The “Superman Syndrome”: Why Men Are Reluctant to Pursue Preventive Care
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James is a self-employed contractor who has been suffering for several months with headaches that now occur daily. He’s been taking up to 10 to 15 aspirin per day, which now provide only minimal relief. In addition to the headaches, he also complains of heartburn and easy bruising. His wife doesn’t understand why he won’t go to their primary care provider. She’s grown tired of listening to him complain and worries that something dangerous has developed since his last checkup 12 years ago—especially with a family history of diabetes, cardiovascular disease, and prostate cancer.
She has implored him, bribed him, and verbally challenged him to get a checkup; nothing has worked. Her mother-in-law shrugs it off, explaining that James’ father always taught him to “take pain like a man,” and that “no matter what, you’ve gotta get your job done.” James finally allows his wife to make an appointment for him when the headaches become so debilitating that he has to miss a week of work.
James is following a pattern that is typical of many men: denial of symptoms, avoidance of preventive care, and action only in the face of extreme pain or disability. James is probably not aware that he’s at greater risk of death than his wife throughout his life or that he will likely die nearly six years younger than his wife.[1,2] It is estimated that in general, men in the United States utilize preventive care services up to 50% less often than women. According to the Agency for Healthcare Research and Quality (AHRQ)—
- Men are 24% less likely than women to have visited a doctor within the past year and are 22% more likely to have neglected their cholesterol tests.
- Men are 28% more likely than women to be hospitalized for congestive heart failure.
- Men are 32% more likely than women to be hospitalized for long-term complications of diabetes and are more than twice as likely as women to have a leg or foot amputated due to complications related to diabetes.
- Men are 24% more likely than women to be hospitalized for pneumonia that could have been prevented by getting an immunization.
It was these disparities that led to the AHRQ “Real Men Wear Gowns” public service campaign, promoting the concept that “real men” should step up to see a healthcare provider and undergo age-appropriate medical tests.
Why The Reluctance?
Obviously no single behavior pattern is typical for all men, and some women fall into this avoidance pattern, as well. As a whole, however, men are reluctant to seek out preventive health services. This was reinforced by a 2007 survey conducted by the American Academy of Family Physicians: 58% of the men disclosed various reasons for avoiding preventive care. Reasons ranged from “I’m afraid to find out something’s wrong with me” (7%) to “I’m healthy and don’t need a doctor” (23%) or simply, “I don’t like doctors” (8%). The survey also reported that 18% of men older than 55 had never received the recommended screening for colon cancer; 29% said they wait “as long as possible” before seeking help when they feel sick, are in pain, or are concerned about their health.
“Today’s health systems don’t speak to the cultural issues that are ingrained in men,” says Jean Bonhomme, MD, MPH, Senior Faculty Advisor at Emory University’s School of Public Health in Atlanta, Georgia. In many cultures men are taught from childhood to “suck it up” and ignore the way their bodies feel. They learn from an early age that boys don’t cry and to “take one for the team.” Additionally, traditional masculinity may cause men to downplay pain. For example, men have been found to “normalize” chest pain from a heart attack, leading to significant delays in seeking help for their condition. This also related to fear and shame. Men are reluctant to appear too “worried” about their health, so they may endure pain and wait to see if it will resolve itself before seeking treatment.
Dr. Bonhomme says these differences lead many men to a pathological stoicism. “So even if a male patient asks for help, some clinicians are stoic on his behalf and will resist ordering tests,” says Dr. Bonhomme, who founded the National Black Men’s Health Network more than 20 years ago and has been a director of Men’s Health Network in the United States since 1992. “We must listen carefully and not minimize men’s concerns.”
One of those barriers is time. Women manage to make and keep appointments, but many men do not. Clinic hours usually overlap work hours, which will take precedence for men who think they will be perceived as weak if they ask for time off. And at least one study suggests that time spent in the waiting room is a critical factor for a man’s decision to avoid a medical appointment. A study published in the American Journal of Public Health reported that 30% of men will not return for an appointment if they’ve had to wait more than 30 minutes at a prior visit.
Another barrier to men seeking preventive care has to do with healthcare flow. When teenaged boys leave pediatric care, many don’t visit a health clinic again for years. In contrast, girls typically progress from their pediatricians into OB/GYN offices and continue a pattern of regular screenings and care. Thus, men do not use preventive services as often as women, and may be less familiar with the healthcare system and encounter greater communication barriers. Men are less likely to perform preventive self-examinations than women, with less than 10% of men report being taught testicular self-examination compared with almost 65% of women who report receiving instruction in breast self-examination.
Men may also be reluctant to seek care because they already distrust the health system,” says Dr. Bonhomme. “For example, veterans feel betrayed by government institutions that promised to care for them; black men may feel alienated and mistrustful for various reasons.”
Your Attitude Can Help
Some of you may assume that male patients can’t and won’t change. Such attitudes are particularly counterproductive because provider fatalism (the belief that behavior change is unlikely) is negatively associated with the likelihood of patients receiving prevention counseling. Patients are less likely to successfully change their behavior if they, or the people administering the intervention, believe that failure is likely.
These assumptions may lead to a lack of preventive health services even when men do come in for primary care. In one study, medical residents were less likely than nurse practitioners to provide these services to men in inner city clinics. And results of a survey of U.S. primary care doctors which found that while 86% routinely teach breast self-examination to women only 29% taught testicular self-examination to men.
According to the Centers for Disease Control and Prevention (CDC), more U.S. men than women died from each of the top 10 causes of death in 2006. Several of these conditions—such as cardiovascular disease and diabetes—are associated with modifiable behaviors such as smoking and alcohol use that occur more frequently in men. Three of these behaviors—tobacco use, lack of exercise, and unhealthy eating habits—contribute to a third of men’s deaths. This is an area where you can play an important role, as there is ample evidence documenting that intensive lifestyle intervention programs delay the onset of diabetes and reduce cardiovascular risk by increasing physical activity, reducing weight, and making changes in dietary habits.
Breaking Down the Barriers
I’m not aware of any studies focused on increasing men’s utilization of primary care practices,” says Masahito Jimbo, MD, PhD, MPH, of the University of Michigan Department of Family Medicine who authored a chapter on the subject in the textbook Clinical Men’s Health.
“To appeal to men, we need to focus on performance and responsibility instead of internal feelings,” says Dr. Bonhomme. “We can emphasize that proper preventive care can help men feel younger, stronger, and more vigorous. It can make them more attractive, help them play sports better, and enable them to be more productive at work and at home.” Improving men’s health comes down to two imperatives for clinicians, he suggests: “First, use what’s available in your office to make contact with patients to get them to schedule a checkup; and then take every opportunity to educate and screen regardless of the presenting complaint.” (Box 1)
What Preventive Screenings Do Men Need?
All men should have their body mass index assessed to screen for obesity; starting at age 35, they should have their cholesterol checked regularly and a blood pressure check is recommended every two years. Men with hypertension or high cholesterol should also be screened for diabetes. At 50, they should get a colorectal cancer screening test, unless there is a family history of the disease, in which case patients may need to be screened earlier. Men between the ages of 65 and 75 need a test for an abdominal aortic aneurysm if they have ever smoked. All men should receive a flu shot and pneumonia shot if older than 65.
As men age, they are also at higher risk for a number of other issues such as osteoporosis. Some endocrinologists believe that by age 70, all men should have their bone mineral density measured. As well, men who experience erectile dysfunction should also be screened for vascular disease, which if left untreated, can put men at high risk for heart attack or stroke.
With many men reluctant to disclose their concerns and fears about possible medical problems, depression is likely to be a particularly taboo subject. But it is an important one. Statistics show that while depression is more prevalent in women, men commit suicide at four times the rate of women. Men who have been diagnosed with depression are more than twice as likely as men without depression to die of any cause.
The high rate of suicide among men suggests that clinicians may be missing the diagnosis, in part because the major diagnostic criteria are expressed in feminine-gendered behaviors not culturally acceptable in men. Women are more likely to “act in” by crying, worrying, and talking about sad feelings. Men are more likely to “act out” and may not even perceive that they are depressed (Box 2). Therefore, you should be alert to a constellation of symptoms that indicate depression and consider referral to psychological services rather than simply prescribing sleep aids and anti-anxiety medication
Reeling Them In
Case Study 2: A 42-year-old African American male accompanied his wife and teenaged daughter to a health fair publicized in their church bulletin. After the screening, he spoke with a young clinician who answered his questions about disease processes and management, and explained how proper diet, exercise, and stress management might improve his performance at work, on the soccer field, and in the bedroom. His wife took home some healthy recipes he liked. And because the clinician treated him as a whole person, “not just a prostate,” he booked a follow-up visit to track his blood sugar results and became part of the clinician’s patient panel.
Most large and national employers now offer free health screenings, but employee use of wellness programs has been estimated at just 20% to 40%; most likely to attend were women, those of higher occupational prestige, and those from a non-English-speaking background. However, these events miss most blue-collar men. “In general, men are more likely to participate if a bunch of other guys are there too, so group events are best,” says Dr. Bonhomme. But, obviously, men are not a homogenous population. They value and seek different types of health services, so a range of strategies is needed.
Of note is that men’s reluctance to undergo preventive screening occurs all over the developed world. In the United States, the Men’s Health Network stages programs jointly with dozens of major national employers. A survey emailed to 11,200 men two weeks after they attended the network’s “Men at Work” screening events in 2007 revealed that nearly 67% of respondents said they had either already consulted a primary care provider about their screening results or intended to do so in the near future.
Organizers have used sports themes[23,24] and packaged health checks as the equivalent of a motor vehicle safety inspection.[25-27] In the Northern Territories, Australia, establishing a separate men’s clinic increased adult male attendance by 600%.
Various other cooperative programs have involved recruiting African American men through barber shops, churches, and other venues to attend large and small discussion groups; appealing to adolescent males with new interactive computer technology; free men’s health clinics; clinic days reserved for men and adolescents at full service clinics; Men’s Night Out Tune Ups; an Internet postcode finder young people can use to find a local chlamydia screening venue; and free gifts and prize drawings just for men.
Men may be more concerned about sexual problems than about the possibility of cardiovascular disease, so asking questions about sexual performance may lead to a well-time teaching moment. If a man perceives that a healthy diet, tobacco avoidance, limiting alcohol intake, weight loss and increased exercise will improve their sexual performance, they may become motivated to healthy change!
Online Patient Materials
Questions are the Answer. Question lists and posters in English and Spanish
Saving Our Men–Public Education Toolkit
Get It Checked. Brochures with screening guidelines for men and women.
Community Campaign Materials
Men’s Health Awareness Materials for community awareness
Jill Shuman, MS, ELS
Published on June 14, 2011
A version of this article appeared in print on page 2 in the Aug/Sept 2008 issue of the Primary Issues newsletter.
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- National chlamydia screening programme aims to target more men with new strategy, UK. Medical News Today website. http://www.medicalnewstoday.com/articles/88468.php. Published November 12, 2007. Accessed June 9, 2011.
- Shabsigh R, Arver S, Channer KS, et al. Sexual health as a portal to men’s health: a problem turned around into an opportunity. Int J Clin Pract. 2008;62(2):173-181.