Men's Health

Opening up

Author: Amanda Lyons

While cultural stereotypes of masculinity are changing, challenges to accessing healthcare remain for GPs and their male patients. 

The phrase ‘men’s health’ tends to bring to mind a fairly narrow range of health issues for many people.

‘We often have a stereotypical view of men’s health, which is that it’s about prostate cancer and sports injuries,’ Prof Mark Harris, Professor of General Practice at the University of New South Wales and a GP with an interest in chronic illness prevention, told Good Practice.

Men’s health encompasses a far wider range of concerns, however. The biggest indicator of these concerns is the continuing life expectancy gap between men and women in Australia, with men’s average lifespan running to 80 years, while the average woman can expect to reach the age of 84.¹ In addition, men are more likely than women to die of lung cancer, cirrhosis and other liver diseases, and ischaemic heart disease.² Men also die of suicide at a rate three times higher than that of women.²

Despite these figures, Dr Greg Malcher, a GP with more than two decades’ experience in the field of men’s health, believes he has seen some positive change in recent years.

‘My perception is that a fair proportion of men are taking more responsibility for their health,’ he told Good Practice. ‘That’s quite a good outcome – if men are seeking to make the changes themselves.’

But while social perspectives of masculinity are slowly changing, stereotypes that can affect men’s decisions regarding accessing healthcare still persist.

‘Men can be very stoic, which means they don’t tend to ask for help,’ Dr James Antoniadis, GP and psychodynamic psychotherapist, told Good Practice.

This stoic attitude among male patients can present definite challenges and concerns regarding their healthcare, but GPs can be key in meeting these challenges.

‘I think primary healthcare teams have got a really good capacity to make a genuine difference in men’s health,’ Dr Malcher said. 

Physical health

While the life expectancy gap between men and women has been persistent, it is not immutable and has actually narrowed in Australia over the past few decades.¹

This change in life expectancy and the reasons behind it are big news for men’s health. Six of the 10 most common risk factors that contribute to worldwide burden of disease – tobacco smoking, alcohol use, high blood pressure, a diet low in fruits, a diet high in sodium, and high-fasting plasma glucose – are represented more strongly in men than in women.³

Given modifications of lifestyle and behaviour can reduce the prevalence and impact of these risk factors, primary care’s emphasis on preventive health makes it crucial in efforts to address them.⁴ Unfortunately, despite their greater risks, men are less likely than women to visit their GP, and when they do present it is usually for acute illnesses, injuries and psychological issues.⁵

Prof Harris believes such reluctance on the part of men means GPs can benefit from adopting an opportunistic approach to treatment when dealing with this patient population.

‘The idea is to really seize the opportunity when they present for something else – such as a certificate for work – in order to do that preventive health check and try to engage with them around things like diet, physical activity and weight,’ he said.

This is particularly important as men reach middle age, specifically 45 years and older, which Prof Harris describes as a crucial intervention point to prevent men from experiencing chronic disease later on in life. An example of a significant issue that can occur in men at this life stage is weight gain, a potential risk factor for diabetes, cardiovascular disease (CVD) and stroke.

Prof Harris has found that when it comes to this issue, male patients often focus on the action-oriented solution of physical activity, while diet, a vital part of the equation, is far less likely to receive their attention.

‘Exercise is an important part of fitness and reducing your cardiovascular risk, and helps to reduce [the likelihood of] putting weight back on, but you’ve got to do a huge amount of exercise to burn enough energy to lose weight,’ Prof Harris said.

‘It’s mostly about diet, controlling your appetite and reducing any weight gain. But, in a recent report by the CSIRO [Commonwealth Scientific and Industrial Research Organisation] on the composition of the Australian diet, only 15% of men in the survey were eating sufficient fruit and vegetables.’⁶

Prof Harris believes that to tackle this issue, it is important for GPs to be proactive with male patients and use techniques to increase health literacy.

‘Men are unlikely to come and say, “I want to lose weight”,’ he said. ‘They might be more receptive to having their blood pressure taken, but less receptive to going on medication for the rest of their life. So it’s important to check and not make assumptions that patients will do what we say and be compliant. 

‘So taking a health literacy teach-back approach of saying, “Can you tell me back what we’ve just talked about?”, and checking that patients have understood is helpful because there may be a bit of reluctance. They often just want to get out the door.’ 

Mental health

Unlike physical risk factors, mental health may not always present clearly or be easily measurable, but it remains a key health issue for many male patients. Dr Antoniadis believes communicating poorly about how they feel can lead to struggles with mental health for many men.

‘[Stereotypes of masculinity] can be a big contributor to stoicism – a belief that men are not meant to talk about their feelings, otherwise they’re not a real man,’ he said.

‘This can result in men withdrawing rather than seeking help and can lead to a slippery slope, sometimes suicide.’

Mental health issues can also result in problems with physical health.

‘These men are often otherwise healthy but become unhealthy because of their difficulties communicating, particularly if they turn to drugs and alcohol as a way of trying to deal with emotions,’ Dr Antoniadis said.

According to Dr Antoniadis, practitioners may sometimes inadvertently collude with these types of stoic behaviour out of an underlying fear that trying to discuss men’s feelings may worsen their mental health, and perhaps even lead to thoughts of suicide. He believes, however, that this fear is unfounded.

‘Suicidality has to do with despair and that’s mostly about not having solutions,’ he said.

‘I think if we can show patients they can open up, work things through and feel them safely, they’ll feel less despair and be less likely to suicide.’

Like Prof Harris, Dr Antoniadis recommends a proactive approach in consultations with male patients. 

‘I think it’s helpful for the GP to be a bit like a mechanic,’ he said. ‘When someone brings in the car for a service, it won’t usually have a lot of problems, but the mechanic will go and look and check the oil, the water and the brake pads, and see whether the car needs major work.

‘It’s one thing for the patient to come along and say, “I’m depressed”, but it’s important we don’t just rely on that and look out for warning signs.’

Dr Antoniadis has found a number of such warning signs of which GPs can be aware during consultations with male patients.

‘Drinking, anger, violent outbursts, withdrawal, such as pulling away from social engagements or clubs or sport,’ he said. ‘Also, if they don’t have a balance, if their life is too much around work and they don’t have friendship groups, or similar sort of things.’

When male patients do present with depression, Dr Antoniadis has found that, in contrast to when they are experiencing physiological issues, they are often more comfortable seeking medication than therapy.

‘I think men tend to think that [taking drugs] is more acceptable than having a trauma or something they need to talk through,’ he said.

But medication may not always be a better solution than therapy, especially in the long term.

‘Many male patients get to me after a long road of having been on antidepressants for many years and realising that they’re not the answer,’ Dr Antoniadis said. ‘Getting them to open up is difficult, because they’re often afraid that if they open the door to grieving, they’ll never stop.

‘But, usually, I see that once people open up, these things can resolve fairly quickly.’

Dr Antoniadis has a vivid analogy for such patients.

‘It’s easy to smash a rock with a sledgehammer, but it’s impossible to smash a pillow with a sledgehammer,’ he said. ‘A lot of men think that by being tough and hard they are making themselves more resilient. In fact, it’s quite the opposite; they are making themselves more fragile.

‘I think that, as GPs, we need to get it out there that hardening yourself up is actually a pathway to breakdown.’ 

Fatherhood

Another area in which social conventions of masculinity are rapidly changing is around the role of fathers within the family.

‘I think there’s a much greater expectation for younger men to be more involved in the health aspects of their children’s lives, and their children’s lives more generally,’ Dr Malcher said.

However, while many fathers’ roles have expanded, they are not necessarily able to access as much support as mothers, such as regularly scheduled doctor’s visits or perinatal mental health care, even while many find themselves experiencing similar problems.

‘There’s an issue of isolation that’s very common in fathers, as they’re often busy trying to provide and often quite cut off from their previous outlets, as well,’ Dr Matthew Roberts, a perinatal psychiatrist with a special interest in fathers’ mental health, told Good Practice.

Postnatal depression can affect fathers as well as mothers, either directly or as supporting partners, and Dr Roberts believes that providing fathers with more help is crucial for their own health and the health of the family as a whole.

‘It was quite common in my practice that the women would come along and say, “I think I’m depressed, but I also think my partner is depressed and he won’t get help”,’ Dr Roberts said.

‘If we don’t recognise that fathers are important, then we don’t recognise that their mental health matters as much.’

For men who are struggling with parenthood, Dr Roberts recommends a ‘strength-based engagement’ approach. This technique involves opening a discussion with a positive experience, which can then enable patient and doctor to access other aspects of parenting that may be more difficult.

‘It’s a bridge into what might be more difficult to talk about,’ Dr Roberts said. ‘We start with, “Isn’t it wonderful the way your daughter lights up when you get home? That’s great”.

‘Then, “Can you also tell me, what’s been the hardest thing [about being a father]?”’

Fatherhood can also provide an extra motivator for men to take care of their own health.

‘If he won’t consider his mental health and his physical health for himself, he’ll often consider it for his child,’ Dr Roberts said. ‘He might not have that extra drink in the evening. He might get off the tram and walk the extra 500 metres to work.

‘All those little things that make a difference in reducing preventable and stress-related illness, if men think of their kids and say, “I want to be a grandad one day. I want to see my kids grow up, and I want to see my kid’s kids get older. I want to be in it for the long run”.’

 

References

1. Australian Institute of Health and Welfare. Life expectancy. Canberra: AIHW. Available at www.aihw.gov.au/deaths/life-expectancy [Accessed 2 May 2017].
2. Australian Bureau of Statistics. Causes of death, Australia, 2015. Canberra: ABS, 2016. Available at www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2015~Main%20Features~Australia’s%20leading%20causes%20of%20death,%202015~3 [Accessed 2 May 2017].
3. Lim S, Vos T, Flaxman A, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380(9859):2224–60.
4. Australian Institute of Health and Welfare. Preventing and treating ill health. Canberra: AIHW, 2014. Available at www.aihw.gov.au/australias-health/2014/preventing-ill-health [Accessed 2 May 2017].
5. Bayram C, Valenti L, Britt H. General practice encounters with men. Aust Fam Physician 2016;45(4):171–74.
6. Hendrie G, Noakes M. Fruit, vegetables and diet score. Canberra: CSIRO, 2017.