Fatherhood as a Component of Men's Health

Modern medicine increasingly understands phenomena specific to men's health. The notion of “men's health,” as distinguished from “women's health,” often centers on differences related to diseases of the reproductive organs, to conditions such as cardiovascular disease that manifest differently in part because of the influence of sex-specific hormones, or to shorter life expectancy for men vs women. This conceptualization of men's health, however, overlooks a central aspect of many men's lives—fatherhood.

The physical and mental health effects of being a father are understudied and largely unknown. This gap in current understanding is important because of its potential magnitude. Of the 108 million adult men in the United States, 66.3 million are fathers and the majority of men younger than 55 years have children in their homes.¹

In addition, marked sociodemographic shifts in the US population are reminders that the stereotypical image of a traditional family, including a wage-earning father and a stay-at-home mother, is fading. In fact, there is no one picture of fatherhood in the United States today. Fathers may be in 1- or 2-parent families; they may be single, married, widowed, divorced, or cohabiting; they may be gay or straight; or they may become new fathers as adolescents or in mid-life. Fathers may raise their own children with 1 partner or with different partners, or may raise others' children as a social, step-, adoptive, or foster parent. They may be unemployed, work full time or part time, and may work inside or outside the home. Some live with their children, some live nearby, some live across the country, and some may be incarcerated. If social context has meaning for men's health, these multiple structural variations of fatherhood would be expected to affect men's health—but in ways that are only beginning to be understood.

An Office of Men's Health in the US Department of Health and Human Services has been proposed to focus on important specific male health concerns, such as prostate and testicular cancers, and the lower overall life expectancy of men compared with women.² As currently conceived, however, the Office of Men's Health most likely would largely ignore the essential role that social context, in particular fatherhood, might play on men's health throughout their lives.

In this commentary, we examine fundamental questions about men's health that are raised by these sociodemographic trends. How does fatherhood affect men's health, and how might different forms of fatherhood affect men's health? Through greater understanding of how fatherhood across the lifespan and in all its forms affects men, physicians and other health care professionals will be better prepared to effectively meet their health care needs.

The predominantly clinical conceptualization of men's health is exemplified by the fact that, even when some of the best-known longitudinal studies of health have tracked father and filial relationships (eg, Framingham Heart Study³ and Framingham Offspring Study⁴ ), they have done so for purposes of tracking genetic relationships that confer specific risks of disease. This approach, although unquestionably integral to understanding genetic determinants of disease, does not principally examine interactions between genes and the social environment—for example, intrafamilial and father-child relationships. Existing longitudinal, multigenerational studies often fail to consider potential differences in health between fathers (whose offspring are represented in the next generation cohorts) and nonfathers (who are not included in next-generation studies).

How might being a father affect a man's health? A bidirectional, dynamic relationship may exist between fathers and children: fathers affect their children's health and children may affect their father's health. This may occur in any of 3 general ways. First, children may affect fathers' health by their very presence in a father's life, in a variety of positive or negative ways. Positive effects may include children being a source of happiness, physical activity, and providing a sense of well-being and contentment for their fathers. On the other hand, children may negatively affect fathers' health if fathers feel pressure to provide financially, distribute limited resources, and balance work and family, or if fathers who do not live with their children feel guilty about geographical distance or lack of involvement. These pressures and benefits may also influence a father's parenting style and the level and quality of involvement in his child's life, whether generally positive and supportive or negative and destructive.⁵ Although there is a growing body of knowledge about how such parenting styles affect children, there is little understanding about how these parenting behaviors may affect children and how they may reflect back on fathers and their health. For example, do fathers with work pressures parent more negatively, thus having more challenging interactions with their children and further increasing their stress with its accompanying morbidities? Could the reverse be true for fathers with constructive, more positive parenting styles? Might some men adopt healthier lifestyles when they become fathers, whereas others adopt less healthy lifestyles? How does this modeling of health behaviors affect their children's lifestyles?

Second, having children and providing financial and emotional support for them affects the relationship between a father and his partner (married or not), and thereby affects any potential health benefits of that partnership. This partnership effect is likely a combination of positive and negative influences on a man's health. The growing literature on fathers and the changing structure of US families indicates that such effects may also differ by race/ethnicity and culture. Given the fact that these partnerships between adults occur both with and without children, they provide a superb but as yet unrealized opportunity to examine differential effects of fatherhood on men's health.

Third, children may indirectly affect fathers' health through their own health. Families with children who have chronic health conditions are known to have higher rates of marital stress, divorce, and unemployment,^{6 - 7} all life events associated with poorer health outcomes among men. What is not known is whether having a healthy child, and presumably lower levels of concern and stress, is associated with health benefits for fathers and whether potential benefits vary with the amount of time spent with the child or children.

These effects will likely vary with the context of fathers' lives and change over time as fathers, partners, children, and their relationships develop and shift. For example, fathers who provide for children early in life may benefit when their children care for them in their older years. Moreover, through their parenting activities at different stages of their children's lives, fathers may influence their children's own dynamic of parenting and health when they become parents themselves. This dynamic, intergenerational notion of fatherhood, and its fundamental connection to men's health through the life cycle and through time, is an important area for future research.

Questions about fatherhood and men's health expand the concept of health from a purely clinical, individually focused perspective to a broader notion that health is influenced by social context. Investigators from several disciplines have illuminated how social determinants of health are integral to individuals' well-being. For example, the concept of allostatic load, which describes links between neuroendocrine activity and health as a process of cumulative wear and tear across multiple physiological systems over time, is one model that has shed light on how the social environment affects health over the lifespan. Higher allostatic load is associated with higher likelihood of mortality and cardiovascular disease and with declines in physical and cognitive functioning.⁸ In addition, Engel's biopsychosocial model⁹ and the more contemporary interactive biopsychosocial model that acknowledges the complexity and relevance of the multidirectional influences on health¹⁰ may help explain risks and benefits inherent to fathering by framing individual health within a social network. These models have not yet been used to investigate the role fatherhood plays in men's health, but they could provide useful frameworks for considering how the potential stressors and supports associated with parenthood affect men's health over the lifespan.

If fatherhood does affect men's health, it is important that men's health research continue to advance and consider the rich and dynamic context of men's lives. While a mother's mental and physical health is assumed to affect her child, research has shown that the same is true for fathers. For example, a father's poor mental health adversely affects both early child development and maternal mental health.^{11 - 13} In addition, becoming a father can be stressful for men. Men often report that they feel unprepared for fatherhood.¹⁴ Moreover, they are also more likely to experience psychological and relationship difficulties during and after their partner's pregnancy.^{14 - 15} Existing data largely focus on the peripartum period and first few years of new fatherhood. More comprehensive, longitudinal work may illuminate how men's roles as fathers change over time and shape key relationships that, in turn, influence their health.

Recent longitudinal studies, such as the Fragile Families and Child Wellbeing Study¹⁶ and the Early Childhood Longitudinal Study-Birth Cohort,¹⁷ were designed to address the need to understand the diversity of fathers and study some intergenerational effects of father presence and involvement. Their samples included nonmarried fathers, married fathers, those living with their child, and those not living with their child. Of the diverse fathers studied, the majority visited their new child in the hospital and attempted to remain part of their children's lives in early childhood.^{18 - 19} Although these studies were designed to examine important psychosocial issues for US families, such as fathers' roles within different family structures and fathers' involvement in children's early development, health outcomes for fathers were not assessed.

As the appreciation of men as fathers increases, a broader concept of men as fathers is warranted in both clinical practice and in future research ( Article ). In pediatrics, this shift is already in progress; a recent report²⁰ strongly encourages physicians to seek to support fathers' interactions with their children and the health care system.

Clinical Practice

Research Methods, Measures, and Mechanisms

The central rationale for a specific focus on fatherhood as it relates to health is that information about men's roles and experiences as fathers can be helpful to physicians in their clinical interactions with men who are parents. With little evidence today, but growing awareness about the potential importance of fatherhood for men's health, physicians can begin engaging men in conversations about fatherhood and explore the physiological and psychological ways in which fathering may be benefiting or burdening men through adult life. For example, for men in early fatherhood, advice for balancing work and family demands and preventive health concerns may be most clinically relevant. Men in mid-fatherhood may be experiencing an empty nest or the return of adult children to the home, in addition to the health concerns common to mid-life. Men in late-fatherhood may need the assistance of their adult children to help manage aspects of daily living and their health care.

If fatherhood becomes a larger focus of research in coming years, physicians may be able to design some clinical approaches using fatherhood as a factor in decision making. Certainly, with a better understanding of the psychosocial dynamics of fatherhood, clinicians will be more prepared to anticipate the needs of their male patients. In an approach that seems novel now but may be commonplace in the future, physicians may also consider a man's fatherhood status when treating clinical problems, such as hyperlipidemia and diabetes mellitus. For example, recent data suggest that adults in households with children consume significantly higher amounts of total fat and saturated fat than adults in households without children.²¹ Information of this nature might lead physicians to modify their approach to clinical problems and ultimately improve men's health.

To reach a deeper appreciation of how fatherhood affects men's health, a comprehensive, integrated, and interdisciplinary research approach is necessary. Fatherhood should be conceptualized not as a binary measure, but rather more richly to include contexts of fathering, such as quantity and quality, and to relevant changes in these domains over time. Only in this way can the effects of fathering, beyond strictly genetic contributions, be linked with potentially meaningful clinical outcomes. Current longitudinal studies provide a methodological starting point and measurement tools⁵ and can shed light on how best to include fathers in research, despite their reputation as research participants who are difficult to recruit and retain.^{22 - 23}

It is impossible to predict how the health of today's and tomorrow's fathers will reflect fatherhood, and how fatherhood as a dynamic influence on men's health will compare with other factors. However, the sociocultural changes that affect men's roles as fathers certainly will continue. Now is the time to gather more complete information about the involvement and impact of different forms of fatherhood for men, and the ensuing benefits and risks that affect the majority of men who are fathers. Illuminating the psychosocial fabric of men's lives may reveal critical links between fatherhood and men's health.