Within any society, there can exist a hierarchy of masculinities that are compared to a dominant or hegemonic ideal [18]. In the United States, the normative form of hegemonic masculinity is defined by race (white), sexual orientation (heterosexual), SES (middle class), and possessing certain traits: assertiveness, dominance, control, physical strength, and emotional restraint [5, 9, 11]. Though it is useful to determine if men adhere to hegemonic ideals of masculinity, hegemonic masculinity does not have uniform meanings and negative influence within and across men’s lives [4, 11]. Masculinity is defined in diverse ways that vary by race, ethnicity, class, sexual identity, disability status, and other factors, but are organized around a common membership in the category of “man” [36].

Masculinity is often defined in relational terms as that which is not feminine [9, 43]. Measures of masculinity serve as the operational definitions of masculinity in empirical studies [11, 44]. How we operationally define masculinity in men’s health helps to determine how well we have captured gendered constructs that are relevant to health. We will briefly describe selected groups of measures of masculinity. Space does not permit an exhaustive review, but see reviews by Loue [45], Smiler [11], and Thompson [46] for a more thorough discussion of measures of masculinity.

The Male Role Norms Inventory [47] and its subscales measure men’s adherence to hegemonic male norms. The Conceptions of Masculinity Scale [39], one of the few measures of masculinity designed specifically with and for gay men, assesses perceptions that masculinity is defined by men’s sexual behavior, social behavior, and physical appearance. The Meaning of Masculinity Scale [39] measures a specific, traditional form of gay men’s masculinity. Factors associated with male norms such as the salience of norms, subjective norms, and conformity to norms (e.g., Conformity to Masculine Norms Inventory [48], Male Gender Norms scales, Salience of Traditional Masculine Norms [49]) have been used in research to highlight different aspects of psychological stressors that affect men’s health and health practices. Measures of male norms assess the degree to which men indicate their level of agreement or disagreement to an array of dominant cultural norms of masculinity in the United States [47, 48, 50, 51]. Measures of attitudes and feelings about the hegemonic gender roles males often perform (e.g., Gender Role Conflict Scale, Male Gender Role Stress Scale [52], Male Subjective Norms [53]) highlight key psychological stressors in the lives of males that result from discrepancies between how men perceive their personal characteristics and how they perceive men are expected to behave. Measures of masculine conceptions or ideologies examine the degree to which men feel that they are able to fulfill a single form of stereotypically masculine roles [46]. Conformity to Masculine Gender Norms describes men’s perceptions of their ability to adhere to traditional masculine norms. Measures of gender role conflict or stress assess ideologies and beliefs about the meaning of being male and the extent to which one endorses or internalizes cultural norms and values of masculinity and the male gender role [54].

While there is considerable research utilizing these scales, there remains surprisingly little empirical research examining how measures of masculinity are associated with, or predictive of, health behaviors or health outcomes [44]. The studies that have included measures of masculinity and health outcomes have had inconsistent findings. Some studies found positive relationships between masculinity and health, while others reported more negative associations [55]. For example, Levant and colleagues (2013) found that masculine risk-taking and self-reliance were negatively related to health behavior measures but that emotional control, primacy of work, and winning were positively related [55, 56]. This complexity is echoed in the work of Gordon and colleagues who found that toughness was related to both more exercise and increased junk food consumption [57]. Engaging in positive health behaviors and being rational and decisive and making autonomous decisions also may draw on hegemonic ideals of masculinity, highlighting that masculinity may not only be associated with risky behavior [4]. The work on masculinity and health is particularly limited to men who are not college students at 4-year colleges and universities, a very selective and non-generalizable group to males in the United States. There also is a paucity of work focusing on masculinity and health across the globe [58]. One area where there is particularly little is in studying how these measures of masculinity are associated with the health of middle-aged and older men, across racial and ethnic groups.

While Kimmel asserts that homophobia is a core characteristic of hegemonic masculinity, studies of Latin and African American men are finding that these men’s definitions of manhood may not include homophobia, violence, physical domination, or emotional isolation [32, 36, 59]. Machismo is measured as a combination of traditional machismo (i.e., hypermasculine traits such as dominance) and caballerismo (i.e., nurturing qualities, family centeredness, social responsibility, and emotional connectedness) [60]. The values espoused in caballerismo and black manhood are most congruent with feminist masculinities that include being an ethical human being, having emotionally healthy relationships with others, being involved with activism in the community, and rejecting aspects of hegemonic masculinity (e.g., objectification of women, physical and sexual domination of women, and homophobia) [32, 33, 36, 59]. The work on Asian American men and masculinity highlights how this group of men has historically been viewed as hypermasculine and effeminate simultaneously [34]. The notion that there is a singular masculinity that represents the hegemonic ideals of a particular racial or ethnic group is a misnomer; the concept of Asian American masculinity, for example, is one that was not defined by that specific population [34]. Thus, masculinity is complex, can be related to desirable as well as undesirable behaviors, and resides both within the psychology of men and their interactions with their social environment [11].

Stress directly and indirectly contributes to high rates of unhealthy behaviors, chronic disease diagnoses, and premature mortality among men [1]. Smoking, alcohol and substance abuse, unhealthy eating, sedentary behavior, and poor sleep all are behaviors that are adversely affected by stress [61]. In the context of medicine and public health, men’s self-representation and internalization of notions of masculinity and masculine social norms and pressures are often implicated in explanations of men’s premature death due to stress and unhealthy behaviors (e.g., interpersonal violence, reckless driving, alcohol and drug abuse, risky sexual behavior, high-risk sports, and leisure activities) [7–9, 14, 22]. These behaviors often are culturally sanctioned ways of distinguishing among males and between males and females and may help explain the association between masculinity and men’s risky and unhealthy behaviors [5, 9].

These behaviors also may be affected by men’s experiences of psychosocial stress. For example, Whitehead’s (1997) Big Man Little Man Complex argues that men are trying to achieve a level of respectability through economic success, educational attainment, and social class status while simultaneously demonstrating prowess along the social and cultural dimensions of traditional masculinity: virility, sexual prowess, risk-taking, physical strength, hardiness, etc. [62]. These factors highlight that masculinity may lead to stress and coping that results from trying to achieve success in areas of respectability and risky behaviors that may represent traditional aspects of masculinity (e.g., eating large portions, alcohol abuse, substance use, speeding while driving, risky types of physical activity, high numbers of sexual partners, inconsistent safe sexual practices). The aspects of masculinity that men find stressful and use to define themselves and that they try to portray to others appear to change over time.

Because the fundamental meaning of masculinity and the salience of different aspects of masculinity change over the life course, it is critical to consider how both the notions of masculinity change over time and the importance of key health behaviors changes over time [4, 9]. Each phase of life can be distinguished, in part, by men’s efforts to fulfill salient role performance goals [7, 63]: educational and professional preparation in the preadult and early adult years, being a provider for himself and his family in the middle-adult years, and dignified aging as men move through older adulthood [63, 64]. While these goals may not be universal, it remains critical to recognize that there are social and cultural pressures that men experience and that these pressures and strains, which may be rooted in efforts to fulfill salient roles, change as men age [25]. Some of the masculinities men try to perform when they are younger tend to demonstrate their physical strength, sexual prowess, and risk tolerance, but as men age, they tend to also want to demonstrate more positive aspects of masculinity: being a responsible father, provider, and husband/partner [14, 32, 63]. These changes in notions of masculinity highlight the positive aspects of masculinity that can be the foundation for interventions to promote healthy behaviors, lifestyles, and outcomes [53, 65–68]. In sum, age-related dimensions of gendered behaviors also demonstrate how masculinities are related to leading causes of death among men at different ages.

From ages 15 to 44 years, the leading cause of death among men is unintentional injury, including accidental drug overdose, which remains a leading cause of death through age 64 years. Often in younger ages, these injuries and accidents are presumed to be the result of reckless and risky social behaviors, while in middle and older ages, it is presumed that these patterns are the result of work-related injuries. Homicide is a leading cause of death for men only from ages 15 through age 44 years, while suicide remains a top 4 leading cause of death from ages 15 to 54 years (and drops to 8th in the 55–64-year age range). Heart disease and cancer are the leading causes of death for men age 45 years and older. For example, the risk of being diagnosed with and dying from cancer, diabetes, and heart disease increases with age [69, 70]. While men are diagnosed with hypertension at a higher rate than women until age 45 years, from ages 45 to 64 years, the percentages of men and women with hypertension are similar. After 65 years of age, women are diagnosed with hypertension at a higher rate than men [70]. These data emphasize the importance of incorporating a life course perspective in our explanations of men’s health and men’s health disparities [71–73].