Wounded Masculinities: Men, Health, and Chronic illness [1st ed. 2023] 3031444353, 9783031444357

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Wounded Masculinities Men, Health, and Chronic illness Valeria Quaglia

Wounded Masculinities

Valeria Quaglia

Wounded Masculinities Men, Health, and Chronic illness

Valeria Quaglia Department of Political Sciences Communication and International Relations University of Macerata Macerata, Italy

ISBN 978-3-031-44435-7    ISBN 978-3-031-44436-4 (eBook) https://doi.org/10.1007/978-3-031-44436-4 © The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrievalv, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover illustration: © Alex Linch shutterstock.com This Palgrave Macmillan imprint is published by the registered company Springer Nature Switzerland AG. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

To my mother

Wounded Masculinities: Men, Health, and Chronic Illness – Foreword

It is no longer correct to say that the issue of men’s health remains at the margins. Several countries now have a men’s health policy, interventions to engage men in health initiatives have increased almost exponentially in the last 30 years, and the topic has received considerable global media attention. However, this position has been reached from a standing start and there is still a very long way to go in ensuring health policies are male inclusive and that interventions are not only established but demonstrated by high-quality evaluation to be effective. Only by doing this can we hope to achieve positive and equitable health outcomes for men. The progress that has already been made has partly been accomplished by listening to men’s voices and hearing about their experiences. Doing this busts the commonly held myth that men are inherently self-­destructive when it comes to their health and gives greater insight into how, when, where, and why men engage in positive and negative health practices. While there are undoubtedly genetic and biological factors that influence men’s health outcomes, men’s health practices, their behaviours, are more often influenced by aspects of gender rather than biological sex. While it is now rightly common practice for health professionals and health services to be gender sensitive in relation to engagement with women, the same cannot always be said in relation to their interactions with men. Despite good progress in gender politics, white, heterosexual men frequently remain the ‘norm’ against which others are measured. However, this can place men so much in the foreground that they (or their gender) are not

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seen and recognized. Many traditional gender norms—such as emotional stoicism and fear of failure—have been associated with negative health practices and outcomes. Others though—such as feelings of control and responsibility—can be linked to positive self-care practices and coping with stressful life events. The point here is that the way men behave, as well as their practices and behaviours, is partly a result of how they internalize and respond to society’s gendered expectations. Understanding how men’s health practices are influenced by social contexts becomes particularly important in the context of chronic illness where men are living with a health condition that requires a degree of monitoring and self-care in order to maintain optimum functioning. This authoritative text allows us to hear men’s voices as they live with and experience a specific chronic health condition, Diabetes Mellitus. Through a combination of in-depth interviews and an innovative visual content analysis, we are given a vivid and nuanced understanding of how masculinities are utilised and (re)negotiated as the men manage their lives in the context of diabetes. In essence, we are provided with a detailed account of how these men construct, utilise, and perform masculinities in ways that reinforce or challenge gender norms and ‘sick role’ expectations. This detailed analysis reinforces the need to recognise masculinities as sets of agentic practices that are influenced by social structures but that also help (re)construct social norms. It also strongly reinforces notions of hybridised masculinities that can simultaneously accept and reject traditional elements to maintain a positive male identity in the context of a chronic health condition. This work has a breadth of scope for its potential readership. Academic scholars working in the sociology of health and illness, the sociology of the body, social psychology and gender studies (among others) would all enjoy and benefit from the comprehensive work presented here. Health professionals and third sector organisations looking to understand more about the links between men, gender and health will find high-quality evidence in this book to help them more sensitively approach and engage with men. The more we understand about the different ways that men ‘do’ health, how they manage and cope in a range of different contexts, and the influence of gender and masculinities on this, the better placed we are as a

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society to assist in appropriate and acceptable ways. Although focused on one specific chronic condition, diabetes, the insights in this work go way beyond that context. As such, this book provides an important step along this journey of understanding that will be very relevant for a range of academics and practitioners working with men. University of Leeds Beckett, UK 

Steve Robertson

Acknowledgements

I am very grateful to all colleagues and friends that have supported me in many ways, that have commented on draft chapters, provided valuable feedback during seminars or conference presentations, and engaged in informal discussions about preliminary results of this work over the years, including Alberto Ardissone, Alessia Bertolazzi, Chiara Bertone, Maddalena Cannito, Mario Cardano, Michele Cioffi, Enzo Colombo, Isabella Crespi, Nicoletta Diasio, Manolo Farci, Raffaella Ferrero Camoletto, Vulca Fidolini, Luigi Gariglio, Rossella Ghigi, Antonio Maturo, Veronica Moretti, Emmanuele Pavolini, Steve Robertson, Eleonora Rossero, Roberta Sassatelli, Marco Scarcelli, Alice Scavarda, Marta Scocco and Francesca Tomatis. Any mistakes or inaccuracies are indeed my responsibility. Furthermore, I wish to thank my parents for their constant support. A special thanks to Margherita for her unconditional and continued support over all these years. Thanks to Emilia for her precious support and for her informatic help during the research process. I am deeply grateful to my late middle school professor, Mariella Mondino, whose teachings and passion for her work continue to inspire and guide me over the years. Finally, I wish to thank the men who took part in the research.

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Contents

1 Introduction  1 1.1 Organization of the Book  5 References  8 2 The  Current Context of Men’s Health and Illness 11 2.1 Introduction 11 2.2 Men’s Health and Illness: Nature or Nurture? 12 2.2.1 The Emergence of Critical Studies on Men and Masculinities 17 2.2.2 Understanding Men’s Health Through Relational Theory 23 2.2.3 The Changing Nature of Hegemonic Masculinities: The Third Wave of CSMM and Its Implications for Men’s Health 29 2.3 Men, Chronic Illness, and the (Re)Configuration of Masculinities 39 References 45 3 Researching Diabetic Men 53 3.1 Doing Qualitative Research on Men, Masculinities, and Chronic Illness 55 3.1.1 Research Design 56

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3.1.2 Gender Issues in the Use of In-Depth Interviews with Diabetic Men 62 3.1.3 Dealing with the Unexpected: A Reflexive Account of the Research Experience 69 3.2 Studying Diabetic Men’s Self-Representations on Social Media 71 3.2.1 Research Design 73 3.2.2 Reflecting on Men, Masculinities, and Self-­­Representations in the Context of Chronic Illness 77 References 79 4 Negotiating  Masculinity Through Technology and Self-­Tracking Practices 85 4.1 The Tracker 88 4.1.1 Self-Quantification and Adherence to Treatment: The Patient 90 4.1.2 Constructing a “Personalized” Diabetes Self-­ Management Strategy: The Lay Expert 97 4.2 Conclusion: The “Measure” of a Man—Diabetic Men Dealing with Vulnerable, Diabetic Bodies104 References105 5 From  Uncertainty to Resilience: Reformulating Masculinity Through Endurance Training and Sport107 5.1 The Athlete111 5.1.1 “I will fight for it, I will achieve it, I will keep it”: Diabetic Athletes Engaging in Individual Sports113 5.1.2 Diabetic Athletes Engaging in Collective Sports123 5.2 Conclusion: The Intersection of Sports, Masculinities in Diabetes, and Gender Power Relations128 References132 6 “I  have never considered myself as sick”: Constructing Masculinity Through Mismanagement of Diabetes135 6.1 The “Free Spirit”: Considering Diabetes as a Nuisance137 6.2 “They call me Terminator”: Performing Masculinity Through Food Consumption Practices141

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6.3 My Body, My Choice. Mismanaging Illness and the “Costs” of Masculinity148 6.4 Conclusion154 References155 7 Dance,  Music, and Workout: Doing Masculinities in Men’s Digital Diabetes Narratives on TikTok157 7.1 Self-Representations of Diabetic Masculinities on TikTok: An Explorative Analysis160 7.1.1 Exploring the Use of TikTok Characteristics in the Content Produced by Diabetic Male Creators160 7.1.2 “I’m a diabetic bodybuilder”: Creators and the Display of Their (Masculine) Bodies162 7.1.3 “I will show you that I can make a good risotto for constructing your muscles”: Dealing with Diabetes While Eating Like a Man169 7.1.4 Being Tough and Vulnerable: The Display of Emotions in Male Diabetic Creators174 7.2 Conclusion181 References182 8 Conclusions185 References192 Afterword: Bodies, Selves, and the Social Order195 Index199

List of Figures

Fig. 7.1 Fig. 7.2 Fig. 7.3 Fig. 7.4 Fig. 7.5 Fig. 7.6 Fig. 7.7

Challenging diabetes stereotypes: muscular body display 165 Screenshot illustrating the exposure of a muscular body 167 Screenshot illustrating food transgressions in a diabetes diet regimen173 Screenshot of self-injecting insulin in public 175 A screenshot depicting a Tiktoker’s disengagement from the realm of fear 177 Screenshots of emotional statuses expression in relation to glycemic trends 179 Showing vulnerability through digital narratives of hypoglycemia 180

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List of Tables

Table 3.1 Table 3.2

Inclusion and exclusion criteria for the selection of the final sample Sample information

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CHAPTER 1

Introduction

This book explores men’s health practices in relation to chronic illness. There has been a growing interest in understanding men and their health in recent decades, especially since the 1980s. Nevertheless, few studies have investigated how men experience chronic illness on a daily basis. Research has shown that illness can highlight traits of vulnerability, weakness, passivity, and dependence—attributes conventionally associated with femininity. For men, this invariably challenges the dominant masculine ideals of invulnerability, physical prowess, activity, and independence (Wenger & Oliffe, 2014; Oliffe, 2006; Charmaz, 1995). Men with type 1 diabetes, in particular, display such characteristics, and are the focus of this book. Type 1 diabetes necessitates constant daily self-monitoring of blood sugar levels, and may involve visible signs during social interactions; these signs may include the use of glucose sensors for monitoring blood sugars or either syringes/or insulin pumps for daily insulin administration. Moreover, it underscores the need to regulate physical activity due to the risk of hypoglycemia, and to adopt healthy behaviors, including maintaining a balanced diet. Importantly, these adjustments can potentially pose a threat to traditional masculinity ideals. For these reasons, as well as its effects on men’s bodies,  autoimmune diabetes can spoil men’s sense of masculine identity (Goffman, 1963; Broom & Whittaker, 2004). Diabetes stigma results from the visible manifestations of the illness—the signs and implications are contingent upon the advancement of the disease and the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Quaglia, Wounded Masculinities, https://doi.org/10.1007/978-3-031-44436-4_1

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extent of its complications. They impact not only on societal attitudes toward the illness but also on how individuals perceive themselves. The stigma associated with diabetes necessitates proactive management during interpersonal encounters and it is intricately rooted in societal norms pertaining to masculine and feminine identities. Diabetes is a particularly relevant case study, because, unlike more severe and visible diseases, it permits some degree of negotiation and compensatory practices. In fact, when men discuss their engagement—or lack thereof—in diabetes self-­ management practices, and when they choose to perform these practices, especially in front of others, their actions effectively become crucial to their overall self-presentation (Goffman, 1959). These health practices inevitably constitute part of the repertoire of information that is more or less consciously employed to express themselves and provide a specific account to others. As diabetic men adopt certain self-management practices or refuse others, they are not merely managing their health and illness; they are complying with, challenging or negotiating social ideals of masculinity. Therefore, the “doing” of health and illness is conceived as a specific and situated form of “doing gender” (West & Zimmerman, 1987; Saltonstall, 1993; Riessman, 1990). In line with Connell (2005) and West and Zimmerman  (1987), here  masculinity is not understood as man’s innate quality but rather as an ongoing process of “doing”, a dynamic configuration of practices that changes according to men’s life phases and the particular historical and social contexts. To accomplish gender, men must gain acceptance from their peers, affirming their alignment with the prevalent norms of masculinity  relevant to a given social context.  This mutual scrutiny establishes an environment where those with whom men interact serve as arbiters, ensuring their adherence to societal gender standards and possibly imposing sanctions for deviations (Gerschick, 2000). In fact, the use of the body has become more and more relevant in the last century for the construction of gender identity. Giddens (1991) asserted that the human body has become like  a canvas upon which individuals engage in reflexive action, contributing to the construction of their own identities and how they are perceived by others. The use of the body during social interactions is crucial in the construction of femininities and masculinities (Sassatelli & Ghigi, 2024) and this entails also how women and men signify and adopt—or refuse to adopt—health related practices. In fact, there are other factors that are influenced by societal gender norms. Factors linked to the particular habitus that has been embodied over time, and relate to social class, age, ethnicity, geographic origin, and

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others, all contribute to the emergence of multiple and distinctive ways of performing femininities and masculinities. More specifically, decisions to adhere to the lifestyle recommended by medical professionals or not, to opt for a healthy diet or not, to monitor glycemic levels or not, and to decide whether or not to administer insulin shots or use an insulin pump—and if so, where and how—are all entwined with distinct notions of what constitute appropriate masculine behavior within a particular socio-cultural context. From this perspective, the way in which men participate in health-­ related practices constitutes an integral component of the masculine self-­ representation. These practices are intertwined with a repertoire of social acts performed with the intention of presenting a particular “impression” of oneself to others. The way in which men engage in and attribute significance to health-related practices exerts an influence on the outcomes of health and illness. It is precisely for this reason that, even today, the lower life expectancy of men in comparison to women and their heightened propensity for accidents and increased incidence of specific illnesses are often regarded as outcomes of their intent to demonstrate manhood (Courtenay, 2000). To construct an adequate self-image as “real men” and to gain recognition as such from others, particularly from their male counterparts, men often engage in unhealthy and risky behaviors, a phenomenon that seems to cut across various social classes. The practices demonstrated range from displaying physical strength through physical confrontations and a muscled body, to consuming more alcohol than others, driving recklessly, working for long hours and doing overtime work, and managing work-­ related stress in pursuit of success and increased earnings (Harrison, 1978). While  conducting interviews with men diagnosed with autoimmune diabetes., during the study, right from the outset it emerged that a substantial number of the interviewees displayed a considerable adherence to treatment, having seamlessly incorporated health practices to the extent that they became an unquestionable part of their daily routines. What’s more, in many instances, over time they had developed specific disciplinary technologies (Foucault, 1984)—ritualistic and daily practices aimed at maintaining and improving  their health status, and preventing complications. On one hand, their enactment of masculinity did not seem particularly affected by illness. On the other hand, at first glance, masculinity appeared almost “invisible.” There was no display of rejection of self-care and health practices, save for a few isolated cases. So, I started asking myself: How

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should I interpret this emerging field data? How can I understand masculinity in connection with health and illness, moving beyond the common rhetoric of masculinity being “harmful” to men’s health? In support of a more profound interpretation of the emerging results, the invaluable literature from the realm of Critical Studies on Men and Masculinities (CSMM) has contributed significantly (Hearn & Howson, 2019; Hearn, 2013; Gough & Robertson, 2010). The literature produced in this context aims to go beyond the oversimplistic hypothesis that masculinity is the main cause of men’s poor health outcomes. By promoting a direct link between masculinity and ill health, this hypothesis risks pathologizing masculinity and failing to adequately capture the complexity of its actual realization. This deficit approach inevitably has negative effects and repercussions on the concrete possibility of intervening to improve the psychophysical health of boys, men, and even women, since they are also influenced by how society perceives, produces, and reproduces the different ways of doing masculinity, at times valorizing and at times rejecting them (Hunt, 2010). This work addresses the need for more critical empirical studies that take into account the nuances, complexities, and sometimes even the contradictions that characterize the relationship between masculinity and health so as to advance our understanding of men’s health and illness  (Gough & Robertson, 2010; Lohan, 2007). The CSMM framework underpins  this book which focuses on the different ways in which diabetic men attribute meaning to, adopt, and discursively use those health practices that they are—at least in part—obliged to adopt for survival, all within a coherent presentation of their masculinities. The use of the term “masculinities” in plural form in this context is not coincidental. In accordance with Critical Studies on Men and Masculinities (CSMM), we acknowledge the significant contribution of Australian sociologist Raewyn Connell (2009) who developed an important theory of gender and masculinities, as we will see in the following chapter. Connell has demonstrated that there is no solitary, monolithic, or universal way of embodying and performing masculinity. Instead, there exist various ways of being a man that change over the course of an individual’s life and across different social contexts. These variations are embedded within a hierarchy of masculinities. The dominant ideal of hegemonic masculinity ranks highest at the top of the gender order. It consists of the prevailing ideals of masculinity within a given context. In contemporary Western society, this refers to being white, heterosexual, able-bodied, successful, healthy, physically

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strong, and assertive. Only a select few men manage to attain such hegemonic ideals  despite all men having to assess themselves in some way against those ideals. In light of this, diabetes inherently positions men outside the realm of the hegemonic masculinity ideal- as it undermines expectations of healthiness, physical strength, invulnerability  and autonomy  through a series of physical and emotional challenges. The very title of this book, Wounded Masculinities, echoes Arthur Frank’s seminal work The Wounded Storyteller (2013, p. xi): staying within the famous metaphor, diabetic men become “wounded” for two main reasons. On one hand, it is because of the illness and its implications. On the other hand, it is because of their inability to fully comply with hegemonic ideals of masculinity. In the process of (re) constructing and negotiating one’s masculine self, which is profoundly affected by the unforeseen nature of illness and its incurability, the possibility of narrating one’s experiences emerges as a fundamental facet. In this book, the research focuses on both on “traditional” illness narratives, that are elicited through in-depth interviews, as well as digital health narratives, a phenomenon that has emerged in recent years with the extensive utilization of social media platforms. By sharing their illness stories with others— whether to a researcher or an invisible audience—diabetic storytellers are engaged in a process of sense-making related to their condition. In doing so, they challenge ingrained cultural stereotypes associated with diabetes, while reconciling with the cognitive dissonance resulted from the chasm between societal expectations and the reality of their actual experiences. Within this sense-making process, they actively seek recognition for their daily struggles marked by the ebb and flow of the disease, ultimately finding validation for the reconstruction of their identities. This book aims to delve deeper into the meanings associated with health practices in the context of diabetes self-management. This exploration is accomplished through the discussion of results from two separate studies on the same topic. I will now illustrate how the organization of the book unfolds, along with the presentation of the theoretical framework, the methodology employed, and the emerging results.

1.1   Organization of the Book Chapter 1 provides an overview of contemporary literature on men’s health and illness focusing on the relationship between masculinities, healthrelated practices and outcomes. In both public and scholarly discourse it is

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widely acknowledged that men usually have poorer health outcomes compared to women. Various  disciplines have attempted to understand the nature of these shortcomings, their probable underlying causes, and the potential measures that could be taken to reduce health disparities. In this chapter, various disciplinary perspectives are considered ranging from early biological and psychological explanations to sociological research and theory. Particular attention is given to discussion of the hegemonic masculinity framework and its further developments as well as current  literary works on “third wave” critical studies on men and masculinities to scrutinize its importance in order to understand men’s health and illness. Chapter 2 delves into the complexity of conducting research on men, masculinity, and chronic illness. Two distinct research approaches and techniques that have informed the research are  examined and the results presented in the book. Furthermore, we will reflect critically on the research processes and their implications in terms of studying gender in different empirical contexts and through different methodological techniques. Two main areas are given priority: firstly, the context of qualitative research interviews with diabetic men, and secondly, the use of digital research methods in studying the masculine self-representations of diabetic men on social media. Both represent innovative approaches within the realm of social research, enabling an expansion of knowledge in a field of study that remains, up to this point, largely unexplored. Chapters 3, 4, and 5 each present one of the three ideal types that emerged from the qualitative research conducted with diabetic men. In particular, Chap. 3 is dedicated to the first ideal type of diabetic masculinity, the “Tracker,” and focuses on the role that technology and self-­tracking practices play in the discursive (re)negotiation of masculinities in the context of diabetes. Diabetic people need to master technical self-care skills to survive. In many cases, the participants reframed their competence in ways that enabled a legitimization of hegemonic traits of masculinity. For instance, they discursively employed self-management practices as a medium for representing the self as rational, competent, autonomous, and constantly “in control.” This configuration of health and gender practices combines techno-scientific and biomedical knowledge while showcasing a hybridized form of hegemonic masculinity. The presentation of qualitative research findings continues in Chap. 4, focusing on the “Athlete” ideal type. The different ways in which sports can be considered as a crucial arena of practices for the production,

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reproduction, and negotiation of an “adequate” masculinity for men after the onset of diabetes  are examined and discussed. The diabetic athletes regularly exercise as prescribed by their doctors, but they often go far beyond the suggestion of taking a quiet postprandial walk. They rather engage in endurance training as a means of improving fitness, reducing the dosage of insulin intake, and maintaining psychological well-being. The diabetic men’s emphasis on endurance sports, on the ability to tolerate pain, and on achieving athletic goals while managing diabetes and controlling its symptoms allow them to enact a form of masculinity that not only  embodies self-monitoring practices, but also  compensates for their emasculating potential with hypermasculine sporting performances. Chapter 5 is devoted to the presentation of the third ideal type, namely the “Free Spirit.” Among the three ideal types presented, the “Free Spirit” aligns more than the others with the stereotypical notion that men are less inclined to engage in self-care practices and adhere to medical treatment. This pattern of attitudes and practices illustrates how men might offset the risk of emasculation and diabetes-related health practice stigmatization by resisting the lifestyle prescribed by diabetologists. Rather, they prioritize on daily practices that promote enjoyment, good food, wine, and freedom from diabetes self-management constraints. This form of resistance possesses a gendered dimension. Participants embodying this ideal type reported challenging societal expectations concerning health maintenance, thus reinforcing a form of masculinity linked to ideals of independence, resistance, and a willingness to take risks. In Chap. 6, our exploration delves deeper into the construction of masculinities and their intersection with chronic disease. Our attention will shift toward the specificities of the visual self-presentations of diabetic men on TikTok. Drawing from—as far as I know—the first digital research to explore this topic, particular attention is  given to three themes that emerged as relevant from the study: the display of the diabetic body, the display of men’s emotional statuses, and the presentation of food consumption practices in the complex process of constructing, representing, and performing masculinities online. Chapter 7 documents the contributions of the empirical studies to the current literature on men, masculinities, and health. The intricate interplay between diabetic men’s self-management practices and the doing of their gender identities are discussed. This unique emphasis on men’s illness narratives, whether in digital or physical realms, aims to fill a gap in contemporary sociological knowledge, which  has predominantly

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concentrated on women’s experiences and representations. Contrary to the prevailing assumption that masculinity has a negative impact on men’s health, the research data reveals a more nuanced and complex relationship between men’s health, illness, and masculinity. While a severe chronic illness may threaten established masculine identities, it does not necessarily lead to the adoption of “unhealthy” behaviors when reaffirming one’s gender. Instead, many diabetic men accept their illness, developing specific self-care techniques that align with dominant forms of masculinity. Despite the inherent limitations of this study, its findings hold relevant implications for clinical practice, men’s well-being, and the advancement of gender equity.

References Broom, D., & Whittaker, A. (2004). Controlling diabetes, controlling diabetics: moral language in the management of diabetes type 2. Social Science & Medicine, 58(11), 2371–2382. Charmaz, K. (1995). Identity, dilemmas of chronically ill men. In D.  Sabo & D.  F. Gordon (Eds.), Men’s health and illness: Gender, power and the body (pp. 266–291). Sage Publications. Connell, R. W. (2005). Masculinities. Berkeley. Connell, R. W. (2009). Gender: In world perspective. Polity Press. Courtenay, W.  H. (2000). Constructions of masculinity and their influence on men’s well-being: a theory of gender and health. Social Science & Medicine, 50(10), 1385–1401. Foucault, M. (1984). Docile bodies. In P. Rabinow (Ed.), The Foucault reader. Pantheon Books. Frank, A. W. (2013). The wounded storyteller: Body, illness & ethics. University of Chicago Press. Gerschick, T. J. (2000). Toward a theory of disability and gender signs. Journal of Women in Culture and Society, 25(4), 1263–1268. https://doi.org/10.1086/ 495558 Giddens, A. (1991). Modernity and self-identity: Self and society in the late modern age. Stanford University Press. Goffman, E. (1959). The presentation of self in everyday life. Anchor Books. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Touchstone. Kindle Edition. Gough, B., & Robertson, S. (2010). Men, masculinities and health: Critical perspectives. Palgrave Macmillan. Harrison, J. (1978). Warning: The male sex role may be dangerous to your health. Journal of Social Issues, 34(1), 65–86.

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Hearn, J. (2013). Methods and methodologies in critical studies on men and masculinities. In Men, masculinities and methodologies (pp.  26–38). Palgrave Macmillan UK. Hearn, J., & Howson, R. (2019). The institutionalization of (critical) studies on men and masculinities. In L.  Gottzén, U.  Mellström, & T.  Shefer (Eds.), Routledge international handbook of masculinity studies (pp. 19–30). Routledge. Hunt, K. (2010). Foreword. In B.  Gough & S.  Robertson (Eds.), Men, Masculinities and health: Critical perspectives. Palgrave Macmillan. Lohan, M. (2007). How might we understand men’s health better? Integrating explanations from critical studies on men and inequalities in health. Social Science & Medicine, 65(3), 493–504. Oliffe, J. (2006). Embodied masculinity and androgen deprivation therapy. Sociology of Health & Illness, 28(4), 410–432. Riessman, C. K. (1990). Strategic uses of narrative in the presentation of self and illness: A research note. Social Science & Medicine, 30(11), 1195–1200. Saltonstall, R. (1993). Healthy bodies, social bodies: men’s and women’s concepts and practices of health in everyday life. Social Science & Medicine, 36(1), 7–14. Sassatelli, R., & Ghigi, R. (2024). Body and gender. Polity Press. Wenger, L. M., & Oliffe, J. L. (2014). Men managing cancer: A gender analysis. Sociology of Health & Illness, 36(1), 108–122. West, C., & Zimmerman, D.  H. (1987). Doing gender. Gender & Society, 1(2), 125–151.

CHAPTER 2

The Current Context of Men’s Health and Illness

2.1   Introduction The terms “women’s health” and “men’s health” have become widely used in public discourse and health policy. Traditionally, these phrases have been viewed as straightforward and self-evident, assuming that health issues are distinctly associated with one’s biological sex. In public discourse as well as in academic debate, men are usually perceived as experiencing poorer health outcomes compared to women, which is attributed to physical factors such as hormones (biological sex) or unhealthy and risk-taking behaviors (gender). However, recent debates surrounding men’s and women’s health reveal a much more complex reality, challenging the assumed simplicity of this association (Schofield et al., 2000). This chapter aims to give an account of the complexity that characterizes research and theorization in this field, with a specific focus on how different disciplines have developed discussions about and provided explanations for the influence of masculinity on men’s practices, and the subsequent health outcomes. In doing so, the aim is to go beyond the simplistic approach to men’s health and delve into the complex relation between masculinities, health, and illness. Studying men is not a novel or inherently radical endeavor. Historically, men have been studying men under the guise of various disciplines such as history, medicine, or sociology, although these studies may not have been explicitly about men. In contrast, contemporary literature presents © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Quaglia, Wounded Masculinities, https://doi.org/10.1007/978-3-031-44436-4_2

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alternative ways of theorizing and studying men, such as through feminist, gay, queer, and pro-feminist perspectives. Critiques outside the male-­ dominated mainstream, including some postcolonial writings, provide different lenses to explore men as a social category, a gender class, specific groups, or diverse collections of individuals who identify as men (Hearn, 2004). These diverse perspectives offer valuable insights into the complexities of masculinities and their relation to health and illness. To problematize masculinity in relation to health (Robertson, 2007; Lohan, 2007), we begin by briefly examining early biological and psychological explanations of masculinities and health. However, the core of the chapter delves much deeper into the realm of sociological understandings, exploring a wide range of different perspectives. Particular attention will be dedicated to the debate on the hegemonic masculinity framework and its further developments, as well as contemporary literature on third wave critical studies on men and masculinities, which has yet to be fully explored by researchers in the fields of men’s health and illness (Robertson & Kilvington-Dowd, 2019). The aim of exploring these different perspectives is to conduct a comprehensive review of the literature—and trace its evolution and criticisms over time—on men’s health and illness, moving beyond simplistic notions that have prevailed in the past and that still influence public discourse, policy, and research. Instead, the aim is to conceptualize men’s health and illness experiences by going beyond the mere individual level and considering the fields as influenced by gender structures, power relations, and broader social and cultural contexts.

2.2   Men’s Health and Illness: Nature or Nurture? Public discourses and research have observed that men’s experiences with health and illness vary significantly from those of women. Almost everywhere in the world, statistics consistently demonstrate that men, in comparison to women, encounter a considerable number of adverse health outcomes. Men’s life expectancy demonstrates substantial disparities between countries, with variations of up to 17 years. Additionally, substantial within-country differences persist among men from various socioeconomic backgrounds (WHO, 2018; Eurostat, 2023). In Italy, where the research presented in this book has been conducted, the estimated life expectancy at birth is 80.5 years for men and 84.8 years for women (ISTAT, 2023).

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In recent decades, an ongoing debate has emerged concerning the reasons for men’s health disparities, the possible underlying causes, and the potential actions to be taken to reduce them. For a considerable period, a prevailing perspective has revolved around sex-related explanations, which refers to biological characteristics. This literature highlights the influence of sex on disease risks, progression, and outcomes through diverse mechanisms such as genetic factors (e.g., the function of X and Y chromosomes) and various physiological pathways, including hormonal regulation. These processes may result in differences in vulnerability to diseases, the advancement of diseases, reactions to treatments, and overall health consequences, and are prone to fluctuate during various life phases (WHO, 2021). This approach is still used mainly in biomedical literature. For instance, Baker et al. (2003) found that women before menopause experience lower rates of heart disease compared to men, mainly due to the protective effects of estrogen against atherosclerosis. However, after menopause, when the levels of estrogen are lower, rates of cardiovascular disease become similar for both men and women. Understanding the influence of genetics and physiology in sex-based health differences is indeed crucial for accurate diagnosis and treatment approaches, as Baker et al. (2003) suggest. In the case of women, this branch of study usually understands and discusses health by referring to hormonal-related and/or reproductive pathologies such as breast and cervical cancer. Similarly, in the case of men the focus is on pathologies regarding their reproductive organs, for example prostate and testicular cancer. These explanations have posited that various male biological determinants, many of which are considered unchangeable, contribute to men’s health outcomes. Within this biological framework, biological sex has been considered the primary determinant also of health behaviors, with the underlying assumption that aggression and risk-taking behaviors are intrinsic expressions of male’s hormones. Such cause-effect relationships have been used to account for and, to some extent, accept the status quo surrounding men’s poorer health outcomes. Hormones levels have, for instance, been linked to male aggression and violence, which, in turn, are believed to lead to negative consequences, including homicide and suicide. Male psyches were believed to be intrinsically hardwired to engage in behaviors that jeopardize rather than promote their own health. By essentializing men through this lens, biologically driven masculine attitudes have been depicted as the underlying factor behind men’s risky behaviors, and the resulting health issues and life expectancy have been associated with them (Creighton & Oliffe, 2010).

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Otherwise, this type of literature usually concentrates on the margins of difference between men and women in terms of mortality rates, diseases, and other related factors (Schofield et al., 2000). This sex-related approach has its roots in essentialism, a perspective that has been a persistent aspect of modern Western thought, which entails the belief in a supposed unchanging essence, be it related to sex or gender, race, or any other characteristic (Petersen, 2009). Although second wave and later forms of feminism extensively sought to challenge the idea of biology-as-destiny by placing attention on the historical and cross-cultural variations in constructions of masculinity and femininity, the notion of complementary and essentialist differences between men and women continues to shape policies and actions concerning men’s (and women’s) health (Petersen, 2009). This two-sex/two-gender model, stemming from Enlightenment thinking to reduce women’s involvement in the public sphere, at the time received significant support from philosophers and anatomists. Many scientists, social scientists, feminists, and pro-feminist male scholars and activists have often uncritically adopted such theories, reinforcing essentialist differences between the sexes in their writings (Petersen, 2009). Interestingly, in the context of research funding, social sciences tend to receive less support compared to physical sciences, with biomedical research taking the lead in the health research agenda. Consequently, the literature has mostly explored sex differences, while the influence of gender has received comparatively less attention (Robertson & Kilvington-­ Dowd, 2019). The essentialist perspective has received a number of criticisms, as it fails to grasp the complex interplay of social and cultural factors that also shape men’s health behaviors and outcomes. Another criticism is that it overlooks within-sex inequalities, such as those related to social class, ethnicity, sexuality, and other identity dimensions (Robertson & Kilvington-­ Dowd, 2019). Health differences and inequalities cannot be only attributed to biology. A first step beyond the biomedical framework consists of considering the different exposure to risk factors, which are influenced by their respective social contexts, that individuals may experience for the fact of being a woman or a man. For instance, in comparison to men and boys, women and girls globally encounter greater obstacles when attempting to access crucial health information and services. These barriers encompass restrictions on mobility, limited ability to make informed decisions regarding health, lower education rates, discriminatory attitudes prevailing in

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communities and among healthcare workers, and a lack of training and awareness within healthcare systems concerning the health needs and challenges specific to women and girls (WHO, 2023). As a consequence, women and girls have elevated risks of adverse health outcomes, including unintended pregnancies, sexually transmitted infections such as HIV, cervical cancer, malnutrition, and respiratory infections. Moreover, they face alarmingly high levels of violence rooted in gender inequality and remain at grave risk of enduring harmful practices, such as female genital mutilation and child, early, and forced marriage. Furthermore, statistics from the World Health Organization reveal that approximately one in three women globally has experienced physical and/or sexual intimate partner abuse or non-partner sexual violence during their lifetime (WHO, 2023). Just like women, men’s risk exposures and responses from the healthcare system are influenced by multiple factors (WHO, 2018). For deaths among men, a substantial 86% are caused by noncommunicable diseases and injuries, with cardiovascular disease, cancer, diabetes, and respiratory diseases being the primary causes for disease-related mortality (WHO, 2018). Such diseases are, more than others, the result of the adopted lifestyle and unhealthy habits. Injuries represent the second leading cause of premature death among men and are the principal cause of mortality for boys aged 5–19 (WHO, 2018). Men’s higher rates of physical injuries often result from work-related accidents or motor vehicle incidents (Scott, 2015). Furthermore, in comparison to women, men visit doctors less frequently and consistently report fewer unmet healthcare needs. Moreover, men, irrespective of their socioeconomic background, have unhealthier smoking habits, poorer dietary behaviors, higher alcohol consumption rates, and increased incidences of injuries and interpersonal violence compared to women. These risky and unhealthy behaviors combined with the underutilization of healthcare services by men are observed across many countries and are influenced by both socioeconomic factors and prevailing norms related to masculinity (WHO, 2018; Scott, 2015). As a result, it is important to consider not only sex but also gender in relation to health. Gender is, in fact, a social construct encompassing the ideals socially ascribed to women, men, girls, and boys, including attitudes and behaviors typically considered as feminine or masculine. These ideals vary across societies and change over time, shaping the way women and men construct their masculine and feminine identities within different cultural contexts. Gender norms exert a significant influence on boys’ and men’s health, contributing to health disparities between genders. Gender is here

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understood from a constructivist perspective, drawing on West and Zimmerman’s conceptualization of “doing gender.” This approach takes an ethnomethodologically informed sociological stance, interpreting gender as an ongoing, systematic, and repeated accomplishment. According to the symbolic interactionist framework of “doing gender,” gender is not an inherent property of individuals, but rather something women and men “do” (West & Zimmerman, 1987). Frequently, scholars within the field of biological sciences tend to merge the concepts of gender and those of biological sex, leading to a considerable number of publications apparently exploring gender while focusing on biologically determined sex distinctions. Collapsing sex and gender in such a way gives rise to a series of considerations. First, it may lead to essentializing men’s and women’s health outcomes, wherein the outcomes and the sex disparities within them are perceived as directly arising from the influence of biological factors such as the chromosomes, hormones (testosterone, in the case of men, and estrogens in the case of women), or other sex-specific physiological differences. Furthermore, failing to acknowledge the distinctions between the impacts of sex and gender on health poses the risk of overemphasizing sex differences (Robertson & Kilvington-Dowd, 2019). By conflating sex and gender, the risk is oversimplifying complex health outcomes and perpetuating a reductionist perspective that attributes variations solely to biological determinants. This perspective disregards the nuanced interplay between biological, social, and cultural factors that shape men’s health inequalities. The distinction made above between the differentiated effects of sex and gender on men’s health, is a simplification, and it has been made primarily for analytical purposes. Nevertheless, as Lohan (2007) notes, it is sometimes difficult, if not impossible, to separate the effects of gender from those of biological sex. Some scholars have analyzed how the social and the biological interact with each other, particularly over time (Annandale, 2003; Fausto-Sterling, 2003; Krieger, 2003; Birke, 2003). To obtain a deeper understanding of men’s health, it is important to adopt a framework that takes into account the mutual shaping and interconnection of different dimensions, including biological, social, and cultural. This approach allows for an in-depth analysis that acknowledges the complex interactions between these factors and how they impact men’s health. In the following sections, we will explore the evolution of research and theorization focusing on gender, and in particular on masculinity and

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men’s health, with a specific focus on relational theory, its developments, and its relevance in this regard. 2.2.1   The Emergence of Critical Studies on Men and Masculinities Over the past decades, there has been a significant emergence of theorizing and empirical evidence studying the relation between masculinity and men’s health. Research has demonstrated that gender identities and relations play a significant role in shaping men’s health and illness practices (Creighton & Oliffe, 2010; Robertson, 2007; Sabo & Gordon, 1995). Gender-related explanations emerged in the 1960s and 1970s as a critical response to the so-called biomedical model dominant at the time. In this regard, researchers focused on the model’s mechanistic approach, the overemphasis on biochemical processes, and its overly simplistic explanations that attribute disease to mere etiological factors (Engel, 1977). In the sociocultural model, instead, health and illness are primarily conceptualized in relation to cultural, social, psychological, and contextual factors. Therefore, some health differences are defined as inequalities because they are socially produced, systematic, and unfair in their distribution (Dahlgren et al., 2006; Cardano et al., 2004; Terraneo, 2015). In this perspective, gender came to be considered as one of the relevant elements affecting health and illness and health inequalities (Sabo & Gordon, 1995). Initially, researchers adopted a more simplistic approach, and considered gender merely as another demographic variable. The aim was to identify health patterns and risk factors. This approach was valuable in epidemiological studies that showed differing rates of illness between men and women, and among various subgroups of men based on factors such as race, ethnicity, socioeconomic status, or residential area. Descriptive research findings showed different disparities, indicating that men experience more life-threatening diseases and have a shorter life expectancy compared to women, while women encounter more non-life-threatening illnesses and live longer (Sabo & Gordon, 1995). The findings of this body of research clearly indicated that relying only on biomedical explanations was insufficient to fully understand the diverse health and illness patterns experienced by women and men. Instead, it emphasized the critical role of gender as a determinant for achieving a comprehensive understanding in sociocultural explanations of health and illness (Sabo & Gordon, 1995).

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Over the following years, during the 1970s and 1980s, researchers made significant progress in theorizing the interconnections between gender and health. These advancements were largely driven by the women’s health movement and the growth of feminist scholarship. Scholars investigated how different gender socialization processes influenced individuals’ perceptions of illness and adjustments to death (Sabo & Gordon, 1995). Moreover, they also documented instances of sex discrimination within the healthcare system and the gender-based stratification within health professions (Muff, 1982; quoted in Sabo & Gordon, 1995). Feminist philosophers of science critically examined how patriarchal and androcentric biases influenced medical science (Sabo & Gordon, 1995). Sexism and structured sex inequality, they claimed, could lead to the misdiagnosis and maltreatment of female patients. This body of research provided a richer understanding of the intricate intersections between gender and health and highlighted the pressing need to address gender-related disparities within healthcare systems and practices. Following these years, a literature started to develop focusing on men and masculinities. It has been defined through different terms, including “Men’s Studies,” “Masculinity Studies,” “Critical Masculinities Studies,” “Critical Men’s Studies,” “Male Dominance Studies,” “Studies on Men and Masculinities,” “Critical Studies on Men,” and “Critical Masculinities Studies.” Although these different namings might seem synonymous, they actually imply different ontologies, epistemologies, and relationships with feminism, and, as a consequence, different ways of understanding men and masculinities (Ibidem). In particular, Hearn (2004), and Hearn and Howson (2020) offer a helpful differentiation between two different types of literature that focus on men and masculinities: Men’s Studies and Critical Studies on Men. Men’s Studies is a term that has different connotations: it might sometimes be synonymous with Critical Studies on Men, but most of the time its meaning is ambiguous because it is not clear whether it refers to studies on men or studies that belong to men, as a form of homosocial arena (Hearn & Howson, 2020; Hearn, 2004). Usually, Men’s Studies refers to a branch which stems from an intellectual and community-based movement, taking an anti-feminist stance and claiming that a supposedly natural order in gender relations has been disrupted by women’s recent attempts to gain more power in different social arenas, leading men to experience greater disadvantage compared to women in contexts such as employment, education, and intimate relationships (Lohan, 2010). In this

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perspective, such societal changes would thus be the cause of an alleged crisis in masculinity or men’s crisis (e.g., Bly, 1990; Faludi, 1999; Kenway, 1995), to which studies would respond by promoting male bonding and suggesting the return to an idealized and essentialist notion of manliness. This perspective portrays men as victims of a society that prioritizes femininity and women’s issues at the expense of strong masculinities (Creighton & Oliffe, 2010; Hearn, 2004). This interpretation of societal change has been subject to debate, and as Lohan (2007) contends, attributing men’s ill health solely to symbolic subjugation overlooks the tangible reality of women’s inequality. Therefore, the label “Men’s Studies” seems to be an equivalent to “Women’s Studies,” but, on the contrary, does not imply any interest in fostering feminist theory and practice (Hearn, 2004). On the other hand, Critical Studies on Men and Masculinities (CSMM) emerges from feminist, gay, and queer studies, and is an interdisciplinary field that developed in the 1980s with the aim of examining men and masculinity through a critical perspective that explicitly takes into account the gendered nature of men’s lives and experiences (Hearn & Howson, 2020; Lohan, 2010; Kimmel et al., 2005; Hearn, 2004; Brod & Kaufman, 1994). Edwards (2004) identifies a three-phase or wave model of CSSM. The first phase or wave is characterized by studies mainly relying on the sex role paradigm in the 1970s (David & Brannon, 1976; Farrell, 1974; Tolson, 1977). Despite some differences, the main emphasis of these studies was, on the one hand, to highlight the social construction of masculinity and to challenge the idea of biological essentialism that characterized previous literature on the topic. For instance, psychoanalytic thinkers, including Freud, Chodorow, and Dinnerstein, developed theories suggesting that masculine and feminine behaviors are shaped by complex psychological processes (Creighton & Oliffe, 2010). In this framework, the male sex role is intended as the result of the socialization process that begins during childhood and is reinforced throughout men’s lives, and includes a set of expectations and behaviors that men are socialized into, such as being strong, resistant, independent, and dominant. On the other hand, sex role theorists emphasized how socialization to a traditional masculinity model could have a negative impact on men and on their mental and physical health, increasing the risk of injuries and specific illnesses (Goldberg, 1976; Harrison, 1978; Nathanson, 1977). For instance, research in this field posited that men’s avoidance of seeking help in healthcare services

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was associated with cultural norms of masculinity that prioritize self-­ reliance and stoicism. This framework for understanding men’s health has been defined as the “deficit model of men’s health” (Sabo, 2005, p. 327), whereas the male role socialization and sex role-related behaviors (Harrison, 1978, p. 81) were thought to be responsible for the higher mortality rate of men. These theories frequently delve into the male inclination for risk-taking and provide valuable insights into the mechanisms through which gender is learned and performed (Scott, 2015). The socialization to the traditional masculinity role was in fact associated with specific masculine behaviors that elevated health risks, such as drinking, smoking, fighting, experiencing career-related stress, competition, concealing emotions, and symptom denial. As Harrison (1978, p. 83) stated: Contemporary research has failed to demonstrate the existence of important intrinsic psychological differences between men and women. However, research on sex-role stereotypes demonstrates the persistence of the belief in such differences in personality traits (Rosenkrantz et al., 1968). This continuing belief brings to mind W. I. Thomas’s famous dictum: ‘If men [people] define situations as real, they are real in their consequences’ (1928, p. 572). It is time that men especially begin to comprehend that the price paid for belief in the male role is shorter life expectancy. The male sex role will become less hazardous to our health only insofar as it ceases to be defined as opposite to the female role, and comes to be defined as one genuinely human way to live.

Initially, psychologists in the 1970s viewed masculinity as a combination of traits that could be identified and measured, and developed specific psychological scales, such as Bem’s Sex Role Inventory (Bem, 1974). Bem’s study on sex role typology has been important for questioning the legitimacy of attributing uniform, sex-based behaviors. She also argued that Western cultures were highly influenced by gender norms, leading even young children to adopt dominant notions of sex-typed behavior (Creighton & Oliffe, 2010). In this perspective, masculinity was represented as an inner psychological process deeply intertwined with external sex roles and societal gender expectations. An illustrative example of this is Robert Brannon’s work (1976), where he outlined four major elements that are distinctive of the male sex role:

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• No sissy stuff: it requires men to be different from women; • Be a big wheel: it invites men to become successful in order to be superior to others; • Be a sturdy oak: it indicates the imperative to be independent and self-reliant; • Give ‘em hell: it refers to the expectation of becoming more powerful than others, even by force if necessary. Boys’ learning and adoption of practices that are considered masculine are strongly influenced by gender socialization processes, where encouragement to fulfill these roles is fostered by a variety of implicit or explicit positive incentives and social sanctions, aimed at facilitating adherence to gender norms. Through a combination of positive and negative reinforcement, the majority of children would acquire gender-appropriate behaviors, adopt traits that align with societal expectations for either women or men, and, consequently, internalize those norms. As a result, they would become fully socialized members of the community, and would in turn apply negative sanctions to those who deviate from the established gender norms, transmitting these societal expectations to future generations. The sex role model is often applied in health research in two distinct ways, which create a paradoxical situation for men. First, it suggests that adherence to traditional male roles, characterized by prolonged working hours, pressure to achieve success, and engagement in risk-taking behaviors, can have detrimental effects on both psychological and physical health. On the other hand, the inability to meet these societal expectations may generate additional strains and pressures, ultimately inducing feelings of failure, stress, and consequent health symptoms (Robertson, 2009). This intricate interplay of conforming to or deviating from traditional male norms poses significant challenges to men’s overall health and well-being. In particular, the pressure to conform to the Give ‘em hell imperative can be at the origin of binge drinking or fast driving, which is one of the main causes of male teenager deaths (Sabo & Gordon, 1995). The pressure to embody an unwavering image of strength and independence, while avoiding any semblance of feminine dependence, may contribute to men’s tendency to deny various symptoms and bodily signs of illness. Although role theory has been important to better understand how gender is learned and performed, and in opening the possibility of understanding gender as located on a continuum instead of as a simple

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male–female dichotomy, it has been criticized for two main reasons. First, because it focuses on individualistic and psychological analysis of dichotomic gendered behaviors and personality traits. Boy’s and men’s practices relating to health were simplistically conceived as a series of behaviors, thus partially reproducing the biological essentialism that the same sex role scholars were trying to overcome (Creighton & Oliffe, 2010). Additionally, Petersen (2009) has pointed out that, similar to feminists from the developing world who have criticized the universalization of concepts like “women” and “sisterhood” introduced by white Western feminists, men and women belonging to minority ethnic and LGBTQI+ communities—who have experienced intra-gender inequalities—have tried to challenge essentialist frameworks mostly developed by white, heterosexual scholars, who generalized in their writings by talking of men’s experiences without acknowledging systems of power and privilege that influence men’s lives. In light of these criticisms, between the late 1970s and the 1980s, feminist sociologists debated the necessity of abandoning the sex roles perspective in favor of a gender relational model that took into account how gender roles changed over time as well as gender relations (Messner, 1998; Connell, 1996). This second phase or wave of CSMM emerged during those years, with the main purpose of criticizing the first wave. In this regard, some authors argued that the term “role” was not appropriate for describing gender (Lopata & Thorne, 1978). The notion of gender role, which is understood as learned behavior based on biological sex, cannot be directly compared, for instance, to the role of a teacher, sister, or friend (Ibidem). The concept of a sex role overlooks essential dimensions such as social contexts, historical influences, life cycle phases, and cultural factors. Furthermore, sex roles imply static and unchanging behaviors and expectations for both women and men, which has been rightfully criticized, since it is not the case with race roles or class roles. Unlike sex roles, these other roles have never been part of sociological discourse (Ibidem). Another criticism concerns the fact that this approach implicitly represents men as a homogeneous group. The concept of sex roles has in fact been subject to critique for lacking historical perspective and, thus, for not considering change over time. According to the sex role perspective, individuals are portrayed as empty vessels at birth that undergo socialization processes determining their specific ways of being, such as adhering to certain masculine norms. Consequently, the mere focus on socialization processes  tends to homogenize men and their behaviors,

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disregarding individual nuances and variations (Carrigan et  al., 1985). Furthermore, it has also been argued that the emphasis on a general and abstract difference in sex roles oversimplifies the complexity of gender relations that are located within power systems in specific social contexts (Segal, 1997). In addition, another observation regards the fact that the sex-role model overlooks structure at the micro-level. In fact, the emphasis on the macro level of socialization limits the exploration of issues of structure and agency in interactions. For instance, this approach hinders the exploration of potential barriers that health professionals and healthcare systems may pose to men’s access to health services (Robertson, 2009). Other authors (e.g., Feigen-Fasteau, 1974; Farrell, 1975) questioned the appropriateness of sex role theory, pointing out that it did not consider—and rather normalized—the existing gender order. Another significant insight was that, despite exploring masculinity in relation to health (e.g., Harrison, 1978), this literature actually tended to frame it in medical terms and to pathologize it (Ibidem). 2.2.2   Understanding Men’s Health Through Relational Theory To go beyond the limits of the sex role theory, it has been crucial to look at the work of Raewyn Connell (1987), and in particular the development of the concept of hegemonic masculinity, embedded in a broader social theory of gender. Connell merged a critical feminist approach with elements of social constructionism, in this way combining Gayle Rubin’s (1975) analyses of the sex/gender system with the approach to hegemony developed by Gramsci (1971, or. ed. 1932). This framework also provided a link between the field of critical studies on men, sociological theories of gender, and feminist accounts of patriarchy. While most of the literature on gender had focused on women and femininity, Connell’s (1995) theory was the first account that specifically aimed at better understanding the construction of masculinity. It has been essential in overcoming sociobiological and sex role theory essentialist and deterministic explanations of men and their social practices, which had prevailed in sociological research on men since the 1950s. Connell instead proposed a relational model, within which gender was conceived as an organized system that can only be understood by considering the relations between the delineated forms of masculinity and femininity. To have an in-depth understanding of masculinity, it is crucial to first give an account of the larger structure of gender relations in which masculinities are situated. Gender, according to

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Connell, “is a relation involving multiple people and categories, linking bodies and institutions” (Connell, 2012, p. 1677). In fact, her relational theory acknowledges gender as a multidimensional concept: it is not only about personal identity, but it involves dimensions such as economic relations, power relations, as well as affective and symbolic relations. The main focus of scholars adopting this perspective is studying how gender is enacted in everyday social practice, considering contexts such as paid labor, parenting and care practices, and sexuality. Such practices are not isolated, but occur in specific institutions and contexts such as families, governments, and companies (Connell, 2012). The underlying assumption is that such practices are ordered and shaped by a social structure, by “the large-scale patterns that can be found across these institutions and sites—patterns such as the contrast between masculinity and femininity, the gender division of labor in the home, or the organization of sexual desire along heterosexual/homosexual lines” (Ibidem, p. 1677). In this perspective, gender is a social structure that shapes and orders social practices. A specific structure of gender relations in a specific historical time and in a specific society is defined by Connell as gender order, while a specific structure of gender relations in a specific institution is defined as gender regimes. The mapping of gender orders and gender regimes is one of the main aims of gender-focused social science research. Another important feature of relational gender theory is that it brings attention to the body, which is particularly relevant for research on health and illness. In fact, bodies and social processes are deeply intertwined. Just as social class differences—mainly in terms of income, education, and cultural resources—have an impact on bodies in terms of limitations and possibilities (e.g., in nutrition, health prevention practices, work injuries), the same mechanism applies in the case of gender. In this regard, Connell (2012) observes that gender is, in fact, a particular form of social embodiment that is linked to bodily structures and processes of human reproduction. It involves a complex interplay of human social practices, encompassing various activities such as childcare, birthing, and sexual interactions, which utilize the bodily capacities related to engendering, giving birth, lactation, and giving and receiving sexual pleasure (Connell & Pearse, 2015). Understanding gender requires recognizing the intricate connection between social and bodily processes. These bodily capacities and their associated practices take place in what Connell has termed the “reproductive arena,” a bodily site where reproductive possibilities assume specific social forms that are deeply connected

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to the historical context and are characterized by constant change over time. Patriarchal gender orders are fundamentally characterized by the institutionalized control exerted by men over women’s reproductive capacities. Various groups of women have sought to transform these dynamics and foster more egalitarian relations within the reproductive arena, which has given rise to some of the most contentious struggles in modern global development, encompassing debates on topics like abortion rights, access to contraception, and technocratic policymaking (Connell, 2012). Just as femininities are subject to contestation, so too are masculinities. Masculinities encompass patterns of social practice that relate to the biological attributes of male bodies, such as their capacities for work, but also violence, and fatherhood. However, masculinities are not determined by mere biological factors. In fact, as shown by the work of Jack Halberstam (1998), people with female bodies can also enact masculine identities. Moreover, there exists considerable diversity in the manifestations of masculinity across various cultures and regions worldwide. According to Connell, masculinities are not mere identities, nor men’s bodies that can be reduced to their genitalia. Masculine and feminine bodies are shaped by gendered patterns of social practices, encompassing, for example, how women and men engage in sports, how they eat, their type of work, and their level of education, which, in turn, contribute to specific bodily attributes and vulnerabilities. Relational theory allows health researchers to go beyond the simplistic idea that masculinity is dangerous for men’s health, as role theory posited. It points to the necessity of considering the multiple dimensions that characterize masculinity and masculine bodies. Contemporary discussions on gender, race, and class have led to the recognition of multiple masculinities, acknowledging, for example, the existence of black, white, working-class, or middle-class masculinities. However, relational theory allows us to go beyond a mere categorization of different masculinities, and invites to consider the interplay between them. To avoid oversimplification, a thorough analysis of gender relations among men is crucial, as it prevents diverse masculinities from collapsing into rigid typologies. In this regard, it’s useful to refer to the concept of gender hierarchy, where masculinities and femininities are differently located depending on power relations between them. The type of masculinity that Connell defines as hegemonic occupies the top position, dominating all other forms of masculinities and femininities. Nonetheless, it is crucial to keep in mind that hegemonic masculinity is not a fixed type, but

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rather a contested position that varies depending on the particular pattern of gender relations in a given historical time and social context (Connell & Messerschmidt, 2005). The form of masculinity that is hegemonic in a specific time and social context is therefore not static, but rather dynamic and open to variation. In the case of Western gender order, hegemonic masculinity implies being white, heterosexual, wealthy, powerful, physically strong, and healthy. Hegemony is constructed through the subordination of women and through the marginalization and subordination of alternative forms of masculinity. Hegemonic masculinity is the most influential enactment of masculinity because though it is socially sustained, it is not necessarily embodied and performed by the majority of actual men. At the same time, it is normative enough to require men to fit it or to position themselves in relation to it. The concept of hegemonic masculinity, formulated three decades ago, has been extensively used in the literature and in empirical research in many different fields, from education (e.g., Skelton, 1993; Martino, 1995) to criminology (e.g., Messerschmidt, 1993), from media representations of men (e.g., Jansen & Sabo, 1994) to health (e.g., Sabo & Gordon, 1995). This concept holds significance in understanding men’s health. For instance, when examining the hegemonic ideal of men playing sports, it becomes evident that many practices within elite sports can be detrimental to men’s bodies and well-being. We can think about the intense stress, the on-field violence, and the overtraining that are some of the aspects that exemplify this (Schofield et al., 2000). Moreover, the culture of elite sports, emphasizing competition and aggression, is linked to health issues such as violence—and consequent injuries— steroid abuse, and stoicism, as well as resistance to pain and denial of vulnerability (Ibidem). Hegemonic masculinity may also be connected to other health issues. Masculine camaraderie is, for example, associated with patterns of alcohol abuse, and displays of toughness can contribute to certain forms of violence in homosocial contexts. Even diet choices, such as consuming a diet high in red meat and low in fresh vegetables, can have masculine symbolism (Fidolini, 2022; Ferrero Camoletto & Scavarda, 2020). Furthermore, the desire to exhibit toughness and hide vulnerability may lead men to be reluctant to seek help, engage in health prevention practices, or disclose their problems (Schofield et al., 2000). Hegemonic masculinity is not the only form of masculinity within gender hierarchy. Next in the gender hierarchy is complicit masculinity, where the majority of men don’t actually meet these idealized standards, yet are complicit in sustaining its hegemony and in benefitting from what Connell

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defined as the patriarchal dividend. That is to say, “the advantage men in general gain from the overall subordination of women” (Connell, 1995, p.  79). Complicit masculinity referred to the cases in which men don’t embody hegemonic masculinity, yet realize the patriarchal dividend without the tension and risk of being “the frontline troops of patriarchy” (Ibidem, p. 79). As Connell (1995, p. 80) defines it: A great many men who draw the patriarchal dividend also respect their wives and mothers, are never violent towards women, do their accustomed share of the housework, bring home the family wage, and can easily convince themselves that feminists must be bra-burning extremists.

There are then a further number of masculinities and femininities that exist in a subordinated relationship to hegemonic masculinity. Connell (Ibidem) identified the most important case—within contemporary European and American society—in the dominance of heterosexual men over homosexual men. Gay men are perceived as the opposite of the so-­ called real men, and their subordinated relationship to hegemonic masculinity goes beyond cultural stigmatization of homosexuality, because it includes a variety of material practices. These practices include “political and cultural exclusion, cultural abuse (in the United States gay men have now become the main symbolic target of the religious statutes), street violence (ranging from intimidation to murder), economic discrimination and personal boycotts” (Ibidem, p. 78). Homosexual masculinity ranks at the bottom of the gender hierarchy among men, mainly because it is culturally assimilated to femininity: gayness often embodiesat the level of stereotypical representations—those traits that are more distant from the hegemonic ideals, ranging from taste in decoration to desire for receptive anal pleasure (Ibidem). When examining health, it is essential to consider the dynamics between heterosexual and homosexual masculinities. Homosexual men, in particular, face heightened physical and mental health risks due to potential exposure to homophobic violence from heterosexual men, which can even lead to fatal outcomes. Furthermore, it should also be considered that healthcare professionals incorporate gender stereotypes and prejudices, which can in turn have a negative impact on non-heterosexual men (Schofield et al., 2000). With regard to the issue of health, in addition to being subordinated to the leading position in the gender order, physical or mental differences may challenge even more the norms and demands of hegemonic

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masculinity, which could result in what Connell defines as marginalized masculinities. Unlike homosexual masculinity, in this case there may be no direct threat to some specific expression of masculinity, yet men located in this position of the hierarchy may be excluded from full participation in society by material practices (Robertson, 2007). As previously mentioned, during the early stages of feminism there was a tendency to categorize men and women as monolithic and homogeneous groups. On the contrary, Connell’s concept of gender hierarchy is particularly useful because it challenges oversimplistic and dualistic notions of gender differences in health, in illness, and in mortality: in fact, in some contexts, differences in behaviors between men are more relevant than differences between women and men (Petersen, 2009). Gender relational theory encompasses the different and evolving nature of masculinities in their multiplicity, acknowledging their different positions within societal structure. With her relational theory, Connell placed particular emphasis on the significance of inequalities among men, which can be as relevant as those between men and women. Connell’s theory of hegemonic masculinity and its subsequent interpretations and criticisms have been crucial for CSMM scholars working on men’s health and illness seeking to move beyond social role theory. In fact, it not only examines health solely through its biological dimension, but also acknowledges how gendered expectations and norms influence men’s health behaviors and outcomes. “A gender-relations approach,” states Schofield et al. (2000, p. 251), “is one that proposes that men’s and women’s interactions with each other and the circumstances under which they interact contribute significantly to health opportunities and constraints.” Connell’s framework has been adopted and expanded by scholars such as Hearn (2004) and Kimmel (1987), who draw on relations theory in advocating a critical approach to the study of male health. If before the 1980s research on gender and health mostly overlooked the influence of power and the male body, contemporary health scholars are increasingly recognizing the significance of how social expectations and ideals surrounding health and the male body can reinforce and perpetuate distinct structures and practices of masculinity (Scott, 2015). This understanding can yield substantial benefits in terms of efficiently providing services to the most vulnerable groups. The gender relation framework facilitates effective action because it shows that the health disparities often mentioned in empirical research are, in fact, perpetuated by the social disadvantage experienced by certain male groups (Scott, 2015). Furthermore,

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adopting gender relational theory to study health means delving into how relations of power are embodied and have different effects on health, some similar for men and women, while others produce differentiated outcomes. This theory allows us to better grasp the variations in health outcomes between men and women, which result from practices influenced by individuals’ positioning in the gender order (Schofield et  al., 2000). These practices involve complex combinations related to different aspects of gender, including the division of labor, emotions, symbolic representation, power relations, and decision-making processes. Notably, gender relations do not always directly manifest as health conditions; instead, they often materialize as general body practices, some of which lead to illness, disability, and premature mortality (Schofield et al., 2000). Since its development, the concept of hegemonic masculinity has been used extensively in various studies focused on male health issues, such as the male experience of arthritis (Gibbs, 2005), prostate cancer (Oliffe, 2006; Gray et al., 2002; Chapple & Ziebland, 2002), depression (Valkonen & Hänninen, 2013), erectile dysfunction (Potts, 2000), hypertension (Torres-Pagán & Toro-Alfonso, 2017), infertility (Rome, 2021), and strokes (Kvigne et al., 2014). 2.2.3   The Changing Nature of Hegemonic Masculinities: The Third Wave of CSMM and Its Implications for Men’s Health Connell’s relational theory, specifically the concept of hegemonic masculinity, has initiated an (ongoing) scholarly debate within the field of masculinity studies. We will not extensively consider here all the critiques and its applications. We will begin by focusing on Courtenay’s (2000) application of the concept within the realm of men’s health. Subsequently, we will delve into other critiques and advancements associated with the third wave of CSMM, specifically exploring the utilization of the community of practice framework and the theorization of hybrid masculinities, both useful in extending Connell’s original formulation and improving our understanding of the interplay between masculinity and men’s health and illness. Will Courtenay (2000) provided a relational analysis of men’s gendered health behaviors, studying how cultural imperatives, social interactions, and social and institutional structures concur to sustain and reproduce men’s health risks. Courtenay argues that to comprehensively understand men’s adoption of harmful behaviors and to address the social structures influencing them, it is important to focus on power and social inequality.

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Drawing from Connell’s relational theory, Courtenay acknowledges that gender is negotiated by power relationships, including microlevel power practices that influence everyday social transactions and sustain broader structures of power and inequality. He observes that health behaviors are also implicated in these power relationships. In fact, the systematic subordination of women and men in lower positions in the gender hierarchy (in other words, patriarchy) is perpetuated, in part, through gendered representations of health and health behaviors. In this perspective, men use health beliefs and behaviors to adhere to hegemonic masculine ideals, and to demonstrate their manhood. “The fact that there are a variety of health risks associated with being a man,” states Courtenay (2000, p. 1388), “in no way implies that men do not hold power.” In fact, men usually put their health at risk to maintain their privilege and to pursue power. Courtenay observes that the acquisition of power involves men disregarding their needs, demonstrating stoicism and resistance to pain, denying their weaknesses or vulnerability, not displaying emotional and physical control, representing themselves as strong and resilient, refusing or not seeking help, showing a constant interest in sex, and exhibiting an aggressive attitude. By enacting these health-related and gender practices, it is reinforced the idea that men’s bodies are stronger than women’s, that they are less vulnerable, and also that seeking help and engaging in self-help practices are feminine traits. In fact, masculinities are also constructed by rejecting feminine ideals. Seeking medical assistance and positive health beliefs is sometimes associated with femininity, constructing them as feminine and feminizing practices. Thus, refusing healthcare needs can serve as a way for men and boys to demonstrate their masculinity while asserting their distance from women and girls, and thus femininity (Courtenay, 2000). In the same line, hegemonic ideals of masculinity involve refusing to take sick leave from work, claiming to be able to drive after drinking, and engaging in risky behaviors such as driving dangerously, or engaging in extreme sports (Ibidem). A man’s adoption of health-promoting behaviors typically associated with femininity, or his avoidance of physically risky behaviors often linked to masculinity, may diminish his so-called ranking among other men, possibly leading to reduced status within the male hierarchy. Courtenay’s work also brings attention to intra-gender differences, namely differences among men. In fact, men may share similar masculine ideals, but they may express these ideals differently based on factors such as age, ethnicity, social class, and sexuality. For instance, the concept of being tough can be manifested through diverse means, including the use

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of a gun, physical strength, sexuality, or financial prowess. These expressions of masculinity clearly can have different physical effects on individuals, depending on how they choose to enact them. Social class is indeed a crucial factor in shaping such practices. “Demonstrating masculinities with fearless, high-risk behaviors may entail skydiving for an upper-class man, mountain climbing for a middle-class man, racing hot rods for a working-­ class man and street fighting for a poor urban man” (Ibidem, p. 1390). In addition to recognizing the multiplicity of masculinities, Courtenay (2000) draws upon Connell’s (1995) theory and considers the relations between different types of masculinity. The relations between dominant and subordinate or marginalized masculinities are shaped through practices “that exclude and include, that intimidate, exploit, and so on” (Ibidem, p.37). Therefore, the health risks linked to different forms of masculinity vary based on whether a man performs a hegemonic, subordinated, marginalized, or complicit kind of masculinity. In situations where men lack access to the social power and resources required for embodying hegemonic masculinity, they are compelled to find alternative resources to construct gender identities that are valid within their contexts. Certain men face disadvantages due to factors like ethnicity, economic status, educational level, and sexual orientation. These factors can lead to their marginalization, and Courtenay highlights the importance of adopting alternative forms of masculinity. In this context, the fact of rejecting health behaviors that are perceived as feminine, while embracing risk-taking and displaying fearlessness, represents accessible ways of performing masculinity (Ibidem, p. 1391). Men who find themselves in a marginalized position may seek to compensate for their subordinate status by rejecting the norms of hegemonic masculinity and instead constructing alternative forms of masculinity. They might employ alternative resources to reposition themselves as real men (Ibidem). As Courtenay observes, these forms of hypermasculinity are often dangerous or self-destructive. They can lead, for example, to binge drinking or substance abuse, criminal behaviors, fighting, predatory heterosexuality, risky sexual behaviors, and so on. It is crucial to recognize that while these hypermasculinities may aim to or be complicit in the reconfiguration of an idealized version of masculinity, they are not hegemonic. Courtenay’s (2000) adaptation of Connell’s relational theory has faced a number of criticisms. Creighton and Oliffe (2010) noted that it provides a limited understanding of social location and gives insufficient attention to men’s gender relations as well as to individual meaning making. For

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instance, when discussing risky health practices of marginalized men, as mentioned above, Courtenay (2000, 2009) suggested that these practices stemmed from their limited access to power, thus reinforcing hegemonic norms of masculinity associated with reckless driving and substance use. However, this approach inadvertently perpetuated hegemonic discourses about marginalized populations without considering the nuanced ways men experience masculinity in the context of intersecting identities. Hegemonic masculinity is represented as having a uniformly negative influence across men’s lives, although other research demonstrates that, instead, men can maintain hegemonic masculinities while showing interest in health and health-related practices. For example, Sloan et  al. (2010) conducted a qualitative study involving men who actively pursued health-­ promoting lifestyles (e.g., regularly engaging in physical exercise, no/low alcohol intake) and found that men embodying hegemonic masculine ideals do not always engage in negative health behaviors. Instead, the adoption of positive health behaviors was justified in terms of, for instance, being action-oriented, setting sporting goals, appearance concerns, and being independent and autonomous, all discursive elements typical of hegemonic masculinity (Ibidem). A last consideration is that Courtenay’s work does not take into account the relevance of significant others, such as men’s peers, partners, and other family members in influencing men’s health practices (Creighton & Oliffe, 2010). In this regard, Creighton and Oliffe propose the fruitful adoption of the community of practice framework in understanding men’s health attitudes and practices. Paechter (2003) explained the production and reproduction of gender through the concept of communities of practice, developed by Lave and Wenger (1991): in this perspective, the construction of femininities and masculinities implies the adoption of specific types of practices in response to local conditions as well as to wider influences. Communities of practice are composed of members that are bound to each other by the practices they do together, as well as by the meaning they assign to such practices. Communities of practice encompass different areas of everyday life such as work, education, family, and hobbies. (Wenger, 1998). Within such a community, the formation of identity follows a similar process to what Bourdieu (1977) described as the gradual acquisition of habitus through situated learning, much like the process of apprenticeship (Creighton & Oliffe, 2010). Individuals gradually learn what it means to “be a man” or to “be a woman” within particular communities that share the common intent of sustaining specific localized

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masculinities and femininities (Paechter, 2003, p.  71). The progressive learning of masculinity and femininity results in acquiring a specific set of practices, which is fluid rather than fixed, and that is crucial because the sharing of such practices holds communities together (Paechter, 2003; Wenger, 1998). As the ideal of a community of practice suggests, individuals perform gender in ways that are influenced by the social contexts in which they are embedded, and by what is intelligible within the gender system in which they live. Individuals cannot avoid considering the existing power relations and gender norms they have to confront with social expectations on an everyday basis by conforming or challenging them. The communities of practice framework is useful for exploring how identities, including masculinities, are learned and reproduced within distinct subgroups and settings. By applying it to the study of men’s health practices, researchers can understand how masculine identities and health behaviors emerge within specific subgroups. It further shows that hegemonic masculinities are not necessarily associated with the adoption of unhealthy or risky practices, nor are they shaped solely by a rigid set of masculine ideals (Creighton & Oliffe, 2010). Men’s health practices are instead understood as a part of the enactment of identities that are developed within specific communities. The fact that each individual is part of a series of communities of practice explains the possibility of changes in men’s health and illness behaviors and attitudes based on the norms and values of the specific communities they are part of. Understanding the dynamics of change is essential when investigating men’s health. Over time, societal expectations related to masculinities and femininities have changed, leading also to changes in the configuration of gender practices. These practices include health-related attitudes and behaviors: for instance, an emerging trend shows women increasingly participating in traditionally masculinized practices, including smoking, binge drinking, and exhibiting aggressive and violent behavior (Day et  al., 2003). Literature on changing masculinities has in turn highlighted the tendency of hegemonic masculinities to incorporate elements that were typical of marginalized or subordinated masculinities. An example is the so-called new man, that is commonly characterized by his sensitivity, emotional awareness, and respect for women, along with his commitment to egalitarian values. Some  authors portray the “new man” as being self-­ centered, and dedicated to his physical appearance, regardless of his sexual orientation (Gill, 2003). Other authors have highlighted the transformation of masculinities toward a new and more involved form of fatherhood,

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portraying men as being more committed to caregiving responsibilities for their children compared to the past (Cannito, 2020; Miller, 2011). Recently, the concept of metrosexuality has emerged—mainly in media and public discourses—(Simpson, 2002) indicating a young, wealthy man living in urban areas, who engages in self-care and appearance-related practices. Influenced by consumer culture, the metrosexual man invests a substantial amount of money to purchase beauty and body care products. Although body self-care and physical appearance seem to be a new feature of masculinity, prevailing notions associated with the male body continue to link it to a perceived lack of concern for beauty. The male body is, in fact, still associated with being active, ready for action, and not to a passive body to which things are done (Sassatelli & Ghigi, 2024). For instance, even today, the act of visiting a beautician signifies a deviation from gender norms, requiring men to provide stronger justifications when admitting to doing so (Ibidem). Despite these significant changes in the realm of contemporary masculinities, health-related practices still seem to remain a context, at least partly, feminized. For instance, in their research, Sloan et al. (2010) found that even men explicitly engaged in healthy practices tended to minimize the significance of health concerns while discussing their lifestyle choices, framing their healthy behaviors in ways that reinforce traditional ideas of hegemonic masculinity. They would present their commitment to a healthy lifestyle within the context of their involvement in sports, employing this strategy to provide an image of strength, athleticism, and a competitive spirit. Similarly, behaviors associated with hegemonic masculinities, such as overindulging in high-fat food or excessive alcohol consumption, are discursively rejected. However, in enacting these traits, men also reaffirm other traits of hegemonic masculinity, such as being rational, active, and autonomous. The same authors also draw attention to the fact that men’s emphasis on agency and autonomy should not be exclusively understood as originating from hegemonic masculine ideals. They point out that there is a substantial literature on the culture of “healthism,” typical of contemporary society, which invites individuals to monitor their daily activities and give a healthy representation of the self to be perceived as moral and rational (Crawford, 1980). This imperative of self-­surveillance, according to a Foucauldian perspective, functions to discipline potentially rebellious minds and bodies (Sloan et al., 2010). The importance attributed to individual responsibility regarding one’s health is influenced by a Western neo-liberal discourse that promotes personal freedom and control

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while downplaying cultural and structural factors that have a significant influence on individuals’ limits and possibilities. Contemporary self-­ disciplinary society constructed the individual as constantly “at risk” (Lupton, 1995): in fact, everybody is expected to conduct a healthy lifestyle to avoid diseases or, if they have one, to control it properly. Conversely, there is an implicit disapproval of bodies that are not managed, that are not fit and healthy, implicitly assuming a moral dimension to health-­ related practices. In fact, healthism “situates the problem of health and disease at the level of the individual. (…) Further, by elevating health to a super value, a metaphor for all that is good in life, healthism reinforces the privatization of the struggle for generalized well-being” (Crawford, 1980, p. 365). Recent research on men’s health issues highlights contradictions within healthism and different hegemonic masculinities, suggesting a dynamic negotiation of health and gender issues (Robertson & Williams, 2010). For instance, the ideal of being healthy could be represented as the following of certain rules or guidelines. However, some of these guidelines can be seen as extreme or conflicting. So, instead of strictly following them, individuals often opt for a balanced lifestyle that combines different aspects of health. With respect to men’s behavior and attitudes toward health, they might switch between two ways of thinking. On one hand, some men may resist strict rules about what they should do for their health, emphasizing their personal freedom to make their own choices. On the other hand, they might also follow sensible health advice to be seen as rational and responsible. “What counts as normative and healthy then both shapes and is shaped by hegemonic masculinities” (Sloan et al., 2010, p. 799). Recent literature aims to better understand how hegemonic masculinity is maintained over time despite its changes (e.g., Bridget & Pascoe, 2014; Arxer, 2011; Demetriou, 2001), and argues that the dominant form of masculinity might actually change, also through the negotiation and appropriation of practices that appear as counter-hegemonic, just as those concerning body care, health, or illness management. Of particular use in this regard is Demetrakis Demetriou’s (2001) critique of the concept of hegemonic masculinity, claiming that “hegemonic masculinity is not purely white or heterosexual configuration of practice, but it is a hybrid bloc that unites practices from diverse masculinities to ensure the reproduction of patriarchy” (Ibidem, p.  337). He formulated the concept of the “hegemonic masculine bloc” to elaborate Connell’s hegemonic/non-­ hegemonic masculinity dualism, and he posited that the dominant form of

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masculinity underwent a perpetual process of negotiation, translation, hybridization, and reconfiguration. That is to say, hegemonic masculinity is indeed a flexible and culturally situated concept, as Connell claimed, but it reconfigures itself through hybridization processes that could also appear as incoherent and contradictory. Hegemonic masculinity, according to Demetriou, may thus also incorporate elements that are at odds with Connell’s definition. For instance, he mentioned the case of adopting traits that are considered as typical of gay subcultures, such as earrings for men, which make traditional and dominant masculinity seem more feminized. Hegemonic masculinity may thus be constructed not only through the distancing from competing and alternative forms, but also with its hybridization and incorporation of counter-hegemonic elements. Within Demetriou’s theorization, hegemonic masculinity does not necessarily need to be characterized by an aggressive and non-effeminate configuration of gender practices. As a result, the dominant form of masculinity (re)creates new forms that allow men to maintain and reproduce patriarchy, while incorporating social attributes conventionally identified as feminine or associated with marginalized and subordinated masculinities. The point becomes, then, not only the analysis of possible forms of marginalization or negation, but also that of the many ways of negotiating and articulating pre-existing hegemonic masculinities, the ways in which they are enacted and idealized, and their construction in combinations of original complicit forms (Rinaldi, 2016, p. 40). Bridget and Pascoe (2014) provided a systematic review of the literature with the main aim of accounting for recent transformations in men and masculinities through the use of the concept of “hybrid masculinities.” They argued that hybrid masculinities function in ways that, on the one hand, reproduce inequalities based on gender, race, and sex, and on the other hand, “obscure this process as it is happening” (Ibidem, p. 247). Drawing from the literature on hybrid masculinities, Bridget and Pascoe identify three recurring consequences related to these “gender projects and performances” (Ibidem, p. 250): • Discursive distancing: The hybridization of masculinity often operates in ways that produce some discursive distance between white, straight men and hegemonic masculinity. At the same time, even if they frame themselves as distanced and outsiders from the current system of privilege, they often also align themselves with it;

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• Strategic Borrowing: Men in privileged positions may strategically borrow from other marginalized or subordinate masculinities in ways that function to reframe themselves as symbolically part of subordinated groups; • Fortifying boundaries: Hybrid masculinities serve to reinforce symbolic and social divisions among various groups based on race, gender, and sexuality, thereby deepening and frequently obscuring inequality in new ways. Another interpretation of change in masculinities is that offered by Erik Anderson (2010), who proposed a critique to Connell’s gender theory by expanding it in an alternative framework. The Inclusive Masculinity Theory (IMT), arguing that in contexts such as the US, UK, and other Western countries witnessing a decline in homophobic attitudes, there has been a substantial change in masculinities. To account for this process, he coined the concept of homohysteria, which refers to “the fear of being socially perceived as gay” (Anderson & McCormarck, 2018, p. 2). Within a homohysteric society, homophobia polices gender practices, as men feel threatened by the stigma of being publicly homosexualized through the infringement of the strict boundaries of heteromasculinity. According to Anderson (2010), in this context, Connell’s gender order (1995; with Messerschmidt, 2005) can be applied, with a multiplicity of masculinity types hierarchically stratified and one hegemonic form on the top. Conversely, according to IMT, in societies where levels of homohysteria decrease, Connell’s hegemonic masculinity theory—that applied in periods of high homohysteria typical of the twentieth century—can no longer function. When homohysteria decreases, he claims that the stratification of masculinities becomes less hierarchical and a multiplicity of masculinities become equally esteemed, legitimized, and culturally valued. In a context where cultural homophobia is absent, Anderson argues that hegemonic masculinity theory fails to account for the multiplicity of less oppressive masculinities emerging without stratification and without one form holding a hegemonic position over the others. In summation, IMT aims to provide a theoretical framework for understanding changing masculinities in social contexts where levels of homohysteria are decreased, a goal that, Anderson argues, Connell’s gender theory fails to accomplish. Considering the context of Italy, where the research presented in this book has been conducted, Anderson’s inclusive masculinity theory could not be applied, as homophobia and homohysteria are still present not only

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in the context of sports, where he conducted the majority of his research studies, but also on a more structural and institutional level. The research presented in this book draws on Connell’s relational theory and its further developments, as it provides the fundamental tools to grasp the complex and changing nature of hegemonic masculinity. This approach enables the investigation of health-related practices by going beyond the confines of the masculine/feminine binary, while also recognizing the broader dynamics of power relationships. It has been noted (Hearn & Howson, 2020) that we are currently observing the emergence of a fourth stage within CSMM, characterized by an increased focus on international, comparative, supranational, global, postcolonial, and transnational perspectives, materialist-discursive, and new materialist approaches, with a significant growth in research pertaining to or originating from the global south. Although these four waves, outlined earlier, are an oversimplification, they are useful in giving an idea of the ongoing evolution of research on men and masculinities. Overall, while recognizing the existing distinctions among diverse investigative and epistemological traditions, studies in this field—including the ones presented in this book—share eight main key points (adapted from Hearn & Howson, 2020, p. 22): • Centering research and theoretical reflection on men and masculinities as explicit objects of analysis; • Acknowledging men and masculinities as gendered concepts; • Recognizing the social construction, production, and reproduction of men and masculinities, instead of considering them as ‘natural’; • Understanding men and masculinities as dynamic and subject to change across historical periods and social and cultural contexts, within societies, and throughout individual biographies; • Focusing on men’s relations to gendered power; • Encompassing both the material and the discursive; • Taking into account feminist, gay, queer, and other critical studies on gender and sexuality; • Examining men and masculinities through intersections with other social divisions.

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2.3   Men, Chronic Illness, and the (Re)Configuration of Masculinities The onset and the management of a chronic illness in a man’s daily life presents a series of challenges to hegemonic masculinity’s ideals such as strength, autonomy, stoicism, and resistance to pain. These traits may be seen as incompatible with the experiences and representations of men who are dealing with chronic health conditions. On the one hand, the inability to conform to such ideals could cause a downward shift in one’s position within the gender hierarchy. On the other hand, drawing from the recent developments of relational theory outlined above, it could be fruitful to consider more broadly how chronically ill men negotiate their masculinities in relation to hegemonic ideals by adopting, refusing, and renegotiating them through health and illness-related practices. Chronic illness usually leads to a real biographical disruption (Bury, 1982). It often entails radical changes in bodily limits and possibilities, in time management, in the redefinition or loss of work-related identity, and in social roles. This could ultimately lead men to experience what Charmaz (1995, p. 266) refers to as a real “identity dilemma.” Kathy Charmaz is among the first scholars to conduct research on the topic of men’s experiences with chronic illness. In her pioneering work, she interviewed men with chronic diseases and identified a series of identity dilemmas that men may face after the onset of a serious illness, especially when they experience sudden serious conditions, such as stroke. In this as in other cases, the fact of being confronted with the potential of death and bodily fallibility challenges men’s perceptions of invulnerability. Sudden mortality threats force a reevaluation of bodily strength and possibilities. In a chronic condition, these bodily changes should be regarded as lasting (or even permanent), which subsequently poses a challenge to male identity. In fact, typically men tend to approach illness and its consequences as problems to be resolved. However, when dealing with chronicity, the inability to find solutions for these challenges can profoundly affect men’s identity. A second dilemma arises when men have to face bodily uncertainty. Men often respond to uncertain health conditions by compartmentalizing the experience, separating it from their sense of self. This can be observed, for instance, in the case of men who survive cancer after successful treatment. This bracketing strategy allows them to define uncertainty as limited to crises events, enabling them to have a sense of continuity with their previous identities. It might also lead them to continue past habits that

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contributed to their health issues, such as excessive workload and unhealthy eating. However, with time, most men come to recognize changes in their bodies, acknowledging uncertainty in their lives. They become conscious of the unpredictability of their health, including treatment outcomes and potential complications. This heightened awareness triggers reevaluations, with some men shifting their focus from work to family, reconsidering unhealthy lifestyles, and discovering new meanings in life. Embracing permanent changes entails accepting uncertainty and its consequences. While some men might revert to old habits after minor adjustments, others construct their new identities around managing both uncertainty and illness (Charmaz, 1995). The way men perceive and define illness significantly impacts their masculinity. For instance, men may  represent illness as an external enemy, and  this specific  metaphor (Sontag, 1978) has the discursive effect of objectifying it and putting a distance between illness and their masculine sense of self (Charmaz, 1995). Defining illness as an enemy often reflects a man’s pursuit of continuity of self despite the onset of an illness. Other men view illness as an ally, an experience that even brings positive consequences. For example, it may provide them with opportunities for reflection and  broader life changes. This echoes Arthur Frank’s (2013, p.  1) words: “Illness takes away parts of your life, but in doing so it gives you the opportunity to choose the life you will lead, as opposed to living out the one you have simply accumulated over the years.” The result entails deciding to adopt healthy habits that support health or are useful in managing illness and postponing illness-related complications (Charmaz, 1995). Usually, chronically ill men develop specific strategies to minimize the visibility and intrusiveness of their illness in their lives. For example, they can avoid extra-work activities with their colleagues (e.g., lunches or dinners), minimizing time spent with them to be able to perform their role as before the onset of illness, and to maintain appearance, although it might require more energy and effort. However, when drastic lifestyle changes occur due to illness—such as reduced or lost employment or a broken marriage—past identities may be lost, leading to further preoccupation and identity dilemmas (Charmaz, 1995). As we have seen in the previous paragraphs, to understand the complex intersection of masculinity, health, and illness, it is necessary to consider multiple intersecting dimensions that shape men’s construction of masculinity. Two relevant dimensions are age and social class. In this regard, it is interesting to observe that  Bury (1982) and Charmaz (1995) focus on

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men experiencing the onset of chronic illness during adulthood. Things might be different in the case of men who are born with a chronic disease or experience chronic disease onset during early childhood. Williams (2003), in his critical examination of chronic illness, notes that for conditions emerging from birth or early childhood, the guiding principle is continuity rather than disruption. This concept extends to the construction of masculinities as well. Being born with a chronic illness or experiencing its onset during early childhood, as seen with conditions like type 1 diabetes (the focus of this book’s research), implies no clear demarcation between before and after the onset; instead, masculinity is constructed in relation to presence of chronic disease from childhood, and in many cases men are able to structure their everyday lives accordingly (e.g., finding jobs that facilitate the everyday management of illness). A second observation regarding age concerns a set of so-called normal crises. For example, older people, especially those from working-class origins, might have lower health expectations and may view illness as an inevitable part of aging, approaching it with a greater degree of acceptance. Consequently, chronic illness, particularly within the framework of lifelong challenges and adversity, could be perceived as an expected occurrence rather than a disruptive event (Williams, 2003). In this regard, class and age are two crucial dimensions that need to be taken into account when studying chronic illness and are so far under-researched (Ibidem). Social class is also relevant in determining both the actual possibilities to mobilize (social, economic, cultural) resources to deal with chronic illness, and also the different gendered meanings associated with health-­ related practices. As we have seen before, men with chronic illness experience specific identity dilemmas and challenges, deriving from the impossibility of fully adhering to hegemonic ideals. Nevertheless, men can employ competence in significant health-related masculine areas to compensate for other non-masculine behaviors. In this regard, it is useful to consider De Visser et al.’s (2009) development of the concept of masculine capital. The authors posit that competence in health-related domains traditionally associated with masculinity leads to the accumulation of a specific capital that can be utilized to compensate for non-masculine behaviors in other contexts. This concept of capital is useful to better understand the construction of masculinities in the case of men with a chronic illness, as they may emphasize their competence in a specific masculine domain to counterbalance their inability to completely conform to dominant norms of masculinity. For example, a man that decides to eat

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healthy food and to not drink alcohol may compensate by emphasizing his success in sports (de Visser & Smith, 2006). Bourdieu’s (1984, 1986) notion of symbolic capital is particularly useful in this regard. It refers to intangible attributes that individuals possess, which society values and that play a role in shaping their social status and dynamics of power. At its core, Bourdieu’s formulation of symbolic capital is deeply rooted within his overarching theoretical framework concerning cultural and social reproduction, shedding light on how inequalities in society endure across generations. In broad terms, symbolic capital concerns an individual’s knowledge, experience, prestige, and social network, and is a source of authority and power that grants success in social contexts. Symbolic capital involves cultural, social, and economic dimensions, with an emphasis on the symbolic and cultural facets. Cultural capital encompasses an array of attributes— knowledge, competencies, education, and cultural inclinations—that individuals accumulate through their upbringing and social interactions. Social capital concerns the networks and connections that individuals cultivate, affording them access to resources and prospects. Economic capital, even though material, can also be understood through a symbolic lens when utilized to secure societal recognition and enhance individuals’ prestige. Adapting this concept to the construction of masculine capital, it is interesting to note that, like other forms of capital, it can be acquired, lost, invested, and exchanged through various means (De Visser et al., 2009) and is deeply connected to social class. The idea of capital is also connected to Bourdieu’s concept of habitus (1977). According to Bourdieu, habitus is a durable set of unconscious dispositions—such as bodily conduct, and ways of talking, thinking, and acting—that is acquired during socialization processes and depends on the specific social groups and social classes in which individuals are located. It is naturalized and, therefore, individuals are mostly unaware of its effects. Habitus is particularly useful because it allows us to explore the links between social structures and individual practices, where action is conceived as, at the same time, influenced by external structures and also reinforcing them, because actions actively contribute to (re)creating social structures. In fact, the habitus, the specific bodily socialization, implies the assimilation of specific schemes of perception and classification that, at the same time, consider physical differences, participate in their existence, and naturalize them through their reification (Ferrero Camoletto, 2015). Habitus, in relation to gender identity, can be intended as the embodiment of social discourses

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surrounding masculinity (De Visser et al., 2009). It is expressed through social practices, which can lead to the accumulation or loss of symbolic social capital. However, the value of specific behaviors and their associated capital may vary depending on the social context or field in which they occur. Therefore, an individual’s standing in a specific context results from the interaction between the specific rules of that field, the individual’s dispositions or embodied habitus, and their actual behavior and social capital. In this sense, masculinity itself can be viewed as a form of symbolic capital within certain social arenas (De Visser et al., 2009). Furthermore, chronically ill men’s masculine capital can be negotiated through their everyday social practices, in a delicate balance between potentially demasculinizing practices that need to be undertaken to survive. They may manage illness, or maintain health, and engage in operations of re-signification, emphasis, or adjustment that enable the compensation, reshaping, and affirming of their masculinity. Chronically ill men, like other men, to comply with hegemonic ideals of masculinity and to be recognized from others as manly, may enact different “compensatory manhood acts” (Schrock & Schwalbe, 2009, p. 287). The masculine self they construct and enact is essentially a virtual construct, a display, a result of how others (mainly male others) perceive and evaluate their outward presentation and their conduct in interaction (Schrock & Schwalbe, 2009; Goffman, 1959). When exploring how men construct their masculine capital within the context of illness, it is essential to avoid neglecting the articulation of these compensatory manhood acts, as they can inadvertently reinforce inequalities, ultimately placing women and certain subgroups of men in a disadvantaged position. The research presented in this book focuses on men experiencing type 1 diabetes, which is one of the most prevalent chronic conditions and affects millions of people globally. The prevalence of diabetes in Italy has nearly doubled in recent decades, with an estimated 3.2 million individuals currently affected by the condition (ISTAT, 2017). Approximately 10% of these cases are attributed to autoimmune diabetes, a disease typically emerging during childhood, adolescence, or occasionally in adulthood. While the experience of living with diabetes may vary for each individual, most people can manage it with daily treatment. However, diabetes can lead to health complications that may influence how men perceive and construct their masculinity. These complications include erectile dysfunction, and hypoglycemia triggered by physical activity or strong emotions. Furthermore, in managing diabetes, men may face specific challenges to

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traditional notions of masculinity. Daily self-management involves monitoring blood sugar levels, administering insulin through injections or an insulin pump, adopting a balanced diet, and regulating carbohydrate intake. These actions are crucial for maintaining glycemic balance and include a series of self-care practices. Engagement with self-monitoring and medical practices may prompt some men to reevaluate their self-­ representation of masculinity and confront established gender norms associated with autonomy, resistance to pain, and strength. Diabetic men construct their bodies with a potentially conflicting double bind: that of masculinity construction and that of illness management. The bodies of men with diabetes “serve as a continual reminder that they are at odds with the expectations of the dominant culture” (Gerschick & Miller, 2013, p. 183), because of the need for insulin injections for survival and constant medical examinations. Furthermore, the potential sudden unreliability of their diabetic bodies may constitute an emasculating factor. In fact, the weakening of their bodies and the risk of losing control of themselves during hyper- or hypoglycemia episodes threaten cultural values of hegemonic masculinity such as strength, stamina, reliability, autonomy, and invincibility. Therefore, it seems important to gain an understanding of how men construct and present their (masculine) selves when they are potentially unable to fully enact the hegemonic ideal of masculinity because of a chronic and degenerative condition such as type 1 diabetes. It is interesting to analyze how they signify the practices of care related to diabetes self-management, how they discipline their bodies and control bodily uncertainty, and which compensatory manhood acts they might carry out to perform an adequate diabetic masculinity.  There is a paucity of research that explored men’s experience of health in ill-contexts, and to my knowledge this is the first Italian study on this topic: previous studies have focused on the intersection of masculinity and men’s experiences of asthma (Fidolini & Merienne, 2022),  rheumatoid arthritis (Flurey et al., 2016), of prostate cancer (Broom, 2004; Oliffe & Thorne, 2007) and of cardiac rehabilitation (Robertson et  al., 2010). Even fewer studies have investigated men’s experiences of diabetes: O’Hara and colleagues (2013) analysed men’s experiences with type 1 diabetes and Broom and Lenagh-­Maguire (2010) explored influence of gender in the experiences of type 2 diabetes. In Italy, the intersection of health and masculinity has been explored by Ferrero e Camoletto and Bertone’s work on the medicalization of masculinity (2016), by Fornasini et al. (2018) on the construction of masculinity of fathers with diabetic

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sons,  and by  Boni  (2004) with his  research on readers of men’s health magazines. Further research is needed in order to better understand the complex relation of masculinity and health by taking into account men’s lived experiences of chronic illness.

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CHAPTER 3

Researching Diabetic Men

Studying men and masculinities does not inherently introduce an element of novelty, nor is it “positive” or “negative” per se. In fact, it is less about the subject under study, and more about how it is studied (Hearn, 2013). The exploration of men’s health and illness has so far mainly concerned quantitative research methods, usually involving the comparison of statistical health data between men and women (Oliffe & Mróz, 2005). For instance, as we have seen in the previous chapter, data from numerous Western nations indicates that men experience a shorter life expectancy than women, encounter elevated rates of injuries and major disease morbidity, and exhibit lower engagement with healthcare services and health promotion initiatives (Pinkhasov et al., 2010; Courtenay, 2000; Huggins, 1998). These health patterns  are usually associated with men’s health-­ related attitudes and behaviors but, as we have seen, they deserve a more in-depth analysis and attention. This book presents the results of two distinctive research projects, each driven by the common objective of exploring more deeply the nuances and specificities of masculinity construction in the context of chronic illness, as well as going beyond the simplistic idea that “masculinity is bad for men’s health,” as posited in many past publications. To do so, I have adopted traditional qualitative research methods in the first case, and digital research methods in the second case. This chapter provides a comprehensive overview of both research paths and their implications. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Quaglia, Wounded Masculinities, https://doi.org/10.1007/978-3-031-44436-4_3

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The methodological approach is particularly relevant to  the subject under analysis. In fact, the first research adds to the existing literature by employing qualitative research methods and in particular in-depth interviews that have proved crucial in gaining a better understanding of men’s approaches and lived experiences of health and illness (Robertson, 2007; Courtenay, 2000; Oliffe, 2005; Charmaz, 1995; Chapple & Ziebland, 2002; Oliffe et  al., 2022). The in-depth interview is among the most widely employed research techniques (Cardano, 2011). Conducting  in-­ depth interviews in the specific context of the research carries, nevertheless, a series of challenges, especially when individuals, often strangers, agree to discuss private matters such as their experiences of health and illness (Oliffe & Mróz, 2005). Since in qualitative research knowledge is co-produced through interactions between researchers and participants, the gender of both influences the dynamics and data gained through qualitative interviews (Herod, 1993). In this chapter, we will explore this aspect  more, allowing room for contemplation on the specificities and unique aspects of conducting qualitative research with men who construct their illness stories. The second research further delves into the realm of the intersection between men, masculinity, and chronic illness, with a specific focus on examining the self-representation of diabetic men on TikTok. As one of the globe’s preeminent social media platforms, TikTok offers a unique and interestingly new context for the study of online self-presentation. This platform enables users to create, share, and view brief videos lasting a maximum of 60  seconds. This social platform primarily shows ironical short videos and offers specific affordances, thus contributing to the formation of a new and, in many respects, distinct context in the digital media landscape (Miltsov, 2022). The self-representations offered by content creators on TikTok serve to convey a public image of themselves constructed upon a repertoire of symbols (of masculinity) widely accepted and valued in our society (Caliandro & Gandini, 2019). These codes and symbols are used in what Erving Goffman (1959) defined as self-presentation, a performance where individuals more or less consciously manage their identities in social interactions. With the development of online spaces, the significance of this performative selfpresentation has increased its complexity and acquired new forms and possibilities, as well as new challenges. In this chapter, by focusing on the specific case of TikTok, we will investigate the relevance of studying the personal storytelling of diabetic men in online spaces to construct their gendered self-presentation.

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3.1   Doing Qualitative Research on Men, Masculinities, and Chronic Illness The first part of the book is dedicated to the results of qualitative research involving  40 diabetic men through in-depth interviews. Qualitative research methods, for their specificities, are particularly useful for studying men’s accounts of illness. Indeed, qualitative research enables a thorough exploration of participants’ experiences by directly listening to their voices. Further, it serves as a valuable instrument for directly observing the construction of masculinity, unfolding within the context of a specific social interaction—namely, the interview. As observed in Chap. 2, the  recent decades have witnessed increased attention from media, policymakers, and researchers toward the topic of men’s health issues (Gough & Robertson, 2009). As we have seen, traditionally the worse health outcomes and increased mortality rates observed among men, as documented in national and international surveys, have been explained through the lens of their intent to adhere to social expectations around dominant forms of masculinity (e.g., Harrison, 1978). In fact, hegemonic ideals of masculinity construct men as able, healthy, strong, autonomous, in control, and indifferent to their health (Connell & Messerschmidt, 2005). But as we have seen in the Chap. 2, this is only part of the story, and the intersection of men, masculinities, and illness necessitates a more comprehensive approach. As Robertson (2007) highlighted, more recent qualitative research on men’s health has in fact uncovered the oversimplistic and pathologizing assumption that underlies the idea that masculinity is dangerous for men’s health. It has posited that masculinity is much more complex than that and it actually might be, at times, even contradictory in its embodied performances (Arxer, 2011; Demetriou, 2001). Examining the intersection of masculinity with diabetes offers an interesting empirical context, particularly from a methodological point of view. As mentioned, diabetes necessitates the incorporation of a set of health-related practices into men’s daily lives. Nevertheless, in its relatively less severe stages, diabetes permits a certain measure of negotiation with the lifestyle prescribed by diabetologists. In the adoption of these practices and the negotiation of their meanings, it offers an opportune avenue for the examination of masculinities in their doing. This is due to the inherent impossibility of diabetic men of fully perform the ideals of hegemonic masculinity. This makes masculinity a no longer taken-­for-­granted and invisible presupposition, but rather a configuration of practices composed through the craftsmanship of compensatory manhood acts, that are nonetheless intrinsically linked to specific social contexts and the embodied habitus. 

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3.1.1   Research Design Drawing from the abovementioned literature, this first study aimed to understand men’s multiple experiences of diabetes by endeavoring to give sound answers to the following research questions: i. What types of masculinities are performed in men’s diabetes narratives? ii. What compensatory manhood acts are enacted to compensate for the emasculating potential of diabetes, and its related health practices? This research contributes to existing scholarship in two distinct ways. Firstly, it focuses on toward an empirical context that, to the best of my knowledge, has remained hitherto unexplored—that being Italy. This geographical context is significant due to its enduring influence with cultural formulations of masculinity, substantially influenced by the enduring legacy of virilism, which denotes an ideological framework accentuating gender disparities and hierarchical configurations of gender (Ferrero Camoletto and Bertone, 2012). Secondly, it provides empirical support confirming the importance of considering the multiplicity of masculinities for a better understanding of how men (mis)manage diabetes in their everyday lives. The sample design strategy employed for the recruitment of participants involved an equal distribution of cases into four main configurations. This typology was constructed by intersecting two crucial socio-demographic dimensions: the first one is age, recognized for its relevance in shaping and understanding the experience of illness (Faircloth et al., 2004; Williams, 2000), as well as for influencing societal expectations around masculine performances (Connell, 1995). The second is social class, which has emerged from scholarly literature as crucial in establishing both the limits and possibilities of health embodiment (Cardano, 2008; White, 2017) and masculinity (Connell, 1995; Morgan, 2005). Adopting these selection criteria enabled the identification of participants to maximize the potential for comparison (Barbour, 2007). Hence 40 young and adult men (aged 20–60) from working- and middle-class background were recruited. The heterogeneity of the sample was further sought considering participants’ age at the time of disease onset, the degree of severity of the disease, and the presence/absence of diabetes-­ related complications.

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Due to the impossibility of gaining access to registries of individuals with diabetes, a diverse range of recruitment strategies was employed. The initial step involved contacting associations dedicated to diabetic individuals. During this phase, I predominantly encountered women: both those living with diabetes and non-diabetic women who were caring for their diabetic partners/spouses, in line with the societal norm that positions caregiving as a predominantly feminine responsibility. This information provided a significant initial insight into how gender influences the organization of caregiving tasks in the family. This becomes particularly evident in the subsequent excerpt from an informal conversation I had with a diabetic woman who was a member of an association dedicated to individuals with diabetes: You were saying [when the tape recorder was turned off] that often women help their husbands… Yes, because they are the ones that cook. Especially for elder people, it has always been the woman who cooks. This is why many [diabetic men] came, and still come, with their wives because it’s her that buys groceries. I also met some of them who know every drug their husband takes, what he eats… And [diabetic men say to me]: “Well, you should speak to my wife because she is the one who knows.” (Maria, 65 years old, onset at 13)

Despite numerous efforts, the initial recruitment invitations distributed in the context of associations went unanswered, except for one participant recruited from an athletes’ association dedicated to sports and diabetes. Additional recruitment approaches encompassed the use of social media: while attending medical conferences about diabetes issues, I was lucky enough to meet Elisa (a pseudonym to protect privacy), a non-diabetic woman administering an online community for people with autoimmune diabetes. She supported the research by sharing the interview invitation among her personal contacts, on her website and through several Facebook pages dedicated to diabetes issues. This attempt proved extremely successful. Subsequently, snowball sampling techniques were adopted. The final sample consists of diabetic men diagnosed with type 1 diabetes (33 out of 40) and LADA diabetes1 (seven out of 40). Among the men interviewed, ages ranged from 23 to 59. Among the participants, two men 1  LADA diabetes, or Latent Autoimmune Diabetes in Adults, is a distinct subtype of autoimmune diabetes mellitus with characteristics of both type 1 and type 2 diabetes. It’s typically diagnosed in adults.

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indicated having a PhD, while 10 held a degree. Additionally, 27 participants had completed their high school education, and one had finished middle school. In terms of occupation, 16 respondents identified as permanent employees, six held temporary positions as shop assistants, ten were self-employed, three were retired (formerly engaged in occupations such as labor, clerical work, and military service), four were engaged in manual labor, and one was unemployed. In-depth interviews are a useful tool for studying men’s experiences of illness: in this special conversation, participants do not narrate their story as if it were a static collection of events, a museum with an ordered, unaltered exposition of past experiences to be described and enumerated. It is rather a dynamic process that takes shape during an interaction, where meanings are (re)constructed and identities (re)produced. As participants discuss their condition, they construct their experiences using an organized and coherent series of events. These events are shared alongside the connected experiences and the meanings attached to them. Illness narratives combine the present context of the interview interaction, and the memory of past experiences, and project them toward future aspirations and goals. In this dynamic process, the interviewer assumes the role of an active and empathetic listener. The interviewees share their illness stories, striving to provide the researcher with a glimpse, even if brief, into their personal world. Hence, collecting narratives from men living with diabetes can yield substantial information. Despite the increasing focus on men’s experiences with health and illness, and the increasing attention directed toward masculinities, there remains a scarcity of research that delves into men’s accounts of illness. Using the in-depth interview as a research technique extends beyond the biomedical understanding of disease, which perceives diabetes solely as a metabolic disorder, with its symptoms and complications, and allows to access the subjective experience of illness (Giarelli et al., 2005; Maturo, 2007; Twaddle, 1969). The narratives of men’s illness experiences show that it  is not only their bodies dealing with uncertain outcomes; their entire lives are implicated. Maintaining constant glucose control entails not only measuring glycemia and injecting insulin but it also implies self-­ disciplining their bodies and shaping new selves. After the onset of an illness, “[t]he self, as well as the body, is shattered, and narrative is the only tool that can be used to build a new link between present and future, the only tool that can make sense of the experience of illness” (Cardano, 2016,

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p. 66). Moreover, men’s health literature shows the usefulness of the in-­ depth interview as an effective research instrument for exploring the enactment of masculinities too, and their intersection with broader social structures (Riessman, 1990). Connell (1995) in this regard observed: “Life histories give rich documentation of personal experience, ideology and subjectivity. (…) But life histories also, paradoxically, document social structures, social movements and institutions. (…)” (Ibidem, p. 89). The interview guide I employed was designed to facilitate the collection of participants’ narratives pertaining to themes deemed pertinent in addressing the research questions. Throughout the interviews, my aim was to give voice to participants and allow them to share their illness experiences in their own words, while guiding the conversation toward themes of significance for my research objectives. Following the pilot interviews to test the initial version of the interview guide, I progressively refined and shortened it. Across all interviews, I addressed consistent key themes, employing a substantial degree of adaptability in their articulation and the sequence in which they were introduced during conversations. All questions were open-ended and intended to delve into the complexity of men’s illness experiences. While some interviewees provided comprehensive insights into each theme in the interview guide, others focused more on particular themes, requiring additional prompting to engage with other topics. Nevertheless, in the course of the interviews, all themes deemed integral for analysis were ultimately addressed. Throughout the interviews, I sometimes maintained consistent question formulation, while in other instances, I opted for modifications, according to the specificities of the participant (age, level of education, etc.). In some cases, participants discussed certain themes without the need for explicit questioning, allowing the conversation to evolve naturally. The interview guide was structured based on the illness-trajectory framework of Corbin and Strauss (1988, 1991). Referred to as the Corbin-­ Strauss Model, this conceptual framework was articulated on the premise that chronic conditions follow a variable and evolving course over time (Ibidem, p.  156). This model adopts a diachronic perspective to study chronic illness, including diabetes in this particular context. It provides insights into the changing patterns of treatment adherence across time, concurrently focusing on both physical transformations and the conduct of everyday life practices.

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Embedded in this framework is the recognition that illness is not a static, universally applicable concept. Rather, it is characterized as a dynamic process, akin to a “trajectory” (Ibidem, p. 162). Intrinsic in its definition is the inevitability of change and varying degrees of uncertainty. The trajectory of illness cannot be anticipated but  can only be reconstructed retrospectively. For the same illness, there can exist multiple “trajectorie projections” (Ibidem, p. 162). This terminology, as expounded by Corbin and Strauss, denotes the distinct visions that distinguish each individual’s experience of illness and its management. These trajectories are shaped by the multiple meanings assigned to the illness, its symptoms, the temporal dimension, and the individual’s life story. Most of the interviews (21 out of 40) were carried out in person, and in cases where geographical constraints made it impossible (19 out of 40 cases), Skype video calls were used. The interviews were conducted between May 2017 and July 2018, amounting to 57  hours of audio recordings,averaging at 1.42  hours per interview  and resulting in 2048 pages of verbatim transcripts. The analysis of empirical data followed a “lean” version of the template analysis approach proposed by King (2012), Cardano (2020, p. 124). The identification of analytical categories was informed by the literature on the topic. These categories provided a template for segmenting empirical data during the categorization process (Cardano, 2020). Consequently, cases were organized based on their characterization concerning various attributes, enabling the identification of shared patterns and differences. Consequently, relations were found between the attributes assigned to distinct segments. For instance, a subset of interviewees who talked about “self-management strategies” in terms of “self-quantification” also emphasized their numerical accomplishments attained through adherence to medical prescriptions. Conversely, another subset framed the same numerical achievements as an individual ability to personalize medical prescription through lay expert knowledge. This allowed the construction of two ideal types, which will be discussed in the next chapter. Before the interviews, participants were requested to provide their consent by signing a consent form. They  were also  informed that all interviews would be audio recorded, transcribed verbatim, and subjected to  pseudonymization. In Skype interviews, oral consent was obtained before starting the audio recording. Generally, I refrained from offering any monetary incentive to encourage participation in the interviews. In our capitalistic society, money seems

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to be the privileged means to purchase everything: goods, services, and even relations. This decision aimed to prevent individuals from joining the study solely for financial reasons, thereby avoiding the potential bias that could emerge from this scenario. It could be argued that providing financial incentives could have facilitated participant recruitment, particularly among those facing economic challenges. This concern was thoroughly addressed during the initial research design phase. In fact, I adopted strategies to ensure accessibility to the research, including the flexibility of conducting interviews at locations most convenient to  interviewees, as well as the option for online interviews  through video calls. In one instance, I personally reimbursed the travel expenses of a participant who wanted to be interviewed at my university offices but faced financial constraints. This approach reflects my commitment to mitigating potential barriers to participation while maintaining the integrity of the research process. Now, one might pose the question: What sort of compensation does a person derive from investing his time in a time-consuming activity like an in-depth interview? Concerning  this, Cardano (2011) laid out a range of potential rewards. To begin with, there is the emotional fulfillment resulting from being the focal point of an interaction, where the interviewees can freely express themselves, unburdened by concerns of being contradicted or silenced. This emotional gratification holds particular significance for those unaccustomed to being in the spotlight. It  is especially relevant for individuals grappling with chronic illness, who often voice dissatisfaction with the lack of time their healthcare providers offer them and the scarcity of contexts to share their feelings about their condition. This is especially true for men, who are less prone to talking about their private issues than women to talking about their private issues. An equally compelling aspect is the cognitive reward, stemming from a process of collaborative self-reflection. Through the interviewer’s questions and observations, the interviewee gains a unique opportunity to critically assess his life and daily routines, unveiling new perspectives they might not have realized otherwise. Lastly, in the case of diabetic men, there is a distinct reward associated with the opportunity to voice grievances about inadequacies in the healthcare system or to reveal personal strategies developed to bridge gaps in, or enhance, medical treatment. This sharing unfolds through the interview, with the hope that it could potentially enrich the lives of others facing similar challenges.

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3.1.2   Gender Issues in the Use of In-Depth Interviews with Diabetic Men Ann Oakley (1981) was among the first feminist scholars who reflected on methodological challenges in traditional interviewing criteria, particularly when employed by female researchers interviewing women. In the context of the present research, I explore the case where a female researcher interviews male participants. Bagilhole and Cross (2006, p. 38) aver “Gender has an effect on interview relations for what is disclosed or withheld, pursued or neglected.” In this study, I approached men’s practices related to illness as simultaneously shaping and being shaped by gender dynamics. I also took gender “seriously” (McKee & O’Brien, 1983), conceiving fieldwork and research as influenced, in turn, by gendered practices. The empirical material, although constructed according to the researcher’s aims and guidance, is nevertheless shaped through the active engagement of participants who narrate their stories within the context of social interactions. Indeed, in-­ depth interviews imply an interactive process of co-creating knowledge, and represent a specific mode of conversation that, like all forms of social interaction, is gendered. Reflexivity in sociological research has been profoundly influenced by its feminist legacy, prompting many women to contemplate how their own gender shapes the research process and its outcomes (e.g., Gair, 2002; McCorkel & Myers, 2003). Recent literature has focused on women interviewing male participants (e.g., Pini & Pease, 2013; Broom et  al., 2009; Bagilhole & Cross, 2006; Golombisky, 2006; Pini, 2005; Arendell, 1997; Hearn, 2007; Green et  al., 1993; McKee & O’Brien, 1983). Drawing insights from this literature, I have sought to contemplate the potential implications of my gender for the construction of empirical material. My gender inevitably had an impact on how my research material was constructed. To illustrate this, we can reflect on a comparative example. In a previous research project, I interviewed gay and lesbian individuals to analyze the construction of non-heterosexual identities. Now, comparing this to the current fieldwork, I noticed some  differences. In fact, in my interactions with heterosexual diabetic men, traditional gender norms have been more evident. More specifically, in my previous experiences, there was an implicit assumption that I would cover the expenses when meeting with participants in a café for conducting the interviews,

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irrespective of whether they identified as gay or lesbian. Since they were dedicating their time gratis to the research, I have always borne such expenses. However, the dynamics in the current study diverged markedly from this precedent. I consistently observed that all diabetic men contacted for formal or informal conversations related to the research insisted on paying for my coffee or meals, as a gesture of chivalry. As I engaged in a critical examination of my gender positioning in the context of the interviews with diabetic men, I asked myself: What would have been different, if anything, had I been a man? In this case, it is conceivable that I would have been spared the physical compliments during the interviews (e.g., comments like, “Do you realize how lovely your smile is?”), as well as questions concerning my age or marital status. These are vividly illustrated in the following excerpt: My brother-in-law went for bone marrow aspiration and they [the doctors] inadvertently punctured a vein, and then they had to operate on him in order to fix the vein. So, [I have] zero confidence [in doctors], no confidence at all. How old are you? Me? I am 32. No way! Really? You don’t look it at all, you look like a little girl, actually I was saying [to myself]: ‘You must have just finished university,’ I said. Actually I finished…. Anyway.… Eh, some years ago. Are you engaged? Married? Engaged, not married Is he a good boyfriend, a good husband? Indeed. I’m so glad, because many men today, when I hear: “Killed the wife, killed the girlfriend”… (Donato, 57 years old, type 2 diabetes, onset at 46 years)

This excerpt constitutes a part of a pilot interview that I conducted during the initial stages of my fieldwork. We could interpret the fact of interrupting the flow of the conversation about illness and addressing me not as a researcher but as a woman, and asking me about my personal life, as a manhood act (Schrock & Schwalbe, 2009) that compensates for the risks of demasculinization entailed in talking about the illness. The combination of factors including my age, my non-medical profession, and, most notably, my gender, along with the absence of diabetes in my personal health experience, might have led participants to view me as an outsider. This perception could have positioned me as a naïve listener, someone who needed their insights to be “educated” about diabetes and

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its implications  enacting what is known as mansplaining. This implied nonetheless a gendered dimension. There is an example  of this, that of Leonardo, a 52-year-old man who had been living with diabetes since the age of four, with a scientific background  who  in this excerpt  highlighted the usefulness of glucose sensors, comparing them to traditional glucometers: You probably know I’m an engineer and therefore I have a predisposition to technology. (…) For me then it is not a big problem to correct a mistake on a vector, right? I just need the time to do it. But for a simple housewife it would be [more difficult]. The point is that this thing [the glucose sensor] eh… it doesn’t only give you a result, like the glucometer does, it gives you a curve, so it gives you a trend. (…) Now, I don’t know how much of a math lady you are, but (…) here, [showing the interviewer a point on a graph of glycemic trends] this is the famous [glycated] haemoglobin value. In this case it’s not high, 6.5 would be a good value, so this is not much, but this is the actual mean, this is the deviation from the same mean. (…) Put simply, if I had to explain this to a child I would say: ‘Lots of inaccurate measurements are better than only 3 accurate measurements because they give me a trend.’ (Leonardo, 52 years old, T1D, engineer, onset at four years)

In this excerpt, and throughout the interview, Leonardo vividly depicted his experience with illness by referring to his technical and scientific expertise. This expertise endowed him with the proficiency to decipher charts, medians, means, and modes. He had a mansplaining approach to me, the (female) interviewer, discursively counterposing his “technological predisposition” with the supposed incompetence of an imaginary housewife/child or even the interviewer, all intended as potential naïve listeners. The interview context offers a rare opportunity, where there is an attentive listener—one who is genuinely interested and values the interviewee’s opinions and perspective, prompting them to contemplate their life from an external and alternative perspective. The intersection of my personal attitudes (e.g., empathy and listening capacity) and gender seems to have fostered a setting where many interviewees felt an increased sense of comfort, particularly when talking about sensitive topics. Even though, as aforementioned, this subject was not without its challenges, the interview proved to be an interactive context for several participants to openly talk about, for example, their sexual difficulties caused by diabetes. In many cases, they reported difficulty in talking about this topic with their

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doctors. We can find an example of this again in Donato’s account when he stated: So, I don’t trust doctors. [Maybe] if I’ll find one that I can feel I can trust, and I see that he cares about the person in front of him, just like you do… It looks like you care, may be because of the type of research you are conducting, because you allow me to express my issues to you, issues that with a woman I would have some difficulties telling, but with you it was easy. And I have never told my doctor anything about this. (Donato, 57 years old, type 2 diabetes, onset at 46 years)

Another example is  Leonardo, who after talking about his “erectile dysfunction,” said: “This is the first time that I actually talk about this with someone.” It is quite reasonable to posit that how participants articulated their narratives in the course of this research, situated in the context of the interview, would possibly have assumed a distinct character, had the interviewer been male. Similarly, had decided to conduct focus groups instead of interviews, the presence of other male participants in the room might have further influenced the narrative dynamics. In essence, this underscores a fundamental question that Lorraine Greaves poses to the reader: “Why incorporate considerations of sex and gender into the realm of health research?” (Oliffe & Greaves, 2012, p. 3). The answer lies in the intrinsic fact that every human being is inherently sexed and gendered. These dual dimensions have a consequential impact on  how individuals engage with health-related practices, and equally shape the way they construct and narrate their experiences of illness. Moreover, these dimensions intricately influence their interactions with the researcher, thereby prompting an imperative exploration into the interplay of sex, gender, and health research. Amidst the intricate interplay of gender dynamics that shaped the research, another noteworthy aspect concerns  an additional challenge highlighted by Brown (2001, p. 192): “Men are not used to talking about health, as it is not normally part of their day-to-day discourse.” Diverse hypotheses have been posited to explain the hesitance of men to engage in health-related conversations. Among these, one hypothesis suggests that men might abstain from participating in such interviews as a demonstration of their masculinity—a means of asserting their autonomy, rationality, and control (Oliffe, 2009). In fact, as mentioned, the recruitment of

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diabetic men has been a labor-intensive and time-consuming process. As we have seen, the main mediators have been women (members of the association, or administrators of Facebook groups) with just one exception, which confirms the rule: the only male mediator has been a member of an association devoted to diabetic athletes, a context—that of sports— that can be perceived as a more “masculine” setting for men to engage in supportive activities. Besides being a challenging population to recruit, men also prove to be difficult interview subjects, often reticent or unwilling to engage in extensive talking. On the whole, a considerable number of men in the sample displayed surprise, and often quite a sense of disorientation, as the interview started with a very open-ended question. Conducting interviews with chronically ill men, particularly those recruited from contexts outside formal associations, meant eliciting stories never been told before. As mentioned, many participants, after concluding the interview, expressed gratitude for facilitating a reflection on issues they had  never considered before. Typically, diabetic men talk about their condition in the context of routine consultations with their diabetologists. During these occasions, they usually find themselves questioned only about numerical values (primarily glycemia levels and glycated hemoglobin) and physical symptoms. In Italy, in the context of the public health care system, these doctor–patient interactions are characterized by their brevity, often not exceeding 15 minutes, which does not permit an extensive conversation. As evident from existing literature, most men rarely engage in conversations regarding their health and well-being “outside the familiar zone of fact-finding and problem-solving” (Oliffe, 2009, p.  74). Typically, their interest in health research pertains to the cause and treatment of diseases, while conversations regerding their personal experiences of illness usually play a marginal role. Based on the insights obtained through this qualitative research, men involved in this study were not accustomed to talking about themselves, particularly regarding their personal experiences of illness. However, after some minutes of conversation, all 40 men proceeded to engage in conversations that, on average, lasted for 1  hour and 40  minutes each. Paolo, 32-year-old diabetic. The person who gave me his contact cautioned: “He tends to be reserved and hesitant; I am uncertain about how much meaningful information you can gain from the interview with him.” Interestingly,

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Paolo’s interview began with succinct, one-word responses, as can be observed in the introductory segment of his interview: Ok. Well, I would like to ask you to tell me your story with diabetes, starting from where you want… Um, are questions that open? [Says while laughing with embarrassment] I will also ask you some questions, later. Yeah, that would be better, because I am not very talkative actually, you know… Don’t worry, I’ll begin. Do you remember when you found out you had diabetes? Yes, in 2006. (Paolo, 32 years old, T1D, laborer, onset at 20 years)

After a few minutes, his responses began to gradually expand. As the interview continued, we found ourselves sharing a meal, which unexpectedly prolonged the interview and made it the lengthiest interview among the entire sample, as well as one of the most detail-rich, characterized by critical self-reflection. Existing literature highlights the challenges in eliciting discussions from men about their health and experiences of illness. This is frequently attributed to their imperative to enact a “stoic” and robust form of masculinity, thereby establishing a distance from domains associated with femininity such as health. However this research  reveals that men are indeed willing  engage in conversations regarding their health and the nuances of their illness experiences, and just need to be in a context that allows it. Central to this circumstance is possibly the need to create a safe space, where they feel comfortable in sharing their experiences, encompassing both the positive and more difficult times and events. This concerns their compliance with medical prescriptions as well as instances of resistance. Crucially, the creation of such a setting ensures that their disclosures are met with understanding and acceptance, devoid of any judgment or criticism. A last consideration involved my personal safety while doing fieldwork. Safety concerns can differ based on the context in which fieldwork is carried out. Green et  al. (1993) compared their research experience with that of other fieldworkers and concluded that the in-depth interview technique, and their own age and gender, alongside those of the male interviewees, in conjunction with the specific research subject (HIV-related risk

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behaviors), rendered them exceptionally susceptible to experiencing sexual harassment in the field. Their observation extended to the recognition that all researchers doing fieldwork are potentially vulnerable. Conducting interviews with men, often in their homes and frequently recruiting them through the Internet, was a context that prompted concerns about my personal safety in a societal context such as Italy’s, where every three days a woman is killed by a man and violence against women is a widespread and common phenomenon (ISTAT, 2015). This scenario made me reflect on my personal safety, as a woman researcher, while doing fieldwork. I was aware of the risks this entailed, particularly as we engaged in conversations encompassing matters of sexuality (in many cases, even if we do not delve into this topic, in this volume, we also discussed erectile dysfunction during the interviews, because it is a common complication of diabetes). As Green et al. (1993) noted, their research experiences have, on various occasions, illuminated how male heterosexual respondents perceive such discussions as “provocative,” which has at times led to overt or covert sexual harassment. To ensure my safety, I adopted a set of precautionary measures. Before arranging appointments, for instance, I decided to engage in pre-appointment phone calls with participants. These conversations served dual purposes: assessing their suitability for the study and checking their actual interest in participation. Additionally, I adopted the practice of asking a colleague to send me a message three and a half hours after the beginning of the interview, to ensure my safety. Ultimately, everything went well. But for  recurrent compliments to my physical appearance, occasional dinner invitations, and one participant who persistently texted me text messages asking me out, the majority of participants showed genuine engagement with the interview topics. In conclusion, I wish to briefly emphasize that the management of personal safety during fieldwork has, in my view, also influenced the shaping of the empirical material. For instance, when I decided to conduct interviews with certain participants in a university setting rather than their own houses—a choice driven by considerations of appropriateness, given the previous conversations with them I forewent the opportunity to engage in interviews within their personal spaces. Such a setting would have facilitated a more comprehensive understanding of their socioeconomic backgrounds and permitted  an exploration of the front stage and back stage dynamics (Goffman, 1959). As Sin (2003, p. 305) pointed out, the process of constructing identities and knowledge through intersubjective dialogue is intricately intertwined with the location in which the interview

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takes place. The inherent nature of conducting interviews in a specific setting should not be underestimated. For instance, when a participant tried to reach me through multiple phone calls and text messages  even at late night—in the week preceding the interview, I found it more prudent to arrange our meeting at the university. Even if this behavior could be that of a very anxious person, given the circumstances, this decision contributed my increased sense of safety and comfort. As a woman, I am no stranger to living in the complex landscape of a patriarchal society, where women often find themselves undervalued and objectified. Yet, I firmly advocate against downplaying these experiences, treating them as unspoken norms, or allowing them to be silenced, because gender power relations have a profound influence on our daily lives, subtly shaping even the way we conduct research. As observed by Broom et al. (2009), gender can be seen as both a resource and a limitation in research practices. It is a reminder that we must consistently recognize how gender plays a role in the construction and analysis of qualitative data. After all, acknowledging these dynamics is a crucial step toward a more insightful and equitable research journey. 3.1.3   Dealing with the Unexpected: A Reflexive Account of the Research Experience The research journey, upon reflection and considering the entirety of the process, has proven far less linear than the preceding paragraphs might imply. In retrospect, it resembles more of a roller coaster ride, characterized by alternating periods of significant discouragement and it all started with enthusiasm. At its beginning, my research journey entailed envisioning participant observation in the context of a urology ward. With this objective, I devoted substantial amount of time to identifying a doctor with whom a collaborative partnership could be established. Initially, my attempts to contact doctors  through emails and phone yielded no responses. Consequently, I adopted an alternative approach to gain entry into the field, bypassing the initial telephonic and email channels which seemed to yield results. I then visited a urology ward in a hospital in a large Italian city during the visiting hours. I approached the head nurse and inquired about the location of the urology department’s attending physician. Following several attempts, I managed to meet a senior doctor specialized in andrology. We engaged in conversations, she agreed to collaborate, and we started to write a research project involving

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participant observation in this setting. Nonetheless, before proceeding, the acquisition of hospital ethical committee approval became necessary. From this moment, my research journey entered the phase of what I can properly term “discouragement.” We engaged in multiple meetings aimed at navigating the labyrinthine realm of bureaucratic obstacles. Upon uncovering a notable stack of forms demanding completion—a voluminous task, to say the least—a subsequent challenge emerged. These forms were initially designed for medical trials, necessitating an intricate adaptation to align with the qualitative and sociological nature of my research. This entailed a comprehensive revision of my initial research project, as well as the composition of the informed consent form, the interview guide, and the meticulous completion of a multitude of forms, all for obtaining the necessary ethical committee approval. After several weeks dedicated to this “bureaucratic” endeavor, the meticulously completed forms were submitted to the hospital’s ethical committee. Regrettably, time ticked by without a timely response. Simultaneously, I encountered challenges in recruiting participants through associations dedicated to diabetic individuals. It was at this point that I opted to explore alternative sampling strategies. Recognizing from the literature that men exhibited a greater inclination toward engagement in quantitative studies than qualitative research, I developed an online questionnaire using SurveyMonkey. While the questionnaire itself would not yield substantial data collection, its primary purpose was to find potential interviewees. Following the questionnaire’s conclusion, alongside a gratitude note for their time, participants were invited to take part in subsequent interviews. This entailed my sharing contact details for further engagement. At this stage, I made the deliberate choice not to request their email addresses at the beginning of the questionnaire, as I wanted to prevent any potential apprehensions about their privacy. Unfortunately, this strategy yielded no useful results. Despite the participation of 76 men who completed the questionnaire, there was no subsequent communication from any of them. Fortunately, the adaptability of qualitative research enables the alignment of research methods with specific contexts or cases, and the fact that the methodological path deviated from the original program is not considered as distortion, a mistake that undermines the rigor of the study (Cardano, 2020); rather, it becomes an integral part of the research process, with its achievements and challenges. A last consideration concerns the fact that in its initial formulation, the research project did not distinguish between type 1 diabetes and type 2.

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However, after conducting preliminary interviews that encompassed participants affected by both conditions and conducting a meticulous analysis of the initial empirical material, I focused solely on autoimmune diabetes. This decision stems from the realization that while the term “diabetes” is the same, its diverse manifestations encompass distinctly different practices of self-monitoring and self-managing diabetic bodies and have a different impact on (gender) identities too. Hence, I opted to focus my attention on autoimmune diabetes due to its distinctive nature from type 2 diabetes. Unlike type 2 diabetes, autoimmune diabetes in fact necessitates constant daily monitoring and the adoption of more uniform and continuous health practices. This characteristic enables for a more feasible comparison among cases.

3.2  Studying Diabetic Men’s Self-Representations on Social Media Social media in general, and TikTok in particular carry interesting implications for both the emergence of new opportunities for accessing and sharing illness narratives and the self-representation of masculinities. In fact, the past few decades have witnessed a remarkable increase in the phenomenon of sharing, viewing, storing, and analyzing illness narratives, largely due to the proliferation of social media platforms and their ever more pervasive use in our everyday life (Lamerichs et al., 2021). This has exerted a significant influence on how individuals understand, attribute meaning to, and experience their illness. This has concurrently spawned to a promising new genre, namely, digital health narratives (e.g., Svalastog et  al., 2021; Lamerichs et al., 2021). This phenomenon has been observed on TikTok too, where individuals share their accounts of illness through short videos. These videos can be found and viewed through hashtag searches regarding a specific subject, for instance #diabetes or #typeonediabetes in the context of diabetes mellitus. Moreover, users have the option to engage with content creators by posting comments, which facilitates interactive dialogues with them. In the realm of digital health narratives, delving into the topic of how diabetic men display their “wounded” masculinities is particularly interesting. In this case, the multiple practices involved in the process of creating and posting a video can be considered as a contemporaneous way of “doing” gender (West & Zimmerman, 1987). Digital technologies

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emerge as a relevant context in the complex construction of one’s gender self-representation,as they offer the opportunity to think and express masculinities in different ways. New social media in fact provide gender models and tools for redefinition and hegemonic reaffirmation of gender (Scarcelli, 2023). Erving Goffman (1959) explained the concept of self-presentation as a performance, as a composite array of symbolic and ceremonial acts enacted in social interaction that allow an individual to manage the impressions on others. Social media add complexity to the mechanisms through which the masculine self is both constructed and displayed to others. Further, they provide new empirical contexts in which to study the construction of masculinity in its doing, and especially the mechanism through which one’s performance of masculinity is constantly constructed under judgment and evaluation from others, as it is a product of how others perceive and assess one’s presentation and behavior during (online) interactions (Schrock & Schwalbe, 2009; Goffman, 1959). In this respect, the process of external validation concerning one’s performance of masculinity (see Chap. 2) becomes particularly evident on social media and is characterized by novel features and social dynamics. In fact, from its outset, the Internet was depicted as a realm of cyberspace utopia, heralding the emergence of a novel domain of freedom, identity reshaping, and the blurring of differences. However, it quickly became apparent that while accessing digital spaces did indeed present a rich terrain of new opportunities, it also carried the risks of violence and discrimination (Farci & Scarcelli, 2022). The realm of personal expression—encompassing not only gender but also other dimensions of the self—is subjected to some form of surveillance. For example, surveillance exists in relation to others (“friends,” “followers,” etc.) who have access to posted information. In this regard, the concept of coveillance comes into play (Rainie & Wellman, 2012, as cited in Scarcelli, 2023). Coveillance refers to a form of surveillance enacted by others, which serves the purpose of better understanding the social context in question, testing existing social bonds, and constructing new ones. It entails a continuous monitoring activity where individuals observe others to gain insights into their activities, check whether there is any news in friendship networks, and so forth. In this reciprocal surveillance activity, each person gains deeper insights into other individuals, as well as themselves. In other words, users find themselves reckoning with their own performances and those of others, intricately intertwined in practices aimed at preserving their own displays and representations, ensuring that

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they align with those of the reference community (Scarcelli, 2023). As noted, individuals internalize shared norms and expectations around masculinity ideals, which then become normative and establish a standard to which one must conform, or, at the very least, around which one’s adequacy is measured in relation to their gender performance. Even in online contexts, therefore, masculinities, just like femininities, are subject to forms of (self-)discipline and control, evaluation, social sanctions, and approval from others. Examining self-representations of diabetic men on TikTok provides a valuable context for delving deeper into the evolving displays of masculinity in the digital media era, while also opening new perspectives on the intersection of masculinity and health. As observed in the preceding chapters, how individuals do health and illness is intricately intertwined with their way of doing gender. Analyzing short videos in which men share their diabetes stories  is an innovative research  field to study how men adopt (or reject) and signify health-related practices and construct their masculinities by reinforcing, challenging, or hybridizing hegemonic ideals of masculinity (Bridges & Pascoe, 2014; Arxer, 2011) 3.2.1   Research Design In the second research presented in this book, I have explored the self-­ presentations of both young and adult diabetic men. The aim was to understand whether these displays are influenced by stereotypical representations of hegemonic masculinity, or whether there has been a change from hegemonic constructions of masculinity as a result of, on the one hand, the necessity to deal with the disease, and on the other the emergence of new affordances provided by the TikTok platform. To do so, I adopted a small data approach (Caliandro & Gandini, 2019) to analyze 100 videos shared on TikTok, to answer the following research question: How are masculinities constructed, negotiated, and displayed in digital diabetes narratives on TikTok? The first step consisted of defining the digital field of research. The sole source of data was the TikTok platform. To create the corpus of data, an account was created on TikTok only for this research, to not influence the algorithm with previous users’ preferences. In fact, this platform shows videos according to a personalization of the content, accomplished through an algorithm based on past preferences. An initial search was conducted on the TikTok platform by using the keywords “diabete tipo 1” (type 1 diabetes) on 15 May, 2023. The search results included the most

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popular videos, determined by the number of views and likes per video. The first 100 videos were then screened to detect the main hashtags used by the content creators to label their videos. Through an Excel file, the hashtags were then ordered and, for each, occurrences were detected. The next step involved the identification of the hashtags most relevant to the topic under analysis, namely, type 1 diabetes. The final selection of hashtags prioritized the ones that a) were related to the topic and b) could lead to the  identification of  content produced in Italian. All the videos labeled with those hashtags were screened, and the content creators detected. This initial selection led to the identification of 20 male content creators who had produced one or more videos concerning type 1 diabetes. The following step implied identifying, among them, those that would compose the final sample. To proceed with this final selection, inclusion and exclusion criteria were adopted (see Table 3.1). More specifically, to be selected for this study, participants first needed to have received a diagnosis of type 1 diabetes or self-define as type 1 diabetic through their profile bio or in their videos; second, they needed to be men;2 and third, had to have posted at least 15 videos on diabetes-related content through the use of diabetes-related hashtags/captions/verbal or nonverbal communication. This last inclusion criterion was to ensure the collection of a sufficient quantity of empirical material, facilitating a more comprehensive exploration of their digital narratives related to diabetes.

Table 3.1  Inclusion and exclusion criteria for the selection of the final sample Inclusion criteria

Exclusion criteria

Personal illness narratives TikToker using (mainly) Italian language Self-defined as type 1 diabetic

Institutional communication TikToker using non-Italian language Non-self-defined as type 1 diabetic (e.g. type two diabetic, etc.) Not men Not posted at least 15 videos on diabetes-­ related content

Men Posted at least 15 videos on diabetes-­ related content

2  I do not intend, through this statement, to adopt an essentialist and binary perspective on gender. Consistent with a constructionist perspective, TikTokers have been identified as men according to their display of gender performance. From what can be inferred from their videos, all of them are cisgender men.

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Table 3.2  Sample information ID

Tiktoker

ID01 edoardoprete

Bio

STREETLIFTING DIABETIC TYPE 1 no bad-vibes qui ID02 diabetiamo2.0 Com’è la vita di un diabetico tipo1? Diabetico dal 2018 Instagram: diabetiamo2.0 ID03 eliafavorido Diabetico sereno Tipo 1 dal 2004 Fotografo e videomaker ID04 alessiocapobianco02 Seguimi su insta Diabetico ID05 lucaromanoyt Sono uno YouTuber E un atleta di streetlifting −10% su Prozis: Lucayt ID06 lightflavours Ho il diabete1 dopo lo sconforto ho reagito creando una cucina sana e gustosa www.mangiavivisorridi.it/ ID07 tolodiabete /

Followers Likes

N. videos

1468

92.3K

137

10.9K

222.6K 715

12.8K

335.8K 32

10.6K

192.8K 92

167.4K

9.3M

960

250

7294

91

102

1361

34

The final selection of TikTokers meeting the inclusion criteria led to a sample of seven tiktokers  whose characteristics are summarized in Table 3.2. Unlike the previous research discussed earlier in this chapter, in this case I will not delve into too many details about the socio-demographic characteristics of the final sample in this case, for obvious reasons. Conducting research through digital data entails, in fact, engaging in post-demographic analyses (Rogers, 2009) a type of analysis that does not consider traditional demographic characteristics such as age and level of education (Caliandro & Gandini, 2019). Nevertheless, even if we cannot be sure about such characteristics, and these have not been taken into consideration in the analysis because of the uncertain reliability, we can assume that among the seven tiktokers taken into consideration, all of them are White, produce content in the Italian language, are presumably cisgender and heterosexual (presumably, only a minority of them talked about or included in their video a female partner), and have a middle-class

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background (again, presumably—this information has been assumed from their specific habitus portrayed in the videos). All of them use TikTok as a channel to share with others their lives with diabetes, the struggles to manage the disease, as well as the strategies to overcome the most common obstacles. After selecting the seven tiktokers composing the final sample, the next step was to  view all the video content on their personal channels—and select all the videos that tackled the topic of diabetes. This implied viewing a total of 2061 videos. For each tiktoker, 15 videos were selected from those deemed the  most pertinent, identified by their association with diabetes-­related hashtags or content, and those with a higher number of views. For each video considered relevant for the topic under analysis, relevant information was collected related to title, duration, name of hashtags, numbers of views, number of likes, number of shares, type of TikTok language (duet, POV, challenge, answer, dance, interaction caption, lip sync, etc.). Data was analyzed through a qualitative approach, employing a thematic analysis. This approach proved particularly useful exploring different ways of constructing masculine self-representations and experiences of diabetes. The analytical process aimed to identify, analyze, and report patterns emerging from the data, as well as differences. The approach to data analysis was both deductive and inductive, depending on the different categories analyzed: on the one hand, in some cases coding and identification of relevant themes were based on the content of the data itself; in others, the approach was deductive. Some key categories, which will be examined in greater detail in Chap. 7, include men’s gendered behaviors and appearance, the presence or absence of jewelry or tattoos, and other similar factors. In this regard, the literature highlights the use of makeup, jewelry, and nail polish as indications of the growing femboy culture on TikTok (Rodgers, 2020) or as signs of evolving boundaries around traditional masculinity ideals in the online sphere. In general, hegemonic masculinity dimensions have relied on Raewyn Connell’s (1995) definition that emphasizes ideals of heterosexuality, power, bodily strength, “healthiness,” potency, stamina, independence, rationality, control, and stoicism. Other dimensions have emerged during the analysis of the data.

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3.2.2   Reflecting on Men, Masculinities, and Self-­Representations in the Context of Chronic Illness As of today, to the best of my knowledge, this study marks the pioneering exploration of the masculine self-representations of men with chronic illnesses on TikTok. Social media have become increasingly integral to our daily lives, evolving into crucial tools for the construction of our gender identities. More specifically, the actual representation of gender on TikTok implies some considerations and ambivalences. On the one hand, as highlighted by Scarcelli (2023), comparing this platform to traditional media reveals a greater diversity in the heterogeneity of individuals and identities being portrayed. While scrolling through the platform’s videos, we can find content created by tiktokers of color, members of the LGBTQIA+ community, individuals with disabilities, chronic illnesses, and more. Given that type 1 diabetes constitutes an autoimmune disease typically emerging in childhood and considering TikTok a platform predominantly frequented by adolescents and young adults, its significance gains particular relevance, particularly for young diabetic males. In this domain, they can encounter peers of similar age who share their condition. This holds importance as it offers young diabetic boys the possibility of producing videos, thereby expressing and receiving recognition for their marginalized identities. Additionally, it proves useful for them to observe videos created by other boys/men with diabetes, helping to alleviate feelings of isolation and offering positive models of others who have incorporated diabetes as a  part of their lives and share their experiences and self-­ management strategies. Further, TikTok, like other platforms, offers the opportunity to engage in interaction facilitated through comments on posted videos or private messages. As will be more thoroughly elucidated in the chapter dedicated to the research findings, diabetic male content creators, in their illness narratives, present multifaceted representations of themselves. These representations encompass the display of practices that, on the one hand, align with the ideals of hegemonic masculinity. For instance, they tend to exhibit a muscular physique, suppress emotional expression, and qualify the adoption of a healthy and light diet (crucial for diabetes management) as a set of practices conducive to the construction of a muscular body. When contemplating the potential repercussions of such masculine self-representations on fellow diabetic viewers, it becomes evident that there are multifaceted implications, encompassing both affirmative and potentially adverse

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dimensions. These facets illuminate the critical role played by cultural gender constructs and their conceivable influence on men’s well-being. A noteworthy example lies in the deliberate choice of numerous diabetic tiktokers of the sample who opted to showcase their physiques devoid of shirts or during their workout routines. This choice is often made with the explicit purpose of dispelling the prevailing stereotype that associates diabetes with physical fragility. These individuals seek to convey the message that despite the societal presumption of diabetic individuals as physically weakened, they can indeed achieve their body-related aspirations. In doing so, they frequently present an exaggeratedly hypermasculine version of themselves, a feat often difficult even for non-diabetic men. This aspect can have different effects. On the one hand, this can foster a positive and active approach toward self-managing diabetes, underscoring the capacity to embody masculinity despite the potentially weakening and stigmatizing impact of illness. This goes in the direction of allowing a hybrid (diabetic) masculinity to be constructed and to gain visibility, a type of masculinity that is not enacted through the rejection of health-related practices but that instead incorporates and re-signifies such practices into specific gender configurations. Thus, it can also have a positive impact on men’s health. On the other hand, the fact of viewing other diabetic men managing to attain hegemonic ideals of masculinitysuch as building a muscular body—might nevertheless cause a feeling of inadequacy, because not everybody can (or wants to) achieve such ideals. The analysis of the videos also revealed, as we will delve into further in subsequent sections of this book, that in a minority of instances, practices associated with marginalized forms of masculinities emerge. These practices encompass expressions of vulnerability, the  adoption of a healthy diet, and the display of skincare routines. This underscores how the dissemination and accessibility of digital illness narratives can catalyze  for change towards novel, “softer” models of masculinity that endorse health-­ promoting behaviors. Clearly, such transformations would require broader cultural shifts, particularly in the context of Italy, which, as we have explained, is marked by the pervasiveness of traditional notions of masculinity and gender power imbalances. Another significant aspect in the realm of masculinity performances pertains to the fact that TikTok engenders spaces of expression that, at least partially, challenge hegemonic ideals of masculinity. For instance, how tiktokers use their voice or body, engaging in activities like dancing, singing, lipsyncing  or recounting their illness  stories, are deeply

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interwoven with the concept of masculinity as a gendered performance. In this context, the adoption of novel social communication rituals, notably, dancing and lipsyncing, by men with diabetes, as a mode of narrating their experiences of illness, is interesting. This observation underscores the platform’s substantial role in broadening the array of practices  historically associated with femininity or considered feminizing. These practices, including dance and singing, have come to shape the scenario of online masculinities. This offers space for identifying presentations that differ from those on other platforms, particularly text-­based ones, where such performances would have more complicated results (Scarcelli, 2023). On the contrary, it is essential to also consider the constraints and limitations of TikTok. For instance, there is the need to consider how the platform’s algorithm-driven selection of videos for the “For You” section might contribute to marginalizing certain minority groups. This poses the risk of videos with the highest view counts predominantly featuring specific individuals, perpetuating normative and hegemonic displays of masculinity (Scarcelli, 2023).

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Miltsov, A. (2022). Researching TikTok: Themes, methods, and future directions (pp. 664–675). SAGE Publications Ltd. Morgan, D. (2005). Class and masculinity. In M. S. Kimmel, J. Hearn, & R. W. Connell (Eds.), Handbook of studies on men and masculinities. Sage Publications Ltd. Oakley, A. (1981). Interviewing women: A contradiction in terms. In H. Roberts (Ed.), Doing feminist research (pp. 30–61). Routledge. Oliffe, J. (2005). Constructions of masculinity following prostatectomy-induced impotence. Social Science & Medicine, 60(10), 2249–2259. https://doi. org/10.1016/j.socscimed.2004.10.016 Oliffe, J., & Mróz, L. (2005). Men interviewing men about health and illness: Ten lessons learned. The Journal of Men’s Health & Gender, 2(2), 257–260. https:// doi.org/10.1016/j.jmhg.2005.03.007 Oliffe, J. L. (2009). Bugging the cone of silence with men’s health interviews. In Masculinities and health: Critical perspectives (pp. 67–90). Palgrave Macmillan. Oliffe, J. L., & Greaves, L. (Eds.). (2012). Designing and conducting gender, sex, and health research. Sage Publications Ltd.. Oliffe, J. L., Kelly, M. T., Montaner, G. G., Seidler, Z. E., Ogrodniczuk, J. S., & Rice, S. M. (2022). Masculinity and mental illness in and after men’s intimate partner relationships. SSM—Qualitative Research in Health, 2, 100039. https://doi.org/10.1016/j.ssmqr.2022.100039 Pini, B. (2005). Interviewing men: Gender and the collection and interpretation of qualitative data. Journal of Sociology, 41(2), 201–216. https://doi. org/10.1177/1440783305053238 Pini, B., & Pease, B. (2013). Men, masculinities and methodologies. Palgrave Macmillan. Pinkhasov, R.  M., Wong, J., Kashanian, J., Lee, M., Samadi, D.  B., Pinkhasov, M. M., & Shabsigh, R. (2010). Are men shortchanged on health? Perspective on health care utilization and health risk behavior in men and women in the United States. International Journal of Clinical Practice, 64(4), 475–487. Rainie, L., & Wellman, B. (2012). Networked individualism: The new social operating system. The MIT Press. Riessman, C. K. (1990). Performing identities in illness narrative: Masculinity and multiple sclerosis. Social Science and Medicine, 30(11), 1195–1200. Robertson, S. (2007). Understanding men’s health: Masculinity, identity and well-­ being. Open University Press. Rodgers, D. (2020). Just how revolutionary is Harry styles’ vogue cover? Retrieved July 23, 2020, from https://www.dazeddigital.com/fashion/article/51147/ 1/harry-­styles-­vogue-­december-­cover-­dress-­gender-­fluid-­guccityler-­mitchell Rogers, R. (2009). The end of the virtual: Digital methods. University Press, Amsterdam. Scarcelli, C. M. (2023). Genere e sessualità su TikTok. In G. Marino & B. Surace (Eds.), 2023. HOEPLI EDITORE.

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Schrock, D., & Schwalbe, M. (2009). Men, masculinity, and manhood acts. Annual Review of Sociology, 35(1), 277–295. https://doi.org/10.1146/ annurev-­soc-­070308-­115933 Sin, C. H. (2003). Interviewing in ‘place’: The socio-spatial construction of interview data. Area, 35(3), 305–312. Svalastog, A. L., Blaakilde, A. L., Ringstad, Ø., & Lamerichs, J. (2021). Narrative genre and health in the digital society. In Navigating digital health landscapes: A multidisciplinary analysis (pp. 15–42). Palgrave Macmillan. Twaddle, A. C. (1969). Influence and illness: Definitions and definers of illness behavior among older males in providence, Rhode Island (PhD Thesis). Rhode Island: Brown University, Providence West, C., & Zimmerman, D.  H. (1987). Doing gender. Gender & society, 1(2), 125–151. White, K. (2017). An introduction to the sociology of health and illness. Sage Publications Ltd. Williams, C. (2000). Doing health, doing gender: Teenagers, diabetes and asthma. Social Science & Medicine, 50, 387–396.

CHAPTER 4

Negotiating Masculinity Through Technology and Self-Tracking Practices

Every time that I eat something, I perform the following operations: I check glycaemia. I mentally count the carbohydrates that I will eat while looking at the quantity and quality of the food. (…) I transform carbohydrates in numbers of insulin units. I add [insulin] units in proportion to the actual glycaemic level. I add or take off [insulin] units depending on how much I ate in the last days, depending on the physical activity I will have in the following hour, depending on how much tired I feel (…). Then I inject a certain amount of insulin units and I hope that I got it right and that I will feel fine for at least one hour. And to think that I never desired to become an accountant… Or an equilibrist…. (Codeluppi, 2012, p. 27, my translation)

As mentioned in previous chapters, diabetes is a chronic illness that leads to bodily uncertainty, requiring affected individuals to manage a range of symptoms on a daily basis, such as fluctuations in glycemia levels, and to tackle the life-threatening as well as social risks associated with this condition. Hence, men with autoimmune diabetes need to develop certain medical skills, in addition to adopting a new lifestyle tailored to their condition, which includes habits such as monitoring blood glucose levels daily, controlling dietary intake and physical activity, and administering precise doses of insulin at various intervals throughout the day (Moretti & Morsello, 2017). These self-management practices require time, dedication, and self-discipline. As we have understood in the previous chapters, the experience of battling a chronic illness and the adoption of such © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Quaglia, Wounded Masculinities, https://doi.org/10.1007/978-3-031-44436-4_4

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self-­management practices present a potential challenge to men’s ability to adhere to hegemonic ideals of masculinity (Connell, 1995). To explore how men perform their masculinities in the context of diabetes, we will refer to the concepts of masculine capital (De Visser et  al., 2009) and hybrid masculinities (Arxer, 2011; Bridges & Pascoe, 2014). In this chapter, we will delve into the case that has been labeled as the “Tracker,” which is the first ideal type of diabetic masculinity that emerged from the analysis of the interviews. This ideal type characterizes those participants who, while narrating their experience of illness, discursively use compensatory manhood acts (Schrock & Schwalbe, 2009) emphasizing their ability to manage bodily uncertainties through practices of self-­ quantification, self-discipline, and self-monitoring. These practices are in alignment with hegemonic ideals of masculinity as they underscore their rationality, proactive approach, and ability to master their bodies and control the illness. Therefore, engaging in these practices serves as a means to acquire masculine capital and allows men to stand in discursive contrast to the emasculated image of those who, instead, remain passive in the face of the illness and its bodily and social implications. This mechanism of compensation intersects with broad shifts in masculinities. As we have observed in the previous chapters, masculinities are continuously evolving, and the so-called new man now encompasses traits previously perceived as feminine, including engagement in self-care practices such as grooming and cosmetics use and participation in a more “involved” fatherhood. A part of this change can be attributed to the assimilation of the contemporary neo-liberal paradigm of health, characterized by the perception of well-­ being and health as individual responsibilities. Consequently, both men and women are expected to actively engage in practices devoted to the management of their health risks. Individuals are in fact “constructed as active consumers of health advice; as responsible citizens with an interest in, and a duty to maintain, their own well-being both to improve health and fight disease” (Crawshaw, 2007, p. 1606). Although we cannot delve into this topic, it is worth mentioning that the phenomenon moral responsibilisation  of health  has progressively  intertwined with the process of datafication of health and digital  technology use, and some authors (see Maturo, 2022; Figueroa et al., 2020) have also highlighted possible consequences of this in a near future, such as the emergence of the so-­ called “Polysocial Risk Scores”, a way of attempting to measure health risks on the base of social factors such as income, education, race/ethnicity, and  lifestyle habits, whose predictive function could be used by

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insurance agencies to measure individuals’ health risks and adapt accordingly insurance pricing.  Although to date this is not the case, at least in Italy, it is something that should be critically considered for future development of health technologies and the use of health data. Practices such as self-tracking, self-observation, and recording and analyzing data about one’s bodily functions are always more common in general, and in particular for diabetic individuals. In a world characterized by uncertainty and instability, numbers, measurements, and calculations play a role in maintaining a sense of control. Self-monitoring and self-tracking practices might be perceived as a means of controlling, predicting, and managing the “messiness and unpredictability of the fleshy body” (Lupton, 2016, p. 77), especially for diabetic individuals. Nevertheless, self-tracking bears gender implications that are intriguing for gaining a deeper understanding of men’s health (Schmechel, 2016). Historically, men have exhibited less inclination toward monitoring their bodily functions. This tendency can be attributed to the hegemonic ideals of masculinity that expect men to devote as little time as possible to tracking and caring for their bodily functions. In contrast, the act of closely observing and tracking one’s bodily processes has been predominantly associated with women and femininity, for instance in contexts such as weight control, fertility tracking, or menstrual cycle tracking (Schmechel, 2016). Relevant changes have been observed in this regard. The case of the so-called quantified self is an interesting example. This concept was developed in 2007 by Gary Wolf and Kevin Kelly—editors of Wired magazine who also created a dedicated website and blog, Quantified Self (www. quantifiedself.com), where “quantified-selfers” (Maturo, 2015, p.  90) share their experiences of self-tracking with each other and discuss the efficacy of these practices in reshaping behaviors. With the slogan “Self-­ knowledge through numbers,” the platform has cultivated the idea that engaging in self-tracking can improve self-awareness and enhance personal performance. The information shared on this site predominantly revolves around topics such as running, weight management, and caloric consumption (Maturo, 2015). In this context, it is interesting to observe that statistics related to comments in online discussions and participation in Quantified Self meetups indicate that approximately 70–90% of the users and attendees are men (e.g., Cornell, 2010). The recent surge in male interest in engaging in self-tracking activities seemingly holds interesting implications for the study of men and their health. The ideal type of the

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Tracker, which will be  discussed in the following pages, represents an incorporation of such changes. Furthermore, the focus on diabetes will offer the opportunity to reflect more broadly on the contemporary changes in masculinities and their hybridization.

4.1   The Tracker This ideal type responds to the uncertainties of the diabetic body by accentuating his competence to exercise control over the illness rather than being passively subjected to it. He achieves this by centering narratives primarily around data pertaining to his bodily metrics such as glycemic levels and carbohydrate intake, with a particular emphasis on the idea that self-tracking practices enhance self-awareness, self-understanding, and, most of all, diabetes management. The data collected through these self-­ tracking practices are viewed as tools to exercise better control over not only diabetes symptoms but also their destiny (Lupton, 2016), since diabetes entails an uncertain future because of the risks associated with its complications. Diabetic men learn how to deal with the unpredictability of glycemic swings and coordinate the different activities they undertake in their everyday lives, from eating to exercising, to maintain constant control over their diabetes symptoms. These activities are real technologies of the self that imply “those intentional and voluntary actions by which men not only set themselves rules of conduct, but also seek to transform themselves, to change themselves in their singular being” (Foucault, 1990, p. 10). The Trackers are in constant pursuit of improving themselves and their ability to manage their diabetic bodies. The participants who could be described by this ideal type usually alluded to being a member some types of diabetes communities that have characteristics of real community of practice (Lave & Wenger, 1991). These communities exist in different forms, ranging from online forums and Facebook groups to in-person associations dedicated to diabetic people or informal groups comprising individuals who share the same condition. Within these communities, the Tracker shares his fundamental beliefs concerning health and illness management. He acquires diabetes self-­ management strategies by learning from more experienced members, and as he gains more experience, he shares his insights and own accomplishments. These participants reported practicing rigorous self-discipline by meticulously upholding self-surveillance practices and adhering to controlled dietary regimens. As mentioned, they engage in discussions about

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their daily diabetes experiences primarily through numbers. This encompasses talking mainly about their fluctuating glycemic levels throughout the day, along with the results of a specific blood test known as glycated hemoglobin—a particularly relevant measurement because it serves as a quantifiable indication of long-term glycemic control. This value  succinctly and symbolically represents an individual’s ability in recent months to maintain glycemic balance and avoid blood sugar swings. Positive results are perceived as personal achievements, serving as proof of the efficacy of the specific technologies of the self that have been developed over time. The Tracker ideal type discursively distances himself from those diabetic individuals who mismanage their condition or have a lifestyle opposite to his. As Broom and Whittaker (2004) outlined, “To be in control denotes power and agency, while being out of control signals chaos, madness, and moral failing” (p. 2381). The primary aim of Trackers is to achieve their numerical targets. The analysis of the interviews brought to light another significant distinction in how the participants achieved these targets and the meanings they attached to the self-management practices they adopted. Specifically, this distinction led to the identification of two distinct subtypes, delineating different disciplinary paradigms discursively reproduced in the narratives. I have termed these subtypes the “Patient” and the “Lay Expert.” The Patient subtype refers to those participants who talk about their diabetic bodies and the associated care practices through an explanatory model rooted in biomedical knowledge, which they fully adopt. The legitimacy and effectiveness of this medical knowledge are not subject to question. They talk about diabetes mainly in terms of “disease” (Twaddle, 1969), that is, they place particular emphasis on the physiological or organic aspects of diabetes rather than their perception and lived experience of the illness. The second subtype, the Lay Expert, shares with the first sub-type the discursive practice of discussing the experience of diabetes and self-­ management primarily through numerical terms. The participants who can be described by this sub-type also attribute significant importance to self-surveillance and self-discipline strategies that guide their daily routines. Similar to the Patient subtype, the Lay Experts incorporate a biomedical framework as well; however, they shape the same around their personal experience. This approach enables them to create a (partially) alternative and personal source of knowledge that, from their perspective,

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improves and refines the more abstract and universal expertise provided by diabetologists and physicians. The two subtypes will be analyzed in further detail in the following paragraphs. 4.1.1   Self-Quantification and Adherence to Treatment: The Patient Out of the 16 participants in this subsample, the majority (11 individuals) could be classified under the Patient subtype, which is characterized by a strong and strict commitment to self-management through strict adherence to medical treatment in the form prescribed by diabetologists. The participants in this subgroup often highlighted the impact of diabetes on the difficulty or impossibility of fulfilling social expectations rooted in hegemonic notions of masculinity. Many participants acknowledged that diabetes and its associated health complications somehow disrupted their social expectations concerning men’s bodily strength, independence, and reliability—which, in turn, affected their ability to perform expected social roles. An illustrative case is that of Silvio, a 51-year-­ old man who developed diabetes at the age of 35. His struggle with diabetes-related health complications led him to a change in employment that rendered him unable to continue fulfilling the traditional role of the “male breadwinner” of the family, which usually stems from hegemonic ideals of masculinity. Silvio:

I wasn’t someone like this. [He laughs] I wasn’t someone to pity, before. (…) Interviewer: How were you before? Silvio: Well, I worked, yes, I worked a lot, maybe too much, but I was always mmm I worked, worked, worked a lot, I mean. So basically I was always… busy. Now… the routine is what it is. … You have to reach—you have to reach a compromise with yourself. This is a little… (…) Eh, it’s tough. (Silvio, 51 years old, diabetes LADA, employee, onset at 35 years of age) The case of Leonardo, a well-known professional who runs a private firm in a large town in Northern Italy, presents another example. He acknowledged his “wounded masculinity” in quite a straightforward manner by observing that he would have been able to better comply with

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hegemonic ideals of masculinity and increase his success in business by being more aggressive and competitive if he did not have diabetes. Another thing I think is: “If I didn’t have diabetes, maybe I would have been much more of an asshole.” What do you mean? [Long pause] In not respecting others’ weaknesses. In my relationship with others, I did hurt some people, and I ask myself: if I were even stronger, maybe I would have been… [even worse] (…) Yes, because in the end I am a person who, if I didn’t have diabetes, I would have been less insecure, stronger in general, I would not have lost a great number of livable and productive life hours (…) just like for all the frequent diabetes medical visits. A question I ask myself is: ‘How much does it cost to the “enterprise myself” to have diabetes?’ (Leonardo, 52 years old, T1D, architect, onset at 4 years of age)

Another example is that of Liam, a 24-year-old man who had diabetes onset at 18 years of age. His case well exemplifies the possibility of experiencing dilemmas pertaining to masculine identity (Charmaz, 1994), particularly regarding the impact of diabetes on physical prowess, which is amplified when drawing a comparison with other non-diabetic males. In his words: Mmm yes, at times I feel a little… weak. Maybe seeing other couples, for example, when… I had a partner, … maybe sometimes I wouldn’t feel like doing something, an effort, of any kind, mmm it—it affected the whole thing. That’s true. Yes. That’s true. More than anything, it was a fear of mine to face, maybe, something, … in general, and maybe the… the other [male] guy did it without a problem, and I was maybe scared of the… of the reactions of glycaemia, that could have decreased, etcetera, etcetera, … and I have always said: ‘No, I don’t feel like it.’ These cases make me feel uncomfortable. (Liam, 24 years old, T1D, shop assistant, onset at 18 years of age)

As mentioned, within this subgroup, the diabetic men responded to such threats to masculinity in different ways. As a first order of business, they strongly accentuated their competence in diabetes management— expertise they had developed over the years. These techniques of the self were often the combined result of reliance on medical recommendations and their independent pursuit of medical information, as can be understood by the accounts of Flavio and Damiano:

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I tend to… ask more to the experts. I have spoken to doctors, not only to him [his diabetologist], also to other people, … I mainly rely on medicine, [while] alternative… things, let’s say… I see them as very dangerous. (…) So, I trust the doctors, yes. Mmm he [the diabetologist] is a person who gives me confidence, so… I tend to trust him. (Flavio, 41 years old, T1D, psychotherapist, onset at 36 years of age) Then I studied the subject a little, so… I was lucky I wasn’t a child, when I got it, but I was already… let’s say, in an age of reason, so I did some research and… I went to my GP, who was not exactly a friend, but I knew him well, and I had him give me some of his medicine books [he laughs] and I read them, [they were] a little pretentious, but still… useful enough. (Damiano, 58 years old, T1D, manager, onset at 33 years of age)

Two participants, Silvio and Renato, reported blogging about their experience with the illness. In the case of Silvio, this was done in collaboration with healthcare professionals who recognized and valued his expertise. Wife: Silvio: Wife: Silvio:

[with the diabetologist] we’re friends [she laughs]. [he laughs] We go there, hugs and kisses. Yes, nurses, I mean, by now they have known me for a lifetime, then–then they always say that I am someone… who knows [this issue] almost like they do. (…) And then- the fact that I’m a computer specialist, a tech expert, I don’t have trouble with the things, … and the fact that I’ve always taken an interest, I wrote a book, I have a website, I have a blog, I mean…. (Silvio, 51 years old, diabetes LADA, employee, onset at 35 years of age)

For this subtype, the critical aspect of diabetes self-management constitutes constant glycemic monitoring. All but one participant reported using the continuous glucose sensor. The only exception was Tommaso—a 53-year-old man who was diagnosed with diabetes at the age of three years and had lost his eyesight as a consequence of the illness. He mentioned that he used the traditional glucose meter because it was more accessible than the continuous glucose sensor and provided spoken display data. Overall, the choice of all participants to utilize the glucose sensor was motivated by the possibility of exercising greater control over their

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symptoms and managing their condition more effectively. Flavio’s words present an illustrative example: I can monitor glycaemia in every moment of the day, and this is very useful (…) I can even measure it during psychotherapy sessions. (Flavio, 41 years old, psychotherapist, T1D, onset at 36 years of age)

Each participant consistently monitored their blood glucose levels throughout the day and routinely transferred this data to their computer. Subsequently, the accumulated data underwent analysis utilizing dedicated software or applications that automatically interpreted and synthesized the information through statistical representations, graphs, or other data visualization tools. These numerical results were regularly shared with family doctors or diabetologists, and they were often shown to me during interviews as a visual support for the participants’ stories or employed as a numerical reference that represented the participants’ abilities to effectively manage diabetes. Another manhood act the participants utilized to compensate for their perceived loss of physical prowess was the exhibition of intellectual prowess and competence in non-physical domains such as self-tracking and understanding data. Men in this subgroup showed a tendency toward “explaining” the graphs, curves, and other aspects of the general data pertaining to their glycemia, often in an expert, condescending, and oversimplified manner. An example of this is seen in the case of Leonardo, who discursively contrasted his “technological predisposition” with the perceived incompetence attributed to an imaginary housewife or child, or even the female (sociologist) interviewer—all portrayed as potential naïve listeners. You probably know I’m an engineer and therefore I have a predisposition to technology. (…) For me then it is not a big problem to correct a mistake on a vector, right? I just need the time to do it. But for a simple housewife it would be [more difficult]. The point is that this thing [the glucose sensor] eh… it doesn’t only give you a result, like the glucometer does, it gives you a curve, so it gives you a trend. (…) Now, I don’t know how much of a math lady you are, but (…) here, [showing the interviewer a point on a graph of glycaemic trends] this is the famous [glycated] haemoglobin value. In this case it’s not high, 6.5 would be a good value, so this is not much, but this is the actual mean, this is the deviation from the same mean. (…) Put simply,

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if I had to explain this to a child I would say: “Lots of inaccurate measurements are better than only 3 accurate measurements because they give me a trend.” (Leonardo, 52 years old, T1D, engineer, onset at 4 years of age)

Another manhood act that goes in the same direction of compensation is that of trying to reverse—within the context of the interview—the asymmetry of power between the male interviewee and the female interviewer through the sexualization of the latter. Questions about the researcher’s age or marital status were asked during the interview, which, together with flatteries and compliments on physical features (e.g., “You look younger!” and “You have a very beautiful smile!”), interrupted the illness narrative and suddenly changed the topic of the conversation. Goffman (1981) identified such footing changes during interactions as ceremonial rituals of masculinity construction (Sassatelli & Ghigi, 2024) that tend to disqualify female expertise in favor of assigning a more “decorative role” to women, in alignment with normative gender expectations. The participants of this subgroup reported having positive experiences with medical devices, and they typically expressed enthusiasm when describing their use. Edoardo, one of the interviewees, recounted that his wife objected to the use of the insulin pump, considering it a real intrusion into their relationship. She was particularly bothered by the noise it emitted at night when issuing alerts for hypoglycemic episodes. He recounted, My wife refused the insulin pump… She thought it was an intrusion in our couple. (…) She said: ‘You have to choose me or it!’ And I chose the insulin pump. (Edoardo, 53 years old, T1D, laborer, onset at three years of age)

By emphasizing his decision to keep the insulin pump, Edoardo affirmed his autonomy and independence from his wife’s preferences and will. He also conveyed a rational perspective by explaining that he chose to keep the insulin pump despite his wife’s reluctance for his own well-being. Well, for me the insulin pump meant… Meant and still means a better living, because I am monitored… Always monitored. (Edoardo, 53 years old, T1D, laborer, onset at three years of age)

Within this subgroup, the participants strongly stressed the significance of maintaining a “controlled” lifestyle for effective diabetes management and prevention of complications. Their dedication consistently aligned

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with diabetologist recommendations. By highlighting their capacity for self-discipline and adherence to medical guidance, they projected themselves as rational individuals capable of exerting authority over their health condition. This focus on control underlines the relevant role it plays in regaining control over lives and shaping one’s masculinities. If I say “diabetes,” what is the first thing that comes to mind? Mh, (…) I think, … for how I see it now, diabetes is… for me it’s being more controlled, compared to a normal person, eating right. (…) And not messing around, (…) you have to be careful with everything that surrounds you. (Liam, 24 years old, T1D, shop assistant, onset at 18 years of age)

Additionally, another element relevant to this point of view was their portrayal of themselves as resilient and strong individuals, not despite but because of diabetes, as they were able to bear the burden of constant self-­ control and self-monitoring every day of their lives. And, instead, subsequently, through a continuous control of glycaemia, it became, how can I say, much more suffocating, or still, you have much more attention. Even if you don’t want it, you have it, because you have the sensor and therefore, for better or worse, you see the cell phone, you see a message and you, as diabetic, you know that glycaemia is the thing… a fundamental thing, so you monitor it and you always constantly keep it under control. (Alessio, 42 years, T1D, employee, onset at 13 years of age) Since I read that there have been people who died for hypoglycaemia, well, [he laughs] you’re always on your toes, you don’t have… that night in which you sleep peacefully, no, you’re always… (…) well, you don’t have that peace of mind of… I say, it’s a job, having diabetes is a job, they should pay us in… as if we had two jobs, because it’s a job. Constantly mmm… a continuous control. (Silvio, 51 years old, diabetes LADA, employee, onset at 35 years of age)

Men in this subgroup also exhibited competence, rationality, and control over their condition through their discourses around food consumption. When they talked about their eating habits, the framework employed was again that of quantification and calculation. They often discursively reduced individual foods to numbers (of carbohydrates) and the corresponding units (of insulin) that composed each meal. This refers to a specific technique defined as “carbohydrate counting,” which, according to the interviewees, was not commonly familiar to everyone. Instead, it was

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typically shared within their community of practice or acquired from fellow diabetic friends and acquaintances. In the words of Patrizio, My breakfast, … well (…) breakfast has always been a bit of a problem. Because I have a 1-to-5 ratio. It’s a very low ratio. Sorry, 1-to-5 ratio, can I ask you what does… it mean? One… one unit of insulin, metabolizes only 5 carbohydrates. So in the morning I, I mean, my breakfast is… 20 carbohydrates, more or less, not more, if I eat a brioche, (…) … while at midday, I have a higher ratio, 1-to-12, and in the evening, 1-to-7 again. So what do I do? I keep on about 20 in the morning, … 50, on average eh, 50 and 20. (Patrizio, 44 years old, diabetes LADA, clerk, onset at 38 years of age)

Measuring, quantifying, and organizing food consumption is an onerous, time-consuming activity. By applying gender lenses to the analysis of health practices, we can pose the following question: Who takes care of this in a diabetic man’s everyday life? Usually, according to the narratives collected, it is the non-diabetic women (wives, mothers) who shoulder the responsibility of preparing and organizing the diabetic men’s meals. Food-­ related practices are quite relevant to the construction of masculinities (Fidolini, 2022; Sassatelli, 2005). For this subgroup of participants, in nine out of 11 narratives, the responsibility for meal preparation was assigned to the participants’ wives (9/11) or mothers (2/11), who were taught how to do the same properly. For example, Patrizio described how his mother, with whom he and his partner lived, cooked for him, while his partner disregarded this (gendered) chore. My mom, I’m telling you, she helps me, because well… I taught her more or less the carbohydrates counting. So, when I get back from work, … mmm she has already counted, what, … I mean, what I have to eat, … she indicatively knows it, so she does the ratio, the proportions, there are no problems. Whereas my partner, mmm… if I ask her: “What shall I eat this evening?” she says: “Well, eat that.” … And I tell her: “But that there, it’s proteins. I need to eat carbohydrates in the evening, because…” … She doesn’t know, despite being a cook, … in an old people’s home, she doesn’t know. (Patrizio, 44 years old, diabetes LADA, clerk, onset at 38 years of age)

Leonardo’s case presents another example, which, besides illustrating how gender relational dynamics influence the organization of domestic

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tasks, demonstrates how, in some cases, the taste of food is also utilized as a means of gender distinction. Within your family, who’s in charge of organizing meals, buying the food, who decides what you eat? My wife. Also because I’m away from home a lot of time, while she works at home, so… Does she consider what you should eat [for diabetes management] or she freely… She has her own theories… And we do have different tastes, I could say blood sausage and zucchini! [He laughs] (Leonardo, 52 years old, T1D, engineer, onset at 4 years of age)

The only exception within this subgroup was Alessandro, a 46-year-old man who experienced the onset of diabetes at a very young age—when he was merely three years old. Alessandro explicitly dissociated from hegemonic masculinity ideals by openly expressing that he shared domestic responsibilities with his wife. Furthermore, he challenged traditional norms and also adopted a vegetarian lifestyle, which he was motivated to pursue due to ethical reasons. 4.1.2   Constructing a “Personalized” Diabetes Self-Management Strategy: The Lay Expert Practicing full adherence to doctors’ recommendations was not universally valued in this subsample. A minority of the participants, specifically five out of 16, indicated that they only partially integrated medical knowledge into their diabetes management practice unconditionally. In the case of the Lay Expert ideal type, emphasis was placed on these men’s ability to “shape” this knowledge according to their personal experiences, aiming to refine the otherwise universal and abstract medical approach. Medical knowledge is thus subjected here to partial questioning in terms of its actual effectiveness and criticized for its limited application to the unique needs of each individual. Men in this subgroup exhibited a critical attitude. Furthermore, unlike the previous subtype, they questioned, at least to some extent, the biomedical approach to diabetes that underpinned the health services provided. On the one hand, they incorporated medical knowledge in terms of conceptualizing diabetes as a medically defined condition and

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acknowledging the crucial role of insulin therapy and regular glucose monitoring. On the other hand, overall, the Lay Expert diabetic men critiqued the pervasive medical paternalism in vogue, with particular reference to healthcare providers’ tendency to underestimate patients’ autonomy and ability to fully comprehend their bodily symptoms and implications of diabetes. The men in this subgroup did not take the efficacy and legitimacy of medical knowledge for granted; instead, they asserted the importance of diabetic people’s autonomy in decision-making and their need to receive all the necessary information to correctly determine the best health choices for them. As Lucio stated, My approach is to say: “All right. Ok. You are the professional. I mustn’t play by my rules. It’s clear that you have some knowledge, and resources, … that I don’t have and cannot have, and that I am not required to have. But I want to know what is happening here, what you’re prescribing me, because you are prescribing it to me, … and I want to understand the procedure that takes you from point A to point B, … and of why that was chosen.” (…) This is something that is kind of typical… unfortunately, of… I noticed, of Italian medical doctors. That (…) they tend to give diagnoses, or still, to… to approach the patient in a one-sided way. I mean, to say: “I know what’s good for you, now I’m telling you what you have to do.” … And as a matter of fact, when I ask some questions, … I notice that some doctors almost feel… almost opposed. Asking a question doesn’t mean opposing someone. I would simply like to understand the reason, and I can assure you I have the [cultural]  instruments to understand, (…) it’s something that… I can understand, and I want to understand. (Lucio, 38 years old, diabetes LADA, entrepreneur, onset at 36 years of age)

As evidenced in the Patient subtype, the Lay Experts also emphasized the importance of always being in control of their bodies and glycemic levels in their narratives. In this case, men’s sense of control is attained through the competence acquired by both comprehending medical directions and effectively tailoring them to their personal needs and circumstances. This involves adjusting the various components that constitute their diabetes management strategy (diet and therapy in particular) to better suit their specific situation. In this context, particular relevance is attributed to medical devices dedicated to self-monitoring and administration of therapy. These devices are depicted in their narratives as fundamental tools to put to the test medical recommendations and personalize them. Their bodies become the center of attention, as they adopt almost an “experimental” approach to refining and enhancing the rules of

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diabetes self-management. For instance, they attempt to adopt a more specific and personalized diet, measuring the effect of each food item on their glycemic levels after eating it by using glucose sensors or glucometers, and create a diet plan that enables balanced nutrition and a reduction in insulin intake simultaneously. Overall, a majority of the participants reported using glucose sensors for measuring glycemia. Most of them expressed a preference for using insulin pens instead of insulin pumps. Generally, this subgroup was different from Patients in so far as they had a positive approach toward medical devices, however, unlike the Patients, the Lay Experts primarily emphasized the utility of such devices in constructing their self-management strategy, which often slightly deviated from their doctors’ recommendations. It is interesting to observe that, as demonstrated in other studies (Ardissone, 2022), the use or rejection of specific technologies was not related to the technology itself but rather to the usefulness and meaning attached to it. Across all analyzed cases, significant importance was placed on developing a personalized diet to maintain proper glucose levels, avoid glycemic swings, and minimize insulin administration. The “rules” informing the participants’ dietary habits were not those related to the recommendations of diabetologists. Instead, they emerged from the participants’ personal research, information exchange (primarily in online forums or groups), and personal direct experimentation on their bodies. This experimentation involved ongoing glucose level monitoring, data analysis, and the search for the most effective combination of food intake and insulin dosage. The interviews highlighted that diabetologists, while offering a vague recommendation to eat “healthily,” generally did not suggest excluding or reducing any particular food items from the interviewees’ diets. Typically, the interviewees were told that they simply needed to increase the insulin units injected in proportion to their carbohydrate intake. This medical advice was strongly criticized by all the Lay Experts, who, instead, emphasized the significance of minimizing pharmaceutical treatment to the greatest extent possible, also through diet. A particularly illustrative case in this regard is that of Paolo—a 32-year-old man who had diabetes onset at the age of 20 years. It seems like the objective of doctors—aside from earning—is that of making you feel normal, no? Well, instead, they should teach [diabetic] people

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to accept the fact that they’re not normal, that they have a problem, and learn to accept it and face it in the best possible way. Not as if you don’t have a problem: you do have a problem! And you will have other [problems] if you keep thinking you don’t have any. (Paolo, 32 years old, T1D, laborer, onset at 20 years of age)

Paolo used pens for insulin administration and the sensor to detect his glycemic levels. He reported analyzing in detail the effects of the food he consumed on his body through constant self-tracking and self-monitoring strategies. He began his illustrative discourse by criticizing the medical approach to food consumption. Well, the method that physicians want you to follow, would be: breakfast, than after 2 or three hours a snack, then lunch, then after 2 or three hours a snack and then dinner. And may be a snack before going to sleep and, every time [you eat], you inject insulin. (Paolo, 32 years old, T1D, laborer, onset at 20 years of age)

He then underscored the reasons he regarded this “schema” as ineffective. According to his perspective, unrestricted eating leads to a perpetual reliance on insulin and constant fluctuations in blood sugar levels, resulting in a difficult situation to manage. Employing a metaphor, he likened this situation to that of a seesaw—constantly oscillating between highs and lows and ultimately creating “chaos.” In contrast to his doctor’s advised strategy, he devised a meticulously tailored dietary plan, which, in combination with a personalized treatment regimen, enabled him to maintain a consistent glycemic balance throughout the day. This approach significantly curtailed his daily insulin intake and culminated in the achievement of a satisfactory glycated hemoglobin value. In the subsequent excerpt, his narrative delves into the nuances of how he meticulously tailored both his dietary choices and treatment strategies. When I wake up… [I eat] lettuce salad, always. Raw vegetables help making a barrier in the stomach and reduce carbohydrate absorption, so I eat them before and not after, because after it’s useless. (…) Then I measure glycaemia, and usually it is quite ok. So, I eat a bunch of salad, and then eat leftovers from the last dinner that usually are pan-seared vegetables cooked somehow, with some legumes, together with 15 grams of bread. Then I have some nuts that usually are 30–40 grams… And I go to work. (…) I also inject some insulin, and I perform it twice, because—may be it is just a psy-

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chological thing- but I observed that it lowers glycaemia more slowly. (Paolo, 32 years old, T1D, laborer, onset at 20 years of age)

Despite disapproving of his personalized dietary regimen, Paolo reported with pride that his diabetologist was nonetheless satisfied with his final glycemic parameters and values. According to Paolo, thanks to the specific technologies of the self that he developed, his “glycated hemoglobin is lowered (…) from 9 to 6, just a little higher than a non-diabetic individual,” and his insulin requirement has decreased “from 9 units of insulin to 2,” as he recounted. A similar approach to diet was also described by Lucio: [After the onset] I radically changed, because now I don’t eat… almost any flour… refined flour, I try to avoid… when possible, all food with… a glycaemic index… with a high glycaemic index. (…) I have lost about twenty kilos, in the last… in the last two years, especially in the last year… It’s that significantly limiting… not many carbohydrates in general, but rather, those with a high glycaemic index, that might come from flour, … or from some refined grains, eaten in great quantity… I realize that… I have… very important benefits. (Lucio, 38 years old, diabetes LADA, entrepreneur, onset at 36 years of age)

Exercising control through a strict diet was Lucio’s main strategy for managing the illness. From a personal point of view, I believe that food is one of the main key… factors, obviously, I mean, how you eat, … is closely related [to] how you’re managing your illness. (Lucio, 38 years old, diabetes LADA, entrepreneur, onset at 36 years of age)

He believed that an improper diet is a contributing factor to autoimmune conditions such as type 1 diabetes. To substantiate this theory, he presented statistics comparing incidence rates over time and across different countries. These statistics indicated varying levels of autoimmune diabetes based on distinct local dietary traditions. Lucio primarily founded his diabetes self-management strategies on a tailored and disciplined diet. His ongoing search to refine this personalized diet led him to try new foods that might help maintain low glycemic levels. For example, he introduced the American sweet potato into his diet. He pointed out its “carbohydrate content of only 3.5%,” which, as he indicated, is in stark contrast

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to the “75–80%” found in conventional potatoes. This numerical evaluation of food carbohydrate levels and glycemic index was the fundamental principle guiding his dietary choices. However, adopting a personalized diet bears implications for the social dynamics of diabetic men. The participants in this subgroup reported experiencing difficulties in eating meals with others, such as at friends’ homes, due to their different dietary habits. Furthermore, it was precisely during meals and interactions with others that they were exposed to the risk of stigma and marginalization due to their non-conformity with the masculine hegemonic ideals of appetite and voracity. In the words of Lucio, Many people might say: “But you’re eating less compared to before”, or who make… the typical little joke: “You eat like a lady!” (Lucio, 38 years old, diabetes LADA, entrepreneur, onset at 36 years of age)

In only one case, the personalization of diet and the reduction in carbohydrate intake were justified by not only the necessity of keeping down and controlling glycemia levels but also the aspiration of constructing a muscled body. This was witnessed in the case of Diego—a 23-year-old man who was diagnosed with diabetes at the age of four years and was actively engaged in bodybuilding at the time of the interview. As observed in previous chapters, muscularity has often been regarded as a pivotal trait of hegemonic masculinity (Connell, 1995). Reframing and rationalizing a restrictive diet, not as a means of weight loss traditionally associated with femininity, but as a strategy for muscle-building, becomes a way to acquire masculine capital in a context where masculinity is perceived as vulnerable. Furthermore, in this case, the representation of oneself as autonomous and independent—also from doctors to some extent—served as a manhood act. For instance, Diego’s diabetologist explicitly cautioned him against excessive protein consumption, stating potential kidney issues, especially given his diabetic condition. However, Diego consciously chose not to adhere to these medical recommendations. He decided to develop and adopt a personalized diet that involved an increase in protein intake through supplements, along with reduced carbohydrate consumption, in line with his dietary goals. Everyone says that proteins are bad for your kidneys, you mustn’t take them, because you’ll feel bad, the usual things, etcetera. So, considering first of all that proteins are also present in food, if I want to add a higher protein

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dose to my… to my day, … you know more or less what the grams-per-kilo ratio you can handle is, without exaggerating… You drink a lot, you’re purified, also in the sense that… your kidneys are purified. (Diego, 23 years old, T1D, confectioner, onset at four years of age)

A recurring theme observed in the Lay Experts’ narratives, similar to the case of the other subtype, is the concept of control. As we have seen, showing to be in control is a fundamental trait pertaining to hegemonic ideals of masculinity. Men within this subgroup actively engage in autonomously seeking disease management strategies. These strategies, on the one hand, challenge a significant domain of masculinity construction, namely, observing specific and “healthy” dietary practices. On the other hand, the potential threat of emasculation stemming from their competence in dietary practices and adoption of a specific diet is counterbalanced by their self-representation as competent individuals, surpassing—according to their point of view—even their diabetologists with respect to nutritional knowledge. This self-representation emphasizes men’s autonomy and rationality, besides demonstrating control over their bodies and selves. Diego’s words exemplify how this subgroup of men constantly refers to the issue of control. If I say ‘diabetes,’ what is the first thing that comes to mind? [Long pause] Mm… (…) I think… [Long pause] Control? Maybe? Ok, … control… of what? Of everything, in general… after all. It goes from the control of sugars, to behaviour- to the control of food, to the control… of the body, of sport, in general. Of life, yes, let’s put it this way. (Diego, 23 years old, T1D, confectioner, onset at four years of age)

A majority of the Lay Experts indicated their involvement in food preparation and organization practices, with only two exceptions, who assigned this responsibility to their wives. A particularly interesting aspect of their narratives in this regard is how the participants who assumed charge of cooking in their households justified this potentially emasculating engagement. For instance, Lucio attributed his active role in the kitchen to his wife’s lack of culinary skills (“she doesn’t know how to cook”). During the interview, Paolo was appreciated as a real “food expert” by his partner, who stated that he cooked “amazing meals,” combining creativity and competence. Raimondo justified his cooking duties with his retirement,

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which afforded him the possibility to allocate more time to house chores than his wife could, as she was still working. In essence, within this subset, most men reported managing their dietary practices. However, these narratives were characterized by an underlying assumption that food organization and preparation practices are still women’s responsibility, and thus they discursively positioned themselves as “exceptionally” assuming this role, implicitly showing that they were aware of and, to some extent, compliant with societal gender norms.

4.2  Conclusion: The “Measure” of a Man— Diabetic Men Dealing with Vulnerable, Diabetic Bodies In the Trackers’ narratives, diabetes is represented as a chronic disease that exerts a significant impact on their daily lives as well as the enactment of their gender performances. Despite the disease leading to a constant experience of bodily uncertainty and the necessity to adopt specific technologies of the self to address it, the interviewees present a masculine self-representation—which, to some extent, reinforces hegemonic ideals of masculinity, without necessarily resorting to practices deemed as “unhealthy” or “risky” for their health. These findings confirm that “doing masculinity” is a complex and sometimes contradictory experience that diverges from the overly simplistic approach of perceiving masculinity in an homogenizing way and as one of the primary “risk factors” for men’s worse health. As observed earlier, the interviewees described digital medical devices and self-tracking practices as useful tools to facilitate self-management of diabetes and simultaneously shape a convincing masculinity by adopting hegemonic traits of masculinity such as rationality, autonomy, and technological expertise. An initial consideration regarding the innovation heralded by digital health revolves around the question of who can afford to access and utilize digital technologies for diabetes self-management. For instance, in some regions of Italy, these devices can be used free of charge with the general practitioner’s authorization, while in others this is not possible. In the analyzed sample, a majority of the participants were able to benefit from this opportunity, while a minority obtained these technologies by paying autonomously. Each of them occupied a social position that empowered

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them to both maintain and safeguard their health status while performing “hybrid” masculinity, with quantification practices concerning their health recognized as valued attributes. A second consideration pertains to the fact that the digital revolution has not only significantly changed the relationship between individuals and their health but also further expanded the boundaries of masculinity through a (re)negotiation of the bodily limits imposed by illness. From being perceived as symbols of stigma, digital medical devices have now become tools to, on one hand, fulfill the moral imperative of maintaining health and, on the other hand, “do gender” by adhering to specific regulatory norms that define the boundaries of appropriate masculinity. In fact, during the interview, self-tracking practices for diabetes management were employed as discursive tools to construct a “successful” diabetic masculinity despite the disruptions imposed by the illness. The specific techniques of the self (Foucault, 1990) adopted were thus employed to acquire masculine capital and enact a self-­representation characterized by rationality, competence, independence, and mastery over one’s body. In tandem with discursive processes of masculinity hybridization, wherein elements of counter-hegemony are incorporated, a reference to the traditional model of gender relations endures. This model perpetuates the invisibility and devaluation of the caregiving role within the family—a role traditionally associated with women and marginalized in the backdrop of taken-for-granted gender role assumptions.

References Ardissone, A. (2022). Selective adoption of therapeutic devices among people with type 1 diabetes. Health Sociology Review, 31(3), 278–292. Arxer, S. L. (2011). Hybrid masculine power: reconceptualizing the relationship between homosociality and hegemonic masculinity. Humanity & Society, 35(4), 390–422. https://doi.org/10.1177/016059761103500404 Bridges, T., & Pascoe, C. J. (2014). Hybrid masculinities: New directions in the sociology of men and masculinities. Sociology Compass, 8(3), 246–258. https:// doi.org/10.1111/soc4.12134 Broom, D., & Whittaker, A. (2004). Controlling diabetes, controlling diabetics: Moral language in the management of diabetes type 2. Social Science & Medicine, 58(11), 2371–2382. Charmaz, K. (1994). Identity dilemmas of chronically ill men. The Sociological Quarterly, 35(2), 269–288. Codeluppi, L. (2012). Lu, la mia vita col diabete. Pioda Imaging. Connell, R. W. (1995). Masculinities. California University Press.

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Cornell, M. (2010). Is There a Self-Experimentation Gender Gap? Retrieved August 2, 2023, from https://quantifiedself.com/blog/is-­there-­a-­self-­ experimentation-­gender-­gap/ Crawshaw, P. (2007). Governing the healthy male citizen: Men, masculinity and popular health in Men’s Health magazine. Social Science & Medicine, 65(8), 1606–1618. https://doi.org/10.1016/j.socscimed.2007.05.026 de Visser, R. O., Smith, J. A., & McDonnell, E. J. (2009). ‘That’s not masculine’: Masculine capital and health-related behaviour. Journal of Health Psychology, 14(7), 1047–1058. https://doi.org/10.1177/1359105309342299 Fidolini, V. (2022). Eating like a man. Food, masculinities and self-care behavior. Food, Culture & Society, 25(2), 254–267. Figueroa, J. F., Frakt, A. B., & Jha, A. K. (2020). Addressing social determinants of health: Time for a polysocial risk score. Jama, 323(16), 1553–1554. Foucault, M. (1990). The history of sexuality: The use of pleasure (Vol. 2). Vintage Books. Goffman, E. (1981). Forms of talk. University of Pennsylvania Press. Lave, J., & Wenger, E. C. (1991). Situated learning: Legitimate peripheral participation. Cambridge University Press. Lupton, D. (2016). The quantified self. Polity Press. Maturo, A. (2015). Doing things with numbers. The quantified self and the gamification of health. Eä (Buenos Aires), 7(1), 87–105. Maturo, A. F. (2022). Polysocial risk scores and behavior-based health insurance: Promises and perils. Tecnoscienza, 13(1), 106–115. Moretti, V., & Morsello, B. (2017). Self–management and type 1 diabetes. How technology redefines illness. TECNOSCIENZA: Italian Journal of Science & Technology Studies, 8(1), 51–72. Sassatelli, R. (2005). Genere e consumi. In S. Cavazza & E. Scarpellini (Eds.), Il secolo dei consumi: Dinamiche sociali nell’Europa del Novecento (pp. 172–200). Carocci. Sassatelli, R., & Ghigi, R. (2024). Body and gender. Polity. Schmechel, C. (2016). Calorie counting or calorie tracking: How quantified self transforms feminized bodily practices into new ways of performing masculinity. In S. Selke (Ed.), Lifelogging: Digital self-tracking and lifelogging—between disruptive technology and cultural transformation (pp.  267–281). Springer Fachmedien Wiesbaden. Schrock, D., & Schwalbe, M. (2009). Men, masculinity, and manhood acts. Annual Review of Sociology, 35, 277–295. Twaddle, A. C. (1969). Influence and illness: Definitions and definers of illness behavior among older males in Providence, Rhode Island [PhD Thesis, Brown University].

CHAPTER 5

From Uncertainty to Resilience: Reformulating Masculinity Through Endurance Training and Sport

The iron-man is considered to be… the man of steel, indestructible, we are iron-men with diabetes, so… we are not heroes… we don’t… don’t want to go beyond our limits, … but we want to provide tangible evidence that… it is possible… to explore our limits, and to fight… (…) to achieve our dreams. (Ivan, 51 years old, T1D, manager, onset at 27 years of age)

Erving Goffman (1963, p. 153) in his book Stigma outlined a set of “norms” and standards that characterized, in his opinion, the “ideal” American man: “A young, married, white, urban, northern, heterosexual Protestant father with college education, fully employed, of good complexion, weight, and height, and a recent record in sports. Any male who fails to qualify in any one of these ways is likely to view himself—during moments at least—as unworthy, incomplete, and inferior.” In contemporary Western society, sports and physical prowess are still considered important features in constructing desirable masculinity, as previous literature has highlighted (Connell, 2005; Messner, 1990, 1992; Robertson, 2003; Anderson, 2008; McKay et  al., 2000). In fact, from childhood, boys are often encouraged more than girls to engage in sports, play outdoors with their peers, exhibit competitiveness and aggression, and embrace activities that involve getting dirty and taking space. Conversely, these same behaviors are often discouraged in girls due to concerns about them getting dirty or being tomboys, and thus not aligned with traditional

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ideals of femininity (Sassatelli & Ghigi, 2024). Sociological and feminist literature on gender and sports has problematized masculinity in relation to sports. This body of work outlines how sports have historically been institutionalized to cultivate values essential for manhood in boys, such as competitiveness, toughness, the drive to win, and a sense of superiority (Robertson, 2003; Beynon, 2002). Connell (1995, p. 54) argues that in recent history, sports in America have become “the leading definer” of masculinity in mass culture, and points to the fact that the organization and institutionalization of sports are embedded in specific gender power relations. In fact, the literature in this regard has highlighted how the domain of sports, especially team sports, is primarily reproduced through masculine homosocial practices that foster the establishment and preservation of male-to-male bonds (Ferrero Camoletto & Bertone, 2017; Bird, 1996). These practices often promote ideals of hegemonic masculinity that are characterized by sexist and misogynistic attitudes toward women, as well as homophobic attitudes and violence (Anderson, 2005; McKay et  al., 2000; Messner, 1992, 2002). As we have seen in Chap. 4, few boys and even fewer men are actually able to achieve hegemonic ideals of physicality and commit to formal sports over time. Nevertheless, the fact of self-representing as competent in a masculine field such as that of sports, even if at an amateur level, can be useful in acquiring masculine capital (de Visser et al., 2009; Bourdieu, 1986). It has been noted that, even when men are not actively involved in sports, sports still permeate male culture not solely through their participation but also through the discourses that are produced around the sports (Seymour, 1998). The notion of masculine capital is connected to another Bourdieusian concept, that of habitus. In fact, men’s involvement in sports mainly depends on the potential costs and benefits an individual perceives from engaging in those activities. Usually, these costs and benefits are culturally shaped and influenced by gender, reflecting variations stemming from one’s “class habitus” (Robertson, 2003). In defining and shaping men’s habitus, social class is also a crucial dimension; in fact, the interest and engagement in different sports (e.g., golf, tennis, football, rugby) implies a diverse availability of resources, both economic and cultural, that also has an important role in defining the margins of masculinities. As discussed in Chap. 1, a person with diabetes often remains associated with the general perception of frailty, vulnerability, uncertainty, and the

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need for constant care and attention. They are deemed unstable, unable to engage in activities considered “too risky,” such as intense sports, and prone to glycemic fluctuations, thus representing a person who is weak and “demasculinized” and far from being able to adhere to the hegemonic sporting ideals of masculinity. Furthermore, as previously mentioned, the necessity to adopt healthy habits, including a balanced diet and constant self-tracking, carries the potential for demasculinization. As observed by Gerschick (2000), crucial in the understanding of the complex interplay between masculinity, illness, and the use of the body is a focus on social interaction. When interacting with others, men with diabetes also need to deal with illness-related stigma. In fact, diabetes is a stigmatizing condition, particularly for men who need intensive insulin therapy, such as in the case of men with type 1 or autoimmune diabetes. The stigma around individuals with diabetes is mainly connected to the possible visible “markers” of the condition, such as insulin injections, the need for constant blood glucose monitoring, dietary restrictions, and possible episodes of hypoglycemia. These visible manifestations, which depend on the progression and severity of the disease and its complications, contribute significantly to the experience of diabetes stigma, shaping social attitudes and self-perceptions around the condition (Liu et al., 2017). The stigma associated with diabetes is something that individuals need to manage in the context of social interactions. The experience of stigma is deeply intertwined with social expectations of masculinities and femininities, because disclosing or disguising illness-related practices and bodily signs involves gender-relevant arenas such as diet and physical activity. The latter is particularly interesting in this regard because, unlike more severe illnesses or visible disabilities, autoimmune diabetes is not immediately visible (e.g., athletes with diabetes can choose to administer insulin injections and check blood glucose in private). Nevertheless, men with diabetes must still ensure their glucose levels are stable before they engage in physical activities. During intense physical activity, they must also be prepared to confront the risk of hypoglycemia, which carries the potential for them to be “unmasked” as diabetes individuals. Consequently, this exposes them to the threat of social stigma and to a potential loss of status within the hierarchy of masculinities, accompanied by the loss of the associated benefits. This highlights the significance, in understanding the construction of diabetic masculinities, of two additional dimensions identified by Gerschick (2000), namely, gender as reproduced in social interactions and the relevance of the body in gender performances. It is worth recalling from

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Chap. 1 that, in line with Connell’s (2005) and West and Zimmerman’s (1987) perspectives, masculinity here is not considered an inner trait of men but rather an ongoing process of “doing,” a configuration of practices that changes depending on men’s phases of life and historical and social contexts. To accomplish gender, individuals must gain acknowledgment from others, confirming their alignment with the prevailing norms of masculinity or femininity typical of a specific social context. This reciprocal scrutiny creates a dynamic in which others with whom we interact act as evaluators, ensuring our adherence to societal gender norms and potentially imposing sanctions for non-conformity (Gerschick, 2000). Men’s desire for social validation and affirmation as gendered beings reinforces conformity. But chronically ill people “are engaged in an asymmetrical power relationship with their more normative-bodied counterparts, who have the power to validate their bodies and their gender” (Gerschick, 2000, p. 373). For men with diabetes who fail to achieve hegemonic masculine ideals in other realms, sports can be considered a compensatory “manhood act” (Schrock & Schwalbe, 2009). As Gerschick (2000) points out, the role of bodies in obtaining acknowledgment as appropriately gendered beings is crucial. Male bodies serve as canvases on which gender is displayed, and they kinesthetically function as the mechanisms through which gender is physically performed (Gerschick, 2000). Bodies hold symbolic significance and function as a form of embodied capital that reflects men’s status. Consequently, men who can display hegemonic attributes have access to privileges that others do not. Notwithstanding the often unattainable and unrealistic expectations of achieving hegemonic ideals, men internalize these ideals. They strive to display these attributes, simultaneously evaluating themselves and their peers through the lens of these standards. As a result, individuals with bodies that deviate from hegemonic norms often face the risk of lacking social acknowledgment and validation. In fact, men with autoimmune diabetes risk not being fully recognized as “real men” because of their (ill) bodies and the visible markers of illness. In this context, the emphasis on the construction of an athletic and sporty physique  can be used as one of the means to enact through the body a compensatory masculinity where “the adoption of some practices neutralizes the de-masculinizing potentials of other practices” (Ferrero Camoletto & Ferritti, 2020, p. 109; my translation).

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5.1   The Athlete In addition to being an important arena for masculinity construction, physical activity and sports are also crucial for managing diabetes in everyday life. In fact, together with insulin treatment, healthy eating, and blood glucose monitoring, it is one of the pillars of diabetes self-management because it is useful to gain better control of blood sugar levels, lower the risk of long-term diabetes-related complications, such as retinopathy, nephropathy, and cardiovascular problems, and avoid being overweight, which could complicate disease management and increase the probability of diabetes-related complications. From the analysis of the interviews, the Athlete is the second ideal type that emerged, where masculinity construction is accomplished through the display of competence in the field of sports. Men with diabetes falling into this ideal type follow doctors’ recommendations to regularly engage in physical activity, but they go far beyond the diabetologist’s suggestion of going for a postprandial, quiet walk every day. They would rather engage in endurance training through running, cycling, and kayaking competitions or intensive and regular, on a daily basis, working out. Such activities are usually deemed “risky” for people with autoimmune diabetes, given their physical intensity and potential to disrupt the glycemic balance. For the “Athlete,” a sport is presented as a sort of counter-­ discourse that resists medical suggestions for moderation in physical activity. Instead, it relies on personal experiences and on the expertise of other athletes with diabetes, which are part of a subcultural world where sports practices are learned and shared with others sharing the same condition. The “Athlete” incorporates, re-signifies, and reappropriates a cultural capital that becomes subcultural, and then, within that specific subcultural context, it acquires value as masculine symbolic capital and allows the subject to obtain a subcultural status. Sports, in this case, is a shared practice, a “compensatory manhood act” (Schrock & Schwalbe, 2009, p. 288) that involves refusing doctors’ recommendations of “taking it easy” and, instead, preferring to engage in competitive “risky” sports activities. As we have seen, diabetes transgresses masculine expectations of corporeal self-­ sufficiency, toughness, and healthiness. But, as mentioned, men with diabetes confront themselves with different and sometimes contrasting bodily expectations: on the one hand, they are expected to fulfill the hegemonic ideal of masculinity deriving from their specific social contexts; on the other hand, they are explicitly asked to comply with adherence to

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biomedical standards. In a way, the Athlete incorporates and complies with both social expectations. In fact, their way of “doing” diabetes through endurance and competitive sports is for the “Athlete” to have an arena where he can enact a hypermasculine gender performance, while at the same time maintaining control of his condition. The subculture of “athletes with diabetes” seems to be structured as a real community of practice (Lave & Wenger, 1991), where the “novice” man with diabetes just approaching sports after the diagnosis, learns from experienced “members” how to practice sports while managing diabetes and how to use endurance sports as almost an alternative therapeutic tool to control his condition. From the interviews, it has emerged that the subculture of “diabetic athletes” is mainly composed of men with diabetes, confirming the importance of homosocial relations in the construction of gender as they contribute to producing a collective array of practices that shape a certain form of “sporty” diabetic masculinity. After the diagnosis, boys often participate in “diabetes camps,” events that help newly diagnosed boys and girls learn how to better manage diabetes and get to know other peers experiencing the same conditions. In some cases, interviewees have learned in this context to better manage diabetes through sports, mainly football. In other cases, when they were already adults, they simply met other men with diabetes (e.g., in online diabetes groups or through diabetes-related associations), who taught them how to use sports as a tool for managing the disease. Then, from being a “peripheral member,” the “Athlete” progressively becomes a full participant in the community, and within the context of the interview, he discursively constructs his full membership in such a community through the discursive references to the “outsiders,” those who cannot be included as full members of the community. In this case, the “Athlete” mainly identifies as outsiders those individuals with diabetes that have a sedentary lifestyle, those that are “passive” and that incorporate medical suggestions, such as the “Quantified Patient” ideal type, or those that overeat, drink alcohol, smoke, and do not discipline their bodies properly. In general, the interviewees have engaged in various sports, each of which entails distinct implications in terms of social interactions with others, thereby generating pressures to conform to normative ideals of masculinity and to manage the visibility of their illness in front of others. For analytical purposes, the interviewees have been categorized into two main groups: athletes with diabetes participating in individual sports and those

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engaged in team sports. The following discussion will elucidate the dynamics inherent in these two subcategories. 5.1.1   “I will fight for it, I will achieve it, I will keep it”: Diabetic Athletes Engaging in Individual Sports The majority of athletes with diabetes in this sample—13 out of 15— engaged in individual sports. Such sports included competitive running, cycling, mountain climbing, boxing, and triathlon races. “Domination” and “battle” were recurring terms that participants of this subgroup used to describe their illness experience, and sports were usually considered a tool for “fighting” diabetes. Below are some illustrative examples: Diabetes is an ugly beast. Because it hits you constantly, trying to weaken your resistance. I always say so. Eventually it knocks you down. If you are not smart enough to fight it back in a certain way, you don’t realize it, but then, you collapse. (Massimo, 59 years old, T1D, retired, onset at 30 years of age) A motto I have come up with is: ‘I will fight for it, I will achieve it, I will keep it’ (…) so… to fight, absolutely to fight, fight, fight, fight, in order to achieve… but what is fundamental, especially for a chronic illness… is to achieve… to keep, to maintain, … so to never let your guard down, to achieve an outcome, and to never, ever, ever lose… sight of it. (Ivan, 51 years old, T1D, manager, onset at 27 years years of age)

As mentioned in the previous paragraph, engagement in competitive sports is informed by rigorous norms of body normativity, and disabled or chronically ill bodies are often perceived to be weak and passive (Shapiro, 1993). Hegemonic ideals of masculinity are particularly amplified in the context of sports, where physical prowess, resistance, and body performance are at the core of the practice. From the analysis of the empirical material, it emerged that the choice to engage in individual rather than collective sports was in itself a coping strategy adopted by participants to deal with impression management (Goffman, 1959) and limit the risk of experiencing stigmatization. An illustrative example might be found in the experience of Martino, a 34-year-old man who was diagnosed with type 1 diabetes at the age of eight; in his narrative, the possibility of experiencing underperformance in sports because of diabetes seemed to be more bearable if he competed outside of a team, only by himself. As he put it,

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I was ok at football [he laughs]. [Then, once they started leaving me as a reserve all the time], I gave it up. I chose individual sports, … because at least I was alone, competing. Also cycling, I go out by myself, I don’t have anyone who forces me to go out, or not, just like with running. So… somehow, doing team sports…? Eh, you are a little penalized by doing team sports, … if you have diabetes. Because… it could be that your teammates see you… as the weak one of the group… and that’s that. Instead, individual sports, it’s you, you deal with yourself and that’s it, most [diabetic people] I know engage in individual sports. Either running, walking, … I know someone who does karate, someone who… who does mountain climbing… Who cycles, but most of [the people] I know do individual sports. Individual sports … (…) it’s you, your team doesn’t have to rely on you, … you can easily make it. If you make it, it’s on you to win. If you lose, it’s on you to lose. (Martino, 34 years, T1D, farmer, onset at 8 years of age)

In fact, individual sports allow for more control over the material dimensions of diabetes; they allow for managing social expectations around normative performances by reducing bodily accountability and keeping it in a more “private” dimension. This is possible because diabetes is, most of the time, an invisible disease. But in the context of sports, it might become “visible” in many ways: through the examination for the medical certificate for competitive sports activity, through the hyper/hypoglycemia episodes that might occur during sports performances, or even through medical devices that are attached to the body, such as the glucose sensor or the insulin pump. In contrast to team sports, individual sports allow deciding whether to train alone or with somebody else, and even in this case, there is no obligation to share locker rooms with others who do not have diabetes or take part in team meals or activities, all social situations that, as we shall see in the next paragraph, would complicate information control (Goffman, 1963). Furthermore, diabetes might also become visible directly through the active disclosure of the athlete with diabetes. In this subsample, all participants reported being “visible”— although with different nuances—in the context of sports. The visibility of illness was mainly associated with participants’ membership in the subcultural world of athletes with diabetes; in fact, despite competing as individuals, participants in this subsample reported being part of a real “community of practices” (Lave & Wenger, 1991) composed of athletes with diabetes that engaged in sports disciplines and shared their experiences and supported each other, to improve at the same time  sports

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performances and diabetes self-management. Participants in this subsample understood sports as a crucial instrument for managing diabetes. Athletes with diabetes knew and incorporated medical knowledge, usually “shaping” their personal expertise through its incorporation and experimentation in their everyday lives. Among this subsample, a recurring issue was that diabetologists adopted a universalistic approach, which was perceived as abstract and far from practical experience, and that life with diabetes could only be really understood by people who experienced it in the first person. Massimo, a 59-year-old triathlete who was diagnosed with diabetes at the age of 30, remarked: [I]t’s not only my opinion. I’m saying that us, us diabetics… mmm who do a certain kind of… of training, we confront one another, we communicate between each other, and we have the same ideas. It’s the doctors who… sports doctors, diabetologists, that are completely… they live in a different world. (…) Only the diabetic understands the diabetic. Who isn’t diabetic, I can guarantee that… they have a partial understanding of diabetes… but not living with it twenty-four hours a day for many years, in fact… they always have a limited understanding. (…) The truth that I have noticed for some time is that if you mmm, aside your… pharmacological treatment and your diet, you don’t add physical activity, which has to be a bit intensive though, not moderated, because a moderated one is not useful at all, in fact you- in fact you don’t… how can I say? … You are doing… the… the… 60 per cent of what you should be doing. You see the problem? Sure, sure. But unfortunately the medical profession doesn’t help us from this point of view. So… each one of us… has to, how can I say, we have to construct ourselves (he laughs) by ourselves. (Massimo, 59 years old, T1D, retired, onset at 30 years of age)

In these narratives, sports practices were a form of knowledge actively constructed by the subject, a lay expertise that could be (partially) counterposed to that of diabetologists and family doctors. Such knowledge was composed of a set of practices that were learned and shared with other athletes with diabetes and that had the main aim of keeping the symptoms of diabetes under control and reducing insulin intake. A first element of “resistance” to medical knowledge was engaging in endurance sports per se, because they were usually conceived as being too risky for subjects with autoimmune diabetes. An illustrative example is that of Ronaldo, a 46-year-old man who was diagnosed with diabetes at the

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age of 39. In his narrative, he re-ported having started sports practice as a real act of resistance to medical knowledge, a way of transforming a vulnerability into a challenge to overcome: No in fact the diabetologist, initially, had… even prohibited me from doing sports, saying: “Look, the diabetic’s lifestyle has to be that of… staying still, immobile, breathing little, eating little, and whatnot.” I gave him proof of the opposite. (Ronaldo, 46 years old, diabetes LADA, high school teacher, onset at 39 years of age)

Another example is provided by the experience of Gioele, a 39-year-old man who has had diabetes since the age of 12. At the time of the onset, he was practicing football, and the doctor had forbidden him from continuing to practice sports, suggesting he engage in “something calmer.” But things went differently. After a period of time spent without practicing any sport and after having become a little overweight, Gioele started running to lose weight, and he increased little by little the challenges and performance goals to reach, ending up first running in marathons and then even competing in national triathlons. When he began engaging in competitive running, Gioele reported having learned—just like a novice—how to manage diabetes during endurance sports from a more “experienced” athlete with diabetes, Ivan, who was described by him as a real “guru.” As Gioele stated: Because it is important. (…) because you can talk with other people, and you listen to their point of view… Like I do with… my friend … who tells me: “Look, today I did this training here, I did this… I stopped the basal [insulin], I did this other thing, I did like this”…. Maybe you try too, doing the same, but it’s not certain that it will go well for you… since we are all different. [He laughs] (Gioele, 39 years old, T1D, employee, onset at 12 years of age)

The “other people” Gioele is referring to in the quotation above are, according to the narratives collected, mainly males; in fact, sports are described here as enacted in a homosocial context (Ferrero Camoletto & Bertone, 2017; Bird, 1996), where men engaged in a shared set of practices that were valued by other male athletes and were crucial to construct a successful masculine identity. In the next excerpt, Gioele recounts an episode where another (male) athlete with diabetes helped him during a triathlon race:

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It happened to me two years ago, also this year… Two years ago at yyy [name of a Spanish city], (…) it was crazy, because… while I was in the sea, for the swimming part, three point eight kilometers of swimming, I started to feel, initially the insulin pump… vibrating, and that was fine, because I always start a little high, in glycaemia. Then it told me I was high, absolutely fine… The thing is that at a certain point it started vibrating and it wouldn’t stop… Because we hadn’t realized that there was a small crack in the battery area, and water had gone in it. And luckily my friend was out… there, watching the race, basically as soon as I was about to go out on the bike, I caught him, and… I took this one [the insulin pump] off, he gave me the other, I attached it, … I continued with that one. (Gioele, 39 years old, T1D, employee, onset at 12 years of age)

Talking to and learning from other athletes with diabetes allowed Gioele to become in turn an “expert member” of the athletes with diabetes subculture, and at the time of the interview he participated in different activities of an association as a testimonial to present himself as a model of a “successful diabetes” and to show to early-diagnosed boys that, despite diabetes, “you can do anything,” as he stated. Athletes with diabetes engaging in individual sports shared a chronic condition and a mutual interest in a set of sports practices primarily aimed at better managing the condition. While they did not always train together or have frequent interactions, they kept in contact. Occasionally, they met to participate together in marathons, but more often they communicated through social media and email. For most of them, knowing other people who were experiencing the same issues was described as crucial, as Ivan highlighted with a meaningful metaphor: [My nickname is the] “gladiator” (…) I like this mmm… not only… because of its meaning of… of being a fighter, one who never gives up. But, most of all, I always say… when the gladiator, in the movie, is in the arena, and the door is about to be opened… he says a very important thing: “Whatever may happen to us on the outside” so… whatever these chronic illnesses may bring up in the future, “the important thing is to be close to each other, … to fight, side by side.” (…) When one… of us, inevitably, experiences a moment… of self-doubt, or of decline, … there is always someone else who can… support them. So the point is: never face this illness… alone, isolating yourself, … and thinking that one is invincible, because if one manages to face it, … he does it together with others. (Ivan, 51 years old, T1D, manager, onset at 27 years of age)

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The majority of the participants who engaged in individual sports reported receiving support and social recognition not only from the peer group but also from the athletes without diabetes, who recognized their subcultural sports capital and expressed admiration for their greater efforts. In Martino’s words: Yes, with those I do sports with, they know my problem, in fact, they admire me, because what they do, I can do it too, …so sometimes they tell me: “You’re great.” They aren’t diabetic…. But… they admire me because… I have the determination to do things. (Martino, 34 years, T1D, farmer, onset at 8 years of age)

In these narratives, athletes without diabetes with whom they interacted were usually not described as stigmatizing. They were often a source of important support and recognition, and Martino recounted a significant episode: I was out with the usual [friend] I go out, I had to stop, and get off the bike because of a hypo, … I measured it [glycemia], I was at 45, … and I didn’t take it that well, mentally, because… in… 8 years that I’ve been doing sports, it never happened that I got off my bike. Getting off the bike, stopping, sitting on the ground, I was clearheaded, I was talking, I took my… carbogel, my sugar, … but it was a defeat (…) Mmm having to give up after the first problem [that is, the illness]… I try not to surrender to the problem, … I deviate here, there, I get over it. Instead, then I actually had to give up. Stop, sit down, stay sitting on the ground… for a quarter of an hour, twenty minutes (…) … but for two, slash three days, the defeat was stuck in my head. … I know- we were out on our bikes, … we had 15 kilometres to get home, … I got home with tears in my eyes… I was defeated. The only time in… all these years. … And… how did your sport mates react? (…) There was the guy who goes with me, … he understood the problem, he knows the problem, he tried to take my mind off it…. “Yes, look here, look there,” but by then I, my head was gone, (he laughs) it was gone, and the same in the evening, he called me again, also the day after, he called me… and for three days I didn’t touch my bike. (…) Then I got back on it, … but it remained… more than the scare… this defeat was…. A big defeat. (Martino, 34 years, T1D, farmer, onset at 8 years of age)

Another key theme that was often intertwined with social relations among athletes with diabetes was that of competition. Overall, all

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participants who engaged in individual sports talked about different forms of competition. Bourdieu asserted that masculinity is produced and maintained not only with respect to femininities but especially within homosocial contexts: “Male habitus is constructed and completed only in connection with the space reserved for men, the space in which the serious games of the competition are played among men” (Bourdieu, 1997, p. 203). The “serious games of the competition” were here described as fuel that sustained participants’ rigorous and hard training or as the main driving force that made them try to always improve their sports performances. In participants’ narratives, competition declined in different dimensions. The first case was that of self-competition; in this regard, an illustrative case was that of Emanuele, a 43-year-old man who had been diagnosed with diabetes at the age of 16. At the time of the interview, he worked as an employee and was a competitive runner. In addition to diabetes, Emanuele also had paresis in one arm and one leg, caused by problems that occurred during his birth. In his narrative, competitive running was highly valued for the personal meaning attached to it; the mere fact of participating in a running race was considered an important achievement for him. He compared his personal story to that of “Forrest Gump,” the protagonist of a 1994 movie directed by Robert Zemeckis, who, just as he did, managed to engage in sports despite physical difficulties and cultural obstacles. Emanuele’s engagement in sports began after an informative event organized by an association dedicated to people with diabetes, where he, just like Gioele, met Ivan and was introduced to the subcultural world of athletes with diabetes. The day after they met, he ran for the first time with Ivan, and despite some initial difficulties, he began to exercise on his own every day. For him, self-competition began after a specific episode, when a physio-therapist who specialized in working with people with diabetes told him that he would never be able to run because of his leg paralysis. At this point, competitive running became a real challenge for him, and his goal was to demonstrate—to the others, but especially to himself—that he could manage to step up to the podium despite diabetes, the paralysis, and others’ disbelief: A girl who studied to be… a physiotherapist and all, and prepared for [working with] diabetics (…), probably, knowing about this leg, not having seen me run, she told me: “No, no, don’t worry about it, because I don’t even know if you’re able to run.” I mean. Said by a stranger, as you could be, I look at you, I stare at you, I smile, and I go away… Said by someone you

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know, someone who loves you, … can I say a bad word? I tell you to fuck off. I mean, … and there I was absolutely furious. I mean, I said, I said: “Now… I will show you.” (Emanuele, 43 years old, T1D, clerk, onset at 16 years of age)

The importance of competition in individual sports was clearly affirmed by Martino when he stated: Anyway, competing gives you the incentive to… to train, to… to participate- to do, well, it gives you the adrenalin rush, it gives you… it gives you many things, competition, … (…) competition is good: I fight for something. (Martino, 34 years, T1D, farmer, onset at 8 years of age)

For Martino, competition had different dimensions: on the one hand, it was a way of testing himself and his strength; it was an objective to be achieved. But on the other hand, it also meant measuring his ability through comparison with “healthy” athletes without diabetes. In his words: Let’s say that, in the context of sports, diabetes teaches you many things. It teaches you that even if you have diabetes, you are strong just like the others… You can arrive… you can arrive among the first ones, you can arrive among the last, … but still, … you are in it like the others, you are… you’re strong like the others. As I said: since I’ve been doing sports, I… I had many satisfactions… Because I saw people who don’t have diabetes, … struggling much more, and arriving after me. It might be selfishness, but I say: “Geez, those people have nothing” so I… I say: “So if I didn’t have diabetes, I would go much faster.” So despite having diabetes, I go faster than certain people of my age, yeah. (Martino, 34 years, T1D, farmer, onset at 8 years of age)

The narratives of the athletes that participated in this research were different from the case described by Connell (2015) in his paper about an Australian Ironman. All participants that engaged in individual sports had other jobs, and they did not—except in the case of Gioele—pursue a career in sports. Competition with the others without diabetes was often enacted at the level of everyday life by comparing their future situation with that of “sedentary” others without diabetes, where, in the future, the situation would somehow be “reversed”: they would be the “healthiests,” thanks to their constant discipline and hard training, while sedentary people without

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diabetes would suffer the consequences of old age and their unhealthy lifestyle. As Ivan affirmed: When you see, with your eyes, … that you’ve obtained a condition of [physical] fitness… and wellbeing, and that, as the years go by, … always less people, peers and even healthy [non-diabetics], whom I—we—call “the sleeping healthies” precisely because they do not engage in physical exercise, … and you see that ironically you are in a better shape, in spite of your chronic illnesses and… because I also… for a year now I’ve also had Crohn’s disease, which is an autoimmune disease, this thing makes you… view… your future with more hope. So the expectations… the expectations grow, I… always say that… at the age of seventy, I will still want to… do the triathlon, and I will still have a better chance to step up… on the podium, because the competitive ones will be much less. [He laughs] (Ivan, 51 years old, T1D, manager, onset at 27 years of age)

A different dimension of self-management was highlighted by Ilario, who, during his description of sporting performances, reported enacting a sort of “passing” strategy: in fact, he reported not “showing off” his “diabetic performance,” but rather focused on his ability to enact a normative, masculine, and healthy bodily sports performance without displaying to others his signs of diabetes. In his words: I went for a gully on the Monte Bianco, [with] a person who… I mean, they knew it [the fact that he has diabetes] beforehand, I went to Norway, with the alpine guide, they knew, I mean… I still like to tell the truth, … But at the end of the holiday, they told me: “Look, … I didn’t notice anything, I only noticed that you like girls, and not [diabetes]….” [He laughs] (Ilario, 28 years old, T1D, shop assistant, onset at 5 years of age)

As for food consumption, individual sports allow greater freedom in organizing time and modalities of eating, and unlike team sports, there are no “social obligations” to share post-training or post-match meals with teammates. All participants that could be assigned to this subgroup reported eating “healthy,” and most of them reported engaging in a low-­ carb diet, where carbohydrates and desserts were eaten only “therapeutically,” namely to avoid hypoglycemia during or before sports performances. Overall, athletic men talked about food in terms of its benefits for sport performance, as can be read in Massimo’s words:

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The diet of an athlete who does what I do, but also that of my son is very… different if compared to that of a… sedentary diabetic. So we almost eat all day long. So… for example? …Eh, for example… for example, from… from six in the afternoon, until… almost midnight, all I do is eat. Because, moreover, I… often skip lunch (…) mmm having… this lunch gap, I end up being so hungry… (…) I eat because… I have to eat because since I work out I have to eat. Because otherwise I have a fall… in… in performance. (Massimo, 59 years old, T1D, retired, onset at 30 years of age)

As for self-management strategies, the majority of participants reported using digital technologies, while a minority reported using traditional devices: five participants reported using insulin pens, 10 reported using the insulin pump, one reported using the glucose meter, and 14 reported using the glucose sensor. Overall, all of them motivated their choices in terms of what was more useful for managing diabetes during sports activities. The majority of them preferred digital technologies, because these allowed them to automatically monitor blood glucose levels and receive alerts if they deviated from predetermined parameters. For sports, so they [the insulin pump and glucose monitor]… help me a lot. Because they give me much more information compared to only seeing the photograph every time [of the traditional glucose meter]. (Nicola, 23 years old, T1D, university student, onset at 13 years) Had it not been for this [the continuous glucose sensor], I would have never done it [sport]. Because with this you have the chance to have the monitor on your arm, managing to see at any… at any moment how I am with glycaemia…. And I feel much safer. (Gioele, 39 years old, T1D, employee, onset at 12 years of age) I asked for it [the insulin pump], but (…) [the doctors] said: “No. Why should we modify something that is working just fine?” I mean, when they told me that there would be some problems concerning sport activity…. So, I said: “Ok, it’s fine, I will continue injecting.” I mean, it’s just 5 minutes… To give yourself an injection I think it requires me from 30 to 35 seconds… (Ilario, 28 years old, T1D, shop assistant, onset at 5 years of age)

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5.1.2   Diabetic Athletes Engaging in Collective Sports Compared to individual sports, team sports usually entail different challenges for a person with a diabetic body, mainly because both training and competitions take place in a context where there is proximity and interaction with other teammates. This specific situation raises a number of issues: while diabetes self-management within individual sports can remain relatively confined to a private sphere, team sports usually  require constant interaction with non-diabetic others. This situation necessitates dealing with normative expectations of peers  without diabetes and also dealing with the potential occurrence of stigma associated with illness. Overall, a minority of participants reported engaging in collective sport—only two out of 15: Filippo and Sebastiano. They were both football players. In Italy, football is perceived as a typically “masculine” sport, a sport that men are encouraged to participate in from their childhood. Their narratives reported similarities and differences. First, Filippo’s and Sebastiano’s experiences with football began in different ways. In the case of Filippo, a 34-year-old man who was diagnosed with diabetes at the age of 14, the initial occasion for playing had been offered by two diabetes camps dedicated to young people with diabetes, in which international football tournaments were organized with teams exclusively composed of insulin-dependent players with diabetes. The context of a diabetic camp exclusively dedicated to athletes with diabetes well illustrates the process of becoming a member of the subcultural world of athletes with diabetes. In this case, Filippo participated as a young “novice” in the learning process that allowed him to develop expertise through participation in a shared set of social practices. Through social interactions with more experienced members of the “community of practice” of athletes with diabetes, Filippo learned how to manage diabetes while playing sports, as he noted: And have you ever participated to camps dedicated to diabetic people? …Yes, two times, always through the xxxx [hospital name] always… both dedicated to sport, to football. (…) They made selections on an Italian level, first at wwww [name of the city], and then I have been [selected] both times to represent Italy abroad, I have done several tournaments. It was a special experience, because changing from having a team like I have here, with non-­ diabetic guys… to play with all diabetic [people], … it is a bit weird, honestly…. [During those camps] they instructed you to measure the blood sugar before doing sports, during the intervals, and you obviously saw various situations… both me, that I took a therapy through insulin shots, while

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others, through… the insulin pump, and I could see the management in various situations, both hyperglycaemia, hypoglycaemia, precisely… that I managed to perform the following year, because there, I was still not very experienced… in this regard. That was a great experience. A great experience, really. And how did you feel with your diabetic teammates, if compared to… to the other team, where they were not? Yes, a little more alike, but however I don’t feel that different in the team, here in my town, let’s say…. You feel a little more part… of the same pathology. (Filippo, 34 years old, T1D, nurse, onset at 14 years of age)

The other case is that of Sebastiano, a 33-year-old man who was recently diagnosed with diabetes at the age of 31. At the beginning of the interview, Sebastiano defined himself as “an athlete” and, subsequently, as a “professional footballer.” He reported playing football even before diabetes’ onset, and when he received the diagnosis, he had to stop all physical activity for a short period of time. In this case, football was a sport dedicated to male homosocial interactions, and it involved an ambivalent combination of competition and complicity that informed his social relations with his teammates. When Sebastiano experienced diabetes’ onset, he reported having received great support from them: With sports, after… a week, or ten days [after the onset], I already… started playing football again. I play football, I’m a professional footballer. So… after a week, 10 days, I grabbed the sport bag again, and everything, little by little, slowly, now I got back to being like before. Maybe even better. [My teammates] helped me a lot, because they encouraged me immediately to return, … in fact, when it [diabetes’ onset] happened to me in early October, … in mid-October I had already come back, let’s say, because they told me: “Come back, come back!” For the first training ten minutes, … and then a quarter of an hour, then twenty minutes, gradually, trying to understand how it [the diabetic body] worked. Then I had a strange effect, when I do intense sport, at that moment it [glycemia] goes up, it’s normal, it goes up, it also arrived at peaks of 200. During intense efforts. And then, after that, it lowered after half an hour, an hour, … but I have to say they helped me a lot, and … thanks to them I returned… just as before, and maybe better. (Sebastiano, 33 years old, T1D, surveyor, onset at 31 years of age)

Both Sebastiano and Filippo trained 2–3 times a week, and both reported using sports as an instrument for better managing diabetes. In

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addition to football, Sebastiano reported also working out in the gym because he thought that this would improve his illness management. As he stated. As mentioned, engaging in a team sport such as football entails specific challenges for players with diabetes, mainly because it implies impression management (Goffman, 1959) with an audience that does not have diabetes. In this regard, Sebastiano and Filippo reported similarities and differences in how they managed the information about their condition within sports contexts. On the one hand, Filippo reported that he had always felt comfortable with respect to the visibility of his illness; in fact, during the interview, he reported that everybody in his team had always known about his condition and that he kept the glucose sensor visible on his arm without any problem in front of his teammates. On the other hand, as a demonstration of the ambivalence of homosociality, he reported that despite the fact that his teammates had been very supportive in the initial period, he nonetheless preferred to administer his insulin injections in the restroom to avoid the possibility of the stigma related to the transgression of bodily normativity in a context of high bodily competition. As he said, “You never know what people might think.” In fact, by disguising the most stigmatizing diabetes self-management performance—that of injecting—Filippo conveyed an image of himself that was more “tolerable” and normative, thus matching expectations and avoiding illness-related stigma. Sebastiano’s experience was quite different from that of Filippo. In his case, he reported injecting insulin in the locker room in front of the other teammates; in fact, this did not go unnoticed, and his teammates frequently taunted him because of the association of insulin injection with shooting up. As he re-called: And did it ever happened that… I don’t know, in the locker room, maybe someone saw your sensor, and they ask you some questions? Yes, yes, everyone, well but everyone knows… so… they asked me. Then they would also make fun of me, obviously joking, eh… They say: “You- you shoot up, you… you take drugs, you shoot up!” But ok, everyone jokes… But ok, it’s normal… that also happens. (…) I laugh about it too. A friend of ours always says: “Mmm if you make me angry, if you don’t… if you don’t pass me the ball, I’ll give you an injection of powdered sugar!” And ok, everyone jokes about it. (Sebastiano, 33 years old, T1D, surveyor, onset at 31 years of age)

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As for glycemia monitoring, Sebastiano recounted checking the glucose sensor in front of everybody, and during the matches he did it at intervals. Measuring glycemia on the sidelines and displaying the glucose sensor attached to his bicep captured the attention of the crowd cheering his opponent, who started making jokes about his condition. Again, the dimension of competition and “sanction” for bodily transgressions and for failing to match expectations of an audience that does not have diabetes led to experiencing stigma. Jokes and insults about him transgressing bodily healthy normativity had the purpose of undermining his credibility as a football player, as a legitimate captain, and as an adequate man. As he described the episode: An episode [that happened]… when we were in the field… [in] another football field, against another team. I stopped a moment, well they were… let’s say, dying of envy, sorry if I say so, as they were losing the match, and some of the supporters of that team, I went towards the bench, I measured it [glycemia] a moment… they say: “Look…” they say: “We’re playing against paralytics.” … They said. (…) Because I was measuring it, yes. I don’t know what they thought, but they used this term. (…) And how did you react in that occasion? …Well, nothing, I had a laugh. (Sebastiano, 33 years old, T1D, surveyor, onset at 31 years of age)

Sebastiano’s negative experience of complete disclosure and illness-­ related stigma and Filippo’s positive experience of a diabetes that was normalized through a combination of disclosure and passing strategies constituted, in a way, the two most distant experiences; it is thus likely that the population of athletes with diabetes engaging in collective sports might be positioned some way in the middle of these different experiences. As far as food is concerned, both Filippo and Sebastiano reported not following a specific diet, yet they preferred adapting the amount of insulin to the quantity of carbohydrates contained in the consumed food. Compared to the athletes engaging in individual sports disciplines, they did not justify their food consumption through a reference to the needs of a sport. They reported that everyday meals were usually organized by the grandmother in the case of Sebastiano and the mother in the case of Filippo—in both cases, a woman. As Filippo stated: For lunch, obviously, you eat what there is, what my mom makes me. [He laughs]

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Usually, what does your mom make for lunch? More or less… are there… Well, it depends, let’s say I adapt based on what there is to eat… If once we don’t have pasta, I decrease… the units of insulin, if we have pasta… I increase them. (Filippo, 34 years old, T1D, nurse, onset at 14 years of age)

To maintain a glycemic balance, Sebastiano reported organizing his meals differently with respect to his teammates who do not have diabetes: If tomorrow I had to [play a football match] at 10 p.m., I [would] come home at 7.30 p.m., and unlike the others, who don’t eat and go to play at 10, if I play at 10 I eat at 7.30, I have a small dinner let’s say, with insulin— some units less of insulin- and… after 2 hours, 2 hours and a half, I can play without problems. (Sebastiano, 33 years old, T1D, surveyor, onset at 31 years of age)

After football matches, dinners were an important opportunity to socialize with teammates, and in this case, they reported eating exactly the same food as their teammates did and compensating by increasing the dose of insulin to inject before or after the meal. Unlike participants engaging in individual sports, neither Sebastiano nor Filippo talked directly about competition as the main incentive to play football. Implicitly, Sebastiano discursively constructed football as a prowess test, as a demonstration of his body’s ability “despite diabetes,” and as an acknowledgment that his condition did not affect his capacity to perform and display his strength. In his discourse, it rather reinforced his determination. During the interview, I asked him how he felt about his performances during the football matches with respect to his teammates who do not have diabetes. On the one hand, he answered by acknowledging that they were “performing” better, probably because of their younger age, but on the other hand, this was somehow discursively counterbalanced by stating his position “of authority” within his team, that of captain: With respect to your teammates, how do you feel about your performance on the field? Well, fine. Very well actually, especially because I am the team captain! There are boys that are younger than me that physically perform better, but… let’s say… they are 19, 20 years old, when I was their age I was more… But now I am 32, may be my performances are worse, but… I can

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hold my own. (Sebastiano, 33 years old, T1D, surveyor, onset at 31 years of age)

5.2   Conclusion: The Intersection of Sports, Masculinities in Diabetes, and Gender Power Relations The case of male athletes who have diabetes raises a number of questions about how the construction of masculinity intersects with the broader gender structure. Overall, the analysis of the empirical material is in line with previous research on sports and masculinity (e.g., Ferrero Camoletto & Ferritti, 2020; Messner, 2005; Seymour, 1998; White et  al., 1995), according to which “sport” is considered a critical vehicle for masculinity construction. Participating in types of sports that challenge one’s own physical limits, being able to perform constant training and self-­disciplining one’s body every day, and competing with oneself and with others, while achieving sporting goals “despite” diabetes, have been valuable discursive tools to construct a successful diabetic masculinity, a compensatory manhood act enacted in conformity with hegemonic ideals of masculinity. As we have seen, another important element of masculinity construction in the context of sports has been the common reference to a homosocial context (Ferrero Camoletto & Bertone, 2017; Bird, 1996). Overall, the majority of the participants described sports as an occasion for social interaction with other men (those who have diabetes as well as those who do not). In fact, the majority of interviewees were “initiated” in sports by other male athletes with diabetes or, as in the case of Cristian, by his father. From the literature on sports, it is common to see the theme of sports as a real “rite of masculinization” (White et al., 1995, p. 165), often occurring within father–son relationships or, as we have seen, relationships with other male peers. Masculinity, as mentioned, is not an isolated object of analysis but is embedded and constructed within a larger structure, and it is constructed not only in relation to other men but also in relation to women and femininities. Cristian’s case is particularly illustrative in this regard. In his story, the gendered subdivision of care roles adopted by his parents when he was a child became evident: he was diagnosed with diabetes at the age of 10, and at the time, while his mother took care of his food preparation and medical treatment, sports and physical activity were considered the

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responsibility of his father. In fact, his father provided for his entrance into the world of sports, just as he had done in the past with his brothers (but not with his sister), confirming a gendered division of parental care roles. In his words, The first day I got ill… when I found out… the first day of hospitalisation they told me: “Diabetes is treated like this, glycaemia (…) sugar level monitoring… insulin, … diet, and sport. These are your four medicines.” … And when they said sport, they didn’t mean going for a walk… They meant sport… And they insisted on this. So much that-… they also brainwashed my parents so much, … that when we got back home, in xxxx (town name), they signed me up straight away, … they made me try all kinds of sports, because I hadn’t done any sport until that moment. That’s it, and my dad made me try them all. (Cristian, 43 years old, T1D, manager, onset at 10 years)

Among this subsample, nobody ever talked about women engaging in sports or doing training with them; they trained alone, with male friends, or, in the case of Massimo, with his son. The most eloquent case in which the embedded gender dimension of sports was repeatedly affirmed during the interview was that of Ronaldo, a competitive cyclist who engaged in cycling only after diabetes’ onset. During the interview, he used an explicit double standard when talking about himself and his wife with respect to sports: they both had an autoimmune disease that needed to be managed through medical treatment and physical activity. In his narrative, despite the fact that his wife had been a swimming champion, he reported that her daily physical “training” did not include physical and athletic prowess, as in his case, yet it included taking care of her elderly parents and doing the housework in a “big house.” This subdivision of roles and possibilities was taken for granted in his discourse, and this clearly emerges in the next excerpt: (. . .) she helps my in-laws, (. . .) she takes care of a three-story house, she . . . cleans it in the morning, (. . .) in fact it’s like she burns up all those sugars, it’s like she is still doing training of . . . at least 4 hours, 5 hours a day, she keeps doing it, and as a matter of fact, a few times when we went to the pool   just to make her happy she easily does 60, 80 laps without any problems, despite not being a . . . mid-level sports person any more. Yes, all she has to do is clean the house, and she keeps trained. Yeah, this is a thing that I . . . often I tell Southern women: “Look, if you clean up your house well, your

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glycaemia willdecrease.” (Ronaldo, 46 years old, diabetes LADA, high school teacher, onset at 39 years)

As Robertson (2003, p.  711) observed, “Sports represent an arena where masculinities can become unstable, evoking contradictory emotions for individual men.” On the one hand, men in this subsample reported expressing emotions and usually giving and receiving support to and from each other within the subculture of athletes. But, on the other hand, their relationships were also informed by competition and by the possibility of being stigmatized in non-diabetic contexts. In analyzing these narratives and comparing them to other ideal types’ experiences, it was evident that engaging in sports was highly associated with a specific class habitus: all participants were in fact heterosexual and had a middle-class background, and they had the economic capital that allowed them to dedicate time and resources to competitive sports. Furthermore, most of them had the actual possibility to engage in competitive sports and follow a specific diet tailored around diabetes and sports training needs because they had a partner, wife, mother, or mother-­ in-­law who took care of their food consumption practices. In this respect, there was a significant difference in how food consumption was managed in the private and public spheres. In the private sphere, food organization and management were usually carried out by a female member of the family who respected “healthy” rules that were considered appropriate for participants’ management of diabetes. With regard to the public sphere, food consumption was considered a crucial context of (male) socialization. With respect to social expectations around masculinity and food, participants reported engaging in different strategies that can be described by two very different cases, that of Nicola and that of Martino, under the assumption that other participants adopted a variety of practices that could be positioned somewhere in between. Nicola, a 23-year-old university student and competitive runner who had diabetes’ onset at the age of 15, reported being aware of the fact that there were different social expectations regarding food consumption for men compared to those for women. In fact, he observed that men were usually expected to have a greater appetite than women. As he remarked, Since there is this stereotype, I have to eat more, I have to… I have to eat more, I have to… show that I won’t collapse, yes. I think, I mean…. Yes…; It’s kind of—it’s kind of in your [nature] of men, this thing here. There is

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this thing, so, you do it. But the point is that, since you have diabetes, the… this thing here then has its consequences for which you also have to find some countermeasures, but… often, yes. There is this thing about the diabetic man, the non-diabetic, that… he has to prove that he is a little more. (Nicola, 23 years old, T1D, university student, onset at 13 years)

For this reason, for men with diabetes, it is even harder to “pass” as one without the disease or to neutralize diabetes’ symptoms. One possible solution was the one adopted by Nicola, which consisted of injecting the regular dose of insulin before the meal, then eating the desired (unquantified) amount of food during the meal, and afterwards adopting “countermeasures”—such as an insulin correction shot—immediately after eating. Also, Martino reported being aware of gendered stereotypes that informed food consumption practices, but he, unlike Nicola, decided not to modify his “healthy” food habits and instead respected the rules of his dietary regimens. Since he was socially sanctioned through marginalization from his group of peers for “transgressing” gender normativity, he decided to keep food consumption practices within the private sphere and to avoid eating on social occasions. I have never loved going out… for dinner with friends, … because they would always look at me a little weird, I went out [only] initially [after the onset]. But I ate my small ration, and that was it. On the other hand, they drink, eat, … and that’s already when they start to exclude you: “Well, you don’t drink, and you don’t eat that much,” they kind of exclude you from the group, (…) … as long as you have to eat pizza it’s ok, … but when you start doing… abundant dinners, … I have never liked it and somehow they judge you, because well… (…) you have a different lifestyle. Could you give me an example, like when you were… having dinner with friends, what did you do differently compared to others? Well, dinner with friends, you go to dinner, I take my still water, as usual. They start… beer, and whatnot, liquor, yeah… (…) my dinner was… not eating excessively, with water, and that’s it, my dinner was over. “Come on, take some dessert!” Well, …I’ve never been, even before I [had] diabetes, … a dessert guy…. (Martino, 34 years, T1D, farmer, onset at 8 years)

Finally, the analysis of these narratives reveals how, on the one hand, sports, in their symbolic significance, enactment, and organization, contribute to the production and perpetuation of hegemonic ideals of masculinity. On the other hand, and simultaneously, aligned with other studies

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(e.g., Robertson, 2003), it can also become a terrain for resisting hegemonic masculinities. This is particularly evident in the case of athletes with diabetes who have chosen not to continue or initiate participation in team sports settings as a means to avoid marginalization and the negative effects of hegemonic masculinities. Instead, they found a way to establish alternative possibilities for self-realization and recognition.

References Anderson, E. (2005). Orthodox and inclusive masculinity: Competing masculinities among heterosexual men in a feminized terrain. Sociological Perspectives, 48(3), 337–355. Anderson, E. (2008). “I Used to Think Women Were Weak”: Orthodox masculinity, gender segregation, and sport. Sociological Forum, 23(2), 257–280. https://doi.org/10.1111/j.1573-­7861.2008.00058.x Beynon, J. (2002). Masculinities and culture. Open University Press. Bird, S. (1996). Welcome to the men’s club: Homosociality and the maintenance of hegemonic masculinity. Gender & Society, 10(2), 120–132. Bourdieu, P. (1986). The forms of capital. In J. Richardson (Ed.), Handbook of theory and research for the sociology of education (pp. 241–258). Greenwood. Bourdieu, P. (1997). Die männliche Herrschaft. In B. Krais & I. Dölling (Eds.), Ein alltägliches Spiel: Geschlechterkonstruktionen in der Praxis (pp. 153–217). Suhrkamp. Connell, R. (2005). Masculinities (2nd ed.). Polity. Connell, R. W. (1995). Masculinities. Polity. Connell, R. (2015). An iron man: The body and some contradictions of hegemonic masculinity. In Sociological perspectives on sport (pp. 141–149). Routledge. de Visser, R. O., Smith, J. A., & McDonnell, E. J. (2009). ‘That’s not masculine’: Masculine capital and health-related behaviour. Journal of Health Psychology, 14(7), 1047–1058. https://doi.org/10.1177/1359105309342299 Ferrero Camoletto, R., & Bertone, C. (2017). Tra uomini: indagare l’omosocialità per orientarsi nelle trasformazioni del maschile. About Gender-International Journal of Gender Studies, 6(11), 45–73. https://doi.org/10.15167/2279-­5057/ ag.2017.6.11.395 Ferrero Camoletto, R., & Ferritti, V. (2020). Maschilità (dis) abilitate?(Ri) fare il genere attraverso disabilità e sport. AG About Gender-International Journal of Gender Studies, 9(18), 103–132. Gerschick, T. J. (2000). Toward a theory of disability and gender. Signs: Journal of Women in Culture and Society, 25(4), 1263–1268. https://doi. org/10.1086/495558

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Goffman, E. (1959). The presentation of self in everyday life. Anchor Books. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall. Lave, J., & Wenger, E. (1991). Situated learning: Legitimate peripheral learning. Cambridge University Press. Liu, N. F., Brown, A. S., Folias, A. E., Younge, M. F., Guzman, S. J., Close, K. L., & Wood, R. (2017). Stigma in people with type 1 or type 2 diabetes. Clinical Diabetes, 35(1), 27–34. McKay, J., Messner, M. A., & Sabo, D. F. (Eds.). (2000). Masculinities, gender relations, and sport. Sage Publications. Messner, M. A. (1990). Boyhood, organized sports, and the construction of masculinities. Journal of Contemporary Ethnography, 18(4), 416–444. Messner, M. A. (1992). Power at play. Beacon. Messner, M.  A. (2002). Taking the field: Women, men and sports. University of Minnesota Press. Messner, M. A. (2005). Still a man’s world?: Studying masculinities and sport. In M. S. Kimmel, J. Hearn, & R. W. Connell (Eds.), Handbook of studies on men & masculinities (pp.  313–325). Sage Publications. https://doi. org/10.4135/9781452233833 Robertson, S. (2003). “If I let a goal in, I’ll get beat up”: Contradictions in masculinity, sport and health. Health Education Research, 18(6), 706–716. Sassatelli, R., & Ghigi, R. (2024). Body and gender. Polity. Schrock, D., & Schwalbe, M. (2009). Men, masculinity, and manhood acts. Annual Review of Sociology, 35(1), 277–295. https://doi.org/10.1146/ annurev-­soc-­070308-­115933 Seymour, W. (Ed.). (1998). Remaking the body: Rehabilitation and change. Routledge. Shapiro, J.  P. (1993). No pity: People with disabilities forging a new civil rights movement. Times Books. West, C., & Zimmerman, D.  H. (1987). Doing gender. Gender & Society, 1(2), 125–151. White, P.  G., Young, K., & McTeer, W.  G. (1995). Sport, masculinity, and the injured body. In D.  Sabo & D.  F. Gordon (Eds.), Men’s health and illness: Gender, power, and the body (pp.  158–182). Sage Publications. https://doi. org/10.4135/9781452243757

CHAPTER 6

“I have never considered myself as sick”: Constructing Masculinity Through Mismanagement of Diabetes

If I want to eat pizza, and everybody eats pizza, doesn’t matter that I have diabetes: I eat pizza. (…) I mean, really, it is just as if a person wants to save money, and keeps saving, saving, saving… But in the end, what do you want to do? You want to die the richest of the cemetery? (Pasquale, 47 years old, employee, diabetes LADA, onset at 30 years of age)

The “Free Spirit” represents the third and final ideal type that emerged from the analysis of the interviews. This ideal type characterizes a different approach to conceptualizing illness by  diabetic men, primarily centered around reducing its seriousness in their lives and seeking methods to minimize its effects on their daily routines. As discussed in previous chapters, chronic illnesses such as diabetes significantly influence the enactment of masculine selves. Diabetes frequently poses a risk of undermining or challenging one’s sense of identity in general (Broom & Whittaker, 2004). In particular, with respect to masculinity, this influence stems from the challenge to hegemonic masculinity ideals associated with bodily attributes such as strength, healthiness, and resistance to pain (Connell, 1995). Men employ a range of strategies to address this threat, utilizing both their discourses and practices. In terms of speech acts, men’s explanations about (mis/managing) diabetes serve as self-presentations, bearing performative attributes that encompass persuasive elements and arguments (Broom & Whittaker, 2004).

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Men whose narratives could be described by this ideal type appeared to be quite aware of the impact of diabetes on their impossibility to perform societal roles aligned with traditional male expectations, such as that of being a hard labor or being strong, autonomous, and independent. In response to this challenge, they developed a strategy of considerably reducing the disease’s significance  in their lives, deeming its impact on their daily routines and on social interactions as minimal. This approach resonates with Charmaz’s concept of “bracketing” illness (1994, p. 274), which involves isolating the expressions of illness by framing them as distinct from the ongoing course of life. By establishing this line of demarcation between illness manifestations and one’s identity, the impact of illness on the construction of the masculine self is reduced. This implies that, unlike the other two ideal types, their priority in presenting themselves in the context of the interview  is not to establish a strict daily routine, meticulously monitoring their diet and physical activity, and self-tracking their bodily functions to maintain stable glucose levels during the day and avoid potential illness-related complications. Rather, it means that they  discorsively prioritize pleasure in eating over dietary control, as well as fun and “freedom” instead of adopting the “restricted” lifestyle that has been prescribed to them by doctors and diabetologists. This intersects with the shaping of their masculinities in different ways; indeed, demonstrating that diabetes does not interfere with the flow of their daily lives, and hence does not affect their identity, leads them to gain masculine capital in the eyes of others (de Visser et al., 2009). Furthermore, this enables them to construct a self-representation as men who are independent and capable of not allowing diabetes to dictate their lives because they can live on their own terms. In fact, striving to exercise control over diabetes, rather than adhering passively to medical prescriptions, could be viewed as an effort to maintain autonomy over one’s own life (O’Hara et al., 2013). Autonomy and control, as we have seen in previous chapters, are crucial traits of hegemonic ideals of masculinity (Connell, 1995), just like being risk-takers. Not taking diabetes management seriously entails specific health risks, because they prioritize avoiding marginalization and preserving identity over living  a “healthy” life that they perceive to be limited and full of constraints.

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6.1   The “Free Spirit”: Considering Diabetes as a Nuisance The prevailing discursive approach employed by the nine participants constituting this subgroup involved reducing the impact of diabetes, the relevance of its symptoms, and the impact of its management in their daily lives. Despite being a severe chronic condition, diabetes is described as a mere nuisance, a condition that requires some time during the day to be managed but does not significantly impact men’s identities or habits. An illustrative example in this regard is Amedeo, a 50-year-old man who was diagnosed with diabetes at the age of 30. He appears to confine his experience of illness to the single practices that constitute his routine of diabetes self-management, which are nonetheless reduced to a minimum. This approach enables him to discursively bracket illness to a private realm and reinforce an autonomous display of his masculine identity: I have to say that I never considered myself as sick, this maybe has always been my lifesaver. It’s a nuisance, another thing to be managed: just like someone who is short-sighted wears glasses, someone who has diabetes takes insulin. But I never perceived it as a limit in my life, it never limited me in doing something. (Amedeo, 50 years old, T1D, realtor, onset at 30 years of age)

Similar to Amedeo, the majority of men in this subgroup did not perceive themselves as “sick.” This is a characteristic attitude within the narratives of this ideal type. In contrast, in the previous two chapters, we discussed that in both the case of the “Tracker” and the ideal type of the “Athlete,” individuals incorporated diabetes into their identities and recognized its significance across various aspects of their lives. In distinct ways, in both cases, participants discursively shaped a representation of themselves as competent and skilled, particularly in managing diabetes through the development of more or less personalized strategies. These strategies were in fact the main focus of their narratives, underscoring the significant presence and importance of diabetes in  both their self-­ representation and interactions with others. In contrast, within this subgroup of participants, the culture of self-­ surveillance and bodily monitoring is perceived as a form of excessive constraint and limitation. Highly compliant individuals managing diabetes diligently are depicted by the “Free Spirits” as being too obsessed with

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numerical goals and with self-monitoring performances, wasting their existence to dedicate themselves entirely to diabetes management. This dedication to disease management, in turn, leads in their perspective to social isolation, to a neglect of the joys and the possibilities of life. In this subsample, the participant who more than others brought this approach to its extreme consequences is probably Giovanni, a 32-year-old man who was diagnosed with autoimmune diabetes just one year before the interview, when he was 31. Diabetes was merely a “condition” to him, not a chronic disease. Having a closer look at his story will reveal some of the main characteristics of this ideal type. Within this specific subgroup, men demonstrated, at least during the interviews, a sense of indifference towards maintaining their health. They exhibited this attitude in different ways. For instance, they consistently depicted  themselves as individuals who preferred to refrain from seeking medical assistance or participating in health-related behaviors, even before the onset of diabetes, highlighting their inclination towards self-sufficiency. Once again, we can see a clear illustration of this in Giovanni’s words, when he was narrating his onset: Well then, the story with diabetes starts with the symptoms, so … (…) I had dizziness, weight loss, chronic tiredness (…) thirst, thirst, and again, so much thirst, and the need to go to the bathroom (…). So I decided to get blood tests done, you know, to dig deeper, right? Because I was starting to suspect that something wasn’t right. Because … luckily I’ve always been in good health, … and usually, I’m also one of those people who struggles to decide—I mean, as soon as they have something, it’s not like I rush to the hospital… (Giovanni, 32 years old, T1D, unemployed, onset at 31 years of age)

In stark contrast to the other two ideal types, in this case the onset of diabetes does not lead to a biographical disruption of everyday life (Bury, 1982) in terms of the need to adhere to a strict regimen that radically modifies routine and habits. On the contrary, in some cases reflecting upon the finiteness and transience of life leads to the choice of not “wasting time” on one’s health, but instead channeling one’s energies to seize the day and to take illness as an opportunity to shape one’s life as one truly desires. This particularly involves focusing on emotional relief, on having fun, and on removing all of the possible causes of discomfort. In this regard, Giovanni said:

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In life… umm, well yeah… for me, umm… let’s say that [after the onset] I started to… umm, live differently, umm… think differently. (…) Maybe I was just waiting for the opportunity to truly start… umm… from this point of view, I can say that the illness forced me to start doing that. And how? If you want to explain more… Well, how, umm, I think I can summarize by saying that I started to be… umm, to put into practice, let’s put it that way, a bit of healthy selfishness. So, so, umm, distancing myself from people that, if you’ll pardon my language, I felt the need to say “fuck you”, and all these things, you know? Finding a way to do things more lightly, having fun, a bit more. (Giovanni, 32 years old, T1D, unemployed, onset at 31 years)

Shaping one’s identity by explicitly excluding diabetes and its management from one’s priorities also reflects the type of social network that the men in this group are striving to construct around themselves. Although in the case of the two previous ideal types the emphasis lays on communities of practice composed of other diabetics, in this ideal type, the main reference is social contexts inhabited by non-diabetics and non-ill individuals. Moreover, in their discourses they emphasize a clear intention of not wanting to join associations for diabetic people. One of the main reasons why they did not participate in such activities was, as Amedeo and Massimiliano observed, that this could become a form of segregation: I have never been someone that goes to those associations, because on the one hand they provide support, but on the other they ghettoize too much (…) closing oneself in this… it is like constructing a ghetto, don’t you think? (Amedeo, 50 years old, T1D, realtor, onset at 30 years of age) I have never done this [going to an association] because if I’d start putting myself into this, diabetes would have become an… everyday thing. It would become a form of “segregation,” in quotes. And this fact… It’s not that I hate this, or that I don’t want to do it. But I never found it stimulating to be part of these things here, you know, mmm… I have had some friends, I continued with those friends. Then, if they had diabetes or not, I didn’t really care. (Massimiliano, 40 years old, T1D, teacher, onset at 4 years)

Within this subgroup, only one participant, Matteo, mentioned engaging in activities organized by a local association dedicated to individuals with diabetes. Nevertheless, his participation appeared to be motivated more by a desire to socialize and have company than to learn or share diabetes management practices. His approach differed significantly from

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the other two ideal types. He distanced himself discursively, often using irony, from the prescribed disciplinary routine aimed at effectively managing diabetes and avoiding potential complications. For example, he recounted an episode that is particularly illustrative of his approach to illness. When the association proposed a course for learning the “carbohydrate counting”1 technique, he reported that it was too complicated, and that actually “No one understood anything.” In that occasion, another man reported struggling with hyperglycemia despite being compliant with medical treatment. Matteo recounted proposing an alternative solution, namely drinking beer together. In his words: Now the [medical] approach is carbohydrate counting. (…) I like attending courses [organized by the association] because it is so funny! I’ll tell you a story [laughing]: a friend of mine, once, he arrived at the course, you know, and he said that he wanted to lower glycemic levels after dinner by running, riding a bike. [Laughing] And he went, he went running after dinner: before he had 250 [of glycemia] and after 300. ‘You got it all wrong… Come with me!’ [I said]. [I told him] one time, two times, and the third evening: “But where do you want to go?” [He asked]. “We go to drink a beer’” [I replied]. [Laughing] “What? We go and drink a beer?” [With a surprised tone] [Laughing] We went and drank a beer, then he went back home… Oh, for god’s sake, then he began to drink beer! [Laughing] (Matteo, 58 years old, T1D, retired, onset at five years)

Similarly, Pietro, a 27-year-old musician, diagnosed with type 1 diabetes at 16 years of age, narrated having participated, in the past, in meetings dedicated to teaching diabetic people how to maintain their glycemic control. However, in his narrative it’s particularly striking how the lifestyle proposed in such settings was at odds with his approach. This was quite evident from the moment we met for the interview, and it was particularly representative of the Free Spirit’s ideal type general approach: when I met him it was late in the afternoon, and he had just woken up because the previous night he had performed at a concert that lasted until the early morning. While we were walking towards his home, he stopped at a grocery store where he bought six cans of beer and a pack of cigarettes. 1  As we have seen in previous chapters, carbohydrate counting is a technique used in diabetes management to estimate the amount of carbohydrates in food. Since carbohydrates affect blood sugar levels, this strategy helps individuals regulate their insulin intake more precisely, promoting better glucose control and balance.

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Later, during our interview, this served as his breakfast, together with several cups of coffee. Despite living with an extremely serious and life-­ threatening disease, Pietro constructed an image of himself as a transgressive, risk-­taking, stoical, and uncompliant man, all dimensions typical of an hegemonic form of masculinity that is counterposed, in his narrative, to the hyper-monitored, hyper-compliant, and overly concerned diabetic women whom he met after his diabetes’ onset, when he attended a course for diabetes self-management. In the following excerpt a notable contrast emerges between the image he portrays of himself as a man able to minimize the time and concerns devoted to his illness, and the image of those diabetic women who become excessively fixated on the disease and its effects. In his perspective, these women, in their obsessive monitoring of glycemic trends, become victimes of their illness, and this leads them to depression. These ladies who live near here who are very much involved… and only think about themselves, you know,…and about their own family, in their own house,…they fall into depression, when they get diabetes. (…) I maybe underestimate certain things too much, but (…) I mean, I don’t care if after you’ve done 300 metres on foot, on a Saturday morning, with your ­poodle,…you measured your blood sugar before leaving home, [and] it was 74, you came back, it was higher. (…) It’s an obsession about numerical value. Don’t you have the obsession for this value? I eh…honestly, in the past months,…I haven’t even measured my blood sugar levels. (…) There are a lot of [other] things that you have to do in life. (…) I cannot always think about it obsessively, otherwise if I spend all day thinking about it, I freak out [he laughs]. (Pietro, 27 years old, T1D, musician, onset at 16 years)

6.2   “They call me Terminator”: Performing Masculinity Through Food Consumption Practices In the context of this subgroup, a prevalent theme that emerged from men’s accounts of illness concerned their refusal to adopt the measured and strict dietary regimes prescribed by their diabetologists. In fact, the Free Spirits associate self-monitoring of dietary intake with overly restrictive measures and self-deprivation, often positioning themselves as prone, instead, to enjoy the gratification of gastronomic pleasures without too many restrictions. This approach is in line with the idea that food-related

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practices and most of all dieting are associated with women and femininity (Fidolini, 2022; Stagi & Benasso, 2018), whereas hegemonic ideals of masculinity entail indifference to healthy eating (Courtenay, 2000). By displaying indifference towards their diet and, conversely, showing a hearty appetite, they engage in specific manhood acts (Schrock & Schwalbe, 2009) that enable them to accumulate masculine capital (de Visser et al., 2009). We can find an example in the illustrative words of Pasquale, who counterposed his “bon vivant” approach to that of another diabetic friend, who instead adopted a more stringent food consumption regimen  that Pasquale, however, perceives as excessively restrictive and detrimental to one's quality of life: (…) He cures [diabetes] through diet: he basically doesn’t eat carbs. Or if he eats them, he just eats few of them. But what kind of a life is that?? I mean, for God’s sake, he sure will live longer than me, but how? Because there is also the quality of life that is different, don’t you think? I mean, I always say: “Life is something else.” Mmm, so … the point is…to live. (Pasquale, 47 years old, employee, diabetes LADA, onset at 30 years of age)

For individuals within this subgroup, this involves maximizing their freedom from the constraints of diabetes self-management, particularly during meals. This entails a shared decision among all men in this subgroup to avoid “carbohydrate counting” rules, which they find too time-­ consuming and which  would have a detrimental impact on their psychological wellbeing, as we can read in Manuel’s words: I should… They always told me that I should do the carbohydrate counting. And it is something that I… In fact, the doctor says: ‘You are not good at it!’ Because counting bothers me… (…) I know that carbohydrate counting is important, because I am old enough to understand it, but it is something that I don’t… If I had to do it… I don’t know, it is something that [he laughs] I can do it for one day, two days, but the third day I already begin feeling awful, I mean. (Manuel, 28 years old, T1D, employee, onset at 16 years of age)

Similarly, Giovanni stated: If I go outside, first course, second course… Bread, wine, alcohol, I don’t… No problem. Especially because it is a time for enjoyment, when you go out with friends. So I don’t spend time in thinking to something that would

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ruin the moment. (Giovanni, 32 years old, T1D, unemployed, onset at 31 years).

Rather than engaging in “carbohydrate counting,” men in this subgroup decided to guess both the carbohydrate quantity of their food and estimate the corresponding units of insulin dosage to inject. This approach highlighted their competence on the one hand, and their ability to resist being “controlled” by illness on the other hand: I don’t do the carbohydrates counting in a precise manner, even if I attended a course with a nutritionist, actually I estimate it. (Amedeo, 50 years old, T1D, realtor, onset at 30 years) You know, because there is no point in doing the math… I see how much pasta I have on the plate, and I adapt… Without…. Because carbohydrate counting is… It is a little bit complicated, come on. The approach is changed, now this is the first thing that they teach you: the carbohydrate counting. I know how it works (…) but I use something in between. (Matteo, 58 years old, T1D, retired, onset at five years)

In the same vein, Massimiliano talked about various approaches to diabetes by referring to those diabetic people who constantly weight their food and obsessively measure glycemia, devoting a large portion of their lives to diabetes self-management: Because I’ve heard some incredible things, [he laughs] they say: “Ah, 95 point 6 grams of pasta.” It’s pasta! [He laughs] There’s something that’s complete madness which is [he laughs] the half a teaspoon of… of sugar in your coffee, which, all you have to do is get up, get your ass off the chair, sorry if I’m telling you, but the half a teaspoon is gone: you take two breaths, and it’s vanished… [He laughs] (Massimiliano, 40 years old, T1D, teacher, onset at 4 years)

Pasquale provided a similar narrative, and the subsequent excerpt is noteworthy for his apparent recognition of the potential diabetes-related complications of his behaviors. In doing so, he presents himself as someone who embraces a risk-taking attitude and disregard to health, in line with hegemonic ideals of masculinity: I do not know, for example I am someone that maybe… I organize work dinners, (…) but among friends, you know, and so someone who knows me,

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but does not know me as well as I know others, because then to the group there is always someone who knows you less, you know, and maybe knows that you have diabetes, you know, and goes: “Pasquale, are you crazy to drink all this Prosecco? … But you have diabetes!!” “Yes, I understand, … but it’s an evening, … please, I mean, the doctor with me, I don’t want him.” (…) Today I have no complications, … maybe in 10 years I will say: “What an idiot!” Sorry (…) my language eh, … and I say this because maybe they might amputate a foot to me- now, just to say, you now—but at a certain point I will say: “Yes, but … I enjoyed it!” (Pasquale, 47 years  old, employee, diabetes LADA, onset at 30 years of age)

Within this subgroup, discussions concerning food frequently centered on the pleasure of eating, whether in solitude or accompanied by others. In some cases, the fact of giving priority to enjoyment in eating instead of dieting seemed to have a gendered dimension, as in the case of Vito, where the expression of masculinity through food choices is particularly evident: And with regard to the… management of diabetes, in your opinion … between men and women, … is there someone who has more rigor, or more resistance? [Long pause] Well, women are seen as being more law-abiding… so… maybe they have less trouble following certain settings… [Long pause] In any field in particular? … Or in general? No, maybe in the diet… or eating. [Long pause] So, let’s say… you feel less law-abiding to your diet Yes, yes, yes… (Long pause[ And why do you think that is? I mean, why for example do you choose… to… break the rules every now and then? Eh, because I like it. I like to eat. [Laughing] Yes, but I mean… I don’t know how to define it. Well not because I want to kill myself, but if I see… If I like red meat, I eat it. (…). Then I like alcohol, wine, … but, …of course, always- of course, it’s not that I eat red meat every day. [Long pause] But if I see something I like, it’s not that I refrain. I mean: I eat it. (Vito, 30 years old, T1D, employee, onset at 23 years)

This context revealed two predominant types of discourse, which mainly depended on participants’ social class. Men’s dietary tastes are in fact influenced also by societal norms and ideals, which reflect their specific habitus (Bourdieu, 1977, 1984), a result of their exposure to cultural influences that define what foods are deemed “good,” appropriate, and adequate with the enactment of specific forms of masculinity. When

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talking about their dietary practices, men with a middle-high cultural capital frequently mentioned the habits of dining out. Central to their narratives is the constant pursuit of enjoying culinary delights, especially in social company. Amedeo, for instance, mentioned frequently going to restaurants, emphasizing that even when he opted for solitary home-cooked meals, his main focus was on avoring appetizing food. In his words: I am someone who likes to eat. I like to eat well, I like to cook, although… if I go out mmm if I go to a restaurant where the food is good or whatnot, I don’t hold back, in the sense that lunch out or dinner out, I mean, what I don’t… I am not the one that doesn’t eat dessert or what is, absolutely. Then at home, I try to be stricter. (Amedeo, 50 years old, T1D, realtor, onset at 30 years of age)

The necessity to deal with diabetes self-management introduces complexities to fully enjoying meals without any constraint. For individuals with diabetes, it’s crucial to inject insulin and avoid hyperglycemia (high blood sugar). To enjoy food with more freedom, some chose to administer insulin after instead of before eating. For example, Amedeo stated: If I am at lunch or dinner outside, once or twice a week, I do it, and I do not do the carbohydrate counting… I order the food I want, at the restaurant I always have insulin afterwards. (Amedeo, 50 years old, T1D, realtor, onset at 30 years)

The second category of discourses, which describes the perspectives of men with a working-class background, centered on the enjoyment of consuming unrestricted amounts of food and indulging in alcoholic drinking, irrespective of diabetes-related consequences. An illustrative case is that of Manuel, a 28-year-old man who was diagnosed with diabetes at the age of 16. During the interview he explained how he prioritized consuming food that made him “feel good” rather than adhering to strict rules. As Manuel remarked: Desserts, …it’s not true that you can’t eat them. For example, I have breakfast with cappuccino and brioches (…) and if there’s cake, I’ll eat it. (…) For example,…let’s say, Saturday (…) in the evening, we went…we had an informative banquet with the association, so there was barbeque.…(…).…I ate—I ate—I had to start eating the grilled meat, then someone didn’t eat the pasta, I ate the pasta, then I ate the grilled meat, squid, and chips. (He

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laughs) So, chips, squid, pasta. So, I basically ate for two. (…) Because…I mean, when there is food left,… I mean, they call me “Terminator’” [he laughs]. (Manuel, 28 years old, T1D, employee, onset at 16 years of age)

Similarly, Pietro recounted engaging in binge drinking when going out with friends, and consuming the foods of his choice. This underscores his inclination towards risk-taking and disregard for medical recommendations, as he claims to  follow dietary practices that are even less health-­ conscious than those followed by non-diabetics I feel good, yeah, because… I’ve always done the same things as others, and I’ve always done more than others. Even with things that… But, umm… I’ve always eaten the pizza I wanted, I’ve always drunk as much as I wanted… (Pietro, 27 years old, T1D, musician, onset at 16 years of age)

Engaging publicly in an unrestricted diet and drinking despite having diabetes exposed these men to the potential of being judged negatively and stigmatized by others  as engaging in immoral activity. In fact, it emerged from their narratives that these men’s eating habits were often viewed as morally unacceptable by some, because they transgressed the healthy male citizen ideals (Crawshaw, 2007) and did not show their explicit intention to maintain their own health and prevent diabetes-­ related health complications. In certain cases, men reported encountering stigma and being subjected to victim-blaming, as individuals without diabetes held them responsible for their own condition (Crawford, 1977). Nevertheless, type 1 diabetes is an autoimmune disease, the onset of which  often occurs during childhood and seems not to be caused by “unhealthy” lifestyle habits, unlike type 2 diabetes. Elio gave an account of this occurrence: There are those people… because, for someone who has no experience of diabetes, on himself or with a close relative, he obviously doesn’t know what this means… And… Because in my opinion people know little about it [autoimmune diabetes], (…) so they think you’re diabetic because you ate a lot of sweets and candies when you were a child. (Elio, 29 years, T1D, shop assistant, onset at 24 years of age)

Usually, men reported reacting to these situations by explaining and giving information about their condition:

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Last Sunday I was having lunch in London with two of my clients, and this lady, she was one who did not know… And we ate ice cream. [She said] “Eh, you cannot eat ice cream!” I said: “Yes, look, trust me [laughter] I can eat ice cream, I have to manage it [diabetes], (…) but I can eat ice cream.” By the way, ice cream is not even the most complicated dessert, but it’s a classic, they look at you as if to say: “No, but it is impossible that…” This is a bit of ignorance… (Amedeo, 50 years old, T1D, realtor, onset at 30 years of age) Sometimes it pisses me off, can I use the term pissed off? [Laughs] Yes, sure. The people that… Because there is unfortunately… there are the people who do not understand anything, I mean, you go outside: “Eh, but you cannot eat the cake!” “But who—who told you that I cannot eat the cake?!?” …I mean… “I eat the dessert! For you, … your pancreas works by itself, while I have this here [the insulin pump], I throw a little extra insulin, but I eat the dessert, it’s not that I don’t eat it.” (Pasquale, 47 years, employee, diabetes LADA, onset at 30 years of age)

Interestingly, unlike the other two ideal types that we have analyzed in previous chapters, in this case the majority of participants—seven out of nine—reported organizing food consumption on their own. In this subsample, three out of nine participants reported being single, two of them reported being in a non-cohabiting relationship, one of them was a widower, two reported being single and living with their parents, and one reported being married and living with his wife. With the exception of Manuel and Elio—28 and 29 years old respectively —who lived with their parents, all the other participants reported organizing food consumption practices on their own. A minority of participants—two out of nine— reported engaging in cooking practices with enthusiasm and described themselves as excellent cooks. In so doing, they engaged in a type of cooking activity that was distant from everyday, ordinary cooking: it was rather the demonstration of a combination of competence and creativity that helps in displaying adequate masculinity (Stagi, 2016). For example, Pasquale recounted: And usually, who cooks at home? …Mmm many times I do, and fewer times my wife does, [he laughs] yes, but I’m very good in the kitchen! You like cooking… Yes, yes, yes, yes. I cook, things like that, I prefer… the first courses. In the sense that… a little bit elaborate, I mean, I do not like to make the sauce

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with the meat, the “Bolognese” is it called? I mean… I’m someone… maybe because I’m often outside for work, and maybe I stop at the restaurant, I eat a particular dish, (…) and mmm so I copy the recipes, you know, maybe I go to restaurants “Oh man, they made that dish…!”…Then maybe I take the picture [of the dish] to remember, then I create eh, maybe I’d add something… (Pasquale, 47 years, employee, diabetes LADA, onset at 30 years of age)

6.3   My Body, My Choice. Mismanaging Illness and the “Costs” of Masculinity Men in this subgroup described themselves as resistant to adopting  the lifestyle prescribed by diabetologists and doctors also by affirming their aversion to continuous glycemia monitoring and, often, medication such as insulin administration. Hence, these accounts vividly reflect a pattern consistent with findings from other studies: the act of presenting an image of “not doing” health emerges as a means of actively “doing” masculinity (Robertson, 2007; Courtenay, 2000). An illustrative example in this regard is that of Massimiliano: during the interview, Massimiliano stated that he considered the medical suggestion of regularly measuring and monitoring glycemia as “excessive.” He believed that such practices could negatively impact his well-being and the overall quality of his daily life. As a result, he made the decision not to frequentlyengage in them: For me, a constantly monitored life, even if it could be functional from the point of view of treatment… Then, from the psychological point of view… I think it is quite difficult. (…) Physicians usually suggest approaching illness in a certain way, but maybe they (…) only look to the number at the end of the exam, you know? Not all of them, not all of them. But they should consider the possibility that… an extra point of glycated [hemoglobin], after all, it’s not that important as the influence that it has in one’s disposition, and in growing with that pathology. (Massimiliano, 40 years old, T1D, teacher, onset at four years of age)

The fact of not constantly monitoring glycemia during the day might lead to experiencing glycemic flows. In this context, Pietro’s account of an episode involving severe hypoglycemia is particularly interesting. What is noteworthy, and an exemplification of this ideal type, is his subsequent reaction: feeling profoundly weak, he promptly consumed a substantial

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amount of food to raise his blood glucose levels. While reflecting on this  topic  during the interview, he nevertheless asserted that he had no intention of regularly monitoring his glycemia. He views such measurements as a constant reminder of his illness, which he believes could adversely affect his psychological well-being: [Once] I lost the ground beneath me… I was scared, at the beginning I didn’t know what it was. (…) Weakness, sweating too much, great anxiety that you have because the brain turns to mush… But then it’s pretty cool, because you can eat… sweets, you have munchies, you are incredibly hungry: I opened the fridge and ate everything: I had a sandwich, then an ice cream, then a yoghurt, then a pasta, I mean… I was really hungry. (…) Now, I really don’t like it, because I have bad vision when I have a hypo. It’s like looking at a cubist painting, you struggle and confuse the object (…) everything is confused in your eyes, and you are confused, and people talk to you, but you cannot answer. And when this happens, what do you do? I get pissed off, because I really don’t like it. (Pietro, 27 years old, T1D, musician, onset at 16 years of age)

In comparison to the other two ideal types, this group of participants described themselves in an “unquantified” way: they measured glycemia infrequently or even not at all, and the avoidance of this constant  self-­ surveillance was considered by them as a prerequisite that improved their psychological well-being. As Giovanni stated: I see other people that set themselves as a goal to have glycaemia always at 90. And if it goes at 120: “Shit!” and they become paranoid. This doesn’t happen to me, so… I think that this approach… Of not being paranoid, I mean, it makes things easier. (Giovanni, 32 years old, T1D, unemployed, onset at 31 years of age)

Constant self-monitoring is considered oppressive, and a real form of slavery, as we can read in Massimiliano’s words: Today that… there is more… control, there are many possibilities, but on the other hand dealing with disease is very… oppressive, from a practical… point of view. Because you know, kids today have to constantly monitor themselves already at the age of 2, 3 years… If [glycemia] goes up to 200: ‘Oh, something must be done!’ While I remember that… except if it was 400 my parents never… All in all: ‘You run, you don’t eat the snack’ You

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see? In this respect I was lucky, I haven’t had great complications so far. But if I see the way I was treated at the very beginning, and compared to the contemporary situation… This is a disaster, ok? (…) They sure are stronger from a therapeutic and medical point of view but it is more difficult to deal with it from a psychological point of view, especially for children, to deal with this thing, because they are forced to constantly being enslaved from therapy, you know? (Massimiliano, 40 years old, T1D, teacher, onset at four years of age)

For many participants, reducing control did not equate to complete avoidance of self-management; instead, it implied adopting an alternative approach. For instance, a prevalent strategy that emerged from the interviews involved relying on “physical sensations” to “estimate” and “feel” their actual glycemic levels, as opposed to constant measurement using medical instruments. As Amedeo put it: Now, if it [hypoglycemia] happens during the day I feel it before, you know? I mean, I start feeling discomfort, you feel dizzy, and you feel that you don’t think straight (…) it’s a sensation that you know well, I already know what it is: so I eat everything obviously, because you have munchies and you want something sweet. (Amedeo, 50 years old, T1D, realtor, onset at 30 years of age)

Pietro, in turn, demonstrated bodily mastery and ability to stay in control of his diabetic body by asserting his capacity to tolerate alcohol and avoid self-monitoring glycemia thanks to his profound knowledge of his body's reactions, which enabled him to effectively predict and manage his physiological responses: I know very well that… it’s not a good idea for me to have 10 beers on Saturday night. Whether I end up drinking them anyway or not, that’s a different story, you know, it’s about the fact that I know what happens to me [after]. (Pietro, 27 years old, T1D, musician, onset at 16 years)

If participants who can be described by  the first two ideal types perceived digital devices as empowering instruments that allowed them to reach numeric objectives, or to elaborate an alternative knowledge around diabetes experience, the larger portion of participants within this subgroup view these devices as constraining and unfamiliar, which would  restrict their autonomy. For this reason, the majority of them

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reported using traditional medical devices (insulin pens and glucometers), whereas a minority of cases reported using the most recent digital devices (glucose sensors and insulin pumps). Although participants made different choices in terms of self-management strategies, all of them justified those strategies by referring to the higher level of freedom and psychophysical well-being that this entailed in their everyday lives. For example, Pietro reported having tried to use the insulin pump, but he had then opted for the insulin pens because he considered that the pump was too time-consuming and he considered it a “foreign” object to his body that could have a negative impact on his well-being: What is the reason that led you to choose… to have… to use [insulin] pens? Because [the insulin pump] is a pain in the arse, mainly because it comes off [by itself]. And this gets on my nerves, because maybe I put it on with a lot of care, I try to stay on track, and then this thing comes off. And then I should pack it up in the middle of my belly, and there is all a work you have to do (…) And, by the way, it is always a thing, that you have attached there. If you put a tape, then you have to shower, and then this thing comes off, and you had just filled it [with insulin], you have to fill it again… (…). Because if you begin to have problems with this thing that you should change every three days, then it comes off every two, or in one day. In the meanwhile you have the other [the sensor] on your arm, that needs to stay there for two weeks, then it comes off… You lose track. This drove me crazy… (Pietro, 27 years old, T1D, musician, onset at 16 years of age)

Massimiliano, who reflected on the possible “downsides” of digital technologies by comparing his experience to that of contemporary hyper-­ monitored diabetic children, gave a similar account: From the point of view—I try to think—to see today’s children… that have the insulin pump, that have the glucose sensor, that are… very much in contact with this thing [illness]… And I… used to spend entire weeks were I hardly injected insulin sometimes… I mean, let’s say the truth… [He laughs] Sometimes I think… it is possible that this could cause in someone some difficulty, not only in dealing with diabetes in itself, but mainly in dealing with life outside diabetes. (Massimiliano, 40 years old, T1D, teacher, onset at four years of age)

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One of the difficulties that he—just like others—envisioned was the possibility of perceiving medical devices as an extraneous object attached to the body, a “ball and chain,” a sensation that could be lived as a constant reminder of the disease and could influence the quality of life experienced. For this reason, he decided to use the glucose sensor every once in the while and to avoid the insulin pump. In his words: I tried to use the insulin pump, but I can’t. For what reason, does it bother you? It is psychologically impossible for me to have one more thing… (…) I don’t want to say that the worse therapy is the best, absolutely, but it is important to look for a compromise within a therapeutic situation where there is less oppression. Honestly, feeling it attached to me, from the psychological point view, this is (…) oppressive. If it can be positive for someone not to inject insulin, conversely for others… to constantly have a machine attached, it could be felt as a real slavery. You know? It is, actually it is. (…) But if you are adult, it sure can give you more tranquility in therapy, unlike the insulin… [that you inject] 4 or 5 times a day (…). So [the insulin pump] allows you to avoid some daily injection, that I don’t know if it is worse if compared to having a needle inserted [into your body] 24 hour a day for 3 days. I would never do that. (Massimiliano, 40 years old, T1D, teacher, onset at four years of age)

According to Massimiliano, on the one hand the fact of having an object attached to the body—the sensor of the insulin pump—could improve adherence to treatment. On the other hand, excessive self-­ surveillance, in his opinion, could have a negative impact on the person’s psychological well-being. In his words: I think it’s often, … the fact that… seeing it, continuously, and having it always [attached] on yourself, this, in quotes, this makes you more aware of what you have to do… From the therapeutic point of view, if compared to… mmm to that of… injections per se, you see… I repeat, I’m not a doctor, but… but… from a psychological point of view… I noticed that too, it’s more the impact of having a thing, or the sensor: obviously, you’ve always it attacked to you, and so you’re constantly going to measure. Don’t you think? When you use the glucose meter, beyond the fact that you… prick your fingers, however, … even with the glucose meter, you could do it continuously, almost. Every half hour, every hour, but you don’t do it… no, because… you focus to do anything else, and instead in that case there,

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you’re constantly instigated mmm… and induced, to measurement… Ok? (Massimiliano, 40 years old, T1D, teacher, onset at four years of age)

On the contrary, three participants reported feeling freer and less under control through the use of digital medical devices. For example, Amedeo at the time of the interview was using the continuous glucose sensor for measuring glycemia and the insulin pump for insulin administration. As mentioned, he did not engage in rigorous and “quantified” self-­ management, but digital devices made him feel less constrained during the day, and allowed him to quickly monitor the situation without the need to stop his activities to inject insulin or prick his finger and measure glycemia. In his words: So I have clients here, I manage real estate in London, I go back and forth. This means that there are days that maybe I stay at home all day and work from home at the computer. And there are days when I’m out all day on foot or by bike and I go out with a client at the restaurant or eat a salad on the fly and… This added to the fact that today I’m cycling or like yesterday I was at home all day, so the physical activity, eating at the restaurant rather than… And mmm there are variables that obviously complicate the self-­ management. (…) And let’s say that today with this [the insulin pump] I manage to correct not so much what I eat, but to keep the basal [insulin] and to manage it in a certain way. (Amedeo, 50 years old, T1D, realtor, onset at 30 years of age)

Similarly, Vito, a 30-year-old man diagnosed with diabetes at the age of  23, empasized in his account the numerous activities he successfully participated in, including partying and leisure travel. He portrayed his self-­ management strategy as intentionally kept to a minimum level to not let it interfere with his daily life. With this approach, he regarded the insulin pump as the optimal method for administering insulin. By doing so, he experienced a heightened sense of liberation, eliminating the need for constantly carrying insulin pens and performing multiple daily injections. In his words: I like to travel, to go around. (…) The thing that bothers me is… having my mind on something. Like thinking about all those things, how to get organized, where to keep the insulin, that’s why I don’t mind this [the insulin pump]. Because in the end I, even if I don’t think about it, once I measure

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it, I tell it what it has to do, [and] it does it. (Vito, 30 years old, T1D, employee, onset at 23 years of age)

In other cases, some men reported that they refrained from engaging in self-management routines as these practices tended to divert their focus from their ongoing activities and served as constant reminders of their medical condition: Sometimes, I think that you’re so focused when… I mean, you’re still with friends, you’re still detached [from illness], … That thinking about it, having to deal with it, it takes you back to that conception of reality that you would rather forget for a moment. So it would be oppressive, and so you put it aside. (Elio, 29 years old, T1D, shop assistant, onset at 24 years of age)

On the other hand, another reason why participants preferred to avoid self-management practices during social occasions was that they not only bring illness into the picture, but may also lead to experiencing stigma. In this case, for example, Elio describes eloquently the difficulties involved in managing diabetes within the realm of social interactions, especially when engaging with acquaintances and strangers: When you are in a group… I mean, as long as you are only with two friends, it is ok. When you are in a group, with people that you don’t know very well, this is more difficult. It is very much more difficult. When I go dancing, you don’t feel like measuring, then you would have to go to the bathroom, you have to inject insulin, you have to count… Or when you go out for eating dinner with people that maybe you don’t know, having to go to the bathroom (…) it’s not easy. You are at some friends’ house, especially when there are people that you know the least. Because there are people that don’t understand, that look… (Elio, 29 years old, T1D, shop assistant, onset at 24 years of age)

6.4   Conclusion In this chapter, we have analyzed and discussed the specific ways in which the men described by the “Free Spirit” ideal type constructed their masculinities. The dominant discourse among the nine men in this subgroup  revolves around the minimization of diabetes’ impact and the significance of its symptoms in their daily lives. Diabetes is portrayed as a minor nuisance, demanding a portion of their day for management but

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not significantly impacting their identities or daily activities. A second recurrent theme arising from their narratives involves rejecting the rigid dietary regimens recommended by their diabetologists. The Free Spirits associate monitoring food intake with excessive control and self-­ deprivation, opting instead to enjoy culinary pleasures with fewer restrictions. This is in line with other studies that highlight how food practices, and especially dieting, are still linked with femininity (Stagi & Benasso, 2018), whereas dominant masculine ideals encompass disregarding healthy eating (Courtenay, 2000). By exhibiting indifference toward their diets and openly indulging in hearty eating, they enact specific manhood acts (Schrock & Schwalbe, 2009), in this way accumulating masculine capital (de Visser et  al., 2009). Additionally, these men describe themselves as resistant to the prescribed lifestyle outlined by diabetologists and physicians, asserting that they refuse to perform constant glycemic monitoring and, often, also to administer medication properly. Hence, these accounts show how the fact of projecting an image of “not doing” health functions as an active demonstration of (hybrid) masculinities.

References Bourdieu, P. (1977). Outline of a theory of practice. Cambridge University Press. Bourdieu, P. (1984). Distinction: A social critique of the judgement of taste. Harvard University Press. Broom, D., & Whittaker, A. (2004). Controlling diabetes, controlling diabetics: Moral language in the management of diabetes type 2. Social Science & Medicine, 58(11), 2371–2382. https://doi.org/10.1016/j. socscimed.2003.09.002 Bury, M. (1982). Chronic illness as biographical disruption. Sociology of Health & Illness, 4(2), 167–182. Charmaz, K. (1994). Identity dilemmas of chronically ill men. The Sociological Quarterly, 35(2), 269–288. Connell, R. W. (1995). Masculinities. University of California Press. Courtenay, W.  H. (2000). Constructions of masculinity and their in¯uence on men’s well-being: A theory of gender and health. Social Science, 50(10), 1385–1401. Crawford, R. (1977). You are dangerous to your health: the ideology and politics of victim blaming. International Journal of Health Services, 7(4), 663–680. Crawshaw, P. (2007). Governing the healthy male citizen: Men, masculinity and popular health in Men’s Health magazine. Social Science & Medicine, 65(8), 1606–1618.

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de Visser, R. O., Smith, J. A., & McDonnell, E. J. (2009). ‘That’s not masculine’: Masculine capital and health-related behaviour. Journal of Health Psychology, 14(7), 1047–1058. https://doi.org/10.1177/1359105309342299 Fidolini, V. (2022). Uomini e diete: Cibo, maschilità, stili di vita. In Uomini e diete (pp. 1–120). Sellier. O’Hara, L., Gough, B., Seymour-Smith, S., & Watts, S. (2013). ‘It’s not a disease, it’s a nuisance’: Controlling diabetes and achieving goals in the context of men with Type 1 diabetes. Psychology & Health, 28(11), 1227–1245. https://doi. org/10.1080/08870446.2013.800516 Robertson, S. (2007). Understanding Men and Health: Masculinities, Identity and Well-being. McGraw-Hill Education (UK). Schrock, D., & Schwalbe, M. (2009). Men, masculinity, and manhood acts. Annual Review of Sociology, 35(1), 277–295. https://doi.org/10.1146/ annurev-­soc-­070308-­115933 Stagi, L. (2016). Food porn: L’ossessione del cibo in TV e nei social media. EGEA spa. Stagi, L., & Benasso, S. (2018). Ma una madre lo sa?: la responsabilità della corretta alimentazione nella società neoliberale. In Ma una madre lo sa? (pp. 1–146). Genova University Press.

CHAPTER 7

Dance, Music, and Workout: Doing Masculinities in Men’s Digital Diabetes Narratives on TikTok

TikTok is one of the world’s most popular social media platforms and constitutes a new and interesting site for analyzing online self-­presentation. Ever since its 2016  launch, this video-sharing platform has rapidly burgeoned in popularity: as of August 7 2023, it has expanded its presence to over 160 countries and maintains a user base surpassing 1.1 billion. The TikTok application has been downloaded over 2.7 billion times worldwide (TikTok Statistics, 2023). Although TikTok offers some features already available on previous platforms such as YouTube, Instagram, or Facebook, it also introduces specific functionalities enabling the creation of new self-­ representations compared to the past. To its users, TikTok offers the possibility of producing, sharing, and accessing short videos that last a maximum of 60 seconds. The content of the platform predominantly consists of playful, ironic short videos, constituting a digital media environment that greatly differs from its counterparts (Miltsov, 2022). Nevertheless, with its affordances, TikTok allows for new forms of political expression and participation (Boccia Artieri et al., 2022). Moreover, the algorithm analyzes TikTok’s  user preferences to offer personalized content recommendations in the “For You” section. Unlike platforms such as Facebook, Twitter, and Instagram, which use continuous content feeds, TikTok adopts a different approach and presents videos one at a time. This unique design enables users to swipe up for the next video, or swipe back to re-watch the previous one. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Quaglia, Wounded Masculinities, https://doi.org/10.1007/978-3-031-44436-4_7

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The research presented in this chapter explores the TikTok platform as an online space in which diabetic men construct and express masculinities while producing and sharing their illness stories. In fact, in recent decades, with the advent of social media, the possibility of sharing and accessing illness narratives and, more in general, health information, has increased exponentially (Bertolazzi et al., 2023; Lamerichs et al., 2021). This situation has indeed had an important impact on the way individuals experiencing chronic illness may understand, signify, and experience their condition, which has indeed also influenced the resources available to them for constructing their identities. These aspects are particularly important as individuals living with an illness often face the risk of societal stigma and struggle to display all the dimensions of their identity. Conversely, they can discover, within online spaces, a milieu of recognition, allowing their narratives to resonate, and their selves to receive validation. In the context of digital media research, this phenomenon has produced a promising new genre, that of digital health narratives (e.g., Svalastog et  al., 2021; Lamerichs et al., 2021): individuals share their personal narratives of illness on blogs, forums, and social media. These stories are commonly presented in the first person, are meant to be heard, read or viewed by an audience, and are often publicly accessible; furthermore, the platforms on which they are shared usually enable readers to interact with the authors (Svalastog et al., 2021; Tshuma et al., 2012). As we have seen in the previous chapters, the way people do health and illness is deeply intersected with how they do gender. In fact, drawing from Connell’s relational theory and its further developments, gender is here intended as an ongoing process of “doing,” a configuration of practices that changes depending on women’s and men’s phases of life and historical and social contexts. As discussed, the acts of talking about and “doing” health are to be considered part of these configurations of practices which occur in specific social and cultural contexts. When this research was conducted, this was the first study carried out to explore how diabetic men “do” masculinities in their illness stories. In fact, despite being crucial and ever-present in an individuals’ everyday life, the social media context is still overlooked in much of critical masculinities research. The decision to expand the research including also online spaces relies on the fact that the “doing” of gender and illness assumes specific forms, according to the different affordances provided from the various social media platforms. TikTok, with its short videos, allows users to carefully construct their videos, select the words to use, select the pose and the

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music that best suits the content, and so on. Thus, such platforms offer the possibility of constructing, modifying, and improving one’s own self-­ presentation (Van Dijck, 2013), often relying on idealized versions of oneself (Marshall et  al., 2020). How a person decides to appear on social media has necessarily to do with gendered ideals of how a woman or a man or a girl or a boy, should appear and behave in public spaces, whether he or she decides to adhere to dominant ideals of femininity or masculinities. Most research in this regard focuses on the representation of femininity (e.g., Butkowski et al., 2020; Caldeira et al., 2018) while only scant research has been conducted on how men represent themselves on social media (e.g., Foster & Baker, 2022; Agustina, 2022). To study how diabetic content creators represent their masculinities in their illness stories on TikTok, the research presented in this chapter relies on Goffman’s (1959) symbolic interactionism approach and thus focuses the analysis on both signs that are intentionally shown, and those that are inadvertently conveyed, which together compose online self-presentations. Crucial for the interpretation of results has been the adoption of concepts of hybrid masculinity (Bridges & Pascoe, 2014; Arxer, 2011) and masculine capital (de Visser et al., 2009) concepts and theoretical approaches that have been elucidated and explored in the previous chapters. By analysing 100 videos posted on TikTok,1 this research investigates whether the visual self-­ presentations of diabetic men on in this online space are mainly shaped by stereotypical portrayals of hegemonic masculinity or if there has been a shift in dominant constructions of gender identity as a result of, on the one hand, the necessity to deal with the disease, and on the other hand, the emergence of new affordances provided by the TikTok platform. After giving an overview of how male creators use TikTok to produce digital diabetes narratives, the findings are organized around three themes that emerged as particularly relevant for masculinity and its self-representation, namely, the  visual display of the diabetic body; the expression of men’s emotional statuses; and the portrayal  of food consumption practices  in diabetic men’s digital illness stories.

1

 For further details regarding the research design, please refer to Chap. 3.

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7.1   Self-Representations of Diabetic Masculinities on TikTok: An Explorative Analysis Among the seven creators analyzed, all of them are White, Italian, cisgender, heterosexual, and have a middle-class background.2 At the level of video content, all of them use TikTok to share with others their diabetes lives, and the struggles to manage the disease as well as the strategies to overcome the most common obstacles in diabetes self-management. All seven cases  pertain to  personal profiles  wherein a diverse array of video content is shared, using a heterogeneous type of content, using different formats. In some cases, the videos posted revolve around aspects of life with diabetes, or diabetes-related topics. In contrast, in other cases videos related to diabetes constitute merely a subset, interspersed among those addressing different topics. In what follows, the preliminary results of the analysis will be presented, focusing on the features of TikTok mainly used in the videos (in the first sub-paragraph), and on how masculinities are represented  in the context of digital diabetic narratives (subsequent sub-paragraphs). 7.1.1   Exploring the Use of TikTok Characteristics in the Content Produced by Diabetic Male Creators One of the aims of this exploratory study was to analyze how video creators utilized the distinct affordances of TikTok to produce and share their content. In general, among the videos under analysis, it is possible to identify various content categories based on how tiktokers employed the diverse functions provided by the platform. In simpler cases, content creators generated self-recorded videos in which they discuss their experiences with diabetes, without including music or captions. This predominantly occurred among older creators, who presumably possess less familiarity with the affordances provided by this specific social platform. Among the videos  analyzed, none fell under the “challenge” category, and only a limited number were categorized as “dance” videos. Additionally, a small subset of videos utilized the lip-sync option. These last functionalities of the platform emerge as particularly intriguing for

2  TikTok does not allow the collection of accurate and reliable information on socio-demographic characteristics. For a critical consideration about this topic, see the Chap. 3.

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studying the intersection of the representation of health and gender. Indeed, the act of dancing and singing in videos introduces expressive and communicative tools that are not conventionally considered masculine. Within the corpus of the  analyzed videos, the most significant in this regard is the one referring to the narration of his diabetes’ onset by @alessiocapoblanco, which has been constructed as follows: The video begins with the song “Elpepe,” featuring a rhythmic melody. In the foreground, we see him from the waist up, dressed in a tracksuit, moving to the beat of the music and lip-syncing the lyrics. While dancing, he provides the narration of the onset of diabetes with the captions that appear on the screen. At times, he points to these captions with his hands, which state: “During the night, I can’t sleep. I’m always feeling warm, and I keep needing to go to the bathroom. So, I tell my parents, and they decide to take me to the hospital. Once I arrive at the hospital, I go to the pediatric department, where they prick my arms with little needles. Then, we wait in the waiting room until the doctor comes out with the results. The doctor approaches us and speaks with my mother first. Afterward, she comes to me and informs me that I have diabetes. I initially think it’s a temporary illness, like a fever that will pass eventually. However, it turns out that it’s not the case. It’s been 9 years now, and it’s going to be 10.”

To the intensity and the criticality typical of the traditional narrative of the ill-ness onset, elements that mitigate its emotional impact, such as music and dance, are juxtaposed. These elements are not conventionally associated with this form of storytelling. On TikTok, the narration of one’s own illness story is shaped, on one hand, by the affordances of the platform, and on the other, by the new self-presentation rituals shared by users, which are observable in the content they publish and share. Furthermore, several creators used the “stitch” function, mainly to  show other tiktokers video-recipes, while also presenting their own variations, which were more or less successful, and commenting on the taste and appearance of the final dish. Moreover, the majority of analyzed  videos used the subtitles or caption functions. Subtitles serve a dual purpose: on one hand, they enable content consumption even without the audio, and on the other hand, they facilitate comprehension of the spoken content. Captions are utilized as supportive text in three different ways (Scarcelli & Lovari, 2022). In the first case, the creator engages with the captions by moving in accordance with their placement in the video. In the second, the caption serves as a supportive narrative text for a video in which the tiktoker does not talk, but showcases objects or

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environments: he might dance, or express himself through facial expressions. Lastly, there are content creators who use captions to incorporate other users’ questions to which they respond in their videos. Within the context of captions, it is essential to mention the use of emoticons, small graphical representation of emotions typically employed as symbolic references representing emotional statuses, feelings or reactions related to the experience of living with diabetes. As mentioned, consistent with the content typically found within TikTok, music accompanies numerous videos. On one hand, the music renders the content more engaging, and on the other in many cases the lyrics of the song as well as its tone and melody “speak” for the creator. As we shall see in the following pages, even if the tiktoker does not use the voice to talk, the music and the song may convey how he feels. Furthermore, the selection of a specific melody and lyrics can enhance the emotional impact of an illness story on the viewers. Adding music and songs can help viewers to better empathize with the illness story that is narrated or portrayed. 7.1.2   “I’m a diabetic bodybuilder”: Creators and the Display of Their (Masculine) Bodies TikTok offers the opportunity to make visible and public what typically remains within the boundaries of the private sphere. One of the first striking results emerging from the analysis of the videos is, in fact, the visibility of the diabetic body. All the content creators within this sample have chosen to display, at least in some of their videos, their bodies bearing visible “marks” of diabetes: a glucose sensor attached to the arm, an insulin pump attached to the abdomen, the syringe/insuline pen for insulin adminisration, glucosemeters in the hands for measuring glycemia, and so forth. The visibility of the diabetic body in these situations is not coincidental; rather, it is intentionally sought, and crafted through choices in framing, in the selection of accompanying songs or music, and in the utilization of specific filters and in  other platform features. A particularly illustrative example is provided by the profile picture of @diabetiamo2.0, a young diabetic man who primarily employs his channel to share with others his experience of diabetes. The image depicts him in a male superhero’s classic pose, with arms confidently crossed and a determined gaze directly into the camera, sporting sunglasses, and showing—attached to his armor—weapons and ammunitions. Notably, instead of real weapons,

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upon closer inspection, it becomes evident that multiple glucose sensors are affixed to his arms, while other medical devices resembling ammunition are attached to his vest and arms. Like claws, insulin syringes protrude from his fingers, thus completing the satirical yet symbolic parody of the diabetic man as a warrior. This image, which echoes Susan Sontag’s metaphor of disease-as-war, alludes to the profound challenges and struggles that individuals experience when living with diabetes. Simultaneously, it has a masculinizing effect because, on the one hand, it depicts not a passive attitude, but rather an active demeanor towards illness, and alludes to typical elements of male superhero representations such as strength, aggressiveness, fearlessness, invulnerability, control and determination. The interplay between hypermasculine elements and elements alluding to diabetes management encapsulated in this image effectively exemplifies the hybridization of hegemonic masculinity arising from the analysis of self-representations by diabetic men on TikTok. The body becomes, in this context, a canvas for negotiating one’s diabetic masculinity. In many cases, tiktokers use their own bodies as a visual support to demonstrate viewers how to use medical devices used for diabetes self-­ management. These videos usually take the typically take the  form of a video tutorial, providing hands-on demonstration of medical device usage (e.g., insulin pumps or glycemic sensors), often accompanied by real-time verbal explanations. Through on-screen annotations and captions, they highlight key steps and often foster interaction. An illustrative example is again provided by @diabetiamo2.0, in a video in which he tries, for the first time, a new glucose sensor model: The video commences with him seated on a couch, dressed in a t-shirt that reveals tattoos on both his biceps. His face reflects concentration as he proceeds to apply the new model of a glucose sensor onto his right bicep. Uttering “Here I go!” followed by “Quick pull, guys!” he exerts pressure on the small, white, circular device against his skin, emitting a distinct “click” sound. The sensor disengages from the applicator, and  its needle penetrating the skin. He shows no signs of pain, though his face is slightly reddened. Gently removing the applicator, he breaks into a satisfied and relieved smile. Folding his arms toward himself, he clenches his fists in a triumphant gesture, declaring, “There you have it, we did it, guys!”

In this category of videos, which follows the structure of self-help video tutorials, the act of illustrating medical procedures shows, on the one hand, a general compliance: all the tiktokers in the sample demonstrate

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their adherence to health practices related to diabetes management. At the same time, in videos dedicated to showcasing the application and use of medical devices through their own bodies as examples, certain elements emerge that can counterbalance the potential demasculinization associated with the adoption of health practices. For instance, the display of medical expertise in these videos contributes to a self-representation that emphasizes competence and self-reliance. Moreover, given that the act of needle insertion and removal is at least somewhat painful, and often evokes apprehension and fear especially among newly diagnosed individuals, the display of composure and self-confidence while carrying out this procedure on their own bodies accentuates normative traits such as courage, stoicism and resistance to pain. A second finding regarding the display of male diabetic bodies pertains to their appearance. Interestingly, the majority of tiktokers flaunted their muscular physiques in their videos, frequently videorecording themselves during gym workouts or even appearing shirtless in videos, with well-­ defined abdominal and arm muscles on display. This emphasis on physical attributes persisted even when the primary focus of the video did not necessarily involve the exposure of those specific body parts. As seen in previous chapters, the body has become in modern society a source of symbolic masculine capital (Bourdieu, 1984), connected not so much to what it can  do, but rather more to how it appears (Gill et  al., 2005). In this regard, the display of a muscular body has consistently symbolized male dominance and played a crucial role in the construction of men’s hegemonic masculine identity (Wamsley, 2007). In the case of diabetes, as seen in previous chapters, physical activity is widely acknowledged as an essential therapeutic tool for managing diabetes. However, in TikTok diabetes narratives, men show their muscled bodies not to provide “evidence” of their compliance to medical treatment. Rather, they show their muscled bodies to depict a successful image of themselves, as they manage to construct a hypermasculine body “despite” having an autoimmune and degenerative disease. By doing so, they challenge prevailing stereotypes that associate diabetes with physical weakness and sick bodies, demonstrating strength, self-discipline, and a fit appearance. One of the most representative examples in this regard is that provided by @tolodiabete, which explicitly contrasts the stereotype of the weakness of diabetic bodies in a video he posted on his TikTok channel. The video begins with him seated on a bicep curl bench, presumably at his home, wearing sneakers and shorts, and with a bare torso exposing well-defined muscles. The

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Fig. 7.1  Challenging diabetes stereotypes: muscular body display

image is accompanied by the caption “when someone tells you that you’ll never see results at the gym because you’re diabetic,” and he responds to this provocative statement by using his body appearance as evidence that, in fact, working on one’s body is achievable even for diabetics. In the video, he does not speak, but he conveys his message by revealing his body and a fragment of a song that he lip-syncs, implicitly directed toward those who perpetuate the stereotype of the diabetic body as being  weak. Significantly, the song fragment includes the line “Shut the fuck up, nobody even wants you here” (see Fig. 7.1).

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Displaying a muscled physique can be interpreted as a sign of successfully managing to reconstruct the body—together with the self—following the onset of diabetes and its debilitating consequences. Their recurring use of body display shows how much the doing of illness is inextricably intertwined with the doing of gender. An example of this “successful trajectory” is well exemplified by a video by @edoardoprete_csw: The video begins with an image, a photograph depicting him as emaciated, visibly frail, and weary, with half-closed eyes, lying in a hospital bed. Overlaying this image is an explanatory statement: “2015, 13 years old, 39 kg, at risk of diabetic coma.” In the subsequent scene, a brief video symbolically represents the results achieved through years of dedicated effort and self-discipline: it portrays him in a gym, dressed in workout clothes and wearing headphones, with a proud gaze. He poses confidently before the camera, flexing his muscles to showcase them. Accompanying the video is a caption stating, “2022, 83 kg of pure muscle, resolute and strong.”

Engaging in rigorous workouts may involve certain health risks for diabetic men. Displaying a well-defined, fit physique signifies an individual’s capability to deal with these risks and demonstrates their capacity to develop significant muscle mass by using specific disciplinary technologies aimed at both constructing and sustaining such muscularity. Frequently, such challenges are openly addressed in the videos under analysis, showing their competence in overcoming them and providing support and motivation for other diabetics, encouraging them to follow their example. A particularly illustrative case in this regard are the videos of @lucaromanoyt, who labels himself as a “diabetic bodybuilder” (see Fig. 7.2) and dedicates the majority of his (extensive) video content to the subject of muscle gain through rigorous workouts and rigid body self-discipline. In one video, he aims to inspire other diabetics by acknowledging that being diabetic can present certain obstacles to intense training—such as the risk of hypoglycemia during exercise, or hyperglycemia from high-glycemic index carbohydrate consumption, and even the concern of the sensor detaching during squats if placed on the gluteus. Yet, he shares his successful two-­ year experience of weightlifting to encourage others living with the same condition. He concludes the video with the statement, “What is this video meant to convey? [For diabetics] there might be a few extra concerns, but surely, this is achievable, so if you’re diabetic, don’t worry.”

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Fig. 7.2  Screenshot illustrating the exposure of a muscular body

Similarly, a video of another content creator, @lightflavours, shares his strategy for preventing both hypoglycemia during workouts and the risk of hyperglycemia caused by excessive sugar intake used to correct the hypoglycemia. Interestingly, in his video, he is seen dressed in a workout t-shirt, and at the top of the screen the caption “how to avoid going from hypo to hyper” can be read. Beneath it, the text reads “diabetic fighter,” accompanied by the drawings of two boxing gloves. “I use these little boxes filled with sugar,” he explains, showing a small black container in his left hand, originally designed to hold strips for capillary glucose testing.

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He says: “Inside, there are 13 grams of sugar, which raise my blood sugar by 30–40 points (…). This is very helpful because it prevents hyperglycemia. I realized that sometimes that, out of fear, I start eating sugar, then bread, and an hour and a half later, my blood sugar is at 250, and then I have to correct it [glycemia] again, and I make a mess.” By displaying athletic and muscular bodies, and by demonstrating their acquired competence in adopting medical practices and managing glycemic fluctuations, these tiktokers convey attributes of rationality, determination, self-­ discipline, and self-control over their instinct and diabetes. It is, therefore, evident how the adoption of health practices is complemented by elements connected to body appearance, which enable content creators to acquire masculine capital (de Visser et al., 2009), serving to compensate for the potential stigmatization associated with the health and care practices they adopt.  Another element that emerged as relevant regarding the display of diabetic men’s bodies in TikTok videos was skin-­ care practices. Traditional notions of masculinity have long been associated with an aversion to anything perceived as unmanly, including cosmetics and skincare practices. Nevertheless, as seen in previous chapters, recent changes in masculinity ideals have also incorporated self-care practices (Boni, 2002). Many creators in this sample showed themselves while using skin-care products, such as oils and moisturizing creams. An illustrative example in this regard is that of @alessiocapobianco02, who in a video dedicated to showing how to remove the insulin pump explains to other diabetics his skincare routine practices:  At the beginning of the video, he is seen smiling at the camera and making a victory gesture with his two fingers—the index and middle fingers—raised. He is shirtless, wearing a pair of pants, and has a smartwatch on his right wrist. Attached to his abdomen is the insulin pump. As he moves, removing the device and proceeding with his skincare routine, his voice can be heard in the background saying: “Hello diabetic friends, today I’m going to show you how to remove the insulin pump, but more importantly, to show you what I use to prevent the skin from getting dry. First of all, I’m going to remove the insulin pump with care, just pull one side and tear it off, simple as that [laughs]. Then, I’m going to grab the alcohol or disinfectant. Next, I take a piece of cotton (…) and I’m going to disinfect and remove any adhesive residue. After that, I’m going to use this one, which is the serum from *** [cosmetics brand]. I know everyone is talking about it [this specific serum] now, but I swear it really works well. It costs 5 euros, there’s about 30 ml in it, but it hydrates a lot. On my skin, it moisturizes a lot and

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leaves the skin soft and beautifully smooth (as he says this, he applies the serum to his skin and gently massages to let it absorb). (…) I hope you found this helpful, bye!” Then he smiles, winks, and turns off the camera. Diabetic men on TikTok thus self-represent themselves in a way that points to an hybridization of masculinities, by openly discussing and practicing skincare routines. On one hand, this attitude defies traditional gender norms that have often discouraged men from such practices. On the other hand, these practices are framed as necessary for health reasons: in fact, they justify the importance of skincare as a means of self-care due to the skin issues arising from diabetes-related practices, such as the use of medical devices and adhesive bandages. These devices can dry the skin, and thus preventing such a problem seems rational. In this sense, their display of skincare can be seen as a way to construct a form of masculinity that does not reject conventional attributes of rationality and pragmatism but adds a layer of self-care and attention to appearance.

7.1.3   “I will show you that I can make a good risotto for constructing your muscles”: Dealing with Diabetes While Eating Like a Man Another theme that emerged in the majority of tiktokers’ channels was diet. As discussed in previous chapters, the realm of food consumption is particularly interesting for studying embodied practices through which men “do” masculinities. Dieting, is, in fact, usually associated primarily with women and with femininity, not only in sociological literature (Stagi, 2016; Gough, 2007; Mallyon et al., 2010) but also within the collective perception (Bell & McNaughton, 2007). Traditionally, men, are expected to eat more fatty foods than women, while women are thought to choose more vegetables to eat than men do. “Real men” are expected to eat more proteins, and in particular more red meat, a food  considered almost a symbol of masculinity (Gough, 2007; Potts & Parry, 2010; Newcombe et al., 2012). The practices connected to modifying or reducing food consumption are thus commonly perceived as feminizing, contrasting with hegemonic conceptions of masculinity. However, recent scholarly work has drawn attention to a growing trend of men participating in dieting, weight loss activities, and “healthy” eating practices (Jensen, 2023; Fidolini, 2021; Brady & Ventresca, 2014; Bell & McNaughton, 2007), and this points to a hybridization of hegemonic masculinity ideals (Bridges & Pascoe, 2014). Acknowledging the significance of this realm of practices in shaping masculinity, it becomes particularly intriguing to delve

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into how young men with diabetes, who are advised by diabetologists to adopt a healthy and controlled diet, “do” masculinity and “do” food at the same time (Brady & Ventresca, 2014), within their visual self-­ representations on TikTok. From the analysis of the videos it emerged that, in their digital diabetes narratives, often male content producers talked about, or showed, the food they usually eat during the day. A first consideration in this regard is that usually they displayed, on the one hand, interest in engaging in a healthy and controlled diet, but on the other hand, they adopted a series of manhood acts (Schrock & Schwalbe, 2009) to counterbalance its stigmazing potential. For example, they displayed hegemonic traits of masculinity by emphasizing a disciplined and controlled body and self. The following excerpt of a transcript of a video by @alessiocapobianco02  is particularly interesting in this regard: [Seated elegantly on a chair, he gazes into the camera] Good morning, diabetic friends! Today, I will show you what I eat [he blinks]. [He displays three biscuits with jam] For breakfast, my mother bought some mixed berries, and I enjoyed the biscuits with the jam that I like the most. [Next, he shows a plastic box filled with dried fruits]. As a snack, I had some dried fruits, but not the entire portion, of course. [He then shows a plate with salmon and another plate with vegetables]. For lunch, I had salmon and vegetables. This particular one is chicory, and I added some cheese to improve the taste. (…) [The camera gradually frames his legs from above as he steps onto a scale to weigh himself]. Later, I also weighed myself because I thought, ‘Oh my, how much did I eat?’ However, I mean, I don’t give much importance to weight. The key is self-acceptance, and I appreciate myself just the way I am. Well, that was my day. Let me know how yours was!

This TikTok video represents an embodiment of hybrid masculinity as it intertwines traditionally feminine elements such as dietary control with more traditional notions of discipline and control. In this case, the tiktoker displays a slender physique devoid of pronounced musculature, and creates a narrative encouraginges other viewers to accept themselves despite not conforming to stereotypical masculine bodily expectations. Another way in which the theme of food emerged pertains to male diabetic tiktokers offering recommendations on diet, cooking, and food consumption. Specifically, they show “light” recipes that enable the enjoyment of tasty cuisine while simultaneously managing diabetes and maintaining glycemic equilibrium. A pertinent exemplar comes from @lucaromanoyt, who

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frequently delves into “fit recipes” within his videos. He frequently employs TikTok’s “stitch” function to show other creators’ recipes alongside his own efforts to replicate them. In a particularly illustrative video, @lucaromanoyt is with his girlfriend in his kitchen. The scene develops as he decides, almost as a challenge, to transform a seemingly mundane ingredient—white rice—into an appetizing meal, all the while adhering to his dietary rules, albeit here the focus revolves around his and her muscle-building. The verbal exchange encapsulates a noteworthy shift in traditional gender roles as he confidently asserts, “I will show you that I can make a good risotto for constructing your muscles,” showing his culinary prowess in this way. Throughout the video, he shows his engagement in every step of the cooking process, from the meticulous preparation of ingredients before the cooking to the final presentation of the risotto to his girlfriend. As the video culminates with his girlfriend’s endorsement of the dish, a reverse of conventional gender dynamics becomes evident, although his role remains that of culinary “expert.” In cases such as this one, while engaging in the presentation of “fit” recipes, the potential for demasculinization is defused through the motivation underlying this practice. The ultimate aim, in fact, revolves around a bodily transformation aimed at embodying traits aligned with the contours of hegemonic masculinity, such as attaining a muscular body. This aspect is intrinsically linked to the display of his well-defined musculature. Indeed, akin to findings in other research on masculinity performances in online spaces (Jensen, 2023), the exhibition of a muscular physique functions as a form of “evidence.” In fact, his visual display underscores that his commitment to dietary choices and consumption patterns is sufficiently aligned with the hegemonically masculine norms underpinning it. In some cases, diabetic tiktokers displayed transgressing from  strict dietary regimens,  involving the consumption of less healthy foods “despite” diabetes. This usually is a temporary transgression, most of all observable when they experience hypoglycemia—a condition marked by low blood sugar levels. During episodes of hypoglycemia, managing blood glucose involves consuming rapidly digestible sources of sugar, such as soft drinks or fruit juice, as well as slower-releasing sources such as crackers, cheese, or sandwiches. In fact, the sense of hunger intensifies during hypoglycemic episodes, making unrestricted eating more socially acceptable and legitimate. For example, a video by @edoardoprete_csw portrays a typical episode of hypoglycemia: it commences with him exhibiting signs

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of weakness and discomfort, evident in his pained facial expression. This scene is followed by a shot focusing on the glucometer’s display, revealing a low blood glucose level along with the message, “Hypoglycemia imminent and urgent. Act immediately to prevent it.” The final scene centers on him, as he opens the refrigerator in search of food, with a smile. The caption accompanying this scene reads, “Only diabetics will understand.” The act of self-indulgence in food consumption is predominantly portrayed as temporary, also is depicted outside the realm of hypoglycemic episodes. The practice of occasionally granting oneself a culinary delight, although situated within the context of a balanced diet and good glycemic equilibrium, engenders the construction of a self-representation that embodies rationality and control while, simultaneously, manifesting a transgressive and risk-taking attitude, because resisting the diet prescriptions entails potential health risks for diabetic men. An illustrative case can be found in a video posted by @tolodiabete. He shares a screenshot showing his glycemic trend throughout the day. Accompanying this visual representation is a caption that reads, “when you’ve experienced nearly impeccable glycemic levels all day.” The resonance of this initial visual and textual composition provides an overarching context. Subsequently, the focus of the video shifts to the tiktoker himself, while consuming a chocolate ice cream, accompanied by song lyrics, “I’ve fallen into the trap once again.” An additional example is presented by @eliafavorido, who shared a video wherein he indulges in a hamburger, accompanied by a side of chips, and a beer—a representation of quintessential “junk food” (see Fig. 7.3). Employing a characteristic feature of TikTok, known as the Face Inset, he employs this tool to display the glycemic monitor, which blinks and smiles. This visual effect is paired with the caption “I’ve got this” and “don’t worry.” Then, he looks at the empty dish after eating, while lip-syncing “Ok, I believe you,” derived from the song “Jump In the Line” by Harry Belafonte. Subsequently, the scene shifts to him walking outside the restaurant, enacting a scenario wherein the glycemic sensor beeps (signaling an alert regarding glycemic levels being out of range), and he displays a scared and surprised facial expression. In fact, food transgressions often lead to hyperglycemia, characterized by elevated blood sugar levels. TikTok offers distinctive features for creating videos, with one prevalent approach involving the integration of a clip with an explanatory caption. An example regarding diabetes and food is provided by @eliafavorido, who employed a well-known clip from “The Office.” In the clip, the protagonist, Michael Scott, arrives in his red car,

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Fig. 7.3  Screenshot illustrating food transgressions in a diabetes diet regimen

gazes into the camera, and declares, “It’s Britney, bitch, and I’m back!” This clip is accompanied by the caption, “My blood sugar increases every time I eat pizza.” This example illustrates well how TikTok features can influence men’s narrates of diabetes, in this case relying on a hybrid depiction of masculinity: on the one hand, there is Michael Scott, manager of a company, dressed in jacket and tie. On the other hand, first the reference

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linked to pop culture, particularly concerning Britney Spears, and secondly the attention to the increase in glycemia after eating both point to an hybridization to the display of masculinity. Another prevalent compensatory manhood act (Schrock & Schwalbe, 2009) observed in the self-representations of diabetic men involves self-­ administering insulin, using an insulin pen, during or after a meal while in the company of non diabetic  others. This practice, possibly one of the most stigmatized diabetes self-management ones, functions as a compensatory manhood act by transforming a health-related practice into a sign of bravery, a form of provocation to observe the reaction of others who are unaware of how diabetes management works. It serves to demonstrate that not only do they have no fear, but also there is a conscious and active choice to engage in an act of diabetes visibility—one that also aims to raise awareness about the condition. An illustrative example is a video that was constructed in such a way that it resembles a candid camera format, featuring a diabetic tiktoker dining with friends at a restaurant (see Fig. 7.4). During the course of the meal, the tiktoker administers an insulin injection into his abdomen using an insulin pen. This action prompts the camera to zoom in on the visibly surprised expression of his (male) friend seated beside him. A voice, belonging to a second  (male) friend in the background, asks, “What are you doing? Are you shooting yourself up?”—followed by laughter. The video caption, “My friend’s face?” accompanied by a laughing emoji, underscores the deliberate intention to elicit a reaction and to demonstrate his  audacity. Below, a screenshot from the video in question provides a visual representation: 7.1.4   Being Tough and Vulnerable: The Display of Emotions in Male Diabetic Creators Arlie Hochschild’s (1979) seminal work allows consideration of individuals’ emotional expressions and experiences in connection with their broader social rules and expectations associated with their roles in society. Men and women, she posits, internalize and follow specific feeling rules, culturally defined norms that prescribe which emotions are appropriate to feel and to express according to different social situations. Men’s emotional displays are thus mediated by societal expectations around masculinity, and Connell (1995) in this regard observes that the most idealized form of masculinity, hegemonic masculinity, often entails emotional restraint and toughness, shaping men’s actual emotional experiences. As Sassatelli and

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Fig. 7.4  Screenshot of self-injecting insulin in public

Ghigi (2024) observe, women are often encouraged to experience and express emotions such as fear and sadness, whereas men are expected to con-ceal these feelings, favoring emotions such as anger and pride instead. Emotional displays are thus to be considered as gendered, as a way of doing gender (de Visser et al., 2009; West & Zimmerman, 1987). Diabetes entails dealing with an uncertain body, with its ups and downs. It implies dealing with social stigma, with different forms of physical pain (related, e.g., to daily insulin injections, or needles applications for the use of the insulin pump, or sensors, or the pain related to diabetes’

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complications). Living with diabetes often also implies the fact of being at the mercy of one’s glucose levels, which frequently without necessarily a clear reason might lead to hyperglycemia or hypoglycemia, both statuses requiring stoppage of daily activity, affecting what a man can do as well as how he feels, with the risk of fainting or even diabetic coma. Interestingly, despite all the implications of diabetes and its symptoms, in the vast majority of tiktokers’ self-representations no clear emotions were displayed. Creators’ expressions remained mostly neutral, their tone of voice flat, and their movements calm and measured. The creators in the sample sample in the majority of cases provided a very confident representation of themselves, controlling their facial expressions when injecting insulin with the pen/syringe or applying the glucose sensor. An illustrative example in this regard is that of @diabetiamo2.0, who in two videos explicitly exhibits his confidence and addresses—and tries to contrast with—the “syringe fear” of others: When the video starts, he appears to be in his bathroom, wearing an undershirt. In his right hand, he holds the insulin pen, which he prominently displays in the foreground of the video. “This is the needle,” he states, removing the pen’s cap and revealing the needle while placing his other hand behind it to provide better focus. “Do you see the tiny needle? It measures 3.5 millimeters. This is insulin,” he explains, showing the pen’s bottom. “Here’s how I do it,” he adds as he positions the pen against his tattooed bicep, mimicking the injection gesture. [The video is divided into two parts due to platform time constraints. It continues in the second part] “What are you afraid of? It’s only a tiny syringe!” He exclaims vehemently. “3 millimeters! No blood comes out, no splatters of blood!” (…)

The act of not showing fear and instead displaying courage and competence enables the accumulation of masculine capital (de Visser et  al., 2009), as those are dimensions relevant in the construction of hegemonic masculinity. Taking distance from “fear” is a commonly recurring theme in diabetic men’s videos. Another illustrative example comes from @edoardoprete_csw, who shared a video of himself working out at the gym, accompanied by the caption “Who taught you not to be afraid anymore?” (see Fig. 7.5). In the second part of the video, in response to this question, he displays an image of himself in the hospital during his initial hospitalization after diabetes’ onset, with the explicative caption “him.”

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Fig. 7.5  A screenshot depicting a Tiktoker’s disengagement from the realm of fear

On the other hand, in a minority of cases, male diabetic creators have conveyed some type of emotion. One specific type of emotion frequently displayed is anger. For instance, @lucaromanoyt distinctly exhibited rage with verbal and non-verbal communication in a video in which he records himself while responding to a comment from someone who has insinuated that, due to his insulin intake, he might possess some form of advantage in athletic performances respect to those of non-diabetic individuals:

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The video commences with a close-up shot of him, dressed in a hoodie, appearing to be indoors. His demeanor portrays evident rage: his brow ­furrows, his eyes narrow, and his right hand engages in the typically Italian gesture of closed fingers lightly tapping one another, moving back and forth. His voice carries a tense tone as he questions, “What the hell are you saying? What kind of fucking question is that?” Subsequently, in the video is the caption, “When they ask me if, given that I’m diabetic and I take insulin, I improve more than a healthy individual.”

Rage manifested particularly strongly also in another case. In a video, @ tolodiabete recounts an incident through a caption in which someone suggested he try alternative medicine because, as they put it, “Somebody’s grandmother had been cured of diabetes with cinnamon and oregano infusions.” Type 1 diabetes is an immune disorder that cannot be cured, and this comment clearly triggers his anger. Employing a common TikTok feature, he responds by lip-syncing to a song with explicitly violent lyrics, which go as follows: “You are a fucking bitch, I feel like killing you by stabbing you and then splash around your blood.” Among the analyses, this video stands as the sole instance in which such aggressive language emerged. While this video does not represent the broader sample, the mere act of posting it under the guise of irony already offers insight into the pervasive incorporation of sexism and gender-based violence. This integration is so deep-rooted that the tiktoker might not fully be aware of the extent of the harm it may cause or grasp how extensively such violent language is considered as acceptable. In a minority of videos, discussing diabetes also involved sharing one’s emotional states connected to their glycemic levels. It  is interesting to note how, in this regard, this phenomenon has manifested in certain cases through distinct features of social media platforms—rather than employing words and narratives, it has been shaped through the use of memes. It is the case, for example, of @eliafavorido (see the screenshots in Fig. 7.6) who puts in a sequence a combination of pictures that display different glycemic trends (glycemia going up, going  down, or staying  stable), to which he matches different types of music (energetic when the glucose level is ok, dramatic when it is too high, etc.) and different facial expressions for each one of the pictures. Finally, another aspect pertaining to the display of diabetic men’s emotional status concerns the act of performing hypoglycemia within their own videos. This entails showing the frustration and disappointment stemming from the sudden impossibility of continuing what they were doing, which

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Fig. 7.6  Screenshots of emotional statuses expression in relation to glycemic trends

is  usually physical activity. This aspect holds significance within a gender perspective as it unveils not only robust and resilient male bodies but also a display that embraces men’s vulnerability. It underscores the notion that at times, acknowledging one’s own fragilities is inevitable. An illustrative example is that of @edoardoprete_csw, who in a video shows a picture of himself looking tired and weak while working out at the gym. It is accompanied by the caption “Me: today it will be a good training. Glycaemia: are you sure?” In the next picture, the display of the glucometer indicates that he is experiencing hypoglycemia. Something similar is also found in a video of @lucaromanoyt wherein he sits in the gym, after interrupting his exercise, looking sad. In his hand, he holds a glycemic sensor, and the caption accompanying the video states, “The most dreadful thing ever.”

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Another interesting case is that of @tolodiabete, who shared with his potential audience how he feels when he is “in hypo.” Initially  in the video, he measures of glycemia using a sensor, with the caption “When you measure the glycaemia, and you are in hypo.” Subsequently, he turns his gaze toward the camera, employing the image distortion effect (see Fig. 7.7). Concurrently, he articulates the phrase “We have a problem, for God’s sake.” By using a voice-changing affordance provided by the platform, this amalgamation of elements serves to encapsulate a narrative that resonates with both personal experience and a sense of shared concern. Fig. 7.7  Showing vulnerability through digital narratives of hypoglycemia

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7.2  Conclusion The findings of this exploratory study on diabetic men’s self-­representations on TikTok point to the emergence of hybrid forms of masculinity. Despite the traditional hegemonic ideals of masculinity that historically prescribed men to exhibit indifference toward practices related to their health and physical appearance, the content creators analyzed in this sample, through their digital illness stories, not only display a general adherence to therapeutic recommendations but also emphasize elements once considered feminine or feminizing, such as dieting and adopting skincare practices. Furthermore, the specific affordances that characterize the platform as well as the shared communicative rituals that emerge from the production of video contents highlight the emergence of softer masculinities, that encompass for example the act of dancing and singing in videos. This specificity introduces expressive and communicative features not conventionally considered masculine. Through the analysis, three primary areas emerge in which elements of hegemonic masculinity intertwine with other traits traditionally considered feminizing, creating space for hybrid ways of performing masculinities. These areas are as follows: the display of the diabetic body, the presentation of dietary habits, and, ultimately, displays of men’s emotional statuses. On one hand, the videos portray in the majority of cases a presentation of athletic, muscular, hyper-masculinized bodies, put forth as “evidence” of their ability to embrace specific disciplinary technologies and exhibit self-discipline, rationality, self-control, and ability to manage their condition. On the other hand, elements interweave and suggest a hybrid form of masculinity. Many creators exhibit themselves moisturizing their skin and offering advice to others on preventing skin dryness. Another domain where the ambivalence between traditional ideals of hegemonic masculinity and more hybrid forms of masculinity intertwine is dietary choices. Generally, the tiktokers under analysis adhere to medical recommendations for healthy and controlled eating, often providing their viewers with advice on “light” recipes. This practice, traditionally considered feminine and associated with food deprivation and the pursuit of a slender physique, is particularly noteworthy. What emerges as intriguing is that, in many cases, the promotion of “light” eating is complemented by another purpose beyond diabetes management, namely, facilitating muscle mass development through reduced intake of carbohydrates and use of proteins. This highlights how the boundaries between the adoption of new forms of

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masculinity blur and intertwine with ideals of hypermasculine and muscular body construction. It is essential to underline, however, that this reframing of potentially stigmatized activities, it legitimizes, in any case, a healthy lifestyle. This lifestyle is oriented towards maintaining one’s health and avoiding or delaying the onset of severe complications associated with the illness.Finally, a final theme that has emerged as significant, further confirming the interweaving of hegemonic elements of masculinity with the emergence of hybrid masculinities, pertains to the display of emotions. While, on one hand, the majority of tiktokers exhibit confidence and indifference to the risk or fear of pain or disease-related complications, in a minority of cases, some content creators openly express their emotional statuses and vulnerabilities. This represents a partial distance from traditional stoic masculinity toward a more emotionally expressive form of masculinity, aligning with the trend in the literature of emerging forms of hybrid masculinities.The copresence of potentially stigmatizing/feminizing and hyper-masculinizing practices can be interpreted as a form of symbolic capital negotiation, in which individuals navigate and adapt to changing norms and expectations related to masculinity while managing their disease and ensuring their well-being and social acceptance.

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Mallyon, A., Holmes, M., Coveney, J., & Zadoroznyj, M. (2010). I’m not dieting,‘I’m doing it for science’: Masculinities and the experience of dieting. Health Sociology Review, 19(3), 330–342. Marshall, K., Chamberlain, K., & Hodgetts, D. (2020). Male bodybuilders on Instagram: Negotiating inclusive masculinities through hegemonic masculine bodies. Journal of Gender Studies, 29(5), 570–589. https://doi.org/10.108 0/09589236.2020.1722620 Miltsov, A. (2022). Researching TikTok: Themes, methods, and future directions. In The SAGE handbook of social media research methods (pp. 664–675). SAGE Publications Ltd. Newcombe, M. A., McCarthy, M. B., Cronin, J. M., & McCarthy, S. N. (2012). “Eat like a man”. A social constructionist analysis of the role of food in men’s lives. Appetite, 59(2), 391–398. Potts, A., & Parry, J. (2010). Vegan sexuality: Challenging heteronormative masculinity through meat-free sex. Feminism & Psychology, 20(1), 53–72. Scarcelli, C.  M., & Lovari, A. (2022). Pratiche comunicative di salute LGBT e social media: una ricerca esplorativa su TikTok. Salute e società, XXI(2), 67–83. Schrock, D., & Schwalbe, M. (2009). Men, masculinity, and manhood acts. Annual Review of Sociology, 35, 277–295. Sassatelli, R., & Ghigi, R. (2024). Body and gender. Polity Press. Stagi, L. (2016). Food porn. L’ossessione del cibo in TV e nei social media. Egea. Svalastog, A. L., Blaakilde, A. L., Ringstad, Ø., & Lamerichs, J. (2021). Narrative genre and health in the digital society. In Navigating digital health landscapes: A multidisciplinary analysis (pp. 15–42). Palgrave Macmillan. TikTok Statistics. (2023). TikTok statistics. Updated Aug 2023. Retrieved August 8, from https://wallaroomedia.com/blog/social-­media/tiktok-­statistics/ Tshuma, N., Aboulela, S., Chowdhury, F., Macken, L., Kamperidis, N., Goodhand, J., & Lindsay, J. (2012). OC-159 Content analysis of illness blogs posted online by patients with IBD. Gut, 61(Suppl 2), A68–A69. Van Dijck, J. (2013). ‘You have one identity’: Performing the self on Facebook and LinkedIn. Media, Culture & Society, 35(2), 199–215. Wamsley, K. (2007). Boxing, masculinity and identity: The ‘I’ of the tiger. Gender Forum, 19, 306–307. West, C., & Zimmerman, D.  H. (1987). Doing gender. Gender & Society, 1, 125–151.

CHAPTER 8

Conclusions

As we reach the end of this journey, which has enabled us to observe different ways of “doing masculinities” within the context of chronic illness, we will briefly review the research  findings that have been presented throughout this volume. Subsequently, research limitations will be discussed, with a reflection on the contribution that the present study aims to provide to the literature and its practical implications. Both studies showcased in this volume center on the experiences of men living with diabetes and their illness narratives. In both cases, the research endeavors were driven by the aim of exploring how gender intricately interweaves with the realms of health and illness within these narratives, thereby shaping the significance attributed to practices associated with the management, or mismanagement, of this condition  The primary finding common to both studies  on which this book draws, that emerged from the analysis of in-depth interviews and video content generated and shared on the TikTok platform is that, contrary to commonly held assumptions, we cannot reduce the relation between masculinity and men’s health to the homogenizing hypothesis that all men forsake health-related practices to align with conventional constructs of manliness. As other works grounded on Critical Studies on Men and Masculinities have shown (Gough &  Robertson 2009), the situation is more complex and deserves a more in-depth exploration, transcending the

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simplistic binaries of health practices adoption versus rejection, and the reductive conception of “masculinity” as a fixed and monolithic dimension. A second relevant finding contradicts the prevailing stereotype—commonly found also in the academic literature—asserting that men are reticent about discussing their health and refrain from sharing their experiences of illness. Just as previous studies have claimed (Robertson, 2007; Emslie et al., 2006; Oliffe & Mròz, 2005), when presented with the appropriate context and conditions, men not only engage in these discussions but also exhibit a capacity for critical reflection upon their own health-related experiences. Overall, the analysis of diabetic men’s illness stories reveals the complexity of the relationship between the doing of masculinities and the doing of health in the context of chronic illness. Adopting health-related practices linked to diabetes self-management, the meanings associated with these practices, the decision to talk about them or not, to display the utilization of medical devices or not, and the extent to which these choices are made, appear to be contingent on factors beyond the singular dimension of being, or not, a man. To better understand this complex relation, it is crucial to consider first the cultural meanings associated with health-­ related practices and masculinity in different social contexts. Furthermore, in addition to the symbolic meanings associated with health practices and their impact on one’s presentation as a “man,” it is vital to consider the “material” constraints and the economic and cultural resources one possesses, which can also change through time. These factors inevitably influence the ability to, on the one hand, access specific health technologies (for instance, not everyone has free access to diabetesrelated technologies or a comprehensive understanding of how they work), and, on the other hand, to freely choose whether, how, and when to adopt diabetes-related health practices. An exemplary case in this regard involves an interviewee who recounted a compelling episode from his past. Due to his involvement in informal manual labor and the risk of job loss associated with his diabetes diagnosis, he could not measure his blood glucose levels, administer insulin, or  adopt a healthy diet publicly, as it would have resulted in unemployment and a lack of means for his sustenance. Therefore, as the analyses presented in this work demonstrate, when examining the relationship between gender and health, it is essential to employ an approach that considers all the dimensions involved—such as the economic and cultural capital and the social context within which individuals are situated. This aspect is particularly evident in the first

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research presented, which adopted a  qualitative  approach and  whose results are detailed in Chaps. 4, 5, and 6. More specifically, the qualitative research engaged 40 diabetic men through in-depth interviews. Overall, it has generally been observed that the emergence of a serious chronic illness tends to challenge men’s masculine selves (Charmaz, 1994: 270), but this does not necessarily imply a uniform engagement in unhealthy behaviors to reaffirm and showcase manhood. On the contrary, diabetic men in the study tended to embody illness and adopt distinct disciplinary technologies (Foucault, 1984) that enabled them to resignify health-related practices, effectively neutralizing their potential feminizing and stigmatizing aspects while accentuating hegemonic traits of masculinity. As we have seen in previous chapters, the management of diabetes allows for the examination of health practices in contexts highly significant for the enactment of masculinity. These include dietary habits, physical activity, selfmonitoring, and self-care practices in the daily management of the illness. The core assumption is that the construction of masculinity constitutes a dynamic and fluid process and an interplay of elements, including the incorporation of the prevailing ideals of masculinity, delineated by Connell as hegemonic masculinity, as well as other factors that may reshape its boundaries. In particular, the identification of three distinct ideal types that emerged from the analysis of interviews highlighted the potential stigmatization of health practices perceived as “unmasculine” and the stigma associated with the inability to conform to the dominant ideals of male bodily representation. This led diabetic men to use various compensatory manhood acts (Schrock and Schwalbe, 2009), which predominantly depended on participants’ socio-­demographic backgrounds. These compensatory practices were employed to maintain the construction of successful diabetic masculinity and discursively acquire masculine capital (de Visser et al., 2009). The three main ideal types are: the “Tracker,” the “Athlete,” and the “Free Spirit.” For the “Tracker” ideal type, discourses around diabetes self-­monitoring practices, such as measuring blood glucose and dietary tracking, served a dual purpose. These practices were not merely descriptive of their daily self-management routines; instead, they were strategically emphasized and functioned as a discursive technique to portray their competence, rationality, and a profound understanding of techno-scientific and biomedical knowledge. This worked to construct a representation of health-related practices that were consistent with the ideals of hegemonic masculinity.

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The findings indicate that the (gendered) interpretations attributed to self-tracking and self-monitoring practices were influenced by the participants’ socio-demographic backgrounds. When examining the narratives described by “the Tracker,” a prevalence of participants possessing elevated cultural capital and hailing from middle-class backgrounds became evident. This ideal type depicts a diabetic man who possesses the cultural and economic means to uphold and sustain his health status. Concurrently, he has the avenue to engage within social networks where the integration of self-quantification health practices is held in high regard as a valued masculine attribute. Likewise, the “healthy lifestyle” and rigorous body self-discipline displayed by the ideal type of the “Athlete” are not only displayed to describe how they manage diabetes; these practices are emphasized and inscribed in a disciplinary regime of practice that is “legitimized” in the pursuit of constructing a strong, athletic physique that accentuates prevailing male attributes like competitiveness, physical prowess, resilience, endurance, and independence. In accordance with prior investigations dedicated  to sport and male physiques (Messner, 2005; Robertson et  al., 2013; Seymour, 1998), sport emerged in this ideal type as a pivotal arena of practices for constructing masculinity. Reflecting on the relevance of cultural and social context, all individuals whose narratives can be described by this ideal type indeed possessed the necessary social and economic capital to commit time and resources to competitive sports and training. The last ideal type that emerged from the analysis has been labeled as the “Free Spirit.” In this case, the potential for stigma and demasculinization connected to diabetes-related health practices was counterbalanced by the participants’ emphasis on resistance to the lifestyle prescribed by diabetologists. In fact, instead of engaging in constant self-tracking and monitoring practices, healthy eating, and regular treatment administration, they reported privileging pleasure without restrictions in eating and freedom from diabetes-related constrictions. This form of resistance also carries a gendered dimension. These discursive acts are in line with a performance of “young” masculinity, connected to hegemonic ideals of autonomy, resistance to pain, and an inclination for risk-taking. Often, participants represented by this ideal type perceived a commitment to a healthy and hyper-monitored lifestyle as having feminine connotations, which led them to employ irony as a discursive strategy to establish a symbolic distance from this realm.

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The three ideal-typical configurations of gender and health practices in the context of chronic illness outlined above underscore a plural understanding of masculinity which is consistent with Connell’s (1987, 1995) theorization of masculinities and reinforces the notion that men, across their life course, might interpret the experience of illness in different ways, depending on their age and culture. These interpretations are contingent upon their embodied gendered habitus (Bourdieu, 1984, 1990) and the meanings ascribed to health-related behaviors within diverse social contexts. The findings of the second study also point to a complex understanding of masculinities in relation to health and illness. In particular, the research aimed to analyze through digital research methods the self-representations of diabetic men talking about diabetes in their digital illness narratives on TikTok. From the analysis of 100 videos produced by seven diabetic male content creators, three main areas emerged as relevant, where elements of hegemonic masculinity intertwined with other aspects that are traditionally considered marginalizing, thus creating space for new and hybrid ways of performing diabetic masculinities. The three areas of concern are: the display of male diabetic bodies; the presentation of food consumption practices; and, lastly, the display of men’s emotional statuses. Contrary to traditional hegemonic ideals that historically prescribed male indifference toward health and physical appearance, content creators within the sample adhere to therapeutic recommendations and stress the elements once deemed feminine, like dieting and skincare practices. Furthermore, the distinctive features of the TikTok platform and its associated communicative rituals give rise to softer masculinities, evident in activities such as dancing and singing in self-recorded videos. This introduction of expressive and communicative features challenges dominant notions of masculinity. On one hand, videos often present hyper-masculinized bodies as proof of self-discipline and self-control, while simultaneously endorsing softer aspects such as skincare routines. With regard to the second theme about dietary choices, content creators usually display the adoption and promotion of healthy and “light” eating, but at the same time they often framed food-related practices as a discipline useful to the development of muscle mass, more than to diabetes management, and this configure a hypermasculine trait. Lastly, the display of emotions represents a shift from stoic masculinity to a more emotionally expressive form. Although they were a minority, some creators openly revealed their vulnerabilities, aligning with the trend of emerging hybrid masculinities in the broader

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literature. The coexistence of potentially stigmatizing or feminizing practices alongside hyper-masculinizing ones can be viewed as a negotiation of symbolic masculine capital. Diabetic men navigate evolving norms and expectations related to masculinity while managing their illness and securing social acceptance and overall well-being. Echoing Demetriou’s (2001) concept of hybrid masculinity,  this ambivalence points to the fact that men can “do” health while “hybridizing” their performances of gender. This is achieved through the incorporation and reinterpretation of practices associated with health and diabetes, without explicitly contesting the legitimacy of the traditional gender order. The results of this study help to reflect on more broad changes in masculinities. Given the enduring presence of consistent gender inequalities and the enduring influence of virilism, Italy stands as a pertinent empirical milieu for investigating cultural enactments of masculinity. Clearly, if the hybridization of hegemonic masculinity occurs within a social and cultural context characterized by high social expectations around traditional conceptions of masculinity, one can reasonably deduce that this phenomenon is even more pronounced in countries where such expectations hold less impact. This work has inevitably its limitations. First, since it has been primarily concerned with one chronic illness, autoimmune diabetes, it is not possible to extend the predictability of the findings (Cardano, 2020) to chronic conditions more generally. However, this methodological decision has allowed access to the complexity of experiences within the same illness, which is usually considered in quite a homogeneous way. Future research centered on the intersection of masculinities and chronic illness could contemplate a comparative study encompassing illnesses of varying degrees of impact on daily life and distinct challenges to masculinity. Within the realm of research employing digital methodologies, a more comprehensive exploration could be pursued, for instance integrating a mixed-­ method approach. This might involve engaging in interviews with content creators to glean a deeper comprehension of the significance that platforms like TikTok held for them, particularly concerning the sharing of experiences related to illness and the construction of  their self-representation. Notwithstanding the intrinsic limitations of this study, its findings offer valuable insights and practical implications. Firstly, the dimension of gender in healthcare delivery, particularly within the realm of chronic illnesses, represents a dimension of significance that has received limited attention.

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This dimension deserves increased consideration, particularly concerning the doctor-patient relationship and communication. This would be useful in the personalization of healthcare responses and in enhancing therapeutic adherence over time. For instance, we can consider the case of a diabetic man who might feel uncomfortable carrying a pink bag containing glucose monitoring and administration equipment. Such discomfort can result in therapeutic non-compliance. This is not merely an illustrative example, but a real-life scenario revealed during an interview. An interviewee reported neglecting diabetes management for years to avoid the stigma associated with the bag’s feminine connotations, considering it emasculating. In an attempt to project strength, autonomy, and a “healthy” and “sufficiently masculine” image to others, this man chose to forego diabetes care. As explained throughout this book, gender norms do not affect everyone uniformly, nor exert an identical influence on health practices. In accordance with a Connellian approach to gender, masculinity constitutes different configurations of practices, including health practices, that vary depending on an individual’s social context and life stage. By recognizing the influence of diverse gendered configurations of practices on health outcomes and inequalities, general practitioners and healthcare providers can refine their interactions with male patients. By doing so, they can foster enhanced adherence to treatment regimens.For instance, when deciding whether to suggest using the glucose sensor, the choice might depend on how patients see these devices and related practices, like what they symbolize and how they relate (also) to their gender identities. Moreover, it is important to reflect on the specific social context where these decisions are made: for example, the situation is different for a manual informal laborer who works in a construction company, where the visibility of an illness could cost him their job, from that of a tenured university professor who experiences more freedom and fewer consequences. Furthermore, it is worth noting that family doctors and healthcare providers have the potential to promote a model of masculinity that supports gender equality rather than reinforcing inequalities, especially considering that women often still bear the burden of caregiving responsibilities. For instance, they could encourage men to take a more active role in looking after their health. This challenges the idea that caregiving is something only women do, especially in everyday practices. Finally, promoting positive masculine models is crucial, both at the cultural level, for example in media representations, that at the interpersonal level for example in the doctor-patient  relationship, where this  could be fostered by

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listening to patients’ stories, allowing emotional expressions, and empower men by giving them the instruments to be autonomous in diabetes self-­ management and suggesting them to join, for example, self-help groups of men experiencing the same condition in online and offline contexts. The emphasis posed on the more “micro” practices within the discourse surrounding health, as analyzed in the illness narratives of diabetic men, encourages those engaged in healthcare research and practice to go beyond the biomedical model and underscore the value of recognizing the social and cultural dimensions intertwined with the enactment of health in everyday life. 

References Bourdieu, P. (1984). La Distinction: Critique Sociale du Jugement. Les Editions de Minuit. Bourdieu, P. (1990). The logic of practice. Polity Press. Cardano, M. (2020). Defending qualitative research. Design, analysis and textualization. Routledge. Charmaz, K. (1994). Identity dilemmas of chronically ill men. The Sociological Quarterly, 35(2), 269–288. Connell, R. W. (1987). Gender and power: Society, the person and sexual politics. Stanford University Press. Connell, R. W. (1995). Masculinities. California University Press. De Visser, R. O., Smith, J. A., & McDonnell, E. J. (2009). That’s not masculine: Masculine capital and health-related behavior. Journal of Health Psychology, 14(7), 1047–1058. Demetriou, D.  Z. (2001). Connell’s concept of hegemonic masculinity: A critique. Theory and Society, 30(3), 337–361. Emslie, C., Ridge, D., Ziebland, S., & Hunt, K. (2006). Men’s accounts of depression: Reconstructing or resisting hegemonic masculinity? Social Science and Medicine, 62(9), 2246–2257. Foucault, M. (1984). Docile bodies. In P. Rabinow (Ed.), The Foucault reader. Pantheon Books. Gough, B., & Robertson, S. (Eds.). (2009). Men, masculinities and health: Critical perspectives. Basingstoke, UK: Palgrave Macmillan. Messner, M. A. (2005). Still a man’s world? Studying masculinities and sport. In M. S. Kimmel, J. Hearn, & R. W. Connell (Eds.), Handbook of studies on men & masculinities. Sage Publications. Oliffe, J., & Mròz, L. (2005). Men interviewing men about health and illness: Ten lessons learned. Journal of Men’s Health and Gender, 2(2), 257–260.

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Robertson, S. (2007). Understanding men and health: Masculinities, identity and well-being. McGraw-Hill Education. Robertson, S., Zwolinsky, S., Pringle, A., McKenna, J., et al. (2013). “It’s fun, fitness and football really”: A process evaluation of a football-based health intervention for men. Qualitative Research in Sport, Exercise and Health, 5(3), 419–439. Schrock, D., & Schwalbe, M. (2009). Men, masculinity, and manhood acts. Annual Review of Sociology, 35(1), 277–295. Seymour, W. (1998). Remaking the body: Rehabilitation and change. Routledge.

Afterword: Bodies, Selves, and the Social Order

Roberta Sassatelli University of Bologna, Italy In contemporary sociology there has been a growing awareness that our bodies are important objects of sociological study. Sociology has questioned the epistemological status of the biomedical framework, thus opening up the space for exploring the social and political implications of bodily representations and practices. We are increasingly aware that our bodies are constructed. Such awareness partly derives from the way our bodies have become salient in contemporary societies and from the way societies depend on fashioning bodies as well as selves: aging populations, a new gender balance, the increasing possibility of body modification and representation, and the development of self-monitoring devices are but a few of the many phenomena that have highlighted the deeply intertwined nature of body and society. Social constructivism has spread its wings across the wide variety of bodily experience. Human bodies have been seen as clay, molded by political and economic constraints. With an emphasis on the power effects of classificatory systems, bodies have also been conceived as symbols speaking of the place their bearers occupy within the social order as well as of what counts as order and disorder. Bodies have been described as texts, emphasizing not so much their metaphoric quality, but rather readership and persuasion, the power to create reality through

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interpretation and representation. The immateriality discerned in textuality has been amended by a notion of the body as practice, whereby the body is concretely realized in every everyday life. Along these lines, bodies have become cultural objects and their importance in the constitution of subjectivity has been foregrounded by the notion of embodiment. The social actor in fact is no longer seen, in contemporary social theory, merely as a cognitive operator, but as a fully embodied subject, who occupies time, space, and relations through several significant bodily practices. Together with bodily matters featuring in today’s political and cultural struggles, criticism of binaries such as culture/nature, body/mind, gender/sex, male/female, other/self has flourished. As calls for an embodied approach to social life have been multiplying, the embodied self has also been problematized. The body is always a tool and measure of the subject. We work on it to give ourselves a certain identity and all along it is telling other people about us. In other words, we use the body to position ourselves in society and, conversely, the body classifies us as we go about our everyday life and conform, or otherwise, to our roles in society. Considering identity, especially as it is related to masculinity and femininity, entails today more than ever understanding how self and body are co-constitutive and how embodiment is shaped by social practices, discourses, and institutions—in turn, contributing to reproducing, and at times challenging, practices, discourses, and institutions. A fundamental element for a sociological understanding of embodiment is to gain insight into subjective experiences and social practices. And this is particularly fertile if we consider health and illness and how they relate to the constitution of embodied subjectivity. If, in modernity, medical experts have acquired the right to approach the naked human body armed with a naturalistic rather than social gaze, the social and cultural dimensions are fundamental to understand how health and illness are managed by social actors. The medical, naturalistic perspective on the body never ceases to accompany us, and yet subjects receive and process medical wisdom in a variety of ways which relate to how they realize in everyday life practices their relation to their bodies and their experience of their bodies. Women’s health and illness has been scrutinized very closely by sociological and feminist studies, but there is now an increased awareness of how a perspective on men’s health and illness is fundamental to understand today’s embodied masculinity. Hegemonic masculinity is blatantly related to an image of perfect prowess and health. Chronic illness therefore represents a challenge for men as it may jeopardize their capacity

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to live up to society’s standards. Exploring the different ways in which men negotiate their masculinity after the onset of a chronic illness such as diabetes, this book has offered a fertile perspective on the many ways in which body and self may be related in everyday life. The detailed emphasis on self-­management practices helps us understand embodiment as a process. Rather than conceiving the body as a given, we thus have the possibility to capture the minute, ordinary practices through which bodies are continuously constituted. The process of embodiment is indeed ceaseless, requiring constant, if often habitual, actions on the part of subjects. And partly because of this it is in some ways always enmeshed with risk, change, and contestation. In the case of people with chronic illness this becomes ever more salient. Faced with chronic illness subjects are wounded selves: often fighting with the limits of their bodies and adjusting their bodies to the requirements of everyday life, constructing narratives and practices that nevertheless help sustain a self which may be adequate to the requirements of society. Their reflexive capacity to deal with their bodies and their limits, their need to come to terms with bodily failures and incorporate them into positive narrations of subjectivity, is particularly instructive about the process through which embodied subjectivity gets stabilized. Such processes are, as the pages of this book show very clearly, negotiational: they entail working on one’s own embodied experience in a dialogue with medical discourse, expertise, and technology, as well as an often-intricate web of everyday relations, with bodily capacities and vulnerabilities becoming the arena in which a sense of self, and a version of gender identity, gradually emerges. Gender identity is indeed tightly related to embodiment. Feminist thought has clearly shown this with respect to women, but embodiment is no less relevant for men’s selves. Masculinity, hegemonic or otherwise, can no longer be understood as disembodied, rational, ideal. It is a matter of flesh and blood. Men’s studies have revealed how muscles, for example, have been important in defining the dominant picture of masculinity, but other embodied aspects are so clearly significant to a perception of manhood. The capacity to be in control of one’s own body is typically associated with masculinity, and chronic illness poses a threat to such capacity. The management of illness, however, is also a crucial way to construct masculinity. The book documents with a wealth of qualitative detail three fundamental ways in which masculinity is constructed via illness management: a rational strategy, based on increased information control; a compensatory strategy based on developing the body’s sport and activity

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capacities; and a subversive strategy which tries to redefine the contours of the limits of the body. Each of these strategies requires a continuous management on the part of the subject that succeeds to gain a sense of self precisely by governing, in specific ways, the body and its limits. Bodies are indeed often portrayed as the limit to the self. As emerges from these pages, they are also the material onto which the gendered self is constructed. Rather than a natural, immutable given, the very ongoing negotiation and construction of the limits of the body are part and parcel of the constitution of gendered subjectivity. And experience is fundamental to that: experience in turn is realized through practices and discourses which construct what is natural, and ultimately moral, to gendered subjectivity. Gendered identities are indeed not neutral; they come together with scripts of action, emotion, and meaning which often work on our bodies and entail visions of moral agency. Ultimately work done one one’s own body is moral work: it constructs visions of subjectivity which we want to be appreciated, validated, and recognized. Embodied, gendered subjectivity is therefore fundamentally related to notions of the social and moral order; it contributes to constructing such social and moral order. The ordinary practices of illness and health management as well as the other bodily practices carried out by the men in this study speak of versions of the good life and the moral self. Wounded bodies may be reconstructed as wholesome in the work that subjects complete to take place in everyday life, their legitimacy and morality stressed precisely by the efforts through which embodied, gendered subjectivity gets stabilized. Gender indeed brings the social order to the core of embodiment. Despite the development of new gender identities, our world is still predominantly binary, with masculinity and femininity complementing each other and consolidating the social order as we know it. Illness opens a space for both the reproduction and the transformation of gender identity: on the one hand, resorting to dominant views of gender, the men in this study try to live up to received views of masculinity; on the other hand, precisely the predicament of chronic illness pushes them to redefine the meanings and qualities of masculinity in ways which are original and creative. The space which opens between self and body, a reflexive space which embodied subjects construct through their bodily practices, is a fertile, if ever changing and contested, space not only for subjectivity constitution, but also for the consolidation of society’s cement. In the minute practices of body management which consolidate masculinity through the difficulties of illness we see reflected the larger social and cultural processes which stabilize our reality and ultimately reproduce or challenge the social order.

Index1

A Athletes, 6, 7, 57, 66, 109, 111–128, 130, 132, 137, 187, 188 B Blood glucose levels, 85, 93, 122, 172 Bodily discipline, 44 Body/bodies, viii, 3, 7, 17, 18, 24–26, 28–30, 34, 35, 40, 44, 58, 71, 78, 86–89, 98–100, 102–105, 108–110, 112–114, 123, 124, 127, 128, 148–154, 159, 162–171, 175, 179, 181, 188, 189, 195–198 Body/bodily uncertainty, 39, 40, 44, 85, 86, 88, 104 Bourdieu, P., 32, 42, 108, 119, 144, 164, 189

C Changing masculinities, 33, 37 Chronic illness, vii–ix, 1, 6, 39–44, 53–71, 77–79, 85, 113, 117, 121, 135, 185, 189, 190, 196–198 Community of practice, 29, 32, 33, 88, 96, 112, 114, 123 Compensatory manhood acts, 43, 44, 86, 111, 128, 174 Complicit masculinity, 26, 27 Construction of gender/femininities/ masculinities, 7, 14, 19, 23, 32, 40, 41, 55, 72, 96, 112, 128 Control, viii, 6, 25, 30, 34, 35, 44, 55, 58, 65, 73, 76, 86–89, 92, 95, 98, 101, 103, 111, 112, 114, 115, 136, 140, 140n1, 149, 150, 153, 155, 172, 197 Critical Studies on Men And Masculinities (CSMM), 4, 6, 12, 17–23, 28–38

 Note: Page numbers followed by ‘n’ refer to notes.

1

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INDEX

D Demasculinizing practices, 43 Diabetes, viii, ix, 1–3, 5–7, 15, 41, 43, 44, 55–59, 57n1, 63–65, 67, 68, 71, 73, 74, 76–78, 85, 86, 88–105, 107–132, 135–155, 157–182, 189, 190, 197 Diabetic masculinity, 6, 44, 78, 86, 105, 112, 128, 154, 160–180, 189 Diet, 3, 26, 44, 98, 99, 101–103, 109, 115, 121, 122, 126, 129, 130, 136, 142, 144, 146, 155, 169, 170, 172 Digital health narratives, 71 Digital research methods, 6, 53, 189 Disease, 7, 13–15, 17, 35, 39, 41, 43, 53, 56, 58, 66, 73, 76, 77, 86, 89, 103, 104, 109, 111, 112, 114, 121, 129, 131, 136, 138, 141, 146, 149, 152, 159, 160, 164 Display, 7, 26, 43, 71–73, 74n2, 79, 92, 110, 111, 127, 137, 159, 162–172, 174–181, 189 E Embodiment, 24, 42, 56, 196–198 Empirical context, 6, 55, 56, 72 Empirical material, 62, 68, 71, 74, 113, 128 F Femininity/femininities, 1, 14, 19, 23–25, 27, 30, 32, 33, 67, 73, 87, 102, 108–110, 119, 128, 142, 155, 159, 169, 196, 198

G Gender gender and health, viii, 18, 28, 65, 189 gender hierarchy, 25–28, 30, 39 gender norms, viii, 15, 20, 21, 33, 44, 62, 104, 110 Goffman, Erving, 1, 2, 43, 68, 72, 94, 107, 113, 114, 125 H Habitus, 32, 42, 43, 76, 108, 119, 130, 144, 189 Healthism, 34, 35 Health-related practices/behaviors, 3, 32, 34, 38, 41, 55, 65, 73, 78, 138, 174, 189 Health risks, 20, 27, 29–31, 86, 136, 166, 172 Healthy lifestyle, 34, 35, 188 Hegemonic masculinity/masculinities, 4–6, 12, 23, 25–39, 44, 73, 76, 97, 102, 108, 110, 132, 135, 159, 164, 169, 171, 174, 176, 181, 189, 190, 196 Heterosexuality, 31, 76 Homohysteria, 37 Hybrid masculinity/masculinities, 29, 36, 37, 86, 105, 155, 159, 190 Hypoglycemia, 43, 44, 109, 114, 121, 148, 150, 166, 167, 171, 172, 176, 178–180 I Ideal type, 6, 7, 60, 86–89, 97, 111, 112, 130, 135–140, 147, 148, 150, 154, 187, 188 Identity, viii, 1, 14, 15, 17, 24, 25, 31–33, 39–42, 58, 62, 68, 71, 72, 77, 91, 116, 135–137, 139, 155, 159, 164, 196–198

 INDEX 

Illness, vii–ix, 1–8, 11–44, 53–71, 73, 77–79, 85, 86, 88, 89, 92, 94, 101, 105, 109, 110, 112–114, 117, 118, 121, 123, 125, 135–141, 143, 148–154, 158, 161, 166, 185, 189, 190, 196–198 Impression management, 113, 125 Inclusive masculinity, 37 Inequality/inequalities, 14–19, 22, 28–30, 36, 37, 42, 43, 190 Interviews, viii, 3, 6, 54, 55, 57–71, 86, 89, 93, 94, 99, 102, 103, 105, 111, 112, 117, 119, 124, 125, 127, 129, 135, 138, 140, 141, 145, 148, 150, 153, 187, 190 L Lay expert, 60, 89, 97–104 M Masculine capital, 41–43, 86, 102, 105, 108, 136, 142, 155, 159, 164, 176 Masculine ideals, 1, 30, 32–34, 110, 155 Masculinities/masculinity, vii–ix, 3–7, 11, 12, 14–20, 23–44, 53–73, 76–79, 85–105, 107–132, 135–155, 157–182, 188–190, 196–198 Men, vii–ix, 1–8, 11–44, 53–79, 85–88, 90, 91, 93, 95–98, 102–105, 108–112, 116, 119, 121, 123, 128, 130, 131, 135–139, 141–146, 148, 154, 155, 157–182, 187, 189, 190, 196–198 Men’s health, vii, viii, 1–8, 11–44, 53, 55, 59, 78, 87, 196

201

Methodological challenges, 62 Metrosexuality, 34 Muscled body/bodies, 3, 102, 164 N New man, 33, 86 P Physical activity, 43, 85, 109, 111, 115, 124, 128, 129, 136, 153, 164, 179 Physical strength, 3, 5, 31 Platform, 54, 71, 73, 77, 79, 87, 157–160, 162, 176, 178, 190 Power, 12, 18, 22–25, 28–33, 38, 42, 69, 76, 89, 94, 108, 110, 128–132, 195 Q Qualitative research, 6, 53–71, 187 Quantification of the self, 60, 86, 90–97 R Reflexivity, 62 Relational theory, 17, 23–31, 38, 39, 158 Research design, 56–61, 73–76, 159n1 Role theory, 21, 23, 25, 28 S Self-care practices, viii, 7, 44, 86, 168 Self-management, 2, 6, 7, 44, 77, 85, 86, 89, 90, 92, 97–104, 111, 115, 121–123, 125, 137, 141–143, 145, 150, 151, 153, 154, 163, 174, 197

202 

INDEX

Self-monitoring, 7, 44, 71, 86, 87, 95, 98, 100, 138, 141, 149, 150, 195 Self-representation, 6, 44, 54, 71–79, 103–105, 136, 137, 157, 160–180, 189, 190 Self-surveillance, 34, 88, 89, 137, 149, 152 Self-tracking, 6, 85–105, 109, 136, 188 Social interaction, 29, 42, 55, 62, 109, 112, 123, 128, 136 Social media, 6, 54, 57, 71–79, 157–159, 178 Sport/sports, 6, 7, 25, 26, 30, 34, 38, 42, 57, 66, 103, 107–132, 188, 197 Stigma, 37, 102, 105, 109, 123, 125, 126, 146, 154, 175, 188 Symbolic capital, 42, 43, 111

T TikTok, 7, 54, 71, 73, 76–79, 157–182, 189, 190 V Virilism, 56, 190 Vulnerable/vulnerability, 1, 13, 25, 26, 28, 30, 68, 102, 104–105, 108, 116, 174–180, 197 W Women, vii, 3, 4, 6, 11–23, 25–30, 33, 43, 53, 57, 61, 62, 66, 68, 69, 86, 87, 94, 96, 104, 105, 108, 128–130, 141, 142, 144, 158, 169, 174, 196, 197