Men's health

Results of two new trials will drive further research into the “andropause hypothesis” Two important research articles, published in a recent issue of the New England Journal of Medicine (NEJM), bracket the topic of prescribing testosterone for older men.1,2 Testosterone treatment for older men is based on considering male ageing as analogous to either menopause or pathologically based hypogonadism. The former is a false analogy — menopause has a unique natural history featuring complete failure of female reproductive hormones in mid-adult life, contrary to all other human hormonal systems which decline gradually and modestly with ageing. The latter is based on the superficial resemblance of non-specific symptoms in ageing men with those of most hormonal deficiencies or chronic diseases. This “andropause hypothesis” is not well substantiated, with the 2004 United States Institute of Medicine’s authoritative review3 concluding that available evidence did not justify a major study of testosterone replacement in older men comparable to the Women’s Health Initiative (WHI) study of oestrogen replacement in menopause. Nevertheless, the past two decades have seen an approximately 20-fold increase in testosterone prescribing despite no proven new indications. This is largely confined to the US, with minimal changes in Australia4 and other regional markets; however, that bandwagon could certainly be viewed as having left the station, fuelled by heavy direct-to-public drug advertising in the US. One of the NEJM articles reports the European Male Ageing Study (EMAS) — a large observational study of male ageing involving more than 3300 men aged 40 years and over from population-based sources in eight European cities, and the European counterpart to the seminal Massachusetts Male Ageing Study (MMAS).1 The EMAS evaluated the relationship of non-specific physical and mental symptoms to serum testosterone levels, an approach originating from clinic-based studies5,6 and used in the analysis of the population-based data of the MMAS,7 to which the EMAS adds a large sample size. Crucially, the statistical power of this study can neither overcome its logical flaws nor the inconsistency between its findings and conclusions. After noting statistically insignificant associations of low testosterone levels with clinically relevant physical or psychological features, the researchers focus on three sexual symptoms — erectile dysfunction, frequency of morning erections and sexual desire. Each symptom shows a weak association with serum testosterone levels, featuring a shallow breakpoint (at levels of 8–11 nmol/L) together with high false-positive and negative rates. Although the only consistent significant association is between all three sexual symptoms and a serum testosterone level threshold of 8 nmol/L, the researchers inexplicably propose a “definition” of “late-onset hypogonadism” requiring the presence of all three sexual symptoms plus a serum testosterone level of less than 11 nmol/L. The proposal is further undermined by the study’s findings that all the associations of the three sexual symptoms with low serum testosterone levels are nullified by adjustment for age, obesity and co-existing illnesses, indicating that they are attributable to confounding rather than any authentic correlation. The study’s authors, in effect, overinterpret cross-sectional data to imply causality. Such quasi-longitudinal interpretation is especially unsafe when blood test results are not steady for the population. This is the case for serum testosterone, with evidence of downward temporal trends in America and Europe,8 probably due to progressive population increases in obesity. The impact of implied causality should not be underestimated — despite its ritual caveats against testosterone prescribing, this article is likely to encourage more overuse of testosterone. The article resonates with past mistakes, notably the decades of excessive oestrogen prescribing, encouraged by overinterpreted observational studies and curbed only by the first placebo-controlled randomised trial of hormonal replacement therapy. Lest we sleepwalk down that same path, let us hope that it will not take decades before the “andropause hypothesis” undergoes rigorous testing. The second NEJM article reports the early termination of a randomised, placebo-controlled clinical trial for excess adverse cardiovascular effects associated with testosterone supplementation.2 The study evaluated the somatic benefits of 6 months of daily use of testosterone gel in frail men over 65 years with low serum testosterone levels. As expected, this population had a high prevalence of cardiovascular disease, which would explain their low serum testosterone levels as a non-specific effect of chronic illness. The progressive excess of adverse cardiovascular effects in testosterone-treated men (23 men receiving testosterone v 5 receiving placebo in the trial’s total of 209 men) was unexpected but persisted despite the use of various definitions of adverse cardiovascular events (the original definition was broad and included unexplained syncope and peripheral oedema). As the study design was conventional in regard to testosterone dosage, titration and monitoring, these findings show a low cardiovascular safety margin for testosterone supplementation in frail older men. They differ from the findings of previous comparable placebo-controlled studies of testosterone use in older men, which reported no excess cardiovascular events,9 even in 12-month studies of men with cardiac failure.10 Nevertheless, these adverse findings cannot be considered surprising given the earlier onset and greater severity of cardiovascular disease in men, together with the refutation of the long-dominant hypothesis that oestrogen provides women with a degree of cardiovascular protection.11 As this second article2 highlights, the effects of a treatment that excessively increases risk for the most common cause of death — cardiovascular disease — overwhelm even substantial improvements in less common or non-fatal disorders. Hence, the study’s finding of a benefit (improved limb muscular strength) was overshadowed by adverse cardiovascular profiles, as has happened with other treatments, such as the WHI’s reductions in bone fractures and colorectal cancer, and the highly effective, gastric-sparing cyclooxygenase-2 (COX-2) inhibiting analgesics and the oral antidiabetic glitazones. A corollary is that overinterpreting the regular association of low serum testosterone in men with cardiovascular disease as a risk factor that might be ameliorated — rather than as a consequence — led to a misplaced focus on prostate cancer as the major risk of testosterone treatment in older men. Taken together, these two studies can be construed as pressing the accelerator and the brakes at the same time on testosterone prescribing for older men . . . with probably the usual effect of spinning wheels. However, several reflections arise for Australian clinical practice. First, Australia’s national guidelines for testosterone use,12 developed in 2000 and adopted by the Pharmaceutical Benefits Scheme as the criteria for subsidised testosterone prescriptions, are vindicated. They aim to restrict testosterone prescribing for age-related androgen deficiency without hindering it for pathologically based androgen deficiency. European and US guidelines (produced in 2005 and 2006, respectively) were republished recently, essentially unchanged.13,14 The northern hemisphere guidelines, in contrast to Australia’s, blur the distinction between pathologically based and age-related androgen deficiency, loosen the diagnostic criteria and lack regulatory force. Thus they minimise the diagnostic hurdle, leading to the perverse outcome of potentially encouraging rather than deterring unproven overuse of testosterone. Second, the EMAS definition of “late-onset hypogonadism” is not suitable for implementation in practice. Findings of the MMAS confirm clinical experience and are reflected in all clinical guidelines:12-14 serial serum testosterone levels in older men are sufficiently variable7 to require the results of at least two blood samples taken weeks apart to establish a sustained low level of serum testosterone. Hence, a definition reliant on a sample of single testosterone measurements is likely to be highly error-prone, due to regression to the mean and other sources of variability. It also relies on testosterone measurements by mass spectrometry, a superior technology not yet available in Australian pathology laboratories despite recognised limitations of testosterone immunoassays.15 Similarly, the so-called “free” testosterone variable, also used in the study but not recommended, is calculated by an inaccurate formula unsuitable for individual diagnosis.16 Third, reflection on these two NEJM articles makes evident the need to reinforce bans on direct-to-public advertising of testosterone supplementation. This critical protection depends on industry self-regulation. Without this protection, an avalanche of misguided testosterone prescribing awaits us, analogous to the massive, unregulated marketing of non-proprietary impotence drugs advertised on billboards and in the media, apparently beyond regulatory reach. Finally, testosterone prescribing for older men is best restricted to clinical trials where ethical oversight ensures appropriate design and warnings to participants. Age alone may not prove a valid indication, but this should not limit essential further research within the framework of placebo-controlled clinical trials aiming to define the benefits and risks of testosterone use in patients with the comorbidities of ageing, such as obesity, diabetes, metabolic syndrome and other chronic conditions.

David J Handelsman MB BS, FRACP, PhD

Objective: To determine the proportion of older Australian men who meet the Pharmaceutical Benefits Scheme (PBS) criteria for osteoporosis treatment and are receiving effective treatment.Design and setting: A population-based, cross-sectional analysis of the baseline phase of the Concord Health and Ageing in Men Project (CHAMP), a large epidemiological study focusing on the health of older men. Data were collected through questionnaires and clinical assessments. Bone mineral density (BMD) of the hip and spine was measured by dual x-ray absorptiometry (DXA). Vertebral deformities were identified from DXA lateral vertebral fracture assessment images. The study was conducted at Concord Hospital, Sydney, between January 2005 and May 2007.Participants: 1705 community-dwelling men aged 70 years or over from a defined geographical region around Concord Hospital.Main outcome measures: Prevalence of vertebral deformities; previous minimal trauma fractures; BMD T-scores ≤ – 3; falls in the previous 12 months; use of bisphosphonates and calcium and vitamin D supplements.Results: Of the 1705 men seen at baseline, 1626 completed all DXA scans and 401 (25%) met one or more of the PBS criteria for osteoporosis treatment. Ninety per cent of the men who met the PBS criteria were unaware they had osteoporosis. Of the men eligible for PBS-subsidised treatment, 39 (10%) reported use of a bisphosphonate, 56 (14%) had taken calcium supplements, and 28 (7%) had taken vitamin D supplements. Only three men had taken calcium, vitamin D and bisphosphonates in combination.Conclusions: Despite a high prevalence of osteoporosis in elderly Australian men, awareness, diagnosis and treatment of the condition remain very low.

Kerrin Bleicher BSc, PostGradDipPhysio · Vasi Naganathan MB BS, FRACP, PhD · Robert G Cumming MB BS, MPH, PhD · Markus J Seibel MD, FRACP, PhD · Philip N Sambrook MD, LLB, FRACP · Fiona M Blyth MPH, FAFPHM, PhD · David G Le Couteur FRACP, GradCertEd, PhD · David J Handelsman MB BS, FRACP, PhD · Louise M Waite MB BS, FRACP, PhD · Helen M Creasey MB BS, FRACP

To the Editor: Costello and Murphy’s lament1 about the discoverer of prostate-specific antigen (PSA), Richard Ablin, describing PSA testing as a “hugely expensive public health disaster”2 contains several egregious claims that require correction. They write that “since the introduction of PSA testing in the 1980s, we have seen a 25% reduction in mortality” from the disease. Thirty years ago (in 1980), before PSA testing was possible, the age-adjusted mortality rate from prostate cancer in Australia was 33.4/100 000. In 2007, it was 31.0/100 000, a decline of 7.2%. Over the same period, prostate cancer incidence rose 110%, from 80.8/100 000 to 170/100 000,3 thanks to the aggressive promotion of PSA testing. Recent New South Wales data show that 3 years after radical prostatectomy, 77.4% of men are impotent and 12.3% have urinary incontinence, compared with 22.3% and 1.0%, respectively, of controls.4 Many of these men are, to use Costello and Murphy’s word, “overtreated”1 — they underwent unnecessary surgery and now live with the consequences. From a 2009 European trial,5 the take-home message for a man being tested today is: There is a one in 50 chance that, in 2019 or later, he will be spared death from a cancer that would otherwise have killed him. And there is a 49 in 50 chance that he will have been treated unnecessarily for a cancer that was never a threat to his life.6 This is what Ablin called a public health disaster. With reference to this European trial,5 Costello and Murphy claim that “PSA testing has led to greatly reduced mortality”. This “great reduction” was from 4.2 to 3.3 deaths per 10 000 person-years. Costello and Murphy propose that “those with a PSA level well below the median for men in their 40s . . . (the vast majority at this stage) could be reassured . . .”, but below the median lie half the men, not the vast majority. This policy would mean that the other half of men aged 40 (not the small minority, as implied by Costello and Murphy) would be above the threshold. They would not be reassured; presumably they would be offered more frequent testing and follow-up. Labelling half the population of men aged 40 as higher risk has enormous implications for the men (anxiety, inconvenience, cost) and the health system that would be called on to fund more appointments and tests. Such a proposal does indeed sound like a public health disaster.

Simon Chapman · Alexandra Barratt

In reply: Chapman and Barratt’s statements about prostate cancer highlight the dramatic difference between the views of sociologists and the views of clinicians who deal daily with the burden of prostate cancer diagnosis, treatment and mortality. In 1851, prostate cancer was considered a rare disease.1 Chapman and Barratt’s views seem to remain consistent with this thesis. However, in 2010 in Australia, prostate cancer is the most common cancer diagnosed in men, and the most common cancer causing death in men. Our own data do not support the contention that treatment for prostate cancer produces dreadful outcomes. We can reassure men that there is a high likelihood of cure through early treatment for prostate cancer, with a less than 5% chance of becoming incontinent and a 70% chance of retaining erectile function.2 Clearly, Chapman and Barratt have not taken into account a recently reported Swedish study which showed that in 20 000 men randomly allocated to prostate-specific antigen (PSA) screening or a control group between 1994 and 2008, there was a 50% reduction in mortality from prostate cancer for men in the screened arm.3 The numbers needed to screen (293) and treat (12) from this study are almost exactly the same as those from breast cancer screening studies. We repeat our recommendation for the early use of a single PSA test4 in men aged in their 40s. This is most beneficial because the background noise from benign prostatic hyperplasia development does not occur, and PSA level is very discriminatory for detecting those who go on to develop significant prostate cancer.

Anthony J Costello · Declan Murphy

Evidence is accruing of associations between male reproductive health disorders and chronic diseases such as coronary heart disease and type 2 diabetes. The links between reproductive health and general health are under-recognised by medical practitioners and the general public. Windows of opportunity exist for a more holistic approach to men’s health when men present with reproductive health symptoms (such as erectile dysfunction) or the reproductive implications of chronic disease are recognised. Further men’s health research is needed in Australia to guide policy, innovative health promotion, and clinical practice.

Carol A Holden PhD · Carolyn A Allan MB BS(Hons), PhD, DRCOG(UK), FRACP · Robert I McLachlan MB BS, FRACP, PhD

The real man’s tool box. A DIY health manual for men. Tammy Farrell. Sydney: Hachette, 2009 (294 pp). ISBN 978 0 7336 2394 3 Written by a registered nurse and nutritionist, The real man’s tool box aims to educate the average bloke with humour, vignettes and sound advice. The book covers common areas of men’s health, with an emphasis on cardiovascular, gastrointestinal, prostate, mental, and genital health. Given the author’s background in nutrition it is not surprising that this subject also has significant emphasis. Some less commonly discussed topics are covered, such as the Men’s Shed movement and “secret women’s business”. The real man’s toolbox fits into the “self-help books for men” genre which includes: Every man by Derek Lllewellyn-Jones, Men’s health by Ian Hamilton Craig, Man maintenance by Jill Margo and The M factor by Andrew Pattison. Its arrival is timely and it’s probably the easiest read in this series. The book has drawn upon many reputable sources for its information, including the Heart Foundation, beyondblue, Cancer Council and Diabetes Australia. It has an excellent bibliography of web-based references and a substantial glossary. The section on “Your personal logbook” is a lay version of the Royal Australian College of General Practitioners’ “Red book”. The information is up to date and accurate. The target audience is the health-illiterate male, especially the ones interested in cars. The author has chosen basic, conversational-style language with plenty of anecdotes and case studies. Simple anatomy and physiology is covered using slang, often with plumbing or mechanical metaphors. It is likely that health professionals might find this book rather hackneyed, containing too many lists and prescriptive advice. However, the target audience male patients with minimum health knowledge should benefit by gaining a practical knowledge of their bodies and how doctors could help them “get their body serviced”.

Nicholas B Cooling

Objective: To describe the prevalence of depressive symptoms in older male Italian-born Australian immigrants.Design, participants and setting: Cross-sectional study of 335 Italian-born and 849 Australian-born men aged 70 years and over who completed written questionnaires and were interviewed in the baseline phase of the Concord Health and Ageing in Men Project (CHAMP).Main outcome measures: Depressive symptoms assessed by the short (15-item) form of the Geriatric Depression Scale; associations between depressive symptoms and country of birth.Results: The prevalence of depressive symptoms in Italian-born men was 18%, almost twice the prevalence of 10% in Australian-born men (odds ratio [OR], 1.9; 95% CI, 1.2–3.0). After adjusting for socioeconomic and health factors, the relationship between country of birth and depressive symptoms was attenuated and no longer statistically significant (OR, 1.7; 95% CI, 0.9–3.0). The strongest confounders of the relationship between country of birth and depressive symptoms were source of income and satisfaction with social support.Conclusion: Male Italian-born immigrants aged over 70 years report more depressive symptoms than their Australian-born counterparts. This association appears to be explained by increased reliance on a government pension as the sole source of income and lower satisfaction with social support among Italian-born men. However, these findings need to be confirmed longitudinally.

Fiona F Stanaway MB BS, MPH · Robert G Cumming MB BS, MPH, PhD · Vasi Naganathan FRACP, MMed(Clin Epi), PhD, Grad Cert Med Ed · Fiona M Blyth MPH, FAFPHM, PhD · Helen M Creasey MB BS, FRACP · Louise M Waite MB BS, FRACP, PhD · David J Handelsman MB BS, FRACP, PhD · Markus J Seibel MD, FRACP, PhD

I am an Aboriginal Kuku Yalanjii and Birri Gubba man. My Yalanjii people are from north of Mareeba, near Cairns, and my Birri Gubba connection is in Proserpine, right next to the beautiful Whitsunday Islands. My family grew up in Inala, on the outskirts of Brisbane, where we have lived for over 25 years. I come from a family of eight children. My mother is from Woorabinda and my father is from Proserpine and they are both Aboriginal. I have always heard about Aboriginal and Torres Strait Islander men having heart attacks at a young age and in higher proportions than non-Indigenous men. I have lost a number of uncles from heart disease, through not eating right, hereditary factors, high alcohol consumption and lack of exercise. In terms of my own health, I thought I was fine because I was always physically active, playing rugby league and touch football and being very involved in the community. I would never have believed it possible that at 34 years of age I could suffer a heart attack. I am sharing this story with other Aboriginal and Torres Strait Islander people around Australia in the hope that it will make some kind of impact on their lives. My story demonstrates how working in the Aboriginal and Torres Strait Islander community can have both a positive and a negative impact on yourself, your family and your community. I started working in the Inala Indigenous Health Service in 2001 as a research assistant and then moved to the role of community health worker. Before this, I’d had no experience in the areas of health or education. The main experience I’d had in community work was as a youth worker with the Queensland Department of Family, Youth and Community Care and as a teacher aide at the Glenala State High School. I’d also had experience as a volunteer coach of a Junior Rugby League side at Inala that has a high proportion of young Aboriginal and Torres Strait Islander people, parents and families involved. Working in the service gave me valuable experience under the guidance of our Aboriginal doctor Noel Hayman and Aboriginal nurse manager Nola White. Together, they gave me the confidence to undertake a Bachelor of Applied Health Science in Indigenous Primary Health Care at the University of Queensland in Brisbane. It took me 5 years to complete the course, while simultaneously juggling commitments to my family, community and employer. All I ever wanted to do was give back to the community that I grew up in, and working at the Inala Indigenous Health Service has given me that opportunity. In the 8 years I have worked at the Health Service, I have been involved in all areas of Indigenous health, including hearing health; drugs and alcohol; health status research; mental health; nutrition; counselling; transport; Indigenous leadership; youth issues; youth and adults incarceration; and health promotion. A major role I shared with my mentor Matilda Bani (Indigenous Service Officer with Centrelink) was coordination of the Inala Aboriginal and Torres Strait Islander Interagency Forum. This forum, which has been going for over 12 years, promotes information-sharing between departments and other agencies working with the Inala Aboriginal and Torres Strait Islander community. Shared Responsibility Agreement: making a differencePerhaps one of the biggest achievements in my life (besides having children) was being involved in establishing a Shared Responsibility Agreement (SRA) between my community and the federal government in 2006 (Box 1). The central aim of the SRA was to improve the health and wellbeing of Aboriginal and Torres Strait Islander men in our community via their engagement in rugby league. Rugby league has been an institution within our community, particularly among Aboriginal and Islander boys and men. For 5 years prior to the SRA, there was no opportunity for men in Inala to play rugby league, due to a lack of activities and sporting programs for Aboriginal and Torres Strait Islander men, and few Aboriginal and Torres Strait Islander men were likely to go outside the community to play rugby league. Without football in the community, few men played sport, and this contributed to many problems such as boredom, poor health, low self-esteem, and high intake of drugs and alcohol — all of which can lead to incarceration. Through conversations with the federal government, I developed a proposal to get a group of respected Aboriginal and Torres Strait Islander men to look at ways of getting our brothers involved in sport, employment and healthy living for themselves and their families. The federal government agreed to fund two open rugby league sides at Inala, on the condition that men in the community participated in health, employment, education and mentoring opportunities within the community. My role as the Community Health Worker was to encourage Aboriginal and Torres Strait Islander men to come to the Inala Indigenous Health Service for adult health assessments, and to participate in other health promotion activities such as the Inala Indigenous Health Calendar (Box 2) and workshops on nutrition and physical activity. The men were also enlisted to participate in mentoring activities, such as coaching, refereeing, volunteering with junior teams, participating in local training and employment initiatives (if they were unemployed), promoting healthy lifestyles, and demonstrating positive behaviour on the sporting field and in the community. Through this process, many local men also participated in training that saw them become qualified referees, coaches and first aid officers. Since being involved with the SRA in Inala, I have seen some great success stories. Seeing other young Aboriginal and Torres Strait Islander men putting their hand up to be involved in rugby league as coaches, referees, first aid officers and volunteers at the club has really built the self-confidence of men in our community. The pressures of community work, family and volunteering: my healthDuring this time, I was so passionate about my work that I forgot who I was. I was doing this as part of my role as Community Health Worker, but was also a volunteer. I was so busy taking care of everyone else that I forgot to take care of myself. I was at the club nearly 7 days a week with the junior and senior teams, feeling constantly stressed, spending a lot of time away from my family, and not taking time out for myself. Because I was always on the go, I was not eating healthily. I just wanted the SRA to succeed and be sustainable, so that Inala Aboriginal and Torres Strait Islander men could be strong, self-reliant, and able to source other avenues such as sponsorship and fundraising. I was also a rugby league player at the time, so I was heavily involved in the game, both on and off the field. Rugby league has always been my passion and, although I would go to games to help with strapping and make sure everything was taken care of, I would often jump on the field and play if the team were short of players. It was towards the end of the 2008 season that I put on the jersey for Inala, like so many times before. But during this particular game, I started experiencing dizziness, came off the field and collapsed. Although I didn’t know it at the time, I had just had a heart attack. Fortunately, the coach of the team (one of my closest friends and a participant in a first aid course delivered under the SRA) and the registered first aid officer kept me alive until an ambulance arrived. It was only their quick actions that saved my life. All I remember is drinking a sports drink and then waking up in the ambulance. When I asked the ambulance officer if I had been knocked out on the field, he told me I’d had a cardiac arrest and said that, if it wasn’t for the coach and first aid officer, I wouldn’t be alive. Since then, I have had three operations on my heart and am now fitted with a defibrillator in my chest in case a similar episode happens again. At 34 years of age, I am very lucky to be alive, and to this day I feel enormous gratitude to the coach and first aid officer to whom I owe my life. There is an irony in the fact that the very thing that caused so much stress in my life was also the very thing that led to my life being saved. My illness also made a big impact on the Inala Aboriginal and Torres Strait Islander community in the south of Brisbane. There has been an increase in the number of people attending the Inala Indigenous Health Service, and the number of health checks has doubled. Many Aboriginal and Torres Strait Islander people aged 35 years and over are now attending the health service. I’m glad that some good has come out of my heart attack, not only for me and my family, but also for the community as a whole. It has changed my life dramatically — I thought I was OK, and then all of a sudden my whole life was turned upside down. Lessons I have learntAfter having all the operations and undergoing mainstream cardiac rehabilitation at a hospital in Brisbane, I started to get my confidence up with doing exercise such as walking and playing tennis and doing things around the house with my family. Back at work a month after having surgery, I am slowly easing my way back into work, eating more healthily, and getting lectures from family and community members about taking it easy in the community. I am doing OK now and just taking life one day at a time. I am grateful to everyone for their support — my family, my work colleagues and my community. There is much good that is happening, and Inala is continuing to grow and develop into a really great community. After all the operations and cardiac rehabilitation, I decided to get married to my lovely partner of many years. I put the pain behind me to set up a new chapter in the lives of me and my family. At times I don’t think about the heart attack, I just think every day what I can do to get my kids out of the house and do something active. My family is my life, my community is my strength, and my work keeps me active. I share my story with people who are reluctant to go for a heart operation and encourage them to have it done so they will be able to live longer and see their children and grandchildren grow up. Today I am enrolled in a Master of Philosophy by research at the University of Queensland, while working as a research fellow with the Inala Indigenous Health Service and at the George Institute for International Health in Sydney. This will broaden my role in my line of work and will enhance my capacity to be a good role model and mentor for my community. I feel very passionate about working in Indigenous health, especially in the field of heart disease, kidney disease and diabetes, with the support of the Inala Indigenous Health Service and the George Institute’s Kanyini program. Rugby league is continuing to thrive in Inala with the keen involvement of other Aboriginal and Torres Strait Islander men in the community. They have been playing the game for 3 years now without any funding assistance from the federal government. They won a grand final in 2007, were runners-up in 2008 (Box 3), and are very actively involved in community events and the junior club. I am slowly working my way back into the community, having learnt some valuable lessons from this journey — in particular, the need to balance my family commitments, work and volunteering. I have taken a big step back from being involved in the community in a voluntary capacity. Inala is going forward in a very positive way, and members of the next generation are putting up their hand to give back to the community that has supported them. 1 Some of the people involved in our Shared Responsibility Agreement Left to right: John Brady, Tricia Button (State Manager, Indigenous Coordination Centre), Mal Brough (former Minister for Families, Community Services and Indigenous Affairs), Robert Duncan (Junior Club President). 2 Health messages from the Inala Indigenous Health Calendar 3 Inala rugby league team members and young supporters

John P Brady BAppHlthSc

Large-scale randomised controlled trials in Europe and the United States are informing evidence-based clinical advice Population-wide prostate-specific antigen (PSA) screening for prostate cancer is not recommended in Australia, primarily because of the lack of large-scale randomised trial evidence of a beneficial effect on prostate cancer mortality and the known harms of overdiagnosis and unnecessary treatment that may ensue. In spite of this, PSA testing is common; the limited evidence available suggests that more than 50% of Australian men over the age of 50 years have had the test.1,2 In March 2009, the New England Journal of Medicine published the first articles from two large, randomised controlled trials to report on whether screening for PSA reduces the risk of death from prostate cancer.3,4 It was hoped that these long expected — albeit not final — reports from the European Randomized Study of Screening for Prostate Cancer and the prostate cancer component of the US Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (Box) would answer outstanding questions about the efficacy of prostate cancer screening. In the European trial, 162 243 men aged 55–69 years were randomly allocated to receive an invitation to undergo PSA screening about once every 4 years or usual care. After a median of 9 years of follow-up, there were 71% more cases of prostate cancer and a 20% reduction in the risk of death from prostate cancer in those allocated to screening than in those receiving usual care (relative risk [RR], 0.80; 95% CI, 0.65–0.98), but no reduction in overall mortality (RR, 0.99; 95% CI, 0.97–1.02). In the US trial, 76 693 men aged 55–74 years were randomly allocated to receive an annual PSA test for 6 years and an annual digital rectal examination for 4 years, or usual care. After a minimum of 7 years of follow-up, there were 22% more cases of prostate cancer but no reduction in the risk of death from prostate cancer in those randomly allocated to screening compared with usual care (RR, 1.13; 95% CI, 0.75–1.70). The trials have a number of notable differences, including length of follow-up, screening interval, PSA threshold for recommending biopsy, and proportion of the control group screened (Box). Although these differences prevent easy comparison of their results, it is important to note that the relative risks for prostate cancer mortality with screening do not differ significantly between the trials (χ12 = 2.19, P = 0.14), and that the 95% confidence interval about their summary relative risk, estimated using fixed-effects meta-analysis, includes unity (summary RR, 0.86; 95% CI, 0.71–1.03) (Box). These trials have important limitations. First, their combined power is low, so that a moderate beneficial effect of screening cannot be established or excluded without longer follow-up or other trials. Moreover, in the US trial, although 85% of the screening arm had a PSA test, so too did 52% of the control arm. With only a 33% difference in screening between the groups, the power of the study to detect an effect of screening was substantially reduced. Screening in the control arm of the European trial was not reported. Second, the trials are yet to report on other outcomes of PSA screening, including major treatment side effects, which are crucial to deciding whether large-scale screening is appropriate. The risk–benefit equation for PSA screening is complex. The major potential benefit is a reduction in risk of death from prostate cancer. The main risks are physical or psychological complications of screening and detection, overdiagnosis and concomitant treatment side effects, and unwarranted costs. Some elements of these risks were reported in the European trial. Overall, 16.2% of all PSA tests gave positive results and presumably led to biopsy, and 75.9% of these were found to be false-positives.4 The risk of undergoing radical prostatectomy in the screening group was nearly three times that in the control group (277 versus 100 per 10 000 men).5 To prevent one prostate cancer death, 1410 men needed to be screened, and 48 men needed to be treated.4 Although the number needed to screen compares favourably with that for breast6 and colorectal7 cancer, the issues around overdiagnosis are probably greater for prostate cancer. The cost-effectiveness of PSA screening is yet to be established. Even if it were shown to be favourable, the appropriate testing interval, target age range and PSA cut-off levels are not known. Hence, the persisting uncertainty about the effect of PSA testing on mortality is compounded by other outstanding questions. What are the implications of the trial results for men and their doctors? The findings of these studies are finely balanced. Before they were reported, we had no valid randomised trial evidence; now we have evidence, but it is inconclusive and consistent with a modest but uncertain reduction in prostate cancer mortality at 10 years. Both trials can continue to inform us with longer-term follow-up and comprehensive assessment of all treatment outcomes. What is the best advice that we can give now about PSA screening for prostate cancer? Population-wide PSA screening should not be recommended. The findings from these two studies provide important evidence but are not adequate to allow a conclusion either for or against a benefit of screening. In addition, they reveal potentially high levels of overdiagnosis and its consequent costs and harm. For individual men considering PSA screening, the potential risks and benefits should be carefully considered. Information from these trials and other studies, and data on the potential of treatments for localised prostate cancer to affect quality of life should be communicated, stating that uncertainty continues to cloud this issue. Clearly, men with a life expectancy of less than 10 years are particularly unlikely to benefit from screening, but those who wish to be tested after considering the evidence available should be given the test. Clinical practice includes treating patient concerns and worries, so that if a well informed man really wants to know whether he has prostate cancer, proceeding with PSA testing is a reasonable step. GPs play a crucial role in disclosing the uncertainties of PSA testing and in supporting men in their decision making. Research assumes even greater importance when decision making is clouded by uncertainty. There is a clear need for more evidence on all effects of PSA testing. A greater understanding of decision making around PSA testing is also needed,8 as is better information to help men and their doctors address the issue. Whether screening for prostate cancer lowers risk of death from prostate cancer remains uncertain. However, our uncertainty is increasingly based on evidence, which is far preferable to uncertainty based on ignorance. Characteristics of two published randomised controlled trials of the effect of PSA screening on prostate cancer mortality ERSPC (n = 162 243) PLCO (n = 76 693) Trial period 1991–2003 1993–2001 Age range (years) 55–69 55–74 No. of participants (S v C) 72 890 v 89 353 38 343 v 38 350 Average screening interval 4 years 1 year PSA cut-off for biopsy 3 ng/mL* 4 ng/mL Tested with PSA (S v C) 82% v not stated 85% v 52% Prostate cancers (no.) 5990 v 4307 2820 v 2322 Cumulative incidence of prostate cancer (S v C) 8.2% v 4.8% 7.4% v 6.1% RR (95% CI) of incident prostate cancer in S v C 1.71 (1.64–1.78)† 1.22 (1.16-1.29) No. of prostate cancer deaths (S v C) 214 v 326 50 v 44 Prostate cancer death rate (per 10 000 person-years) (S v C) 3.3 v 4.1 2.0 v 1.7 RR of prostate cancer death in S v C (95% CI) 0.80 (0.65–0.98) 1.13 (0.75–1.70) Summary RR of prostate cancer death in S v C (95% CI) 0.86 (0.71–1.03)‡ PSA = prostate-specific antigen. ERSPC = European Randomized Study of Screening for Prostate Cancer. PLCO = prostate cancer component of the US Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. S = screening group. C = control group. RR = relative risk. * Two centres had slightly different cut-offs, of around 4 ng/mL. † Calculated from data presented in the report of the ERSPC, Table 1, using a Poisson approximation for the variance. ‡ χ2 (heterogeneity) = 2.19, P = 0.14.

David P Smith BA, MPH, PhD · Emily Banks MB BS(Hons), PhD, FAFPHM · Mark S Clements BSc(Hons), PhD · Robert A Gardiner MD, FRCS, FRACS · Bruce K Armstrong MB BS(Hons), DPhil, FAFPHM

Objective: To explore use of bone densitometry in Australia and to identify any sex and geographic differences, as a marker of osteoporosis diagnosis and care.Design and setting: Analysis of claims data from Medicare Australia in patients aged over 45 years during the period 2001–2005.Main outcome measures: Age-standardised rates of bone densitometry use, by sex and by metropolitan, rural or remote classification.Results: Bone densitometry use increased by 26% over the 5 years. Rates were lower for rural and remote populations, with people in capital cities about three times as likely to undergo the investigation as those in remote areas. The sex ratio for the rate of bone densitometry use (women to men) decreased from more than 6 : 1 in 2001 to 4 : 1 in 2005.Conclusion: Although the sex ratio for osteoporotic fracture is close to 2 : 1 (women to men), the sex ratio for testing is much higher, suggesting underuse of bone densitometry in men. Sex and rural inequities in use of the investigation need to be addressed as part of a national approach to reducing minimal trauma fracture.

Dan P Ewald FRACGP, MAppEpid, FAFPHM · John A Eisman FRACP, PhD, AO · Ben D Ewald BMed, MClinEpid, PhD · Tania M Winzenberg FRACGP, MMedSci(ClinEpid), PhD · Markus J Seibel MD, PhD, FRACP · Peter R Ebeling MB BS, MD, FRACP · Leon A Flicker MB BS, FRACP, PhD · Peter T Nash MB BS(Hons), FRACP

Objective: To determine the core qualities that men value when communicating with general practitioners in primary care settings.Design, setting and participants: In a qualitative study using semi-structured interviews in non-clinical environments, 36 white Australian men drawn from the Florey Adelaide Male Ageing Study, stratified by age and marital status, discussed their help-seeking behaviour and health service use. Participants were from the North West Adelaide region. Interviews were conducted between January and November 2005.Results: The core qualities men value when communicating with GPs in primary care settings include the adoption of a “frank approach”, demonstrable competence, thoughtful use of humour, empathy, and prompt resolution of health issues.Conclusions: The core qualities men value when communicating with GPs are concordant with most key dimensions of a patient-centred approach, but not necessarily all. Adopting these qualities has the potential to enhance communication with and care of men in primary care settings.

James A Smith BAppSc(HumMovt)(Hons), BEd · Annette J Braunack-Mayer PhD · Gary A Wittert MB BCh, MD, FRACP · Megan J Warin PhD

Objectives: To examine self-reported patterns of alcohol consumption and experience of alcohol-related harms among professional Australian Football League (AFL) players.Design, setting and participants: Cross-sectional survey of player alcohol consumption and self-reported alcohol-related harms among members of all 16 professional AFL clubs. Data relating to the 2006 football year were collected between 25 July and 30 August 2006 at regular football training sessions using a self-administered structured questionnaire.Main outcome measures: Risky/high-risk drinking for long- and short-term harm at different times of the year; Alcohol Use Disorders Identification Test (AUDIT) score.Results: 582 AFL players completed the questionnaire (an 83% response rate). Alcohol consumption varied at different times of the year. During the playing season (approximately 22 weeks), the level of risky/high-risk consumption for long-term harm in AFL players (11/564 [2%]) was typically lower than in age-matched Australian men in the general population (15%). However, risky/high-risk consumption for long-term harm was higher in AFL players during the end-of-season period (approximately 2 weeks) (303/561 [54%]) and vacation period (6–8 weeks) (231/559 [41%]) than in age-matched Australian men. Risky/high-risk drinking for short-term harm on a monthly basis was frequent at all times of the year (eg, 395/560 [71%] in the pre-season period). The mean AUDIT score was 8.8 (95% CI, 8.4 to 9.1; range, 0 to 36). Reports of harmful effects of drinking and negative consequences, such as getting involved in a fight (physical or verbal) while drinking (146/556 [26%]), were common. Risky/high-risk consumption for short-term harm on a monthly basis was associated with a variety of player characteristics, such as usually drinking in public locations (odds ratio, 1.55 [95% CI, 1.02 to 2.35]). AUDIT score was associated with variables such as marital status, with married players scoring more than two points lower (95% CI, – 3.58 to – 0.58) than single players. Formal club rules on alcohol consumption had little effect on outcome measures.Conclusions: Drinking among AFL players is intricately related to time of year. This seasonal drinking pattern requires the development of specific club and league strategies to minimise drinking-related harms to players.

Paul M Dietze PhD · John L Fitzgerald PhD · Rebecca A Jenkinson MEpid, GradDipEpiBiostat

Men surviving cancer. Barry Leigh. Sydney: Jane Curry Publications, 2007 (viii + 255 pp). ISBN 978 1 920727 31 4. This account of men’s stories provides a lesson in the power of interaction and how what we say as health professionals can change people’s perceptions. A single “throw away” statement or sentence can be etched into a patient’s mind forever. It can shape the way a person diagnosed with a life-threatening illness views both their prognosis and their future. Most of the accounts in Men surviving cancer are about Australian men who have had above average difficulties. It could be confronting for those who have been recently diagnosed, as the path ahead may seem horrendous. Those in the course of challenging treatment, however, may be encouraged by the ultimate success of such treatment. The accounts in this book, as well as those in numerous other books on the cancer journey, suggest that men experience the same physical, emotional and sociological problems as do women. Men cry too. Men feel isolated too. Men change their priorities too: focusing on the importance of family, of friends and of nature. This account of men’s experiences may help others in a similar situation recognise that emotions are normal in the abnormal situation of having cancer. These individual inspiring stories help us recognise that fear of death is at the heart of much of our day-to-day anxiety when faced with a cancer diagnosis. Perhaps the title will attract men who would not normally consider reading a book about cancer, and the upbeat nature of the accounts will help them cope better. As health providers, we can be inspired to communicate more deeply with our patients and appreciate more keenly their willingness to appreciate the power of the spoken word.

Dawn Hooper · Mark Tweeddale

Objective: To describe trends in prostate-specific antigen (PSA) testing, prostate cancer incidence and mortality in New South Wales.Design and setting: Descriptive analysis using routinely collected data of observed trends in PSA testing from 1989 to 2006, and prostate cancer cases and deaths from 1972 to 2005 in NSW.Main outcome measures: Age-standardised and age-specific rates and joinpoint regression to identify changes in trends; projected trends observed before the introduction of PSA testing to quantify its impact on incidence and mortality rates.Results: The number of PSA tests per year more than doubled between 1994 and 2006. Age-standardised incidence of prostate cancer peaked in 1994, fell by 10.0% per year to 1998 and then increased by 4.9% per year from 2001 to 2005. An estimated 19 602 (43%) more men than expected from preceding trends were diagnosed with prostate cancer between 1989 and 2005 after PSA testing was introduced. The incidence of recorded advanced prostate cancer at diagnosis fell from 13.0 per 100 000 men in 1987–1991 to 7.0 per 100 000 men in 2002–2005. The age-standardised mortality from prostate cancer increased by 3.6% per year between 1984 and 1990 and then fell by 2.0% per year to 2005.Conclusions: There was a sustained increase in prostate cancer incidence in NSW after PSA testing was introduced. While falls in the incidence of advanced disease at diagnosis and mortality from prostate cancer after 1993 are consistent with a benefit from PSA testing, other explanations cannot be excluded.

David P Smith BA, MPH · Rajah Supramaniam MSc, MPH(Hons) · Villis R Marshall MD, FRACS · Bruce K Armstrong MB BS, DPhil, FRACP

To the Editor: We all privately seek statistics that enable us to put ourselves in perspective (even if we keep the results to ourselves!), but I am now unsure where my sexual performance stands.1 On the one hand, I am told premature ejaculation affects at least one, and from time to time two, of every three males (is that the < 2 minutes version?), and on the other that there is a skewed distribution with a median of 5.4 minutes and a range of 0.55–44.1 minutes. I’m impressed by the aerobic fitness, never mind the sex. It seems we have a continuously distributed, perhaps skewed, normal distribution of an apparently genetically determined variable, with which individual players (?70%) and their partners are dissatisfied at times. Is that not like height, or IQ? “Premature” ejaculation may not be caused by individual psychology, but it is defined by it: from our beginnings in the Garden of Eden we have always wanted more than we have! The early sperm may not get the bird but historically it got its share of the ovum and thus has persisted over millennia. There may be a role for medicine in some extreme cases (as for “constitutional” dwarfism and gigantism, where being very different carries a significant psychological disadvantage), but for the rest are we not colluding to some extent with an escape from the reality of our limitations? How much of this is treatment and how much is performance enhancement?

Paul T Dignam

In reply: Dignam queries the validity of treating early ejaculation that may simply be a variant of normal. However, if one in three men complain to us of premature ejaculation and how it affects their relationships, we listen. They may regard themselves as very different from other men and may become psychologically disadvantaged. In our article we detailed various presentations of premature ejaculation (PE), including that of a subjective perception of PE although the intravaginal ejaculatory time is normal.1 In such cases, reassurance is an appropriate response. However, for men with primary PE, for whom ejaculation consistently occurs within 1 minute or even before vaginal penetration, there is a problem. This problem can be treated successfully to improve a relationship that may have been foundering. And, yes, this may mean performance enhancement unrelated to aerobic fitness. If men are unsure where their sexual performance stands, they should ask their partner. After all, communication improves a loving relationship.

Neil R Palmer · Bronwyn G A Stuckey

To the Editor: Perusing your long-needed issue on men’s health,1 I was struck by the absence of any mention of obstructive sleep apnoea. As an anaesthetist in private practice, I see three or four middle-aged men with previously undiagnosed obstructive sleep apnoea each week. Usually, I also see at least one man who has had the diagnosis confirmed, but has not persisted with treatment because his wife has become used to his snoring or has moved to another bedroom. Advising the undiagnosed men of the importance of a sleep test, I refer them back to their general practitioner for follow-up, and suggest a couple of respiratory physicians who could perform the test. On a somewhat random follow-up, I have been disappointed with the results, as the following comments were reported back after men’s GP consultations: “Most blokes over 50 snore”; “Your wife will get used to it”; and “Surgery doesn’t work”. Men who have been diagnosed but haven’t persisted with treatment (together with their wives) are often totally unaware of the health risks; they believe that they are only managing the unacceptable noise of their snore! I would have thought that some of the articles in the issue would have mentioned the contribution of obstructive sleep apnoea to hypertension, atrial fibrillation, erectile dysfunction and sleep disturbances, with resulting poor performance during the day, particularly in the workplace. This is an extremely important health issue (and not only in men) that appears to be sadly neglected, still.

Kenneth W Sleeman

In reply: We thank Sleeman for his astute comment. In the men’s health issue,1 our intention was to highlight several major areas relevant to men’s health rather than attempt comprehensive coverage of the field. Sleep apnoea was indeed one of the potential topics we identified when we planned the issue. We anticipated that sleep apnoea would be discussed within some of the key contributions to the issue. Although this did not eventuate, we acknowledge the importance of sleep apnoea in general medical practice, and plan to revisit the topic in future issues of the Journal.

Ann T Gregory

What men don’t talk about. Maggie Hamilton. Melbourne: Penguin Australia, 2006 (x + 364 pp). ISBN 0 670 02879 7. What makes a man a man? Once this might have been a simple question. Since feminism and sociobiology, however, things have got a lot more complicated. Firstly, there is the distinction between sex and gender. Sex is a matter of being biologically male or female. Gender is a broader concept, incorporating social roles, norms and psychological traits, and is a key determinant of personal identity. Spaces and objects, as well as people, may be gendered: a Hummer is masculine, while a Ford Focus, even without a chihuahua accidentally left on the roof, is more feminine. Much of the argument has been about whether gender differences are intrinsic or constructed (by biology or society), and how society has developed in the face of these differences. There are a number of opinions about this. Philosophers like Luce Iragaray believe gender differences are intrinsic, but historically the feminine has been overlooked; evolutionary psychologists like Helena Cronin view them as largely biological and the result of natural selection; and those “second wave” feminists see sex as biological but gender as an artificial, political construct. Maggie Hamilton is not a philosopher; she is an Australian writer and publisher with an interest in personal development. Perhaps sensibly, she does not buy into the contentious issue of whence gender arises, though her book might have been more interesting if she did. Growing up with feminism, she assumed that, although women had suffered under patriarchy, life for men must be pretty good. Prompted by a range of personal experiences and the alarming increase in male suicides, she came to realise that men experience their share of gender-related suffering too, and that she had little understanding of men beyond anecdote and stereotype. This book, drawing on a range of interviews with men and psychologists and other therapists who deal with them, is an attempt to overcome that deficit. It examines the ways in which stereotyped expectations of masculinity affect men at all stages of their life cycles, from infancy to old age. If there is one key message, it would be “don’t be fooled by appearances”. Men have feelings, men need affection, men are vulnerable, men need to communicate — even though they are not always very good at it. In short, men are nowhere near as tough or self-sufficient as they look. It seems to me that how useful this book will be — to a doctor or a patient — will depend on how uncritically they have previously accepted male stereotypes. Someone who has been taking the conventional image of masculinity at face value will find its many encounters with real men and their manifold vulnerabilities very illuminating. Those who have already critically engaged with the male psyche as subjects, partners, family members, friends or clinicians may want something a little more scholarly. Simon CowapGeneral Practitioner, Sydney, NSW

Simon Cowap

Tackling the problems of men’s health requires a comprehensive national policy Health care service delivery takes into account many patient factors, such as age, ethnicity, socioeconomic status — and sex. While the place of “women’s health” is now well established in health care, many contributors to this special men’s health issue of the Journal believe that “men’s health” has not received sufficient, specific attention. Are they right? Enter “men’s health” into PubMed and you will retrieve about 400 citations; do the same for “women’s health” and you will get about 18 000. Perhaps “men’s health” is a relatively new concept in the coding world. Or perhaps there is uncertainty about what the term encompasses, and thus a tendency to prefer other, better defined, keywords. Should men’s health be largely concerned with the functioning and diseases of uniquely male organs, such as the prostate, penis and testis, and related sexual health concerns? Or, should it be a response to the lower life expectancy and higher rates of many health problems and risk factors for men in our society? In this issue, various perspectives of the developing discipline of men’s health are acknowledged. In Australia, it is well known that men do not live as long as women, and that Indigenous men live nowhere near as long as non-Indigenous men. Less well known is that the mortality rate ratio in Australia in 1998–2000 for men aged 25–64 years in the most socially advantaged group of the population was higher than that for women in the same age range in the most socially disadvantaged group — 218.8 v 206.7 per 100 000 people, respectively1 (see Malcher, "What is it with men's health?" Men, their health and the system: a personal perspective). So, it seems that Australian men in all circumstances are at a disadvantage when it comes to health. Common health problems well known to be more prevalent in men include ischaemic heart disease in men aged 40–74 years2 (see Harris and McKenzie, Men's health: what's a GP to do?) and the metabolic syndrome when two of three commonly used definitions are applied (see Chew et al, Revisiting the metabolic syndrome). Lung cancer in men causes nearly one in four of all cancer deaths in Australia.3 Suicide is higher among males than females in the 15–24-years and the over-65-years age groups.4 Further, one in three men over the age of 40 years reports erectile dysfunction, prostate disease and/or lower urinary tract symptoms (see de Kretser et al, The Men in Australia Telephone Survey (MATeS) — lessons for all). While there can be no dispute that men suffer significant health problems, there is ongoing debate about the contributions of biological, psychological, social and environmental influences on men’s health, including their fertility (see Aitken et al, Male reproductive health and the environment; Cram et al, Y chromosome microdeletions: implications for assisted conception). What also seems to be at issue is whether a male sex-based approach to health care service delivery would (or even could) make a significant difference to health outcomes. Here, the different approaches to men’s health do seem to have several key features in common; in particular, emerging evidence that common stereotypical presumptions about men and their health may not be true. Contrary to commonly held notions, contributors to this issue believe that men do seek to be physically and emotionally healthy and some men do see doctors (see Macdonald et al, Men’s health: Indigenous and non-Indigenous men getting together; Holden et al, Men in Australia Telephone Survey (MATeS): predictors of men’s help-seeking behaviour for reproductive health disorders; Woodhouse, Woody's story: fighting prostate cancer). These contributors also share a conviction that men may be more willing to engage with health care services if such services better met (or, at least, acknowledged) specific needs — for example, the needs of “men who have sex with men” (see Pitts et al, Men who have sex with men (MSM): how much to assume and what to ask?), veterans (see Cooper et al, Mental health initiatives for veterans and serving personnel) or men at particular stages of their life cycle (see Fletcher et al, Addressing depression and anxiety among new fathers; White et al, Is there a case for differential treatment of young men and women?; Handelsman, Testosterone: use, misuse and abuse). Lastly, contributors to this issue of the Journal share a belief that, while there is much that organisations and individual medical practitioners can achieve, our men, our relationships, our families and our society will better benefit if we direct our efforts through coordinated, sustained activity. Such activity might be spearheaded by an Australian national men’s health policy. Such a policy might incorporate and build on as many perspectives as possible, including the social determinants of men’s health (see Macdonald, Shifting paradigms: a social-determinants approach to solving problems in men’s health policy and practice) and existing position statements. Such statements would include the Australian Medical Association’s position statement on men’s health5 and the Royal Australian College of General Practitioners’ position statement.6 Having identified and taken up the baton of men’s health, it’s time for us to keep running with it.

Ann T Gregory MB BS, GradDipPopHealth · Michael P Lowy MB BS, MPM, FAChSHM · Nicholas A Zwar MPH, PhD, FRACGP

Dispelling the belief that men are not interested in their health Despite the well known shorter life span of men compared with women,1 strategies to raise awareness of the burden of disease in men — such as social population health approaches2 — have only recently emerged. While men’s increased risk of disorders such as atherosclerotic vascular disease is well known, there has been little focus on male reproductive health — the emerging specialty of andrology. In particular, the prevalence of disorders such as prostate disease, lower urinary tract symptoms (LUTS), erectile dysfunction, androgen deficiency and male infertility have been poorly defined. The Men in Australia Telephone Survey (MATeS) conducted in 2003 is the first whole-of-nation, population-based study focusing on the reproductive health and other problems of middle-aged and older Australian men3 (Box). As the first accurate picture of reproductive health in Australian men over the age of 40 years, it provides prevalence data not previously available, stratified by age and state. The depth of questioning provides a unique snapshot, not only of reproductive health, but also of issues relating to general health, lifestyle and sexual behaviour.3,4 Ongoing data-mining of this comprehensive dataset may help identify risk factors and potential areas of preventive health. For example, in this issue of the Journal, Holden and colleagues explore the sociodemographic factors that affect help-seeking behaviour of men aged over 40 years with reproductive health disorders.5 But, beyond biomedical outcomes, the MATeS study uniquely challenges several general misconceptions about men’s health. MATeS differs from most other reported population studies in that it covers a broader demographic group; previous studies have been confined to geographic areas, such as Massachusetts in the United States,6 and South Australia,7 or to particular population groups, such as men recruited from general practice.8 The results of MATeS are thus better able to be extrapolated to the entire Australian population of men. In addition, studies on male reproductive health tend to be restricted to single components (eg, erectile dysfunction, LUTS or prostate disease), while MATeS provides prevalence rates for a range of conditions and allows interactions to be explored. Similarly, while the large Australian Study of Health and Relationships (Sex in Australia)9 has provided the cornerstone of research and understanding in Australia on sexual health, behaviour and relationships in a younger population (aged 16 to 59 years),10 its findings cannot be directly extrapolated to an older population. MATeS is thus unique in allowing us to challenge existing men’s health constructs for this older age group. Firstly, MATeS demonstrates that significant numbers of men are affected by reproductive health disorders, with one in three men over the age of 40 years reporting erectile dysfunction, prostate disease and/or LUTS. Prevalence rates in the over-40-years age group are: erectile dysfunction, 21%; LUTS, 16%; prostate disease, 14%; and infertility, 8%. The rates of the first three conditions increase sharply with age. While these conditions are not considered life-threatening, the significant numbers of men affected and the potential link with other chronic diseases, such as cardiovascular disease, hypertension, diabetes and depression,6,11 highlight the need to educate both the community and health professions to ensure reproductive health disorders are not overlooked or dismissed. They may be early warning signs of more serious disease. Secondly, the study challenges the belief that men are not interested in or concerned about their health.1 Almost 90% of men aged over 40 years had visited a doctor in the 12 months before interview, and men expressed high levels of concern about developing reproductive health problems as they age: 80% were concerned about developing erectile dysfunction, and 57% about developing prostate cancer.3 However, the study suggests that men are selective about the issues they will discuss openly, and the social, cultural and environmental influences that modulate such health behaviours need to be better understood. In a clinical setting, these barriers need to be overcome by allowing men, particularly older men, opportunities to disclose reproductive health concerns that may otherwise remain unspoken. Health promotion strategies that address men’s health concerns may assist in overcoming barriers to help-seeking behaviour.5 Examples include targeted health education sessions and promotional displays as part of other social events, such as community men’s health nights,12 and workplace or local community events.13 Thirdly, MATeS achieved a high response rate of 78%. Not only does this response rate ensure the validity of the dataset, but it also demonstrates the acceptance of this research by the target group, which is commonly considered to be more difficult to recruit and is often excluded from studies on sexual health.14 Finally, MATeS also challenges the widely accepted notion that older couples are sexually inactive (37% of men aged over 70 years were sexually active4), thereby implicitly dismissing their sexual health needs in many settings. The inclusion of older couples in sexual health studies needs to be considered as part of the healthy ageing research agenda, as relationships and sexual expression are a key component of ongoing good health across the life span. In addition, medical practitioners and allied health professionals need to consider that sexual relationships remain important for many couples as they age, and should not be overlooked or dismissed on the basis of patient age. A progressive decline in male reproductive health with advancing age is well recognised.3,6 However, the physiological causes of this decline may be multifaceted and influenced by lifestyle, social, cultural and environmental issues. Population-based studies of the incidence and progression of disease and related health issues are necessary components of public health and health outcomes research to allow the development of strategies for promotion, prevention and intervention. This was recognised in 1995 when the Commonwealth Department of Health and Aged Care commissioned the Australian Longitudinal Study of Women’s Health to assess a wide range of women’s health and health-related issues.15 Although longitudinal studies of men’s health issues have been conducted overseas,6 there is no similar study in Australia. With Australia’s increasingly ageing population, MATeS provides the impetus for a formal longitudinal study to help us understand the impact of social and biomedical determinants on the health of middle-aged and older Australian men. This would help us to lessen the burden of disease and ensure that quality of life and wellbeing are maintained as far as possible in later life. Outcomes from such a longitudinal study would potentially help the development of better clinical management options for men as they approach their middle years. An effective men’s health research agenda should be implemented in Australia to coordinate the research effort, involve the many and varied stakeholders, address the prevailing assumptions in men’s health, and develop a sound evidence base for future policy and practice. However, any development of men’s health research should not be used to argue for a diminution of the existing emphasis on women’s health. Instead, it should be recognised that biological and sociocultural factors can profoundly affect the behavioural responses of both sexes to disease, the environment and the stresses of life.1,16 Overview of MATeS (Men in Australia Telephone Survey)3-5 Design A representative sample of men aged 40 years and over was contacted from 7636 households which had been randomly selected from the Electronic White Pages. Unbiased sampling stratified by age (40–49, 50–59, 60–69 and 70 + years) and across all states and territories. All men participated in a 20-minute computer-assisted telephone interview exploring general and reproductive health, including related knowledge and beliefs, and sociodemographic and lifestyle factors. Participants 5990 men participated from 7636 randomly selected households, with an individual response rate of 78%. Outcomes High rates of reproductive health disorders and related concerns. A low level of specific enquiry and treatment for reproductive health disorders. This suggests that opportunities to talk to general practitioners about reproductive health problems are being missed. A strong link between reproductive health disorders and age. This suggests that more men will seek help in the future.

David M de Kretser MB BS, PhD · Megan Cock PhD · Carol Holden PhD

Some boys conceived through artificial techniques may inherit their fathers’ subfertility Clinical assessment of couples unable to conceive naturally often identifies causative or contributory factors associated with the male partner. Male infertility affects one in 20 men, accounts for a third of all infertility, and is a cofactor in over half of assisted reproductive technology (ART) treatments worldwide.1 Primary spermatogenic failure (SgF, also termed idiopathic infertility) accounts for more than half the cases, yet, in most of these cases, its cause is unknown.1 In clinical practice, classification of SgF is based on semen parameters (describing combinations of poor sperm number, motility or function) and reflects an ignorance of the pathogenesis.2 However, recent research has determined that up to 15% of SgF is related to at least six known Y chromosomal deletions, with implications for genetic testing, counselling, assisted reproduction and even subsequent male offspring conceived by ART. Spermatogenesis is a complex process of cell division and structural modification involving the coordinated expression and interplay of many gene products. Recent data point increasingly towards a genetic basis for SgF. In particular, deletions of the Y chromosome — called microdeletions — are the most significant recognised cause of SgF in otherwise healthy men.3 The Y chromosome is 60 megabases (Mb) in size, and comprises a short arm (Yp) that encodes the male sex-determining gene Sry, and a long arm (Yq) (Box). Of the 27 Y chromosome genes identified, nine are located on Yp and the remaining 18 on Yq.4 Twelve of the 18 Yq genes are expressed in a testes-specific manner and are vital for normal sperm production.4 Y chromosome microdeletions in fact involve substantial DNA deletions within the Yq region, ranging from 1.6 to 14.5 Mb and, depending on the deletion type, result in the loss of specific combinations of spermatogenic genes. Accordingly, men with Yq microdeletions are often (but not always) infertile, but many can still father children through intracytoplasmic sperm injection (ICSI),5 using the few viable sperm present in semen or mature spermatids isolated directly from the testis.6 An association between Y chromosomal deletions and infertility was first reported in 1976 by Tiepolo and Zuffardi,7 who detected large Yq deletions in six azoospermic men by routine karyotyping involving chromosomal banding. They proposed that an azoospermia factor (AZF) region was associated with spermatogenesis. Extensive physical, functional and genetic analyses of the Y chromosome8,9 have now identified three AZF regions (AZFa, AZFb and AZFc), which encode spermatogenic genes such as USP9Y, RBMY1, and BPY2 and DAZ (Deleted in AZoospermia) (Box). DNA sequencing of the Y chromosome has identified unique structural features such as large palindromes (DNA sequences that read the same in both directions) that encompass highly repetitive DNA elements.4 Homologous recombination, involving elimination of one repetitive sequence at the expense of another, is believed to be the underlying mechanism that accounts for the random appearance of de novo AZF microdeletions in men. Interestingly, the fathers and brothers of men with Yq microdeletions usually have non-deleted Y chromosomes and normal sperm counts, indicating that these deletions are spontaneous events. The reason for the appearance of Yq microdeletions in some men is not known. We speculate that these deletion events occur during gametogenesis or early preimplantation development and may involve a deficiency in enzymes responsible for normal DNA repair. Up to 15% of men with SgF and sperm densities below 5 million/mL have AZF deletions.3 Variation in the reported incidence of Yq deletions in infertile men has been attributed to factors such as patient selection criteria, the molecular test format, and the propagation of specific Y chromosome types (called haplotypes) within population groups that have different susceptibilities to deletion events. The three identified AZF regions contribute to six different Yq deletion types: AZFa, AZFb, AZFc, AZFbc, AZFabc,8 and the gr/gr subdeletion9 within AZFc (Box). There is no clear relationship between genotype and spermatogenic phenotype, but some generalisations can be made. Most microdeletions (59.6%) involve the AZFc region3 and are associated with the histological appearance of hypospermatogenesis, which is characterised by a reduction in germ cell number, mature elongated spermatids in some or all tubules, and low sperm densities ranging from 5 million/mL to azoospermia.10 Less common Yq deletions involve AZFb (15.8%), AZFbc (13.6%), AZFa (4.9%) and AZFabc (< 1%) regions; such men are often azoospermic and have more severe spermatogenic pathologies, such as arrested germ cell development or the Sertoli-cell-only syndrome. In 6% of cases, Yq deletions that involve regions outside of the three AZF regions have been identified in men with spermatogenic failure.3 Recent investigations of the Y chromosome have identified several smaller deletions within the AZFc region. For example, we have found that one such deletion, called gr/gr,9,11 is more prevalent than AZFc deletions in severely oligospermic or azoospermic men (4.7% v 2.2%, respectively).12 However, we also found gr/gr deletions at a similar frequency in oligospermic men (sperm densities, 5–40 million/mL). Interestingly, gr/gr deletions have also been found in some fertile men who have a particular Y haplotype.13 Thus, gr/gr deletions are relatively independent of sperm density, but significantly associated with infertility. At this stage, the gr/gr deletion appears to be a risk factor for infertility rather than a definitive cause of SgF. The variable sperm parameters observed in men with AZFc and gr/gr deletions could be due to a number of factors, including molecular heterogeneity of the deletion or functional compensation of the lost DAZ gene by its gene homologue DAZLA on chromosome 3. We are currently involved in an international effort to define more precise correlations between sequence variants of these deletions and semen parameters. Vertical transmission of AZFc Yq deletions from infertile men to their sons via ICSI14 and natural conception13 has been reported, the latter underscoring that male fertility is possible even at low sperm output. We have generated a DNA database of more than 150 infertile men and their ICSI-conceived sons, and have identified and mapped the AZFc deletions in three Y-deleted men: in all cases, the same deletion was transmitted to the sons without expansion to other AZF regions.14 Furthermore, analysis of a larger panel of Y chromosomal markers located throughout the AZF and surrounding regions has not identified de novo Yq deletions in 100 ICSI-conceived sons tested to date, indicating that ISCI treatment is not a risk factor for the generation of Yq deletions. However, it seems very likely that these ICSI-conceived boys with AZFc deletions will be subfertile and will need close review as they reach sexual maturation and proceed into adulthood with aspirations for fatherhood. The European Molecular Genetics Quality Network (http://www.emqn.org) has established guidelines for Yq deletion testing and provides an important quality assurance function.15 These laboratory guidelines have been widely adopted and have led to standardisation of Yq testing. The test is based on the analysis of a large panel of conserved molecular markers or genes located within and outside the AZF regions, using multiplex polymerase chain reaction (PCR) on peripheral blood genomic DNA. The pattern of these markers determines the Yq deletion type. Because of the inherent instability of the Y chromosome, it is likely that new Yq microdeletions will be identified and associated with SgF. High-resolution microarrays for chromosome screening will enable further investigation of the Y chromosome in fertile and infertile men, and microarray-based testing may replace multiplex PCR as the gold standard for Y chromosome testing in the future. Given the relatively high prevalence of Yq deletions, most andrology and infertility centres now routinely offer Y chromosome testing to men with severe SgF, especially before ART treatment. Yq deletions have important implications for infertile couples, and genetic counselling following testing is recommended. There are several considerations that support routine assessment of Yq deletions. Firstly, a positive test will provide a firm diagnosis of the man’s problem, which, for some couples with longstanding infertility, can help resolve stress, blame or feelings of guilt. Secondly, knowledge of the type of Yq deletion may assist the clinician in determining the best ART treatment. For example, a Yq microdeletion involving the AZFa or AZFb regions carries a poor prospect of sperm retrieval, even with testicular biopsy,16 thereby questioning the value of this approach and raising donor sperm treatment for discussion. Thirdly, couples should be offered this information, as they must understand that their male offspring will almost certainly be subfertile and require reproductive monitoring from the time of sexual maturation. As the natural history of SgF is poorly understood, it seems wise that consideration be given to sperm storage, as these young men born by ICSI may move from oligospermia to azoospermia before seeking fatherhood. Lastly, infertile men are known to be at increased risk of androgen deficiency17 and testicular neoplasia;18 however, whether the subgroup with Yq deletions have a greater risk also requires careful monitoring. Following genetic counselling about their Yq deletion, most couples still proceed with in-vitro fertilisation using either the male partner’s sperm or donor sperm.19 In a small number of cases, couples have used preimplantation genetic diagnosis to select female embryos for transfer,19 in an attempt to avoid passing on the genetic abnormality to their children. The relationship of Y chromosome deletions and other genetic lesions to male infertility will continue to be an active area of interest. Given the widespread use of ICSI to resolve male infertility, it is important that this research is translated rapidly and appropriately into clinical practice, and that prospective couples are provided with essential information that allows them to be fully informed when making this crucial life decision. The human Y chromosome A: Normal Y chromosome showing AZF regions and representative spermatogenic genes. B: Different Y chromosome deletion types. Dotted lines indicate the deleted regions.

David S Cram PhD · Elissa Osborne PhD · Robert I McLachlan PhD, FRACP

Testosterone is among the oldest drugs in medicine. It has a long efficacy and safety record for its prime role of androgen replacement therapy in men with androgen deficiency. Testosterone and synthetic analogue androgens have also been used in pharmacological androgen therapy (PAT) to produce androgenic effects on marrow, muscle or bone. Although PAT is increasingly being superseded by newer, more expensive drugs, androgens remain cost-effective in many older applications. Androgen misuse is the systematic over-prescribing for unproven medical indications. Misuse is increasingly evident for male ageing (“andropause”) and some other clinical conditions. Further trials for new indications for androgens require reliable safety data, but rising costs may make it increasingly attractive to circumvent the need for evidence by promoting off-label mass marketing. Androgen abuse is the illicit self-administration of often massive doses of androgens for non-medical purposes — notably power sports and body building. In parallel with effective detection reducing androgen abuse in elite sports, more focus is needed on non-sporting cosmetic, recreational and occupational androgen abuse. Despite ongoing androgen misuse and abuse, testosterone remains under-prescribed for younger men with classical androgen deficiency that frequently remains undiagnosed.

David J Handelsman MB BS, FRACP, PhD

In Australia, about 150 000 men aged 16–59 years identify as gay or bisexual, while a similar number identify as heterosexual but have some history of same-sex sexual contact. Pitts, Couch and Smith advise that the clinical implications for these men include more than sexual health concerns. They suggest several consultation skills that can help doctors to recognise these men and better meet their needs. Human sexual practice is diverse. In response to the need to better understand that diversity in the face of the HIV epidemic, a fact became widely known that had previously been understood by few: a significant population of men who do not self-identify as “gay” or “bisexual” sometimes have sexual contact with other men. It was recognised that a descriptor for behaviour, rather than an assertion of social identity, was needed, and the term “men who have sex with men”, and its acronym MSM, came into being. We believe there are “definitional” challenges associated with this term, as well as clinical and practical implications when working with men to whom such a descriptor might be applied. What's in a definition?It is rare for medical journals to include sexuality and sexual behaviour as important components of men’s health and wellbeing. It is even more unusual to acknowledge MSM outside the context of HIV. Use of this acronym in a men’s health context both illuminates and challenges. MSM is a behavioural definition; it does not imply an identity, and it does not consider sexual attraction. We prefer the term “male-to-male sexual practices” (MMSP), as it explicitly acknowledges that the sexual practices, rather than the person, are at issue. The choice of “practices” in the plural also signals that male-to-male sex may incorporate a range of sexual behaviours which may, or may not, include oral and anal sex. How many men fit the definition?The Australian Study of Health and Relationships in 2001 surveyed a nationally representative sample of 19 307 Australians aged 16–59 years. These included 10 173 men, of whom 97.4% identified as heterosexual, 1.6% as homosexual or gay, and 0.9% as bisexual, while 0.1% were undecided or “other”. A lifetime history of sexual attraction that included other men was reported by 6.8%, and sexual experience with other men by 6.0%. Of the men who identified as heterosexual, 2.7% reported having had sex with at least one other man. By extrapolation to the general Australian population, this suggests that there are about 158 000 men aged 16–59 years who identify as heterosexual but have some history of same-sex sexual contact. This is in addition to the 148 000 men who identify as gay or bisexual.1 What are the clinical implications?Sex, risk and MSMWhat does it matter that the patient, whatever his sense of identity, has anal sex with men, and perhaps also has penetrative sex with women? The international medical literature on MSM builds a picture of a risk-taking and at-risk group. They are particularly, if not exclusively, considered in the context of HIV risk, and to a much lesser extent are known to be at risk of other sexually transmitted infections (STIs). We recently completed a study of the knowledge and attitudes of gay men towards anal cancer and human papilloma virus (HPV).2 We know that anal sex carries a high risk of HPV transmission, particularly for men who are HIV-positive, but our study showed that very few gay men had even heard of HPV, and most were not aware of its association with sexual practices. In this regard, they differ little from women, who are at similarly high risk — of cervical cancer — through HPV exposure. MSM are at greater risk of gonorrhoea or syphilis than are other men. However, most consultations with MSM are for issues other than STIs and reflect the profile of health conditions experienced by Australian men. Substance useCertainly, if a category or group is defined only in terms of sexual activity, it is unsurprising that STIs feature large. However, there is some evidence of health risks other than sexual health risks in MSM, which nevertheless derives from HIV studies. These indicate a higher than expected rate among some MSM subcultures of alcohol use, and injecting and other illegal drug use. Men in the Australian Study of Health and Relationships who identified as bisexual were eight times more likely to report a history of injecting drug use, and gay men were twice as likely, as those who identified as heterosexual.3 However, they were no more or less likely than other men reporting a history of injecting drug use to report sharing needles or injecting paraphernalia. In Private lives, our national online survey of health and wellbeing among gay, lesbian, bisexual, transgender and intersex Australians, we found that 38.3% of gay-identifying men reported tobacco use on more than five occasions in the previous month,4 which compares with 26% for Australian men in general.5 Mental healthFindings about MSM are mixed in the area of mental health. Numerous studies have indicated higher rates of depression and anxiety in gay men. A 5-year study in South Australia reported 30% of homosexually active men met the criteria for a major depressive episode, as measured by the Primary Care Evaluation of Mental Disorders screening tool.6 Twenty-seven per cent of the men in the survey were diagnosed with dysthymic disorder on enrolment, while the survey indicated a lifetime prevalence of a depressive disorder of 48%. This is five times the rate for all men reported from primary health care clinics in the United States where the survey instrument was validated.7 In Private lives, which involved 3429 gay men from all Australian states and territories, we found that the prevalence of depressive disorders was high, with 48.7% of men scoring on at least one of the two criteria for a major depressive episode. Nearly a quarter of respondents (23.8%) met the criteria for a major depressive episode, with a similar proportion reporting experiencing depression (24.2%). It is of particular concern that 15.7% of gay men indicated suicidal ideation in the 2 weeks before completing the survey. While the causes are not easily identified, it is probable that living in a society characterised by homophobia is a contributing factor.4 What are the practical implications?Recognition of MSMHow does one recognise MSM? Would the behavioural question be: “Have you ever had sex with a man?” or “Have you had sex with a man in the past year?” and/or “Have you also had sex with a woman?” And how would the word “sex” be interpreted? Presumably, the narrowest definition of MSM would be a man who has experienced anal sex (insertive or receptive) on at least one occasion in his life. However, it is not surprising that publications on MSM almost never offer a definition or, if they do, proceed to bundle MSM with gay, bisexual and other homosexually active men into a single analysis. MSM and their health needs are most likely to evade recognition because of the heteronormative nature of most clinical practice — based on the assumptions that, until proven otherwise, all people have a simple sexual identity, and that it is heterosexual. A gay man who is “out” about his sexuality to his doctor (67.2% of men in the Private lives survey had told their doctors) may find his general health concerns sometimes overshadowed by concerns about sexual health. This may be understandable, given the relatively high rates of HIV and other STIs among these men. However, STIs or any other single issue should not become an overriding focus of any clinician–patient relationship. When, how, and what to ask a man about sex? Simply put, when and if you consider it matters, avoiding a default assumption that the man is heterosexual, even if he is married, partnered with a woman or has children. MSM have wives and children too! In most cases, the need to ask is determined by the presenting condition, and it may not matter so much to whom a man is attracted, or what he identifies as his sexual identity, as what his recent sexual practices have been. So, ask questions about the sex he does, rather than about what he is. Of course, if the presenting problem has to do with a complicated life course perhaps including mental health issues, then questions about sexual attraction and identity could well be the important ones. The case scenarios (Box) show the differing process and outcomes when a doctor recognises, or fails to recognise, the possibilities. For new patients, it may be easy to indicate that a full sexual history is a usual part of an initial consultation, whatever the presentation. For existing patients, sexual history may be best approached indirectly. A statement that hepatitis B vaccination is freely available and recommended for all men who have had sex with another man can be mentioned in the context of reminding all male patients of vaccination schedules. If a clinician (or a practice) takes a “no default assumptions” approach to sex, then the move into questions of sexual attraction, identity and practice will happen when, and if, they matter. Finally, we are confident that it is rare that health articles define the population in terms of a single behavioural characteristic. To think analogously, would we not shrink from referring to WWR (women who reproduce), PWJ (people who jog), or indeed MSW (men who have sex with women)? Is it so surprising that we would prefer the term “male-to-male sexual practices” or MMSP? Case scenarios Scenario 1 — MSM not recognised Rob is a 36-year-old man who lives in a regional town. He is married with three young children and is feeling guilty and highly anxious following an unsafe sexual episode with another man a while ago. He feels he will be able to relieve his anxiety only by having an HIV test. He goes to a local doctor he does not know, as he does not want to use his family doctor, who also treats his wife and children. On the information form, he states that he is married. In the consultation, Doctor A invites him to discuss his presenting problem, and Rob leads into it by saying he is very embarrassed because he has been unfaithful to his wife. Doctor A, sensing his embarrassment, tries to help by asking whether the woman is someone he is having an ongoing affair with and whether he feels she might have had an STI. Not knowing how to get round this, Rob says that he is worried about STIs. Doctor A ends the discussion, which is clearly becoming more uncomfortable, by ordering a series of STI checks and suggesting the affair has been a bad idea and should end. The tests do not include an HIV test. Rob has gained nothing from the visit; he does not return for the test results. Scenario 2 — MSM recognised Rob, still anxious, goes to another doctor in the town to try to have an HIV test. This time he notices a health promotion poster for same-sex attracted people (Figure*) in the waiting room and so feels more confident. He completes the information form again to say he is married but notes an option for “same sex relationship”. These signals lead him to feel safer about discussing his concerns. Doctor B asks why he has come, and he says he has had unsafe sex with someone other than his wife. “Was that with a male or a female partner?” asks Doctor B. He then asks what Rob actually did with that partner. Rob and Doctor B agree that an HIV test is necessary and discuss other STI tests as well. Hepatitis B vaccine is also discussed, along with the levels of anxiety Rob has been feeling. Doctor B takes the opportunity for a reminder about the importance of practising safe sex in the kind of situation Rob describes, but acknowledges that is not always easy. He will see Rob again for his test results, and makes sure he will return by telling Rob he is pleased to have met him and that he would be happy to see him any time he needs to talk about things. When his test results come back negative, Rob and Doctor B use the feeling of relief to talk through some of his health risks and to plan strategies to avoid anxiety in the future. After the consultation, Rob feels less guilty and more in control of his life, and less likely to take risks with his own health and the health of his wife in the future. * This poster and other useful resources are available at http://www.glhv.org.au/ MSM = men who have sex with men. STI = sexually transmitted infection.

Marian K Pitts PhD, AFBPS, MAPS · Murray A Couch BA(Hons) · Anthony M A Smith PhD

Men’s health needs, health beliefs, and health-related behaviour are different to those of women Our current research examining young men aged 15–44 years presents worrying epidemiological evidence — a picture of men dying prematurely of conditions such as ischaemic heart disease and cancer, at a time when screening and treatment for many of these diseases has improved (Box).1 This evidence suggests that these men are either not following health advice or not using health services soon enough for effective remedial treatment. Here, we argue that there is a need for health professionals to rethink service provision for young men. What is “men’s health”?Men’s health may be defined as “. . . any issue, condition or determinant that affects the quality of life of men and/or for which different responses are required in order for men (and boys) to experience optimal social, emotional and physical health”.2 This definition highlights that men’s health is concerned with a broader range of issues than specific diseases of the male reproductive organs. In general, epidemiological evidence suggests that men and women have different health challenges through the lifespan, with men consistently having the higher mortality across all countries surveyed from conception onwards.3,4 For most disease states, men appear to have a higher rate of premature death and are more susceptible to the effect of worsening socioeconomic status.1,4 Men’s poorer social and emotional wellbeing is also reflected in higher suicide rates;1,4 for example, in Australia, men are four times more likely than women to commit suicide in the age range 15–44 years (1206 male deaths and 291 female deaths in 2001).1 Men are also more likely to die from drug and alcohol misuse.4 If the health challenges facing men and women are different, then you might expect that there should be visible recognition of this in the way services are configured and the way health policy is framed. Similarly, if men and women differ in the way that they use health services, having one service for all is likely to end up serving men or women (or both) inappropriately. What do we know about men’s help-seeking behaviour?As interest in men’s health has grown during the past 5–10 years, there has been a corresponding increase in research suggesting that men do differ from women in their help-seeking behaviour,5-8 with sporadic and infrequent use of services, lack of engagement with health material, and a tendency to delay when faced with health problems of key concern. These problems appear most pronounced in younger men. We suggest there may be three main reasons for these findings and offer suggestions as to how services might be reconfigured. Firstly, men are not invited to engage actively with health services in the same way that women are from puberty onwards for non-illness related reasons (eg, within formal screening programs, and for contraception and antenatal care). This leads to men failing to recognise the range of health service provision available and its link with preventive health practices. Secondly, it can be argued that most health service provision is female-orientated, with services predominantly provided during the day, when men are more likely to work full-time, have less opportunity for flexible working, and are often in precarious employment where taking time off for visits to doctors may be perceived as a sign of vulnerability, by the men themselves and by their peers and employers. Thirdly, beyond these structural constraints, there is another difference between men’s and women’s health behaviour that merits consideration. How men and women manage their health and wellbeing is, in part, predicated on their own health beliefs and how these beliefs affect their health behaviour — whether these beliefs differ between men and women is, therefore, germane. For example, patterns of premature mortality among young men suggest that risk-taking is a significant factor, and rates of premature death from disease processes also implicate aspects of men’s lifestyles.1,4 But this question goes deeper: we need to explore both the intrinsic drivers of men’s behaviour and how society moulds men’s values, attitudes, and behaviour. It is widely accepted that the expression of masculinity is socially constructed and there are multiple masculinities.9 In Western cultures, there is a restrictive conceptualisation of masculinity, which limits men’s choices and appears to have a negative influence on their health.10 For example, at the individual level, gender roles may partially explain a variety of risk-taking behaviours (such as unsafe sex, binge drinking, and steroid and other drug use).10,11 In addition, stigma and the fear of discrimination may work against men with mental or physical health difficulties. Together with the social pressures relating to full-time work and the current work environments for men, the so-called benefits, or patriarchal dividend, that men are said to enjoy can also be a powerful negative force for men experiencing problems.10 Where do we go from here?As the mortality data confirm, men’s health is not as good when compared with women’s, but such direct comparison with the way women manage their own health may be inappropriate, as we are not comparing like with like. Thus, the challenge that men face with regard to their help-seeking behaviour is a complex issue,12 which is not amenable to a “quick fix”. The common perception that men are being stubborn, or in denial, about their health is clearly simplistic and, if it is true, may be as much a product of socialisation and how services are structured as it is about individual choice. Nevertheless, we cannot maintain the status quo and wait for some sort of “new man” to emerge — the current and future threats to men’s health are too pressing. The increases in skin cancer, in young male obesity with its related health risks, and in substance use all suggest a pressing need to target the young man. There is already considerable recognition within Australia,13 as elsewhere, that men’s health requires specific attention and that health services and policy need to take this into account in making knowledge and services more accessible to men, for example, via specialist men’s health care clinics, and men’s health information nights held in men-friendly environments (such as pubs and sporting clubs) or the workplace.14 This work is already being taken forward through the ongoing activities of the Men’s Health Information & Resource Centre at the University of Western Sydney; the GPs4MeN group; the biannual National Men’s Health Conference; and, in 1997, the House of Representatives Standing Committee on Family and Community Affairs’ discussion of a National Men’s Health Policy.15 Nevertheless, as with many other countries, these initiatives have yet to permeate into mainstream action.16 The fact that a number of Australian organisations have begun implementing such innovations is to be celebrated; however, these approaches could be further developed. This includes tackling boys’ and men’s beliefs about their health from an early age through both formal education and more broad-based health promotion campaigns, with more focus on providing services and education through the workplace, as has been done successfully in Europe and the United States. For example, the Internet-based weight loss campaign run by the Men’s Health Forum in England with British Telecom workers saw 4000 men lose an average of 2.2 kg over the 6-week program. More fundamentally, there is a need for the public, the health care professions, and policymakers to recognise that men’s health needs, health beliefs, and health-related behaviour are different to those of women. The recognition of Men’s Health as a field of practice in its own right, to stimulate the development of research, debate, education and practice, would seem a prerequisite step. Patterns of mortality in young men and women Our study1 was the first international analysis of patterns of mortality in young men and women (aged 15–44 years). Data from 44 countries were considered using the World Health Organization Statistical Information Service Mortality Database. We found that men were at greater risk of premature death, with accidents and suicide being the key causes in the earlier years. Deaths as a result of disease processes became markedly more prominent in the 35–44 years age group.

Alan White PhD, RN · Helen J Fawkner BSc, MSc, PhD · Mike Holmes PhD