It’s just over 10 years since a report from the Institute of Public Health in Ireland¹ described the gap (at that time) in life expectancy between men and women as “a fundamental inequality in health”. Around the same time, the late Anthony Clare, consultant psychiatrist, was writing about (Irish) men having somewhat lost their way in the world and about masculinity being ‘in crisis’.² One might have expected such language to have provoked the wider populace of Irish men to take to the streets with placards demanding urgent action to address their health needs. But alas, such is not the way of men.

In fact, although men have traditionally been at the forefront of all matters to do with health, men themselves have been conspicuously silent about lobbying or campaigning for improvements to their health at a personal or individual level. So what has changed in 10 years? Is there still a case for approaching men’s health from the perspective of male/female differences in health, or should we be asking different questions? Was Anthony Clare right, and, if so, has the ‘crisis’ in masculinity not now deepened further in the midst of economic recession and such an uncertain future? These are some of the questions that this article poses and will be discussed in the wider context of key developments in men’s health in recent years. 

Key men’s health statistics

While there are many positive developments to report in men’s health, regrettably, the overall picture, in terms of key statistics, has changed little in 10 years. Although the gap has narrowed slightly, men in Ireland still die, on average, almost five years younger than women do (76.8 versus 81.6 years) and have higher death rates from all of the leading causes of death (see Table 1) and at all ages (see Table 2).³

In the case of cancer, for example, age-standardised incidence and mortality rates (for non-sex-specific cancers) clearly indicate higher incidence and mortality rates in men compared to women⁴ (see Table 3).

Perhaps not surprisingly, therefore, 85% of last year’s 368 centenarians in Ireland were women! While the gap in male: female mortality for all causes of death is consistent across all age groups, it is most pronounced between young men and young women, with suicide and road traffic accidents accounting in large part for this differential. 

 

 

 

Are men less healthy than women?

Men’s poorer lifestyles account for a high proportion of chronic diseases such as coronary heart disease, diabetes, stroke and some cancers. Over two-thirds (69.6%) of Irish men are either overweight or obese.⁵ Men’s diets are less healthy than women’s diets, with men eating more fried foods and high-caloric items and less fruit and vegetables than women.⁶ Men are more likely than women (11% versus 8%) to drink in excess of the recommended weekly limit (21 standard drinks for men and 14 for women) and to binge drink (38% men and 17% women).⁷ Men are also more likely to have a ‘positive’ AUDIT-C score which indicates a harmful pattern of drinking.⁷ Despite this, men often view themselves as having better health than women, and young men in particular tend to minimise the potential consequences of practices damaging to their health and to see themselves as invulnerable to danger and to risk.

It is also well documented that men tend to be slow to recognise symptoms of ill-health and to present late to health services, leading to higher levels of potentially preventable health problems among men and fewer treatment options.⁸

A recent Danish study,⁹ which demonstrated an overall pattern among men of lower contact rates with GPs but higher hospitalisation and mortality rates, led the authors to conclude that men react later than women in seeking help for severe symptoms, resulting in higher rates of hospitalisations among men for the causative condition. The proportionally greater use of primary care services by women in the early years reflects the provision of antenatal care, contraception and screening services that are more likely to habituate women into regular contact with health services. The general absence of male-targeted healthcare programmes hinders the surveillance capability for men’s health problems and men’s ability to identify as participants in healthcare. Perhaps not surprisingly, therefore, many men eschew traditional interpersonal medical consultations and instead opt for online medicinal products, an increasingly worrying trend given the risk of exposure to potentially harmful counterfeit drugs. Men’s poorer knowledge and awareness of health also points towards the need for targeted health information to be delivered to men.

Differences in health outcomes between men

There is increasing awareness in recent years of the need to account for the substantive differences in health status between different categories of men. It is now well recognised that social, economic, environmental and cultural factors are key determinants of the health status of men. 

The burden of ill-health and mortality is borne, in particular, by men from the lower socioeconomic (SEG) groups. There is what can be described as a ‘stepwise gradient’,¹⁰ with ill-health and premature death increasing with each step down the SEG scale, and the steepness of this gradient being particularly pronounced in men. The recent publication of the first State of Men’s Health in Europe report¹¹ highlights that across the EU – 27 countries – over 630,000 male deaths occur in working-age men (15-64 years) as compared to 300,000 for women, and that these deaths are disproportionately concentrated among lower SEGs. This high level of premature mortality has far-reaching repercussions, affecting not only industry and commerce, but also impacting upon the social and financial positions of families through the loss of what is still, in many households, the primary income earner. This is of particular concern in light of future population trends. Based on current projections, there will be nearly 24 million fewer working-age men (aged 15-64 years) than now across the EU by 2060 and an increase in the number of men over 65 by some 32 million.¹¹ In Ireland, economic recession with its accompanying rise in unemployment rates has been linked to extremely adverse effects for men’s mental health.¹²

The need for a gendered approach

It is also crucially important to focus on key gendered aspects of men’s health, and to consider men and women as more than simply biological categories, constituted solely by biological differences. Such an approach enables us to recognise how different patterns of gender conditioning impact upon the value that men place upon their health and how they manage their health within the healthcare system. For example, numerous studies have highlighted how men tend to avoid seeking help when they are unwell because of fear of being labelled feminine or effeminate.⁸ It has also been shown that men who engage in health-damaging or risky behaviours often do so to prove their masculinity to others.⁸

And yet, while men are often considered ‘hard work’ by health service providers for not caring for their health, society continues to reward and valorise aspects of male identity associated with risk, daring and foregoing safety. For example, men continue to dominate those industries that have high levels of occupational injury and death – the construction industry, work involving heavy machinery or work conducted in heavily polluted environments – yet this has traditionally been taken for granted as normal and expected masculine practice, as ‘men’s work’. 

The extent to which men endorse ‘traditional’ or ‘dominant’ definitions of masculinity is related to unhealthy behaviours such as poor diet, excessive alcohol consumption, and non-use of health services.⁸ Men’s depression and other mental health problems are under-detected and under-treated.¹¹ One study¹³ described as the “unwelcome scrutiny of their male identities”, men’s attitude to seeking help for depression, which, the authors conclude, continues to contribute to the relative invisibility of men’s mental health problems. It has been argued that male depression is often manifested through more ‘acceptable’ male outlets, such as alcohol abuse and aggressive behaviour. With depression being implicated in over half of suicides,¹¹ this gives rise to the anomaly that although women are diagnosed with depression about twice more often than men, men are two to three times more likely to die from suicide. 

What’s new in men’s health over the past 10 years?

Encouragingly, there have been many positive developments in men’s health at a research, policy and practice level. At a research level, there has been a dramatic increase in men’s health research publications across a broad range of disciplines.

 These disciplines range from urology to andrology to sociology, with dedicated men’s health journals, numerous men’s health themes and features within the broader literature and several international conferences on men’s health. At a policy level, Ireland has led the way and was the first country in the world to publish a National Men’s Health Policy⁸ (Australia and Brazil have followed). Although constrained by funding cutbacks, the policy has been instrumental in creating a vision and an identity for ‘men’s health’ and in acting as a blueprint and a resource for practitioners.¹⁴

Some of the more notable developments that have taken place at a practice level include: 

• An increased focus on men’s health in the workplace (eg. An Post and Eircom have been very proactive in this area)
• Increased attention on community development approaches to men’s health, where the Men’s Development Network,¹⁵ the Larkin Centre’s men’s health and well-being programme¹⁶ and the Irish ‘Men’s Sheds’ movement¹⁷ lead the way; and
• The annual celebration of Men’s Health Week. 

Indeed, the theme for Men’s Health Week 2009 was ‘Men and access to services’ and included ‘Top Tips’ to support men to access primary care services.¹⁸

The Centre for Men’s Health at IT Carlow has also been active in developing men’s health training for practitioners with a men’s health training resource pack due for completion in 2012. These developments could support the development of a type of ‘Q Mark’ at a practice level that would reflect best practice in engaging men with health services. 

Conclusion

This short snapshot of men’s health should provoke a more informed and more nuanced approach to understanding ‘men’ as the complex creatures that we are. Essentialist approaches that seek to polarise men’s and women’s health issues (the former from Mars, the latter from Venus etc.) are surely less constructive than unravelling differences within each sex. Rather than seeing men as ‘the problem’, the onus should be on practitioners to work with men and to take more account of the gendered ‘baggage’ that (in some men) underpins risky behaviours, reluctance to seek help and reticence to be more engaged or proactive about their health. Yes, there are unprecedented challenges to masculinity, but there are also multiple ways of being masculine and we need to harness the resilience and strength that is at the cornerstone of masculinities in all our endeavours to promote men’s health.

References

1. Balanda KP, Wilde J. Inequalities in Mortality – A Report on All-Ireland Mortality Data. The Institute of Public Health in Ireland: Dublin, 2001
2. Clare A. On Men: Masculinity in Crisis. Chatto and Windus: 2000
3. Women and Men in Ireland. Central Statistics Office: 2010. Available at: http://www.cso.ie/en/media/csoie/releasespublications/documents/otherreleases/2010/womenandmen2010.pdf
4. Cancer in Ireland 2011: Annual report of the National Cancer Registry. National Cancer Registry Ireland: 2011. Available at: http://www.ncri.ie/ncri/index.shtml
5. Irish Universities Nutrition Alliance. National Adult Nutrition Survey: Summary Report, 2011. Available at: http://www.iuna.net/wp-content/uploads/2010/12/National-Adult-Nutrition-Survey-Summary-Report-March-2011.pdf (Accessed May 21, 2011)
6. Morgan K, Mc Gee H, Watson D et al. The National Health and Lifestyle Survey (SLÁN) Survey of Lifestyle, Attitudes and Nutrition in Ireland. Department of Health and Children, 2008. The Stationery Office: Dublin 
7. Morgan K, McGee H, Dicker P et al. SLÁN 2007: Survey of Lifestyle, Attitudes and Nutrition in Ireland. Alcohol use in Ireland: A profile of drinking patterns and alcohol-related harm from SLÁN 2007, Department of Health and Children, 2009. The Stationery Office: Dublin
8. Department of Health and Children. National men’s health policy. Department of Health and Children, 2008. Hawkins House: Dublin
9. Juel C, Christensen K. Are men seeking help too late? Contacts to general practitioners and hospital admissions in Denmark 2005. J Public Health 2007; 30(1): 111-113
10. Lohan M. How might we understand men’s health better? Integrating explanations from critical studies on men and inequalities in health. Soc Sci Med 2007; 65: 493-504
11. White A, McKee M, Richardson N et al. The state of men’s health in Europe report 2011. European Commission: http://ec.europa.eu/health/population_groups/docs/men_health_report_en.pdf
12. Institute of Public Health in Ireland. Facing the Challenge – The Impact of the Recession and Unemployment on Men’s Health in Ireland, 2011. Available at: http://www.publichealth.ie/files/file/Publications/Facing%20the%20challenge.pdf 
13. O’Brien R, Hunt K, Hart G. It’s caveman stuff, but that is to a certain extent how guys will operate: men’s account of masculinity and help seeking. Soc Sci Med 2005; 61: 503-516
14. Richardson N, Smith J. National men’s health policies in Ireland and Australia: what are the challenges associated with transitioning from development to implementation? Public Health 2011; 125(7): 424-432 
15. http://www.mens-network.net/
16. http://larkinctr.com/education/mens-health.php
17. http://www.menssheds.ie/
18. http://www.mhfi.org/international-mens-health-week.html