At a recent conference in Philadelphia, Sonoma State University psychologist Will Courtenay recounted a story that summed up a pressing issue in men's health. He described a man named John who had died of a heart attack the previous month. The 65-year-old shopkeeper knew his high blood pressure and high cholesterol put him at risk for heart disease, but like so many American men, he insisted that his health was just fine. He went right on eating bacon, eggs, and pancakes every morning and avoiding his doctor until his untimely death.
"Why did John die?" Courtenay later wrote in The Journal of Men's Studies. The answer, he said, lay among the medical and emotional factors that shaped John's life, from the way his heart operated to the everyday stresses he faced. His age alone had placed John at a higher risk of having a heart attack. As an African American male, his race and gender put him at a higher risk of premature death. It certainly didn't help that John had inherited his father's blood pressure problems. And, like other men, he had learned since childhood to conceal pain, a behavior that has done countless males a disservice, often leading to tragedy.
"We cannot isolate men's health from all the other aspects of men's lives," mused Courtenay, the founder of Men's Health Consulting in Berkeley, California. "We cannot separate men's health from what makes men men."
Avoiding health care
Unfortunately, one male habit that's caught up to men is avoiding the health care system almost entirely. Men are raised to depend on themselves, according to Dr. Robert Tan, codirector of the Geriatric Medicine Fellowship Program at the University of Texas Health Science Center at Houston. "They don't want to be seen as weak," says Tan. "There could be something seriously wrong, and they don't want to know about it."
That kind of denial can let a potentially curable condition become hopeless. Tan had one patient who ignored a sudden onset of back pain only to find out several months later that he had prostate cancer, which had already metastasized to his spine. Another pooh-poohed a mysterious rash on his arm; it, too, didn't seem to be serious, but it ultimately resulted in a terminal case of cancer.
"Our cultural conditioning has dealt men a bad hand when it comes to our health and taking care of ourselves," says Rob Waters, a Berkeley, California-based writer and the coauthor of From Boys to Men: A Woman's Guide to the Health of Husbands, Partners, Sons, Fathers, and Brothers. "The sad truth is that for many men, being a man means being attracted to risk, being stoic in the face of physical and emotional pain, and being averse to anything that smacks of selfcare, especially seeing the doctor. Too often, it's a toxic combination."
The message is more relevant today than ever: Men aren't taking care of themselves. While the women's health movement has steadily advanced since the publication of Our Bodies, Ourselves more than three decades ago, men's health is still mired in a "don't ask, don't tell" mindset. While medications like Viagra and Propecia have made successful inroads because of male vanity and performance issues, other potentially life-saving drugs, procedures, and preventive tests are ignored. The irony, of course, is that men have the most to gain from modern medicine. On average, men live 5.3 years less than women and are at higher risk of death from cancer, heart attack, chronic liver disease and many other conditions.
Small progress
Some progress has been made — the gender gap in life expectancy has shrunk after hitting 7.8 years in 1979. Yet the statistics on male health are still sobering. Almost 75,000 men were diagnosed with colon and rectal cancer in 2006, according to the American Cancer Society. The American Heart Association predicts that approximately 520,000 men will have a heart attack and over 300,000 will suffer a stroke annually. Many of these conditions can be successfully treated if discovered early; others can often be prevented altogether with proper medication and lifestyle changes.
Even once a problem has been uncovered, some men are loath to undergo proper treatment. For example, when the diagnosis is high cholesterol, Tan says, many male patients initially refuse medication. "They say, 'I can figure it out. I just need to exercise and lose some weight.'"
Such stubborn independence is hardwired into the male psyche, say mental-health experts. "Our reliance on the physician is a kind of despair of ourselves," wrote philosopher Ralph Waldo Emerson, and history is rife with men who clearly agreed. US President William Henry Harrison gave a nearly two-hour inaugural address in freezing weather without a coat and died of pneumonia a month later.
Magician Harry Houdini ignored the searing pain above his right hip until his appendix ruptured, causing fatal peritonitis. And running guru Jim Fixx, whose father died of a heart attack at a very young age, might have benefited from his doctor's advice to take a stress test. Even though he had cholesterol levels above 250, Fixx declined — and dropped dead in mid-stride at age 52. An autopsy revealed severe blockages in his three main arteries. And in a recent example, former President Bill Clinton was rushed to the hospital after suffering chest pains. His doctors reported that although the former president had been experiencing pain for months, he stopped taking the statin Zocor. After his quadruple bypass surgery, he returned to the statin regimen and a more healthy diet.
Statistics bear out the anecdotes. In a landmark 2000 survey of 1,500 men by The Commonwealth Fund, the country's largest public affairs forum, one out of every three respondents reported having no regular doctor, and one out of four said he would wait as long as possible before getting treatment if he felt sick or was worried about his health. One quarter of the men questioned hadn't had a complete physical in at least three years, and more than half of those over 50 hadn't had an annual colon cancer screening.
When a man does decide to visit the doctor, it may be at the insistence of his wife, girlfriend, mother, daughter, or some other influential female in his life. But that may not be just because women are more in touch with their own bodies. While some men rarely — or never — see a physician until well into middle age, most young women become accustomed to regular office visits with their first gynecological exams, where a serious underlying problem stands a good chance of being detected.
Coming in for a PAP smear is an opportunity for women to have other medical issues addressed, and many women take advantage of this opportunity. "Gynecologists pick up things that are not necessarily gynecological in nature," says Dr. Jean Bonhomme, a member of the senior research faculty at the Emory University School of Public Health and president of the National Black Men's Health Network. "A women may have a yeast infection that's not getting better, and they'll test her and find that she's diabetic. They might even find that she's HIV-positive."
Bearing the pain
Bonhomme says men see little need for such contact because they're taught from childhood to deal with pain. "When a boy is 8-years-old and he skins his knees, he gets told, 'Brave boys don't cry,' " he says. "When he's in his teens and playing high school football and he gets hurt, they tell him 'Take one for the team.' Then, when he's 50 and having chest pains, he says, 'It's just indigestion.'"
That is, if he even notices the pain. "Our work roles reinforce this cultural stoicism," says Bonhomme. "For certain jobs, especially jobs involving physical labor, there's a need to detach from your feelings just to get through the work day." Lumbar ache or chest tightness may be ignored like so much background noise, both on the job and at home. Added to this is the inconvenience of typical doctors' office hours, which coincide with most working hours. Finding time to slip out is impractical — at times even impossible — for salaried professionals and hourly wage earners alike.
Since so many men won't seek health care, some providers and organizations are bringing health care to them. The Men's Health Network, a Washington, DC-based nonprofit group, stages mobile clinics, including at the Capitol building, where dozens of congressmen have rolled up their sleeves to have their blood pressure, cholesterol, and other levels checked. Though such outreach is fairly uncommon, these services can be very valuable for men who don't see their doctors regularly.
US Sen. Mike Crapo can attest to the benefit of preventive screenings after a PSA test led to a diagnosis of prostate cancer in 2000. The test was part of his first physical exam in years. "My staff was pushing me to get a physical," he says. "My family was pushing me."
After undergoing successful surgery to remove his prostate, the Idaho Republican has advocated establishing an Office of Men's Health in the US Department of Health and Human Services. (He has already won approval for an Office of Men's Health in the Indian Health Service.) Since 1991 the department has had an Office of Women's Health, which has focused attention on women's health issues such as breast cancer, osteoporosis, and domestic violence. Crapo thinks men would benefit from a similar clearinghouse.
"A silent crisis is currently affecting American men," Crapo told a senate subcommittee in October 2005. "On average American men live shorter and less healthy lives than American women." Although he has no annual budget estimate for the proposed office, Crapo says many of its components would be cobbled together from existing programs such as the National Institutes of Health's prostate cancer research.
A similar imbalance exists in the private sector, where women's health clinics have gained popularity since the 1980s while men's clinics have met with failure for lack of clientele. The Garage, a Seattle clinic that offered men metaphorical treatments such as "tune-ups" (checkups) and "spark-plug service" (Viagra prescriptions), opened in 1999 and closed six months later. Seven patients were seen.
Shuttered services for men
Even the nation's first and most successful men's health clinic is now shuttered, although not for lack of popularity. In 1989, Dallas urologist Ken Goldberg founded the Male Health Center, which offered both primary care and a range of specialties, from cardiology to psychology. To promote awareness and attract patients, the center purchased a mobile unit with two examining rooms and did on-site screenings at Texas Instruments, American Airlines, and other local businesses.
Goldberg, the author of several books on men's health, closed the clinic in 2001 for personal reasons. Business volume was not a problem — the clinic was averaging more than 2,000 male patient contacts a month. Future men's clinics that pursue the same in-your-face strategy could succeed where their passive predecessors didn't, he says. "We provided a nonthreatening environment," says Goldberg. "We involved fellow men in the education process."
One of Goldberg's patients was retired drug company executive Gordon Miller, who was diagnosed with early-stage prostate cancer. In some cases an early stage prostate cancer will grow so slowly that a malignancy might not be a health issue for decades, and Miller, 76, admits he only underwent the screening because it was free. Like Crapo, he hadn't had a general health exam in years. "I credit Dr. Goldberg for saving my life," he says. To express his gratitude after his prostatectomy, he signed on at the center to counsel other prostate cancer patients.
Likewise, physicians themselves are starting to lead by example. Sometimes portrayed in cartoons as pot-bellied healers dedicated to every patient except the one in the mirror, the truth is that male MDs are more health-conscious than the average man, according to recent studies at Emory University. Male physicians, for example, are less likely to die of liver disease. Moreover, as a group they outlive other men by an average of three years.
"Physicians who have healthy personal habits are more likely to discuss related preventive behaviors with their patients," wrote Dr. Erica Frank, a professor at the Emory University School of Medicine, in the Journal of the American Medical Association.
Other men, too, are inching toward better awareness — and better well-being — says Goldberg, a change that's accompanied by greater candor and openness on the part of the medical profession. In 1988, people could barely use the word 'penis' in print, he says: "Look how far we've come."
—Joshua Tompkins is a freelance writer whose work has appeared in Men's Journal, The New York Times, and the Los Angeles Times, among others.
References
Interview with Robert Tan, MD, co-director of the Geriatric Medicine Fellowship Program at the University of Texas Health Science Center at Houston
Interview with Jean Bonhomme, a member of the senior research faculty at the Emory University School of Public Health and president of the National Black Men's Health Network
Interview with Senator Mike Crapo (R-Idaho)
Interview with Ken Goldberg, MD, of Dallas, Texas
Interview with Gordon Miller, retired executive
Email correspondence with Rob Waters, co-author of From Boys to Men: A Woman's Guide to the Health of Husbands, Partners, Sons, Fathers, and Brothers
Courtenay, Will H. Teaming Up for the New Men's Health Movement. Journal of Men's Studies, vol. 8, No. 3, Spring 2000.
Men's Health Network, a nonprofit educational organization. www.menshealthnetwork.org
The Office on Women's Health, U.S. Department of Health and Human Services
Frank, Erica, MD, MPH. Physician Health and Patient Care. Journal of the American Medical Association, February 4, 2004.
Harrison, William Henry. Encyclopedia Britannica Online.
Houdini program transcript. The American Experience, Public Broadcasting system, WGBH. www.pbs.org
Harry Houdini. http://en.wikipedia.org
Higdon, Hal. The Legacy of Jim Fixx. Runner's World. www.runnersworld.com
Sandman, David et al. Out of Touch: American Men and the Healthcare System. Commonwealth Fund Men's and Women's Health Survey Findings. March 2000. www.cmwf.org
Heart Disease and Stroke Statistics — 2004 Update. American Heart Association.
Estimated New Cancer Cases and Deaths for 2004. National Cancer Institute.
Men Get Screened for Prostate Cancer More Than Colon Cancer. American Cancer Society News Center.
Clinton ignored heart symptoms. By Carolyn Susman. Cox News Service. Sept. 10, 2004
Heart-Health Lessons From the Clinton Case. By Lawrence K. Altman, MD. The New York Times. Sept. 21, 2004.
National Center for Health Statistics, Centers for Disease Control and Prevention, "Life Expectancy Hits Record High," 2005. http://www.cdc.gov/nchs/pressroom/05facts/lifeexpectancy.htm
American Cancer Society. All About Colon and Rectum Cancer. March 2006.
Reviewed by Michael Potter, MD, an attending physician and associate clinical professor at the University of California, San Francisco. He is board-certified in family practice.
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