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The term ‘men’s health’ is used here to refer both to the physical and mental health problems that are of concern for men and to health diﬀerentials among men. Moreover, when one speaks of ‘men’s health’ one also draws attention to diﬀerences in the health and health care needs of boys and men as compared to girls and women. These diﬀerences extend far beyond the obvious diﬀerences in the reproductive systems. Men in most developed countries suﬀer more severe chronic conditions than women. They also have higher death rates for most leading causes of death and die about six years younger than women on average. Biological and social factors contribute to gender diﬀerences in health. From a biological perspective, these gender diﬀerences can be attributed to anatomical and physiological diﬀerences between men and women. Health behaviors are important factors inﬂuencing health and longevity, and men are more likely than women to engage in behaviors that increase the risk of disease and death. A social constructivist approach argues that the practices that undermine men’s health are often signiﬁers of masculinity and instruments men use in the negotiation of social power and status. Because most of the research on men’s health has been done in developed countries, this review is strongly biased in that direction.
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Life expectancy is a synthetic measure of current mortality conditions in a particular year, and it is widely used as a general indicator of health and mortality. International comparisons (World Health Organization 2000) indicate that in 1999 men’s life expectancy at birth was highest in Japan with 77.6 years, followed by Sweden (77.1 years), and Australia (76.8 years). Life expectancy was lowest in Sierra Leone (33.2 years), Niger (37.2 years), and Zambia (38.0 years). Men’s life expectancy at birth rose dramatically during the twentieth century in developed countries. For example, from 1900 to 1995, men’s life expectancy increased by 30 years in France, 25 years in Sweden, and 26 years in the USA. Progress in the area of mortality was evident also at older ages. Men’s remaining life expectancy at age 80 almost doubled—from about four years in 1900 to about seven years in 1995. Improvements in survival at older ages have been more pronounced in recent decades than they were in earlier ones.
Although these secular improvements are impressive, they lag behind the improvements observed for women. As a consequence the gender gap in mortality, which favors women, widened during the twentieth century. In developed countries today men die about six years earlier than women on average. Gender disparities in mortality vary considerably in magnitude across countries, with gender diﬀerences in life expectancy as high as 11.3 years in the Russian Federation and 11.1 years in Kazakhstan (World Health Organization 2000). Also in most developing countries men have a lower life expectancy than women. However, the gender diﬀerences in these countries are somewhat smaller in magnitude. Gender diﬀerences in life expectancy are very small or even reversed in countries that exhibit pronounced discrimination against women, such as India.
The mortality disadvantage of men is present at all ages. There is some evidence that this male disadvantage starts even before birth. The sex ratio at conception is unknown. More than two-thirds of prenatal mortality occurs before pregnancies are clinically recognized, and the sex ratios for those very early deaths are also unknown. Evidence reviewed by Waldron (1998) suggests that between the second and ﬁfth months of pregnancy male embryos have higher mortality risk than female embryos. Data for developed countries show that males had higher rates of late fetal mortality than females in the early and midcentury but that those sex diﬀerences decreased late in the twentieth century. No signiﬁcant sex diﬀerences in late fetal mortality risk have been observed in recent data for a number of developed countries.
At the start of the twenty-ﬁrst century the sex ratio at birth (boys girls) in developed countries varies between 1.04 and 1.07. This ratio is elevated in countries with a strong son preference such as China (with sex ratios of 1.11 to 1.13 in the late 1980s). Infant and childhood mortality is higher for boys than for girls and these higher death rates for males continue throughout the entire life span. Higher male death rates at all ages translate into a population sex ratio that is increasingly unbalanced with age. Among octogenarians in developed countries there are more than twice as many women as men, and among centenarians women outnumber men by a factor of 4 to 6.
Consistently higher male mortality across ages and countries has led some authors to conclude that men are inherently more fragile than women for biological reasons. Sex hormones have been identiﬁed as making a major contribution to the gender gap in mortality. These hormones modulate the cholesterol-carrying lipoprotein patterns, and women have a healthier lipoprotein pattern than men (Hazzard 1986). It has also been suggested that there is an advantage to having two X-chromosomes (Christensen et al. 2000). Sexual selection theory, a part of evolutionary theory, has been used to explain the origins of sex diﬀerences in mortality. In humans and some other species, females typically make a greater parental investment in their oﬀspring than do males. For a woman, this investment includes a nine-month gestation period, which is followed by lactation and much subsequent nurture. Evolutionary psychologists argue that sex diﬀerences in parental investment favor diﬀerent reproductive strategies for men and women and, consequently, that diﬀerent traits were selected for in men and women. The greater female parental investment becomes a resource for which males compete and which thus limits their ﬁtness. Wang and Hertwig (1999) argued that reproductive success and personal survival tend to be antagonistic goals in human males, because males’ design for personal survival is compromised by the requirements for achieving success in intrasexual competition. In contrast, reproductive success and personal survival tend to be interdependent goals in human females, because the mother’s presence is critical for the survival of the child. This argument suggests that evolution has favored traits that increase reproduction in males and traits that increase survival in females. Sexual selection theory is consistent with the female survival advantage that is evident across ages and countries. However, sexual selection theory alone cannot explain why gender diﬀerences in mortality increased so noticeably during the twentieth century. In addition to biological factors, social and behavioral inﬂuences are clearly important determinants of men’s health and of gender diﬀerences in death rates.
2. Morbidity and Disease
The leading cause of male deaths in developed countries is heart disease, followed by cancer, accidents, and cerebrovascular disease. The leading causes of death diﬀer by age. In the USA in 1998, accidents were the leading cause of death for boys and men aged 1 to 44 (Murphy 2000). Cancer was the leading cause of death for those aged 45 to 64, while heart disease was the leading cause for those aged 65 and older. These age-related patterns were similar for women and men. For each of the 10 leading causes of death, however, age-adjusted death rates were higher for men than for women. The greatest gender diﬀerence in age-adjusted death rates was for suicides, with a mortality sex ratio of 4.3 male deaths to 1 female death. The smallest gender diﬀerences were for stroke and hypertension, each with a ratio of 1.1 male deaths to 1 female death.
It has long been believed in social epidemiology that men die earlier than women, but that women have poorer health than men. This paradigm of higher morbidity for women has recently been challenged. MacIntyre et al. (1996) examined two large British data sets and concluded that the magnitude and direction of gender diﬀerences in morbidity vary according to the condition in question and to the phase of the life span. Excess female morbidity was found consistently across the life span only for psychological distress, and it was far less apparent, if not reversed, for a number of physical symptoms and conditions. In a similar vein, Verbrugge (1989) pointed out that women’s excess morbidity tends to be limited to symptoms and less serious conditions, while men have higher prevalence rates for heart disease, atherosclerosis, emphysema, and other fatal conditions.
Men’s lower rates of anxiety, depression, and general emotional malaise seem to be a consistent, international phenomenon. Courtenay (2000b) suggested that denial of depression is one of the means men use to demonstrate their manhood and to avoid relegation to a lower status position relative to women and other men. A consequence of such denial may be a form of unhappiness that ﬁnds expression in higher drug use and alcohol consumption (Schoﬁeld et al. 2000).
3. Health Disparities Among Men
There are pronounced diﬀerences in men’s health and life expectancy across countries. Boys born in aﬄuent societies, such as Japan and the USA, can expect to live more than 30 years longer than boys in the poor countries of sub-Saharan Africa. There are also considerable health disparities within developed regions. Of particular concern is the recent mortality crisis aﬀecting men in the former Soviet republics. From 1992 to 1994, the life expectancy of Russian men dropped by 6.1 years, and the gender diﬀerence in life expectancy increased to an astounding 13.6 years (Shkolnikov et al. 1998). Eﬀorts to detect the underlying causes of the crisis suggest that the mortality upsurge cannot be explained by the collapse of the health care system or environmental pollution. Instead, psychological stress caused by the shock of an abrupt and severe economic transition is likely to have played a major role, perhaps mediated by the adverse health eﬀects of excessive alcohol consumption. Similar patterns are also evident in the former Soviet republics other than Russia, although they are less pronounced there. These patterns provide a telling example of the profound eﬀects that psychological and behavioral factors can have on men’s health.
Particular groups of men and boys within a society have elevated health risks. These groups include African-American men (in the USA), gay men, homeless men, men in prison, men with disabilities, and unemployed men. Social hierarchies within societies are linked with health diﬀerentials. Men of lower socioeconomic status and those who are less socially integrated exhibit poorer health outcomes when measured in terms of mortality, disability, chronic illness, or injury rates.
4. Health Behavior
Many health scientists believe that health behaviors and lifestyles are among the most important factors inﬂuencing health and longevity and that both men and women can substantially decrease their health risks by adopting appropriate preventive practices. Men are more likely to adopt beliefs and behaviors that increase their risks and less likely to engage in behaviors that are linked with health and longevity. Gender diﬀerences in alcohol abuse are particularly pronounced. National survey data from the USA indicate that about 13 percent of men are classiﬁed as heavy drinkers, as compared to only 3 percent of women (Waldron 1995).
Cigarette smoking is probably the single most important behavioral risk factor for disease and premature mortality. In many developed countries, the prevalence of cigarette smoking is declining and gender diﬀerences in smoking behavior have been decreasing for decades, but even today cigarette smoking continues to be more prevalent among men. There is evidence that regular physical activity reduces the risk of major chronic diseases. Many authors have noted that in general, men are slightly more physically active than women. However, the type and intensity of physical activity seem to diﬀer by gender. It appears that men are more likely to engage in infrequent but strenuous activities that may increase the risk of injury (such as weight-lifting or team sports). In contrast, women seem to be more likely to engage in regular, light to moderate exercise (e.g., walking, gardening, housework) that confers optimal health beneﬁts (Courtenay 2000a).
Regular medical examinations are critical for the early detection of many diseases and may result in a better prognosis. It is true that women visit physicians more often than men, but this diﬀerence is observed primarily for conditions that are not major causes of death. Gender diﬀerences in health care utilization generally begin to disappear when the health problem is more serious. For heart disease and most types of cancer, women delay seeking medical care as long as or longer than men, and thus do not have a better prognosis in the case of illness (Waldron 1995).
Courtenay (2000a) reviewed the evidence on gender diﬀerences in more than 30 health practices, including self-examinations, dietary practices, safety belt use, violence, and various risk-taking behaviors. He concluded that men are signiﬁcantly more likely than women to engage in practices that increase the risk of disease, injury, and death. These behaviors tend to cooccur in healthy or unhealthy clusters, and the interaction of unhealthy practices (e.g., cigarette smoking combined with alcohol abuse) may compound men’s health risks.
5. Masculinity and Men’s Health
Some recent sociocultural studies on men’s health and illness have been inﬂuenced by critical feminist theories. These studies focus on gender as a key factor for understanding the patterns of men’s health risks and men’s psychological adjustment to illness. The term gender encompasses expectations and behaviors that individuals learn about masculinity and femininity. From a social constructivist perspective, both men and women construct gender by adopting from their culture concepts of masculinity and femininity. In this view a person’s gender is not something one is, but rather something one does in social interactions.
There is very high level of agreement within societies about what are considered to be typically masculine and typically feminine characteristics. For example, typically masculine gender stereotypes in contemporary Western societies include aggression, competitiveness, dominance, independence, and invulnerability (Moynihan 1998). These stereotypes provide collective and dichotomous meanings of gender, and they often become widely shared beliefs about who men and women innately are. People are encouraged to conform to these stereotypic beliefs and behaviors. In most instances men and women do conform, and they adopt these dominant norms of masculinity and femininity.
Courtenay (2000b) argued that health-related beliefs and behaviors are prominent means for demonstrating masculinity and femininity. Health behaviors can be understood as ways of constructing or demonstrating gender, and the ‘doing of health’ is a form of ‘doing gender.’ Men use health beliefs and behaviors to demonstrate masculine ideals that clearly establish them as men. Among these health-related beliefs and behaviors are the denial of weakness and vulnerability, emotional and physical control, the appearance of being strong and robust, dismissal of any need for help, a ceaseless interest in sex, and the display of aggressive behavior and physical dominance.
In exhibiting masculine ideals with health behavior, men reinforce cultural beliefs that men are more powerful and less vulnerable than women; that men’s bodies are structurally more eﬃcient than and superior to women’s bodies; that asking for help and caring for one’s health are feminine; and that the most powerful men among men are those for whom health and safety are irrelevant (Courtenay 2000b, p. 1389).
In these ways masculinity is constructed and deﬁned at the expense of men’s health. For instance, fear of being ‘soft’ may deter men from applying sunscreen to prevent skin cancer, and the need to display toughness to win peer approval may result in violence or risky driving. Similarly, men are demonstrating dominant norms of manhood when they refuse to take sick leave from work, when they boast that drinking does not impair their driving, or when they brag that they have not been to a doctor for a very long time.
Although health research has frequently used males as study subjects, it has typically neglected to examine men and the health risks associated with men’s gender. However, men’s greater susceptibility to disease and premature death is being increasingly noted, and the health of men is becoming a public health concern. Men’s health advocates have pointed out that it is important to contest stereotypes of masculinity that are widely disseminated and deeply entrenched in the healthcare system and other institutions. It has also been suggested that behavioral interventions designed to improve health behaviors should prove eﬀective for prevention, because these behaviors are important determinants of health and longevity. Considering that many health practices are diﬀerentially linked to notions of masculinity and femininity, the design of gender-speciﬁc interventions may be required to yield eﬀective outcomes (Weidner 2000).
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