Janis Jenkins (1997:40)

We must be careful not to pathologize stress.

Randy Boddam, psychiatrist with the Canadian Forces

In addition to summarizing the contributions, implications and limitations of this study, I want to add one more dimension to the complex relationship between gender, migration and health among Guatemalan immigrant men in Toronto. As I have illustrated throughout this thesis, the men in my sample have faced emotional and physical health problems as a result of displacement, migration and resettlement. Loneliness, stress, drinking and bodily aches and pains, in particular, are common health problems among these men. These problems stem largely from the traumatic experiences of political persecution, family separation, loss of employment and employment status, language difficulties, unfulfilled goals and aspirations, and a sense of "not belonging" (no pertenecer; no parte de).

However, by virtue of their ability to continue with their lives after experiencing political persecution, leaving Guatemala, separating themselves from friends and family, and interrupting political, career, and recreational pursuits, these Guatemalan immigrant men have also exhibited tremendous emotional and physical perseverance. These men have employed some strategies in order to cope with the potentially traumatic experiences of displacement and resettlement. Keeping busy, forgetting or learning about the past, seeking professional care¾ these and other practices have helped these men to maintain or improve well-being in the diaspora. Although one predominant theme throughout the course of my fieldwork was the greater difficulty Guatemalan immigrant men have salir adelante compared to Guatemalan immigrant women, this does not mean that these men necessarily lead pathological lives or that they live on the brink of emotional or physical collapse. Rather, my aim in this section is to briefly illustrate the resilience strategies of the men in my sample, and to highlight the importance of developing a medical anthropology that writes against the pathologization of immigrants and refugees.

First, a few men mentioned that "keeping busy," (me mantiene ocupado), "making yourself super busy" or "working hard" were strategies for maintaining health. For Enrique, trying to "keep busy" is one way that he deals with loneliness (see Chapter 6 for Enrique’s narrative on feeling lonely in Canada). Because he is single, has no family in Canada, and cannot afford to talk regularly with friends and family on the phone, Enrique suffers from loneliness and has since returned to Mexico. However, while in Canada Enrique would try to cope with loneliness by painting, visiting the few friends he had in Toronto, and going on long bike rides. Similarly, the other men in my sample who tried to "keep busy" in order to maintain health emphasized the importance of physical work, bike riding, running (corriendo), and sweating (transpiración).

Second, forgetting, remembering, or learning about the past was another set of resilience strategies for some Guatemalan immigrant men. When I asked Ruben if he thinks about Guatemala, he replied:

For the first ten years I thought about it, but not anymore. Forgetting about it gave me hope for the future…. When I came to Canada I tried to pretend that I didn’t have anything, I cut myself off from Guatemala completely.

But then [my wife and I] started going to the library to learn about Guatemala to deal with the anxiety of living in Canada. Because we Guatemalans were not given the truth about our position in the world.

Other men, such as Jaime, emphasized the importance of remembering Guatemala in order to cope with life in Canada. "If you don’t think about the past," he said, "you won’t have any ideas in the present. I don’t really forget about [Guatemala], I have to think about it."

A third mode of maintaining health was visiting church or health professionals for either physical and emotional distress. Surprisingly only a few men in my sample sought help from priests for emotional problems. Victor talked about the importance of staying physically and mentally healthy, and explained that although he doesn’t consider himself to be a religious person, most Guatemalans use the church as a source of help for problems with alcoholism and family relations. After seeking help from a parenting support group and a psychologist for his violent behavior towards his ex-wife, Carlos, too, mentioned the importance of the church. I had asked him about his experience with the psychologist and he responded:

Well, it was a wonderful experience. She helped me to realize that I was raised in an environment and people make changes in their life. I can learn new ways of dealing with my anger. And then I went to the church; that was another resource that I needed.

Similarly, Jaime has used the church to overcome his problems with drinking in Canada. In fact, Jaime is now a church worker and believes he should act as a role model for other men with similar health problems.

In addition to seeking healing from local pastors, a few men in my sample reflected on the important role that support services have played in improving their health. Although a large number of men complained about formal health services¾ or stated that they’ve never visited a doctor or hospital since they’ve lived in Canada¾ some men had had positive experiences with formal support services and argued that these individuals have provided excellent care. Those who criticized services cited alleged corruption among Spanish-speaking doctors, mistrust, problems with interpretation, and discrimination as factors that have influenced their decisions to limit their use of health care services in Toronto. Manuel, for example, mentioned that in Canada he has had difficulty finding a good family doctor, and therefore consults several doctors to get a collective diagnosis of his problem, such as his problem with nerves (see Chapter 6). He emphasized the importance of finding a Latin American doctor but complained that because of money laundering, he doesn’t trust most Spanish-speaking doctors in Toronto. Similarly, Jaime, who has struggled with drinking, back problems, and stress in Canada (problems that had developed or exacerbated since he migrated to Canada in 1986) argued that:

I’ll be honest. In Guatemala I never drank; I never had a problem with my back. Right now, I’m in Canada. I go to doctors, hospitals but I don’t feel good. I’m in a good place, a good country, but I’m staying the same.

Health is really hard. People don’t trust you. I have this pain in my back but nobody finds anything for this pain.

Augusto has had problems with his back and has gained about 30 pounds over the past few years. He told me that in Guatemala he used to run 10 kilometers a day, climb mountains, swim, play baseball, and do push-ups and sit ups. But now, due to a busy university and work schedule, he doesn’t have time for these activities and lacks motivation to be physically active. I asked him if he has visited anyone for his problems, and he replied:

I don’t go to anyone unless I’m feeling very bad. I don’t like going to the doctor for any reason. If I feel like my back is hurting, I just try to relax and that usually takes away the pain.

In contrast to these negative perceptions and experiences with health care services, a few men have benefited from support services. Carlos suffered from stress and depression after separating from his wife a few years after he migrated to Canada. He had abused his ex-wife and was struggling to learn new ways to deal with his anger besides physical violence. He was able to find a parenting support group for his problems, and, in fact, now leads a Spanish-speaking group for men who have abused their partners:

school a sign, it was about a parents group and I decided to join them and this group were about twelve women, and then I join them and the first session I was crying. I just open the door and I say "This is a parenting group?" They said yes, so I start crying and they listened to me, they were saying "If you want to talk just talk. You want to cry, just cry but we are not judge you, we are not criticize you", and then they were listening to me. I tell them that I have problems at home and I don't know how to deal with them, and it was when I realized I was under depression.

 

What I wanted to do is to keep my family together and I realized that I was the one who has a problem, I was blaming my wife and my kids. I thought they didn't understand me, but I got information from the community centre, I then realized that I was the one who had problem with my dealing with my anger, and I identified that I was losing my identity as a man because I couldn't deal with the situation like I did in Guatemala.

Another source of help for one man in my sample was Alcoholics Anonymous (AA). Rolando, whose story about drinking appears in Chapter 6, struggled with alcoholism as a result of interrupted career aspirations and memories of war and violence in Guatemala. He cites a sense of belonging among the other participants in his AA group as a key factor that helped him curb his drinking habits:

After a few years [of drinking] I decided that it was enough. I thought that I could go to the hospital and get an injection. I wanted to get well. Later on I learned that alcoholism was a disease. A progressive disease based on denial. The people at the hospital said that AA would help. So I went and it was quite an experience. I thought it was only for bums. When I went there, there was mainly healthy people, well-dressed, nice, clean. I expected it different than this. We all started telling stories, in all different languages. People from all different backgrounds: English, French, Canadian. What they said had an impact on me. I felt relieved; I knew I wasn’t crazy. I was sick, but it wasn’t cancer. It can kill you but it can be put to rest.

The narratives in this section¾ though brief¾ provide a glimpse at some of the ways that Guatemalan immigrant men have improved their individual health or maintain a sense of everyday well-being. These diverse strategies of resilience not only influence individual health, but also contribute to¾ or reflect¾ processes of identity-making. For the men who cite "keeping busy" as important strategies for maintaining health, these men seem to reproduce a particular¾ if not hegemonic¾ construction of ser hombre that emphasises "keeping it inside" as a key expression of masculinity. These men embody¾ rather than actively discuss or narrate¾ processes of recovery or healing through physical activity, work and daily tasks. The body, then, is not only a site for disruption, as I’ve argued throughout this thesis, but also a locus for resilience or maintaining a sense of normalcy (Becker 1997; Becker et al. 2000; Lock 1993; Scheper-Hughes and Lock 1987).

The role of forgetting and remembering in the lives of people who have lived through war and political persecution has been well-documented in medical anthropology (Antze and Lambek 1996; Boyarin 1994; Irwin-Zarecka 1994; Zur 1998). Although the role of memory was not a key focus of my interviews with Guatemalan immigrant men and women, several men did mention the practices of forgetting, remembering and learning about Guatemala’s history as key practices that have promoted healing. Remembering through retelling the past, according to Kleinman and Kleinman (1994:714), may be one way of authorizing social memory and unmaking the embodiment of violence. "Memory is invoked to heal, to blame, to legitimate" argue Antze and Lambek (1996:vii), especially for those who have been displaced due to political persecution. The local library for Ruben and his family, for example, has become an important site for "relearning" about Guatemala’s past and has facilitated a way for them to salir adelante in Canada.

The few men in my sample who have sought formal care through support groups, doctors or psychologists have employed particular resilience strategies that also inform processes of identity-making. For Carlos, seeking help for his problem with abusive behavior involved a major shift in his construction of what it means to be a man. Citing his children as a key reason for his help-seeking, he foregrounds his role as a father and attempts to find new ways to deal with anger ("What I wanted to do is to keep my family together."). Feeling like he was "losing his identity," Carlos sought to shift his sense of manhood in order to promote a more healthy life for himself and the people around him.

Rolando’s use of the services at Alcoholics Anonymous is also an example of how resilience and identity intertwine. Rolando’s effort to stop drinking involved developing a new sense of belonging and "fitting-in" in Canada. A critical part of his success at AA was not only feeling part of a group of people with similar problems. The particular class and ethnic backgrounds of the participants also motivated Rolando to improve his health. That some of the participants were middle-class (not just "bums") and from several ethnic backgrounds (not just Latino), his own sense of personhood was placed in a cross-class, multicultural context. I would argue that Rolando developed a new sense of belonging with this experience. That other "healthy people, well-dressed, nice, clean" were facing similar struggles allowed Rolando to overcome his drinking problem, in part, because he felt like he belonged in this new social context.

There is little medical anthropological literature in which to contextualize my findings on resilience strategies among Guatemalan immigrant men. One exception is Janis Jenkins’ (1997) excellent commentary on research with recently resettled Bosnian refugees in the United States. Jenkins argues that "psychiatry and social science have been slow to take up the project of analyzing the full force of human response to genocide and warfare" (1997:40-41). Similar to the findings from my brief discussion of the coping mechanisms of Guatemalan immigrant men, Jenkins comments on the strength and courage of Central American refugees fleeing political violence (1997:42). Profound resilience, Jenkins concludes, is as much at issue as is severe psychopathology, and she urges researchers and practitioners to close the gap in their relative understandings of each. I would hope that my own limited findings on this issue is an initial step towards understanding the interconnections between resilience and gender for immigrants and refugees.

As I stated at the outset, this thesis explores the relationship between gender, migration, and health among Guatemalan immigrant men in Toronto, Canada. As one of the few medical anthropological studies on immigrant men’s health, I demonstrate that although both Guatemalan immigrant men and women face a range of health problems during the processes of displacement and resettlement, men in particular (with the few exceptions noted above) seem reluctant to talk about health problems or visit health professionals. Gender constructions and practices, therefore, are key factors that may influence health beliefs and behaviors.

This section concentrates on the contributions and implications of my study in three specific areas: health, gender and belonging.

First of all, this thesis suggests new directions in understanding the health and resettlement experiences of immigrants and refugees. As survivors of political persecution and war, the men and women in my study exhibited tremendous resilience, courage and perseverance in the face of obstacles that were largely out of their control. My study focused on the health and illness experiences of men, in particular, and discovered that these men may suffer from a range of emotional and physical problems, including stress, loneliness, drinking, and bodily aches and pains (such as back problems, weight gain, and work-related injuries). My argument is that health problems among Guatemalan immigrant men are less indicative of their class background, time of arrival and entry status than the attitudes and behaviors associated with ser hombre ("being a man"). Of course, class and other social factors do shape people’s lives. Participants in my study were mostly middle-class, for example, and so many could at least afford to reach and resettle in Canada. But because my sample was relatively homogenous in that most men had experienced a decline in employment and social status in Canada, and had arrived in the late-1980s or early-1990s as refugees, I argue that gender constructions and practices¾ rather than class, ethnicity, or entry status¾ is a more productive site for understanding the health experiences of Guatemalan immigrant men in Toronto. In brief, attitudes and behaviors associated with machismo, although diverse and changing, may contribute to pathology. As such, one major theoretical contribution of this study is that it suggests that shifting gender identities and roles (particularly the constructions and practices associated with machismo among Latin American men) should be key concerns in the study of immigrant and refugee health.

The implication of this argument is that shifting gender identities, roles, and expectations need to become a critical focus of immigrant and refugee health research and care. My review of literature indicates that few studies and initiatives have concentrated on these issues. Directions for future research should include quantitative investigation of the gendered dynamics of health care utilization. Quantitative studies measuring help-seeking behaviors by gender¾ among immigrants and native-born Canadians¾ would provide a broader scope on this policy and service provision issue. Future health and settlement research should focus on who does¾ or does not¾ use formal health care and support services and why. This research direction would complement smaller scale explorations of health beliefs, practices and narratives.

Second, on the theme of gender more specifically, this study provides an analysis of the meanings of machismo among a group of Latino immigrant men. My study complements the work of Matthew Gutmann (1996) and other gender studies researchers on Latin America (Archetti 1999; Castañeda 1996; Lancaster 1992) who argue that machismo is a highly ambiguous, contested and fluid concept. But what is lacking in these other studies of machismo is discussion of how machismo may¾ or may not¾ influence health. While we must be careful not to pathologize machismo by assuming that it necessarily contributes to destructive or unhealthy behaviors, certain behaviors associated with "being macho" (such as drinking, "keeping the pain," and being violent) can influence health in negative ways. While social scientists must account for the multiple meanings of macho, medical anthropologists and other health researchers need to pay attention to how certain gendered practices can lead to pathology, as well as contribute to resilience strategies (like "keeping busy"). In short, one important contribution of this study has been to point that despite the fluid, negotiated and performative nature of machismo, attitudes and behaviors associated with this gender concept can have health implications, and thus the issue of machismo needs to be at the forefront of future health research with Latin American populations.

Further, building on an innovative study by Jane Margold (1995), I argue that migration and resettlement can influence what it means to be a man. While a shift in place may not always mean complete abandonment of gendered beliefs and practices, the establishment of new work and friendship relations, as well as interaction with new institutions and legal regimes can cause shifts in personhood while in the host country. In my study, men had difficulty salir adelante ("moving on") because they resisted certain practices that did not resonate with their perceptions of what it meant to be a man, including such practices as crying, talking about emotions, and (with exceptions) seeking help for health problems. Surrounded by a new language and forced into underemployment due to the lack of recognition of credentials and qualifications in Canada, many men had difficulty finding other sources of employment and new social circles. Of course, these men are not simply powerless actors who have been forced into a new milieu. But resisting certain changes in gender identity and roles can have implications for Guatemalan immigrant men and women to salir adelante.

The third key contribution of this study is that it broadens our understanding of the lexicon and meanings that immigrants and refugees attach to the processes of migration and resettlement. Pertenecer ("belonging") and salir adelante ("moving on"; "getting on with life") were common expressions and phrases that the participants in my study used to make sense of the recent changes in their lives. I argue that "belonging" in particular is a idiom through which Guatemalan immigrant men narrate about their struggles in Canada. Though not all of these men necessarily strive to belong, it is a key process that may shape resettlement and adjustment experiences in the host country. As well, my findings on the salience of belonging as an idiom of resettlement calls into question¾ or perhaps complements¾ recent literature that highlights the increasing de-territorialization and diasporization of peoples and relations (see Clifford 1994; Hall 1990; Malkki 1995; Rapport and Dawson 1998a; Soysal 2000). That Guatemalan immigrant men do try to belong (in Canada) suggests that terms such as "adjustment," "integration" and "community" should perhaps remain part of the social scientist’s theoretical toolkit. What I want to emphasize, though, is that belonging is a process that is not necessarily¾ though sometimes indirectly¾ linked to space or place. Belonging is expressed or embodied through the everyday practices, tasks, and goals of Guatemalan immigrant men: being employed, speaking English, keeping fit, and fulfilling goals and aspirations. In brief, one important theoretical contribution of this study is that it urges scholars to analyze precisely what it means to belong for immigrants and refugees¾ rather than assume that belonging is a universal category in people’s lives¾ and to take seriously the implications of belonging for healthy resettlement.

From an applied or service-oriented perspective, one key implication of this finding on the importance of "belonging" among Guatemalan immigrant men would be the need to develop support groups that promote a sense of belonging. This recommendation builds on other research that illustrates Latino men’s sociocentric identity, whereby friendship and group activity is central to personhood (Gutmann 1996). As I argued earlier in this Conclusion, this study suggests that support groups can play an important role in helping men salir adelante. These groups open-up new sites and opportunities for men to negotiate and shift their identities to promote healthy resettlement. Such groups could be linked with employment and language services, and could also promote the role of fatherhood and the importance of family responsibility.

When I set out to research the health of Guatemalan immigrant men in the summer of 1999, I had high expectations. As a novice researcher full of ideas following a three-week trip to the beautiful western highlands of Guatemala, I was eager to do fieldwork for the first time and put into practice some key concepts that I had learned in my graduate seminars. Equipped with photographs, regalos for key informants, and an expanded Spanish vocabulary, I hoped to gain "entrée" into the Guatemalan community in Toronto and make some new friends along the way. As well, I wanted to contribute to community events, participate in solidarity meetings, and squeeze in a few soccer games while I was at it.

But fieldwork was hard. Making contacts wasn’t easy, nor was setting up mutually convenient interview times or locations. Comprehensive by nature, I hoped to cover a lot of material in each of my interviews without losing the interest or patience of the participant. Analysing the data and "writing up" were challenging, too. What themes to cover, which narratives to include, how "reflective" or "professional" to write¾ these were the kinds of dilemmas that always sounded easy to reconcile in methodology handbooks, but in practice they were extremely challenging. As any ethnographer will confess, these are the sorts of questions that keep us up at night.

As such, any research project has its own set of limitations, and I close this thesis by outlining them here. First of all, this study does not provide quantitative, epidemiological or clinical data on the levels of illness among Guatemalan immigrant men, and therefore I can only make limited claims about the health of this population. For example, I conducted semi-structured interviews seeking narratives on health, migration and gender identity, but I did not include a companion survey questionnaire on types of health problems, perceived levels of severity, and number of visits to health care professionals or other support services. Nor does my study provide quantitative data on health care perceptions and practices in Guatemala. As a consequence, my study makes use of a limited and fragmentary set of data on health and health across time and space.

Second, as mentioned in Chapter 1, this is not a comparative study of immigrant men and women. My study does not provide a balanced set of data on Guatemalan immigrant men’s and women’s health perceptions and problems. Also, since I do not have data on whether "belonging" is an important idiom of resettlement among Guatemalan immigrant women, my arguments about the relationship between gender and belonging are limited to instances where participants (either men or women) emphasise that a particular issue is predominantly male or female (such as the interruption of goals and aspirations as contributing to a sense of not belonging among men). My aim in interviewing only a small handful of Guatemalan immigrant women about men and their health was to gain a broader, more informed perspective on the relationship between gender and health for men. In my view, comparative research on immigrant men’s and women’s health is needed to further improve our understanding of the relationship between gendered constructions and practices and their implications for health and healing.

Finally, given the short time frame and limited goals of this study, it relies almost exclusively on reported, rather than observed data. Since I did not spend much time with participants outside of interviews or community events, I was not privy to the conversations, jokes and debates that fill the participants’ everyday lives. This limitation forced me to focus on what Guatemalan immigrant men and women said about gender and health in an interview setting, and precluded an analysis of how actions or behaviours resonated with or contradicted these statements. An expanded methodology that included extensive participant-observation of these men and women in their homes, at cafes, at church, or even at the doctor, would have provided a richer context for data collection. With these aveats aside, my focus in this thesis on Guatemalan immigrant men’s and women’s narratives of gender, migration, and health, should provide social scientists with a qualitative, exploratory foundation for future participant-observation research that takes seriously the ways people "do" gender and "do" health in their everyday lives.

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