In the context of midwifery, reflection allows for the critical examination of practice and procedures from a holistic perspective. Maternity services' ability to ensure clinical excellence relies on safe navigation of the physical, cultural and psychological factors that uniquely impact each service user.
This reflection seeks to develop an insight into common perceptions of family structures that the author identified during their time working alongside a community organisation that promotes men's wellbeing, and how these are reflected in maternity services. Atkins and Murphy's (1993) model of reflection is applied, as it encourages analysis at each stage and invites the user to consider their awareness of why an event felt significant. The processes of analysis, evaluation and identification of learning encouraged by the model promotes a methodical and considered engagement with the event. These steps are carried out to help identify ways in which the issues raised can be addressed to optimise outcomes. The author acknowledges that not all couples who receive midwifery care are heterosexual, but this review focuses on this demographic because of the author's experiences at a men's charity.
Awareness
The event I will be reflecting on not only felt significant at the time, but has remained in my psyche since. While in conversation with a man I had recently met during a community engagement experience, he stated that ‘toxic masculinity is a health issue’. This in itself was a pertinent notion. I had not previously considered the link between this particular sociopolitical concept and health. He went on to say that he felt the impact was not only on the health of those around toxic masculinity, but also on the individual who displays such characteristics.
My understanding of toxic masculinities was not influenced by this interaction and remains, throughout this reflection, as a reference to an inhibited expression of emotions or actions that may signify weakness or vulnerability, such as empathy, depression, compassion or embarrassment that may result in aggression, violence and conflict. This is arguably a product of entrenched and perpetuated gender politics that seek to maintain historical masculine hegemony by emphasising the innate emotional and physical superiority of the male sex (American Psychological Association, 2018).
I became aware that I had not considered toxic masculinities in this bidirectional dynamic before. As a student midwife, public health is a consideration and focus of much of my practice, as per the Nursing and Midwifery Council's (2019) standard of proficiencies for midwives and I considered myself to have a working understanding of the sociocultural, biological, behavioural and environmental determinants of health (Marmot et al, 2020). I was aware that I had neglected to consider toxic masculinity in the context of health and maternity service provision, and thus began my reflective journey to explore this issue.
Description
This discussion took place during my engagement with a community-based charity as part of my university course. MensCraft (2023) is a Norfolk-based charity who provide support services promoting men's health and wellbeing. I was attending a ‘pit stop’; a weekly meet-up providing a safe space for men to share their feelings and socialise, for the purposes of gaining an insight into the services MensCraft provide and to discuss these with service users. My first interaction was with the coordinator of the day, whose role was to facilitate group discussions and oversee the running of the event.
During a discussion surrounding the importance of these events for him in overcoming an inability to constructively express emotion, that he owed to a history of complex trauma, he stated that toxic masculinity is a health issue. This had an immediate impact on me. I was struck by his awareness, both of his own emotions and coping mechanisms, and how these were indicative of a wider societal issue. I felt privileged to be in a space where this candid exploration of sensitive issues was encouraged and nurtured and I felt a definitive awareness of how, in my role as a student midwife, I had begun to develop a perception of masculinity that was potentially damaging.
Throughout my training I had developed a notion, that in the dynamic of families whose care I was involved in, a man could be a source of emotional, physical and psychological danger. In attempts to support women in my care, I had often ‘othered’ men. I refer here to the process described by Akbulut and Razum (2022) of ‘social psychological dimensions of in-group and out-group formations’. I felt compelled to reflect on why this had occurred and how maternity service provision may be perpetuating this and dismissing, neglecting or sustaining possible health risks associated with toxic masculinity.
Analysis
The analysis of this situation comprises two parts. The first is of the reductive nature of my perception of toxic masculinity in relation to public health. I merely determined that risks to health and wellbeing, associated with toxic masculinity, were overt and extreme manifestations, such as domestic abuse (Gov. uk, 2021). While this is not an incorrect determination, as one in four women will experience domestic abuse in their lifetime, with those exposed at an increased risk of mental health issues and substance abuse, this is a segmented view of a complex interplay of factors (Home Office, 2021).
The reality is that perpetrators of domestic abuse are likely to have a history of complex trauma. Those who have experienced multiple disadvantages, such as poverty, involvement in the criminal justice system, substance misuse and childhood exposure to domestic abuse, are at an increased risk of becoming perpetrators themselves (Yakubovich, 2019). The impact of this on health outcomes has been shown as definitively negative. A study conducted by Promundo, a global consortium aimed at promoting gender equality, found that multiple adverse health outcomes were linked to masculine norms (Ragonese et al, 2019). These included poor diet, alcohol, tobacco and drug use, unsafe sex and limited health seeking. The latter of these has been attributed to the act of health-seeking as being contrary to ‘dominant masculine norms around self-reliance, physical toughness and emotional control’ (Addis and Mahalik, 2003). My perception of the link between toxic masculinity and public health had been limited up until this point and reflective analysis has revealed the dynamic interplay between complex social factors and the health of men and their families.
The second analysis prompted by this reflection is of how maternity services interact with the public health issues that stem from toxic masculinities. A feminist critique of domestic abuse perpetrated by men attributes the issue to patriarchally constructed masculinities that maintain hegemony through gender inequality (Namy et al, 2017). This construction validates domestic abuse, which has inter-generational consequences on families, and increases adverse health outcomes among men. In maternity services, it could be argued that this societal issue is tackled with a unilateral approach, seeking purely to protect women with policies such as routine enquiries into women's domestic safety at each contact (RCM, 2021). This negates alternative approaches that could include men in the dialogue of care provision.
The National Institute for Health and Care Excellence (NICE, 2021a) identified a gendered perception of maternity services that had an exclusionary effect on men. This is corroborated by Wright and Geraghty (2017), who found recurrent themes of disempowerment and active exclusion from service provision among men accessing maternity services. However, the NMC (2019) references the Lancet's (2014) definition of midwifery in its standards of proficiencies for midwives, which states that midwives should ‘strengthen women's own capabilities to care for themselves and their families’. Men are entirely excluded in this statement and the onus is placed on women to care for their families. The legal and regulatory framework that guides midwifery services is gendered in such a way that fathers are ‘othered’ by being identified as part of women's families, who need caring for, rather than being stakeholders in the pregnancy. As domestic abuse against women is known to increase during pregnancy (Women's Aid, 2019), it is significant that maternity services are reactive to extreme manifestations of toxic masculinities, rather than proactive in preventing them. Viewing toxic masculinities as products of health and social inequalities, changes the focus to a public health issue that could be addressed through holistic and inclusive measures.
Evaluation
The health implications of toxic masculinity reveal this phenomenon as a societal presence that permeates emotional, social, cultural and physical spheres. Maternity services provide pivotal opportunities to promote public health. However, their exclusively gendered approach can negate the opportunity for initiating conversations surrounding toxic masculinity.
The NHS and maternity services have suffered from long-term austerity, which has resulted in ‘inadequate’ staffing levels (House of Commons, 2021). Funding restrictions exist in tandem with growing pressure for safety improvements following the Kirkup (2015) and Ockenden (2022) reports. This socio-political atmosphere may limit the extent to which support is given to wider familial networks. That said, the literature surrounding men's experiences of maternity services indicate there are small, but potentially significant behavioural changes that could be made in order for these to be improved (NICE, 2021a). The main themes identify feelings of disempowerment, exclusion and a perpetuation of unhelpful gender stereotypes (NICE, 2021a).
When these themes are viewed in the context of a patriarchal society that self-perpetuates harmful notions of masculinity, such as unwavering physical and emotional strength, it can be said that through excluding men, maternity services maintain these notions. Pregnancy and impending fatherhood present a time of change and uncertainty. Approximately 5–10% of men experience depression in the perinatal period and 5–15% experience perinatal anxiety (Darwin et al, 2017). The prevalence of these mental health issues for women in pregnancy is 12% and 13% respectively (NICE, 2023), and monitoring and support for these conditions is embedded in antenatal care guidelines (NICE, 2021b). It is significant that despite the evidence that the psycho-social safety of men is also at risk in the perinatal period, and that instances of domestic abuse increase, healthcare professionals use gendered approaches to care (NICE, 2021a).
As hegemonic notions of masculinities have been shown to decrease engagement with health professionals (Ragonese et al, 2019), the valuable opportunity presented by maternity services to engage men in physical and mental health is often missed. The impact of toxic masculinities on the health of men and their families is addressed once it has manifested into something intractable, namely abuse of some form. It is clear that protective approaches to an issue that disproportionately affects those already vulnerable to health inequalities (Alhusen et al, 2015) could have intergenerational benefits. While maternity services are not single-handedly responsible for tackling such a complex issue, the potential they have for engaging men positively and helping to re-shape notions of masculinities is often missed.
Conclusions
This reflective process was prompted by a statement that made me aware of the reductive nature of my views on masculinities. I had a segmented view of the trope of toxic masculinities, which had limited my consideration of the topic. In my practice, I correlated toxic masculinities with domestic abuse and the damaging impact of this on women. This perspective neglected wider and nuanced factors relating to masculinities. This reflection has highlighted the complex interplay between social, environmental, psychological and physical elements and so called ‘toxic masculinities’. This revelation, in turn, led me to interrogate how maternity services interact with this issue. It appears as though the relationship is one where intersection is limited to instances where the issue has manifested into its most extreme result and the potential for protective measures to be implemented prior to this is lost. Early identification of behaviours, engagement of partners with healthcare services and a generalised consideration of men as stakeholders in a pregnancy journey are omitted in current frameworks and practice, and further research is required.
Maternity services are not responsible for toxic masculinities, and often provide safe spaces for survivors of abuse. However, by considering toxic masculinities as socially constructed, rather than innate, human conditions, it can be understood that small changes to approaches in care and engagement may help to quietly dismantle barriers to emotional expression and provide gateways to support. In this way, the healthier and happier masculinities that MensCraft promotes, can be nurtured in wider, unexpected spaces.