Until recently, there had only been a fragmented view on men’s health. A few country reports on men’s health had been published, for example in Germany and Austria, or in the context of analyses in white papers119 and similar documents (e.g. Norwegian Ministry of Children and Equality, 2009 and the Irish Men’s Health Policy).
This situation was comparable to the situation in countries outside the EU, for example Canada, where “[...] in terms of a real discussion about the gender determinants of men’s health – the fact that men don’t ask for help, go to doctors less frequently than women, smoke more and drink more than women, commit suicide more often, live far shorter, and so forth – we’ve had little discussion of such things with a clear, gender analysis.” (Kaufman, 2012)
118 The women’s movement from 1960 onwards is referred to as ‘second wave of feminist movement’. The ‘first wave of feminist movement’ is the period from the second half of the 19th century to approximately 1930.
119 White papers in politics contain proposals for common action in certain policy field.
Also in countries like Brazil or Mexico basic data on men’s health show a similar pattern, and there is a growing recognition that further research and action is needed: “[...] men have far higher occupation injuries, external causes of death, whether that’s traffic accidents, homi-cides, suihomi-cides, other injuries. Men are much more likely to suffer those, so we need some attention to this.” (Barker, 2012; see also White & Holmes, 2006)
The State of Men’s Health in Europe Report gives, for the first time, a complete picture of the variety of issues affecting men’s health in one report. (See White, de Sousa, et al., 2011) The report covers a detailed examination of the male population; of lifestyles and preventable risk factors; men’s access to health services; health status; cardiovascular disease; cancer;
accidents, injuries and violence; mental health; problems of the male reproductive system;
communicable diseases; dental and oral health, and other conditions affecting men. The headline finding from the report is that there is a persistent trend of higher rates of prema-ture morbidity and mortality not just with men as compared to women but also when compar-ing men from other socio-economic and cultural backgrounds.
An important part of the analysis was the examination of the effect of premature death on the male working age population. In the European member states there were over 630,000 male deaths between the ages of 15 and 64 as compared to 300,000 female deaths. (See EC, 2011a) Across the European member states, deaths in this 15-64 age group accounted for 26% of total male deaths, compared to 13% of female deaths. However, these proportions varied considerably between countries: ranging from nearly 44% of total male deaths occur-ring in this age group in Lithuania to 18% in Sweden.
Men, clearly, have a higher rate of premature death than that seen with women. A closer look at these deaths reveals that men seem to be more vulnerable to the majority of health conditions that could be seen to have no link to sex-specific diseases. For example, there is a relatively well known problem of men having higher rates of cardiovascular disease and accidents, but it is not so well recognised that men tend to die earlier from digestive prob-lems; respiratory disease; neoplasms; infections; and many other conditions. (See annex 5.2.1)
However, such different rates do not mean that any of these diseases and health problems can be labelled as a ‘male’ or a ‘female’ problem. In fact, different segments of the population are affected by various health problems in a different manner. As will be outlined below, not only gender but also other categories of social inequality (e.g., socio-economic status, migra-tion, age) can have a combined effect on differences in people’s health status.
In all countries the life expectancy of women is higher than that of men, with higher dif-ferences across countries for men, and with the lowest values for men living in the Post-socialist countries. (See figure 5.2.1) Life expectancy is increasing for men as for women, and the gender gap is narrowing in many, but not in all countries. (See annex 5.2.2)
Figure 5.2.1 Life expectancy in absolute values at birth by gender, 2010
Source: Eurostat (online data code: hlth_hlye); extracted on March 12th, 2012; own calculations.
When men’s life expectancy across countries is connected to socioeconomic variables, such as the level of education, a consistent pattern emerges (see figure 5.2.2; annex 5.2.3): The higher the level of education, the higher the life expectancy; the lower the level of education, the lower the life expectancy.
This influence of the educational level on life expectancy holds for all countries under analy-sis, for men as well as for women. However, the influence is much stronger for men than for women, in all countries that have been analysed. The most accentuated differences between higher and lower education groups can be found in the Post-socialist countries.
If only men and women with tertiary education are compared, the gender gaps in life ex-pectancy are below five years in most of the countries. Gender gaps below four years can be found in the Czech Republic, Italy, Malta, Denmark, Sweden and Norway.
On the other hand, the biggest gender gaps in life expectancy (ten years and above) can be found for the gender groups with lower secondary education in the Czech Republic, Esto-nia, Hungary, Poland, Romania and Slovenia. The life expectancy of men with lower secon-dary education in the Post-socialist countries is the lowest of all groups, with values below 70 years (from 62.1 years in Estonia to 68.7 years in Slovenia), while the life expectancy for women with lower secondary education is ranging from 72.6 years in Bulgaria to 79.6 years in Slovenia. (See annex 5.2.3)
Figure 5.2.2 Life expectancy in absolute values for men by highest level of education at-tained, 2010*,**
Source: Eurostat (online data code: demo_mlexpecedu); extracted on March 12th, 2012; * data Italy, Romania, Slovenia 2009; ** data Malta 2007.
As can be seen in figure 5.2.2, men’s overall low life expectancy in Post-socialist countries is a problem of men with lower education in the first place, as the life expectancies of men with tertiary education are relatively high and show less variation across the countries.
It can be concluded that “[...] there is much variation in health and life expectancy between men living in different contexts (for example different countries within Europe) and between men living in the same context (for example age-related or socioeconomic differences within the same country).“ (EC, 2011b, p. 10)
The combined effect of gender and socio-economic position points to the need for differenti-ated gender-specific approaches to prevention and health promotion. For example, while the need to prevent premature deaths is a clear priority regarding certain segments of the male population, poor health status and poor quality of life is highly relevant regarding women of higher age and of lower socio-economic position.
This also means that an approach to the analysis of health data is recommended which will not only take gender into account, but also other aspects, especially educational level, occu-pation and income level, ethnicity and race, sexual orientation, and a deeper analysis of so-cio-economic status (Griffith, 2012; Hearn & Kolga, 2009; Mackenbach, 2006), to detect rele-vant health differences between various population groups, and to address them in an ap-propriate way. However, data for this so-called intersectional approach are often lacking.
There is a higher risk behaviour of (especially young) men, as can be interpreted from statistics regarding fatal traffic accidents. (See annex 5.2.4) Although progress has been made in the last decade, differences between countries remain high, with deaths from road accidents being 1.5 times higher in lower and middle income countries than in higher income countries and also being higher among men with lower socio-economic status and less education. Among women, no clear differences have been found. (See EC, 2011a)
Risks for men also result from hazardous occupations, with men accounting for 95% of fatal accidents and 76% of non-fatal accidents at the workplace. (See EC, 2011a) The highest
proportions of fatal as well as non-fatal accidents are observed in the fields of construction, manufacturing and transport, storage and communication which are typically male-dominated sectors.120
Also in other fields of life men tend to accept a higher level of all kinds of risks and risky behaviour, for example smoking, alcohol consumption, sexuality or sports. This high level of risk-taking is seen as one of the major causes for men’s high prevalence concerning accidents as well as their relatively low life expectancy and high rate of life-threatening illnesses. (See Faltermaier, 2008)
The rate of men committing suicide is much higher than that of women (figure 5.2.3), which also contributes to the higher number of premature deaths among men. The differences between countries are high: some of the Post-socialist countries as well as Central European countries (Belgium, France, Austria, Switzerland) and Finland show the highest rates for both men and women.
Most countries show reductions in standardised suicide rates from 1999 to 2009, and some of the countries with the highest rates in 1999 also show the most progress, although they remain on a high level: Estonia, Latvia, Lithuania, Hungary and Slovenia. On the other hand, there are some countries with almost no change or even increases of standardised suicide rates from 1999 to 2009, namely Belgium, Ireland, Greece, Malta, Poland, Portugal and Iceland. It is noteworthy that to this group there belong countries that have been hit hard by economic crisis and recession. The effects of the economic situation on suicide rates of men need to be explored further. Analyses of current data on suicide rates from Greece and Ireland suggest that a rising number of suicide incidents can be seen as a consequence of the recession. (See Stuckler, Basu, Suhrcke, Coutts & McKee, 2009; 2011) However, comparisons between countries should be made with caution.121 Comparisons within countries and developments of countries may be considered more reliable.
120 Due to methodological differences in surveillance of workplace accidents (see EC, 2011a), a comparison be-tween countries can be misleading. Comparisons bebe-tween men and women within one country are not af-fected by this problem, as a possible surveillance bias would affect both genders.
121 “Although there have been efforts to try and reduce the underestimation of deaths by suicide due to the lack of standardisation of registering the ‘manner of death’, there are still differences in the occurrence of suicide among the European countries, which may be attributed to shortcomings still to be overcome. Examples in-clude countries where death certificates are used for insurance purposes, and perhaps the most important reason for underrecording might be where cultural and religious beliefs result in suicide being a taboo.“ (EC, 2011a, p. 318)
Figure 5.2.3 Death due to suicide, by gender, standardised death ratio by 100.000 inhabi-tants, 2009
Source: Eurostat (online data code: tps00122); extracted on April 12th, 2012; * data Belgium 2006, Switzerland 2007, France, Italy 2008
Figure 5.2.4 Death due to suicide: men, standardised death rate by 100.000 inhabitants, by different age groups, 2009*
Source: Eurostat (online data code: tps00122); extracted on April 12th, 2012; * data 85 years or over: Belgium, Malta 2005; Ireland, Luxembourg 2008; Iceland, Switzerland 2007; from 50 to 54 years: Belgium 2005, Switzerland 2007; from 15 to 19 years: Malta 2004; Belgium 2005; Luxembourg 2007; Cyprus, Iceland, Switzerland 2007
Clearly, age plays an important role. As shown by a comparison of selected age groups (figure 5.2.4), suicide rates are highest among old men in most countries, compared to younger men. However, this effect of age does not hold for women. Men at the age of 70 years and older have five times higher rates of suicide than women. (See EC, 2011a)
Depression and suicide can serve as related examples for men’s mental health problems:
hospital admission rates and attendance at surgeries in case of depression are higher for
women than for men, and so are the rates of suicide attempts (often by drug intoxication), but the rates for completed suicide are higher for men (often by more aggressive methods like hanging or shooting). (See Winklbaur, Ebner & Fischer, 2008) It has also been proposed that male depression is under-diagnosed and under-treated. As a consequence, the concept of a specific male depressive syndrome has been introduced (see Brownhill, Wilhelm, Barclay
& Schmied, 2005; Möller-Leimkühler, Bottlender, Strauß & Rutz, 2004; Rutz, v. Knorring, Pihlgren, Rihmer & Walinder, 1995; Winkler, Pjrek & Kasper, 2005;), which includes symptoms like acting out, low stress threshold or alcohol abuse, among others (instead of a subdued and inward directed reaction of self-deprecation and feelings of guilt, which is currently the common definition of depression).
The concern that men’s mental health is being under-reported was also recognised within the European Mental Health Report, where it is noted that whilst women have higher levels of internalising disorders (e.g., depression, anxiety) men have higher levels of externalising disorders (e.g., antisocial disorder) (EC, 2004) which can be detrimental for men, their friends and family, and their community (Kupers, 2005; Stewart & Harmon, 2004; Winkler, Pjrek & Kasper, 2006).
A relatively low uptake rate of medical and psychosocial help by men, compared to women, is another factor that is detrimental to men’s health. Recent data show that a higher proportion of men than women agreed to the item “I wanted to wait and see if the problem got better on its own” in case of unmet needs. (See annex 5.2.5) The rate of men reporting unmet needs covaries with educational level and income; the higher the educational level and the income, the lower is the proportion of men with unmet needs for medical examination. (See annex 5.2.6 and 5.2.7) Again, the combined effect of gender and socioeconomic position becomes apparent.
Concerning consultations of a physician during the past 12 months, there are also clear differences between men and women as well as between countries. (See annex 5.2.8 and 5.2.9)
5.2.3 Analysis
It is widely accepted that the bigger part of health differences between the genders – as well as differences within gender – are not due to biological and genetic factors but arise from social and psychosocial conditions. (See Sihto, 2006) In Public Health, the factors which influence the health status of individuals and communities are summarised as social determinants of health, including the physical, social, economic environment as well as a person’s individual characteristics and behaviours. (See World Health Organisation [WHO], 2012) The circumstances and ways in which people are working, consuming or living their relationships and private lives determine their health status.
As becomes evident, these conditions and behaviours are different according to socio-economic position and according to gender. For individuals as well as for segments of the population the situation is different, concerning the resources and constraints, in terms of developing and maintaining a good health status. For example, men with a low socio-economic position or men with a migration background often face health disadvantages.
Box 5.2.1 Socio-economic status, gender and health
It has been argued that the socio-economic status is indirectly linked to the health status (see Mack-enbach, 2006):
by material factors, for example low income and poverty, which can result in bad housing conditions, poor diet and reduced access to health-promoting facilities; occupational risks like exposure to chemicals, accident risks, or physically strenuous work;
by psychosocial factors, like daily hassles, high demands and low control at work, or work strain leading to psychosocial stress, which can be detrimental to health;
by behavioural factors, such as higher rates of alcohol consumption and smoking among populations with lower socio-economic status.
These factors are interacting: “[...] for example, the higher frequency of material disadvantage in lower socio-economic groups may partly explain their higher frequency of psychosocial stress or lack of leisure time physical exercise.“ (Mackenbach, 2006, p. 32)
Finally, these factors affect men and women in different ways, leading to complex patterns of explana-tion for gender differences in morbidity and mortality. For example, the exposure to occupaexplana-tional risks is distributed very differently among the genders, according to the labour market segregation in each country, and consequently accidents at the workplace are distributed differently.
The differences in life expectancies of men in the old EU-member states versus Post-socialist coun-tries can be explained in a similar manner:
“Since the political transition, mortality rates have changed dramatically in many countries in Eastern Europe, sometimes for the better (e.g. in the Czech Republic) but often for the worse (e.g. in Hungary and Estonia), particularly among men. This is probably due to a combination of (interlinked) factors: a rise in economic insecurity and poverty; a breakdown of protective social, public health and health care institutions; and a rise in excessive drinking and other risk factors for premature mortality.“
(Mackenbach, 2006 p. 10)
Various explanations are given for the lower life expectancy of men compared to women, for the related health problems of the male population and their subgroups, especially according to socio-economic status. As outlined above, men’s higher risk behaviour and risky lifestyles are named, their different help-seeking behaviour, and different conditions of work and life, among other factors. (See e.g., Dierks, 2008)
The reason for the higher level of all kinds of risks and risk-taking behaviour among men is seen in male socialisation. (See EC, 2011a; Scambor & Scambor, 2008) following the ide-ology of “[...] the man as the hard, outgoing instrumental type” (Holter, 2003, p. 25), ready for self-exploitation, reckless competition and a working life as an “expendable” (Holter, 2003, p. 25) performer. Being ready to accept a high level of risks is part of this pattern, also in working life, where dangerous and unhealthy working environments continue “to be taken for granted as normal and expected masculine practice, as ‘men’s work’” (EC, 2011a, p.
277).
However, the ‘cost’- (also in economic terms) or disadvantage side of socialising men in such roles and environments includes high rates of accidents, violent behaviour, attitudes towards work and life that could be described as “the ‘go till you drop’ syndrome” (Holter, 2003, p.
25), with a one-sided orientation towards labour and non-caring, and the establishment of a male identity by ’undoing health’ (Balkmar, 2011). Attitudes and behaviours that are detri-mental to health and linked to male identities, such as poor diet and obesity, alcohol con-sumption, smoking, etc (see White, McKee, et al., 2011), take their gender-specific, detri-mental toll.
The way in which boys are raised as well as men’s roles in society are also seen as reasons behind the specific shape of male depressions, which can result in extreme behaviour like suicide: “[...] there is not much room for giving oneself permission and space to be sad, to be ambivalent or, on the whole, to attempt to feel states within oneself ... Reactions to conflicting or painful conditions are therefore often actions whose objective is to avoid or to quickly get over doubts and pain. Such actions can, in the case of mental health, be extreme
behaviour [...]” (EC, 2011a, p. 311). While women prevail as far as suicide attempts by
‘softer’ methods are concerned, which can be interpreted as a ‘cry for help’ in many cases, the higher rate of completed suicides by men is interpreted as “a way of escaping a problem”
(EC, 2011a, p. 311) and as a gender-specific reaction to conflicting or painful conditions.
The high rate of suicides among old men is seen in connection with men’s retirement, being single, widowed or in ill health, which suggests a strong social and economic impact on this phenomenon. (See EC, 2011a) A large older male population is a relatively new phenome-non, and there is little provision focussed onto their needs. Though it has long been recog-nised that women often suffer significant social isolation in old age new studies are showing that a growing proportion of older men are also living alone and isolated, not only as a result
The high rate of suicides among old men is seen in connection with men’s retirement, being single, widowed or in ill health, which suggests a strong social and economic impact on this phenomenon. (See EC, 2011a) A large older male population is a relatively new phenome-non, and there is little provision focussed onto their needs. Though it has long been recog-nised that women often suffer significant social isolation in old age new studies are showing that a growing proportion of older men are also living alone and isolated, not only as a result