Experiences With Machismo and Pain: Latino Veterans.

Physical and emotional pain from combat-related injuries and experiences are serious problems among Latino veterans. This study fleshes out existing cultural constructs and concepts (e.g., machismo and familism) from the participants' point of view and may serve as an important step in unraveling the influence of Latino culture on pain, providing a deeper and more critical theorization between masculinity, race/ethnicity, and the military. Using 26 interviews from U.S.-born Latino veterans, this study analyzes the meanings and experiences of pain from combat, masculinity, and how culture affects expressions of pain. The following themes emerged: (a) Latino culture and ethnicity, (b) machismo and pain, (c) the transforming self, and (d) feeling disconnected and dealing with pain. Overall, respondents were governed by strict gender standards influenced by their ethnic identity and exacerbated by military masculinity. Findings suggest that the study of race/ethnicity acts as a fundamental framework from which to understand the experiences and behaviors of pain.

Traumatic combat experiences have long been associated with psychiatric injury, particularly posttraumatic stress disorder (PTSD; Coleman, 2006; Lawrence-Wood et al., 2016). Both physical and emotional pains are the most reported stress symptoms of PTSD (Ravn et al., 2018). PTSD and pain[1] co-occur because traumatic events lead to the experience of physical and emotional pain (Sharp and Harvey, 2001). Equally, the physical pain from combat-related injuries and emotional pain resulting from combat experiences are associated with PTSD and is a serious problem among Latino veterans (Cancio, 2015, 2018; Pittman, 2014).

Approximately 1.25 million Latinos aged 18 and older are veterans of the U.S. Armed Forces (United States Census Bureau, 2019). According to a study conducted by the U.S. Department of Veteran Affairs, male Latino veterans have much higher rates of psychiatric injury (28%) as compared to whites (14%) (Loo, 2014). Latinos are not proportionally represented in the military, comprising approximately 18% of the general population and 36% of active duty service members (U.S. Department of Defense, 2011). However, according to the Department of Defense, Population Representation in the Military Services, Latinos claim a larger share of U.S. military enlisted personnel (Johnson, 2018) and are overrepresented in combat positions by as much as 85%; consequently, they face a higher risk of developing PTSD (Arminio et al., 2014). In tandem, Latino/as recruits are only overrepresented in the Marine Corps, America’s premier crisis response force trained to intensely engaged in conflict response (2009, US Marine Corps). Additionally, Latino veterans in the United States are expected to have a 23% enrollment increase by 2030 (Office of the Under Secretary of Defense, 2011; US Department of Veterans Affairs, 2014). Therefore, with growing enlistment rates (Melin, 2016), the number of Latinos experiencing pain (i.e., either physical and/or emotional) from combat (Cancio, 2018) has the potential to increase and continue to climb above other ethnic and racial groups.

The high prevalence of PTSD among Latinos has generated many studies that present various inconclusive results attempting to explain why this group is at higher risk of developing PTSD (Craven et al., 2014; Heilemann et al., 2005; Pole et al., 2005). These studies have exhibited various methodological shortcomings (e.g., poorly defined samples and substantial lack of systematically applied diagnosis criteria). Studies have been more anecdotal in nature, relying on minimal observations or a few case studies. None of these studies have attempted to investigate the lived experiences of this veteran population. Since culture and gendered identities govern how individuals share experiences about pain, what experiences they share, and the contexts in which they share these experiences (Cancio, 2018), research about what it means to be a Latino (i.e., understanding how the intersection between machismo, race/ethnicity, and the military shape social identity and perceptions of pain) offers potentially important contributions to social services and may expand sociological, ethnic/culture studies, and psychology literature.

Although machismo, war, and PTSD have been well documented in empirical research (e.g., linking machismo with higher PTSD severity, see Herrera et al. [2013]; moral injury and PTSD, see Jamieson et al. [2020]; machismo as guiding principle, see Cancio [2018]), there is a scarcity of information concerning its association with physical and emotional pain, mental health, and the construction of identity. It is important to understand how gender roles relate to cognitive-emotional factors, especially when considering that gender role experiences also occur cognitively, emotionally, and behaviorally (O’Neil, 2008). Thus, the present study uses in-depth interviews in order to explore how pain—as a physical and emotional experience— shapes situations in which the person learns new definitions of self and often relinquishes old ones. The individual in pain draws upon past social experiences, cultural meanings, and knowledge to engage in a mental dialogue about the meanings of present physical, and social existence.

Literature Review

Studying the intricate connections among Latino veterans and their experiences with pain requires an examination into understanding the ways in which culture establishes social and psychological conditions from which pain behavior materializes. Since the study is focused on cultural identity, symbolic interactionism offers an ideal theoretical approach to observe the multiple connections between being a man, a veteran, Latino, and how these factors contribute to expressions of pain for respondents. Many studies have contributed to our understanding of ethnicity/race and pain behavior (Cancio, 2015; Kwok and Bhuvanakrishna, 2014; Mahadeva et al., 2015; Matsuura et al., 2012), the impact of PTSD-related pain in the context of ethnicity (Cancio, 2018; Shin et al., 2012), and the developmental effects of ethnicity on perceptions of pain (Boissoneault et al., 2015; Bourke, 2014).

Different cultural groups have diverse sets of values, norms, and attitudes about health and the experience of health (Bourke, 2014). Culture and context shape pain beliefs and health behaviors in various ways. For example, many Latinos believe that feeling pain should be without complaint (Sobralske, 2006). Additionally, pain expressions influence culturally appropriate behaviors (Cancio, 2018), suggesting that manifestations of pain (e.g., moaning) may have distinct functions among various groups (Cancio et al., 2018).

Pain norms and values provide a conceptual framework for understanding the connection(s) between Latino culture and health beliefs. For example, first-generation Mexican American males believe a healthy person is one who is fulfilling his or her functional role and is free of any pain (Horevitz and Organista, 2013; Murillo et al., 2015). Horevitz and Organista’s (2013) study on Mexican health beliefs identified that self-control was important in Mexican culture. This is because self-control is a regulatory behavior applied in conjunction with Mexican cultural norms (Horevitz and Organista, 2013). In addition, masculine impressions also have an essential role in the health behavior and definitions of pain for Latino men (Gast et al., 2017). Machismo, for Latinos, is an important area to study because gender is a common antecedent of health behaviors (Houle et al., 2008).

The social process and construct of machismo is the intersection between cultural beliefs and expectations regarding the role of men in society. Machismo encompasses both positive (e.g., caballerismo[2]) and negative aspects of masculinity (e.g., dominance, aggression, sexism; Nuñez et al., 2016). Machismo is a grand narrative about Latino masculine cultural history, social experiences, and gendered behavior (Falicov, 2010). Machismo involves “doing” cultured masculinity (West and Zimmerman, 1987). An example of “doing” masculinity is emotion management or emotion work,[3] where individuals inhibit feelings to render them appropriate to any given situation (Hochschild, 1983). The effort on managing emotions in order to maintain a level of machismo may explain how Latino veterans experience pain management both in and out a military setting.

This perspective allows us to observe how coping works with emotional trauma from combat experiences. Over time, individuals socialized by the military (e.g., by means of boot camp, military training, and military culture) learn to rely on emotion work not only during training but also during deployments, during combat situations, and at home. Military socialization makes emotional management an overarching component of a successful military service member, making emotional management a normal function within the context of the military. Work performance coping strategies may contribute to issues with resocialization when returning home and/or transition back into civilian life. Dependence on emotion work, while important in military settings, may be an unwanted consequence in PTSD-related pain.

Machismo for Latinos is a salient a part of cultural self and ethnic identity. Machismo can be most noticeable when operational demands of high-risk and high-stress occupations (e.g., military jobs) are experienced (Canive et al., 2001; Herrera et al., 2013). For example, restricting emotional expression may complement military training during a deployment. However, this may become problematic at home, after a deployment, due to the long period of separation and adjustment. Collectively machismo and military norms compound pain behaviors for men (Canive et al., 2001; Craven et al., 2014; Herrera et al., 2013; Sobralske, 2006). As a result, Latinos follow socially approved culturally gendered health behaviors and expectations.

Pain is a ubiquitous experience, simultaneously influenced by several factors, and subjective (Kotarba, 1983; Osborn and Rodman, 2010). This makes inferences on pain dynamic and extremely difficult to quantify (Osborn and Rodman, 2010). Since the private nature of pain makes drawing quantifiable inferences problematic, a qualitative approach is appropriate,[4] as it elicits thorough explanations that cannot currently be investigated by biomedical evidence (Cahana, 2007). This study attempts to explore the nuances of culture and pain for Latino veterans.

This study attempts to flesh out some of the existing cultural constructs and concepts (e.g., machismo and familism) from the participants’ point of view and will serve as an important step in unraveling the influence of culture on the construction of social meanings, providing a deeper and more critical theorization of masculinity, race–class–gender, and machismo. This study focuses on the following research question: How do veterans draw on ethnocultural meanings/ideas to manage with their PTSD-related pain?

Method and Procedures

While pain and PTSD have been documented in research, there is a scarcity of information concerning its association with Latino veterans and masculinity. It is important to understand how gender roles relate cognitively, emotionally, and behaviorally (O’Neil, 2008). Given the possible relationship of gender roles with emotional and physical health, the present study examines associations of pain, PTSD, race/ethnicity, and gender in the context of Latino masculinity. Using in-depth interviews, this study contributes to the existing literature by constructing meanings and experiences for Latino veterans who suffer from physical and/or emotional pain from combat. Since the private nature of pain makes drawing quantifiable inferences problematic, a qualitative approach is appropriate, as it elicits thorough explanations that cannot simply be investigated by biomedical evidence (Cahana, 2007). Qualitative methods to inferences about pain are appropriate because qualitative approaches attempt to explore the personal experience of pain, access the insider’s experience, and adopt a different ontological position[5] to quantitative work.

Participants

Data consisted of 26 in-depth[6] interviews with U.S.-born Latino veterans. Interviews lasted between 30 and 45 min. Data for the study were collected using a snowball sample in San Francisco and Los Angeles, California, from 2014 to 2015. The process of recruitment involved contacting personal references and networks. Selected participants met the following inclusion criteria: (a) self-identified as male, (b) self-identified as Latino, (c) have served in the U.S. Armed Forces, and (d) diagnosed or self-identify as experiencing posttraumatic stress from combat military service. Verbal consent script and protocol approved by the (University of Miami IRB #20140864). The average age of respondents was 46. Information about each respondent and descriptive statistics is provided in Table 1.

Table1.

Participant Demographics and Statistics.

Participant Pseudonyms	Age	LOC	Conflict	# of Deployments	Service Branch	Years of Service	Military Occupation
Ocotillo	24	OC	Afghan.	1	USA	4	Calvary Scout
Tomas	26	SF	Iraq	1	USA	5	Combat Engineer
Lucas	28	SD	Iraq	3	USN	8	Military Police
Manuel	28	CA	Iraq	1	USMC	4	Mechanic
Uriel	28	LA	Iraq	3	USMC	9	Transportation
Wilfred	28	LBC	Afghan.	1	USA	5	Military Police
Ivan	29	BA	Afghan.	1	USA	4	Military Police
Kiko	29	SVF	Afghan.	2	USMC	9	Motor-t
Diego	30	SD	Afghan.	1	USA	4	Mechanic
Pablo	30	LA	Afghan.	1	USMC	4	Mechanic
Alfredo	32	LA	Iraq	3	USMC	6	Infantryman
Yago	32	CV	Iraq	1	USA	4	Radioman
Hector	33	LA	Iraq	1	USN	4	Corpsman
Carlos	35	LA	Iraq	3	USMC	10	Infantryman
Xavier	35	LA	Afghan.	3	USA	8	Infantryman
Nicholas	65	OX	Vietnam	1	USMC	4	Infantryman
Francisco	66	LA	Vietnam	2	USA	3	Radioman
Guillermo	67	LA	Vietnam	1	USA	3	Infantryman
Roberto	67	LA	Vietnam	1	USA	4	Infantryman
Valentino	67	SF	Vietnam	1	USMC	4	Infantryman
Emmanuel	68	LA	Vietnam	1	USA	4	Rifleman
Queretaro	68	SF	Vietnam	1	USMC	4	Radioman
Baldomero	69	LA	Vietnam	1	USA	4	Infantryman
Santiago	69	SFV	Vietnam	1	USA	4	Infantryman
Joaquin	70	LA	Vietnam	2	USMC	3	Medic
Zapata	71	SFV	Vietnam	2	USA	4	Infantryman

Note: LA = Los Angeles; SF = San Francisco/Bay Area; LBC = Long Beach; SD = San Diego; SFV = San Fernando Valley; CA = Calexico; BA = Bakersfield; CV = Central Valley; OX = Oxnard. Service branches: USA = U.S. Army; USM = U.S. Military; USN = U.S. Navy; USMC = U.S. Marine Corps.

Theory

The current study uses a symbolic interactionist[7] theoretical approach[8] complemented with a grounded theoretical methodology. Constructivist grounded theory methodology allows for the study of a group of people who have experienced a similar process and allows for a personalized theoretical understanding created by the participants (Charmaz, 2006). The aim of constructivist grounded theory is to contextualize social processes in the interactive world, and not to generate generalizable evidence. Each study has a specific context (e.g., time, space, culture, and situation) and social processes generated from these context are evaluated as plausible accounts rather than as objectively verifiable (Charmaz, 2006). This methodology works well with the symbolic interactionist perspective, which understands processes and meanings as social constructions rooted in social interaction (Charmaz, 2006).

In an attempt to understand pain and ethnicity, constructivist grounded theory allowed the researcher to attend to what was heard, seen, and sensed during the interviews. The interview questions were open-ended to explore all aspects of physical and emotional pain, the impact of pain on the lives of participants, and questions about ethnicity. Once the first interview was transcribed, the researcher began line-by-line coding, giving initial codes to the data. Three levels of coding were employed: open coding, selective coding, and theoretical coding (Charmaz and Belgrave, 2012). The coding stages were consecutive, sequential, and not iterative. The product of each stage guided the following phase. Using this methodology, data formed categories of similar phenomena. As the categories began to develop, those that were most dense were identified as core categories (Glaser, 2001). Through this process of densification, core categories become theoretical articulations of basic social process (Glaser and Strauss, 1967).

Results

Analyses highlighted multiple interactive dimensions related to the pain experience (Figure 1). These were classified as input factors about how pain was socially constructed and output factors representing the lived experience of pain and PTSD. Four themes underpinning the construction of the pain experience emerged—Latino culture and ethnicity; machismo and pain; transforming self; and feeling disconnected and dealing with pain—and were viewed as interrelated. This, in turn, influenced each participant lived experience of pain. Table 2 presents descriptions of the themes constructed from the data used to examine the four subsections.

Figure 1.

Thematic map of the multidimensional experience of PTSD and pain for Latino veterans. PTSD = posttraumatic stress disorder.

Table 2.

Themes and Descriptions.

Theme	Description
Latino culture and ethnicity	Complex socio-historic forces that include culture, aspects of ethnicity, and discrimination shape the Latino culture. In addition, it provides a fundamental framework from which to understand pain as a manifestation of a disorder, a disturbance, or medical condition because meanings are shared among cultural groups
Machismo and pain	Expressing and emphasizing the degree to which physical and emotional pain from combat affects their life while exhibiting masculine social traits (e.g., hide emotions, work ethic, and present manhood in daily tasks). A form of “being” masculine. The cultural effects of masculinity affect health beliefs. Exhibiting masculine standards is considered an idea
Transforming self	Self is defined as a process, and process, in turn, emphasizing forming, transforming, ordering, and pattering.
Feeling disconnected and dealing with pain	Returning from deployment and losing the sense of family and community ties and personal involvement with the family. Consequently, this could result in a possible loss of social support. This does not mean that the individual has lost family in the literal sense. The individual fears loss of connectedness, security, and well-being. Feeling that no one understands them. Dealing effectively (coping) with pain using support from individuals, institutions, and other support groups. Alternatively, not dealing with pain effectively by isolating one’s self from others, possibly causing bodily harm to self and others.

Latino Culture and Ethnicity

Adherence to a particular cultural group has implications for their individual, the collective personality, and how individuals interact (Burkitt, 2008). Across interviews, the concept of culture arose recurrently. Tomas, an Iraq-Afghanistan Veteran (IAV), shared how men in his family and interacting with his mother gave him a sense of how to navigate pain and suffering as a Latino:

My apa and my grandpa had jacked up nails. They were all dirty, bent, some were missing and even some were cut in pieces with fungus too. I remember I asked my mom once, why their nails were so ugly. She would say things like, they got that working, with their hands. And their nails got like that because they were too busy to stop and too manly for medicina (medicine). “Se chingan, no se cuidan las manos para que tengas lo que tienes, para la familia” (They grind, they don’t take care of their themselves, so that you can have what you have, for the family.) That’s what it was, that’s what it’s about. . . that’s what being a man is about.

Consistently, the concept of culture arises within the context of familialism. Familialism is a social context from which relationships with and attitudes among the family were more important than individuality. Like Tomas, other respondents discussed manifestations of masculinity, being Latino, and living with pain, from family members.

The idea of work ethic is another significant behavior for Latinos. As seen previously, the general agreement is that Latinos work hard, strive, and provide for the family. Some respondents pointed out that Latinos in the military are often willing to take the jobs that no one wanted. When asked what it means to be Latino, Juaquin, a Vietnam Veteran (VV), shared how being Latino and being a man:

It’s a religion, being Mexican, being Chicano, or whatever type you want to be called, it’s all the same shit. It’s about being Azteca (Aztec), it’s about being a warrior like Pancho Villa and Emiliano Zapata. Being Mexican to my generation was about revolt. [Whites] called us dirty, but even the dirt has salt, we have flavor. Your generations forget that being a Mexican man is about survival. Since Cortez, we survive . . . we survived the diseases, the war, the racism. Being Mexicano, a macho, and your pain is what we always were since before you and I. It’s our cross to bear, our burden. And we love it. From Aztec to Marine, from Mexico to the US, we survived it because we are real men.

Respondents articulated pride in being Latino because their identity reflected a sense of survivability across time and geographic location. The Latino culture is shaped by complex socio-historic forces that include culture, aspects of ethnicity, and discrimination. For respondents, Latinos have strong family ties, work ethic, and abide by specific sets of hyper-masculine norms. Embodying the Latino culture places a considerable consciousness on the development of the self (Burkitt, 2008). In addition, personifying the Latino culture provides a fundamental framework from which to understand pain as a manifestation of a disorder, a disturbance, or medical condition because meanings are shared among cultural groups (Boissoneault et al., 2015). Following the sociological concept of dramaturgy (Goffman, 1959), respondents consciously and unconsciously follow impression management as they follow culturally, gendered, and military-approved manifestations of pain management. Latino cultural value-based impression management provides guidelines for Latinos in the dual evaluative work that is undertaken by both the Latino Veteran (performer) and, as an example, the family (audience), thus demonstrating the inseparable link between performer and audience, individual and society.

Machismo and Pain

Many studies focus on the negative characteristic of machismo. Scholars like Falicov (2010) describe machismo as violent, rude, and womanizing. Nonetheless, instead of showing the negative features of machismo, respondents instead pointed to the functional role machismo plays. Nuñez et al. (2016) argued that machismo has a positive side as well; moreover, this positive image of male gender role characteristics encompasses concepts such as chivalry, bravery, and family provider attributes. Participants connected their roles and responsibilities to positive masculine behaviors and norms. Uriel (IAV) shared how it was important to be a man when it came to his pain because his family depended on him as the primary source of familial income:

I have to man up because they [my family] depend on me. I bring the checks in. I have a wife and a kid and I just don’t have time for it. I don’t want my girl to get sad, especially ‘cause she thinks so highly of me. She fell in love with me wearing a uniform, I’m not going to tell her those things, and I don’t want her to think I’m crazy. I just don’t want to think about it right now, I have bigger things to worry about.

Being healthy was also seen as essential and part of machismo. Manuel (IAV) highlighted the importance of identifying being unhealthy and seeking help, with the aim of returning to a state of normalcy:

When I came back from Iraq, I had two toddlers depending on me. I lost my sanity in Iraq, but not my responsibilities. When I left the Corps I didn’t want to be that shit bag that picked up drinking and losing his family. I had to man up and talk to someone. So yeah, I did some counseling when I was still in Camp Pendleton. I didn’t tell anyone I would go see the chaplain, but you know what, it was worth it because I felt better after.

Xavier (IAV) also shared why it was important to him to “man up” in stating:

I didn’t want to visit a chaplain because I didn’t want them sending me anything at home or me walking out of the office and there’s someone I know. But I knew that I had a problem that could only get worse. I didn’t want to lose my job or my family. So I started going to a counselor at my community college. It wasn’t formal, but he was a veteran, too, and he would let me unwind. We would work out. I would call him my workout buddy.

Throughout the interviews, machismo exists and is responsible for sustaining the health beliefs of Latinos. For the participants, machismo enhances men’s awareness of their health status because respondents believed that they had to be healthy to be good fathers, husbands, brothers, sons, and workers (Sobralske, 2006). Arciniega et al. (2008) also identified that male gender roles represent multidimensional behaviors that fall on a continuum from positive to negative. This finding amplifies the idea that machismo includes many positive elements not previously addressed in the literature.

On some occasions, pain may obstruct gendered-responsibilities, respondents discussed finding ways to regain their ideal health status so they can return to work. Ocotillo (IAV) articulated that being a man is about work and providing for his family. He shares:

You need to be tough and have the balls to take care of business. I just pretend that everything is okay. I have a daughter and I have to think about her. She depends on daddy to feed and clothe her. If I hurt, okay, I hurt. Let’s get this shit fixed up because I have things to do and responsibilities.

Among respondents, functional limitations serve as motivating factors in seeking treatment and finding ways to regain optimal health (Sobralske, 2006). Zoucha and Purnell (2003) claim that good health for many Latinos is being free of pain and being able to work; however, as participants suggested, it is not being free of the pain that constitutes being Latino. It is more so the ability to work through the pain. This process of negotiation between masculinity and pain is strictly an internal process informed by external understandings of masculinity.

Transforming Self

For respondents, the application of machismo was a lonely process since communication was perceived as a sign of weakness and impression mismanagement. Respondents navigate the social world feeling gendered pressures and cultural obligations that manifest and make respondents feel disconnected. The process prompts a transforming state from which participants feel different and disconnected, both from their pre-deployment self and their ties with family, friends, and society. The hidden self is a component in the process of feeling disconnected. Participants that expressed being disconnected also expressed a sense of brokenness. They expressed that there was something wrong with them, something was missing from them, or that they no longer felt whole. Hector (IAV) shared how feeling broken led to him feeling disconnected:

It’s like I was broken or something. My mom’s cooking didn’t taste the same, kisses from my girl felt weird, and I feel like everyone is always judging me.

Feeling broken is associated with feeling disconnection. Wilfred (IAV) shares his experience coming back from his second deployment:

I fucking loved going to the movies. I love watching movies. I would be to Long Beach with my girl since we were in high school to the theaters there. But after my second deployment, I didn’t like being around crowds or people I didn’t know. I didn’t trust anyone. So we stopped going. She wouldn’t argue with me, but I know she thought I was weird now. I knew I was weird. Acting a little funny. . .but it wasn’t funny at all. My whole life changed. And now. . .now I can’t go watch a fucking movie in the theaters.

Participants identified a sense of brokenness as both a cause and effect of losing connections or ties. Feeling broken leads to feeling disconnected. Feeling disconnected means and/or occurs when returning from deployment and losing one’s sense of social ties, which existed prior to deployment. These were fundamental to such an extent that a person feels the need to acknowledge them as a loss in normality, in terms of relationships. The disruption in, or the loss of, important relationships with someone or something has a profound impact.

This loss of social ties and connections becomes a loss of personal involvement with family, friends, and other relationships that provide social support. Loss of belonging or feeling disconnected can amount to the feeling of losing social support. This does not mean that the individual loses friends or family in the literal sense. Rather, he believes that his social relationships cease to exist. The individual feels a loss of connectedness, security, and well-being. The ultimate feeling of loneliness is when the individual feels no one can understand him and/or he does not understand others. Feeling disconnected arises post-deployment after a traumatic event. Feeling disconnected arises in the mind of the person as he encounters pre-deployment social relationships. This feeling is maintained as the individual sees explicit developments that draw him further from connections previously held.

The consequences of loss of belonging or feeling disconnected vary across individuals. However, at the extreme, these tend to be clustered in the severing of social ties and the loss of relationships. Loss of belonging is affected by temporality and severity. An individual may feel initially disconnected and choose not to participate in family events. For instance, upon arrival from deployment, Lucas walked off the base, passed his family, and went into a local bar. Lateron, Lucas began to interact more and more with his family, although still feeling disconnected. Yago, on the contrary, felt so disconnected that he left his pregnant girlfriend. He did not want to be around her. Joaquin also felt disconnected. While he still feels that way, he does interact with his family. Sometimes, he feels more disconnected than others do, but he does not leave. Nicholas (VV) shares how the feeling of being disconnected changes over time:

You know [PTSD] its a forever thing when, every time you think you finally feel like you have control, you lose it. . .Well, sometimes I feel like I belong here and sometimes I don’t. Sometimes when I feel like I’m losing it, I’ll get nightmares at night, I’ll yell and kick and scream. I’ll wake up on the deck and my wife crying running out of the room. Then I say to myself, I’m back to square one. Then sometimes I wake up cuddling with my vieja (woman), and I says, I’m gonna be okay.

Roberto (VV) shares this similar notion of feeling disconnected from time to time. He shares:

Over the years I’ve been able to control my anger and depression. Pero (but), some days I wake up after a night full of nightmares and I get all fidgety. I’m snappy and I get easily frustrated with people and with me too. Little things make me snap and I’m in my head going crazy. Like seeing all these military movie commercials of PTSD on TV, I don’t sit there and say oh shit I can be famous now, it’s cool to have PTSD. No! I’m not a fucking Joker like the Steve Miller song. I am a person! I have a heart! I live this pain every day.

Figure 2 illustrates the processes of feeling disconnected and transforming the self. It is important to remember that some participants navigate the diagram at different times and with different consequences. Navigating through this process is another factor that plays a major role in how the participants defined their pain, as associated with their own combat experience. It is important to note that age did not matter in terms of where an individual was in the processes of feeling disconnected, only that all participants felt they are constantly navigating through this process.

Figure 2.

The transforming self and the continuous processes of feeling disconnected.

Figure 2 highlights the continuous process of feeling disconnected and transforming the self as described by all the participants. It is clear based on the model that there is a perpetual flux in the transforming self. This flux highlights the constant inconsistency of living with PTSD. It makes sense that participants feel different in terms of the level of connectedness and how it affects them every day. Respondents’ feelings are consistent with criterion D: 6 of the DSM-5, feeling alienated, detached, or estranged (American Psychiatric Association, 2013, 309.81: F43.10). This social psychological phenomenon makes clear that the self is not being transformed into any particular outcome. More so, this process supports the notion that the self is fluid and in constant social negotiation. More importantly, the transforming self proposes that the meanings of pain too are fluid and constantly in negotiation.

Feeling Disconnected and Dealing With Pain

Feeling disconnected and dealing with pain are interconnected. The relationship between feeling disconnected and dealing with pain stems from the inseparable relationship between one’s transitional self, as it manages other themes associated with one’s pain, and constantly adjusts based on the level of connectedness. For example, as the participants shared, this inconsistency and perpetual flux of “losing it” showcased a noteworthy dynamic process. Since participants felt they were in a transitional state, with a self that is constantly changing, they are not able to bind and build consistent bonds with family, friends, and others in society. Constantly changing levels of connectedness impact the needs, coping strategies, and pain management techniques that veterans utilize in dealing with their pain. Ivan (IAV), like most participants, identified the constant inner and outer negotiations made on a daily basis, while dealing with relationships with others and daily functioning. He shares a negotiation he had between himself and his younger brother:

I haven’t worn my uniform since I got out, it’s not that I don’t like the way I look in it, but I just don’t know how I would feel. The medals I earned are not awards, but reminders of those days. I ‘member one time my little carnal {brother} came home from school, it was career day or something, he was dressed like a little soldier. I kinda looked at him all weird because he was wearing my medals. I was gonna snap, hit him for taking my shit. . .but before I could he ran up to me and said, ‘Mano {brother}, look, look I’m like you now! I’m going to be cool like you when I get bigger!’ I was about to snap and then I took a deep breath and high-fived him. He didn’t know what I felt, it’s not his fault I’m all beat up inside. I had to suck it up and man up, he just wanted to be like me, cool like me. . .so that’s what I do, I keep it cool for him because I’m the only man he has, the only man he can depend on.

Ivan’s story is an example of the deep connections between the negotiations of dealing with pain, the positive role masculinity plays in health beliefs, the negotiations of maintaining social bonds and connections, and dealing with pain. In Ivan’s case, there is a singular negotiation in terms of his relationship with his younger brother, but for others like Lucas (IAV) negotiating the transitional self manifests itself quite differently. He shares:

I’m still in the military, I got out for a few months, tried the whole civilian life, but it wasn’t for me. For some guys taking the uniform off is their thing to deal with whatever PTSD they have, but for me, it’s all about my comfort zone. Even though sometimes I get a little down when I see platoons come back with a little memorial thing for the guys that didn’t make it, I blame the military. Then other times I love the military because it’s my safe zone. It’s like every day I’m thinking about leaving and staying at the same time. I’m on deployable status and I know that in the next nine months my unit might have to go, sometimes I’m cool about it. . .sometimes I feel like my comfort zone is my penitentiary. . .I’m just scared because I know I can’t stay in forever, then what?

Emmanuel (VV) shares his experience of dealing with his PTSD and feeling disconnected; he also shares how women in his family helped him deal with his pain by reinforcing masculinity in his character:

No pudever a mi ama {I couldn’t look my mother} in her eyes. . .I didn’t want them [family] to see that I wasn’t me, the same Emmanuel. . .it really is. . .it’s about being strong being macho, I mean it happened almost fifty years ago but you. . .you can’t beat it, but you can control it. My hermanas {sisters} and ama {mother} never asked me anything. They pretended I was normal. I know they knew I wasn’t but it was good for me you know, good for me to pretend. . .they never asked anything. . .they would still mess with me, my oldest sister would still pinch me and punch me, tell me to suck it up or be a man about little things. . .mi vieja {wife/woman/old lady} still does that [laughter], but its more about getting it up [laughter].

Several participants like Emmanuel expressed how they used familial structures to help cope with their PTSD. Those respondents who shared using family structures as a way of dealing with their pain identified with feeling higher levels of masculinity. There seems to be a relationship between family structures, values, and norms, which reinforce masculinity to overcome the pain associated with war.

Feeling disconnected and dealing with/coping with pain is tied to Goffman’s (1959) idea of role distance. This may explain how the role of a service member, among veterans, is difficult to detach from the ‘self.’ As a result, this may be a survival strategy and coping process as veterans attempt to deal with PTSD-associated pain. Conversely, culturally-based masculine roles may preclude Turner’s (1978) idea of role merger, especially among Latino veterans, where the intersection of culture and gender norms may impede coping with PTSD-associated pain. Other possible manifestations of gendered identity on pain beliefs might include Cooley’s idea of looking-glass-self, where gendered identity may shape a person’s self-concept and their understanding of how others perceive them (Rawls et al., 2018). By reflecting on the in-depth understandings of the meanings associated with the emotional and physical pain of combat, this study was able to observe the phenomenon of pain as a daily experience, tangled in the interpretation of the self.

Discussion

Pain, as a physical and an emotional phenomenon, is influenced by interconnected social and cultural factors. Pain, as an experience, is a process of coping, disconnect, and masculinity for Latino veterans. Pain is an overarching experience depended on culture and gender. For participants, being Latino was a social context from which to navigate and interpret the world around them. Pride in being Latino derives from the socio-historical experiences Latinos have encountered. This cultural identity, although not necessarily homogeneous, is rooted in its history of survival and adaptation across various Latino subpopulations. Latino governance of pain behaviors is centered on the various ways that an individual can maintaining familial and cultural expectations. For Latinos, silence reconnects and maintains bonds among family. In this context, machismo provides a framework from which individuals can maintain cultural norms and behaviors. For that reason, for Latino veterans’ health and health behaviors is deeply rooted in enduring pain, so that one may be able to fulfill perceived social responsibilities. Culture is a social framework and process from which individuals exercise gendered expression of pain and coping strategies. Machismo is an integral social construct and process in the expression and daily experience with pain for Latino veterans. Findings suggest that the study of culture and gender plays a major role in understanding the experiences and behaviors of the pain of combat for Latino veterans.

This study is one of the first to explore ways in which PTSD and pain are framed and experienced by Latino combat veterans diagnosed or self-identify as experiencing posttraumatic stress from combat. In doing so, this research adds to the body of literature that speaks to the nonhomogeneous and fluid nature of ethnoculture, recognizing multiple and intertwining variables including ethnicity, gender, and role category and/or social and community group membership. An individual may draw concurrently from a multitude of cultural identities to frame their understanding of health and illness. This work provides nuanced recommendations for health-care providers regarding services and support to Latino men with a history of military service. For example, providing treatment/intervention(s) that take into account the continuous process of the transforming self and feeling disconnected (Figure 2). The relative contribution of each cultural variable to an individual’s experience of pain will vary, being influenced by socio-environmental contexts and personal histories. This, in turn, impacts the explanatory model of health and illness that will manifest in different ways (Kleinman, 2017). Skillful inquiry into these relative contributions will enable health-care providers to approach pain management with sensitivity to the diversity of culture while respecting the individual and their unique illness narrative.

In addition to the major themes discussed in the aforementioned section, themes highlight that gender is a significant social construct in the study of pain and pain behaviors. Pain is, by definition, always subjective and can be influenced by social factors, like gender. From an early age, children are socialized along with gender norms for how to respond to pain (Hoffmann & Tarzian, 2001). Consequently, gender role expectations influence perception and report of pain. Gender norms, like military masculinities, are culture-based and express expectations central to the construction of a serviceman and fundamental in men’s interests, behaviors, and choices in life (Cancio, 2017). Rather than a single and highly embodied model of masculinity, our analysis takes the argument further, through the investigation of the connections between ideas of masculinity, ethnicity, culture, and the military, and finds support for the manifestation of a unique typology of military masculinities among this group of combat veterans. Although experiences of pain are shaped by sociocultural context, what is innovative about these results is the finding that pain and pain behaviors are exacerbated military masculinities as they compound to earlier forms of socialization (e.g., ethnicity) that predate military experiences and military masculinities are not uniform across the generation of veterans (i.e., Vietnam era veterans/Iraq-Afghanistan era veterans).

Future research should attempt to consider current military servicemen and women in order to evaluate how the ongoing influence of working in the military plays a role in shaping the meanings of pain and masculinity for Latinos. Masculinity does not solely manifest among Latinos; future research should begin asking, how is being a man from other cultural backgrounds differ in terms of health beliefs and behaviors when compared to other masculine cultures?

The general agreement is that Latinos work hard, strive, and provide for the family (Cancio, 2018; Mirande, 2018). Latinos have ridged norms and values that regulate health behaviors and health views. More importantly, these ridged norms and values provide guidelines for men as they navigate the social world. For respondents, masculinity is a socially valued resource. Following Zinn’s (1982) work on masculinity, race, and class, findings suggest that, for participants, machismo is viewed as a compensatory stance by men who are marginalized and subordinated by their culture and class situation. These men, due to their intersectional positionality, disproportionately pay high costs of masculinity, including health costs; dangerous military service; and the psychological and interpersonal constraints that are so evident in the interviews are amplified for these men by the combination of military training and culture with the narrow conceptions of masculinity.

While this work contributes to the understanding of pain among Latino veterans, there are several limitations that need to be addressed. First, participation in this project was strictly voluntary, as a result participants’ responses may have differed from nonparticipants. While many clear themes emerged, it is beyond the scope of this study to survey the magnitude to which these themes contributed to the meanings of pain. Nonetheless, this study is still beneficial, as it can serve as a possible frame for future studies. Going forward, researchers should consider the programs the military has developed to deal with incidents of pain-related PTSD (e.g., PTSD-related hyperarousal symptoms often cause tense muscle pain that can become chronic[9]) and whether they have considered specific ethnic and cultural barriers. Overall, the interviews echoed a deeper and more critical theorization of masculinity, culture–class, ethnic identity, and pain behaviors. Through participants’ responses, the intersection of culture and class was examined and the synergistic effect of military experience, ethnic identity, and gender on masculine frameworks.