture of a community that has accepted the inevitability of sell-destruction among a generation of vulnerable young people who are learning to live and die through the medium of drug use.
 Well, they leave home and come back and leave home and come
 back, and they leave a trail of kids here and there, and they can
 go and get their methadone, and they can go and screw houses, and
 the mothers are too willing to look alter them. My ma would say,
 "I'm not giving you money for drugs, but here's tobacco, and
 here's food, and here's your washing." So out of everything he
 had to worry about that day, the heroin was the only worry he had
 alter he had seen my mother.... All the mothers are like that. I've
 seen them. In the old days, they would kick out about it, but now
 it's, "Oh, our little Johnny, he's on heroin." (Case 7, brother)


DISCUSSION

This study offers a representation of the ways that male opiate users possibly construct masculinities and how these constructions relate to their risk taking and self-destructive behaviour. That is, these data report the constructed realities of friends and relatives who have interpreted what the young men presented to them. However, since masculinities are often invisible to men themselves, they offer an interesting insight into the ways these men were perceived by others. The findings of the study endorse Connell's concept of protest masculinity and the view that marginalised men rework notions of hegemonic masculinity in poverty, in this case through risk taking and self destructive behaviour. This suggests then that aspects of gender are constructed in relation to an individual's structural situation. However, the implication that these young men had challenging behaviour from early childhood and that their behaviours were different from their siblings suggests that there were additional factors at play. It is not clear whether the experiences of these young men differed in some way from their siblings and their friends, whether circumstances led them to be more marginalized from their peers, for example, or whether some individual aspect of their character rendered them more likely to engage in life-threatening behaviour. Such questions cannot be answered by a study of this nature, but the findings do raise some interesting questions about individual proneness and resilience to self-destructive tendencies.

Connell emphasises that there is not one type of masculinity; rather there is a range of possible masculinities (1999). Despite this, it appears that the possible constructions of those masculinities are fairly limited among marginalised men. This is not to suggest there are fixed masculinities, but rather that the behaviours open to the most marginalised follow a rigid code, and the (social) penalty for stepping outside the code may be considerable.

The narratives illustrate the role played by shared drug use in providing masculine group identification. In particular, men with their masculine identity and self-esteem undermined by their subordinated position in relation to higher-status males have the greatest need to use other resources including group identification, risking injury and death, in a variety of ways. Messerschmidt (2000) refers to this as a display of oppositional masculinities, which is a way of attempting to break away from hegemonic forms of masculinities. Drug use and its associated behaviours such as crime could be described as forms of oppositional masculinities, and these men demonstrated these masculinities, many before they had reached their teenage years. Both addiction and the illegal nature of intravenous drug use require members of this subculture to take an inordinate amount of risks in order to maintain their drug habit. On a daily basis, they risk arrest, overdose, and becoming victims of theft, violence, and illnesses related to drug use (Connors, 1992). These discourses imply that the young men chose drug use and its associated risks as a means of reaffirming their masculinities.

The concept of social exclusion resonates strongly with Connell's notion of marginalisation. Social exclusion refers not only to the economic hardship of relative economic poverty but also incorporates the notion of the process of marginalisation, that is, how individuals come, through their lives, to be excluded and marginalised from various aspects of social and community life (Shaw, 1999). The narratives also emphasise the importance of gender as another axis of inequality, that impacts on the health of men (as well as women). According to Connell (1999), hegemony is the cultural dynamic by which a group claims a leading position in social life. By definition, this group maintains all the power and, by implication, health advantages, whereas those with the lowest positions have the greatest health disadvantages. It is therefore the contradiction between hegemonic masculinity and the lived experience of those men who are most marginalised that constructs and sustains the self-destructive masculinities demonstrated in these narratives. Marginality itself is painfully visceral (Kimmel, 1990). The more marginalised, the more necessary it appears to be to continually reaffirm masculine status. In these cases, the suggestion is that reaffirmation clearly contributed to their demise.

CONCLUSION

In summary, this research has highlighted the damaging impact of masculinities on the health of marginalised young men and also on those around them including partners and families. The findings are relevant to a number of disciplines and literatures including gender and illness, men and masculinities, social exclusion, and drug use. In particular, the narratives suggest that the impact of hegemonic masculinity on marginalised men appears to be integral to constructing and sustaining risk taking and self-destructive masculinities.

In these narratives, structural exclusion and the effects of marginalisation resulting from the power of hegemonic masculinity suggest the need for population-based rather than individually focused solutions to improving the health of marginalised men. This is also the view expressed by Brooks and Silverstein (1987), who argue that, while individual men must be held accountable for their behaviour, the solution to "dark side" behaviour (which includes violence, self-destructive behaviour, and substance abuse) must be found at a societal level as well as an individual one. Thus, it could be argued that an understanding of the contribution of hegemonic masculinity to the process of social exclusion among marginalised men is intrinsic to beginning to address the problem.

If such an assertion is correct, this implies that risk taking and self-destructiveness, motivated by protest masculinity, will only be reduced if population measures are taken to reduce the extent of inequalities between men. Given that there is already a large literature on health inequalities (Marmot & Wilkinson, 1999), it would be useful to examine how current knowledge relating to other marginalised groups could be adapted to inform policies to reduce the social inequalities experienced by marginalised young men. More research is needed to identify how current knowledge of the effects of marginalized masculinities can inform such policy and strategy development. Much of the literature suggests broad policy measures, such as the pursuit of economic policies that lead to greater economic equality and a redistribution of wealth to improve the health of those who are worst off (Wilkinson, 1996). In particular, the Independent Inquiry into Inequalities in Health (Acheson, 1998) suggests that policies that decrease socioeconomic inequalities will have a differential effect by decreasing mortality, particularly among disadvantaged men. Reducing inequalities is already part of the English National Public Health Strategy, "Our Healthier Nation" (Department of Health, 1999), but inequalities may be particularly pertinent as a contributory factor to violent death among young men, and this needs to be addressed specifically within the strategy. Finally, the findings of this study suggest that risk taking may be an important method of compensating for the emasculating effects of poverty. Policies and strategy to reduce risk taking and self-destructive behaviours need to address, in particular, the issue of poverty if they are to be effective.

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NOTES

(1.) After each quote, the number denotes the individual to whom the comment refers and the relationship of the respondent to the deceased.

(2.) Messerchmidt (2002) describes these resources as masculine resources that can be drawn upon so that men and boys can demonstrate to others that they are manly.

Correspondence concerning this article should be sent to Debbi Stanistreel, Division of Public Health, University of Liverpool, Whelan Building, The Quadrangle, Liverpool L69 3GB, UK. Electronic mail: debbi@liv.ac.uk.

DEBBI STANISTREET

University of Liverpool

United Kingdom
Table 1
Description of Cases

Case Cause of death Study participants

1 Overdose of morphine Sister
 Friend
2 Overdose of morphine and Aunt (and
 temazepam foster parent)
 Cousin
3 Overdose of morphine Father
4 Overdose of morphine Father
 Mother
5 Overdose of morphine and
 cocaine Mother
 Sister
 Girlfriend
6 Road traffic accident and
 positive for morphine Mother
7 Overdose of morphine and Brother
 temazepam Friend
8 Overdose of methadone and
 temazepam Sister
 Brother
 Counsellor
9 Overdose of cocaine Sister
10 Overdose of morphine Brother
 Counsellor
11 Overdose of methadone/
 temazepam Father
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Publication:International Journal of Men's Health
Geographic Code:4EUUK
Date:Sep 22, 2005
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