Damaged Masculinity: How Honor Endorsement Can Influence Prostate Cancer Screening Decision-Making and Prostate Cancer Mortality Rates

Abstract

Prior research has established factors that contribute to the likelihood that men seek out prostate cancer screenings. The current study addresses how endorsing the ideology found in cultures of honor may serve as a barrier to prostate cancer screenings. Two studies were conducted which analyzed the impact of stigma on men’s decisions to seek out prostate cancer screenings (Study 1) as well as how prostate cancer deaths may be higher in the culture of honor regions due to men’s reticence to seek out screenings (Study 2). Results suggest that older, honor-endorsing men are less likely to have ever sought out a prostate cancer screening due to screening stigma and that an honor-oriented region (southern and western United States) displays higher rates of prostate cancer death than a non-honor-oriented region (northern United States). These findings suggest that honor may be a cultural framework to consider when practitioners address patients’ screening-related concerns.

Keywords

stigma culture and self health

Aside from various forms of skin cancer, prostate cancer is the most common cancer and the second leading cause of cancer death among men in the United States (American Cancer Society, 2020a). While 5-year survival rates are high for prostate cancer detected early in its progression, undetected cases can lead to the spreading of cancer to distant areas of the body, such as the bones, brain, liver, and lungs. For these cases, 5-year survival rates drop dramatically to approximately 31% (American Cancer Society, 2020b). Furthermore, advanced late-stage prostate cancer is often painful and distressing due to its spread to adjacent organs, causing painful urination, loss of bladder control, painful ejaculation, and blood in urine or semen (Cancer Treatment Centers of America, 2020). Due to these symptoms and the possible propagation of cancer to other areas of the body, it is important for men to seek out screenings if they begin to experience symptoms. This screening is recommended for men who are approaching a particular age, around 50 years old, where it becomes important to detect possibly cancerous abnormalities beginning to form in the prostate.

Although recently there appears to be a controversy regarding the predictive validity of prostate cancer screenings, as well as some contention regarding the association between screening procedures and prostate cancer mortality rates (see Andriole et al., 2009; Getaneh et al., 2020; Pinsky et al., 2019), population studies of prostate cancer screenings have consistently shown a long-term decrease in prostate cancer mortality rates due to screening attendance (Carlsson et al., 2017; Hugosson et al., 2019; Osses et al., 2019; Tabei et al., 2020). Moreover, when the Centers for Disease Control and Prevention (CDC) downgraded their prostate cancer screening recommendation to a “D” grade, evidence suggested that this change led to increases in metastatic prostate cancer and prostate cancer mortality rates due to lower levels of screening attendance and, therefore, decreased detection of dangerous, metastatic prostate cancer (Butler et al., 2020; Joshi & Filson, 2020; I. E. Kim et al., 2020). Overall, these findings, in conjunction with findings from population studies, do emphasize the importance of prostate cancer screenings.

Prostate cancer screenings help decrease prostate cancer mortality rates through early detection in average-risk men, with prevention rates of 1.3 deaths per 1,000 for nonmetastatic prostate cancer and 3 deaths per 1,000 for metastatic prostate cancer (Fenton et al., 2018). Prostate cancer screening may also prevent as high as one in six prostate cancer deaths in individuals who are at a higher risk of prostate cancer (Callender et al., 2019). These effects, as demonstrated in the aforementioned population studies, are consistent with the current American Cancer Society and CDC screening guidelines which recommend that, after discussion with a doctor, men with an average risk of developing prostate cancer may begin to get screened at age 50, with recurring screenings every 2 years for those who test below the 2.5 ng/mL threshold for the PSA and annually for those who test above the 2.5 ng/mL threshold for the PSA (American Cancer Society, 2019; CDC, 2020).

Screening for prostate cancer typically involves two procedures. The first consists of a prostate-specific antigen (PSA) blood test intended to detect a prostate-specific antigen in the blood produced by tissue in the prostate. The second procedure consists of a digital rectal examination (DRE), where a healthcare provider inserts a gloved, lubricated finger into a man’s rectum to feel abnormalities on his prostate. While the validity of using the DRE as a cancer screening procedure has been debated (D. Jones et al., 2018; Naji et al., 2018), surveys show that the DRE is still relatively commonly used as a screening method, most frequently in combination with the PSA test. In fact, recent estimates range somewhere between 42% and 64% of physicians using both PSA and DRE for screening (Akerman et al., 2018; Andonian et al., 2020; Mikkilineni & Rutman, 2018).

Given the aforementioned screening recommendations, as well as the potential life-saving benefits of screenings, one would hope that men seek out a shared decision-making process with their doctors to determine whether they should obtain a screening and, if needed, receive a recommended PSA test without hesitation. Unfortunately, certain factors appear to serve as barriers that keep men from seeking out prostate cancer screenings. Such factors include demographic characteristics, such as age and a lack of family history of prostate cancer (CDC, 2019), as well as psychological factors, such as level of education and perceived risk of getting prostate cancer (Dillard et al., 2010; Winterich, Grzywacz, et al., 2009). One additional factor that may be preventing men from engaging in prostate cancer screening behaviors is the stigma attached to prostate cancer screenings. Broadly speaking, stigma has been shown to be a significant barrier to various screening procedures, including screening for colorectal cancer, cervical cancer, and sexually transmitted infections, such as gonorrhea and HIV (Barth et al., 2002; Fortenberry et al., 2002; Goldman et al., 2009). For many of the aforementioned screenings, many individuals indicate that they fear the negative social implications associated with these screenings due to the stigma that these screenings hold.

In regard to prostate cancer screening, it appears that the attached stigma centers around its association with the DRE as a screening procedure and the fear that receiving the DRE implies a loss of masculinity of some sort. For example, Rivera-Ramos and Buki (2011) found that many Latino men expressed reluctance to receive a prostate cancer screening due to the fact the DRE procedure would threaten their manliness. The researchers also noted that this stigma may contribute to the fact that Latino men are 4 times as likely to be diagnosed with advanced prostate cancer compared with their non-Latino White counterparts (Siegel et al., 2008). Moreover, both Ogunsanya et al. (2017) and Ferrante et al. (2011) recently found that the emasculating and embarrassing nature of the DRE was a common theme discussed by men as to why they viewed prostate screening negatively. Similarly, Winterich, Quandt, et al. (2009) found that for men, the emasculating nature of screenings involving the rectum was primarily due to the DRE being performed by a doctor’s finger as opposed to a mechanical imaging device used, for example, in a colonoscopy. Finally, Seymour-Smith et al. (2016) found that associating the DRE with homosexuality and seeing it as a threat to masculinity were major reasons why men did not intend to participate in prostate cancer screenings. This threat to masculinity posed by prostate cancer screenings has been found in a multitude of other studies as well (see James et al., 2017). It should also be noted that although not every physician still uses the DRE as a screening method (even in combination with the PSA test), men still associate prostate cancer screening with the DRE and list it as a cause for avoiding screening procedures. For example, in a 2016 study of men’s attitudes toward prostate cancer screenings, approximately 67% of men indicated that the DRE was an impediment against attending a visit to their urologist (García et al., 2016). Overall, it appears that men associate the DRE with prostate cancer screenings, and this association may ultimately be keeping men from screenings due to the stigma attached to the DRE procedure.

While it has been known that men are less likely to partake in various health behaviors and screenings (Galdas et al., 2005; James et al., 2017), the stigma surrounding prostate cancer screenings may be particularly deleterious for certain men whose masculine reputation is more central to their self-concept. Such men may be found in the culture of honor prevalent in the United States. Cultures of honor exist all over the world, including the Mediterranean, Latin America, and the American South (Brown, 2016; Dietrich & Schuett, 2013; Rodriguez Mosquera, 2016). In cultures of honor, one’s social reputation is seen as vitally important, and individuals are even willing to defend their reputation to the point of using physical violence (Cohen et al., 1996). For men in these cultures, masculine honor entails being seen as strong and fearless, virile, and displaying traditionally masculine traits (Barnes et al., 2012; Cohen & Leung, 2012; Rodriguez Mosquera et al., 2002; Saucier et al., 2016), while feminine honor entails being seen as sexually pure and loyal to a woman’s partner and family (Rodriguez Mosquera, 2016; Vandello et al., 2009).

Past research in the United States has shown that honor endorsers (those who closely follow and adhere to the norms in cultures of honor) will not only partake in certain aggressive behaviors to defend and maintain their masculine reputation (Barnes et al., 2012, 2014; Brown et al., 2009; Vandello & Cohen, 2003) but will also avoid certain behaviors to maintain their honor as well. For example, Foster, Carvallo, Lee, Fisher, and Traxler (2020) found that honor-endorsing women were less likely to seek out human papilloma virus (HPV) screening and HPV vaccinations to avoid being seen as sexually promiscuous. Similar effects have been found in regard to health behaviors with men. Work by both Brown et al. (2014) and Bock et al. (2019) found honor endorsers are significantly less likely to seek out psychological services for depression and are more likely to commit suicide when they feel a lack of “honor fulfillment.” These findings were expanded upon by Foster, Carvallo, Lee, and Bernier (2020) who found that the link between honor endorsement and decreased psychological help-seeking was due to reputation concerns and the fear of being stigmatized by others. Recent work has even shown that honor-endorsing men will avoid seeking help for erectile dysfunction for fear of being seen as less masculine (see Foster et al., in press). In sum, there is evidence to suggest that honor endorsers actively avoid certain health-seeking behaviors that are perceived as a threat to one’s reputation as “honorable.”

One should note that the reticence to seek out screenings has been found in other areas of research addressing masculinity and reputation concerns, despite the lack of work that specifically analyzes honor-endorsing individuals, a distinct subgroup where masculinity is placed at a premium. For example, machismo (masculinity) in Latino men has been implicated as a barrier to prostate cancer screening within this population (see Neff, 2001; Rovito & Leone, 2012; Winterich, Grzywacz, et al., 2009), and the masculinity threat of screenings has been suggested to be a barrier for Black men as well (Harvey & Alston, 2011). However, this qualitative research looking at how masculinity concerns may impact prostate cancer screening has primarily been conducted in non-White populations (see James et al., 2017), and quantitative work in this area is also relatively sparse. This poses an issue for practitioners who may be less concerned with masculinity as a source of screening reticence in White populations. While no work has yet been conducted on the influence of honor concerns on prostate cancer screening reticence, the culture of honor research regarding the utilization of health services has primarily focused on such non-Hispanic, White individuals (see Osterman & Brown, 2011). Within this cultural group, the masculinity associated with men’s honor cannot be understated—this suggests that masculinity may influence screening reticence in subgroups of White populations who endorse honor-oriented norms and ideals. Researchers note that “the defining characteristic of honor culture is its emphasis on the link between. . .reputation and individual self-worth” (Crowder & Kemmelmeier, 2017), and that, although all humans are concerned about their reputation, honor cultures take reputation concern and “magnify it,” putting reputation concern on “cultural steroids” (Brown, 2016; p. 10). The strength of this concern is clearly found in evidence suggesting that those who feel they are not fulfilling the ideals of being an honorable man are at higher risk for the enactment of suicide (Bock et al., 2019). In other words, masculinity is a defining feature of men’s reputation in cultures of honor and is therefore emphasized more strongly than in other populations. This may implicate honor-endorsing subgroups of White populations as being at a similar risk for masculinity-related concerns as has been shown in prior qualitative work with Black and Latino populations.

In summary, while concern for one’s masculine reputation has been linked with reticence to seek prostate cancer screenings in a wide range of populations and cultural frameworks, this link has not yet been examined in the culture of honor. We propose that the concern for one’s masculine reputation is a particularly strong risk factor preventing men in cultures of honor from seeking out screenings, which may threaten one’s masculine reputation. Such a finding would expand prior research by showing that although men, in general, may be concerned about their masculinity, men in cultures of honor are at particularly high risk for prostate cancer due to their heightened concerns about the masculinity threat of screening procedures. We propose that honor-endorsing men will be less likely to have sought a prostate cancer screening due to the potential threat screening would pose to their masculinity.

Hypothesis 1 (H1): Honor endorsement, at the individual level, will be associated with a decreased likelihood to have ever sought out a prostate cancer screening in men aged 50 and older. This link will be explained by prostate cancer screening stigma.

Furthermore, it is known that prostate cancer screenings are essential for the primary prevention of this disease, and lack of screenings can be particularly dangerous for older men, as the cancer incidence and mortality rates increase with age. Therefore, one possible consequence of honor-endorsing men not seeking out prostate cancer screenings is a decreased likelihood of early detection and, ultimately, a greater risk of prostate cancer-associated mortality. This outcome can be revealed when testing for regional differences in prostate cancer deaths in honor and non-honor states, an analysis consistent with past research that compares the southern and western United States, an honor-oriented region, and the Northern United States, a non-honor-oriented region (Barnes et al., 2012; Brown et al., 2009, 2014, 2018; Osterman & Brown, 2011).

Hypothesis 2 (H2): Honor states, compared with non-honor states, will demonstrate higher rates of prostate cancer deaths after controlling for a series of theoretically supported statewide covariates.

Study 1

Study 1 intended to address if individual-level honor concerns might be associated with a decreased likelihood of having sought out a prostate cancer screening in men 50 years old or older. As noted by K. Leung (1989), analyzing individual-level variation in a cultural ideology provides useful evidence of how cultural factors may impact individuals within that culture. Study 1 intended to use this approach to investigate whether the culture of honor ideology endorsement would impact the likelihood that men seek out prostate cancer screenings. Furthermore, we intended to address if the hypothesized link between honor endorsement and prostate screening status might be explained by the stigma attached to prostate cancer screenings.

Method and Procedure

Participants

Participants were 190 men above the age of 50 (M_age = 65.30, SD = 6.04) who completed a survey via Amazon Mechanical Turk (MTurk). Participants were predominately non-Latino White (85.8%), with the remainder of the participants identifying as Asian (5.3%), non-White Latino/Hispanic (5.3%), African American (3.2%), or “Other” (0.5%). Respondents volunteered to complete a survey on their health and social attitudes, which was distributed using the Qualtrics interface. Upon completion of the survey, which took approximately 12 min to complete, men were compensated US$1.60. All participants completed an informed consent document before beginning the study, and the study followed all APA ethical standards. About 54.7% of respondents indicated that they had, at some point, received some combination of the DRE and the PSA test. Study materials can be found online (Foster, 2021).

Measures

Honor Ideology for Manhood Scale

The 16-item Honor Ideology for Manhood Scale (HIM; α = .96) scale (Barnes et al., 2012) measures how much participants endorse the masculine identity facet of honor. Participants indicated to what extent they agreed or disagreed with statements such as “A real man doesn’t let other people push him around” and “A real man will never back down from a fight,” on a scale from 1 (Strongly Disagree) to 7 (Strongly Agree). Scores were averaged so that higher scores indicated higher masculine honor ideology endorsement.

Prostate Cancer screening procedure knowledge (PC-Know)

To assess the frequency of participants who associated prostate cancer screenings with the DRE, participants were asked to “briefly describe, to the best of your knowledge and without consulting outside sources, what primary procedure/method is used when a doctor performs a prostate cancer screening on his or her patient.” This question was open-ended and later coded by independent raters to fall into one of three categories—a DRE group who identified the DRE as the primary procedure, a PSA group who identified the PSA blood draw as the primary procedure, and the “Unclassified” group who indicated in some way that they did not know what the primary prostate cancer screening procedure was.

Prostate cancer exam attendance (ExamEver)

To assess if men had ever received a prostate exam, we provided participants with the following prompt:

A prostate cancer screening is performed by a doctor using either a digital rectal exam (DRE), a PSA blood test, or a combination of both. The digital rectal exam involves the doctor using a gloved finger to enter the rectum and feel for any irregularities on a man’s prostate. The PSA blood test involves drawing blood to test for a prostate-specific antigen in the blood that can indicate cancer of the prostate. Please indicate if you have ever received one or both of these procedures in your lifetime.

Individuals who indicated that they had received the PSA test, the DRE, or the combination of the two were coded as having received a prostate exam (0 = never received an exam, 1 = have received an exam). It should be noted that participants received this item after receiving the PC-Know item to ensure that the vivid description of the DRE procedure did not influence participants’ knowledge responses.

Prostate cancer screening attitudes (P-Attitude)

To measure the level of stigma men held regarding prostate cancer screenings, a 5-item stigma scale was administered to participants (α = .96). The scale asked participants the extent to which they agreed with statements regarding the stigmatizing elements of prostate cancer screenings, including items such as “Receiving a prostate cancer screening makes you less of a man” and “Receiving a prostate cancer screening would damage my masculinity.” Participants responded on a scale from 1 (Strongly Disagree) to 7 (Strongly Agree). Scores were averaged so that higher scores indicated higher prostate cancer screening stigma.

Prostate cancer screening shame (P-Shame)

To measure the level of shame and embarrassment men would feel receiving a prostate cancer screening, a 5-item stigma scale was administered to participants (α = .96). The scale asked participants the extent to which they agreed with statements regarding the shame and embarrassment associated with prostate cancer screenings, including items such as “I would be ashamed if people knew I had received a prostate cancer screening” and “It would embarrass me if people knew I had received a prostate cancer screening.” Participants responded on a scale from 1 (Strongly Disagree) to 7 (Strongly Agree). Scores were averaged so that higher scores indicated higher prostate cancer screening shame.

Covariates

To control for other possible factors that may be contributing to men’s decision to seek out a prostate cancer screening, we controlled for a series of covariates. First, we controlled for demographic characteristics, including participant age, ethnicity (0 = non-Latino, 1 = Latino), due to the reticence in Latino populations to seek out screenings (Rivera-Ramos & Buki, 2011), and presence of a family history of prostate cancer (0 = no family history, 1 = family history), as higher age and having a family history of prostate cancer are risk factors for prostate cancer, perhaps increasing the likelihood that men think screening is warranted (CDC, 2019). We also included education level on a scale from 0 (no formal education) to 8 (doctorate degree), perceived risk for prostate cancer on a scale from 0 (no risk at all) to 100 (high risk), and income level on a scale from 1 (less than US$20,000) to 13 (more than US$200,000), as higher levels of education, income, and greater perceived risk for prostate cancer have been associated with likelihood to seek out prostate cancer screenings in prior research (Dillard et al., 2010; Winterich, Grzywacz, et al., 2009).

Results

Bivariate correlations, means, and standard deviations for the variables of interest can be found in Table 1. Due to the strong correlation between the P-Shame and P-Attitudes variable (r = .91, p < .001), these two scales were combined to create a composite stigma variable (P-Stigma). Honor endorsement was linked with a decreased likelihood to have ever received a prostate cancer screening (r = −.25, p = .001) and higher levels of prostate cancer screening stigma (r = .31, p < .001). Greater likelihood of having ever received a prostate cancer screening was associated with lower levels of prostate cancer screening stigma (r = −.20, p = .005) and higher age (r = .15, p = .03).

Table 1.

Bivariate Correlations, Means, and Standard Deviations for the Variables of Interest in Study 1.

Var.	1	2	3	4	5	6	7	8	9	M	SD
1. Honor	—	−.25*	.31*	−.05	−.04	.20	−.22*	.002	−.13	3.35	1.38
2. Exam		—	−.20*	.15*	.10	.003	.10	.06	.16*	0.83	0.38
3. Stigma			—	−.19*	.20*	−.06	.07	.22**	.05	1.31	0.79
4. Age				—	−.17*	−.16*	.12	−.02	−.29*	65.30	6.04
5. Hist.					—	−.02	.10	.16*	.17*	0.13	0.34
6. Etnc.						—	−.19*	−.20*	.09	0.05	0.22
7. Edu.							—	−.08	.19*	4.37	1.35
8. Risk								—	−.004	31.10	23.87
9. Income									—	3.32	1.97

Note. N = 190. Honor = Culture of Honor Endorsement. Exam = Prostate Cancer Screening Attendance. Stigma = Prostate Cancer Screening Stigma. Shame = Prostate Cancer Screening Shame. Hist. = Family History of prostate Cancer. Etnc. = Ethnicity. Edu. = Education Level. Risk = Perceived Risk.

†

p < .10. * p < .05. ** p < .01.

We conducted analyses of indirect effects using the PROCESS macro (Hayes, 2013; Model 4) in SPSS version 24.0 to assess the indirect effect of honor endorsement on the receipt of a prostate cancer screening through prostate cancer screening stigma. These analyses were conducted while controlling for age, ethnicity, family history of prostate cancer, perceived risk, level of education, and income level. Analyses revealed a significant 2-path indirect effect from the HIM to prostate cancer screening status through the P-Stigma variable (Mediated Effect [ME] = −.11, SE = .09, 95% CI [−.336, −.001], p < .05), indicating that higher level of honor endorsement is associated with higher levels of prostate cancer screening stigma, which were associated with a lower likelihood of ever having been screened for prostate cancer. The final model can be found in Figure 1.

Figure 1.

The impact of honor endorsement on prostate cancer screening status through prostate cancer screening stigma and prostate cancer screening shame and embarrassment.

Finally, to assess the frequency of participants who indicated the DRE as the primary screening procedure, independent raters classified the open-ended responses to the PC-Know item into the DRE, PSA, and Unclassified categories. Frequencies showed that approximately 70% of participants indicated the DRE as the primary screening method, with an additional 20% falling into the Unclassified category, and only 10% falling into the PSA category. In other words, the vast majority of participants in the study associated prostate cancer screening exclusively with the DRE procedure.¹

Study 1 Discussion

Study 1 intended to establish whether honor-endorsing individuals are less likely to seek out prostate cancer screenings considering the possible masculinity threat that seeking out such screening may pose to them. The findings provide individual-level evidence that honor endorsement is, in fact, associated with decreased likelihood to have ever received a prostate cancer screening and suggest that this association is explained by the negative attitudes honor endorsers have regarding screenings. These findings also add to a body of research showing how stigma prevents certain men from seeking out screenings, primarily due to the association of this screening with the digital rectal exam (James et al., 2017; Ogunsanya et al., 2017; Seymour-Smith et al., 2016; Winterich, Quandt, et al., 2009). These findings also contribute to a body of research showing how cultural factors can impact screening decision-making (Foster, Carvallo, Lee, Fisher, & Traxler, 2020; Griffith et al., 2011; Holroyd et al., 2004; M. Kim et al., 2019; S. Y. Lee, 2015).

Furthermore, Study 1 showed that nearly 70% of participants indicated that the DRE was the primary screening procedure used for detecting prostate cancer, despite concerns with the predictive validity of the DRE. While it may appear that participants are misled when it comes to screening procedures, one must also consider the findings by prior researchers which show that somewhere between 42% and 81% of physicians seem to still use the DRE in some way during prostate screening procedures (Akerman et al., 2018; Andonian et al., 2020; Mikkilineni & Rutman, 2018). In addition, the high frequency of DRE responses seems to show that it is the screening’s association with the DRE that is likely driving the findings in Study 1. Considering that we are not aware of any emasculating stigma associated with a PSA blood draw, it is even possible that those who designated the PSA test as the main screening method may still be aware of the emasculating nature of the DRE. To this end, we feel the current findings linking honor endorsement to prostate cancer screening attendance are primarily due to the emasculating attitudes regarding the DRE, not the PSA test.

Study 2

Evidence from Study 1 suggests that honor-endorsing men are less likely to seek out prostate cancer screenings. In considering the possible consequences of this reticence to seek out screenings, one might consider the possibility that prostate cancer mortality could be an unfortunate potential outcome. Consistent with this view, in Study 2, we tested the assumption that prostate cancer deaths may be higher in regions where honor-oriented values are presumed to be more common.

Although not all undiagnosed cases of prostate cancer result in death, population studies have provided consistent evidence that screening procedures are linked with decreased prostate cancer mortality rates, likely due to the early detection of aggressive prostate cancers that these screening can help to identify (Callender et al., 2019; Fenton et al., 2018; Hugosson et al., 2019; Osses et al., 2019; Tabei et al., 2020). As noted by Riihimäki et al. (2011), decreases in the number of men with prostate cancer who actually die from cancer itself are primarily associated with early detection from screenings. This claim is further substantiated by analyses showing that if one was to apply the loosened 2013 screening guidelines of the American Urological Association to actual screening data from 2005 to 2010, approximately 27,000 annual prostate cancer cases would have been subsequently missed, with 13.5% of such cases being higher-grade, advanced-stage cancers (see Auffenberg & Meeks, 2014).

Further support for our hypothesis that honor-endorsing men are less likely to seek out prostate cancer screenings could be found if certain honor-oriented regions displayed higher levels of prostate cancer deaths, a direct, deleterious outcome of lower levels of screening. In Study 2, we specifically intended to test the hypothesis that prostate cancer deaths should be higher in honor states as opposed to non-honor states. Honor-state group classification divides the United States into honor and non-honor groups primarily by regional location. This division places most southern and western states in the honor-state category, with all other states (including Alaska and Hawaii) in the non-honor state category—this categorization established by Cohen (1998) has been used in a myriad of studies examining different outcomes as a function of regional differences in honor orientation (e.g., Barnes et al., 2012; Brown et al., 2009, 2014, 2018; Foster et al., in press; Osterman & Brown, 2011).

Analytic Framework: Data and Method

Outcome variable

Prostate cancer deaths were collected via the CDC’s WONDER database. Deaths were age-standardized rates per 100,000 for White, non-Hispanic males in the year 2017 (the most recent year in the WONDER data set). We elected for this approach to inherently control for age, ethnicity, and race to make values comparable across states while controlling for these variables. These data were compiled and made publicly available on the CDC website (CDC WONDER, 2020).

Culture of honor

Culture of honor group status, the predictor of interest for the current study, was constructed using Cohen’s (1998) dichotomy of the culture of honor states (0 = non-culture of honor state, 1 = culture of honor state).

Covariates

To isolate the impact of the culture of honor group status on prostate cancer deaths, as series of covariates were included. These included the proportion of individuals in each living close to an exercise location, the proportion of individuals who reported not having a secure source of food, and the obesity rate (each of these covariates are found at the University of Wisconsin Population Health Institute [UWPHI], 2017)—these covariates were selected as food insecurity, physical activity, and obesity have been implicated as contributing risk factors for prostate cancer (Brawley, 2012; Friedenreich et al., 2004; Orsini et al., 2009; Patel et al., 2019; Peisch et al., 2017). We also included the proportion of individuals who reported not having health insurance (Kaiser Foundation, 2017), as well as the proportion of individuals reporting not having a primary care physician (Kaiser Foundation, 2017), as individuals without health insurance or primary care physicians are less likely to seek out healthcare services, which may contribute to higher prostate cancer deaths (Moore et al., 2004; Wong et al., 2001).

Results

Bivariate correlations, means, and standard deviations can be found in Table 2. Culture of honor group status was significantly correlated with food insecurity (r = .58, p < .001), the percentage of individuals without a primary care physicians (r = .50, p < .001), and the percentage of individuals uninsured (r = .75, p < .001). The bivariate association between a culture of honor and prostate cancer death rate only approached significance (r = .25, p = .081). However, due to the fact that confounding variables may be suppressing the effect of the culture of honor on prostate cancer death rates, we continued with our analyses.

Table 2.

Bivariate Correlations, Means, and Standard Deviations for the Variables of Interest in Study 2.

Variable	1	2	3	4	5	6	7	M	SD
1. Honor	—	.25^†	.58**	−.28*	.50**	.75**	.08	0.50	0.51
2. Prostate		—	−.07	−.12	.25^†	.01	−.27^†	18.77	2.44
3. Food			—	−.34**	.27^†	.68**	.40**	0.15	0.03
4. Exercise				—	−.24^†	−.28^†	−.68**	0.79	0.11
5. Doctor					—	.61**	−.06	0.21	0.06
6. Insurance						—	.18	0.19	0.05
7. Obesity							—	0.28	0.04

Note. N = 50. Honor = Culture of Honor Group Status. Prostate = Prostate Cancer Death Rate. Food = Food Insecurity. Doctor = No Primary Care Physician. Insurance = Percent Uninsured.

†

p < .10. * p < .05. ** p < .01.

To isolate the effect of the culture of honor group membership, we first centered all predictors and covariates to be utilized in the following sequential regression analyses with prostate cancer death rate as the outcome variable. In Step 1 of our analysis, we entered all of our covariates, which included the exercise, obesity, food insecurity, primary care physician, and insurance status variables. Only the exercise variable (β = .50, p = .011) and obesity variable (β = −.59, p = .004) emerged as significant covariates—the set of covariates explained approximately 26% of the variability in prostate cancer death rates (R² = .263). In Step 2, we entered the dummy-coded “culture of honor group membership” variable into the regression analyses. Culture of honor group membership emerged as a significant predictor (β = .41, p = .048), indicating that culture of honor states tended to have higher prostate cancer death rates. Culture of honor explained an additional 6% of the variability in prostate cancer death rates (∆R² = .064).²

Study 2 Discussion

Study 2 intended to address whether cultures of honor states may have higher levels of prostate cancer deaths in White, non-Hispanic men, under the assumption that men in cultures of honor are less likely to seek out prostate cancer screenings. This state-level analysis provides evidence supporting this hypothesis, showing that culture of honor states tended to have higher levels of prostate cancer death rates compared with non-honor states, even after controlling for different covariates that have been implicated as contributing risk factors for prostate cancer. These findings are consistent with prior research showing that cultures of honor may pose a barrier to certain healthcare prevention procedures and screenings due to the stigma that such procedures may carry (Brown et al., 2014; Foster, Carvallo, Lee, Fisher, & Traxler, 2020). This evidence is also consistent with prior work showing geographical differences in the epidemiology of prostate cancer (see Klassen & Platz, 2006) as well as how culture may impact decision-makings to seek out screenings (see Chan et al., 2003). Finally, these findings help to support the individual-level evidence provided in Study 1 and suggest that honor-endorsing individuals may be at higher risk of prostate cancer-related death. Future research should continue to consider how regional variation in certain health outcomes and procedures may be a reflection of the culture of honor values manifesting at the regional level.

General Discussion

Prostate cancer is the second leading cause of death in men in the United States (American Cancer Society, 2020a). While the 5-year survival rates for early detection are near 100%, the 5-year survival rates for late detection (particularly in cases where cancer has metastasized) are as low as 31% (American Cancer Society, 2020b), rendering it critical for research to investigate factors that might help to facilitate screenings and ensure early detection. The current research examined the impact of the emasculating stigma attached to prostate cancer screenings on screening attendance in men from cultures of honor, whose masculine reputation is a central facet of a one’s identity. More specifically, we examined if honor-endorsing men are less likely to seek out and receive prostate cancer screenings and whether this behavior could result, ultimately, in a higher frequency of prostate cancer deaths in honor-oriented regions. We found support for our hypotheses across two studies. First, we showed that honor-endorsing men older than 50 years of age were less likely to have ever received a prostate cancer screening and that this association was due to the stigma of prostate cancer screenings (Study 1). Next, we showed that a culture of honor region tended to have higher levels of prostate cancer deaths than a nonculture of honor region, under the assumption that men in such cultures are not receiving screenings (Study 2).

These findings provide insight into how a cultural mindset (honor endorsement) appears to be decreasing the likelihood that certain men are seeking out prostate cancer screenings, putting them at greater risk for undetected prostate cancer and, subsequently, death from prostate cancer. Prior research has shown that, for certain groups, prostate cancer screening rates are particularly low. Such rates include those for African Americans and Asian Americans and are due to various factors, such as linguistic barriers, educational misunderstandings about screening practices, as well as embarrassment in regard to the digital rectal exam (R. A. Jones et al., 2009; Kandula et al., 2006; H. Y. Lee & Vang, 2010). The current study’s findings indicate yet another group, honor-endorsing men, who appear to exhibit a decreased likelihood to seek out screenings. In this case, reticence appears to be primarily a result of stigma.

As has been suggested by researchers and practitioners (see Chan et al., 2003), it would likely be beneficial for physicians to understand that, during patient–physician discussions, certain worries and concerns may be stemming from the patient’s cultural background and may, therefore, be extremely important to address. For honor-endorsing men, it may be useful to address concerns about prostate cancer screenings by informing patients as to the utility and application of the PSA test or the normalcy of screenings. More specifically, honor-endorsers in the United States may need to have concerns regarding threats to their own personal reputation explicitly addressed. This may be done by ensuring the confidentiality of screening procedures, thus reassuring men that others will not be aware of them partaking in a prostate screening procedure, therefore preserving their social reputation.

Prior research has also shown that men may avoid screenings for fear of a positive test, as treatment for prostate cancer may lead to the loss or damage of their sexual function (James et al., 2017). Given that sexual virility is also an aspect of honor-endorsers’ masculine reputation (Brown, 2016; Foster et al., in press), these fears may need to be assuaged as well. It would likely be useful to use specific message-framing when practitioners present screening options to honor-endorsing patients. Cherubini and colleagues (2005) found that framing prostate cancer screenings using a loss-framing method (i.e., stating that not being screened means you may lose out on certain health benefits) was the most effective method in improving attitudes toward prostate cancer screening. Honor endorsers may be particularly receptive to a loss-framing method if it was emphasized that early detection may prevent them from losing certain “honorable” traits, such as a loss of strength caused by treatment of metastatic prostate cancer, or the loss of erectile function often found in those with prostate cancer (see Burnett et al., 2007). Future research should consider employing a message-framing manipulation to test whether targeting these traits may be particularly beneficial for combatting screening reticence in honor-endorsing men.

One limitation of the current research is that due to the nature of our dependent variable (having either received a prostate cancer screening or never having receive one), it is unclear if honor-endorsing men are not actively following advice from their physician to obtain a screening, or if they are reluctant to discuss the topic with their doctor, altogether. While this ambiguity does not substantially change the findings of Study 1 (either way, honor-endorsing men appear to be avoiding screenings), it would provide further insight into which aspect of the patient–physician interaction would need to be targeted to increase screening rates through an intervention. For example, if honor-endorsing men are not actively following their physician’s advice to obtain a screening, interventions may be most useful if they are designed to establish trust with their primary doctor and to increase compliance to their doctor’s direction—after all, trust in and compliance to one’s doctor have been shown to be predictors of cancer screening behaviors in prior research (Adams et al., 2017; O’Malley et al., 2002). In contrast, if men are reluctant to engage even in discussing screenings with their doctors, it may be more reasonable to focus intervention strategies on other well-known, influential aspects of healthcare decision-making, such as a man’s significant other and peers (Bergner et al., 2018; Hoffman et al., 2010; R. A. Jones et al., 2009; McFall et al., 2009). Finally, it is also possible that doctors themselves are reluctant to discuss prostate cancer screenings with their patients. An honor-oriented physician may, perhaps, be more likely to feel that discussion of prostate cancer screenings poses a threat to their patient’s masculine identity in some way, or even avoid discussion of prostate cancer screenings so as to keep from having to administer the screening procedures, which they may see as threatening to their own identity or uncomfortable. All of these aspects of the patient–physician interaction would be important avenues for future research.

Finally, one may consider if such findings could be found in groups endorsing other cultural logics, such as those in face and dignity cultures. While research in these groups should certainly be explored, the tenets of these cultures suggest masculinity concerns may not be as strong of a threat to screening behavior compared with men in cultures of honor. As noted by Gul and Schuster (2020), one’s “self-worth is viewed as inherent and inalienable” in dignity cultures, and men are therefore not as strongly affected by the perceptions of others as in honor cultures (p. 342). In face cultures, self-worth is centered around harmony, humility, and deference to the social hierarchy, and overstepping one’s social boundaries can cause one to “lose face” (A. K. Leung & Cohen, 2011)—and would therefore expect deference to screening recommendations from doctors, considering the likely difference in hierarchical status between patient and practitioner. Considering that dignity and face cultures tend to also be found in certain geographical regions (e.g., the Northern United States and Japan, respectively), the current research therefore provides evidence suggesting that practitioners in specific regions (e.g., the southern and western United States) should be particularly attentive to the possibility of honor concerns influencing a patient’s health decisions. Future research should continue to explore how these concerns may impact other health decisions and screening behaviors that hold potentially threatening stigma.

It has already been established that men are disproportionately reticent to partake in preventive health measures, such as health screenings, to preserve their masculine identity in some way. Evidence also suggested that stigma may be a barrier to care in non-White populations (James et al., 2017). The current research expands upon this research W populations by showing that men from cultures of honor, who are perpetually concerned with their masculine reputation, would be less likely to seek out prostate cancer screenings. It also appears that honor endorsement subsequently increases the likelihood of death from prostate cancer, as evidenced by higher levels of prostate cancer deaths in honor-oriented regions. Given the widespread nature of honor endorsement in areas such as the southern and western United States, these findings present a significant yet complex cultural impact, which practitioners and healthcare providers will need to address to effectively manage this aspect of men’s health for this particular cultural subgroup.

Supplemental Material

sj-docx-1-psp-10.1177_01461672211065293 – Supplemental material for Damaged Masculinity: How Honor Endorsement Can Influence Prostate Cancer Screening Decision-Making and Prostate Cancer Mortality Rates

Supplemental material, sj-docx-1-psp-10.1177_01461672211065293 for Damaged Masculinity: How Honor Endorsement Can Influence Prostate Cancer Screening Decision-Making and Prostate Cancer Mortality Rates by Stephen Foster, Mauricio Carvallo, Matthew Wenske and Jongwon Lee in Personality and Social Psychology Bulletin

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Stephen Foster

Supplemental Material

Supplemental material is available online with this article.

Notes

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