I’m done calling it the ‘Men’s Health Crisis’ because all the men I’ve encountered in my life hate suffering, hate pain and hate illness just as much as the next human being. If it’s not the individual men that are the problem there must be more factors involved in what the WHO has recognised as a global crisis in health outcomes for men (try as I might I cannot find the report on the global men’s health crisis, but I have read it previously and if you can find it its is troubling reading). I am done seeing this as a problem with ‘men’, because the evidence would suggest it is mainly about the expectations of what a man is, or should be, in society; that would be the masculine identity.
I say this as, anecdotally at least (though never forget, anecdotes are not data), men do not wish to live in pain, to suffer and struggle through, and most of them do not want to die prematurely. I’ve read that this is a “silent crisis” which to me suggests selective deafness because if even a Curious Idiot™ like me can see it clearly it’s evidently not that silent. Perhaps we are just listening for the wrong things?
What there does seem to be is a significant influence of the idea that to take care of one’s health, to worry or to seek help is not ‘masculine’. Men should suffer, even though few if any of them want to. It is masculine to endure suffering, and feminine to alleviate it. I don’t believe this, but I believe society, as a whole, does and men in particular; even if they are not aware they believe so. Men are supposed to be able to take it. This is not merely an attitude of men to other men since there are a significant number of women out there who enforce this harmful social attitude too.
This crisis comes despite the fact that the majority of medicine’s models are built to the specifications of the average white male, despite the imbalance of numbers of scientists and doctors who are men. Globally there is a pattern of premature mortality, worse health outcomes, and a lack visits to the doctor or other healthcare professionals in men despite the system being fine-tuned for them.
Why? Since my experience dictates men are just as susceptible to pain as anyone else, could there be wider social factors applying pressure? Are men being socially coded to not show it? Is it considered weakness to admit that you are suffering a health problem?
A WHO report into men’s health in the European region has this absolutely telling line;
“The higher risk of premature mortality for men compared to women and the large differences among men are almost considered natural phenomena.”
A lot of this is not natural at all! There are a huge number of factors involved but anyone who does not see the intrinsic, masculine coding – that to suffer and endure is manly – is just not looking for it. Most of this is not innately biological and what biological factors are at play are having their effects increased by social expectation to present a masculine identity.
Men are literally killing themselves to prove to everybody how manly they are. Society expects it.
I have heard it said, and read far too many times, that differences in development and risk-seeking behaviour are the reason for a lot of this difference in mortality. Basically men are dumb, do dumb things and die younger because of it. This premature death of men through accident and misadventure allegedly skews the statistics.
However a 2021 paper – available through PNAS here – suggests that whilst this may have been true in prior generations the bulk of the difference today comes from men aged 60+, with youth mortality making only a marginal difference in comparison.
Their conclusions contain things I find it hard to find any data or anecdote to counter;
“The sex gap in life expectancy appears to be rooted in biological differences between males and females, modulated by social norms, constraints, incentives, roles and epidemiological contexts that permit behavioural and environmental differences that affect health.”
Death rates at specific life stages mold the sex gap in life expectancy
Zarulli et al, PNAS. May 18, 2021.
In essence, “Boys will be boys” kills boys, but not necessarily through things we could apportion blame for, or associate with reckless masculinity, like risk-taking behaviours. Most of it is likely wider social pressure allowing men to exacerbate ill health rather than be seen as unmanly.
According to data from the WHO (link to PDF) ‘road injury’, traffic accidents, are a large factor worldwide, taking approximately 0.47 years off a man’s life. Arbitrary risk-taking or thrill-seeking, though, is not necessarily the reason. The report states that a lot of this is down to gender related factors such as occupation. Men, worldwide, tend to take riskier jobs than women. There are numerous studies showing that men are much more likely to die either of an accident, or else of ill health, caused by their occupation than women.
However, this is nothing compared to the contribution of baseline health factors. The same report has heart disease as the biggest contributor, knocking the equivalent of approximately 0.84 years off of a man’s life. What’s more heart disease is not the lone medical issue causing premature male mortality compared to women. Cancers, respiratory conditions, self-harm and liver disease all show, globally, a greater effect on men’s mortality than they do on women’s.
So why, when as previously stated the medical models are highly favourable to men, is this?
In the UK (but I believe the pattern holds globally) men are often significantly less likely to consult their GP. Considering the UK has free healthcare at the point of service, i.e. we don’t have to pay to see a doctor, this is outrageous.
Let us look closer at heart disease. This is, without a doubt, the leading cause of death in most developed countries. It’s a human weakness, not an exclusively male one and heart disease in women is drastically understudied. However, ischaemic heart disease is approximately twice as prevalent in men as in women according to a 2017 NHS survey. It is predominantly a male health problem.
Typically, a first myocardial infarction (commonly known as a heart attack), will occur around the age of 65.
Other incredible numbers in this Gallup poll are that it suggests people without high school diplomas are about twice as likely to have been told they have had a heart attack than those with a high school diploma. Even those with a high school diploma are twice as likely to have been told they have had a heart attack than graduates. Health inequality is real and the evidence says low socio-economic status men suffer more.
(Credit: Gallup, Well-Being Index – Used without permission)
A heart attack is where blood vessels in the heart are restricted, usually by a clot. This causes a lack of oxygen to the heart tissue, which causes necrosis – tissue death – in the heart muscle. The thing is, whilst the average age of a first ‘attack’ is 65 this is usually after the onset of coronary or vascular issues, ‘furring’ of the arteries for example, caused by a combination of biology, genetics, age and lifestyle risk factors. In essence the signs are usually already there. The symptoms have likely been building for maybe a decade or more. The problem with that is that men between the ages of 16-60 are a lot less likely to visit their GP. A 2010 look at crude rates of consultation from the BMJ suggests men are around 32% less likely to visit their GP than women. A man may even be in excruciating pain, the kind of chest pain, neck and shoulder discomfort associated with a heart attack and choose to ignore it in the moment and ‘sleep it off’ rather than seek help. They suffer and die because of this. This problem does not throw itself out of the window in the face of emergency as you might expect. This runs deep.
What’s interesting to note about this BMJ piece is they go on to look at differences in consultation rates for certain conditions. In that case, where cardiovascular disease is being treated, men are only 5% less likely to visit their GP. This would suggest to me that not going to see your doctor is the biggest issue here. Once men can see the door is open and something has to be done they are perfectly willing to seek help, visit a doctor, and take care of themselves better.
Men who are aware of their heart disease go to the doctor. Men who are unaware…well they have heart attacks than can significantly decrease their long term prognosis (although modern treatment methods have mitigated this a lot) and lower their quality of life, if not kill them. I cannot immediately find data on prognosis in people after a heart attack when they were previously being treated for heart disease versus those who were not. My prediction would be that people who are being treated would, if nothing else, be likely to delay the onset of their first heart attack and have better survival rates. If for nothing else than for their own awareness of their condition and what would indicate a problem with it.
Look, I’m not here to “Woe is me!” or suggest the medical establishment needs to do better – though they clearly need to work harder on recognising and mitigating their own biases (and many, thankfully, do). There are many facets of healthcare I will criticise, especially mental health care which is often woefully inadequate. But in this case this is not a systemic issue with health and this is not exclusively a medical establishment problem. Whilst there are a lot of factors involved the biggest ones, to me, seem to be social and behavioural. The social idea of what a man is supposed to be twinned with social enforcement behaviours and attitudes is a leading cause of premature death in men. This is not merely through bullish, pig-headed defiance in those men, either. Rather the collective data seems to suggest the notion that silently suffering is masculine is a huge, if not the biggest, factor.
There’s a lot of work going on to puzzle this out and try and get men to look after their health a bit better.
I’m a man myself, and I know the pressures. Masculinity is not fixed. It is a plastic concept. It has changed across times and cultures. It is perceived differently in different countries. It is even a completely different concept across socio-economic barriers. What does seem common, however, is that it is not considered intrinsic. Rather it is something which must be ‘proved’. One is not simply a man one must show oneself to be manly. Femininity is permitted, indeed socially expected, to be passive. Masculinity is seen as an active trait.
In some circles this masculinity may be proved by wealth, success, achievement, a big house or a fancy car – but we’re not all rich! And there is a significant discrepancy – indeed the largest discrepancy – in health outcomes between rich and poor. The life expectancy difference between men and women in the UK is around 5 years. The life expectancy difference between rich and poor, regardless of sex, is around 7.5-10 years.
As a poor man what I can say is that masculinity around me was ‘proved’ by showing ‘strength’. This does not just include risk-taking behaviours; extreme sports, speeding in the car, climbing on rocks you shouldn’t be, drinking to excess etc. but was mostly done through much more casual and insidious means. Carrying a limp without getting it looked at, saying “It’s just a bit of tummy trouble” when you’re in tremendous pain, or surrounding yourself with other people acting in ways detrimental to their health for fear of judgement or social alienation.
If all of your peers smoke and yet you say “Nah, I don’t want a heart attack or lung cancer, thanks!” You will be judged. You will be mocked. You will be called a “Pussy”, a deliberately gendered, effeminising, insult. It is a specific challenge to the idea that you could be masculine. If you do not succumb to the peer pressure you are less of a man and you risk alienation and separation from your peer group.
You may be thinking “Good! They sound like dicks!” but this is poor person’s life we’re talking about here. Those peers may be your only friends and the only network you feel you can trust. They are also, often, your protection from other harmful masculine behaviours. They protect you from other men. I have covered masculine violence in another article and it, too, is horrific reading for any men who want to suggest there is not a problem of violence linked to masculinity. There is and we’re killing ourselves and each other there, too. Men are overwhelmingly, worldwide, the predominant victims of violence. Many of the same mechanisms feeding the violence problem are also feeding the health problem.
These combined factors lead us into a tangled web of misery. These health problems, being enforced by social expectations, cause more health problems, themselves then gendered, increasing social expectation and causing yet more health problems. Whilst COVID-19 may have disrupted the statistics in the last few years, suicide is generally one of the leading causes of death in men aged 20-50, if not the leading cause, claiming the lives of approximately three times as many man than women in the UK; certainly here in the UK but I believe that pattern holds true worldwide. More than misadventure, more than accident or occupational hazard, more than premature heart disease, more than cancer, men aged 50 and under are dying more by their own efforts. This does not strike me as the kind of thing that would manifest in a group of people who had no problem with their sense of personal identity.
The statistics would indicate significantly more women than men suffer mental health conditions. I have even read this as “women have an increased prevalence to mental disorders than men.” This is a statement of fact that totally ignores everything we know about reporting bias. I find this very difficult to believe, to the point of angry protestation. Men are suffering mental health issues, likely in at least equal numbers to women, they are simply not seeking help, getting diagnosed and allowing the numbers to reflect the reality. There is an excellent paper on it in the American Journal of Men’s Health here. A lot is made in the literature of the differences of presentations between male and female mental health disorders, indeed there is a paper looking at how these assumptions manifest in the research, by Smith et al, also in the American Journal of Men’s Health, here. It is suggested women are more likely to exhibit internalising symptoms – depressive behaviours, anxious behaviours, eating disorders etc. Men, meanwhile, have a higher tendency towards acting out – with defiant behaviours, violence or substance abuse for example.
One of the most telling lines in that Smith paper is;
“Research that compares men and women’s mental health neglects the similarities between men and women’s experiences of stress, instead focusing on the different outcomes of stress…”
As a man who has suffered all his life with mental health issues I can tell you that getting pissed up and into a scrap is not a ‘symptom’ of a mental health disorder in the same sense that anxiety, intrusive thoughts, depression etc. are. Acting out is an indicator that this is a person in distress, a person experiencing mental disorder, e.g. anxiety and depression. It’s a self-medication to alleviate the base symptoms! The outcome of the stress is different only because men are not permitted to leave it in its proper place and so displace their suffering.
These men are just as depressed and just as anxious. Unfortunately the manner by which men express this is often looked upon not as a sign of distress but as a personal failing, a failing of virtue or worse as a standard exhibition of masculinity. We either think of these people as perfectly normal men, or else we judge them as not good people, rather than as people in tremendous pain with no idea or understanding how to express or alleviate it due to a social pressure to prove themselves as men.
That is not to excuse the acts of violence of men, nor are all acts of violence committed out of mental distress. The data is pretty unequivocal here, too. People in mental stress, people with mental health disorders, are significantly more likely to be the victims, rather than the perpetrators, of violence. There is a very good look at the issue of violence and mental health in The Lancet, including a discussion of the financial (as well as obvious social) benefits to tackling this issue. It is quite apparent that to see violence merely as a personal failing rather than indicative of wider issues is counter to decades of biological, psychological and sociological research linking increased tendency to violence with a vast array of biopsychosocial factors. Without understanding these factors we risk never getting to the core of the problem or reaping the benefits of efforts to alleviate them.
And to pour more masculine fuel on this fire, I mentioned earlier that a huge amount of professionals in the healthcare industry are men. They are men who have ‘proven’ their masculinity by going through the arduous hard work of medical training, no less. They tend to be upper-middle class, have good incomes and a high degree of social standing – factors that would lead to their being perceived of as masculine. To what extent are these professionals enforcing and projecting the same masculine social pressures as wider society?
Whilst I’m sure it is not every doctor who would downplay the psychological suffering of a man I have consulted with GPs who definitely do just that. What’s more it is not an isolated thing. It has not been one medical professional out of all of them I have ever seen. It has been many. My dealings with mental health professionals have turned up most of those, with mental health problems being seen more often as a personal failing, something a man should just ‘toughen up’ to deal with, than other non-mental issues. The same attitudes, expectations and projections of this harmful masculine identity are embedded in the medical profession. This is not through a deliberate and systemic pursuit of them, but simply because the human individual finds it hard to put their biases to one side even when their effective fulfilment of their role requires it. As far as I am aware this is not disputed by anyone and is a key argument in any inequality debate. The innateness, indeed inertness of our bias and prejudice is one of the key barriers to effective social change.
The result is what looks in the scientific literature like a multi-faceted bias. There is a lack of study and understanding of what is perceived of as ‘feminine’ traits in men, such as depression, anxiety and eating disorders. To add to the already ludicrous stigma associated with mental illness and its symptoms, they have also become gendered. Therefore there is a perception, for example, that a man with anxiety is merely frightened, and less of a man. A man with depression is just unwilling to fight, he’s not a warrior. A man with an eating disorder is considered effeminate. Society at large makes fun of men with diagnosed eating disorders. Just consider the reception to John Prescott expressing his struggles with bulimia. He was pilloried, mocked and lambasted – for one because of his body type, but also because he was a man with what was thought of as a very feminine disorder. It’s horrific.
But this then works the other way. Not only are typically ‘male’ presentations of mental disorder – tendencies to violence or substance abuse – judged as a failing of virtue in the man rather than an exhibition of mental discomfort. Not only are ‘feminine’ presentations of mental disorder judged, dismissed or misunderstood in men. Those same issues, reversed, are then ignored in women and similarly judged as a personal, rather than a health, failure. A woman exhibiting ‘male’ presentations of mental disorder will struggle to get the care, help and understanding she needs because of those same forces.
These aspects have led to what can only be described as a wilful underestimation of the psychological problems faced by men and a dismissal of women who present with typically male medical problems not only with regards to mental health (so things such as aggression or substance abuse) but in the under-study or social judgement of those women who suffer heart disease and stroke – often considered more ‘male’ conditions. It leads to a belief that if those women are having a masculine problem they are doing something wrong. Science does not operate in a vacuum, it is not separate from society and those same wider social attitudes and judgements are also at play in the academic study and consideration of these issues. Social attitudes affect research. This gendering of health issues is harmful to men and women alike. This patriarchal health crisis makes everyone worse off! It hurts us all!
I use this argument regularly in my discussions with men when talking about gender equality. This health data is one of the primary arguments I use against ‘masculinity’ in its current form, and its place in the male identity. Men, worldwide, may be ‘winning’ in terms of gender dominance, but they are seemingly killing themselves to do it. I merely present the data and ask them if they think that’s worth it. Most, unsurprisingly, think not.
Yes, it shouldn’t require a selfish motivation for people to try to make the world, as a whole, a better place. For some, though, it’s the crowbar needed to break in the doors and open someone up to the reality. This problem is going to require men choosing to reconsider the way they think of masculinity, and society supporting them in that. Castigation, judgement, mocking or calling men idiots for finding themselves caught in a wave of current social expectation that, to challenge, would require them to adopt a pariah role is not helpful. A huge part of the problem is a lack of compassion to male suffering, and behaving like that only serves to reinforce it.
The data is, honestly, harrowing and overwhelming. It cannot be denied even in the staunchest of manly men or the most misandrist of people. The debate to be had is not “Do men suffer worse health outcomes, seek help for medical issues less, commit suicide more, and die younger?” That’s just a near-universal fact. If people want to disagree with this piece they will disagree on ideological grounds, matters of opinion, apportioning of blame or how to solve the problem. Nobody can argue with me about the data or the facts unless they also want to argue with every major medical organisation in the world.
“So what?” you might be thinking, “It’s not my problem”. Perhaps you’re a woman, a non-binary person or a man who feels it truly is masculine to portray ‘toughness’ in all aspects of your life, even to the detriment of your genuine toughness. It is hard to argue any separation between the impacts of negative health on an individual and wider society, and gender. The two things are linked. This is absolutely a gendered problem. In a world addled with male advantage this is a categorical inequality in which men are the primary victims. The numbers across time, age, wealth, race and national boundaries, show it. But the problems radiate. Men may be the primary victims, but all of society suffers.
This health crisis creates further social problems. Men are suffering. Instead of seeking help men are suffering. Yet it is nearly impossible to do so in silence, or without affecting the world around you. That pain, discomfort, distress and stress finds a way to manifest externally. Conflict, fighting, murder, mockery, bullying, physical abuse, psychological abuse and domestic abuse – these things are all linked to stress, pressure or mental health issues, particularly in men with their pressures of fulfilling a ‘masculine’ role. It becomes hard to argue against the notion of ‘toxic masculinity’ when the data suggests not only are masculine expectations slowly poisoning men and killing them prematurely, but when those same masculine expectations are contagious and negatively affecting the world around them. What’s more it is doing it in a subtle way. Most people, men and women, will not see a man suffering ‘quietly’ as being as large of a problem as it truly is. We will see masculine expressions of pain, those violent or self-destructive behaviours we have discussed, as just them being them. It is just “the way it is”, many people will think, without analysing why it is or whether or not an effort to change it could make all of us better off. Male suffering and sacrifice is socially normalised, indeed expected.
It also becomes a negative feedback loop. Those men who have learned, often the hard way, to take care of themselves are those with conditions. They die younger, leaving a corpse where a role-model could have been. There are insufficient men out there telling boys and younger men, telling their sons and grandsons, to actually take care of themselves, to be okay with not being okay. This further exacerbates the problem.
Inequalities have also made men the primary income source for families across a lot of the world. When they are no longer capable of providing it leads to increases in stress and poverty, a lower quality of life that is, itself, linked to negative health outcomes across borders, ages, races and genders. Sick men are making everybody else sicker, a lot of that being through the social idea of what a man is expected to be in society. That is to say it is not exclusively a man’s fault, but the fault of a society that so often perpetuates these expectations of a man.
The greatest irony in the whole situation is that in their attempts to not be perceived of as weak, men are making themselves objectively weaker. I don’t think there is any better demonstration of the power of perception versus reality than that. To many men it is better to be seen as strong by your peers, friends, family and colleagues than to exhibit actual strength, to maintain a strong and healthy body and mind. That’s sad, and whilst I don’t judge those unaware souls caught in the tide, any man wilfully perpetuating this notion should be ashamed.
When a man is willing to lash out and inflict pain upon the world, or worse to entirely remove himself from the world through suicide, rather than admit he is in pain himself we have serious problems with masculine identity in our society.
This piece began as a sardonic joke on Twitter about how society would respond if men got periods. I responded to the original tweeter who suggested we’d have “So many treatments and other forms of care available.” And I understand that perspective. As mentioned the medical models we use are biased to the white, male body. However I said I was too cynical to agree. Instead we’d ‘tough it out’ but, unable to control the pain and our hormones we would lash out. Meanwhile society would do little to help our plight or hinder our destruction. It would go down as “boys will be boys!” and much as men might dismiss a tearful woman by saying “On her period…” in a world of the masculine period it wouldn’t be screams and tears we would forgive – it would be violence and destruction.
I am glad I don’t live in that world. The things I have looked at not just today but over the course of years of being a mentally ill man, the data I have seen, the opinions of doctors, psychologists and social scientists seems to indicate that the fragility and insecurity, the inability to express male pain and suffering, for all the complex reasons discussed here, is already causing untold harm on people worldwide. Matched with the masculine identity as it stands, and the attitude towards health that it has inherited from successive generations who harmed themselves and others but insist they “turned out just fine!”, the male period would be a nightmare.
Perhaps, though, the regularity of that pain and discomfort, the inescapability of it, the unifying nature of it being prevalent across men would lead to something wonderful; A male acceptance that they are, as everyone else, a fragile sack of meat-mechanics. Things fail; physically, mentally and emotionally, in the human body. This is not effeminate, it is inevitably human. Whilst there would likely be some judgement, much as people judge women for expressing discomfort during their periods. Indeed in male/male interactions there could be a lot of “Nah my period doesn’t hurt, you’re just a pussy!” But perhaps a universal and relatively blame-resistant condition behind which all men could empathise with each other, and truly know and share each other’s pain, would alter that identity. Indeed, experiencing and expressing pain could, itself, become part of a new masculine identity in those circumstances.
Sadly this is just speculation and the reality is that men hurt, but they attempt not to show it. They suffer, but they don’t talk about it. They die young, often of things that if not preventable were at least treatable sooner. Instead men kill themselves. It’s tremendously sad, and it needs to change if we hope to have anything like a future with more compassion, equality and understanding.
Equality will never be won ignoring these stark and difficult facts about men’s health. I can see few, if any, negatives to men being socially permitted to take care of their health. Financially, socially and as far as advancing the causes of equality goes – It is win, win, win.
What I do see is the current carpet-bomb of misery that the ignorance of men’s health causes, not just for men but for everyone.
We ignore it at everyone’s peril.
We Lack Discipline 