Men's health is coming in from the cold

Last month MHF CEO Peter Baker addressed a packed public meeting of the Royal Society for Public Health. This is what he said.

Peter lecturing It's a pleasure to be here, at this wonderful venue, to talk to you about the state of men's health. And by that I don't just mean how men — and boys too of course — are doing in terms of their physical and mental wellbeing. I also mean how the government, the NHS and other organisations are doing in terms of their approach to men and boys.

The Department of Health, as I'm sure you know, is introducing a LifeCheck programme for various age groups. My presentation is, I guess, a kind of 'MaleCheck', looking at where things are going well and what further action might be needed.

The Royal Society has shown great interest in men's health and has supported the Men's Health Forum in many ways. Although the Royal Society's support is exceptional, it nevertheless does reflect a much wider and growing level of interest in men's health among a swathe of organisations involved in medicine and public health.

Gender often overlooked

The first substantial point I want to make is that gender — and by that I mean both men and women — is still too often overlooked in discussions about health policy, service delivery or tackling inequalities. It is undeniably true that this is beginning to change, but we at the Men's Health Forum are used to seeing much more of a focus on social class, which is obviously critically important but by no means the whole picture.

We often find that when gender is referred to, it is frequently in passing — typically, the word appears in the introduction to a policy or strategy document, lumped with the other equality issues the author knows have to be acknowledged, but that is the first and last time gender is mentioned. In these circumstances, the box has certainly not been ticked; it has effectively been completely erased.

My argument is not that gender is more important than class or race or age or any of the other inequality issues but that inequalities cannot be properly understood without looking at how all these strands inter-relate. If we view suicide, for example, as simply a class issue, we will see that, yes, it is mainly people in socially-disadvantaged groups who kill themselves. But then we will overlook that three-quarters of suicides are male. If we just look at gender, we will overlook the social class dimension.

RSPH logo The suicide is higher for men than women in all groups and that the rates are also higher for both sexes in the most deprived groups. Interestingly, there is a much closer relationship between deprivation and suicide for men than women —the rates increase much more steeply for men.

Ther are higher rates of attempted suicide among gay men and higher death rates among male prisoners. We need to take all this into account if we want to understand and respond to the issue of suicide effectively. And the same is true of many other important health issues.

Women's health far from perfect

In any talk on men's health it is also very important at the outset to make it crystal clear that women's health is not perfect — far from it — and that we need to allocate more resources to improving the health of both sexes. The Men's Health Forum is committed to working within a gender equality framework which acknowledges that in some areas men do worse and that in some areas women do worse and that there should be no competition between us to win the status of biggest victim.

Far from wanting to fight some sort of absurd sex war, the Men's Health Forum has worked — and will continue working — with women's organisations to make sure the case for gender as a whole is made as powerfully as possible.

Where we make comparisons between men's and women's health it is to highlight where there is a potential to improve men's health and, from a more tactical point of view, to draw attention to areas that are susceptible to improvement through the gender equality duty.

Just in case you have not heard of the gender equality duty, it was introduced as part of the Equality Act in April 2007. It requires the public sector, including the NHS, to promote equality of outcomes between men and women and to make sure policies and services are tailored to meet the specific needs of both sexes. Quite rightly, overall, this legislation is designed to tackle discrimination against women which is, of course, much more prevalent than any discrimination that might exist against men. But in health the picture is rather more complicated as there are many areas where men do less well than women and the duty requires the Department of Health, the NHS and others to pay attention to these.

What is the MHF?

Before I go any further, I'd like to say a few words about the Men's Health Forum. We are nothing to do with Men's Health magazine.

The idea that, to be a healthy man, you have to have a six-pack and bulging biceps is of course absurd. More worryingly, these sorts of images of men reinforce what is now a disturbing increase in body image anxiety, especially in young men. We are now seeing a steady rise in eating disorders, exercise addiction, dysmorphia and anabolic steroid abuse in part because of the unrealistic images of masculinity men are increasingly exposed to.

Nor do we believe that men's health is just about men's reproductive system and what can go wrong with it. In the early days, it is true that we talked far more about testicular cancer, prostate disease and erectile dysfunction. Of course these issues are still important — it is wrong, for example, that arbitrary rules still prevent tens of thousands of men with erection problems from getting NHS treatments from their GP — but our focus is now much more on the broader social and public health issues. So obesity, heart disease, cancer generally, mental health — these are all issues of concern to us.

The key questions that matter to us are in fact completely cross-cutting and not about specific health conditions at all — we want to do something about men's late presentation to the health system which results in delayed diagnosis and treatment, we want to tackle men's under-use of key parts of the primary care system, and we want to enable men to look after themselves better. These are big issues and they will be a central theme of my presentation today.

In fact, almost any issue can be a men's health issue. We have recently drawn the Department of Health's attention to gender differences in people's responses to swine flu. There has been evidence for some time that both male health professionals and other men are generally less likely to follow preventive advice on hand-washing.

Our suspicions that this might be relevant to swine flu were confirmed a week or so ago when the BMJ published research showing that men were significantly less likely than women to be following the current advice on how to prevent flu transmission. We are also concerned that men may well be less likely to report symptoms early and may attempt to soldier on, passing the virus on while they do so. We believe there is a good case for considering how swine flu messages can be designed and delivered in ways that men are more likely to respond to.

The Men's Health Forum has two main roles. One is to do what we can to ensure that policy and practice throughout the health system takes proper account of men and the second is to help health providers engage with men more effectively.

We do all this through a mixture of lobbying, policy development, training, research, project work and producing health materials that are acceptable to men, such as the malehealth website and the books and booklets that I'm sure many of you have seen that are published by Haynes and designed to look like car maintenance manuals.

I am very lucky to be able to work with such a committed and talented team. Sometimes people think the Forum must have a staff of 20 — or perhaps even more. In fact, we currently have the equivalent of just seven full-time staff.

Over 40% of men die prematurely

Men's health is unnecessarily poor. Over 40% of men still die prematurely, that is before the age of 75. Let me present this data another way. Over 100,000 men in England die prematurely each year — and most of these deaths are preventable.

There is, quite rightly, currently great concern about the deaths of soldiers in Afghanistan. Since 2001, about 190 have been killed. These losses are a tragedy, and a men's health issue in their own right, yet almost some 275 men in England die every day before the age of 75. That's one death every five minutes. Yet this fact excites virtually no media interest, no discussion in parliament, no national debate. It is almost as if we simply expect men to self-destruct and keel over prematurely whether because of some genetic defect, a hormonal deficiency or perhaps because they are just plain daft.

But it gets worse than this.

If the population is divided into two broad social groups — manual and non-manual, life expectancy at birth for males born in the last few years is 79.2 for non-manuals and 75.9 for manuals. The class difference is obvious and a huge cause of concern.

If you look at the data at a ward level, there are some parts of England where male life expectancy is as low as 65. And if you look at particular communities, the situation is even graver. The average life expectancy for gypsy and traveller men is estimated at 48 years. Imagine living in a community, in this country, where you are effectively an old man when you are in your 40s.

We are very worried that the recession will have a major impact on men's mental and physical health. According to a recent MIND report on men's mental health, one in seven men who are unemployed will develop depression within six months of losing their jobs and there is a real concern that the recent fall in the male suicide rate will be reversed — we know that, 10 years ago, the Asian economic crisis led to a huge increase. There is also evidence that unemployment impacts on men's physical health, with more deaths from cancer, accidents and violence.

Lifestyle not biology

Biology provides only a partial explanation for poor health in men. Lifestyle is a much more significant factor. Men are more likely than women to drink alcohol above recommended levels, smoke cigarettes and eat a poor diet. Just over one third of men are physically active at the level that results in health benefits. By 2015, 36% of men will be obese and, by 2025, only 13% will have a healthy body mass index.

Peter lecturing If evidence is required of the damaging impact of lifestyle on men's health, one need look little further than data published last week by Diabetes UK. This shows that twice as many men as women aged 35-44 in England have diabetes. The statistics also show that diabetes has risen four times faster in men aged 35-44 over the last 12 years compared to women of the same age.

I want to draw particular attention to smoking as it once again highlights the need to look at the inter-relationship of different equality issues.

Although men do still smoke more than women, the difference is shrinking and, overall, now quite marginal. There is a wider gap min between men and women in manual groups but there is a far bigger difference between men and women in several ethnic groups, especially Bangladeshis, Indians, Pakistanis and Chinese. It should go without saying that as well as targeting smoking messages at the general population, we need to target men from these particular communities.

Men's use of primary health services is critically important. While neither men nor women use health services optimally, the overall pattern is that men use health services far less effectively.

Why don't men use health services?

In Great Britain, men visit their GP 20% less frequently than women. The difference in usage is most marked for the 16-44 age group — women of this age are more than twice as likely to use services as men. Women have higher consultation rates for a wide range of illnesses, so the gender differences cannot be explained simply by their need for contraceptive and pregnancy care.

A recent analysis of men's use of GP services shows the potential impact on men's health and the healthcare system.

This research was based on a total of 35.8 million contacts with GPs and 1.2 million hospitalisations in Denmark in 2005. (Like the UK, Denmark has free access to primary and hospital healthcare.)

Women are more likely than men to be admitted to hospital until the age of 54 when the female/ratio dips below 1 — at that point, men are more likely to be admitted. Now, if the sex-specific admissions (for reproductive health) are omitted, the male/female ratio is pretty equal until the age of 40 when men are more likely to be admitted.

The authors of this analysis suggest that the data is compatible with a scenario in which men are reacting later to severe symptoms than women with the result that they are more likely to be hospitalized or die. This is bad news for men, their families, their employers and for the NHS which has to pay for all the expensive hospital healthcare.

This is also consistent with UK and Europe-wide data on malignant melanoma which shows that while women are more likely to develop this type of cancer, men are more likely to die from it.

The higher death rates in men are almost certainly because men are presenting when the cancer is more advanced and harder to treat. We also know that nearly four men in 10 are not diagnosed with prostate cancer until it has spread, again suggesting that men are presenting late.

In mid-June, the National Cancer Intelligence Network published data on men and cancer which confirmed what MHF data has already shown: if you compare the 10 most common cancers that both men and women can develop (excluding breast cancer which is very rare in men), men are much more likely to develop one of these cancers and more likely to die. The difference between men and women is in the order of 60-70%. It is not known exactly why there is such a large difference between the sexes and more research is needed but it is a good bet that much of it is due to a combination of lifestyle and late presentation by men to primary care.

And it is not just GPs that men are not using effectively. Men, especially young men, are also much less likely than women to have regular dental check-ups or to use community pharmacies as a source of advice and information about health. And just 10% of NHS community contraception service users are male.

NHS smoking cessation programmes are less well used by men than women and the same is true of NHS and commercial weight management services, health trainers and of disease-specific helplines run by charities. Male uptake was also markedly lower than female uptake in the pilot programmes for the NHS Bowel Cancer Screening Programme.

One consequence of men's poorer use of health services is that many attempt inappropriate self-diagnosis and self-treatment. Every year in the UK, an estimated 330,000 men purchase prescription-only medicines without a prescription from illicit sources, particularly internet sites. This phenomenon is almost a barometer of men's ineffective use of mainstream services.

A failure to diagnose correctly a serious underlying condition creates a significant risk — erection problems, for which many men obtain counterfeit drugs online, are often caused by undiagnosed diabetes or cardiovascular disease.

But why do men use health services poorly? Men's reluctance to seek help must be an underlying cause. This is a result of the way men are brought up to behave. Men are not supposed to admit to personal problems, weakness or vulnerability. As a consequence, men often wait until they are in considerable pain or are convinced they have a serious problem.

Practical barriers to men

Men's unwillingness to seek help is reinforced by a number of practical barriers, including the demands of long working hours and problems with accessing primary care services near the workplace.

audience Anecdotal evidence suggests that some men are deterred by a perception that GP and pharmacy services are aimed mainly at women and children and feel like 'feminised' spaces.

One man responding to a MHF survey on men's use of GP services said 'It's like visiting a ladies' hairdresser'. When we interviewed men about their use of pharmacies, one said he didn't go because 'There are racks and racks of lipstick and no spanners.'

Lack of familiarity with the health system may also be a factor. Women are much more likely to use health services routinely — for contraception, cervical cancer screening (after the age of 25), pregnancy, childbirth and for their children's health. When they are ill, they are more likely to know how to access services, and which services to use, and to feel more comfortable with a healthcare professional.

Consider this. Teenage girls can find out a lot about health and health services form magazines. There are loads of them, all offering advice and information, some of it bad and some of it very good. What can teenage boys read? Magazines like Zoo and Nuts. If young men followed the lifestyle promoted in these magazines, they would probably be dead before the next issue comes out. Yet there is nothing out there for young men that addresses health issues in any useful way.

Men in specific groups may be deterred from accessing services because they fear or experience discrimination. There is evidence of widespread homophobia among health professionals that impacts on the ability of gay and bisexual men to access healthcare. African and Caribbean men can be deterred from approaching mental health services because of a belief that they will be discriminated against. Gypsy and traveller men face particular difficulties accessing mainstream primary care services.

Older men often do not feel that services run specifically for their age group are appropriate for their needs except perhaps as a last resort. They tend to avoid services where participants (and staff) are mostly women and consider that attendance at a day centre suggests that they have 'given up'. Older men are frequently not referred on to relevant support services by social services, GPs or other professionals.

Even though men have poor health outcomes and use more expensive health care services at a younger age, these barriers to men's effective use of health and related services have not yet been systematically addressed by government, the NHS and other organisations. The Gender Equality Duty is not yet being implemented sufficiently or consistently.

And the effect of this is much more than a set of grim statistics and some boxes left unticked. We are, of course, ultimately talking about real people here.

The men who are dying prematurely are our fathers, our husbands or partners, our brothers, our grandfathers and our sons. Our collective historic failure to make a real difference to men's health is actually a story of pain, fear and grief experienced by untold numbers of individual men and the people who love and care about them.

But there is some good news. And that is what I want to focus on now before ending with some proposals for action.

Strategic Partner of the DH

There is undeniably evidence of change at the national level. The Department of Health has appointed the Men's Health Forum as one of 11 Strategic Partner organisations as from April this year. This recognition of our work and of men's health as an issue gives us a marvellous platform for working with the Department and also getting our messages out much more widely, especially to the rest of the third sector.

The Department has also commissioned the Men's Health Forum to develop ways of increasing male uptake of screening within the National Bowel Cancer Screening Programme and to develop new forms of health information aimed at specific groups of socially-disadvantaged men. The Department has also consistently supported National Men's Health Week as a way of reaching large numbers of men directly with health information.

The National Chlamydia Screening Programme's efforts to engage men have led to an increase in male participation in screening from 17% in 2004/5 to 28% in 2007/8. This is real progress and the Screening Programme deserves real credit for taking on board the Men's Health Forum's arguments for screening men and the evidence we provided about how this could be done.

The Cancer Reform Strategy, which will set the direction for cancer services until 2012, acknowledges that there is a particular need for services to address late presentation by men with potential cancer symptoms. Mike Richards, the cancer national director, has been leading a national cancer equalities initiative which brings stakeholders together. As part of this, there was a symposium specifically looking at gender equality issues which will feed into proposals for action.

The recent extension of GP opening hours should make it easier for men as well as women in full-time work to access services. The national vascular checks programme, now being rolled out around the country, offers the NHS a significant opportunity to think more creatively about service delivery to men.

The new abdominal aortic aneurysm (AAA) screening programme, the only national screening service specifically for men, could not only reduce deaths from AAAs but also has the potential to improve older men's contact with health services more generally.

Local action

There are also now some good examples of local action to improve men's health. Knowsley PCT/MBC's Pitstop programme used social marketing principles to deliver health checks to over 3,000 local men. 85 per cent of men who were followed up reported lifestyle changes.

The Go campaign, run by NHS Halton and St Helens' encourages men over 40 in deprived areas to take better care of their health and to make more use of health services. 57% of men attending health checks have gone on to access further services, including diet and exercise interventions, smoking cessation and health trainer services.

Through Premier League Health, 16 top football clubs will develop physical activity and wider health programmes targeting a total of some 4,000 men in deprived communities near their stadia. Some major employers like Royal Mail and BT have made major efforts to improve the health of their male staff.

Mini manual Many of these initiatives have sought to take services and health improvement campaigns to men — at work, sports stadia, military bases, pubs, barbers' shops and prisons — and have used male-targeted health information, such as MHF booklets designed to look like Haynes' car maintenance manuals.

We know that this sort of approach resonates with the mechanistic way that many men perceive their bodies and health but also with how many also feel comfortable accessing information. The use of humour has also proved to be important because it helps to break down the men's internal barriers to addressing health issues.

I must also mention the potential role of websites in reaching men. The Forum runs the only comprehensive and independent website for men in the UK. It is called malehealth.co.uk. It runs on a shoestring budget but has 1.5 million unique visitors each year. That means that 1.5m different people are using it each year and not one hypochondriac coming back 1.5m times. It shows the potential of websites for men.

This was taken to another level in work we did a few years ago now with British Telecom where we successfully utilised the company intranet to get literally thousands of men to take part in a lifestyle change programme with very successful outcomes.

Men are interested in health

All this work demonstrates that men are willing to take greater responsibility for their own health if the services provided are sensitive to their needs and it provides a good evidence base for further activity. The evidence from the Forum's work with men, and the work of other pioneers in this field, is that the idea that men simply do not care about their health and will never do anything to improve it is simply a myth.

Recent progress has therefore been encouraging but there is still a long way to go. The overwhelming majority of men in England have not had an opportunity to take advantage of the initiatives introduced so far. Men remain, overwhelmingly, poor users of services and the number of health organizations making a concerted effort to tackle the problem is small. The commitment to men's health shown by the minority of service providers must now be mainstreamed throughout the primary health care system.

Challenges for the future

In this year's Men's Health Week, we issued 20 challenges to government, the NHS, employers, other NGOs and men themselves.

First, three challenges for the Department of Health. Ensure that all policy takes proper account of men's health and gender inequalities through rigorous equality impact assessments.

Second, establish a national Tackling Gender Inequalities Programme to support, evaluate and disseminate local initiatives which seek to improve men's health and close gender gaps in service use and health outcomes.

Third, ensure that the Review of Health Inequalities Post 2010 — the Marmot Review — addresses men's health and gender. To date, we have seen little evidence that this is happening.

Primary Care Trusts should develop outcome-focused Gender Equality Schemes which contain specific actions to improve men's health. The first round of schemes, published in 2007, were generally wholly inadequate. These schemes need to be reviewed and updated over the next year so a good opportunity exists to put this right.

PCTs must address men's under-use of the range of primary care services, ensure that men are fully part of the new vascular checks programme and take advantage of the World Cup 2010 and the 2012 Olympics to engage more men in physical activity.

There should be more work with schools to improve boys' awareness of health and boys should leave school at the very least knowing how to make an appointment with a doctor.

Employers should do more to improve the health of men through a range of health services and improvement activities and third sector organisations should ensure that their services are equitably meeting the needs of both men and women.

And men themselves should improve their understanding of the range of health services and use them more effectively, especially by seeking help early for potentially serious conditions. They should consider their lifestyles and not be tempted by offers to purchase what are almost certainly counterfeit drugs from dodgy websites.

Those of us who are men's health activists each have each made a different journey to this point. Some of us started as clinicians who reflected on their direct experience of male patients. Others come are health promotion specialists who realised that the traditional approaches just did not work very well with men.

My journey in men's health

I guess my journey began some 35 years ago when I became a university student. I studied history and was hugely influenced by what was then a titanic intellectual debate about the impact of the industrial revolution on the English working class. Basically, the debate was between those who thought it improved their lot and those who believed it led to greater poverty and suffering.

As a lower middle class boy dropped into the class-ridden atmosphere of a Cambridge college, I needed little persuasion that the Marxist analysis was the better one. This left me with, among other things, a strong and enduring commitment to tackling inequalities. I understood that the way people think and behave and the quality of their lives is significantly influenced by their social class and the wider environment rather than just by their genes.

Exposure to feminism through my academic studies as well as through personal relationships had a similar impact on my thinking. It created an awareness of another huge layer of injustice and of the idea that gender was primarily a social rather than a biological construct. If the traditional roles of women were socially constructed then, of course, the same must be true of men and masculinity. For whatever reason, and you will forgive me if I avoid speculating on this now, this resonated with me and, as a consequence, for the past 30 years I have been involved in what might be called 'men's issues'.

It began in the privacy of small men's groups and, by the late 1980s, I was writing about men's issues of all kinds — fatherhood and violence, for example, as well as health. Some of this writing was for small radical magazines, such as Achilles Heel, that few ever saw and even fewer now remember. Some of my writing even managed to get into the mainstream media. But I never could have imagined, even 15 years ago, when the Men's Health Forum was established, with great foresight, by the Royal College of Nursing, that we would have got to where we are today.

Our job is to complain

It is part of the role of activists and campaigning organisations to complain — and it certainly is pretty clear from even the brief picture of men's health that I have described today that there is a lot justifiably to complain about.

But if the challenges I have outlined are met, as they are beginning to be, there is a good chance that we can begin to develop the kinds of health services men are much more likely to use. If we can get men to the doctor or other professionals sooner rather than later, and improve the delivery of health campaigns to men, there is a good chance we can begin to tackle men's overuse of acute services, change their lifestyles and improve their outcomes.

This would be very good news for those of us who are men. It would be very good news for all the men in our lives.

We would be beginning to make serious inroads into one of the biggest and until recently one of the least recognised health inequalities. We could begin to say that men's health is now truly coming in from the cold.

Thank you very much.