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Report of a one-day multidisciplinary conference held on
Tuesday 11 December 2001 at the Royal College of Physicians,
Regent’s Park, London by kind permission of the treasurer
Tackling men’s health inequalities: what can the government do?
Richard Parish, Health Development Agency
The state we’re in: an overview of men’s health
Peter Baker, Men’s Health Forum
Why being apple shaped is such a big problem
Tony Barnett, University of Birmingham and Birmingham Heartlands Hospital
Testosterone and the cardiovascular system – friend or foe?
Peter Collins, National Heart & Lung Institute, Imperial College of Science, Technology and Medicine, London
Prevention: what works?
David Wilkins, Healthworks, Dorset
Prostate cancer: separating out the high-risk cancers
Tim Oliver, St Bartholomew’s Hospital & Royal London Hospital
New treatments for erectile dysfunction
Roger Kirby, St George’s Hospital, London
Getting men to see the doctor
Shaun O’Leary, The Prostate Cancer Charity
Hidden illness: hidden patients: hidden cost
Rodney Elgie, GAMIAN-Europe
Helping young men ask for help
Pippa Sargent, Campaign Against Living Miserably (CALM)
The role of health authorities
Meryl Johnson, Worcestershire Health Authority
Health promotion: getting the message across to men
Maggie Robinson, Community Learning Consultant
Community health development: opportunities and challenges
Terry Drummond, Community Health UK
Primary care: what can we do?
Jane Deville-Almond, Independent Nurse Consultant in Primary Care
Getting them young: promoting men’s health in schools and colleges
Simon Forrest, University College London
The Men’s Health
Sponsored by an
MEN’S Forum in
the Men’s Health
from Lilly Icos
Welcome and IntroductionDr Ian Banks, President, Men’s Health Forum Men’s Health Conference
Royal College of Physicians
11 December 2001
“This conference could not be better timed,” said DrBanks: ■ The UK Men’s Health Forum now has six staff and ■ There is an All-Party Parliamentary Group on Men’s ■ The Men’s Health Journal was launched in 2001 ■ National Men’s Health Week will take place on ■ The first, highly successful World Congress on Men’s Health was held in Vienna in November 2001and saw the launch of the European Men’s HealthForum ■ There is now an International Society for Men’s The aim of the conference, continued Dr Banks, is not simply to complain about the condition of men’shealth, but to highlight the problems and to suggestpractical action to improve the situation. He stressedthat it is no longer appropriate to adopt the ‘divide-and-rule’ approach, which compares the health of menand women, since the health of men and the health ofwomen are inextricably linked. Instead, the conference should focus on more relevant inequalities such as the 10-year difference inmale life expectancy between the north and south ofthe UK. “It is these inequalities that we wish to THE MEDICAL EDUCATION
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WITH THE MEN’S HEALTH
For further information contact
Tel: 44 (0) 1279 714510
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Tackling men’s health inequalities: what can the government do?Richard Parish, Chief Executive, Health Development Agency, London According to Professor Parish, inequality – whether defined Table: Priorities for men’s health services
by social class, geography, ethnicity, or gender – is a major theme for all the work of the Health Development Agency New ways of providing services to men, such as (HDA). This is because the government regards inequali- ties in health as a major priority – an attitude that is influencing government policy for the National Health Health information that is sensitive to the needs of men and enables them to access the services that they need “We probably now have the best-ever policy canvas Consideration of men’s health through all the planning across the whole of government to tackle inequalities in health,” continued Professor Parish. Some people may Professional training that takes account of men’s health question the precise targets for reducing inequalities, but the very fact that targets now exist gives a sense of direc-tion and raises the profile of the issue. The NationalService Frameworks (NSFs) are another important move occupational health services should be strengthened.
forward, though they do not necessarily focus on gender Professor Parish also drew attention to priorities in the Department of Health’s R&D programme that are rele- Professor Parish drew attention to the Chief Medical vant to men’s health such as: the prevention of deliberate Officer’s Annual Report for 1992, in which Sir Kenneth self-harm and suicide, reducing risk-taking behaviour, Calman commented on the considerable scope for men to diagnosis and treatment of male-specific diseases, and – improve their health and to prolong active healthy life1.
perhaps most important – involving men in health-related ■ In general men experience five years less life expectancy Professor Parish stressed the importance of building than women. More importantly, the variation in life men’s health issues into Health Improvement (HImP) expectancy between social classes I/II and social classes plans. Local authority community plans should also take IV/V is greater in men than in women – over 5 years account of men’s health needs, and Local Strategic Partnerships will provide the opportunity to take an over- ■ Death rates for heart disease and all cancers are higher arching view of inequalities of all kinds. “Increasingly, in men. The male suicide rate is almost four times that with the emergence of primary care trusts (PCTs) and the of women. More men are overweight, although slight- appointment of Directors of Public Health, I would cer- ly more women are classified as obese.
tainly hope and expect that there will be an annual public ■ Men visit their general practitioner (GP) much less fre- health report from each PCT that will involve issues such As outlined in a recent HDA literature review2, To Professor Parish, the role of the voluntary sector is traditional male characteristics are rarely considered when absolutely critical, since these organisations can act as planning services. Sexual health is still viewed very much as strong advocates for men’s health, representing the needs a female, and not a male, issue. Most significantly, there is of a very diffuse group of people in planning and consul- still no proper understanding or definition of what consti- tation mechanisms. The voluntary sector may play an tutes men’s health. “This is a barrier to the provision of ser- important role in delivering services and contributing to vices and the training of health and other professionals,” the research agenda, in public education, and in monitor- ing the work of the NHS and agencies such as the HDA. There is the potential for many initiatives, but Professor Finally, Professor Parish concluded: “It is essential to Parish identified several priorities to be taken into account involve men in decision-making, since planning that truly when developing services (Table). Services should also be takes into account the needs of people on the ground has sensitive to men’s concerns and attitudes. There should be to be at the heart of improvements in services.” more men’s health clinics (drop-in clinics seem to be espe-cially popular). Telephone and online services should be developed, since men prefer the anonymity of such 1. Annual Report of the Chief Medical Officer. On the state of the public health. December 2001. www.doh.gov.uk/cmo/annualreport2001.
services. Opening hours should take account of the com- 2. Health Development Agency. Boys’ and Young Men’s Health.
mitments of people who work full time, and the role of London: HDA, 2001. ISBN 1-84279-061-7.
The state we’re in: an overview of men’s healthPeter Baker, Director, Men’s Health Forum “If I had to summarise the state of men’s health, I would Table: Main causes of death in men (1999)1
say that it could be better,” commented Mr Baker. Many analyses of men’s health still make a simplistic comparison of men’s and women’s health statistics to demonstrate that men are disadvantaged, he continued.
While this may have been a useful approach a few years ago when the case for men’s health still needed to bemade, it is now unhelpful because:■ Women’s health is not the gold standard. Women have (GUM) clinics compared with 217,639 in 1995. It is, serious, specific health problems, which are neither however, surprising that so many men are attending highlighted nor solved by a comparison with men. these clinics, continued Mr Baker, because a Men’s ■ An unsophisticated analysis that compares men with Health Forum/Doctor-Patient Partnership survey found women masks inequalities within men’s health. that about 20% of men believe that a GUM clinic deals ■ It also encourages unhelpful competition between with gum problems. “It is difficult to think of a more ludicrous name for a service that is supposed to be about “Now, however, we are moving towards to a position where men and women are working together to put gen- The increase in reported cases of chlamydia – from 14,303 in 1995 to 24,523 in 1999 – is a particular prob- Mr Baker explained that, while life expectancy for all lem, continued Mr Baker, because although it is largely men at birth is 74 years in England and Wales, this masks asymptomatic in men, the infection can have serious con- wide differences between professional and unskilled men sequences for the future fertility of women. As a result, (77.7 years versus 68.2 years)1. There are also inequalities the Men’s Health Forum is now pressing the case for between areas of the country: for example, there is a 10- year difference in life expectancy between men living in According to Mr Baker, hours of work are one indica- central Glasgow and men living in parts of Bucking- tor of growing male levels of stress, which is a known hamshire2. Indeed, the CMO’s latest Annual Report cause of mental and physical problems. On average, mencommented that the current death rates of unskilled men work 40 hours per week, but 25% of men without, and in parts of Stockton-on-Tees, Liverpool and St Helens 33% of men with, dependent children work more than were similar to the national average for the 1940s3. Disease of the circulatory system, especially heart dis- Mr Baker reported that the average man goes to the ease and stroke, is the largest single cause of death in GP four times a year – a figure that means little in isola- men, continued Mr Baker. This illustrates why men’s tion but that is relatively low – and men are particularly health must be considered in its widest sense and not be poor at attending preventive primary care health clinics.
confined to male-specific diseases. Mr Baker added that He advised that any strategy to improve men’s health the CMO’s report also highlighted the growing problem must increase men’s use of primary healthcare services, of alcohol misuse. Twenty-seven per cent of men drink which could mean operating clinics in non-traditional over the recommended 21 units a week, a percentage settings, such as the workplace, pubs, clubs and barber that rises to 36% in younger men (aged 16-24 years), who are also more likely to engage in binge drinking3.
“I think that, until we develop a health service and An increasing proportion of men have a body mass policies that effectively meet men’s needs, men’s health index (BMI) >25 (usually considered the upper limit of will remain a contradiction in terms and one of the great- desirable). Being overweight increases a man’s risk of est areas of health inequality will remain entrenched,” diabetes, heart attack, hypertension and coronary heart disease (CHD): a man with a BMI of 22-23 is about halfas likely to suffer from CHD than a man with a BMI >30 and he is eight times less likely to develop diabetes4.
1. Office for National Statistics. Social Focus on Men. London: The This problem will worsen as men become increasingly sedentary and eat a high fat diet, he added. 2. Griffiths C, Fitzpatrick J. Geographical inequalities in life expectancy Mr Baker drew attention to another important indica- in the United Kingdom, 1995-97. Health Statistics Quarterly 2001; tor of male health: the recent increase in rates of sexually 3. The Annual Report of the Chief Medical Office at the Department of transmitted infections (STIs). In 1999, 271,552 new Health. London: Department of Health, 2001.
episodes were reported to genitourinary medicine 4. Baker P. Real Health for Men. London: Vega, 2002.
Why being apple shaped is such a big problem Tony Barnett, Professor of Medicine, University of Birmingham and Birmingham HeartlandsHospital Professor Barnett reported that in the last 15 years UK ≥ 36 inch waist or if you are a man with a ≥ 40 inch waist, rates of obesity (body mass index [BMI] >30) have tre- you have a greatly increased risk of type 2 diabetes, bled from about 6% to around 20%, and approximately insulin resistance and cardiovascular disease” 6.
60% of the population is now overweight (BMI >25)1.
Professor Barnett explained that adipocytes (fat cells) This has particular implications for men because, although secrete several factors involved in insulin resistance, includ- there are more obese women, a higher proportion of men ing a recently identified fat-cell-derived hormone called are overweight. In addition, there will be major public- resistin. Levels are increased in female rats with either health problems in future because about 15% of teenagers genetic or diet-induced obesity7. In these animals, resistin and over 12% of young children in the UK are now clini- causes impaired glucose tolerance, and insulin action is cally obese2. Professor Barnett explained that the reasons improved if resistin protein expression is reduced. These for this explosion in obesity are increased fat in the diet animal data may not apply to humans, but according to a and, more important, sedentary lifestyle. “As a nation, we recent report8, there is four times the level of resistin are very, very sedentary. We do not take sufficient exercise” expression in central fat stores compared with peripheral fat, possibly linking the hormone with insulin resistance, Obesity is a disease in its own right. This is especially and suggesting the possibility of future treatments. true of central obesity involving the abdominal organs in a Professor Barnett ended on a positive note by drawing so-called ‘apple distribution’ of fat. This is not only very attention to the potential benefits of even moderate strongly linked to insulin resistance, but also to increased weight loss (Table). “What is more, these benefits do not cardiovascular risk, dyslipidaemia, hypertension and type include the substantial benefits to psychological and Professor Barnett outlined the long-term consequences of obesity. It trebles the risk of sudden death by about Table: Benefits of 10 kg weight loss over five
three fold, doubles the risk of stroke or heart failure, and years in a person with obesity
increases the risk of coronary heart disease (CHD) by 1.5 fold. “It is important to point out that this is predictive and independent of age, cholesterol, blood pressure, >40% ↓ obesity-related cancer deaths smoking, glucose intolerance, and other risk factors,” he Similarly, there is a 100-fold increased relative risk of type 2 diabetes in middle-aged people with the highest BMI compared with those with the lowest BMI4. In short, obesity is the single most important modifiable risk factor, not only for cardiovascular disease but also for type 2 diabetes. The likelihood of respiratory disease, hormonal abnormalities, and gout are also increased, and there is a Adapted with permission from Obesity in Scotland, SIGN 19969 higher (and less well known) risk of certain cancers, forexample colon and prostate cancer. References1. Report of the British Nutrition Foundation Task Force. Oxford: In the UK the insulin resistance syndrome is a particular problem in some ethnic groups, especially the Asian popu- 2. Reilly JJ, Dorosty AR. Epidemic of obesity in UK children. Lancet 1999; lation, added Professor Barnett. Recent data suggest that 3. Hubert HB, Feinleib M, McNamara N, et al. Obesity as an independent 25% of adult members of the Asian community now have risk factor for cardiovascular disease: a 26-year follow-up of type 2 diabetes5. “This is a real problem in many parts of participants in the Framingham Heart Study. Circulation 1983; 67(5): the country. For example, people of Asian ethnicity com- 4. Colditz GA, Willett WC, Rotnitzky A, et al. Weight gain as a risk factor for prise well over one third of my patients in Birmingham clinical diabetes mellitus in women. Ann Intern Med 1995; 122: 481–86.
and represent 12% of the UK diabetic population.” 5. Mather HM, Keen H. The Southall diabetes survey: prevalence of According to Professor Barnett, this increased risk of known diabetes in Asians and Europeans. BMJ 1985; 291: 1081–84.
type 2 diabetes is not a consequence of migration, but of 6. Lean MEJ, Hans TS, Seidell JC. Waist circumference indicates a larger burden of ill health than body mass index. Lancet 1998; 351: 853–56.
westernisation, since the prevalence of type 2 diabetes 7. Steppan CM, Bailey ST, Bhat S, et al. The hormone resistin links rises dramatically among people living in, for example, obesity to diabetes. Nature 2001; 409: 307–12.
India who become westernised. The explanation is not 8. McTernan CL, McTernan PG, Harte AL, et al. Resistin, central obesity and type 2 diabetes. Lancet 2002; 359: 46–47.
entirely clear, but one of the major factors appears to be 9. Scottish Intercollegiate Guidelines Network. Obesity in Scotland.
the presence of abdominal fat. “If you are a woman with a MEN'S HEALTH
Testosterone and the cardiovascular system - friend or foe?Peter Collins, Professor of Clinical Cardiology and Honorary Consultant Cardiologist, NationalHeart & Lung Institute, Imperial College of Science, Technology and Medicine, London Although myocardial infarction (MI) or heart attack – CAD and low testosterone underwent a treadmill test to caused by atheroma (fatty plaques) in the coronary blood assess their exercise capacity. The men were then given an vessels – is the commonest cause of death in both men and i.v. dose of testosterone, followed 40 minutes later by women, women usually develop coronary artery disease another treadmill test. When the men received testosterone (CAD) 10-15 years later than men. According to a long- they were able to exercise further to angina pain than when standing theory, this is because women are protected by they were given a placebo, demonstrating that testosterone oestrogen, which is said to benefit the cardiovascular sys- has a beneficial effect on myocardial ischaemia5. This prop- tem, unlike testosterone – the so-called ‘male’ hormone – erty has been confirmed in a recently published four-week which is thought to increase the risk of CAD. transdermal testosterone treatment study, demonstrating a However, research indicates that the relationship chronic beneficial effect on myocardial ischaemia in men between levels of free testosterone (i.e. in the blood) and with coronary heart disease6. The mechanism of benefit CAD in men is not so straightforward in practice. For may involve its ability to increase the release of nitric oxide example, the extent of CAD was scored in 55 men, based from the endothelium (lining of the blood vessels)8.
on the amount of atheroma in their coronary arteries. The Testosterone may not be that detrimental to women with investigators expected that there would be a positive rela- CAD. All women release androgens (‘male hormones’) tionship between CAD and levels of free testosterone, but including testosterone from the ovaries and adrenal glands, they found quite the opposite. There was in fact an inverse and the relationship between endogenous or natural levels relationship – that is, CAD was more likely in men with of free testosterone and atheroma in the carotid artery has low levels of free testosterone1. “Of course, this did not tell been assessed in pre- and postmenopausal women. The us that testosterone is good for the heart, but it made us investigators found that, within the physiological range, think about whether testosterone is actually as bad as we higher endogenous levels of testosterone in women are thought,” commented Professor Collins. associated with a lower risk of carotid atheroma, suggest- Subsequent animal studies demonstrated that testos- ing that testosterone may not adversely effect the cardio- terone is in fact a coronary vasodilator. It relaxes, rather than constricts, coronary arteries2, and in relatively high “In conclusion,” said Professor Collins, “testosterone concentrations increases coronary blood flow in animals3.
may not be as bad or as harmful to the cardiovascular sys- It seems that this effect is specific to testosterone and is tem as we once thought. I cannot make any claims about reduced in analogues of the hormone. “Using different long-term benefit, as those studies have not been done, but testosterone analogues the relaxing potency can decrease by I think we have enough information now to develop scien- almost 90%2. This suggests that the relaxing response to tific rationales for further long-term randomised studies on testosterone relies on the shape of the molecule”, explained the effect of testosterone on the vasculature in men with The beneficial, vasodilatory effects of testosterone were demonstrated in humans in a study involving 13 men with a mean age of 61(±11) years with either one or two vessel 1. Phillips GB, Pinkernell BH, Jing TY. The association of hypotestosteron- aemia with coronary artery disease in men. Arterioscler Thromb 1994; CAD. Testosterone was infused directly into the coronary artery, and at low concentrations significantly increased 2. Yue P, Chatterjee K, Beale C, et al. Testosterone relaxes rabbit coronary coronary blood flow from baseline. This was not dose- arteries and aorta. Circulation 1995; 91 (4): 1154–60.
3. Chou TM, Sudhir K, Hutchison SJ, et al. Testosterone induces dilatation dependent, but a direct effect of testosterone on the coro- of canine coronary conductance and resistance arteries in vivo.
nary arteries4. Interestingly, the baseline levels of testos- Circulation 1996; 94 (10): 2614–19.
terone were at the lower limit of normal (about 11 4. Webb CM, McNeill JG, Hayward CS, et al. Effects of testosterone on coronary vasomotor regulation in men with coronary artery disease.
nmol/L) in these men – who were not selected because of Circulation 1999; 100 (16): 1690–96.
their testosterone levels but because they had CAD – while 5. Webb CN, Adamson DL, de Zeigler D, Collins P. Effect of acute oestradiol was 139 p/L. “This level of oestrogen is proba- testosterone on myocardial ischaemia in men with coronary arterydisease. Am J Cardiol 1999; 83 (3): 437–39.
bly higher than in most postmenopausal women; indeed 6. English KM, Steeds RP, Jones TH, et al. Low-dose transdermal many people do not realise that oestrogen levels in men are testosterone therapy improves angina threshold in men with chronic on the whole greater than in postmenopausal women,” stable angina. A randomised, double-blind placebo-controlled study.
Circulation 2000; 102(16): 1906–11.
7. Ong PJ, Patrizi G, Chong WC, et al. Testosterone enhances flow- Testosterone has also been investigated for its potential mediated brachial artery reactivity in men with coronary artery disease.
anti-anginal properties; that is, whether it can improve Am J Cardiol 2000; 85 (2): 269–72.
8. Bernini GP, Sgro’ M, Moretti A, et al. Endogenous androgens and myocardial ischaemia (inadequate blood flow to the heart carotid intimal-medial thickness in women. J Clin Endocrinol Metab because of coronary atheroma). In this study, 14 men with MEN'S HEALTH
Prevention: what works?David Wilkins, Lecturer/Practitioner in Health Promotion, Healthworks, Dorset Mr Wilkins described a Dorset-based programme that has Table: Attitudes to exercise and fitness of men
successfully educated and improved the health of men aged over 40
aged over 40. The programme was inspired by three facts: It is ‘natural’ to put on weight with increasing age and it ■ Two thirds of men in the UK are overweight ■ Weight gain increases with advancing age and peaks It is a pity to lose physical attractiveness but it is ■ Being overweight increases a man’s risk of a number of ‘unmanly’ or a ‘women’s thing’ to worry about it diseases, including heart disease and diabetes.
They knew little about nutrition and depended on their Against this background, the aims of the programme were to encourage men aged over 40 to lose weight, increase their physical activity and improve their knowl- ‘Keeping fit’ is a ‘middle class’ concern Mr Wilkins explained that the first step was to hold struc- Team sports are more fun than exercising alone tured discussion groups drawn from men in the target age group – ‘a process of reflective analysis’ – that revealed not If you are unfit, it is embarrassing to exercise with people only the men’s negative attitudes towards fitness and exer- cise, but also their positive, practical advice (Table). The A work-based programme is more likely to attract men’s feedback was used to design a programme that has been relatively successful in working with a target groupwhich is acknowledged to be difficult to reach. The programme takes the form of an inter-workplace shown clear improvements in fitness, knowledge of competition in which teams of eight men compete over six health, and reduced stress levels, while longer-term months to lose body fat, continued Mr Wilkins. Each team follow-up suggests that the men maintain their weight is supported by a local health professional – usually a health loss and increased levels of physical activity.
visitor – who advises on healthy eating, physical activity Although work itself is a major cause of illness and and stress management. In order to avoid embarrassment stress, the programme has demonstrated that the work- and to build up team camaraderie, teams can only be select- place can be a key setting for health improvement. It also ed from men aged 40-55 with a BMI >27. A monthly should also be recognised that some individuals (such as ‘league table’ is published, and at the end of each ‘season’ a working-class men) are more at risk. Furthermore, it is trophy is awarded to the winning team and the individual essential to consider not only prevention of illness, but also how we improve men’s health. “People don’t just Mr Wilkins reported that the competitive element in the want to prevent illness, they want to feel well and happy.
programme had provoked some adverse comments from We should ask ourselves what we can do to work with fellow health-promotion professionals. “Typically I am men to improve men’s health and quality of life,” he asked whether the programme panders to the ‘worst aspects’ of being a man. However, if we are going to Mr Wilkins’ final recommendation was that men’s encourage men to improve their health, we need to take health should be seen within a sociological and cultural specific account of male sensibilities,” he commented. context. “We cannot hope to improve men’s health simply Since 1995, the programme has been operated four by individual health promotion programmes – important times with a new season about to start. Mr Wilkins added as they are – and we cannot just leave it to the NHS to that the programme has been refined over the years, most provide treatment. We must think, for example, about notably with a final quiz to maintain interest in the compe- work/life balance, the way we work with young men in tition. The programme, which has been well supported by schools and social centres and so on. We need to do this in both participants and local employers, was evaluated in a coordinated and structured way. It is the only way that 1995 and is about to be reassessed. Men involved have we will make the changes that are needed,” he concluded.
Prostate cancer: separating out the high-risk cancers Tim Oliver, Sir Maxwell Joseph Professor in Medical Oncology, St Bartholomew’s & RoyalLondon Hospital Despite at least 25 studies, no one has ever shown that one Japanese study, there was a significant association patients at time of diagnosis of prostate cancer have higher between prostate cancer and prostatitis, phimosis, high ani- testosterone levels than unaffected men. The majority of mal fat and low consumption of vegetables2.
studies have shown no difference; in fact, there are more The role of testosterone in controlling progression of showing a possible connection with lower, rather than prostate cancer is equally relevant in determining treatment strategy. There has been a long-standing debate about the However, the association between testosterone levels at timing of chemical castration (endocrine therapy), espe- puberty and future risk of prostate cancer is clearer, and cially whether it should be deferred for as long as possible.
may be critical for the initiation of cancer, particularly when However, it is now thought that the gain from endocrine the ethnic distribution of prostate cancer is examined. At therapy is far clearer in patients who receive treatment puberty, Africans have higher levels and greater risk than early, despite the inevitable increasing problems from side Caucasians, but interestingly Japanese men, who have an intermediate level of testosterone, are at lowest risk.
Animal studies suggest that intermittent androgen Professor Oliver explained that this is due to them having a therapy may double survival time3, but at present most much lower level of androgens in the prostate as a result of men – over 95% – are given continuous treatment. This a relative deficiency of 5-alpha reductase – the enzyme that issue has been investigated in phase II studies involving converts testosterone into 5-alpha-dihydrotestosterone over 400 men4, but there needs to be randomised phase III (DHT), which plays a key role in controlling prostatic studies to be sure it is safe to use intermittent therapy.
“However,” commented Professor Oliver, “over one quar- At puberty high testosterone levels might interact with ter of men can go for more than three years off treatment.
sexual behaviour to initiate damage to the prostate. One So there are definitely men in whom intermittent treat- study suggested that starting sexual intercourse below the age of 16, and the acquisition of subclinical (early, asymp- After a cycle of intermittent anti-androgen therapy, men tomatic) infection with chlamydia increases levels of are still candidates for radical surgical or radiotherapy prostate-specific antigen (PSA) more than 50 years before treatment if their PSA rises (an indication of disease pro- prostate cancer develops1. “This observation has important gression). “In my opinion, the use of intermittent andro- implications for health promotion given the conventional gen blockade, even just bicalutamide (Casodex), could be focus on the consequences of chlamydial infection in a method of improving case selection to determine which women,” commented Professor Oliver.
men with early prostate cancer need radical treatment,” The concept that low-grade sexually acquired infection may lead to prostate and testes damage, causing accelerated Professor Oliver concluded that testosterone definitely loss of testosterone drive, may explain why there is a less plays a part in the development of prostate cancer, but its clear association with testosterone levels at the time of diag- role is modulated by low-grade sexually acquired infec- nosis of prostate cancer than at puberty. It may also explain tion. Young men need to be educated about these risks why, because of the promotion of safer-sex practices follow- around the start of puberty. As a substantial number of ing the AIDS’ epidemic, mortality from prostate cancer has men with prostate cancer survive without disease progres- declined both in the UK and the USA in the last 15 years sion after a cycle of intermittent anti-androgen treatment, despite the lack of a prevention programme in the UK.
despite maintaining their testosterone levels, it may be Professor Oliver described testosterone as the ‘tiger in the possible to use early relapse after such therapy to distin- tank’ of prostate cancer. It is involved in the initiation and guish those men who need radical treatment. development of the disease, but it is not the main cause –indeed, the most malignant cancers are seen in men with low testosterone levels at diagnosis, perhaps because of 1. Oliver JC, Oliver RTD, Ballard RC. PSA in patients attending an STD clinic. Prostate Cancer and Prostate Diseases 2001; 4: 228–31.
Other factors that increase the risk of prostate cancer 2. Nakata S, Imai K, Yamanaka H. Study of risk factors for prostatic cancer. Hinyokika Kiyo 1993; 39 (11): 1017–24.
include exposure to pesticides, radiation or heavy metals 3. Sato N, Gleave M E, Bruchovsky N, et al. Intermittent androgen such as cadmium, and nutritional deficiencies, especially of suppression delays progression to androgen-independent regulation vitamins A and D. In short, prostate cancer may be the of prostate-specific antigen in the LNCaP prostate tumour model. J result of early, subclinical prostate damage that is main- Steroid Biochem Mol Biol 1996; 58 (2): 139–46.
4. Oliver RTD, Farrugia D, Answell W et al. Intermittent hormone tained over a lifetime by environmental factors. These risk therapy for M+ +MO prostate cancer. Prostate Cancer and Prostate factors are equally relevant even in a low risk population. In MEN'S HEALTH
New treatments for erectile dysfunctionRoger Kirby, Professor of Urology, St George’s Hospital, London “There is probably no field of medicine that has seen a Tadalafil has similar efficacy rates. At 16-24 hours it has a greater transformation in the way treatment is directed longer half-life than sildenafil and vardenafil6. According to than erectile dysfunction (ED). Over a decade, treatment Professor Kirby, the longer duration of action of tadalafil has gone from surgery to injection therapy and then to would avoid the need to take the tablet just before inter- effective oral drugs,” said Professor Kirby.
course. This may mean that for some patients less planning Since its launch in 1998, sildenafil (ViagraTM) has been is involved in their sex life. The optimum dose of tadalafil a phenomenal success, continued Professor Kirby. It has been given to over 15.5 million men in over 45 million Although there are no comparative data yet for the prescriptions and has revolutionised the treatment of ED.
PDE5 inhibitors, side effects for vardenafil and tadalafil, In randomised, controlled studies, sildenafil produces like sildenafil, appear to be mild and transient and include dramatic improvements in erectile function and inter- headache and dyspepsia. Vardenafil is not associated with course satisfaction with a mean 5.9 successful attempts at any blue vision reporting, but there have been reports of intercourse in men taking sildenafil compared to 1.5 for some vision disturbance7. Tadalafil is not associated with those taking placebo1. Interestingly in depressed men any visual disturbances and incidence of facial flushing is with ED, sildenafil not only improves erections, but also Professor Kirby said that three years after its launch, The only published sub-group data on ED treatments for there is no question that sildenafil is an effective and well- patients with cardiovascular disease relate to sildenafil, tolerated treatment for ED. Apomorphine SL is likely to showing improvement in erections in 70% of patients with be the first of many drugs that act on the brain to ischaemic heart disease (IHD), compared with 20% in the improve sexual function. Early data suggest that other placebo group. Similar efficacy is seen in men with hyper- new drugs may also offer benefits to millions of patients tension. A recent analysis of pooled data confirms treat- suffering from this prevalent condition that demoralises ment to be effective and well-tolerated in ED patients both men and women. However, despite the revolution across a wide range of conditions including IHD, diabetes in the treatment of ED, just 10% of men with the condi- and depression2. Published Prescription Event Monitoring tion currently receive NHS prescriptions. The govern- data confirms no increase in cardiovascular events or risk in ment remains concerned about the potential costs to the users of sildenafil than in the average population. Also, in a NHS and Professor Kirby believes that it remains study including men with exercise-limiting angina, silde- extremely difficult to convince the Department of Health nafil actually increased the time men were able to exercise that ED is a serious condition – patients deserve effective before they experienced angina pain3.
Professor Kirby continued with data relating to apo- morphine SL (Uprima), licensed in the UK in October 2001. Apomorphine promotes an erection by acting on 1. Goldstein I, Lue TF, Padma-Nathan H, et al. Oral sildenafil in the treatment of erectile dysfunction. Sildenafil Study Group. N Engl J the brain rather than on the blood vessels in the copora cavernosa in the penis. It may be less effective than silde- 2. Osterloh I, Gillies H, Siegel R, et al. Efficacy and safety of ViagraTM nafil4, but there have been no head-to-head studies pub- (sildenafil citrate). Presented at the 4th Congress of the European lished to date. In clinical trials, 30% of patients taking 3 Society for Sexual and Impotence Research 2001, Rome, Italy.
3. Fox K, et al. Time to onset of limiting angina during treadmill exercise mg apomorphine SL reported an improvement in erectile in men with erectile dysfunction and stable chronic angina: effect of function and 28% improvement in intercourse satisfac- sildenafil citrate. Presented at the American Heart Association’s tion versus 4% and 12% in the respective placebo groups.
Scientific Sessions 2001, Anaheim, California. A100019. (Fox K, etal, Circulation 2001; 104 (17 Suppl): II-601-II-602) Apomorphine SL is taken sublingually, and has a rapid 4. Dula E, Bukofzer S, Perdock R, et al. Apomorphine SL Study Group.
onset of action (20 minutes). It is associated with nausea Double-blind crossover comparison of 3 mg apomorphine SL with and yawning when the dose is increased from 3 mg to 4 placebo and with 4 mg with placebo in male erectile dysfunction.
mg4, but Professor Kirby reported a positive response Eur Urol 2001; 39 (5): 558–63.
5. Klotz T, Sachse R, Heldrich A, et al. Vardenafil increases penile rigidity and tumescence in erectile dysfunction patients; A RigiScan Not yet licensed, tadalafil and vardenafil, like sildenafil, and pharmacokinetics study. World J Urol 2001; 19(1): 32–39.
belong to the drug class, phosphodiesterase type-5 6. Patterson B, Bedding A, Jewell H, et al. Dose-normalised pharma- cokinetics of tadalafil (IC351) administered as a single dose to healthy (PDE5) inhibitors. Vardenafil appears to be as effective in volunteers. Presented at the 4th Congress of the European Society treating ED in men with diabetes as in other physical for Sexual and Impotence Research 2001, Rome, Italy.
causes of ED. Professor Kirby added that vardenafil has a 7. Porst H, Rose R, Padma-Nathan H, et al. The efficacy and tolerability of vardenafil, a new oral selective phosphodiesterase type reassuring dose-response curve with clear improvement 5 inhibitor, in patients with erectile dysfunction; the first at-home in rigidity and duration of erections as the dose increases5.
clinic trial. Int J Impotence Res 2001; 13 (4): 192–99.
Getting men to see the doctorShaun O’Leary, Director of Operations, The Prostate Cancer Charity Mr O’Leary reported that men (especially young men) when discussing ‘trouser problems’ such as prostate are far more reluctant than women to consult their GP.
cancer, and is probably one reason why many men pre- There are significant differences between men’s and fer to use the telephone or the internet to seek health women’s use of health services because women are information, especially about intimate problems.
brought into the healthcare system at an early age. For Men’s embarrassment may be heightened by their lack example, young women visit health professionals to of the correct vocabulary to describe their symptoms: obtain contraception, and then antenatal and postnatal for example, they may not be familiar with terms such care. Later in adult life, women tend to be responsible for bringing the children to the GP for immunisation, and ■ Socialisation – that is, how we see ourselves and how also attend the surgery for their own regular preventive we believe that we should behave – also makes it diffi- care, such as cervical smears or menopause clinics.
cult for men to regard a concern with health as part of Men’s lack of contact with primary care is important because, in the long run, it prevents them from addressing Mr O’Leary advised that health interventions are more their healthcare needs, continued Mr O’Leary. Visits to likely to be effective if they are targeted to the needs of GPs are not only concerned with the treatment of illness.
different groups of men. Health services should be made If men do not visit their local surgery, GPs and other pri- more attractive to men – at present health centres seem mary healthcare professionals miss vital opportunities to dominated by health promotion material for women and intervene to discuss health promotion and offer preven- children – and evening surgeries and drop-in clinics should be provided. Services should also seek men out at According to Mr O’Leary, there are several reasons why work and at sports centres, and in pubs and clubs. Male- men do not visit their doctor. Married men tend to rely specific health-promotion materials should be produced on their wives to manage their health1, and as a result are to challenge typical risk-taking behaviour, such as heavy in general much less likely to follow up and question drinking, an unhealthy diet, and dangerous driving.
symptoms, or to seek information on health promotion.
Health professionals should not only talk to men in Men also differ fundamentally from women in their expe- their language, but should also be prepared to learn from rience, expression and response to pain. A man will go them. Men should be informed about symptoms, but through a process of rationalisation and denial of, for this education should be ongoing. “We should never stop example, chest pain that unfortunately prevents him from giving out straightforward information,” commented Mr obtaining healthcare services that he needs. In short, said O’Leary. “Health services should be demystified; for Mr O’Leary, men do not see themselves at risk or are example, The Prostate Cancer Charity’s ‘Secret Sex unable to make the connection between their symptoms Gland’ campaign, to be launched in 2002, aims to edu- and a serious health condition that may be the cause2.
cate men about the existence and function of the prostate Mr O’Leary also reported the results of an analysis of telephone calls to The Prostate Cancer Charity helpline It is important to work with peer support groups – for that suggests other reasons why men delay in consulting a example, The Prostate Cancer Charity offers men the opportunity to talk to another man to reduce embarrass- ■ Some men (and some women) are afraid to confront ment when discussing symptoms. Finally, said Mr the reality that their symptoms might involve.
O’Leary, health professionals should explain their activi- ■ Men may not have enough knowledge about symp- ties, and share good practice about successful pro- toms to relate them to their experience. grammes in men’s healthcare services. “We must also ■ Equally, many men do not have the vocabulary in keep the dialogue going, learn from our mistakes and which to express their concerns. “We spend a lot of never be afraid to take risks,” he concluded.
time talking about providing information, but less timeon checking how that information is assimilated,” 1. Umberson D. Gender, marital status and the social control of health behaviour. Soc Sci Med 1992; 34(8): 907–17.
■ Embarrassment may also cause men to ignore poten- 2. White A K, Johnson M. Men making sense of their chest pain – tially serious conditions. This is a particular problem niggles, doubts, denials. J Clin Nurs 2000; 9(4): 534–41.
Hidden illness: hidden patients: hidden costRodney Elgie, President, GAMIAN-Europe In Europe, the issue of mental health was raised by Depression may be one reason why over the last 50 years, Finland during the country’s Presidency of the European life expectancy of males in Russia has declined by ten Union (EU) on the grounds that ‘there can be no health years and is continuing to fall4. Men with depression or without mental health’. Even so, Mr Elgie reported that other mental illness may drink heavily, and become one of the many problems faced by mental health organi- involved in accidents when driving. “They may also sations is to persuade politicians to accept that mental ill- engage in high-risk sexual activity. As a result, it is not South Africa, but Russia that has one of the highest rates Mr Elgie believes that most European politicians do not take mental illness seriously because it is not seen as The burden on depression is increasingly recognised in life threatening – unlike cardiovascular disease, HIV and Europe, particularly the rising incidence of stress and AIDS, and cancer. However, continued Mr Elgie, each depression in the workplace, Mr Elgie continued. In the year among the 272 million people in the 15 member 1911 UK census, 90% of people lived within a 10-mile states of the EU, there are 50,000 suicides and about radius of where they were born; in 1991 the proportion 300,000 attempt suicide, while in the 870 million people had fallen to 10%, so most people do not have a family of Europe as a whole, there are about 120,000 suicides network to support them. Work and work colleagues and 2 million attempted suicides each year. “Globally form an increasingly central part of an individual’s social there is one suicide every 30 seconds, one attempted sui- circle, and that too can be stressful if people lose their In addition, within the EU in any one week, 59 million Such factors are likely to become increasingly impor- people are affected by mental illness to the extent that it tant over the next five to 10 years with enlargement of adversely impacts on their life, either at work, when the EU from 15 to possibly 31 member states. Mr Elgie looking after family or when engaging in social explained that many countries in central and eastern activities2. “Mental illness is therefore a major problem, Europe will go through the agricultural, industrial and yet there is incredible ignorance, misunderstanding, prej- technological revolutions in 20 years – an experience that udice and stigmatisation,” commented Mr Elgie. For took over 200 years in western Europe. So there is likely example, depression is seen as a woman’s illness, or an ill- to be huge amount of unemployment in agricultural and ness of old age, and therefore it seems impossible for the rural communities. “In western Europe, the highest inci- young to be depressed. In fact, continued Mr Elgie, dence of mental illness is in inner-city areas; in central depression and subsequent suicide are one of the major and eastern Europe the highest incidence is in rural com- People with depression suffer from the stigma and fear As increasingly recognised by the European that still surrounds mental illness in general, or depression Commission (EC), these problems take place against the is dismissed as ‘just a mental illness’. In fact, reported Mr background of an ageing population. This has cost and Elgie, five out of ten of the leading causes of disability in personal implications for everyone, including men, since the world are mental illnesses, including depression, bipo- women are no longer willing to act as a pool of unpaid lar disorder (manic depression), schizophrenia, and carers. Mr Elgie ended his presentation by reminding the obsessive compulsive disorder. Indeed, the World Health audience of the link between depression and many physi- Organisation (WHO) has forecast that depression will cal illnesses, including heart disease and many cancers, become the leading cause of disease, disability and the concluding that, “there can indeed be no health without burden of disease by the year 2020 in the developing world, and will be second only to ischaemic heart diseasein economically advanced countries3.
Depression should therefore be a major cause for con- 1. Angst J. Suicide in Europe: Amsterdam 1998. EUROSAVE Report to cern, especially for men. In the UK three times as many the European Commission. University of Glasgow, 2002.
2. Thompson C. Presentation to European Parliament, 21 March 2001.
men take their own lives compared to women, a ratio that 3. Mental Health: new understanding, new hope. Geneva: WHO 2001.
rises to ten to one in countries such as Russia and Latvia4.
4. Rutz W. Gamian-Europe Convention. Malta, November 2001.
Helping young men ask for helpPippa Sargent, National Coordinator, CALM The government has set national targets to reduce suicide,and Ms Sargent explained that these are especially relevantto young men since suicide is the main cause of death, afterroad accidents, in men aged 15-24. One way of tackling theproblem would be to offer advice and information at theonset of depression, but young men are resistant to healthpromotion messages, and are reluctant to engage with conventional helplines and primary care. Ms Sargent presented an overview of the Campaign Against Living Miserably (CALM), and discussed some ofthe lessons from this experience that might be useful toother professionals involved in enabling young men to askfor help about mental health problems. “We need to findnew approaches that specifically target young men,” she CALM urinal poster
Young men may question the relevance of helplines and information rather than counselling, but many find that so only contact them as a last resort. Ms Sargent explained they need both services,” said Ms Sargent. CALM’s service that CALM is a communications strategy, based on a free- is free, confidential and anonymous. It is also available out phone helpline that aims, not only to encourage young of hours: from 5.00 pm to 3.00 am every day of the year. men to talk about their problems and seek help at the onset Between December 1997 and December 2001 CALM’s of depression, but also to raise awareness about depression helpline received over 25,000 interactive calls (many are non-interactive since callers appear to sound out the service From the outset CALM’s strategy was to copy the adver- before they decide to talk to an adviser). Most calls are tising industry and appeal to young men through the quite long and can last 45 minutes or more. Ninety-four design and promotion of its message. Seeking help became per cent of callers are ringing on behalf of themselves, and the ‘product’ and was deliberately marketed by a brand 68% of callers are male. “This is unusual,” commented Ms designed to appeal to young men. This philosophy was Sargent, “as women are traditionally more likely than men reflected in the product design – produced by a large to use helplines.” advertising agency – that was influenced by men’s style CALM seems to be getting the message across to its tar- magazines, CD covers, music flyers, websites, and current get group of young men. Over one half of callers to the helpline are aged between 15 and 35, and of the young In promoting the service, CALM used traditional media, men who call 60% have not accessed health services but also used posters in urinals, information on beer mats, before telephoning. Only 8% of callers telephone because gym water bottles, and bus tickets. CALM also recruited of suicidal thoughts, and again this suggests that CALM partners and supporters from among people whom young is fulfiling its brief by reaching young men before they are men admired and aspired to emulate, including local sufficiently depressed to contemplate self harm. celebrities drawn from bars, clubs, bands, sports teams, Young men have a very negative image of conventional record labels, radio stations, and music and clothes shops. health services, but since its launch as a pilot in December “It is much more powerful for a young man to hear a DJ 1997 in the Manchester area CALM’s service has been say that he too has been depressed, than to receive informa- extended to Merseyside, Cumbria and Bedfordshire.
tion from a health professional,” commented Ms Sargent.
“There are many reasons for CALM’s success, but the cam- CALM’s supporters advise on keeping up with current paign’s image, sponsors, and branding mean that young trends and suggest the future direction of the campaign.
men respect CALM and feel a sense of ownership,” con- They also endorse CALM’s materials to convey a positive CALM’s helpline is staffed by a specialist charity opera- For an information pack about CALM contact:
tor. Trained professional advisers offer callers counselling, information and self-referral based on a database of local and national agencies and can help to plug young men into these other services. A variety of problems are reported to the helpline, but relationship issues inspire the largest num- ber of calls, followed by drugs and alcohol, loneliness andworries about sexuality. “Most men begin by asking for MEN'S HEALTH
The role of health authoritiesMeryl Johnson, Health Promotion Coordinator, Worcestershire Health Authority On 31 March 2002, health authorities will be replaced by was operated by 18 professionals, including health visi- primary care trusts (PCTs), explained Ms Johnson. The tors, occupational therapists, a dermatologist, Ms aim is an integrated approach to planning, commission- Johnson and a health-promotion colleague. Weight, ing and delivery of local services, via a common agenda height and blood pressure were measured, and staff dis- for health and social care, based partly on priorities set cussed health problems and lifestyle issues with each of out in the government’s NHS Plan1. “This process of the men. Bovis also offered healthy food and fresh fruit, modernisation and change is unprecedented in its attempt free of charge, in the site canteen.
to incorporate multiple organisational shifts into a new Ms Johnson reported that 89 of the 200 men received a configuration designed to optimise a health improvement health check. As expected, there were many problems strategy, particularly in terms of health inequality”.
related to smoking, drinking and unhealthy diet, while The following two comments summarise why change is the men also reported stress because of the insecurity of short-term contract work. However, the men did not ■ ‘Too often in the past, the members and officers take highlight only physical problems. “Men were using us to the paternalistic view that it is for them to decide what allow themselves to talk more openly, and some health services are provided and the interests of the public workers found out more about men’s psychological ill health in those two hours than they had in the previous ■ ‘Patients are the most important people in the health service. It does not always appear that way and toomany patients feel talked at rather than listened to and Typical comments included:
“Basically I’m pretty healthy, but I’m an emotional wreck” Since 1990 there have been efforts to make user “I don’t want to bother my GP with my concerns” involvement in the NHS a reality, but it remains a chal-lenge to tackle the culture that restricts change and to “This is the first time I have spoken about my depression; develop an approach that takes into account performance- I felt I should pull myself together, but I just can’t” management arrangements between strategic health “I didn’t know other people felt like me; that information authorities and PCTs, local issues as well as national tar- More important, NHS health professionals must recog- nise that they never have all the answers. “We have to Many men appeared to be clinically depressed and their recognise that others may have some of them, and that sense of isolation was profound because they did not talk those who are disconnected from the issues faced by the to one another about their concerns. Two men cried and NHS are not just the socially excluded,” said Ms said that they had never spoken to anyone about their Johnson. Health professionals need to engage with entre- feelings, for example, about the death of a father. preneurs and leaders in science, industry, business, com- “The challenge is to remind ourselves of the job that we merce, learning, and the community. Decision-makers are here to do. Like those health visitors at Bovis, we need should be informed about key health issues, so that tar- to find a real purpose working with less motivated or less gets are based on gender-specific principles. “We want to able people.” commented Ms Johnson. Health care build healthy communities that recognise the inequalities should be accessible, approachable and achievable for that are suffered by some, but disadvantage everyone.
everyone. Professionals should work with local business- This will be achieved by understanding the issues, by es, especially those found in poorer communities, to set changing how we do things and accepting that the needs up drop-in clinics. Roaming services should be developed of people must be at the heart of everything we do”.
in clubs, factories, offices, shopping centres, motorway Ms Johnson gave the example of a successful day clinic service stations, and port terminals to attract people held at a hospital building site in Worcester and organised working long hours or away from home. “If we really at just three weeks’ notice. As part of European Health want change, it must begin with us as professionals. It and Safety Week and in cooperation with Bovis Lend must begin now and it must begin with people who want Lease (the project managers of the construction site), all to make change happen,” she concluded. site workers were offered a health check. The processbegan with a questionnaire, which investigated the men’s health and informed workers about the health day at the 1. Department of Health. NHS Plan. London: The Stationery Office, site. Eighty-five of 200 questionnaires were returned, 2. DETR. Modern Local Government. London: The Stationery Office, which was regarded as a good response. The health day MEN'S HEALTH
Health promotion: getting the message across to menMaggie Robinson, Community Learning Consultant Ms Robinson had been involved with a men’s health pro- ing the evenings. “If we are going to work with men, we ject run in conjunction with the Department of Health must go to where they are. We must be more flexible in called ‘Alive and Kicking’, in which she worked with week- end football clubs. It had been a positive experience, but As a woman, Ms Robinson had at first found it difficult to go to a working men’s club and talk about health issues, At the beginning, it had been very difficult to get but it had been rewarding to see the positive peer pressure through to health authorities. “I had the funding,” she from the club committee in improving the younger men’s explained, “but it was very hard to find the right person health. Interestingly, these young men told Ms Robinson within a trust who could discuss men’s health. Some trusts that they looked in the Yellow Pages when they needed – even though I was bringing money to them – could not health information, although she wondered how many get round to seeing me or working out who should see health organisations make sure that they are listed.
me.” She therefore believes each trust should appoint a Sensitivity to language and literacy is essential. Men do named individual for men’s health, even if it is not their not ring up ‘helplines’, but they will contact ‘information lines’. Any organisation advertising ‘health’ or ‘advice’ will When Ms Robinson joined the board of her local trust, not attract men. Furthermore, poor health and literacy are she discovered that men’s health was never on the agenda, connected. On the whole men have poorer literacy skills even though it ought to have been central to health plan- than women, and so find it more difficult to access infor- ning. In addition, because women access health services more regularly, it seems much easier to consult them. “I According to Ms Robinson, men’s health could be would say that when we consult people during clinical gov- improved in future by working with young boys in nurs- ernance work, we are on the whole consulting women and eries and first schools. Similarly, natural places for a health check should be found in men’s lives, such as before a dri- Health services are also inflexible. During the football ving test. “Women’s lives are perhaps over-medicalised project, the local health promotion service could not supply with regular health checks, but at present men’s lives are the services of a dietitian because the games took place dur- certainly under-medicalised,” she concluded. Community health development: opportunities and challengesTerry Drummond, Chair, Community Health UK and Advisor in Social Responsibility Mr Drummond said that he started from the premise that cafes and shops, and the many small groups in the com- it was essential to work with and understand the views of munity. The development of local strategic partnerships members of the local community in shopping centres, pub offers opportunities for health authorities and the local and clubs, football and sports clubs, gyms and other sports authority to discuss health issues. Similarly, public facilities. In addition, places of worship were another, cur- organisations should ensure that they work with the vol- rently underestimated, venue for health promotion. untary sector. “Partnership is about equality, not about Faith buildings are to be found in every community and people with authority saying to those without authority all faiths have health and wholeness at the centre of their that, ‘We know best’,” he said.
understanding. “If you want to contact minority ethnic “To build healthy communities, professionals need to men, particularly Muslims, the mosque is a natural place to work with local people by bringing them into partner- go to. If you want to meet Afro-Caribbean men, many of ship within the locality in which services are placed, them will go to black majority churches. Churches, working within a context of dialogue that leads to mosques, and temples are about people coming together in action,” added Mr Drummond. “People often know bet- a community and there is an opportunity to learn from ter than you or I ever will what is best for them.
Professionals may know more about health, but first of Health professionals should think laterally. They all we need to trust people and then they need to trust us should work with local businesses, especially small com- so that we meet on an equal basis. The aim should panies where people are under pressure. They should always be to help people to feel secure in obtaining help base services in youth centres, unemployment centres, and information about health,” he concluded.
Primary care: what can we do?Jane Deville-Almond, Independent Nurse Consultant in Primary Care “There is a rumour that men are not interested in their Ms Deville-Almond explained that the idea for the health. The problem is not that men are uninterested in MOT clinic had originated in Australia. “Don’t be afraid health, it’s that health professionals are not interested in to copy other people’s ideas. A good idea is only brilliant According to Ms Deville-Almond, part of the problem Ms Deville-Almond wanted to operate a surgery that relates to the names and locations of conventional health took place regularly but was still accessible to men. “A services. ‘Surgery’ has unpleasant connotations, ‘Men’s clinic in a pub is a great way of getting men to think Clinic’ does not sound inviting, while ‘Well Man Clinic’ is about health, but it is difficult to continue because men also unlikely to attract men who do not use health ser- go to the pub to relax, not to be talked at about health vices. Men who attend such clinics are usually well and and lifestyle,” she explained. Next to the Harley Davidson already know about health. Non-attenders are probably shop, there is a barbers called GI’s, a well-known estab- unhealthy men, who know that they are likely to be told lishment in Wolverhampton that sees over 1000 men each off about their lifestyle when they see a health profession- month, which seemed an ideal location.
al. “In this way, we alienate half the population who are The health session at GI’s barbershop is held one day a week at varying times so that different men can attend.
In contrast, Ms Deville-Almond described a clinic held This clinic focuses on weight control since many men are in the local pubs, where three health professionals saw worried about being overweight, but are reluctant to seek help at a conventional weight control clinic or female-dominated slimming group. Every man is offered a com- Of the first 100 men seen in the local pubs:
plete health check, including height and weight, blood 68-72% had at least one long-term health problem pressure and cholesterol levels, peak flow, and bloodsugar. Smoking, drinking and family histories are also dis- cussed. Each man is seen for about 25 minutes. “Fellow 25% drank more than 140 units of alcohol a week, and health professionals have said that they do not have time for a 25 minute check, but if you take the time during the 62% of the overweight men had high blood pressure first visit, you can probably give a man all the information that he needs and he will not have to keep on comingback,” said Ms Deville-Almond.
Forty-one per cent of the men seen to date have one or Young men are an especially difficult group to reach, more long-term health problem, and the proportions because they are not interested in the long-term results of with specific health problems are similar to the previous an unhealthy lifestyle. They can, however, be persuaded clinics. In addition, 22% complained of prostate prob- to consider the immediate impact of current ill health.
lems or erectile dysfunction. Ms Deville-Almond “We need to change the way in which we market health,” explained: “This is because I actually asked about these she said. Ms Deville-Almond therefore approached the symptoms. If we do not raise an issue, we will not always Harley Davidson Group, which has motorbike show- get the answer.” It was also important to use language rooms throughout Britain. Every third month, the show- that men understand. “Urinate does not mean anything rooms hold an ‘MOT pit stop’, an open weekend where to a lot of people. We need to feel comfortable in using a men can get their bikes checked. “So I decided to dress up language that people understand,” she added. as a mechanic and offer ‘MOTs’ for the men at the Ms Deville-Almond said that she was often asked if she is intimidated when running a clinic at, say, a garage orbarber shop. But men feel exactly the same intimidation Of the first 55 men seen at Wolverhampton
when they visit a conventional health clinic. “We need to ‘MOT pit stop’:
remember that the services we provide are for the men 65% had more than one long-term health problem and not for our convenience. And, if we carry on doing what we have always done, we will end up with what wealready have. We need to be more innovative in providing 55% with BMI >28 had high blood pressure (25% of total) services that truly meet men’s needs,” she MEN'S HEALTH
Getting them young: promoting men’s health in schoolsand collegesSimon Forrest, Fellow, University College London When working with boys and men, health professionals Table: Young men aged 16-19 and sex
experience problems of access, observed Mr Forrest. “You (aggregated data)1,2
have information for men, but you can’t reach them”. About 30% had sex for the first time when they were In general, UK data about young men’s sexual behav- iour is patchy – indeed, until 1997 hardly anyone hadasked a population-sample of young British people under Most started foreplay about three years before first 16 years if they had had sex. Consequently, information is derived from aggregated data from national, retrospective 70% of all sex takes place within the context of a surveys (Table). “Based on the figures, sex seems pretty relationship, either long-standing or close good for most young men. Professionals worry about 80% said their first sexual relationship occurred at about young men’s failure to use barrier contraceptives – and it is certainly an issue – but men seem to realise that there is About 7% have been attracted to another man, and about 3% have had some physical sexual contact with Young men say that they learn about sex primarily from their mothers, their school and each other. In fact, there isan ‘endemic use’ of pornography among young men and 25-40% used a condom at first intercourse this is a primary source of information about sex. The A man’s experience of sex is influenced by his class and reality is that most young men feel poorly informed about ‘having sex’ and say that they feel excluded from school-based sex and relationship education (SRE) and sexualhealth services. “Young men say it’s all too little, all too pregnancies are in women aged under 16. This is high compared to other European countries, but it is still Current SRE promotes the primary message that young men should not have sex, preferably not outside It was equally important not to stereotype young men.
marriage, but as a second best not outside a loving rela- They are not necessarily heterosexual; they do not always tionship. Young men should also always use contracep- want to have sex immediately and with anybody; not all tion and should be motivated primarily by concerns are macho and sexist. Many young men are anxious about about love. Mr Forrest felt that such messages are unhelp- their performance and masculinity. Professionals would ful because they are unrealistic. “They do not reflect a lot gain more information by asking realistic questions, such of adult behaviour, let alone that of young people,” he as “How’s your sex life?”. It was essential to have a posi- tive view of masculinity and to abandon monolithic pre- There are a number of issues that are of great concern to conceptions. “Traditional masculine qualities of indepen- young men, yet these are not addressed by current SRE.
dence, strength, action when necessary, and purpose, are good for young men and should not be discarded along ■ How big should my penis be? (‘it depends’ is not a with negative aspects of masculinity,” said Mr Forrest. Current SRE is inadequate, and is certainly failing to ■ How much should I ejaculate and how far? meet young men’s needs, concluded Mr Forrest. He rec- ommended that more men should be involved in SRE, more fathers should talk to their sons and there should be less moralistic and pathological approaches and more respect given to young men. Finally, Mr Forrest advised Mr Forest reported that young men do not want professionals to seek opportunities to take SRE to set- to know very much about fertilisation or contraception.
tings beyond secondary education, for example to further “We insist on talking to them about the Pill, when their and higher education, or the armed forces.
primary concern might be losing an erection”.
Professionals should be explicit when discussing sex, especially about sex and pleasure: “We cannot seem to 1. Wight D, Henderson M, Raab G, et al. Extent of regretted sexual talk about sex as fun, when this is most people’s primary intercouse among young teenagers in Scotland: a cross sectionalsurvey. BMJ 2000; 320: 1243–44.
motivation.” Professionals should also be realistic and 2. Wellings K, Nanchahal K, Macdowall W, et al. Sexual behaviour in honest about the risk of pregnancy. Nine per 1000 Britain: early heterosexual experience. Lancet 2001; 358: 1843.
Comunicazione diretta agli operatori sanitari su lariam (meflochina) per la chemioprofilassi della malaria e rischio di reazioni avverse neuropsichiatriche
NOTA INFORMATIVA IMPORTANTE CONCORDATA CON L’AGENZIA ITALIANA DEL FARMACO (AIFA) Comunicazione diretta agli operatori sanitari su Lariam (meflochina) per la chemioprofilassi della malaria e rischio di reazioni avverse neuropsichiatriche. Lariam® (meflochina) può indurre disordini neuropsichiatrici potenzialmente gravi. Le più comuni reazioni neuropsichiatriche alla mefloc