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Despite significant advances in nutrition, health and weight-loss treatments, there is a global epidemic of overweight and obesity [1]. Obesity is the result of significantly greater energy consumption than expenditure, and it is associated with long-term health problems including diabetes, cardiovascular disease, high-blood pressure, high cholesterol and some cancers [2]. Excess body weight has also been associated with depression, anxiety and low self-esteem [3]. Colagiuri and colleagues [4] estimate that the total direct cost of overweight and obesity in Australia was a substantial A$21 billion in 2005. Obesity is a serious issue and current treatment strategies are modest at best with limited long-term success [5], making it critical to investigate new approaches to the prevention and treatment of obesity.

Gender research provides a new approach to understanding obesity. It is generally recognised that multiple factors contribute to excess weight, and medical, nursing and psychological literature have all considered this issue. The rapid increase in obesity rates worldwide suggests genetic causes alone are not sufficient to account for the epidemic and the importance of technology and sedentary lifestyles is well recognised [6]. Gender research has the potential to investigate the heterogeneity between and amongst men and women that may explain or give insight into why lifestyle behaviours are generally not altered by obese people. Consideration of an individual’s experience of obesity will enable

108the development of tailored weight-loss programs, rather than treatments that treat all men and all women as a collective group.

The gender relations approach

The contemporary theory of gender is gender relations, where gender is defined as ‘a structure of social relations that centres on the reproductive arena, and the set of practices (governed by this structure) that bring reproductive distinctions between bodies into social processes’ [7, p10]. Gender is an internally complex social structure that is actively constructed and comes into being as people (inter)act. An individual’s gender is dynamic and constantly configured as it interacts with other social structures including ethnicity, sexuality and class. Multiple femininities and masculinities exist, and these are viewed as gender projects that can be challenged, reconstructed and contested [8, 9]. An individual’s gender is considered relational to other’s constructions of gender and thus people are positioned within a gender order. Hegemony, for example, is an idealised and dominant form of masculinity that is powerful, influential and strong. Other types of masculinity include complicit, marginalised and subordinated masculinities [6].

The body is a reproductive arena through which social practice occurs and gender is constructed. The body is both a recipient of social practice as well as an agent in social practice. As embodied beings we are recipients of emotions from others’ actions, while simultaneously able to act in ways that create emotions in others. Social embodiment refers to the way bodies, as agencies, participate in society, and how in turn society affects bodies [10]. Some bodies for example encounter violence, accidents and sickness as a result of social practices, and this contributes to their configuration of gender [10]. To this end, obese bodies are constituted in social processes that are created in history and subject to change, and therefore could be explored as patterns of gendered social embodiment.

Gender, health and obesity

From the perspective of a gender relations approach, research on obesity demonstrates the validity of gender as a concept that manifests in social practice. For example, differences and inequalities between genders may help to explain general health differences among men and women. For example men are less likely to receive health screens, report symptoms and attend medical services than women [11, 12], and are more likely to engage in risky behaviour [13]. However not all men engage in risky behaviour and not all women have regular medical check-ups. Societal norms can influence the health of different genders beyond any biological sex differences, although there are differences in how people are affected. A gender relations approach focuses on how an individual’s interactions with others and society significantly contribute both to opportunities for and constraints on health [14]. These, in turn, can give insight into the cause, maintenance and treatment of obesity.

The focus in the empirical literature on sex differences in obesity is a starting point for understanding the impact of gender on health behaviours. There are complex sex differences in the prevalence, effects and treatment of obesity. A growing number of studies 109for example suggest sex differences in rates of obesity exist in a dynamic relationship with ethnicity, age, geography and socioeconomic status worldwide [15, 16, 17]. Wang and Beydon’s [15] systematic review and meta-regression analysis of obesity prevalence studies in the US reported large ethnic differences in obesity prevalence, especially among women. Minority groups, including non-Hispanic blacks and Mexican Americans, had a higher combined prevalence than non-Hispanic whites. Non-Hispanic blacks overall had the highest prevalence of obesity which, in women, was 20 percentage points higher than obesity prevalence among white women [15]. Prevalence was also affected by socioeconomic status (SES) and the effect differed by ethnic group. Less educated persons were more likely to be obese than their more educated counterparts, except amongst black women where higher education was associated with a higher rate of obesity [15].

The complex dynamic between sex, SES, ethnicity and obesity prevalence also exists in Australia. Obesity prevalence is higher among men and women from lower socioeconomic status, less educated people, Aboriginal and Torres Strait Islander peoples, and among migrants [18]. Data from the 2004 to 2005 National Health Survey indicate that people born overseas are more likely than people born in Australia to be overweight or obese, and within this group, men are more likely to be overweight or obese than women (58% compared to 43%). Indigenous Australians have nearly double the likelihood of non-Indigenous Australians to be obese, and are almost three times more likely to be morbidly obese [18].

The differences between males and females and the effects of obesity also appear to be complex. A recent meta-analysis of cross-sectional studies of depression and obesity (defined by BMI) in the community found a significant positive association for women but not men [19]. However another systematic review and meta-analysis of longitudinal studies revealed a reciprocal link between depression and obesity (n = 58 745) in both men and women [20]. This study also found a potential cultural influence as the risk of developing depression when obese was more pronounced in the American subjects compared to their European counterparts [20]. This complexity also exists in research on sex differences in obesity and anxiety, body image, quality of life [21, 22, 23, 24], and weight loss. Considerable individual differences exist in the efficacy of weight-loss interventions, however this is often concealed by reporting mean differences [5]. Rates of dropout in weight-loss studies are also high (30%–60%) [5]. A range of behavioural, physiological and inherited factors have been put forward to explain the relative success of different individuals in losing weight through exercise [25].

Gender theory can help untangle the inconsistencies in the literature as it refrains from categorising men and women into groups, as gender is dependent on an individual’s social and historical context. The failure to account for within-group and within-person variability has been suggested to be partially responsible for inconsistencies within the literature on sexual differences in other areas including healthcare utilisation [26]. Categorising by sex does not adequately explain why only some men and some women become obese, nor does it explain why only some obese men and some obese women lose a significant amount of weight. Biological and inherited characteristics are known to contribute to adipose profile 110[6] and the propensity to lose weight [25]; however social factors of obesity are also strongly acknowledged. Gender relations theory focuses on how the body navigates through and how it is affected by society.

The study and its method

While there is growing research investigating sex differences in obesity, there is a paucity of studies investigating the role of gender. Gender as configurations of social practice may influence the lifestyle behaviours people engage in. It could be hypothesised that a person’s positioning within the gender order will influence their ability to alter lifestyle behaviours (eating habits, smoking, diet and exercise), thus influencing their weight.

We conducted a study to examine, using a gender relations approach, the lived experience of men who are or have been obese. We investigated the impact obesity has on identity, social practice and gender relations in order to discover why individuals are successful (or not) in changing their lifestyles and behaviours. Life history methodology was used to collect personal narratives from obese men, two of which are presented here. The life history method is used to explain an individual’s understanding of social events, movements and political causes, and how individual members of groups or institutions see, experience and interpret those events [27]. It is thus a useful way to gain a perspective on and understanding of the gendered experiences of obese men.

Data analysis consisted of the identification of patterns of social response to trace a historical dynamic of gender. A progressive-regressive method of analysis was employed where the life story provides the personal link to wider issues of history and culture [27]. In the first phase of analysis, a four-dimensional structural model of gender relations (production, power, emotion and symbolism) described by Connell [9, 10] was used to ascertain the informant’s experience of gender and their position in the gender order. Each transcript was then analysed to map the informant’s gender project – the construction and reconstruction of masculinity. Gender starting points and the trajectories of the gender projects are highlighted. These case studies were re-analysed to explore similarities and differences in the trajectories. These methods are consistent with those used in critical studies of men and masculinities [8, 28].

Group and context

Both men whose life stories are the subject of this study, have been significantly affected by their obesity throughout the course of their life and both are currently trying to lose weight. Lukman (24 years old) and Justin (25 years old) have similar starting points for their construction of masculinity and a strikingly similar gender project. They have a similar family history, both growing up in the middle class with relatively conservative parents. Both families were quite religious; Lukman’s family was Coptic Christian and Justin’s was Catholic. Lukman was born in Jordan and moved with his family when he was in Year 11 at school. Justin’s background is Spanish (his mother) and Italian (his father). Both participants grew up in families with a conventional division of labour and a conventional power structure. They shared a closer relationship with their mothers than fathers. The 111mother was often quite involved in the participants’ life while communication with the father was generally avoided and the relationship was tense. Lukman’s father was obese and died two and a half years ago due to complications after surgery. Lukman has a family history of diabetes, cardiovascular disease, high-blood pressure and cancer. Both Justin’s parents are alive and his mother struggles to lose weight. Both participants live at home and have been overweight since childhood.

Lukman and Justin appear to be at different points on the weight-loss trajectory. Although they currently weigh similar amounts, Justin, the heavier of the pair, became committed to weight loss at an earlier age. Lukman is 183 cm tall and weighs approximately 147 kg. Justin is 189 cm tall and weighs 136 kg. Their respective BMIs are 43.9 and 38.1. Lukman underwent gastric-sleeve banding two weeks prior to the interview and has so far lost 20 kg. His weight-loss efforts prior to surgery were minor, with his only significant attempt at the age of 13, when his family forced him to lose weight to make him more presentable for his sister’s wedding. His father’s health complications associated with the obesity have prompted Lukman’s recent commitment to weight loss.

Justin has a longer weight-loss history, undergoing lap-band surgery after graduating high school at age 18. He weighed 250 kg at this point, and lost 40 kg in the following year. He comments that although he initially reduced his portion size and fat intake, no lifestyle changes were made and the weight-loss eventually plateaued at approximately 180 kg. Justin tried other methods of weight loss while at university, however these were largely unsuccessful. A significant change occurred when a friend introduced him to a weight-loss retreat, which he visited several times. This experience and access to information on nutrition, health and exercise inspired Justin to focus on his eating habits and caloric intake. He has been exercising regularly and closely monitoring his diet since then. He graduated from university in 2009 and spent the following year exercising and focusing on weight loss. He has a personal trainer, visits the gym regularly and has so far lost 114 kg. Although his BMI is still classified as obese, much of his weight is due to muscle mass and his latest visit to a physician reported that he was in good health.

Gender substructures analysis

The construction of masculinity of Lukman and Justin was analysed using Connell’s [10] substructures of gender relations: a) Gender production relations: the gender division, allocation and organisation of labour; b) Gender power relations: the organisation of power, the way power is contested and the way groups mobilise to counteract power inequalities; c) Cathexis or gender emotional relations: a person’s emotional attachment with another (or an object), including desire, sexuality and sexual relations; and d) Symbolism: the communication of gender ideologies.

Production

Lukman and Justin are situated in a similar subordinated position in production relations. They have an unimpressive work history, are currently unemployed, rely on other family members for financial support, and have limited qualifications and skills. They both 112experienced times at university that were difficult and resulted in failed subjects, and Justin partially attributes this to a low mood because of his weight. Both participants have a transient work history and no skills available to sell, resulting in a limited position in the labour market. Lukman has worked primarily in temporary jobs in the fast food industry, for the local council, in administrative roles, and for an IT company assembling computers for private use. Justin has worked at a call centre and recently in an IT sales job. They both lack any affection for these positions, and being relatively unskilled, they remain replaceable employees in the workplace.

Both Lukman and Justin have acknowledged a role of their weight in limiting their employment options. Lukman comments that for many jobs you ‘need to look good in a shirt’ and he believes he is not ‘employable-looking’. Justin also indicates how his weight has affected his work: he resigned from his call centre position after believing staff perceived him as ‘a grumpy person who couldn’t talk to other people and couldn’t relate and didn’t have time for anybody’, as he was struggling with severe back pain. His relationship with staff prior to the onset of back pain had been friendly and warm. Justin further indicates that working reduces time spent on weight loss,

He left his last job of three months because he was unhappy in the position and found this affected his eating habits and potential to gain weight.

Although Lukman and Justin have worked in abstract labour positions, they both express dissatisfaction with these roles and have a positive attitude to their future role in the labour market. They appear eager to support themselves. Justin is committed to ‘find something I love doing and do it’. Lukman expresses feeling ‘terrible’ about having to rely on the financial support of his sister and her husband, and indicates his goals are to find work, finish uni, complete any postgraduate qualifications in psychology that may be necessary, and to eventually support himself and his mother. Justin intends to complete a personal training qualification and to pursue work in the fitness industry. Although these men are currently dispensable in the workplace, they express motivation to becoming a valuable contributor to the labour market.

Power

There have been significant issues of power in the lives of Lukman and Justin. They both cite an estranged relationship with their fathers from an early age. Both fathers were perceived as aggressive, with rare occasions of violence, and the mothers were the more approachable parent. They both believe however that their mothers also perceived them as powerless. Lukman labels his mother as the ‘doting’ mother, always involved and always enquiring about his wants and needs,

113Justin acknowledges a more general perceived powerlessness because of his weight,

They both believe their weight has significantly contributed to a powerlessness and marginalisation in society.

They also acknowledge their own role in power relations by recognising their chosen submissiveness in relationships. Justin comments that he was ‘friendly to everyone so they would be friendly to me’. He used humour to be likeable and to avoid being the victim of bullying,

Lukman comments that he transformed from being ‘a very social animal … a very involved person to more of an introvert.’ He is unsure why this change occurred, but believes his obesity played a role in the transformation. He did experience some bullying during high school but nothing he couldn’t really ‘shrug off’. He believes his weight may have some role in it as ‘first appearances mean a lot’, but he says that the bullying disappeared when he was one-on-one with the perpetrators.

Importantly, both participants express a desire to increase their power. Lukman says that he wishes to ‘survive without’ the help of his doting mother and that he wishes to ‘become more of an extrovert’ so that he can advance in his career and in relationships. Justin is dedicated to training and eating nutritiously so that he can ‘inspire people and eventually raise some money for some charities.’ A key weight-loss trigger for both these men has been a desire to increase their power, and thus to improve their position in the gender order.

Cathexis: emotion and relationships

Relationships have been significantly affected by the obesity of these two men. Within the family unit, tension often arose because of weight,

Justin believes his dad may have felt ‘helpless’ and was unsure how to handle his increasing weight, resulting in their tense relationship. Obesity similarly affected Justin’s ability to communicate with his father.

Obesity has also affected the friendships of the two men, however in a less overt way to relationships with their parents. Both men report having few sound friendships. Lukman believes he is more of ‘a deep friendship kind of person’ as he prefers close, intimate relationships over a ‘legion of friends.’ Obesity though has affected the activities that the 114men can participate in with friends. Justin comments that he ‘wasn’t really doing the same kind of things that other kids were’ because he ‘wasn’t able to’,

He ‘felt it was easier just to stay home than to be bothered with it because of all the things that I would have to encounter throughout the day.’ Lukman also limits his social activities, avoiding going to the beach and places where he would have to take his shirt off. He feels more comfortable around people who are aware he is trying to lose weight; otherwise he becomes very self-conscious.

Obesity has also had a major role in the sexual relations of the two participants. Both participants reported having had a few, short-term relationships with a female partner that broke up primarily because of their low self-esteem.

Justin also comments that he did not want to be seen with a girl because he was concerned about his appearance and he did not want to be an embarrassment. Despite losing a significant amount of weight, he still feels this way. His first girlfriend since the weight loss had also experienced a significant drop in weight and he comments that this made it easier to have a sexual relationship, as they felt less judgemental about the other’s body. Justin however realises that he was insecure in the relationship,

Lukman struggles with his sexuality and he believes his obesity has limited his sexual opportunities and ability to explore this. Although he believes he is a heterosexual, his first sexual encounter was with a gay man who he met through a friend. He is unsure if this was due to a ‘lack of long-term success with females’ or homosexual tendencies of his own:

He indicates that because of his obesity he has been prevented in investigating his sexuality further, noting this as one of the reasons for undergoing weight-loss surgery. He believes his attraction to men may be just sexual, and he thinks he may be ‘bi-sexual with a heterosexual skew’.115

Symbolism

The symbol of obesity in society has affected both participants and has had a role in triggering their weight loss. Lukman acknowledges that his decision to undergo gastric-sleeve surgery was partially due to a desire to ‘fit in’. He comments that he wants to ‘look normal’. Justin uses the train as an example,

These men are aware of their marginalisation by others because of their weight. Justin believes many people judge obese people as selfish and lazy,

Both participants are aware of the symbolic meanings that subjugate the body and place stress on the construction of gender. The body is inextricably linked to gender, and as Parker [29] notes, a healthy looking physique is associated with a sense of respect for oneself and a commitment to health and fitness – the converse of the perception of obesity, as experienced by these men. The stigma associated with obesity is considerable [30].

Discussion

The two life histories presented here are valuable to the study of gender and health as they highlight the significant effect of the body on one’s construction of masculinity. The weight of the participants has affected their position in the labour market, their power relations and their emotional and sexual relationships. This has resulted in their marginalisation and thus the construction of a marginalised masculinity.

The life-history methodology allows the dynamic of gender to be traced across the life course and the study of obesity serves as an interesting example of embodied masculinity developing over time. Both participants believed they would improve their position in the gender order by losing weight. Both men believe their weight loss will allow them to ‘advance’ in society, which is synonymous to being closer to achieving the hegemonic dividend, that is, being complicit with patriarchy and receiving its rewards. There is a sense that things will improve when they weigh less,

Weight loss is an embodied transformative process in these cases, essential for the reconfiguration of one’s masculinity. Physicality is closely tied with gender and the desire to achieve a more powerful, athletic body is a trigger for weight loss.116

One’s position in the gender order, however, is not solely determined by the physical body. Social practices have a role in shaping an individual’s body which exists in a reciprocal relationship with the individual’s production, power, cathexis and symbolism. Justin, who is further along the weight-loss journey than Lukman, appears to be realising that his change in physical size is not matched with a change in positioning in the gender order,

Justin is struggling to reconfigure his masculinity despite weight loss. The marginalisation of obese people in terms of power, production and emotional and sexual relations has been well researched. A large study (n = 12 364) using telephone interviews found sexual behaviour differed for obese people compared to normal weight [31]. Obese women were less likely than women of normal weight to report having a sexual partner in the previous 12 months, and obese men were more likely to suffer from erectile dysfunction than normal weight men, and had fewer sexual partners [31]. Obesity has also been found to affect employment opportunities. A high BMI is associated with an increased likelihood of receiving a disability pension [32]. The evidence that obesity impacts negatively on job evaluations and hiring has also been rated as strong [30]. The stigma associated with obesity is considerable [30], comparable to racial discrimination [33], and this has a marginalising effect for many individuals.

Consideration of embodied masculinities and femininities in weight loss has the potential to contribute to individualising weight-loss plans. Justin commented that although surgery was necessary to lose the initial weight, he did not learn sustainable healthy behaviours from this process. His education in nutrition and lifestyle came from his time spent at a weight-loss retreat that focused on the personal experience in the weight-loss journey. Lukman, who has recently undergone gastric-sleeve surgery, recognises that his eating habits preceding surgery were unhealthy, but he did not indicate a desire to increase his exercise or engage in a healthy lifestyle now that he has had the surgery. Shah and colleagues’ [34] review found weight-loss surgeries were associated with significant initial weight reduction, but that this was not maintained long term [34]. Douketis and colleagues’ [5] systematic review of weight loss in obesity found weight loss of 25 kg to 75 kg in the two to four years following surgery, which was higher than the other interventions (eg diet therapy, pharmacologic therapy). Current weight-loss treatments overall for obese persons are modestly successful [35], however a focus on mean values may conceal individuals who do lose a significant amount of weight [5]. Justin comments:

It is an empirical question if an intervention involving a discussion about gender, personality and weight loss earlier in the weight-loss journey would facilitate quicker and sustained weight loss.

Conclusion

The life histories presented demonstrate the value of gender relations theory in analysing the obesity issue. Life-history methodology has the potential to shed light on the inconsistencies in data on the prevalence and effects of obesity by focusing on the individual experience. The cases presented highlight how the body is integral to constructing gender, but also how social aspects of ethnicity and class, as well as aspects of production, relationships and power, shape the body and contribute to the gender project. These preliminary results suggest that the construction of masculinity of an individual who is attempting to lose weight is closely tied with the body and that a trigger for weight loss may be a desire to improve one’s position in the gender order. Challenges to maintaining this weight loss may however include the realisation that physical changes to the body are not the only obstacle to achieving a dominant form of masculinity or femininity. Weight-loss approaches that recognise the individual struggle with gender and the influence of other social structures may be an alternative to current, largely unsuccessful treatments of obesity.