The Meaning of Bariatric Surgery Among Male Patients: Self-Concept and The Search for Masculinity


Darren D. Moore, PhD, LMFT (Georgia)1 and April L. Few-Demo, PhD2


1 Couple and Family Therapy Program, California School of Professional, Psychology, Alliant International University, San Francisco, California.
2Department of Human Development, Virginia Tech, Blacksburg, VA. Correspondence: darren.moore@alliant.edu



Abstract

Using symbolic interaction theory, this phenomenological study was designed to explore how male patients made sense of their self-concept and masculinity during the bariatric surgery process, including their expe-rience prior to surgical intervention and post-surgery. Twenty men who had undergone bariatric surgery in the previous 5 years in the United States were interviewed. Three major themes emerged in the study: (1) men’s search to embody a stereotypical notion of masculinity; (2) men’s reflexive process about their own masculinity as their bodies changed; and (3) men’s efforts to sustain their renewed sense of manhood after bariatric surgery. Implications for research and clinical practice are provided.

Key words: Bariatric Surgery, Masculinity, Meaning, Self-concept


While there has been an increase in the number of individuals who have undergone bariatric surgery, there is a significant disparity among male patients, when compared to female patient counterparts. Specifically, researchers have found that women constitute 85% of all bariatric surgery cases, with men only constituting 15% in the United States.1 Possible reasons for the current disparity may include masculinity as it relates to men’s unwillingness to pursue weight loss treatment, men’s sense of personal responsibility for their weight gain, men’s issue with asking for help, and men’s stigma related to seeking medical intervention. 2 Due to the disparity regarding the rates of bariatric surgery among men when compared to women, researchers have neglected to explore men’s experiences as they transition through the weight loss surgery process.


A lack of research regarding male patients may contribute to a lack of understanding regarding a unique treatment population. Further, failing to conduct research regarding male patients may inad-vertently perpetuate gender disparities as it relates to bariatric surgery utilization and treatment. When considering the implications of obesity specifically on men’s health3 and that bariatric surgery is the most effective treatment for morbid obesity, 4 it is not only important, but critical to explore men’s experiences transitioning through the weight loss surgery process. The overall purpose of this phenomenological study was to explore how men constructed meaning out of their experience of dramatic weight loss due to bariatric surgery, specifically how the surgery influ-ences their sense of self-concept. The overall research question of this study was to explain how male patients’ experience of bariatric surgery influenced their self-concept and sense of masculinity.

RELEVANT LITERATURE

Self-Concept and Masculinity

Self-concept is a term used to describe the process by which individuals view themselves in juxtaposition to others.4,5 According to Yahaya and Ramli,4 “self-concept refers to the totality of a complex, organized, and dynamic system of learned beliefs, attitudes and opinions that each person holds to be true about his or her personal existence” (p. 25). Self-concept influ-ences identity construction, and can include thoughts, beliefs, and feelings, about self-worth, body image, and self-esteem.6 Self-concept for men seeking weight loss is filtered through their sense of masculinity. The phenomenology of men’s health should include men’s gendered sense of self which impacts their utilization of medical services and overall experience of under going medical treatment for weight loss. Identity, which is often associated with masculinity for men, may impact how one navigates through the health care system. Masculinity is expressed through the internalization and enactment of culturally-inscribed expectations about appropriate actions, behaviours, and thoughts for biological, male-identified men.7 Masculinity, in some ways, regulates the actions, behaviours, and thoughts of men, and it has an impact on how men perceive their bodies and help-seeking in regard to obesity and weight loss.

Masculinity and The Body

While researchers have traditionally focused on female gendered scripts as it relates to weight loss, they have started to consider gender scripts as it relates to men.8 From the literature on male body image, men who are overweight are considered less masculine. The male body has been referred to as either the “soft body” or the “hard” body. Feminist scholar Susan Bordo suggested that “the hard body is a symbolic representation of manhood, strength, virility, and dominance, while a soft body is a repre-sentation of femininity and weakness.”9 Bordo also stated that for men, “to be exposed as ‘soft’ at the core is one of the worst things a man can suffer in this culture.”9 Further, in Western society, a “real man” who is masculine does not ask for help.10 In addition, a real man presents with muscles, fashion sense, and the appearance of success. 11 In addition, Pope, Phil-lips, and Olivarida argued that achieving a muscular physique has become a coveted goal for men and that muscularity was “intimately tied to cultural views of masculinity and the male sex role.”12 According to Pope et al, a muscular body was a physical embodi-ment of power, strength, and efficacy.12

Masculinity is not only about how the body looks, but it is also about what the body does. High levels of body satisfaction are associated with the ability to engage in physical activity well.13 One of the issues that appear most frequently in the literature regarding obesity in men is sexual functioning. Researchers have suggested that obesity impacts men’s reproductive system and increases risks of sexual dysfunction and infertility.14 According to Hammoud et al, obesity decreases the ability for men to produce sperm and results in low sperm concentration. The inability to have children due to obesity status may pose as a threat to masculinity and one’s sense of identity.15 Father-hood is another contextual factor that is inextricably tied to masculinity for some men.16

Asking for Help

Researchers have identified that the mere act of men asking for help to lose weight is stigmatized as a personal weakness. This perception may be deeply rooted in some men’s dominant notions of masculinity or hegemonic masculinity and may serve as a barrier to them against seeking medical treatment. 17 Accord-ing to Barrett, “hegemonic masculinity” refers to·a particular idealized image of masculinity in relation to which images of femininity and other masculini-ties are marginalized and subordinated. 18 In order to seek help, men have to admit that there is something wrong with themselves and that obesity has had an impact on their understanding of gender and identity. Through the admission of helplessness, men are forced to take off the guise of a masculine toughness and their vulnerability is exposed. For example, psychologist Frank Pittman suggested that men often posed mas-culinity. Pittman argued that “men go through life struggling with what they believe to be the demands of their masculinity.”19 Thus, men’s decision-making processes includes, or at least is constructed around, dominant notions of masculinity which is related to self-concept.20

Post-Surgical Self-Concept

Researchers have explored the impact of bariat-ric surgery on self-concept and the findings vary.21 Researchers who have examined the post-operative stage of bariatric surgery have reported that most individuals experience improvements in self-concept, specifically as it relates to psychological health.22 However, Greenberg, Smith, and Rockhart found that improvements in self-concept were temporary and ceased to exist after a couple of years after surgery.23 In addition, researchers have documented that post-surgical patients do experience negative outcomes, specifically as it relates to self-esteem and making adjustments to a new lifestyle. A negative self-concept may result from a variety or chain of behaviours. For instance, some individuals become dispirited after failing to lose weight or regaining weight due to their inability to adhere to required behaviour changes and post-surgical medical appointments.24 Some individu-als develop eating disorders and other psychological issues after surgery.25 Negative reactions by peers, family, and other individuals can contribute to a negative self-concept.26 Finally, negative body image post-surgery due to the excessive amount of hanging skin that often occurs after weight loss can influence one’s self-concept.27

METHOD

For this study, a phenomenological design was utilized. Phenomenology is a qualitative research methodology that allows researchers to examine individuals’ in-depth perception of a specific lived experience. 28 The goal of phenomenology is to describe a phenomenon as it is experienced and described by participants. This study is part of a larger project in which the authors sought to investigate the impact of bariatric surgery on the marital relationship dynamics.29 Symbolic interactionism was selected specifically to guide the study because of its frequent use with phenomenology and its inherent focus on the self, self-concept, and meaning-making. According to Shirpak, Matika-Tyndale, and Chinichiam, “people actively engage in the interpretation and creation of symbols as a way of making sense of, assigning meanings to, and communicating about their daily lives and the world in which they live.”30 Symbolic interactionists believe that individuals act towards things based on the meaning they ascribe to them. In the case of dramatic weight loss, men assign meaning to this phenomenon through a multidirectional exchange between the individual (i.e., the male patient), his family system, and the larger society. In addition, symbolic interac-tionism attends to the concept of identity construction (i.e., how an individual represents himself and how an individual perceives he or she is viewed by others.5

SAMPLING PROCEDURES

We used a purposive sample of 20 men who have undergone a type of bariatric surgical procedure which included but was not be limited to the lap band, roux-en-y gastric bypass, duodenal switch, and gastroplasty. McCambridge, Mitcheson, Winstock, and Hunt suggested that “in purposive sampling, the sample is constructed according to predefined needs for data collection.” 31 Participants met the follow-ing inclusion criteria: (a) they had to identify as a heterosexual man; (b) they had weight loss surgery within the last 5 years; (c) they were at least 26 years old at the time of surgical intervention but not older than 65; (d) they were at least 6 months post-surgery at time of study; (e) they had been in at least one intimate or committed relationship after surgery; and (f) they had to be US residents. We selected the minimum age of 26 to specifically exclude adolescent populations and participants who would be considered emerging adults.32 Within qualitative research, there is an emphasis on a attaining a homogenous sample, and after a review of the literature it was determined that pursing the topic of weight loss surgery, gay, bi-sexual, or transgender individuals may have distinct experiences and perspectives regarding body image and masculinity.33 For example, researchers have in-dicated that body image and masculinity is uniquely complex and that having a larger sized body is one way for some gay men to exert their masculinity (i.e., bears and cubs).34

After IRB approval, 2 popular social networking websites served as the primary mechanism for recruit-ment. The first author created a channel on YouTube, and specifically recorded a video where the study was discussed. Specifically, the author read the content of the recruitment flyer which provided information regarding the study, eligibility criteria, as well as contact information for the principle investigator. Interested participants who came across the video had the ability to contact the researcher via email or directly through YouTube. The second recruitment site was a Facebook page created by the first author. Individuals who were connected to the first author had the ability to share the flyer within their Facebook network. Likewise, the first author searched for public Facebook pages specifically focused on weight loss surgery using Facebook’s analytics and advertising mechanisms and was able to post flyers to recruit participants via sent private messages. Facebook has been discussed as an online recruitment research tool in scholarly literature.5 Utilizing the Internet for re-cruitment has been widely implemented as a research method among scholarly researchers.35 In addition, a number of weight loss and bariatric surgery Internet websites were targeted for recruitment. Finally, flyers were posted at targeted local weight loss programs, hospital programs, and bariatric surgery centres in major cities in a southeastern state.

After being screened for the inclusion criteria, participants submitted signed copies of the informed consent form online. The men participated in a 60 to 90-minute semi-structured interview. Interviews took place in the participant’s home or online via Skype, a computer program that allows individuals the capability to have voice and video interaction over the Internet.36 Phenomenologists argue that a phenomenon of interest should be studied in its natural state of existence and that data should represent an actor’s (i.e., participant’s) own perspective.37 Before proceeding with online inter-views, participants confirmed that they were alone in a location during the interview process. All interviews were recorded utilizing a digital audio recorder.

ANALYTIC STRATEGY

After informed consent was confirmed and the interviews were conducted, the data was transcribed and coded utilizing a general inductive process. Ac-cording to Thomas, “an inductive analysis refers to approaches that primarily use detailed readings of raw data to derive concepts, themes, or a model through interpretations made from the raw data by an evalu-ator or researcher.”38 Further, the purpose of induc-tive analysis is to allow findings to emerge without constraints of preexisting theory. 39 Coding involved reading the interviews several times, making initial codes, and re-working codes simultaneously. Dahl and Boss suggested that analyzing phenom-enological data includes immersion, incubation, and reflection, as well as creative synthesis.37

The analysis process involved breaking each interview apart and searching for words, thoughts, and experiences. The first author assigned codes to bodies of text within the interviews and developed themes out of the codes which were utilized to show patterns in the research. The analysis process also involved comparing and contrasting the data from the multiple interviews. In the re-contextualization process of the phenomenological approach, the re-searchers examined the codes for patterns and then reintegrated, organized, and reduced the data around central themes and relationships.40 The first author coded the transcripts independently, along with a research assistant for triangulation purposes. The first author and research assistant utilized the following steps as described by Thomas: (1) conducting an initial reading of text data; (2) identifying specific texts segments related to objectives; (3) labelling the segments of the text to create categories, (4) reducing overlap and redundancy among the categories; and (5) creating a model incorporating most important categories.38 In addition, the researchers focused on meaning making and described participants’ lived experiences. After the first author and research as-sistant independently developed overarching themes, they met to discuss interpretation and the overarching themes for study. Cronbach alpha was not analyzed, as there was an overwhelming consensus regarding the themes. Further, Barbour suggested that “the degree of concordance between researchers is not really important; what is ultimately of value is the content of disagreements and the insights that discussion can provide for refining coding frames.”41 However, peer debriefing was provided by the second author, the qualitative research expert, to ensure rigour of interpretation and re-contextualization. The research expert also agreed with the emerging themes.

Rigour strategies. In efforts to promote credibility and transferability,41,42 the authors utilized the current literature and theory to guide the study and interview questions were developed by the authors’ understand-ing of major themes evident in the literature. We also addressed credibility through the incorporation of triangulation.43,44 The first author utilized several strategies to triangulate the data. He interacted with the second author to assist with coding for validation purposes.45 The second author assisted with changing the coding scheme and peer debriefing.46 Member checks were conducted in the research process to al-low participants the opportunity to provide feedback and further clarification regarding the interview.47 Participants had access to a copy of the interview transcript and initial research findings if so desired, and could propose changes to the research document. Emerging themes also were tested and triangulated by the analysis of negative cases.48 The first author com-pleted reflexivity assignments in efforts to acknowledge personal bias in the researcher 49 and maintained an exhaustive audit trail.50

RESULTS

Sample

Twenty men participated in a 60–90-minute semi-structured interview. Fourteen participants came from online sources while 6 came from offline sources. Of the 14 participants originally recruited online, 5 men were recruited from Facebook, 3 men were recruited from YouTube, 3 men were recruited from Obesityhelp. com, and 3 men were recruited from lapbandtalk.com. Seventeen interviews were conducted via Skype. Only 3 interviews were conducted in person. Sixteen par-ticipants self-identified as Caucasian, 2 identified as Hispanic, and 2 identified as being biracial (Mexican and Caucasian; Caucasian and Native American). The age range of participants was 29–64 (M=44). There was variation in terms of geography, religion, educa-tion level, income, number of children, length of being in a relationship, age, profession, type of weight loss procedure, total weight loss, and length of time out from surgery at the time of the interview. Participants reported a number of religious affiliations, 3 having no religious affiliation. Education level also varied, with the majority having a high school degree. Although some participants were unemployed, the average in-come for others was $43,225. Sixteen were married with children. The range for length of marriage was 3–36 years (M=14). Seventeen participants had gastric bypass surgery and 3 had the lap band procedure. The length of time post-surgery at the time of the study ranged from 6 months to 31 months (M=13.3 months). The average amount of weight lost by the participants was 122.5 pounds. Participants selected a pseudonym to protect confidentiality.

EMERGING THEMES

Men’s Search for Masculinity

One particularly poignant theme was the belief that real masculinity was inextricably tied to one’s ability to control oneself, specifically, one’s weight. Nineteen of 20 participants reported that they felt that losing weight by artificial means, such as weight loss surgery, embodied weakness. For example, one participant reported that having weight loss surgery meant that “you [were] powerless and less of a man.” During the surgery process, men revealed that they constantly ruminated about what it meant to be an obese male, and specifically discussed their percep-tions of gender as it related to obtaining weight loss surgery. For example, 3 participants stated:

Actually I think maybe if you’re a man you should be strong enough to lose it [weight] on your own, that’s what I think…so I think its [surgery], you know, for women. It is more acceptable for them to get surgery because, hey, they’re not as strong as a man…Whereas a man, they should be able to do it on their own…Suck it up and do it. (Paco, Age 32)

One of the biggest hurdles for me when it came to bariatric surgery was almost giving in to the idea that you are not man enough to do it on your own. If you can’t admit that, then you’ll never do it because you feel like it is an easy “non-man” way out. So, I think getting men to be able to say it, and admit they can’t use will power to do it, is important. (Bob, age 40)

For these men and others, being obese meant to be “less than real,” to be less masculine, to “be a failure,” and to be viewed as someone who did not measure up to what it means to be a man. For these participants, real men were capable of being a normal weight and body size. The men seemed to have internalized a belief that obese men were lazy and undisciplined. Obese men were perceived, as one participant (Mr. Green) described, as “non-people.” Participants adhered to a prevailing stereotypical, ideological construction of masculinity.

Fifteen participants discussed how their under-standing of masculinity impacted their decision to undergo weight loss surgery. First, they feared be-ing stigmatized by others, in particular, other men. Surgical intervention was a difficult decision for men to consider. Yet, these men also recognized that they had a health problem that they could not deny. Many participants (n = 19) believed that it was more accept-able for women to undergo weight loss surgery than men. Fifteen men reported that the people around them, including friends and family, perceived surgery to be taking the “easy way out.”

While participants eventually overcame their negative perceptions about having surgery, their responses revealed that this perceived violation of masculinity evoked a certain level of anxiety in them. For example, some purposely withheld or denied the fact that they had surgery. Some preferred to keep their surgery private in order to prevent others from judging them. Many reported that they felt ashamed by not being unable to lose weight on their own, for even considering the decision to undergo surgical intervention, and not being able to embody “real” masculinity. Bariatric surgery, for these men, became the only way to attain a true manhood, and become a real man in the eyes of their peers, family, intimate partners, and society at large.

“I’M A REAL MAN NOW:” MEN’S REEVALUATION OF SELF AFTER SURGERY

The men’s significant weight loss had an impact on how they perceived their bodies, social relationships, and health. All participants, reported experiencing a cognitive identity shift in how they saw themselves as “men” during the pre- and post-operative processes.

Prior to surgical intervention, men viewed themselves as depressed, unhappy, and as “less than a man.” After surgery, all of the men reported that they thought about themselves in more positive ways. They reported having a higher self-concept. They also reported changes in how they felt about themselves and how they perceived they were viewed by others:

I think of myself as a good father and husband because now I’m able to do everything now that I never had energy to do before. I go bike riding with my boys. I go swimming with my boys. I go hiking with the cub scouts and I’m actually the dad that doesn’t get tired doing these things. No.….I’m a role model to them, whereas before I was kind of ashamed of the type of person that I was, and now I’m pretty proud of who I am. (Nobley, age 42)

I’m a lot more sure of myself. I think at 405 pounds I had almost given up on myself, given up on challenging myself and chasing my dreams. But now, it’s like I feel like there’s nothing I can’t do if I work hard enough. I mean I have goals…and I th ink if I just stay focused on them and work hard, I will get there. Whereas before, I just kind of gave up on pursuing them. (Paco, age 32).

After the surgery, all participants reported that they had a more positive outlook on life. They described themselves as excited, happy, nervous, surprised, energetic, lively, exuberant, not self-conscious, and positive, attractive, masculine, strong, confident, secure, and as a real man. They reported feeling less self-conscious about their bodies after surgery. For example, they reported feeling less self-conscious about eating in public places, sitting down in chairs, flying on airplanes, and interacting with others. They had an ability to do more things after surgery than they were able to do before surgery, specifically as it related to employment and exercise.

Eighteen participants discussed how surgery resulted in an increased level of social interaction. Some men who previously self-identified as an “introvert” became more socially active. For example, Lucas stated:

Before I was just kind of like an introvert, like in a shell, because I was really afraid to talk and would always be off to the side at a party, until I drank enough and built up the courage … But now, when I walk in I don’t mind being in the centre of attention and cracking jokes. I do a lot more of that now that I’m less heavy. (Lucas, age 48).

During the interviews, participants talked about how their mental health had been impacted through the weight loss process. Overall, all participants felt less depressed after surgery. They reported that they no longer struggled with depression. James shared:

I think just with the depression being gone, I think that was one of the biggest things that was holding me back just from doing anything. I feel now that I’m not as insecure about what people may think about me because of my size. (James, age 33)

I think of myself as a good father and husband now because I’m able to do everything now that I never had energy to do before… I’m actually the dad that doesn’t get tired doing these things now. I enjoy doing all the things that the other kids’ fathers were able to do without effort. Now I do it without effort and I enjoy doing it, and I think it’s made me a better husband and a better father and how I view myself as being just more of a role model to my family. (Nobley, age 42)

After the surgical intervention, men shifted from viewing themselves and experiencing life as “less than a man,” as inadequate fathers and male counterparts, and as depressed. After the weight loss, they viewed themselves as men, as healthy men, better fathers, and better husbands. The men’s change in self-concept had implications regarding the way in which they viewed their role in the world, fundamentally influencing their interaction with it.

MEN’S EFFORTS TO SUSTAIN “ACQUIRED”

MANHOOD

Having achieved a change in status with their new bodies and positive interactions with the social world, the men expressed a desire to work at maintaining t heir newly acquired sense of authentic manhood. Part of sustaining this redefined self, involved a commit-ment to maintenance work, specifically as it related to food consumption, exercise, and health and wellness.

A work in progress…I’m not there yet, I still have [more to lose]…I set a pretty realistic goal of 225 pounds. I still have about 66 pounds before I get to that. It’s do-able, but I know when I look at myself I’m not there yet. I’m getting there. (Tom, Age 35)

Since the weight loss, I have a lot of extra skin… I’m not comfortable with my shirt off now…I am a little self-conscious. I have extra skin on my chest. I have extra skin on my stomach; there is extra skin on my whole arm… loose skin. (Al Cargo, Age 59)

My goals have moved onto bigger and better things… I have a 15K and 2 half marathons this year and next year I’m competing in the Augusta Half Iron Man, the 73-point triathlon. Having these races and events keep me on track with my lifestyle, because I know that’s going to be my key to success and long-term mainte-nance, and being able to maintain who I’ve become. (Nobley, Age 42)

Their efforts to maintain a new self was demon-strated by the men’s perception of their bodies as evolving and as “still a work in progress.” Participants described their post-surgical bodies as “changing in the moment.” The men also reported that they were still adjusting to their new bodies. For example, Bruce stated, “I feel okay. I’m still getting used to it, you know, it’s like, I think that I look pretty slim. I wear like a 36 pants now and extra-large shirt which is like a miracle in itself, you know.”

In addition, participants reported that while they had lost some weight, they still had the desire to lose more to obtain their ideal body size, shape, and level of muscularity. All of the men mentioned that they had not yet achieved their weight loss goals. Thirteen participants reported feeling positive about their bodies and about the responses they received from others, they also mentioned experiencing body dis-satisfaction. Likewise, 13 men felt some level of dis-comfort about their bodies due to excess and “loose” skin that resulted from the surgery. At least 3 men explicitly stated that they experienced issues with body image beyond excess skin. Although Andrew, Nobley, and Gratz lost a significant amount of weight, they still struggled with how they viewed themselves and how they constructed their identity as men. This physical incongruence with how they believed that their bodies should be is indicative of the variance in their self-perceptions over time. For example, when asked about his sense of body image after surgery, Gratz stated:

Um…It’s kind of weird to say this, I know I’ve lost a lot of weight. I went from a 4X shirt down to a M but I still view myself as being the same size…I expected to have the surgery, lose the weight, feel great, want to go do things, and show off my new body, but I still tend to be shy. I don’t want to take my shirt off in public. Mentally, I’m still the same.

Although Nobley was one of the participants who was actively engaged in maintaining his new self through running marathons among other things, he also experienced times when he viewed himself as overweight. He stated, “I still see myself and think about myself as the fat guy and I’ll always to some degree see myself as being the fat guy.” Overall, the men expressed that sustaining their newly acquired masculinity and self-concept was a continual process, requiring much vigilance to maintain their perceived new status among partners, children, and others. In-formants discussed new workout regimens, dieting procedures, and ways in which they obtained social support in their endeavours after surgery.

NEGATIVE CASES

There was one case, Paco, who contradicted our major theme that most men equated weight loss to a reinvigorated sense of masculinity and existence. How-ever, it is important to note that Paco self-identified as half Caucasian and half Mexican, which is different than all of the other participants in the study. While Paco did not explicitly state culture or race and ethnicity as contextual factors that influenced his experience, it is possible that his experience could possibly be related to ethnicity. There have been a number of researchers who have found that larger bodies are viewed as ideal among some Mexican and other Hispanic or Latino populations when compared to European Americans.51 In addition, there have been other researchers who have explored the concept of body size and machismo among Hispanic and Latino populations.52 These gendered cultural expectations and body size preferences potentially could have nfluenced how Paco viewed his body. However, e thnicity was not a specific focus of the study and additional questions were not incorporated to appro-priately explore these contextual factors.

DISCUSSION

Identity, Masculinity, and Social Construction

As the men in this study lost weight, they grappled with how they thought of themselves as men as their bodies “changed,” how they perceived others might see them as men, and how the weight loss changed their overall sense of self-concept. From the data, it seems that the process of bariatric surgery for middle-aged men is one that is filled with gladness and ambivalence. All of the men adhered to a traditional, stereotypical sense of masculinity in that they saw their previous “soft” bodies as not being in alignment with an ideal male body. Their desire to alter their bodies in order to achieve some semblance of masculine perfection and status was a major intrapersonal motivation for surgical intervention. From the data, it seems that the men were, in a way, unprepared emotionally for the “identity shift” that co-occurred with the metamor-phosis of a physical body that was still in the process of becoming something that aligned more with their understanding of physical masculinity. In addition, this lack of preparation appeared to have implications for how men experienced the transition after surgery, and specifically how they perceived to be viewed by others. This is a new finding particularly in the areas of weight loss surgery among obese men and may have implications for clinical treatment.

Significantly, many men described their lives prior to surgery as being one of non-existence as a human being, not just as a man. They described their obese bodies as a detriment and a barrier to presenting a masculine self to the world as well as enacting and participating in a social world. They described their bodies as disallowing them of engaging in physical activities that normal sized men engaged in. The con-sequence of becoming more “real,” more masculine, was a lingering feeling of ambivalence as men were confronted with internal thoughts and perceptions. In addition, it is important to note that participants experienced weight loss and becoming “real” men within the context of relationships, which involved receiving feedback from others. Although men reported positive feelings, they also felt uncomfortable with their bodies. This paradox is consistent with other studies regarding men’s body image.53 During the study, men reported viewing their bodies as “a work in progress,” thus still evolving.

Many of the men lost half of their body size or close to it. They reported that they wanted to lose more weight and that they saw their bodies as still needing improvement. The term “still a work in progress” also represents the perception that men’s bodies have not reached their full potential. Thus, body dissatisfac-tion certainly informed their sense of self. Although men lost weight, many men perceived their bodies as being “soft” due to the enormous amount of hanging skin that they had. Although men lost weight, it is important to note that they may have not been trained to become physically fit in order to align their bod-ies with their perceptions of the phenotype of a real man’s body. This omission may have contributed to some participants’ ambivalence after surgery and their increased desire to obtain the ideal male body type. Many men reported not only wanting to lose weight, but also wanting to gain muscle, as they viewed muscularity an important aspect of their new identity. According to Filiault, “the reason for such importance of muscle to men may be its cultural as-sociation with masculinity, in that muscle is thought to be indicative of masculinity and a man’s status as a man.”54 Therefore, as one thinks about the weight loss process, it is important to include body shape, not just weight, when considering dominant notions of masculinity and identity development. Unlike previous studies that have focused only on changes in pounds, this study emphasized the cognitive process of men making sense of their bodies through weight loss. Fur-ther, it appears that mens’ ideas about surgery and its ability to help them achieve an ideal masculine body, and their experiences are not congruent. Therefore, it may be worth considering ways to address cognition when preparing men for such a surgical intervention.

Although their evolving bodies provided affirmable indicators moving toward the physical representation of authentic masculinity, most men still struggled with body image. This struggle may partially explain the increase in men attempting to obtain body contouring after surgery or an increase in the use of supplements (i.e., anabolic and adrongenic steroids) 55 to enhance their bodies.56 It should be noted that men reported feeling more confident in their ability to live a normal well-adjusted life. Prior to surgery, they reported that they felt insecure about their weight and their bod-ies. However, they mentioned that as they began to lose weight, they started to feel an increased level of confidence. They reported transitioning from a life of mere existence to one that was vibrant, most of which they attributed to their weight and body size.

Symbolic Interactionism and Masculinity Scripts

Given that social interaction is a bi-directional process, it can be hypothesized that men’s self-concept also impacted how they viewed their own sense of masculinity. In this study, men’s decision-making processes included, or at least was constructed around, how dominant notions of a traditional masculinity intersected with an archetypical muscular male body type that was not immediately attainable. Also, many participants discussed the fact that to have surgery meant that the men had to admit that there is a prob-lem. For these men, admitting that one doesn’t have the self-control to lose weight was equated with being weak. Help-seeking was internalized as stigmatizing. Their help-seeking behaviours forced the men to work through the cognitive dissonance of desiring a legitimate manhood and seeing a physical body and meeting an unattainable ideal without the surgery. To attain help, one needed to expose vulnerabilities in terms of how they perceived themselves as men and how they presented themselves to others.

Masculinity scripts could be viewed as support-ing the idea that it is not fitting for a man to undergo weight loss surgery, especially when considering the affirming messages received from women and loved ones. Scripts may have contributed to many partici-pants’ decision not tell others that they had surgical intervention. Many participants reported that they desired to keep their surgery a secret. The need to keep surgery private arguably also contributes to the marginalization and the silencing of men who have surgery. This is consistent with the literature regarding men and masculinities as it relates to help-seeking barriers for men seeking to lose weight.17 In essence, self-concept was not simply achieved; it maintained, re-negotiated, and re-constructed over time as it relates to men’s weight, body image, and self-worth.

CLINICAL IMPLICATIONS

With bariatric surgery being an intervention that impacts one’s self-concept and how one views masculinity, it might be appropriate to consider ways to broach such topics prior to surgical intervention. As part of the screening process or pre-clinical inter-view, it might be appropriate to consider including questions regarding masculinity and weight to inquire about how men view themselves prior to intervention. As men prepare for surgery, talking with men about their ideas regarding their expectations of weight loss could prove to be helpful in assisting men with having clear goals and realistic ideas about their post-surgery experience. For example, it could be beneficial for male patients to meet with a licensed mental health profes-sional to tease out why they are interested in surgery and to help them consider ways to ameliorate their perspectives of authentic masculinity post-surgery. A licensed mental health professional perhaps could also assist men with making the transition after surgery as it relates to some of the concerns they may have related to their excess hanging skin as well as their perceived demands of maintaining after weight loss. It may also be warranted to consider ways to connect men through support groups. Social support groups, in person or online, may be helpful when considering ways to connected men who may feel isolated in their own respective geographical location. Further, with the emergence of technology, online curriculum and social networking may be beneficial in supporting men and educating men regarding body image, masculinity, and identity. Likewise, considering men’s experiences within the context of interpersonal relationships may be warranted as men engage in social interaction and intimate relationships.29 Other clinical interventions could be developed to assist men as it relates to mas-culinity and seeking weight loss intervention.

LIMITATIONS OF RESEARCH

The sample included mainly middle-class Caucasian men. Perhaps having men from lower and higher socioeconomic statuses may have yielded different results. Another limitation regarding the sample relates to race and ethnicity. We were not able to obtain participants from the African American community, which could have enriched the study due to the increasing rates of obesity among this population. Likewise, additional research is needed to explore health disparities as it relates to bariatric sur-gery and race, ethnicity, and socioeconomic status.57

FUTURE RESEARCH

The research regarding men and bariatric surgery could be expanded in a number of ways to enhance the extant literature. One area in which the research could be expanded is regarding race and ethnicity. A study that includes African American men could provide additional information regarding contextual factors particular to them.58 In a future investigation, a sample consisting of African American men could be utilized to explore cultural group differences and African American male identity. A future study could also utilize a sample of gay men to see if their experi-ences are similar or different from heterosexual men as it relates to shifts in identity construction. Additional ways to expand the research include interviewing men and their partners as well as incorporating ad-vanced statistical design.

REFERENCES

1. Hensrud DD and Klein S. Extreme obesity: A new medical crisis in the United States. Mayo Clinic Proc 2006;81:S5-S10.

2. Lewis S, Thomas SL, Hyde J, and. A qualitative inves-tigation of obese men’s experiences with their weight. Am J Health Behav 2011;35;458–69.

3. Moore DD and Willis ME. Men’s experiences and per-spectives regarding social support after weight loss surgery. J Mens Health 2017;12(2).

4. Buchwald H. Bariatric surgery for morbid obesity: Health implications for patients, health professionals, and third-party payers. Surg Obesity Relat Dis 2005; 4 371–81.

5. Zhao S, Grasmuck S, and Martin J. Identity construc-tion on Facebook: Digital empowerment in anchored relationships. Comput Human Behav 2008;24:1816–36. doi: 10.1.1.168.4349[1]

6. Clabaugh A, Karpinksi A, and Griffin K. Body weight contingency of self worth. Self Ident 2008;7:334–59.

7. Pleck JH, Sonenstein FL, and Ku LC. Masculinity ideology: Its impact on adolescent males’ heterosexual relationships. J Soc Issues 1993;49(3):11–29.

8. Monaghan LF. Men and the war on obesity: A socio-logical study. Routledge. 2008.

9. Bordo S. The male body: A new look at men in public and in private. New York: Farrar, Straus and Giroux; 1999.

10. Galli N and Reel JJ. (2009). Adonis or hephaestus? Exploring body image in male athletes. Psychol Men Masculin 2009;10:95–108. doi:10.1037/a0014005

11.Alexander S. Stylish hard bodies: Branded masculin-ity in “Men’s Health” magazine. Sociolog Perspect 2003;46:535–54.

12. Pope HG, Phillips KA, and Olivardia R. The Adonis complex: The secret crisis of male body obsession. New York, New York: The Free Press. Philadelphia, PA: Brunner-Routledge; 2000.

13. Philips JM and Drummond M. An investigation into the body image perception, body satisfaction and exercise expectations of male fitness leaders: Implications for professional practice. Leisure Studies 2001;20:95-105.

14. Kort HI, Massey JB, Elsner CW, et al. Impact of body mass index values on sperm quantity and quality. J Androl 2006;27:450–52.

15. Hammoud AO, Gibson M, Peterson CM, et al. Impact of male obesity on infertility: A critical review of the current literature. Fertil Steril 2008;90:897–904.

16. Finn M and Henwood K. Exploring masculinities within men’s identificatory imaginings of first-time father-hood. Br J Soc Psychol 2009;48:547–62.

17. Sabinsky MS, Toft U, Raben A, and Holm L. Overweight men’s motivations and perceived barriers towards weight loss. Eur J Clin Nutrit 2007;61:526–31.

18.Barrett FJ. The organizational construction of hegemonic masculinity: The case of the US Navy. Gender, Work Organiz 1996;3:129–42.

19.Pittman F. Man enough: Fathers, sons, and the search for masculinity. NewYork, New York: Berkeley Pub-lishing; 1993.

20. Courtenay WH. Constructions of masculinity and their influence on men’s well-being: a theory of gender and health. Soc Sci Med 2000;50:1385–401.

21. Grimaldi D and Van Etten D. Psychosocial adjustment following weight loss surgery. J Psychosoc Nursing Ment Health Serv 2010;48:24–29, doi: 10.3928/02793695

22. Andersen JR, Aasprang A, Bergsholm P, et al. Anxiety and depression in association with morbid obesity: Changes with improved physical health after duodenal switch. Health Qual Life Outcomes 2010;8:1–7. doi: 10.1186/1477-7525-8-52

24.Tejirian T, Jensen C, Lewis C, et al. Laparoscopic gastric bypass at a large academic medical center: Lessons learned from the first 1000 cases. Am Surg 2008;74:962–66.

25.Kalarchian MA, Marcus MD, Wilson GT, et al. Binge eating among gastric bypass patients at long-term follow-up. Obes Surg 2002;12:270–75.

26.Earvolino-Ramirez M. Living with bariatric surgery: Totally different but still evolving. Bariat Nurs Surg Patient Care 2008;3:17–24.

27.Mitchell JE, Crosby RD, Ertelt TW, et al. The desire for body contouring surgery after bariatric surgery. Obes Surg 2008;18:1308–12.

28.Rossman G and Rallis S. Learning in the field: An introduction to qualitative research. Thousand Oaks, California: Sage; 2003.

29. Moore DD and Cooper CE. Life after bariatric surgery: Perceptions of male patients and their intimate relationships. J Marital Family Ther 2016;42(3):495–508.

30.Shirpak KR, Matika-Tyndale E, and Chinichiam M. Iranian immigrants’ perceptions of sexuality in Canada: A symbolic interactionist approach. Can J Human Sexual 2007;16:113–28.

31. McCambridge J, Mitcheson L, Winstock A, and Hunt N. Five year trends in patterns of drug use among people who use stimulants in dance contexts in the United Kingdom. Soc Study Addict 2005;100:1140–49. doi:10.1111/j.1360-0443.2005.01127.x

32. Arnett JJ. Emerging adulthood: A theory of development from the late teens through the twenties. Am Psychol 2000;55:469–80. doi: 10.1037//0003-066X.55.5.469

33.Duncan D. Out of the closet and into the gym: Gay men and body image in Melbourne, Australia. J Mens Studies 2007;15:331–46.

34. Manley E, Levitt H, and Mosher C. Understanding the bear movement in gay male culture: Redefining masculinity. J Homosexuality 2007;53:89–112.

35. Suarez-Balcazar Y, Balcazar FE, and Taylor-Ritzler T. Using the Internet to conduct research with culturally diverse populations: Challenges and opportunities. Cultural Divers Ethnic Minor Psychol 2009;15:96-104. doi:10.1037/a0013179

36.Nicholas D and Rowlands I. Social media use in the research workflow. Information Service Use 2011;31:61-83. doi:10.3233/ISU-2011-0623

37. Dahl CM, and Boss, P. The use of phenomenology for family therapy research: The search for meaning. In D. H. Sprenkle & F. P. Piercy (Eds.), Research methods in family therapy (2nd ed., pp. 63-84). New York: Guilford; 2005.

38. Thomas DR. A general inductive approach for analyzing qualitative evaluation data. Am J Eval 2006;27:237–46.

39. Strauss A and Corbin J. Basics of qualitative research (2nd ed.). Newbury Park, CA: Sage; 1998.

40. Starks H and Trinidad S. Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qualitat Health Res 2007;17:1372–80.

41.Baxter J and Eyles J. Evaluating qualitative research in social geography: Establishing rigor in interview analysis. Transactions of the Institute of British Geo graphers 1997;22, 505-525. doi: 10.1111/j.0020-2754.1997.00 505.x

42. Guba EG and Lincoln YS. Competing paradigms in qualitative research. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (pp. 105-117). Thousand Oaks, CA: Sage; 1994.

43. Denzin NK. The research act: A theoretical introduc-tion to sociological methods. Chicago: Aldine; 1970.

44.Seale C. Quality in quality research. Qualitat Inquiry 1999;5:465–68.

45. Parkman TS. The transition to adulthood and prisoner reentry: Investigating the experiences of young adult men and their caregivers. (Unpublished doctoral disserta-tion). Virginia Tech University, Blacksburg, VA; 2009.

46.Lincoln YS and Guba EG. Naturalistic inquiry. Newbury Park, CA: Sage Publications; 1985.

47. Guba, E. G., & Lincoln, Y. S. (1989). Fourth generation evaluation. Newbury Park, CA: Sage.

48.Mays N and Pope C. Qualitative research in health care: Assessing quality in qualitative research. BMJ 2000;320:50–52.

49. Richardson L and St. Pierre EA. Writing a method of inquiry. In Denzin NK and Lincoln YS. (Eds.), The Sage handbook of qualitative research (pp. 959-978). Thousand Oaks, CA: Sage; 2005.

50. Golafshani N. Understanding reliability and validity in qualitative research. Qualit Rep 2003;8:597–607.

51. Sira N and Pawlak R. Prevalence of overweight and obesity, and dieting attitudes among Caucasian and African American college students in Eastern North Carolina: A cross-sectional survey. Nutrit Res Pract 2010;4:36–42.

52. Fragoso JM and Kashubeck S. Machismo, gender role conflict, and mental health in Mexican American men. Psychol Men Masculin 2000;1:87–89.

53. Drummond M. Men’s bodies and the meaning of mascu-linity. Paper presented at the Ian Potter Museum of Art Masculinities Symposium Proceedings: Masculinities: Gender, Art and Popular Culture; 2005.

54.Filiault SM. Measuring up in the bedroom: Muscle, thinness, and men’s sex lives. Internat J Mens Health 2007;6:127–42.

55. Song AY, Rubin JP, Thomas V, et al. Body image and quality of life in post massive weight loss body contour-ing patients. Obesity 2006;14:1626–36.

56. Atkinson M. Playing with fire: Masculinity, health, and sports supplements. Sociol Sport J 2007;24:165–86.

57. Varela JE and Nguyen NT. Disparities in access to basic laparoscopic surgery at U.S. academic medical centers. Surg Endoscop 2011;24:1209–14.

58. Moore D, Cooper C, and Davis-Smith YM. African American obese mens' attitudes and perceptions of bariatric surgery: a phenomenological study. Spec-trum: J Black Men 2016;4(2):43–60.