March 25, 2023
In 1897, sociologist Emile Durkheim suggested that suicide is a consequence of an individual’s difficulty belonging to a group—whether a failure to fit in with others or an excessive submission to others’ goals, beliefs, and rules. Inspired by Durkheim’s seminal sociological research, as well as other ideas developed by members of the Chicago school of sociology at the University of Chicago, CDRP PITCH fellow Nathaniel Glasser has been asking how social pressure to fit in with a group can result in harmful health outcomes.
Now in his second year as a fellow in General Internal Medicine, Glasser majored in sociology at Yale before attending the Humanities and Medicine Early Assurance Program at the Icahn School of Medicine in Mount Sinai, where he admits to initially struggling in a program intended to combine a background in liberal arts with the study and practice of medicine. “I wasn’t sure how to utilize my interests in ethnography and symbolic interactionism—both of which were created or at least significantly developed at the University of Chicago—alongside a career in medicine as a practicing physician,” he recalls. Advice from a similarly sociologically minded mentor led to a stint at Harvard, where he earned a masters degree in social and urban policy.
During his medicine and pediatrics residency at Tulane University in New Orleans, Glasser facilitated engagement with well-child care with the Welcoming Project, a program to support youths who were returning home from incarceration, many of whom were from communities that frequently used emergency medical services but rarely enrolled in pediatric primary care. Glasser noticed certain behaviors among his patients—smoking and fighting—that seemed primarily driven by the kind of interaction with symbols and imagery that he had studied in college.
“There were 12- or 13-year-olds who were smoking joints—not to get high. I understood it as symbolic gesture, strategically deployed to project the image of a tough, cool guy to peers. Fighting similarly would frequently land kids in the ER and result in their getting stitches, but could be useful, or even necessary to the kids, because of what fighting could communicate, ‘I’m not afraid of fights. I get in fights. I win fights.’ Shortly after starting to make these observations, the pandemic arrived and we started wearing masks, which had and have health implications, but also quickly developed symbolic social meanings around identity and particularly political affiliation,” Glasser recalls. “I was seeing multiple health behaviors motivated by social concerns. I was fascinated by the power of symbols as an undergraduate—now, as a practicing physician, I was seeing that the way people interact with symbols was having an influence on their clinical outcomes. That became the thing I wanted to study.”
However, rather than focus on a particular behavior or symbol, Glasser studies how they collectively produce identity. “Durkheim says there’s a basic human need to fit in, achieving an identity that’s consistent with the norms, values, and expectations of your milieu,” he says. “Right now I focus on masculine identity writ large—how cultural stereotypes around what it means to be ‘male,’ ‘masculine,’ or ‘a man’ constrains behavior, particularly in my research of cis-gendered boys and men and how that’s associated with clinically relevant behaviors, such as use of medication or substance use.”
Glasser focuses his research on substance use, firearms, and management of cardiovascular disease. “Major modifiable risk factors of cardiovascular disease are blood pressure, diabetes, weight, smoking, and cholesterol,” he says. “The higher on an empirically-derived measure of male gendered behavior individuals are, [the more] they seem to be underdiagnosed with hypertension, diabetes, and hyperlipidemia, and, even when they have been diagnosed, the more they appear to be undertreating their conditions, as they are less likely to be taking a medication to treat that disease. And, if I were to speculate about why that is, the doctor is a symbol of health care, vulnerability, lack of self-reliance. Not seeing a doctor, not adhering to medical recommendations, is strategically using behavior to emphasize self-reliance and dominance, which decades of social science literature says are things men feel relatively more pressure to demonstrate with their behavior.”
“I think sometimes healthcare is overindexed on economic explanations of human behaviors,” he says. “A lot of people have heard of food deserts and choice architecture: that we’re nudged in one way or another when we’re at the grocery store deciding what to buy and eat by the convenient location of Kit-Kats versus kale. It’s important and real, and the price of food is real and people respond to that, but there are social dimensions we’re responding to, as well. For example, what does it mean socially for a teenage boy, maybe one who plays football, to eat a kale salad? What does it signal about the boy’s identity?”
“I am most interested in the prevailing, dominant culture,” says Glasser. “How the patriarchy might eat its own. I think it’s a universal experience to be constrained by norms, values, and expectations. We’ve all inherited them, but thinking about mechanisms by which social meanings become attached to concerning behaviors is maybe one thought experiment for getting at the possible solutions. Less prescriptive definitions of what it means to be somebody of a particular gender might be helpful. People should have more opportunities to construct their identities free of pressures to engage in self-harm and harm to others.”
As a PITCH fellow at the University of Chicago, Glasser has studied primarily under the mentorship of CDRP faculty affiliates Harold Pollack, Stacy Lindau, Neda Laiteerapong, Elbert Huang, Monica Peek, and Elizabeth Tung, all of whom he credits with his integration of sociological thought with medical practice.
“The most important thing I’ve learned during my time here was figuring out how to employ my sociological imagination,” says Glasser. “I learned how to use these Chicago school theories I’m really excited about and have been since I was an undergraduate college student. In fellowship, I think I’ve figured out ways of operationalizing and measuring the impact of pressures around identity and thinking about how the impact of strategic interactions with symbols and identity construction, with a health equity frame. One of the big barriers to health is that people are overly limited in ways they are allowed to construct their identity. That limitation can lead to healthy or unhealthy behaviors. Learning to study and operationalize that dynamic is the most exciting thing that has happened to me, and I think it’s the work of my life.”
Story and photo by Irene Hsiao