Many men exhibit health care avoidance

Physicians, public health officials look for ways to increase men's involvement in medical care and improve health indicators.

By Victoria Stagg Elliott, amednews staff. June 17, 2002.

The 17-year-old male was discovered unconscious in his home days after being a passenger in a car that crashed into a tree.

After the incident, he had been treated for minor injuries and sent home. But then, four days later, he was found with no pulse and rushed to the hospital. He was declared dead 30 minutes after arrival -- an outcome initially blamed on internal injuries not immediately apparent after the crash.

Death by testicular cancer
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But this suspicion did not bear out.

An autopsy revealed that the teen had died of a blood clot in his lung caused by undiagnosed testicular cancer. The cancer had spread throughout his body.

This case was tragic. But what makes it even more noteworthy is a theme it highlights. Physicians, researchers and public health policy experts increasingly view the disparity in health outcomes between men and women as a result of how the sexes interact with the health care system.

Doctors at the Netherlands' Wilhelmina Hospital and the Netherlands Forensic Institute, for instance, wrote in the May 11 issue of The Lancet that this was not the case of a hidden cancer. The tumor would have weighed several pounds if it had all been removed. They also doubted that there was any chance the patient could have been unaware of the five-inch mass on his testicle.

On average, women live 6 years longer than men.

Still, the patient didn't seek care. And testicular cancer, one of the least common cancers, is also one of the most curable. The article's authors suggest that the delay in diagnosis was probably caused by patient ignorance, fear and embarrassment.

"The sexes are taught to deal very differently with pain and fear," said Jean Bonhomme, MD, MPH, a board member of the Men's Health Network. "But the same learned indifference to pain and fear that helps men win on the football field or the battlefield doesn't make for a good interface with the health care field."

There is growing interest in taking steps to change these attitudes. Some physicians are talking about a specialty in men's health much like gynecology, and a bill has been introduced in the House of Representatives that would set up an office of men's health within the Dept. of Health and Human Services.

A growing number of male celebrities and sports heroes such as cyclist Lance Armstrong and basketball player Magic Johnson have spoken out about personal health issues. But experts say that the need for more attention is evident.

Fear and denial

Consider one basic fact: On average, women live nearly six years longer than men. Many believe that at least part of this phenomenon can be attributed to a lack of access to care either because of male patients' fears or because of systemic issues, such as a lack of insurance.

"I've had men come in with masses in their scrotum the size of grapefruits," said Kenneth Goldberg, MD, a urologist with Texas Urology in Dallas. "You ask them how long it's been there, and they say last week. Obviously, it hasn't. They ignore it, and they're in denial."

In an effort to gain a foothold in addressing this issue, the authors of The Lancet paper suggest using education about testicular self-exam. Women have long been sold on the idea of breast self-exam, and many look for ways to sell the male equivalent. This approach would emphasize the need for prompt medical attention at the first sign that anything is out of sorts.

"Self-exams are important, because you can catch things early, and you can do a lot to dispel the myth of invincibility, which is probably equally important," Dr. Goldberg said.

Targeting the messages

But many recognize that the key to connecting men to prevention messages and regular medical care may require different strategies than those that have proven effective in reaching women.

Doctors say men are less likely to give personal information and need to be asked directly about sensitive issues. Some even suggest a change in the medical care environment. Men are taught to avoid situations that would make them vulnerable, but a medical exam frequently does just that.

"Could you name a place where a man feels more threatened and out of control than being in an exam room naked?" Dr. Goldberg asked. "The whole atmosphere is counter to everything they want." He has set up temporary clinics in workplaces and community centers to reach men in a nonthreatening environment.

Men's priorities

What men want to accomplish when they go to the doctor is also very different. Physicians say men go to the doctor when they are concerned about physical strength and sexual prowess -- which has turned Viagra into a blockbuster drug. Some physicians see this as their "in" to talk to men about other health issues.

"A lot of men who come to see me want to bulk up," said John Rich, MD, MPH, medical director of the Boston Public Health Commission, who runs a young men's health clinic. "Typically we don't consider that to be an important medical issue, but if one were to dismiss that as a concern, we've taken away the very thing that made them want to connect with medical care. Our approach is to make sure we're equipped to deal with their concerns, and then we move to the things that we believe are most important, such as smoking, substance abuse, sexual behavior and cardiovascular disease."

Women are also more tethered to medical care because of contraceptive needs and the annual Pap smear. There has yet to be a male equivalent, although this connection does sometimes spill over to influence male partners. Physicians say men are more likely to go to the doctor if a woman in their life makes them.

"Men sometimes get better at taking care of themselves as they get older," Dr. Goldberg said. "But that has a lot to do with the partners in their lives. The women are veterans when it comes to health care."

But for some men, the lack of access is also connected to a lack of insurance. A report by the Commonwealth Fund found that many men lacked insurance because public aid programs are targeted to women with children. Also, those who can afford it may choose not to.

"It's not a priority for them," said Dr. Bonhomme, a senior faculty associate in behavioral science and health education at Emory University in Atlanta. "You can have all the money in the world and put it into sports cars or investments and not think about your own health."

ADDITIONAL INFORMATION:

Death by testicular cancer

The patient: A 17-year-old who died four days after a car crash
Cause of death, initial suspicion: Hemorrhage of the abdominal aorta
Actual cause of death: Undiagnosed testicular cancer that led to a blood clot in the lung
Findings: Testicular cancer is the most curable of all the cancers, but treatment is often hampered by late presentation because of patient fears, embarrassment and lack of knowledge of the disease. Testicular self-exam should be encouraged, and men should be educated about the need for prompt medical attention if there are any changes.

Source: The Lancet, May 11

Weblink

Report, "Testicular carcinoma: postmortem diagnosis after a car accident," The Lancet, May 11 (registration required) (http://www.thelancet.com/journal/vol359/iss9318/full/llan.359.9318.original_research.21043.1)

Editorial and review, "Testicular cancer: perils of very late presentation," The Lancet, May 11 (http://www.thelancet.com/journal/vol359/iss9318/full/llan.359.9318.editorial_and_review.21057.1)

Men's Health Network Media Center, offering resources related to health concerns specific to men. (http://www.menshealthnetwork.org/)

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