Men's health: what's a GP to do?

The health of men has received greater attention in recent years — partly because they have a higher risk of certain health problems and injury, but also because of the way in which men use (or do not use) health services. We present a generalist approach to men’s health, focusing on their most important health problems and what general practitioners can do about them. Of course, men are not a homogeneous group, and it is important to consider the influence that other factors, including socioeconomic status, ethnicity and where they live, have on their health risks and health service use.

Men’s health is much more than reproductive health. The major burden of disease in Australian men is attributable to cardiovascular disease, cancer and injury, and, for many conditions, men have higher incidences and higher age-standardised death rates than women.1

Despite declines in cardiovascular disease mortality, ischaemic heart disease is still common and much more prevalent in men than in women aged 40–74 years, with men being twice as likely to die from it. This is partly because of the greater contribution of smoking, alcohol intake, overweight, elevated cholesterol levels and type 2 diabetes to their cardiovascular risk. Indigenous men are particularly vulnerable, having 2.6 times the risk of dying from cardiovascular diseases than non-Indigenous men.2 More generally, men with low socioeconomic status are more likely to develop cardiovascular disease. Hypertension and ischaemic heart disease are particularly prevalent in men, increasing dramatically from the age of 45 years (Box 1).2

Box 1 shows the incidence of and mortality from major cancers affecting men in 2001.3 The dramatic increase in both incidence and mortality from around age 50 is notable. The rate of death from lung cancer in men (23% of cancer deaths) was 2.4 times the rate in women. Prostate cancer accounted for 14% of cancer deaths and the death rate from colorectal cancer (12% of cancer deaths) was 1.6 times the female rate. Melanoma was the third most common cancer and the fourth most common cause of cancer death in men (3.5% of cancer deaths).3 Testicular cancer had a low incidence and mortality rate.

The 2004 age-standardised death rate from accidents and adverse events was 2.5 times higher for males than for females, with a third of injury-related deaths involving men aged 25–44 years. Most of the non-suicide deaths were the result of transport injuries (24.4%) and falls (19.4%).1 This is partly because of the higher risk involved in male-dominated occupations, especially in the building and transport industries (with almost all the occupational deaths involving males). Mortality among young men from road traffic accidents is associated with higher levels of risk-taking behaviour.4

Although the 2004 prevalence of depression was higher in females, the mortality rate from suicide was much higher in males than females in the 15–24-years age group and in the over-65-years age group. It was especially high in rural and remote areas, probably because of the greater availability of more lethal means and higher rates of alcohol misuse.1 Depression may manifest differently in men, especially through somatic symptoms and anger, or risky or uncontrolled behaviour.5

Reproductive and sexual health problems in men are relatively common, especially in those over the age of 40. They include:

• Benign prostatic hypertrophy, affecting 20% of men aged 40–49 years and 40%–50% of those aged over 65 years.6

• Erectile dysfunction, affecting 20% of 40–64-year-olds, increasing to 43% in those aged 65 years or over.7 The cause may be organic and/or psychological. Organic causes are more frequent, especially in middle-aged and older men, most frequently penile vascular disorders, often in association with cardiovascular disease or type 2 diabetes.

• Male hormone disorders (including androgen deficiency), which occur in about one in 200 adult men (although undiagnosed cases may make this an underestimate).8

Logically, the priorities in men’s health should be consistent with the impact of male health problems in the community, provided effective interventions are available. Thus, cardiovascular disease, cancers, injury and depression should receive the most attention, especially among males aged 15–64 years. However, other effective preventive strategies such as immunisation for tetanus (at age 50), influenza (yearly from age 65) and pneumococcal disease (repeated once, 10 years after the first dose) should not be neglected, especially in high-risk patients with chronic illnesses (eg, chronic obstructive pulmonary disease, diabetes, renal disease).9

The principal tasks for GPs in dealing with men’s health problems can be summarised by the 5As approach:10

• Ask about risk factors or early signs of major health problems;

• Assess the level of risk and diagnose as early as possible;

• Advise and motivate patients to lower their risk;

• Assist patients with pharmacological and non-pharmacological therapies;

• Arrange referral and follow-up.

How do we do this in general practice, where men are likely to present with a specific problem that may be unrelated to other potential health problems for which they may have risk factors, or in response to suggestions from their partners? And how do we deal with their reluctance to discuss emotional issues or reproductive health issues?

Incorporating a systematic preventive approach into the consultation involves understanding the whole person in his or her context.11,12 To achieve this understanding involves assessing five components of the patient’s world: (i) present and potential disease; (ii) the patient’s experience of health and illness; (iii) the patient’s potential for health; (iv) the patient’s context; and (v) the patient–doctor relationship. Over time and multiple consultations, the processes of establishing common goals, exploring alternative ways of looking at current practices, and finding and trying new ways of fulfilling personal values, needs, motives and expectations will help men to become more aware of their health, and to be able to play an active role in reducing their risk of disease.

Thus, the first task is to proactively identify and assess health problems and their risk factors in the context of the whole person. The priorities for preventive care will vary across a man’s life cycle (see Box 2). Key areas that should be be assessed are described in Box 3.

Assessment should take into account that each area may have different priority for the individual concerned, depending on the presence of other risk factors or disease. For example, the risk of diabetes increases in patients who are obese or have hypertension. More sensitive issues such as alcohol dependence, mental illness or sexual dysfunction may not be revealed until trust has been established with the doctor.

Prostate and testicular cancer are not specifically identified in this list of preventive assessments. This may be surprising given the importance of prostate cancer in terms of its incidence and mortality. However, while screening (with a prostate-specific antigen test) can detect early-stage prostate cancer, there are problems with the accuracy of the test. There is also insufficient evidence that screening can reduce mortality, and screening, investigating and treating early prostate cancer is associated with significant risk of erectile dysfunction and urinary incontinence.14 Similarly, there is insufficient evidence to support screening for testicular cancer. However, when men present with concerns about prostate or testicular cancer, their concerns should be respected and they should be informed of the potential benefits, risks and uncertainties of screening.13

Having assessed some of the more important health problems in men, the task remains of developing with patients an agreed plan with shared goals to help them make changes to decrease their health risks. For GPs, playing a supportive role is part of the process — listening, empathising and validating changed perspectives through rational discussion.12 Developing a relationship based on trust and shared decision making will help to enhance men’s sense of self-efficacy, and is critically important if GPs are to overcome some of the denial or anxiety that some male patients have about their health. Beginning with non-pharmacological interventions that patients can control themselves may be an important first step in reducing feelings of vulnerability or loss of control. Motivational interviewing techniques that challenge the patient’s thinking and expectations of the consultation (such as asking them to list the good things about a health risk behaviour as well as the bad) may be especially useful.15 The effectiveness of this strategy varies according to the problem, but it has produced changes in alcohol and diet behaviour in over 50% of “unsure” patients in trials.16 An example of how such techniques might be applied is provided in the case study in Box 4.

Of course, if problems are identified, both follow-up and referral may be required. Engaging the patient in planning referral or follow-up visits and discussing the expected outcomes are important to help achieve goals.17

Although they suffer higher premature mortality rates than women, males aged 15–64 years are less likely to use GPs’ services than women.18 Almost one in four males hasn’t seen a doctor in 12 months (compared with one in 10 females), with much lower rates of consultation in males than females aged between 15 and 44 years.19 One of the main reasons is a reluctance to seek help until symptoms become undeniable.20 This militates against a proactive approach to managing risk and early detection, which may be compounded by not having a previous relationship with a GP. Promoting the importance of early detection and help-seeking behaviour through practice newsletters may help. Metaphors such as looking after their bodies in the same way that they look after their motor cars may help some men to see the value in preventive health care interventions.21,22 They are also very likely to be influenced by partners, both in seeking help and in changing their behaviour as a result.23

While there are no differences in rates of prescription per general practice encounter with males or females, females are more likely to have longer consultations.24 This may be associated with the reluctance of male patients to signal the need for a comprehensive “check-up” and their lack of familiarity with general practice. Information in the waiting room highlighting the importance of a regular health check, encouraging longer appointments for patients who have not had a check-up for a number of years or who have multiple problems, and providing practice newsletters with specific information about men’s health may help to encourage men to present more regularly to the GP. The effectiveness of establishing special clinic sessions for men’s health check-ups has not been established.25 It may also be useful to engage men’s partners in supporting them to undertake preventive health care.26

Of course, we GPs ourselves may be reluctant or embarrassed to raise sensitive, emotional or reproductive health issues, especially if the patient is unfamiliar to us or reluctant to talk about their problems.27 This may be compounded by concerns about lack of time, or our own adequacy in dealing with the problems uncovered. Obviously this requires reflection and education, but may be aided by prompts such as men’s health questionnaires for patients to complete in the waiting room. Box 5 summarises some specific strategies GPs can use to make it easier for men to seek optimal health care.

It is important to realise that, even having overcome the hurdle of coming to the GP, men from low socioeconomic groups tend to experience barriers to preventive care. Men from low socioeconomic groups, including Indigenous patients, are less likely to receive preventive care such as colorectal cancer screening even after they present to general practice.33 The reasons for this are not clear, but relate in part to the lower supply of GPs and shorter consultations in general practices in low socioeconomic areas.34 Strategies to overcome this include increasing the supply and use of other health care professionals in general practices in disadvantaged areas, specific incentives to support GPs to provide preventive care in these areas, and population-based measures, such as taking health screening to workplaces.

General practice can play an effective role in identifying, assessing and managing some of the major health problems faced by men. Priorities should be set according to the impact of the conditions being focused on, the availability of effective interventions and the patient’s own views. Barriers to effective preventive care for men in general practice include not only barriers to patients attending the practice but also barriers to GPs providing the best care — especially for patients from low socioeconomic backgrounds who have an increased burden of disease. Overcoming these barriers to men’s health requires specific attention at both the practice and policy levels. Preventive care will certainly be greatly aided by the introduction of a Medicare item number for a routine comprehensive health assessment at age 45–55 years for all men, as this group is both less likely to present for preventive care and more likely to be at risk of disease.

1 Prevalence of common diseases2 and incidence of and mortality from selected cancers affecting men3