Disease-a-Month 60 (2014) 138–144
Contents lists available at ScienceDirect
Disease-a-Month journal homepage: www.elsevier.com/locate/disamonth
Gender and health disparities: The case of male gender Martin S. Lipsky, MD, MS, Melissa Cannon, BS, M. Nawal Lutfiyya, PhD, FACE
Introduction Over the past few decades, many academic centers, institutions, and hospitals developed centers addressing womenʼs health with the goal of improving the quality of health for women. Only recently in the United States has men's health emerged as an equally important topic of interest and discussion.1–3 In a society where men are typically advantaged economically, socially, and politically, it is not surprising that health disparities experienced by men often remain unrecognized. In addition to the obvious differences related to reproductive health, men and women face different patterns of disease, mortality, and disability.4,5 Feminist scholars were among the first to explore the connection of sex to health and to bring attention to gender-related health disparities.6–8 This association grew out of the recognition that researchers commonly overrepresented men in clinical trials and a growing awareness that male outcomes in clinical trials might not apply equally to females.8 However, the connection of gender to health remained almost exclusively associated with womenʼs health, despite evidence that men also experience health-related disparities, defined as unjust and potentially avoidable differences in morbidity and mortality. In most developed countries, men are more likely to die prematurely than women and many of these deaths are associated with preventable risk factors. Despite evidence that being male is a major health determinant, few researchers have examined gender-related health disparities from the male perspective. Like womenʼs health, however, menʼs health should not be considered solely a male issue but should be viewed as a community issue because a manʼs health profoundly affects his children, family, and spouse.9–11 For example, women whose male partners die prematurely experience a far greater risk for living in poverty than those with healthy male partners. About 40% of widows fall into poverty for at least some time within the first 5 years after the death of their husbands.9,11 More than half of elderly widows who live in poverty were not poor before the death of their husbands. Menʼs health incorporates physiological, psychological, cultural, and environmental issues that are frequently different from those pertaining to women. In this article and its
http://dx.doi.org/10.1016/j.disamonth.2014.02.001 0011-5029 & 2014 Elsevier Inc. All rights reserved.
M.S. Lipsky et al. / Disease-a-Month 60 (2014) 138–144
139
companion pieces, we will review some health disparities experienced by men. An appreciation of menʼs health as a distinct and important issue may help health care providers target strategies to improve therapies, and an increased awareness of the unique health issues faced by men and an understanding that can lead to strategies that improve the overall health of men.
The longevity gap Since the turn of the century, the overall trend in life expectancy has been one of gradual improvement. In 2010, life expectancy at birth in the US was 78.7 years, an increase of 11% since 1900.12 Although longevity is increasing for both men and women, on average men in the US still live about 5 years fewer than women. Changes in live expectancy over the past century suggest, however, that the gap in longevity is not fixed and there may be opportunities to increase male life expectancy and to reduce the disparity in longevity between the sexes. In 1920, the life-expectancy gap between men and women was smaller—about 2 years—and rose in the 1970s to almost 8 years. The gap in life expectancy is narrowing and while the reasons are multifactorial, key factors include a proportionately larger increase in lung cancer mortality in women compared to men and a proportionately larger decrease in mortality from heart disease among men. Even though mortality differences for heart disease between men and women are narrowing, nearly 3 out of 4 persons who die before the age of 65 years from a heart attack are male, and premature death from heart disease accounts for more than half of the difference in life expectancy.1,13 In addition to premature death from heart disease, the years of lost life for men from suicide, accidental injury, and motor vehicle accidents remain twice that of women and represent opportunities to increase male life expectancy.12 Although a gap in life expectancy exists for all ages, the longevity gap is greatest in adolescents and young adults largely due to greater risk for men dying from an accident, a violent act, or suicide. As men and women get older, the difference in life expectancy narrows between them. By the age of 65 years there is only approximately a 2-year difference, and by the age of 100 years the gap is negligible. Few men, however, live to be among the oldest, and at the age of 85 years women outnumber men by more than 2.2 to 1. Only 1 in 4 centenarians is male.14 The gender gap is not unique to the United States. Virtually all developed countries with reliable health statistics demonstrate differences in longevity that favor women over men.15 The consistently shorter life span for men across multiple cultures, environments, and heath care systems suggests that there are likely some fundamental biological and intrinsic genetic differences affecting the health and longevity of men and women. Yet, the significant variations in life expectancy found across a range of cultures and societies imply that modifiable environmental and societal factors contribute significantly to the longevity gap.
Causes of death An examination of death rates for the leading causes of death in the US reveals a disparity between genders. All but 20% of deaths in the US are accounted for by the 15 leading causes of death (see Table 1 for the list by rank of the 15 leading causes of death in the US for 2010 and the relative risk of death of men compared to women expressed as a ratio).12 Ratios based on ageadjusted death rates show that males have higher rates than females for 12 of the 15 leading causes of death for 2010 (Table 1). For 4 of the leading causes of death, Parkinsonʼs disease, chronic liver disease and cirrhosis, suicide, and unintentional injuries, the age-adjusted risk of death was at least 2 times higher for men than for women.12 While differences in biology likely account for some of the disparity, differences in lifestyle clearly play a role. Men in the US are less likely to adopt healthy behaviors and more likely to engage in risky behaviors.14,16 Specific beliefs about what constitutes masculinity and “toughness” are deeply rooted in society and may influence men in ways that negatively
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Table 1 Ratio of male-to-female age-adjusted death rates in 2010 for the 15 leading causes of death in the US for the total population.12 Rank
Cause of death
Age-adjusted death rate (per 100,000)
Male-to-female ratio
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Diseases of heart Malignant neoplasms Chronic lower respiratory diseases Cerebrovascular diseases Accidents (unintentional injuries) Alzheimer's disease Diabetes mellitus Nephritis, nephrotic syndrome, and nephrosis Influenza and pneumonia Intentional self-harm (suicide) Septicemia Chronic liver disease and cirrhosis Essential hypertension and hypertensive renal disease Parkinson's disease Pneumonitis due to solids and liquids
179.1 172.8 42.2 39.1 38.0 25.1 20.8 15.3 15.1 12.1 10.6 9.4 8.0 6.8 5.1
1.6 1.4 1.3 1.0 2.0 0.8 1.4 1.4 1.4 4.0 1.2 2.1 1.0 2.3 1.9
impact and threaten a manʼs health. For instance, men are encouraged from an early age to “tough it out,” that boys should not cry, and that a man keeps his emotions to himself and acts independently without seeking help. The belief that “when things are tough, one should ‘man up’” highlights these masculine values. Consequently, it ought not to be surprising that middleaged men with strong masculine identities are almost 50% less likely to seek preventive health services and more likely to delay seeking emergency care.16 The male ethos may also lead men to view mental health issues, such as depression, as a sign of weakness and to avoid seeking help.16 Suicide represents the single greatest disparity among the leading causes of death with a male-to-female ratio of 4.3:1,9,12 and a lack of male engagement with mental health providers may be an important contributing factor. While heart disease is the leading cause of death for both sexes, far more years of life are lost to men from it than to women. Men typically develop coronary artery disease (CAD) 10–15 years earlier than women, and it is far less common to see a middle-aged woman die unexpectedly of heart disease than a man.17 Several modifiable risk factors place men at a greater risk for both heart disease and other leading causes of death. Males are more likely than females to engage in 30 risky health behaviors, including smoking, drinking to excess, eating a poor diet, and living a sedentary lifestyle.18 Hegemonic masculinity often endorses unhealthy behaviors as being manly and may create a social environment that adversely affects a man who is adopting healthy behaviors, such as limiting saturated fat in his diet and saying “no” to another beer when out with male friends or colleagues. Developing effective strategies that target men to adopt health behaviors represent an opportunity to address male health disparities. One example of a maletargeted health campaign is the “Real Men Wear Gowns” campaign to encourage men to get cancer screening.19 Biological factors related to sex, such as differences in lipid levels, also contribute to excess heart disease in men. Estrogen appears to have a beneficial effect on lipid profiles, and before menopause women tend to have higher HDL cholesterol levels, lower LDL cholesterol levels, and lower triglyceride levels. As estrogen levels fall after menopause, female lipid profiles become more similar to male profiles and the risk of CAD for women rises. While estrogen is believed to be an important factor for women developing heart disease about 10–15 years later than men, the hormonal picture is not quite as simple as “estrogen is protective and testosterone is harmful.” For example, giving supplemental estrogen to a postmenopausal woman is not necessarily cardio-protective, and administering testosterone to an aging, androgen-deficient male may actually reduce his risk of heart disease.20,21
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Table 2 Estimateda new cases (incidence) from 9 leading cancer types in US adults for 2012.b Cancer site
All sites Lung and bronchus Colon and rectum Melanoma of the skin Kidney and renal pelvis Non-Hodgkin lymphoma Pancreas Prostate Breast (women)
Men
Women
Cases
Men (%)
Cases
Women (%)
848,170 116,470 73,420 44,250 40,250 38,160 22,090 241,740
51.7c 13.7 8.6 5.2 4.7 4.5 2.6 28.5
790,740 109,690 70,040 32,000 24,520 31,970 21,830
48.2c 13.8 8.8 4.0 3.1 4.0 2.7
226,870
28.7
a Estimates have been rounded to the nearest 10 and exclude basal and squamous cell skin cancers and in situ carcinoma. b Data for the table were obtained from the work by Siegel et al.22 c Percentage calculated from all sites for both men and women.
Cancer rates also differ for men and women. In the US for the years 2006–2008, cancer incidence and mortality trended higher for men than for women.22 Table 2 displays cancer incidence for 2006–2008, and Table 3 shows deaths from cancer. The estimated lifetime probability of receiving an invasive cancer (all sites) diagnosis was 45% for men and 38% for women. Over a lifetime, a man has roughly a 1 in 2 chance of developing cancer compared to about a 1 in 3 chance for a woman.22 Between the years 2006 and 2008, lung cancer was the leading cause of cancer death for both men and women. Epidemiologists note that as the prevalence of smoking among men has decreased, there has been a concomitant decline among lung cancer deaths in men.22 In contrast, as women increase their use of tobacco products, there has been an accompanying increase in tobacco-related deaths among women.22 In addition to smoking, men are more likely to abuse drugs, to abuse alcohol, and to engage in higher risk occupations. Men account for 90% of work fatalities and typically face greater indirect occupational risks from exposures to toxins and hazardous environments.22 A substantial
Table 3 Estimateda deaths from 6 leading cancer types in US adults for 2012b Cancer site
All sites Lung and bronchus Colon and rectum Liver and intrahepatic bile duct Leukemia Non-Hodgkin lymphoma Pancreas Prostate Breast (women) a
Men
Women
Deaths
Men (%)
Deaths
Women (%)
301,820 87,750 26,470 13,980 13,500 10,320 18,850 28,170
54.2c 29.0 8.8 4.6 4.6 3.4 6.2 9.3
275,370 72,590 25,220 6570 10,040 8620 18,540
49.4c 26.4 9.2 2.4 3.6 3.1 6.7
39,510
14.3
Estimates have been rounded to the nearest 10 and exclude basal and squamous cell skin cancers and in situ carcinoma. b Data for the table were obtained from the work by Siegel et al.22 c Percentage calculated from all sites for both men and women.
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portion of cancer is related to lifestyle and environmental exposures, both risks influenced by gender.22 For example, the higher rate of melanoma in men may be due to having more occupational exposure to sun and, behaviorally, to men using sunscreen less frequently than women.
Biological factors Sex is defined as the biological and physical differences between men and women. It is usually categorized as bimodal, that is, an individual is either male or female and is determined according to the reproductive organs and functions assigned by chromosome complement. In contrast, gender refers to masculinity and while intimately related to a personʼs biological sex, gender is a social construct shaped by the environment and experience.23 Both sex and gender impact health and are relevant to health and illness. Gender clearly influences health in many ways such as having access to services, engaging in risky behaviors, and facing environmental exposures. As Lutfiyya et al.24 illustrate in an accompanying article, the social construct of gender is an important determinant of health. The universality of differences in the longevity of men and women suggests that intrinsic biologic factors contribute to the gender health disparity. Biological differences between the sexes extend beyond reproductive issues and include a wide range of genetic, hormonal, metabolic, and other intrinsic factors. Male vulnerability starts early, as male infants have an increased risk of prenatal vulnerability, prematurity, and are more likely to die during their first year of life.25 Boys also have a greater risk for developmental disabilities, autism, and color blindness.25 While diseases such as ovarian cancer in women and prostate in cancer in men clearly relate to sex, many non-gender specific diseases that affect both men and women differ in incidence, prevalence, symptoms, and severity between both the sexes.12 Perhaps the most fundamental biologic difference is the genetic composition of a male. The human genome contains between 20,000 and 25,000 genes and each person has 23 pairs of chromosomes; 22 autosomes and 1 pair of sex genes. While the autosomes are similar, the Y chromosome confers maleness and contains the SRY gene that determines the development of the fetal testes and directs the secretion of the male hormones that differentiate the fetus into a male. The Y chromosome is also only about one-third as large as the X chromosome, and genes on the sex chromosome are expressed differently between males and females. The loss of redundant X genes leads to several well-known sex-linked diseases, such as hemophilia. Male fragility, while less obvious than the sex-linked diseases, may also be caused by the lack of genetic redundancy. Skuse et al.26 proposed that the X chromosome carries genes related to social behavior, and that a lack of redundancy may contribute to the increased risk of social and conduct disorders in boys. Separating biology from social and cultural influences is difficult, however, since they clearly are intricately entwined. Genes that promote risk taking, aggressiveness, and competitive ability may provide an advantage for mating and an evolutionary pressure for expressing these genes in a man, but may come at the expense of genes that promote longevity. So while cultural pressures clearly influence behavior, in complex ways biologic factors also influence how an individual reacts to social and cultural factors. For example, different patterns of neurologic regulation between men and women may contribute to misjudging risks that leads to the higher rates of accidents, substance abuse, and violent deaths seen in males.26
Racial differences Among major race–sex groups, white females have the longest life expectancy (81.3 years) followed by black females (78.0 years).12 Among all groups, men of color have shorter life expectancies than white males. For example, white males have a life expectancy at birth of 76.5
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years compared to a life expectancy for black males of 71.8 years, a gap of 4.7 years.12 About 65% of the gap is due to heart disease, homicide, cancer, stroke, and infant mortality.12 Heart disease alone accounted for 1.117 years. In contrast, black males experience lower death rates from suicide, injuries, chronic liver disease, chronic respiratory diseases, and Parkinsonʼs disease.12
Conclusion Sex is an important variable that influences the health of an individual. Though the issue of sex and health is often viewed as a womanʼs issue, men die younger and experience higher mortality rates than women for nearly all leading causes of death. Despite this, few recognize that men are an “at-risk group” for health. These differences in morbidity and mortality result from a complex mixture of biology, genetics, and behavior. While differences in biology and genetics are not modifiable, a substantial portion of years of life lost to men can be traced to modifiable risk factors. Understanding these differences and providing care in a genderappropriate manner creates opportunities for clinicians to improve the lives of their male patients.27 References 1. Courtenay WH, Keeling RP. Men, gender, and health: toward an interdisciplinary approach. J Am Coll Health. 2000;48(6): 243–246. 2. Courtenay W. College menʼs health: an overview and a call to action. J Am Coll Health. 1998;46(6):279–290. 3. Bates LM, Hankivsky O, Springer KW. Gender and health inequities: a comment on the final report of the WHO Commission on the Social Determinants of Health. Soc Sci Med. 2009;69:1002–1004. 4. Eisler RM, Hersen M. Handbook of Gender, Culture, and Health. Mahwah, NJ: Erlbaum; 2000. 5. Lent B, Bishop JE. Sense and sensitivity: developing a gender issues perspective in medical education. J Womens Health. 1998;7(3):339–342. 6. Hankivsky O. Womenʼs health, menʼs health, and gender and health: implications of intersectionality. Soc Sci Med. 2012;74:1712–1720. 7. Turshen M. Gender and health (commentary). J Public Health Policy. 2007;28(3):319–321. 8. Doull M, Runnels VE, Tudiver S, Boscoe M. Appraising the evidence: applying Sex- and Gender-based Analysis (SGBA) to Cochrane systematic reviews on cardiovascular diseases. J Womens Health. 2008;19(5):997–1003. 9. Bonhomme JJ. Menʼs health: key to healthier women, children, and communities. Am J Mens Health. 2007;1(4): 35–338. 10. Morgan LA. Economic well-being following marital termination: a comparison of widowed and divorced women. J Fam Issues. 1989;10(1):86–101. 11. Bonhomme JJ. Menʼs health: impact on women, children and society. J Mens Health Gend. 2007;4(2):124–130. 12. Murphy SL, Xu J, Kochanek KD. Deaths: final data for 2010. Natl Vital Stat Rep. 2013;61:1–117. 13. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e46–e215. (Accessed January 6, 2014) 〈http://circ.ahajournals. org/content/121/7/e46.extract〉. 14. Willcox BJ, He Q, Chen R, et al. Midlife risk factors and healthy survival in men. J Am Med Assoc. 2006;296: 2343–2350. 15. National Research Council. Explaining Divergent Levels of Longevity in High-Income Countries. Washington, DC: The National Academies Press, 2011. 16. Evans J, Frank B, Oliffe JL, Gregory D. Health, illness, men and masculinities (HIMM): a theoretical framework for understanding men and their health. J Mens Health. 2011;8(1):7–15. 17. Worrall-Carter L, Ski C, Scruth E, Campbell M, Page K. Systematic review of cardiovascular disease in women: assessing the risk. Nurse Health Sci. 2011;13:529–535. 18. Garfield CF, Isacco A, Rogers TE. A review of menʼs health and masculinity. Am J Lifestyle Med. 2008;2:474. 19. Clancy CM. Real men wear gowns—and help their health. Agency for Healthcare Research and Quality website. 〈http://www.ahrq.gov/news/columns/navigating-the-health-care-system/050608.html〉; Updated May 2008 Accessed January 6, 2014. 20. Sturdee DW, Pines Aon behalf of the International Menopause Society Writing Group. Updated IMS recommendations on postmenopausal hormone therapy and preventive strategies for midlife health. Climacteric. 2011;14: 302–320. 21. Ruige JB, Ouwens DM, Kaufman JM. Beneficial and adverse effects of testosterone on the cardiovascular system in men. J Clin Endocrinol Metab. 2013;98(11):4300–4310. 22. Siegel R, Naishadham D, Jemal Ahmedin. Cancer statistics, 2012. CA Cancer J Clin. 2012;62:10–29. 23. Wood JT. Gendered Lives: Communication, Gender, and Culture. 8th ed. Boston: Wadsworth; 2009. 24. Lutfiyya MN, Lipsky MS, Cannon M. An argument for male gender as a root cause or fundamental social determinant of health.
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25. Kraemer S. The fragile male. Br Med J. 2000;321(7276):1609–1612. 26. Skuse D, James RS, Bishop DVM, et al. Evidence from Turnerʼs syndrome of an imprinted X-linked locus affecting cognitive function. Nature. 1997;387:705–708. 27. National Institute on Aging. Action Plan for Aging Research: Strategic Plan for Fiscal Years 2001-2005. Washington DC: NIH publication; 2001; p 01–4951.
Contents lists available at ScienceDirect
Disease-a-Month journal homepage: www.elsevier.com/locate/disamonth
Gender and health disparities: The case of male gender Martin S. Lipsky, MD, MS, Melissa Cannon, BS, M. Nawal Lutfiyya, PhD, FACE
Introduction Over the past few decades, many academic centers, institutions, and hospitals developed centers addressing womenʼs health with the goal of improving the quality of health for women. Only recently in the United States has men's health emerged as an equally important topic of interest and discussion.1–3 In a society where men are typically advantaged economically, socially, and politically, it is not surprising that health disparities experienced by men often remain unrecognized. In addition to the obvious differences related to reproductive health, men and women face different patterns of disease, mortality, and disability.4,5 Feminist scholars were among the first to explore the connection of sex to health and to bring attention to gender-related health disparities.6–8 This association grew out of the recognition that researchers commonly overrepresented men in clinical trials and a growing awareness that male outcomes in clinical trials might not apply equally to females.8 However, the connection of gender to health remained almost exclusively associated with womenʼs health, despite evidence that men also experience health-related disparities, defined as unjust and potentially avoidable differences in morbidity and mortality. In most developed countries, men are more likely to die prematurely than women and many of these deaths are associated with preventable risk factors. Despite evidence that being male is a major health determinant, few researchers have examined gender-related health disparities from the male perspective. Like womenʼs health, however, menʼs health should not be considered solely a male issue but should be viewed as a community issue because a manʼs health profoundly affects his children, family, and spouse.9–11 For example, women whose male partners die prematurely experience a far greater risk for living in poverty than those with healthy male partners. About 40% of widows fall into poverty for at least some time within the first 5 years after the death of their husbands.9,11 More than half of elderly widows who live in poverty were not poor before the death of their husbands. Menʼs health incorporates physiological, psychological, cultural, and environmental issues that are frequently different from those pertaining to women. In this article and its
http://dx.doi.org/10.1016/j.disamonth.2014.02.001 0011-5029 & 2014 Elsevier Inc. All rights reserved.
M.S. Lipsky et al. / Disease-a-Month 60 (2014) 138–144
139
companion pieces, we will review some health disparities experienced by men. An appreciation of menʼs health as a distinct and important issue may help health care providers target strategies to improve therapies, and an increased awareness of the unique health issues faced by men and an understanding that can lead to strategies that improve the overall health of men.
The longevity gap Since the turn of the century, the overall trend in life expectancy has been one of gradual improvement. In 2010, life expectancy at birth in the US was 78.7 years, an increase of 11% since 1900.12 Although longevity is increasing for both men and women, on average men in the US still live about 5 years fewer than women. Changes in live expectancy over the past century suggest, however, that the gap in longevity is not fixed and there may be opportunities to increase male life expectancy and to reduce the disparity in longevity between the sexes. In 1920, the life-expectancy gap between men and women was smaller—about 2 years—and rose in the 1970s to almost 8 years. The gap in life expectancy is narrowing and while the reasons are multifactorial, key factors include a proportionately larger increase in lung cancer mortality in women compared to men and a proportionately larger decrease in mortality from heart disease among men. Even though mortality differences for heart disease between men and women are narrowing, nearly 3 out of 4 persons who die before the age of 65 years from a heart attack are male, and premature death from heart disease accounts for more than half of the difference in life expectancy.1,13 In addition to premature death from heart disease, the years of lost life for men from suicide, accidental injury, and motor vehicle accidents remain twice that of women and represent opportunities to increase male life expectancy.12 Although a gap in life expectancy exists for all ages, the longevity gap is greatest in adolescents and young adults largely due to greater risk for men dying from an accident, a violent act, or suicide. As men and women get older, the difference in life expectancy narrows between them. By the age of 65 years there is only approximately a 2-year difference, and by the age of 100 years the gap is negligible. Few men, however, live to be among the oldest, and at the age of 85 years women outnumber men by more than 2.2 to 1. Only 1 in 4 centenarians is male.14 The gender gap is not unique to the United States. Virtually all developed countries with reliable health statistics demonstrate differences in longevity that favor women over men.15 The consistently shorter life span for men across multiple cultures, environments, and heath care systems suggests that there are likely some fundamental biological and intrinsic genetic differences affecting the health and longevity of men and women. Yet, the significant variations in life expectancy found across a range of cultures and societies imply that modifiable environmental and societal factors contribute significantly to the longevity gap.
Causes of death An examination of death rates for the leading causes of death in the US reveals a disparity between genders. All but 20% of deaths in the US are accounted for by the 15 leading causes of death (see Table 1 for the list by rank of the 15 leading causes of death in the US for 2010 and the relative risk of death of men compared to women expressed as a ratio).12 Ratios based on ageadjusted death rates show that males have higher rates than females for 12 of the 15 leading causes of death for 2010 (Table 1). For 4 of the leading causes of death, Parkinsonʼs disease, chronic liver disease and cirrhosis, suicide, and unintentional injuries, the age-adjusted risk of death was at least 2 times higher for men than for women.12 While differences in biology likely account for some of the disparity, differences in lifestyle clearly play a role. Men in the US are less likely to adopt healthy behaviors and more likely to engage in risky behaviors.14,16 Specific beliefs about what constitutes masculinity and “toughness” are deeply rooted in society and may influence men in ways that negatively
140
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Table 1 Ratio of male-to-female age-adjusted death rates in 2010 for the 15 leading causes of death in the US for the total population.12 Rank
Cause of death
Age-adjusted death rate (per 100,000)
Male-to-female ratio
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Diseases of heart Malignant neoplasms Chronic lower respiratory diseases Cerebrovascular diseases Accidents (unintentional injuries) Alzheimer's disease Diabetes mellitus Nephritis, nephrotic syndrome, and nephrosis Influenza and pneumonia Intentional self-harm (suicide) Septicemia Chronic liver disease and cirrhosis Essential hypertension and hypertensive renal disease Parkinson's disease Pneumonitis due to solids and liquids
179.1 172.8 42.2 39.1 38.0 25.1 20.8 15.3 15.1 12.1 10.6 9.4 8.0 6.8 5.1
1.6 1.4 1.3 1.0 2.0 0.8 1.4 1.4 1.4 4.0 1.2 2.1 1.0 2.3 1.9
impact and threaten a manʼs health. For instance, men are encouraged from an early age to “tough it out,” that boys should not cry, and that a man keeps his emotions to himself and acts independently without seeking help. The belief that “when things are tough, one should ‘man up’” highlights these masculine values. Consequently, it ought not to be surprising that middleaged men with strong masculine identities are almost 50% less likely to seek preventive health services and more likely to delay seeking emergency care.16 The male ethos may also lead men to view mental health issues, such as depression, as a sign of weakness and to avoid seeking help.16 Suicide represents the single greatest disparity among the leading causes of death with a male-to-female ratio of 4.3:1,9,12 and a lack of male engagement with mental health providers may be an important contributing factor. While heart disease is the leading cause of death for both sexes, far more years of life are lost to men from it than to women. Men typically develop coronary artery disease (CAD) 10–15 years earlier than women, and it is far less common to see a middle-aged woman die unexpectedly of heart disease than a man.17 Several modifiable risk factors place men at a greater risk for both heart disease and other leading causes of death. Males are more likely than females to engage in 30 risky health behaviors, including smoking, drinking to excess, eating a poor diet, and living a sedentary lifestyle.18 Hegemonic masculinity often endorses unhealthy behaviors as being manly and may create a social environment that adversely affects a man who is adopting healthy behaviors, such as limiting saturated fat in his diet and saying “no” to another beer when out with male friends or colleagues. Developing effective strategies that target men to adopt health behaviors represent an opportunity to address male health disparities. One example of a maletargeted health campaign is the “Real Men Wear Gowns” campaign to encourage men to get cancer screening.19 Biological factors related to sex, such as differences in lipid levels, also contribute to excess heart disease in men. Estrogen appears to have a beneficial effect on lipid profiles, and before menopause women tend to have higher HDL cholesterol levels, lower LDL cholesterol levels, and lower triglyceride levels. As estrogen levels fall after menopause, female lipid profiles become more similar to male profiles and the risk of CAD for women rises. While estrogen is believed to be an important factor for women developing heart disease about 10–15 years later than men, the hormonal picture is not quite as simple as “estrogen is protective and testosterone is harmful.” For example, giving supplemental estrogen to a postmenopausal woman is not necessarily cardio-protective, and administering testosterone to an aging, androgen-deficient male may actually reduce his risk of heart disease.20,21
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Table 2 Estimateda new cases (incidence) from 9 leading cancer types in US adults for 2012.b Cancer site
All sites Lung and bronchus Colon and rectum Melanoma of the skin Kidney and renal pelvis Non-Hodgkin lymphoma Pancreas Prostate Breast (women)
Men
Women
Cases
Men (%)
Cases
Women (%)
848,170 116,470 73,420 44,250 40,250 38,160 22,090 241,740
51.7c 13.7 8.6 5.2 4.7 4.5 2.6 28.5
790,740 109,690 70,040 32,000 24,520 31,970 21,830
48.2c 13.8 8.8 4.0 3.1 4.0 2.7
226,870
28.7
a Estimates have been rounded to the nearest 10 and exclude basal and squamous cell skin cancers and in situ carcinoma. b Data for the table were obtained from the work by Siegel et al.22 c Percentage calculated from all sites for both men and women.
Cancer rates also differ for men and women. In the US for the years 2006–2008, cancer incidence and mortality trended higher for men than for women.22 Table 2 displays cancer incidence for 2006–2008, and Table 3 shows deaths from cancer. The estimated lifetime probability of receiving an invasive cancer (all sites) diagnosis was 45% for men and 38% for women. Over a lifetime, a man has roughly a 1 in 2 chance of developing cancer compared to about a 1 in 3 chance for a woman.22 Between the years 2006 and 2008, lung cancer was the leading cause of cancer death for both men and women. Epidemiologists note that as the prevalence of smoking among men has decreased, there has been a concomitant decline among lung cancer deaths in men.22 In contrast, as women increase their use of tobacco products, there has been an accompanying increase in tobacco-related deaths among women.22 In addition to smoking, men are more likely to abuse drugs, to abuse alcohol, and to engage in higher risk occupations. Men account for 90% of work fatalities and typically face greater indirect occupational risks from exposures to toxins and hazardous environments.22 A substantial
Table 3 Estimateda deaths from 6 leading cancer types in US adults for 2012b Cancer site
All sites Lung and bronchus Colon and rectum Liver and intrahepatic bile duct Leukemia Non-Hodgkin lymphoma Pancreas Prostate Breast (women) a
Men
Women
Deaths
Men (%)
Deaths
Women (%)
301,820 87,750 26,470 13,980 13,500 10,320 18,850 28,170
54.2c 29.0 8.8 4.6 4.6 3.4 6.2 9.3
275,370 72,590 25,220 6570 10,040 8620 18,540
49.4c 26.4 9.2 2.4 3.6 3.1 6.7
39,510
14.3
Estimates have been rounded to the nearest 10 and exclude basal and squamous cell skin cancers and in situ carcinoma. b Data for the table were obtained from the work by Siegel et al.22 c Percentage calculated from all sites for both men and women.
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portion of cancer is related to lifestyle and environmental exposures, both risks influenced by gender.22 For example, the higher rate of melanoma in men may be due to having more occupational exposure to sun and, behaviorally, to men using sunscreen less frequently than women.
Biological factors Sex is defined as the biological and physical differences between men and women. It is usually categorized as bimodal, that is, an individual is either male or female and is determined according to the reproductive organs and functions assigned by chromosome complement. In contrast, gender refers to masculinity and while intimately related to a personʼs biological sex, gender is a social construct shaped by the environment and experience.23 Both sex and gender impact health and are relevant to health and illness. Gender clearly influences health in many ways such as having access to services, engaging in risky behaviors, and facing environmental exposures. As Lutfiyya et al.24 illustrate in an accompanying article, the social construct of gender is an important determinant of health. The universality of differences in the longevity of men and women suggests that intrinsic biologic factors contribute to the gender health disparity. Biological differences between the sexes extend beyond reproductive issues and include a wide range of genetic, hormonal, metabolic, and other intrinsic factors. Male vulnerability starts early, as male infants have an increased risk of prenatal vulnerability, prematurity, and are more likely to die during their first year of life.25 Boys also have a greater risk for developmental disabilities, autism, and color blindness.25 While diseases such as ovarian cancer in women and prostate in cancer in men clearly relate to sex, many non-gender specific diseases that affect both men and women differ in incidence, prevalence, symptoms, and severity between both the sexes.12 Perhaps the most fundamental biologic difference is the genetic composition of a male. The human genome contains between 20,000 and 25,000 genes and each person has 23 pairs of chromosomes; 22 autosomes and 1 pair of sex genes. While the autosomes are similar, the Y chromosome confers maleness and contains the SRY gene that determines the development of the fetal testes and directs the secretion of the male hormones that differentiate the fetus into a male. The Y chromosome is also only about one-third as large as the X chromosome, and genes on the sex chromosome are expressed differently between males and females. The loss of redundant X genes leads to several well-known sex-linked diseases, such as hemophilia. Male fragility, while less obvious than the sex-linked diseases, may also be caused by the lack of genetic redundancy. Skuse et al.26 proposed that the X chromosome carries genes related to social behavior, and that a lack of redundancy may contribute to the increased risk of social and conduct disorders in boys. Separating biology from social and cultural influences is difficult, however, since they clearly are intricately entwined. Genes that promote risk taking, aggressiveness, and competitive ability may provide an advantage for mating and an evolutionary pressure for expressing these genes in a man, but may come at the expense of genes that promote longevity. So while cultural pressures clearly influence behavior, in complex ways biologic factors also influence how an individual reacts to social and cultural factors. For example, different patterns of neurologic regulation between men and women may contribute to misjudging risks that leads to the higher rates of accidents, substance abuse, and violent deaths seen in males.26
Racial differences Among major race–sex groups, white females have the longest life expectancy (81.3 years) followed by black females (78.0 years).12 Among all groups, men of color have shorter life expectancies than white males. For example, white males have a life expectancy at birth of 76.5
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years compared to a life expectancy for black males of 71.8 years, a gap of 4.7 years.12 About 65% of the gap is due to heart disease, homicide, cancer, stroke, and infant mortality.12 Heart disease alone accounted for 1.117 years. In contrast, black males experience lower death rates from suicide, injuries, chronic liver disease, chronic respiratory diseases, and Parkinsonʼs disease.12
Conclusion Sex is an important variable that influences the health of an individual. Though the issue of sex and health is often viewed as a womanʼs issue, men die younger and experience higher mortality rates than women for nearly all leading causes of death. Despite this, few recognize that men are an “at-risk group” for health. These differences in morbidity and mortality result from a complex mixture of biology, genetics, and behavior. While differences in biology and genetics are not modifiable, a substantial portion of years of life lost to men can be traced to modifiable risk factors. Understanding these differences and providing care in a genderappropriate manner creates opportunities for clinicians to improve the lives of their male patients.27 References 1. Courtenay WH, Keeling RP. Men, gender, and health: toward an interdisciplinary approach. J Am Coll Health. 2000;48(6): 243–246. 2. Courtenay W. College menʼs health: an overview and a call to action. J Am Coll Health. 1998;46(6):279–290. 3. Bates LM, Hankivsky O, Springer KW. Gender and health inequities: a comment on the final report of the WHO Commission on the Social Determinants of Health. Soc Sci Med. 2009;69:1002–1004. 4. Eisler RM, Hersen M. Handbook of Gender, Culture, and Health. Mahwah, NJ: Erlbaum; 2000. 5. Lent B, Bishop JE. Sense and sensitivity: developing a gender issues perspective in medical education. J Womens Health. 1998;7(3):339–342. 6. Hankivsky O. Womenʼs health, menʼs health, and gender and health: implications of intersectionality. Soc Sci Med. 2012;74:1712–1720. 7. Turshen M. Gender and health (commentary). J Public Health Policy. 2007;28(3):319–321. 8. Doull M, Runnels VE, Tudiver S, Boscoe M. Appraising the evidence: applying Sex- and Gender-based Analysis (SGBA) to Cochrane systematic reviews on cardiovascular diseases. J Womens Health. 2008;19(5):997–1003. 9. Bonhomme JJ. Menʼs health: key to healthier women, children, and communities. Am J Mens Health. 2007;1(4): 35–338. 10. Morgan LA. Economic well-being following marital termination: a comparison of widowed and divorced women. J Fam Issues. 1989;10(1):86–101. 11. Bonhomme JJ. Menʼs health: impact on women, children and society. J Mens Health Gend. 2007;4(2):124–130. 12. Murphy SL, Xu J, Kochanek KD. Deaths: final data for 2010. Natl Vital Stat Rep. 2013;61:1–117. 13. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e46–e215. (Accessed January 6, 2014) 〈http://circ.ahajournals. org/content/121/7/e46.extract〉. 14. Willcox BJ, He Q, Chen R, et al. Midlife risk factors and healthy survival in men. J Am Med Assoc. 2006;296: 2343–2350. 15. National Research Council. Explaining Divergent Levels of Longevity in High-Income Countries. Washington, DC: The National Academies Press, 2011. 16. Evans J, Frank B, Oliffe JL, Gregory D. Health, illness, men and masculinities (HIMM): a theoretical framework for understanding men and their health. J Mens Health. 2011;8(1):7–15. 17. Worrall-Carter L, Ski C, Scruth E, Campbell M, Page K. Systematic review of cardiovascular disease in women: assessing the risk. Nurse Health Sci. 2011;13:529–535. 18. Garfield CF, Isacco A, Rogers TE. A review of menʼs health and masculinity. Am J Lifestyle Med. 2008;2:474. 19. Clancy CM. Real men wear gowns—and help their health. Agency for Healthcare Research and Quality website. 〈http://www.ahrq.gov/news/columns/navigating-the-health-care-system/050608.html〉; Updated May 2008 Accessed January 6, 2014. 20. Sturdee DW, Pines Aon behalf of the International Menopause Society Writing Group. Updated IMS recommendations on postmenopausal hormone therapy and preventive strategies for midlife health. Climacteric. 2011;14: 302–320. 21. Ruige JB, Ouwens DM, Kaufman JM. Beneficial and adverse effects of testosterone on the cardiovascular system in men. J Clin Endocrinol Metab. 2013;98(11):4300–4310. 22. Siegel R, Naishadham D, Jemal Ahmedin. Cancer statistics, 2012. CA Cancer J Clin. 2012;62:10–29. 23. Wood JT. Gendered Lives: Communication, Gender, and Culture. 8th ed. Boston: Wadsworth; 2009. 24. Lutfiyya MN, Lipsky MS, Cannon M. An argument for male gender as a root cause or fundamental social determinant of health.
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25. Kraemer S. The fragile male. Br Med J. 2000;321(7276):1609–1612. 26. Skuse D, James RS, Bishop DVM, et al. Evidence from Turnerʼs syndrome of an imprinted X-linked locus affecting cognitive function. Nature. 1997;387:705–708. 27. National Institute on Aging. Action Plan for Aging Research: Strategic Plan for Fiscal Years 2001-2005. Washington DC: NIH publication; 2001; p 01–4951.
