The inaugural lecture of Alan White PhD RN, the world's first Professor of Men’s Health.
A member of the board of the European Men's Health Forum and author of its landmark publication Men's Health Across 17 European Countries, Alan was appointed to the post at Leeds Metropolitan University in England last year. In April he gave his inaugural lecture, a wide-ranging and thoughtful discussion entitled 'Being male in the twenty-first century – the emergence of men’s health as a major public health concern.'
This ground-breaking lecture is reproduced with permission below.
Ladies and Gentlemen
Before we get into the lecture I would just like to thank Leeds Metropolitan University for their support of my work over the years and for bestowing this personal chair, the first of its kind. My colleagues in the Faculty of Health and the School of Health and Community Care. I would also like to acknowledge and thank all those inspiring men and women (many of whom are in this room) who have pushed men’s health to the forefront of people’s minds and been so crucial in getting us to where we are today.
So what’s this men’s health all about?
The easiest way to begin a talk on men’s health is to make comparisons with women’s health, this is not the ideal as we are not in game of looking for cheap headlines around the battle of the sexes or some such. Our concern is in relation to how men’s health differs from community to community, from one socio-economic group to another and for identifying issues that affect all men rather than assuming that if our health matched women’s we would be alright. That argument is based on an assumption that women’s health is the gold standard, and we know that is not the case and that much work has to be done on improving the health of women as well as men.
However it is inevitable that some comparisons have to be made and so I will keep them brief and hopefully you will see them as indicators of the issues for men.
The most telling but perhaps the most easily forgotten of the differences between men and women is that women live on average 5 years longer than men. A fact that so many people know that it hardly raises an eyebrow. However, when you break down the mortality data to age by age you see that there are more men than women dying at every age bracket, until you get past the age of 75 years
The next question is why do men have this increased number of deaths.
In 2003 the European Men’s Health Forum commissioned us to undertake a study on the State of Men’s Health Across 17 European Countries, as part of this study all the data from the 1,890,508 male deaths and 1,949,523 female deaths that occurred, were analysed and broken down by major disease classifications and by age and though it can be seen that overall more women than men died in that year when the ratio of male deaths to female deaths were looked at across the age groups then we can see men have nearly 2½ times as many deaths in the 1 to 24 year age bracket as women, nearly 2 times as high a ratio in the 25 to 74 year age bracket and it is only after the age of 75 years do women show a higher ratio. When the data is looked at closer the higher proportion of deaths occur across nearly all the causes of death that should affect men and women equally.
So what we have is an issue that affects all men across all the major disease states. This same pattern of greater vulnerability is also seen when the chances of developing cancer are considered. Across all the major cancers the incidence of men developing the disease is higher than for women, expect for melanoma (which we will see again later) and for thyroid cancer.
But though these comparisons with women are important to raise questions it is the differences in life expectancy between men that are the more staggering.
The recent ‘Choosing Health’ White paper talks of a 15 year difference in men’s health in differing wards in Westminster, with the lowest life expectancy being 67.5 years. In Leeds the City and Holbeck ward has a life expectancy for men of 66 years as compared to 79 years for Wetherby, 13 miles, 13 years difference.
We also have to contend with issues such as the fact that the biggest cause of death in men under the age of 44 years is suicide. In this slide we can see that when we map the number of deaths caused by suicide and intentional self harm against road traffic accidents in the UK we can see that many more men die as a result of suicide.
We also have to acknowledge that prostate cancer is now the most common male cancer and yet the levels of awareness of men of this problem are still poor, that the sexually transmitted diseases and HIV is on a rapid increase, etc etc
To meet the challenges now facing us with regard to men’s health we are seeing a massive increase in activity around the world. Australia has seen the most development, with America and Ireland working on a National Men’s Health Policy; at the European Men’s Health Forum we now have a network that spans 14 countries, there is also a MHF in the Philippines and in Hong Kong. And of course there is our own Men’s Health Forum of which I am proud to the Chair of the Board of Trustees. There is a growing academic press with the Journal of Men’s Health & Gender now launched and with a growing readership. We have had three World Congresses to date and are seeing conferences occurring on a more frequent basis around the country. More importantly we are seeing a massive increase in activity from practitioners working with men in many different settings.
The challenge therefore as we enter the 21st Century is to bring together the range of work being done from the biological, social and political sides to achieve a better appreciation of the health issues facing men. The focus of this lecture therefore is to consider what needs to happen in five key areas to see this emerging field grow and mature into a fully fledged discipline in its own right.
These areas are the need to discuss and debate with others about what men’s health is and how it should be developing; to consider the role of research in this field; to campaign to get recognition and action; to explore practice; and to consider how we inform both the professional groups and the men on the street on the major factors affecting men and what can be done about them.
To discuss and to debate
If we develop this idea that men’s health is emerging as a discipline in its own right then this needs to be put under a critical lens and examined, both by those working within the field and those outside of it.
Within this section I wish to explore what it is this thing called ‘men’s health’ and what do we need to do to develop its academic base.
With regard to its definition, it has not been a long debate because the field has only emerged in the last 10 years, but it created problems in the early days where it focused almost entirely on the male-specific illnesses. And with these being so immediately identifiable as a ‘man’s issue’ a strong lobby still exists for this viewpoint. Interestingly for women, reproductive health is still a mainstay of many key women’s health organisations.
The Men’s Health Forum (MHF) as part of their policy development document "Getting it Sorted" created the following definition which reflects the current thinking:
‘A male health issue is one arising from physiological, psychological, social or environmental factors which have a specific impact on boys or men and/or where particular interventions are required for boys or men in order to achieve improvements in health and well-being at either the individual or the population level.’
This movement beyond the biological reinforces the scope of the widely differing disciplines that are, or can be, brought under the ‘men’s health’ umbrella. And I hope that through this lecture academics from different fields can begin to see how their own work can inform and be informed by this emerging field.
We need to explore how the theories relating to men and masculinity can help in unravelling men’s health beliefs and behaviour. There are many scholars on masculinity and key work has been undertaken in trying to understand how men live and work in the social world but until recently a focus on health has been lacking.
This is beginning to change, with scholars such as Don Sabo, Will Courteney from America, John McDonald from Australia, Donald McCreary from Canada, to name but a few that are working in this area.
It is worth considering Will Courtney’s observations on what it means to be a ‘proper man’ to see what pressures men are under when it comes to considering the impact that a threat to their health or independence poses.
"A man who does gender correctly would be relatively unconcerned about his health and well-being in general. See himself as stronger, both physically and emotionally, than most women. Think of himself as independent, not needing to be nurtured by others. Be unlikely to ask others for help. Spend much time out in the world and away from home. Take risk frequently, and have little concern for his own safety." Courteney 1998
You and I know that not every man sees himself in this way and so we come to another problem. Within our debate there is also a need to acknowledge that there are many of us men living many different lives, such that ethnicity, race, culture, religious beliefs, socio-economic status, age, sexual orientation, disability, employment, family, friends, schooling, past medical history, even our weight and leisure activities all have an impact on who we are and how we are perceived by ourselves and by others.
Does this therefore negate our endeavour? If all men are so different how can we talk of a male health issue other than referring directly to a medical condition that affects men only?
But as we have seen from the statistics there are commonalities, there is a stark reality that male premature mortality differentiates us by sex but also by socio-economic status, and therefore it cannot be purely biological there must be psychological, social or environmental factors involved
All men are different, but all men are the same – they are men. They have all been subject to the same evolution and the same bag of socialisation influences that will have had an impact on who they are and how they see themselves. Those of you fortunate to be here a few weeks ago when Professor Chou discussed the implications of the media representation of men’s bodies on how men perceived themselves can see this as a case in point. Men are biologically different from women and also brought up into a different social world. This needs to be unpacked so that we can identify how it impacts on our health beliefs and behaviour.
The research being undertaken by Robin Lewis, one of our PhD students into how men with type 2 diabetes adapt to their new circumstances is revealing some of these issues – a case that reflects the difficulties is a 46 year old man who has a ‘high powered’ job that involves lots of travel and entertaining, working late is the norm and he is in an extremely competitive environment. We can see here how his ‘patriarchal dividend’ is now going to work against him when he comes to have to juggle a balanced diet, regular visits to the clinic and a more settled work – life balance.
But this social theory has to be considered alongside the emerging research on sex differences at the biological level. A comprehensive text from the American Medial Association, which has explored the literature and research on this area has shown a significant degree of variation between men and women: Differences associated with the sex chromosomes, differences in immune response; differences in symptoms, type, and onset of cardiovascular disease; differences in response to toxins; differences in brain organisation; differences in pain perception. (Wizemann & Pardue 2001).
There is another area that is perhaps more controversial: whether behaviour is a result of our nurture or through our nature . Is our biological hard wiring more of an issue than our up-bringing? Can we ignore the ten’s of thousands of years of evolution when faced with a couple of hundred years of social development?
All these approaches looked at individually still leaves unanswered why men seem to have a higher incidence of nearly all the cancers, and have a greater chance of premature death for nearly all the major disease processes. By generating a better understanding of how men experience their health and illness we may be better able to target men more effectively.
A further area for discussion is that no area of human life is without contention and when considering the health of half the population it is inevitable that difficult issues need to be tackled. Legitimising the work of men’s health enables hitherto avoided debates to opened up about men as fathers, perpetrators and victims of violence, the broader health needs of gay men, the needs of homeless men, men who use drugs, men who are disabled and other marginalised groups.
The work of all the different disciplines engaged in investigating men’s health needs to be synthesised and through that synthesis will emerge the basis of the new discipline of men’s health. A dialogue has to be established and opportunities created to bring together scholars and practitioners to enable discussion and debate as to how men’s health can be taken forward, a coming together of the parts to create this fuller picture.
We also need to engage with our colleagues working in women’s health to continue the debates we have started at the Gender and Health Partnership and the first Gender and Health Conference to identify what we can learn from each other and how we can both move the debate on in terms of developing gender aware theory and practice.
Early work on men and their health was in fact undertaken as part of comparative studies where men’s and women were analysed to identify commonalities and differences, the work of Nathanson in 1975 and Verbrugge in the early 80’s for instance. However though there is a lot that can be achieved by developing the dialogue with women’s health, there is also a need to 'problematize' men in their own right, to study men qua men (Caplan 1988). For as Clarke states:
... illness is a multifaceted, complex phenomenon which has been measured in a wide variety of ways in many different studies. … [But] When we do not know whether men or women view the same things as symptoms of illness, when we do not know to what extent physicians diagnose the same symptoms differently in men and women, when we do not know about the differential effects on men and women of the hospital experience, how can we theorize about sex differences in illness? (Clarke 1983 p77)
But the discussions within women’s health groups have already lead to two important events, which will have an impact despite Clarke’s reservations. The first was the WHO funded International Gender and Health conference in Vienna in 2002, to which men’s health organisations were invited for the first time to contribute to discussions. The second was the UK Gender and Health Summit in 2003, hosted by the Gender and Health Partnership (GAHP). This dialogue enables not only differences between the different organisations to be identified and addressed but also the creation of coherent policy frameworks that can start to address just how important it is that sex and gender becomes central to all health policy decision making.
Research
Moving onto the research agenda – what is the evidence base for men’s health?
There will be some that raise their eyebrows at this statement and we have to acknowledge that most early medical research was biased towards the white middle class well man and the charge that most research was done on men by men is correct. The assumption was that the research could be extrapolated to women and also across age and race. Few now doubt the folly of this approach. The research did not serve women at all and didn’t serve men well either because using men as a convenient homogenous sample and ruling sex and gender out as a variable acted to make the men just as invisible as women. The research was also done on the men, it did not take note of their personal experiences of illness or of their health beliefs or behaviour.
When you actually explore the research on men and their health you will be surprised how little there is and what is emerging is the need for a whole new area of research; as so many questions, across such a broad expanse of men’s lives, remain unexplored.
A key quote from the Scoping Study on Men’s Health that I conducted for the Department of Health in 2000 was that "Men’s health is not a medical issue it is societal. Therefore a much broader approach needs to be taken". Which leads us into research questions around men’s lifestyles, the social pressures on men to perform their lives in certain ways. It makes us look at social structures – of education, work, leisure and relationships.
Basic questions such as how men use the health service still need to be explored. We know that men do not go to the doctors as often as women and that the likelihood of ending up in hospital increases for men as their visits to the doctor [STOP AND EXPLAIN ] but interestingly we still do not know if the claim that men delay going to the doctors is in fact true. There are pointers that suggest that is the case, for instance melanoma (SLIDE), the skin cancer, has a higher incidence rate in all of the 17 Western European countries but the mortality is far higher in men, suggesting a delay in seeking help. However a recent systematic review on gender and cancer comes to the conclusion that there is no differences between men and women. So a disagreement exists.
We are currently undertaking a 4 year study with the Bradford & Keighley Health of Men team, on men’s decision making with regard to their health. The team, many of whom are here today, received a £1m lottery grant with matched funding from the 4 PCT’s in the area to develop services for men. Field work and interviews carried out with men using these services suggests that the men certainly do care about their health, but there is a degree of uncertainty in using the conventional health centres for getting a health check. They see the doctors as a place to go when you are ‘poorly’, and having no other need to make an appointment tend not to want to ‘bother’ the doctor in case they are seen as time wasters. A related issue is that men are more likely to work full time, work over 48 hours a week, and be less likely to have the option of flexi time. Therefore going to the doctors requires a lot of planning. But when the team go to their work place or conduct a pub quiz or as here in a local barbers to conduct health checks the men can be seen and often willingly as they are in their ‘comfort zone’ and not in the alien place of the health centre and it is easy. For men do care about their health.
An interesting finding from another colleague in men’s health, Trefor Lloyd, was that when he set a group of teenage lads the task of making an appointment at the doctors, they didn’t know how to – their mothers had always done it for them. They were left with no appreciation of how to make an appointment, how to get past the receptionist or indeed the concept of having to wait. Young girls appear very quickly to be able to manage the health centre, for contraception, antenatal care etc and they appear to become far more sophisticated in their ability to manage the system. Young men have no need to go to the doctors unless they are ill, their bodies are unchanging from one day to the next and so for many there is no requirement to go and for one man I interviewed as part of a study on prostate cancer said, the doctors was like a foreign place to him.
On a personal note I remember once being charged with making an appointment for my son when he was younger, I rang up got an appointment for later on that week but when I told my wife she said, ‘that’s no good’ and rang up and got him in that same day.
We cannot limit ourselves to purely social research though: biomedical, epidemiological and clinical research is also needed to be able to tackle the diseases that men suffer from.
For instance: 10 years ago the total grant for research on prostate cancer was something like £30,000. I remember a very disturbing time when I was a student nurse in theatres being quizzed over what’s the relevance of a degree in nursing whilst the surgeon was doing a bi-lateral sub capsular orchidectomy for prostate cancer, which involves scraping out the contents of the testicles. (thankfully I have no slides for that point!) Castration was at the time, which is not that long ago, the only treatment available. As the life expectancy of men increases and we are now in the position were prostate cancer is the most common form of cancer in men this lack of research is reflected in the uncertainty over what is the most effective form of screening, diagnosis and indeed treatment. This is a problem which makes it even harder to be able to guide the man on the street, who is just becoming aware that his prostate health may be problematic.
But when the reason why men have the problems are examined this approach can be seen as part of the solution, but not the entire answer. It is similar to the parable of the person who leaves the rescuers of the drowning to wade upstream to find out who is pushing them in or why they are falling in.
In part some of the impetus for research into men and their health will come from academics working in the field, but we also need to be aware that soon it will become a central requirement for all researchers (which will no doubt create a quite a demand for consultancy!)
There is a now a clear steer from the WHO and the EU in relation to gender mainstreaming and through my work with the European Men’s Health Forum I have been involved in discussions with the Directorate General for Health research in the EU about their requirement that gender has to be acknowledged as a factor in all research. This has highlighted a problem in that there is now fairly good understanding as to how women’s specific issues should be addressed but there is not the same degree of awareness for men’s issues. We lack a vocabulary for men because there has not been a debate about what constitutes male-aware research, especially as this rule now spreads across all the different research programmes including nanotechnology!
What is apparent is that there is a wealth of research that needs to be undertaken, with numerous collaborations possible across all the different discipline groups – from the health professions through to psychology, sociology, physiology, sport science, education,
Here we are in Headingley Campus with the Carnegie Institute of Sport, so much of their research has a direct impact on the health of men, especially with the concern over boy’s and men’s weight problems and the problems of inactivity.
Such fundamental questions as to what makes men stop being active Need to be explored. A hint may be from my own study of men who suffered chest pain where one man’s competitive spirit meant that having his first heart attack was a relief as it saved him the indignity of having to step down from refereeing top level matches as he had realised that he couldn’t continue.
Does the same competitive spirit that accelerates us to compete also act as the break to stop us completely when we know we cannot win?
To campaign
Sitting quietly in our offices working on papers for arcane journals or practitioners carrying out tremendous, but invisible work will not enable us to improve the health of men. As we enter the 21st Century we must capitalise on the inroads that such key individuals as Ian Banks and Peter Baker have made into the consciousness of Government to extend our campaigning far and wide.
And as we enter the final week of the General Election it seems appropriate that we should consider the role of campaigning within the men’s health debate. For it is at the societal level that we are going to have to aim if change in men’s health is to be truly effective. And without National Policy it is very unlikely that resources will be made available for local practitioners to enable them to engage in the kinds of service provision required to attract and help men.
But it is worth spending a moment considering the origins of the men’s health movement and how it differed from the women’s health movement for we have started from a very different position. With women health was very much a part of their emancipation and was a central part of the feminist movement. The growing realisation of the patriarchal medicalisation of women and their health was a very visible and divisive issue for women and getting improvements in the services offered to women was driven by women themselves and became very potent political issue. This ground swell of public disquiet has not occurred with men’s health.
It was in 1992 that the then Chief Medical Officer included a section on men’s health within his annual report. This was the first time that there had been any acknowledgement at a governmental level that men’s health was problematic. In that report he stated that:
"Gender differences in mortality and morbidity undoubtedly exist: but what are they caused by and what can be done about them? There is increasing evidence that many of the patterns observed stem from differences in health-related behaviour, which may be influenced by the knowledge, attitudes and beliefs of men." (DoH 1993 p105)
Prior to this official sanction talk of ‘men’s health’ was seen as almost heretical and those few who were vocal faced a very suspicious and unreceptive audience.
What advances there were made in reducing male deaths were see at the population level rather than focused specifically onto men, with this approach still being the most common adopted for instance:
Health and Safety at work, the use of seat belts and crash helmets, legislation limiting speed on roads, hours worked. For instance two personal issues, this is my son Jon, who has a passion for motorcycles but at 14 he is too young to go on the roads – as a result of legislation; he now goes to a charity called BUMPY – the Birstall Urban Motorcycle Project for Youth, where (through legislation) he is in a safe environment, wearing a helmet on a restricted bike again through legislation. This isn’t my other son, David – but as he is starting a forestry degree shortly and he has his sights on being able to use a chain saw up a tree I am grateful for Health & Safety ensuring he is kitted out with the right gear!
Reducing salt and fat in processed food, increasing the budget and the guidance to schools in relation to school dinners and also in respect of activity levels for children. Limiting tobacco and alcohol advertisements
But these grand statements, though extremely important and have undoubtedly saved countless lives were still not capturing the wider issues that were affecting men and their health.
Through the nineties there was an increase in the number of individuals starting to make their presence felt, with the formation of the Men’s Health Forum (originally situated as part of the Royal College of Nursing) and locally the Kirklees Men’s Health Network and the start of the Bradford Health of Men.
Our ability to generate real interest and therefore to become more effective campaigners took off in earnest however when we attracted the attention of the then Public Health minister, Yvette Cooper who became concerned about the state of men’s health and gave her public support of the work of the Men’s Health Forum.
The success of the campaigning to date can be seen in the formation of the All Party Parliamentary Group on Men’s Health, Department of Health funding for the first Gender and Health Summit. There is also talk of a National Director of Men’s Health.
We are also seeing inroads into the European Union and the World Health Organisation, through the work of the European Men’s Health Forum, where the idea of Gender Mainstreaming is now being recognised as including men and their health.
The impact of this lobbying has started as we have seen this last month the publication of the new Pharmacy contracts, which has included a requirement to target men as part of their provision. We have also seen inroads into the need to have gender as part of the local provision of services through the recent introduction of gender equity audit.
Most of this activity has however been on the public health side but we are now seeing a move into more mainstream medical services.
Our report on the State of Men’s Health in Europe took us to the heart of family medicine in Europe, with a presentation to the Annual General Meeting of UEMO (the organisation that represents 1.4 million doctors).
We have had an edition of the British Medical Journal focused onto men’s health (SLIDE), however as can be seen the image portrayed on the front cover is anything but what we would have preferred. Within this edition we were able to bring to a wider medical audience the issues that were confronting men and indeed women, for in an editorial Lesley Lockyer and I were able to explore the deficiencies in the National Service Framework for coronary heart disease, which managed to completely miss that this disease was one of younger men and older women.
There is also an international Journal of Men’s Health & Gender, along with the International Journal of Men’s Health and we are increasingly seeing articles into other health related journals.
Following the success of last years National Men’s Health Week, which saw cancer as its main focus we are now in discussions with the National Cancer Director in relation to the plans for a screening programme on Bowel Cancer.
Campaigning though, must be local as well as National and International. Take a city like Leeds, which spends a fortune on setting up programmes to tackle health inequalities and yet the life expectancy of a man living in the City and Holbeck area is lower than the majority of eastern European countries and could well be the lowest life expectancy of anywhere in Britain. Why do we not have a person whose role is to tackle the largest inequality of all? Through campaigning we are seeking more and more dedicated posts to develop services that can directly help those most at risk.
To practice
Up to this point in my lecture we have been working at a mainly theoretical level: discussion, debate, research, but the reality out there is that the majority of the pioneering work was started in practice. It was the clinicians who created new opportunities for targeting and working with men and boys (SLIDE). The work of Jayne Deville-Almond, the Bradford Health of Men team, and Meryl Johnson setting up the first Health Improvement Programme for men, to name some of the early pioneers who were the v
