Sex Appeal
To address the gender gap in health and male patients' reluctance to seek medical attention, nurses strive to make the care experience more comfortable for men

By Donna Hemmila
January 14, 2004

It's a guy thing, and according to men's health advocates, a significant contributor to an escalating crisis in medical care.

Men think they're invincible is the way Tim King, RN, sums it up.

Could that simple but false notion of indestructibility actually be a factor in the deteriorating health of American men? Many researchers and practitioners say yes, because it means many men don't take care of themselves.

They are less likely to visit a doctor, to take preventive health measures or to follow doctor's orders when they do become ill. They die, on average, five years sooner than women, according to the National Center for Health Statistics, and for all leading causes of death, including heart and lung disease, men and boys have higher fatality rates than women and girls.

Despite the ominous health statistics and a growing life expectancy gap between men and women, the average American male doesn't seem to put much effort into his physical or mental well-being.

"They think they're invincible-until something happens," King said.

King works in a prison hospital north of Seattle where just about all the patients are men. In that setting, he finds inmates are more apt to seek care as a way of getting attention than the general population of men. Yet during his years as an emergency nurse, King saw a common male response to health needs: denial. A man is going to ignore the chest pains, he said, until he actually collapses and someone has to take him in for medical attention.

Aversion to health care

Blame it on the "boy code," a concept developed by William Pollack, director of the Center for Men and Young Men at McLean Hospital in Belmont, Mass. Pollack, an assistant professor of psychiatry at Harvard Medical School, traces the male aversion to health care back to the "tough guy" lessons learned during boyhood.

Men are socialized to feel illness is a defect in their masculinity, Pollack said. From a young age, they're taught a code of conduct that says real men do not cry, nor do they ask for help. If boys do ask for help, often they're put down for their "weakness."

When grown men do seek health care, many report feeling put down by doctors and nurses. "The patient feels one down," Pollack said. "They feel like the other person knows more. They feel defective."

Although the health care profession has made progress in addressing male health issues, Pollack believes more needs to happen to make the health care system male-friendly.

The most successful way to reach out to male patients is to work more with the way men think, Pollack said. Approach self-care from a problem-solving perspective, he said, and make it a team project. Make sure the man feels part of that team.

This is where male nurses can make a difference.

Demetrius Porsche, DNS, RN, in a speech during last month's American Assembly for Men in Nursing conference in Cleveland, called on male nurses to help establish a national men's health research agenda.

Porsche serves on the advisory board of the Men's Health Network, a Washington-based advocacy group lobbying for the Office of Men's Health. First introduced in Congress in 2001 and again in 2003, the Men's Health Act aims to create a national Office of Men's Health within the Department of Health and Human Services. This new health department, modeled on the Office of Women's Health, would promote men's health screenings and research on male-specific diseases.

People have misconceptions about men's health issues, said Porsche, associate dean for nursing research and evaluation at Louisiana State University in Baton Rouge. Although many research studies use men as test subjects, few are actually about men's health, he said.

"You don't hear anyone talking about men's access to health care," he said. Yet in reality, men are less likely than women to have health care access. Men are seen as the perpetrators of violence, Porsche said, yet they are more apt than women to be the victims of violence. Although breast cancer afflicts only a small percentage of men, they are more likely to die from it because there is less breast tissue for the cancer to spread.

Porsche has a long list of male health issues that need more research, including studies on how men express pain and depression. He'd like to see the goals of a national men's health agenda go beyond the obvious male health problems of testicular and prostate cancer. The life-expectancy gap, early detection of disease, healthy eating and the economic effects of men's health are some of the themes that need to be explored.

"The men's health movement is struggling like the women's health movement was a few decades ago," Porsche said.

Recruiting men

One way to win the struggle is to bring more men into the nursing profession.

"We're the role models," Porsche said. "We know how the system works."

Will Courtenay, Ph.D., LCSW, of the department of psychiatry at Harvard Medical School and the University of California, San Francisco, Medical School, founded Men's Health Consulting in Berkeley, Calif., to train health professionals in effective ways to make the system work for men.

Courtenay has identified six aspects of men's behavior that affect their health outcomes: health-promoting behavior, risk-taking behavior, physical abuse and violence, social support, behavioral responses to stress and health care use.

Courtenay, who is also the editor of The International Journal of Men's Health, has reviewed hundreds of studies dealing with male-specific health factors. Some of the research focuses on male behavior.

For example, researchers have found that men and boys are less likely than women to have a support system in times of illness or high stress. Men without a support system are two to three times more likely to die from illness than those who can count on family and friends. At the same time, men are more likely to deny illness and to use avoidance props, such as drugs and alcohol, to cope with illness.

Other studies turned up some differences in the way that health care providers treat men and women. Although men are more likely to engage in high-risk behaviors than women and less likely to embrace healthy lifestyle behaviors, they receive less advice from doctors during checkups than women. They're also less likely to be taught how to perform self-examinations for testicular cancer compared to women, who receive this instruction about breast cancer. One study that Courtenay reviewed showed that only 29 percent of doctors taught self-exam procedures to men, compared to 86 percent who provided instruction to women for performing breast self-exams.

Courtenay has developed a best-practices strategy for improving communication between clinicians and male patients. A key part of that strategy is for doctors and nurses to humanize the care experience. Men need to know that asking for help, admitting pain and expressing emotions are natural human behaviors.

Man to man

Although no one says female nurses cannot care for male patients effectively, at times, a man-to-man approach works best.

"We know that men interact differently in front of male clinicians than they do with a female," Courtenay said. "Men are less likely to admit pain to a woman clinician." Although it may seem sexist, he said, some men tend to assign more authority to male clinicians.

This is no secret to men in nursing. Certain male patients simply do better with a male nurse, said Rich Polli, RN. "There was one gentleman who had smoked himself into chronic obstructive pulmonary disease," Polli recalled. "His lungs just didn't work anymore."

In the ICU where Polli worked, this patient had a reputation with the female nurses of being difficult. But Polli had a different experience with the man.

"I bathed him every day and shaved him," Polli said. "I took care of him like he was my own father."

The next time the man was admitted to the ICU, Polli said, it was like a reunion. The difficult patient had even stopped smoking. There are times, Polli said, when a male nurse is just going to be more tolerant of the male patient.

Although this may be true with some patients, if you're a good clinician, gender ultimately shouldn't matter, said Lynda Moore, NP, RN. She operates a health center at an oil refinery in Benicia, Calif., northeast of San Francisco, where the workers are predominantly men.

As part of the employee wellness program, she shows the men how to perform testicular self-exams. For many of the guys, this is a new concept.

"A couple of my fellows get a little red-faced," Moore said. "I deal with it in a very matter-of-fact way. I could just as well be talking about a phone bill. If they sense I'm uncomfortable, they'll be uncomfortable. When I hand them the little scrotum model, some of them do say 'ack.' "

Other times, a male patient might be more comfortable talking to a female nurse, she said. When discussing the side effects of blood pressure medication, for example, some men might feel more comfortable bringing up erectile dysfunction with women. "It's the testosterone thing," she said. "Men are always in competition with each other."

Moore recalls one of her male patients who didn't want to be examined, especially by a woman. Moore didn't get defensive about being put down as a woman, and the man agreed to the skin cancer screening. She discovered a fast-spreading cancerous lesion on his back that had to be removed.

Every nurse, male or female, needs to adapt to the male patient's individual and cultural attitudes, Moore said. If the nurse gets defensive or uncomfortable, she said, so will the patient.

Contact Donna Hemmila at dhemmila@prodigy.net