Men's Health in the 21st century.

The challenge of those working in the emerging field of men's health is outlined in this inaugural presentation given on the conferment of the first Chair in Men's Health. Discussion and debate to fully explore the parameters of what "men's health" actually means must be had with the broader academic community. In addition we have to establish what research is required to generate an evidence base in this fledgling discipline. Learning from, and guiding the development of, practice must also be a key element of this process. All this, though, requires campaigning: if our message does not get through to the politicians and the wider professional body then change will not occur. The final but most important aspect of this framework is to inform and enable men themselves.

Keywords: men's health, gender, politics, research, campaigning, practice

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Ladies and Gentlemen:

The easiest way to begin a talk on men's health is to make comparisons with women's health; this is not the ideal, since we are not in a game of looking for cheap headlines around the battle of the sexes. Our concern is how men's health differs from community to community, from one socioeconomic group to another, and how to identify issues that affect all men rather than assuming that if our health matched women's we would be all right. That argument is based on an assumption that women's health is the gold standard, and yet we know that this is not the case and that much work has to be done to improve the health of women as well as men. It is inevitable, however, that some comparisons must be made; I will keep them brief and hope they will act as indicators of the issues for men.

The most telling but perhaps the most easily forgotten of the differences between men and women is that women live on average five years longer than men, a fact so many people know that it hardly raises an eyebrow. When the mortality data are broken down age by age, however, we see that until the age of 75 more men than women are dying in every age bracket (see Figure 1).

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The question is why men have this increased number of deaths. In 2003, the European Men's Health Forum commissioned us to undertake a study on the state of men's health across 17 European countries (White & Cash, 2003). When we looked at the ratio of male deaths to female deaths across all age groups, we found that nearly 2.5 times as many male deaths occurred in the 1-24 year age bracket and nearly twice as many in the 25-74 year age bracket. Only beyond the age of 75 did women show a higher ratio of death. When the data are looked at more closely (see Figure 2), this higher proportion of male deaths occurs across nearly all causes of death, which should affect men and women equally.

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We see the same pattern of greater vulnerability in men when looking at the chances of developing cancer. Across all major cancers the incidence of men developing the disease is higher than for women except for thyroid cancer and melanoma, which we will come back to later.

So what we have is an issue that affects all men across all major disease states. Even more staggering are the differences in men's life expectancy. The recent "Choosing Health" White Paper (Department of Health, 2004) talks of a 15-year variation in men's life expectancy in different areas of London, with the lowest life expectancy being 67.5 years. In Leeds we see a similar picture, with City and Holbeck, a poor area within the city centre, having a life expectancy for men of just 66 years, compared to the more prosperous area of Wetherby, 13 miles away, where a man can be expected to live 13 years longer. Even more concerning is that the life expectancy of a man living in the local Gypsy and Traveller community is just 50 years (Graham, 2005).

We also have to consider the issue of suicide. Figure 3 maps the number of deaths caused by suicide and intentional self-harm compared to road traffic accidents in England and Wales. We see that many more men die as a result of suicide.

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Prostate cancer is another serious issue. It is now the most common cancer in males, and yet men's awareness of this problem is still poor. The rapid rise in sexually transmitted diseases and HIV is also a major area of concern. The list can go on and on.

To meet the challenges now facing us with regard to men's health, there has been a massive increase in activity around the world. Australia has seen substantial development, with America and Ireland working on a National Men's Health Policy.

At the European Men's Health Forum we now have a network that spans 14 countries, and there is also a Men's Health Forum in the Philippines and in Hong Kong. in England, of course, is our own Men's Health Forum, of which I am proud to be the Chair of the Board of Trustees. There is a growing academic press, with the International Journal of Men's Health and the newly launched Journal of Men's Health and Gender. We have had four world congresses to date and are seeing conferences occurring on a more frequent basis in many countries. More important, we are seeing a massive increase in activity among practitioners working with men in a wide range of settings.

The challenge as we enter the 21st century is to bring together the range of work that is being done in the biological, social, and political fields to achieve a better appreciation of the health issues that are facing men. The focus of this lecture therefore is to consider what needs to happen in five key areas to see this emerging field of men's health grow and mature into a fully fledged discipline in its own right.

Firstly, we need to discuss and debate with others what men's health is and how it should be developed. We must then consider the role of research in this field, campaign for recognition and action, explore practice, and, finally, consider how to inform both professional groups and the men on the street about the major factors affecting men's health and what can be done about them.

TO DISCUSS AND TO DEBATE

I first wish to explore the questions of what this thing called "men's health" is and what we need to do to develop its academic base. Because specific interest in men's health can only really be traced back over the past 10 years, there has not been a long debate regarding its definition. In the early days the focus was almost entirely on male-specific illnesses, which were immediately identifiable as "men's issues" and a strong lobby still exists for this viewpoint. It is interesting that reproductive health is still a mainstay of many key women's health organisations.

The Men's Health Forum (MHF), as part of its policy development document "Getting It Sorted" (MHF, 2004), created the following definition, which reflects the current thinking:

   A male health issue is one arising from physiological,
   psychological, social or environmental factors which have a
   specific impact on boys or men and/or where particular
   interventions are required for boys or men in order to achieve
   improvements in health and well-being at either the individual
   or the population level.

This shift from a purely biological definition reinforces the scope of the widely differing disciplines that are, or can be, brought under the "men's health" umbrella. I hope that through this lecture academics from different fields will begin to see how their own work can inform and be informed by this emerging field.

We need to explore how theories relating to men and masculinity can help in unravelling men's health beliefs and behaviour. There are many scholars on masculinity, and key work has been undertaken in trying to understand how men live and work in the social world. Until recently, though, a focus on health has been lacking. This is beginning to change, thanks to scholars such as Don Sabo and Will Courtenay from America, John McDonald from Australia, and Donald McCreary from Canada, to name but a few.

Will Courtenay's observations on what it means to be a "proper man" provide an insight into the pressures that men are under when they consider the impact posed by a threat to their health or independence:

   In exhibiting or enacting hegemonic ideals with health behaviours,
   men reinforce strongly held cultural beliefs that men are more
   powerful and less vulnerable than women; that men's bodies are
   structurally more efficient than and superior to women's bodies;
   that asking for help and caring for one's health are feminine; and
   that the most powerful men among men are those for whom health
   and safety are irrelevant (Courtenay, 2000).

Not every man, of course, sees himself in this way. Within our debate there is also a need to acknowledge that men are living many different lives and that their health beliefs and behaviours are not all identical. Ethnicity, race, culture, religious beliefs, socioeconomic status, age, sexual orientation, disability, employment, family, friends, schooling, past medical history, and even our weight and leisure activities all have an impact on who we are and how we are perceived by others and ourselves.

Does this therefore negate our endeavour? If all men are so different, how can we talk of a "male health issue" other than by referring directly to a medical condition that affects only men? As we have seen from the statistics, there are commonalities. There is a stark reality that premature mortality differentiates us not only by sex but also by socioeconomic status, and therefore it cannot be purely biological: there must be psychological, social, and environmental factors involved.

All men are different, but they also have one thing in common--they are men. They have all been subject to the same evolution and the same bag of socialising influences on who they are and how they see themselves. Men are biologically different from women and also brought up into a different social world. These differences need to be examined to learn how they affect men's health beliefs and behaviour. Research being undertaken by Robin Lewis, one of our Ph.D. students, into how men diagnosed with Type 2 diabetes adapt to their new circumstances is revealing some of the social issues. The case of a 46-year-old man who has a "high-powered" job involving lots of travel and entertaining highlights some of the difficulties which men face. Working late is the norm, and he is in an extremely competitive environment. His "patriarchal dividend" works against him when it comes to juggling a balanced diet, regular visits to the clinic, and a more settled work/life balance.

These types of social factors have to be considered alongside the emerging research on sex differences at the biological level. A comprehensive text from the American Medical Association (Wizemann & Pardue, 2001), which has explored the literature and research in this area, has shown a significant degree of variation between men and women, including differences associated with sex chromosomes, immune response, symptoms, type, onset of cardiovascular disease, response to toxins, brain organisation, and pain perception. Whether men's health behaviour is a result of nurture or nature is a controversial topic. Is our biological hard-wiring more of an issue than our upbringing?

No aspect of human life is without contention, and when considering the health of half the population it is inevitable that difficult issues will need to be tackled. Legitimising the work of men's health enables hitherto avoided debates to be opened up about men as fathers, perpetrators and victims of violence, the special health needs of gay men, the needs of homeless men, men who use drugs, men who are disabled, and other marginalized groups. The work of all the disciplines engaged in investigating men's health needs to be synthesised, and through that synthesis will emerge the basis of the new discipline of men's health. A dialogue has to be established and opportunities created to bring together scholars and practitioners to enable discussion and debate as to how men's health can be taken forward and lead to a coming together of the parts to create a fuller picture.

We also need to engage with our colleagues working in women's health to identify what we can learn from each other and how we can both move the debate forward in terms of developing gender-aware theory and practice. Early work on men and their health was in fact undertaken as part of comparative studies in which men and women were analysed to identify commonalities and differences (Nathanson, 1975; Verbrugge, 1983, 1985). Although there is a lot that can be achieved by developing the dialogue with women's health, there is, also a need to "problematize" men in their own right, to study men qua men (Caplan, 1988). As Clarke (1983) states,

   [I]llness is a multifaceted, complex phenomenon which has been
   measured in a wide variety of ways in many different studies....
   [But] when we do not know whether men or women view the
   same things as symptoms of illness, when we do not know to what
   extent physicians diagnose the same symptoms differently in men
   and women, when we do not know about the differential effects on
   men and women of the hospital experience, how can we theorize
   about sex differences in illness?

Discussions with women's health groups have already led to two important events--the WHO-funded International Gender and Health Conference in Vienna in 2002, to which men's health organisations were invited for the first time, and the U.K. Gender and Health Summit in 2003, hosted by the Gender and Health Partnership (GAHP) (O'Brien & White, 2003). As well as helping to identify differences between organisations, this dialogue also creates coherent policy frameworks for addressing the importance of a central place for sex and gender in all health policy decision making.

RESEARCH

Moving on to the research agenda, what is the evidence base for men's health? We have to acknowledge that most early medical research was biased toward the white middle-class well man and that most research was done on men by men. It was assumed that this research could be extrapolated to women and also across ages and races. Few now doubt the folly of this approach. The research did not serve women at all. It did not serve men well, either, because using men as a convenient homogenous sample and ruling sex and gender out as variables acted to make men just as invisible as women. The research also failed to take note of men's personal experiences of illness or their health beliefs and behaviour.

When we actually explore the research that has been done with men in relation to their health, it is surprising how little there is. What is emerging is the need for a whole new programme of research to be developed, since so many questions, across such a broad spectrum of men's lives, remain unexplored. A key quote from the Scoping Study on Men's Health (White, 2001) that I conducted for the Department of Health in 2001 was: "Men's health is not a medical issue; it is societal. Therefore a much broader approach needs to be taken." This leads us into research questions around men's lifestyles and the social pressures on men to conduct their lives in certain ways; it makes us look at social structures, including education, work, leisure, and relationships.

Basic questions, such as how men use the health service, still need to be explored. We know that men do not go to the doctor's office as often as women, but it is interesting that we still do not know whether the claim that men delay going to the doctor is in fact true. There are indicators that this is the case; for instance, that melanoma (see Figure 4) has a higher incidence rate among women in all of the 17 Western European countries, but the mortality is far higher in men (see Figure 5), suggesting a delay in seeking help. The recent, as yet unpublished, systematic review of gender and cancer, however, found no evidence existed that could either support or refute the suggestion that men delayed in presentation.

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We are currently undertaking a five-year study with the Bradford and Airedale Health of Men team (healthofmen.org) on men's decision making with regard to their health. The team received a 1m [pounds sterling] Lottery Grant with matched funding from the four local health authorities to develop services for men. Field work and interviews carried out with men using these services suggests that the men certainly do care about their health, but there is a degree of uncertainty in using the conventional health centres for getting a health check. They see the doctor's office as a place to go when you are "poorly" and, having no other need to make an appointment, they do not wish to "bother" the doctor and be seen as time wasters. Also, men are more likely to work full-time, work more than 48 hours a week, and be less likely to have the option of flexi-time. Going to see the doctor therefore requires a lot of planning. When the Health of Men team goes into men's workplaces or conducts a pub quiz or, as illustrated here (see Illustration 1), conduct health checks in a local barber's, men use these services willingly as it is easy for them and they are in their "comfort zone" rather than the alien health centre.

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An interesting finding from another colleague in men's health, Trefor Lloyd, was that when he set a group of teenage lads the task of making a doctor's appointment, they did not know how to because their mothers had always done it for them. They were left with no appreciation of how to make an appointment, how to get past the receptionist, or indeed the concept of having to wait for an appointment. Young girls appear very quickly to be able to manage the health centre, for contraception, antenatal care, and the like, and appear to become far more sophisticated in their ability to manage the system. Young men have no need to go to the doctor's office unless they are all. Their bodies are unchanging from one day to the next, and so, for many, there is no requirement to go. As one man I interviewed as part of a study on prostate cancer said, the doctor's office was like a foreign place to him.

We cannot limit ourselves to purely social research, though. Biomedical, epidemiological, and clinical research is also needed to be able to tackle the diseases from which men suffer. Ten years ago the total grant for research on prostate cancer in the UK was in the region of 30,000 [pounds sterling]. I remember a very disturbing experience when I was a student nurse in the operating theatres, being quizzed over the relevance of a degree in nursing while the surgeon was doing a bilateral subcapsular orchidectomy for prostate cancer, which involves scraping out the contents of the testicles. Castration was, at the time (not that long ago), the only treatment available. As the life expectancy of men increases and we are now in the position where prostate cancer is the most common form of cancer in men, lack of research in this area is reflected in uncertainty over what are the most effective forms of screening, diagnosis, and indeed treatment. This makes it even harder to guide the man on the street, who is just becoming aware that his prostate health may be problematic.

Some of the impetus for research into men will come from academics working in the field of men's health, but we also need to be aware that soon it will become a central requirement for all researchers. There is now a clear steer from the WHO and the EU in relation to gender mainstreaming with the requirement that gender has to be acknowledged as a factor in all research. This has highlighted the problem that there is now a fairly good understanding of how women's specific issues should be addressed, but there is not the same degree of awareness about men's issues. We lack a vocabulary for men because there has been limited debate about what constitutes male-aware research (White & Johnson, 1998).

What is apparent is that a wealth of research needs to be undertaken. Numerous collaborations are possible across all the different discipline groups, from the health professions to psychology, sociology, physiology, sport science, and education. Here we are today, for example, in our Headingley Campus, the home of the Carnegie Institute of Sport. So much of its research has a direct impact on the health of men, especially with the increasing concern over boys' and men's weight problems and inactivity. Such fundamental questions as why so many men stop being active when they enter adulthood need to be explored. Does the same competitive spirit that accelerates us to compete also act as the brake to stop us completely when we know we cannot win?

TO CAMPAIGN

Sitting quietly in our offices working on papers for academic journals or acting as practitioners carrying out tremendous but invisible work will not enable us to improve the health of men. As we enter the 21st century, we must consider the role of campaigning within the men's health debate, for it is at the societal level that we must aim if truly effective changes in men's health are to be achieved.

It is worth spending a moment considering the origins of the men's health movement and how it differed from the women's health movement, for we have started from a very different position. For women, health was very much a part of their emancipation and a central part of the feminist movement. The growing realisation of the patriarchal medicalisation of women and their health was a very visible and divisive issue for women. Getting improvements in the services offered to women was driven by women themselves and became a very potent political issue. This groundswell of public disquiet has not occurred with men's health.

In 1992, the then Chief Medical Officer in the UK included a section on men's health within his annual report. This was the first time that there had been any acknowledgement at a governmental level that men's health was problematic. In that report he stated:

   Gender differences in mortality and morbidity undoubtedly exist:
   but what are they caused by and what can be done about them?
   There is increasing evidence that many of the patterns observed
   stem from differences in health-related behaviour, which may be
   influenced by the knowledge, attitudes and beliefs of men.
   (Department of Health, 1993)

Prior to this official sanction, talk of "men's health" was seen as almost heretical and those few who were vocal faced a very suspicious and unreceptive audience.

What advances were made in reducing male deaths were seen at the population level rather than focused specifically on men, with this approach still being the most commonly adopted, such as Health and Safety at work, the use of seat belts and crash helmets, and legislation limiting speed on roads and the number of hours worked. Two personal issues provide good illustrations of this. My son Jon (see Illustration 2) has a passion for motorcycles, but at 14 he is too young to go on the roads, as a result of legislation. He now goes to a charity called BUMPY (Birstall Urban Motorcycle Project for Youth), where through legislation he is in a safe environment, wearing a helmet on a restricted bike. My other son, David, has just started a forestry degree and has his sights on being able to use a chain saw up a tree. I am grateful for Health and Safety ensuring that he is kitted out with the right gear!

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The national promotion of healthy diets, the limiting of tobacco and alcohol advertisements, and, on a bigger scale, the impact of banning smoking in public places in countries such as Ireland are other examples of legislation having an effect. These grand statements, however, though extremely important and undoubtedly having saved countless lives, are still not capturing the wider issues that affect men and their health.

Through the 1990s there was an increase in the number of individuals and pressure groups starting to make their presence felt, with the formation of the Men's Health Forum (England and Wales) and the European Men's Health Forum, as well as smaller local groups such as the Kirklees Men's Health Network and the Bradford Health of Men team. The impact of their lobbying has started to bear fruit, as we have seen in key legislation now emerging in the UK, such as the new pharmacy contracts, which include a specific requirement to target men as part of their provision (Department of Health, 2005). We have also seen inroads into the need to have gender as part of the local provision of services through the recent introduction of statutory obligation to carry out gender equity audits.

Most of this activity has been on the public health side, but we are now also seeing a move into more mainstream medical services. An edition of the British Medical Journal recently focused on men's health and brought to a wider medical audience issues that were confronting men and indeed women. In an editorial (White & Lockyer, 2001), for example, Lesley Lockyer and I were able to explore deficiencies in the National Service Framework for coronary heart disease (Department of Health, 2000), which had managed to completely miss that this disease was principally one of younger men and older women, with significant differences in the way the disease presents and develops between the sexes.

The International Journal of Men's Health, the Journal of Men's Health and Gender, and articles in other health-related journals have also helped to bring discussion of men's health to a wider audience.

TO PRACTICE

Up to this point in my lecture we have been working at a mainly theoretical level of discussion, debate, and research, but the reality out there is that the majority of the pioneering work was started in practice. It was the clinicians who created new opportunities for targeting and working with men and boys. The Bradford Health of Men team, Jayne Deville-Almond, who set up the first Barber Shop clinic, and Meryl Johnson, who set up the first Health Improvement Programme for men in Worcestershire, are just some of the early pioneers and visionaries who saw beyond what was currently being done and moved into new arenas.

What typifies the majority of the services being offered to men is that many are not what you can class as "conventional," with clinics being set up in barber shops, in bars, and in factories; events being staged at fishing conferences and football grounds; dads and lads weekends; and health sessions being organised in schools and in youth clubs, to name but a few. The men who have been described as the hardest to reach are also the hardest to avoid in some areas of town. These practitioners have taken their initiatives to the men and boys rather than waiting for them to come to health centres, where "well man" clinics sat dismally empty or were accessed by the occasional "well man."

Within the study we are undertaking with the Bradford Health of Men team we interviewed all the key workers to try and identify what worked and what did not when setting up initiatives for men (White & Cash, 2005). During the analysis it became apparent that it was not just what they did that was important--it was how they did it. The personal and professional attributes of the individual workers were an essential factor affecting the success of the operations. These key attributes included being nonjudgmental, nonthreatening, male-focussed, creative, willing to go to the men, able to see beyond the behaviour of the lads, able to use humour appropriately, and willing to wait for success, since some initiatives can take months (if not years) to be accepted. Above all, it seemed that they were working within a public health model, undertaking screening but primarily concerned with tackling lifestyle issues that were affecting the boy's and men's health.

When I set up the database of projects and initiatives for the Department of Health in 2000 (menshealthforum.org.uk), we contacted all the health authorities in England and Wales to try and find out what work was being undertaken. We also spoke to all those we already knew were working in the area. By the end of this process, which had expanded to include Scotland, we had been able to uncover 80 projects, most of which had been going for less than five years. In 2003 when the Men's Health Forum ran the first men's health week in the UK, 200 groups registered their interest. This last year there were more than 2,500, and even more are coming on board.

This rapid growth is also reflected in my men's health module. In the first year in which I wanted to run it, there were insufficient numbers, but this year I have had to set up a waiting list since I was over subscribed. Looking at those taking the current module, it is important that the diversity of students reflects the breadth of impact that work in this area has had. There are practitioners working in the field of men's health from around the country along with nurses from critical care, urology, and the Leeds Student Services, an occupational health practitioner from a leading national company and a participant who runs a community health educator course. Also included are the director and one of his colleagues from the Black Elders Association of Leeds and workers from the Hamara Centre and the Touchstone Community Mental Health Centre. All are exploring how best to understand the men they are working with and how to improve their health. The demand is such that now we are introducing a whole men's health course, which will run at diploma, undergraduate, and master's levels to cater to a broad multidisciplinary audience.

The originators of work in men's health needed space to experiment, to determine what is a "male friendly" service. Now that we are trying to roll this work out to the wider health community, we need to develop protocols and to generate guidelines that others can follow. We are now coming to a tricky problem in that much of the work has not been formally evaluated, and so it is problematic to try and move to the prescription of any one approach. Working at an intuitive level and looking at the data from Bradford, we can see that it works, but will it also work with a different population group in a different location?

There is another important aspect to this section on practice that needs to be considered, and that is whether "men's health" is the same as "treating men." When we are discussing developing men's health, does it mean that we are delivering something different from what has been seen before? At any one time there will be men at a doctor's surgery, at an outpatient clinic, or in the hospital. Is that men's health? My current position is that there is something different. When you consider what is being done and how it is being done with men in a specifically male-centred, male-orientated, male-focussed way, can one not argue that this is a new field of practice?

TO INFORM

This leads us to the next phase--how to inform the wider health community. We need to have a mechanism by which men's health can be incorporated into curricula, not just for the key medical professions of medicine, dentistry, nursing, physiotherapy, dietetics, speech and language therapy, and sports medicine, but also for a broader range of disciplines and practice areas such as education, play work, and youth work. This needs to be done in a way that enables practitioners to see that men's health and women's health have to become much more mainstream, as central to the curriculum as ethnicity or socioeconomic status. It has to become relevant to the student to know that "gender-blind" practice will have little lasting impact and may even be damaging to men and women. It is important for practitioners to know the biological differences between men and women but also that it is not purely a biomedical issue and that knowledge of masculinity and the social pressures men are under gives a much clearer picture of why men behave as they do.

What initially brought me to work in men's health was the realisation that nurses do not have any formal preparation to care for men and that there was no mention of men's health beliefs or behaviour or even of male-specific diseases apart from a brief mention of prostate cancer and testicular cancer. I am now engaged in speaking to nursing groups, medical students, and physiotherapy students and, in the past, have spoken to play work groups. When I have finished a session, the students are amazed by how little they knew or understood about men, which is quite staggering, really, since they are often already qualified. It is incomprehensible that only now are we beginning to fully realise the extent of the differences in the way men and women experience both health and illness and that practitioners are left in ignorance of why this is the case.

This then brings us to perhaps the most important issue of how to inform men themselves, for if professionals are uninformed then what chance has the general public? How do we get boys, young men, middle-aged men, and older men to be aware of the health needs of their particular age group and of what is to come so that they are prepared and enabled? What work is possible as part of antenatal care to inform mothers and fathers-to-be of how the health needs of a boy child differ from the health needs of a girl child and about the different pressures boys face as they grow and the implications this has for their upbringing?

How can we extend our curriculum in schools so that boys get useful life skills and the tools to be able to manage their health when surrounded by peer pressure and such a powerful socialisation process? At the same time, we must acknowledge that boys are boys and young men are young men and that the pressures on men to conform to outside guidance are often outweighed by a deeper instinct to find their own way. We also have to be realistic and recognise that young men are unlikely to remember much detail, since they will probably go many years before health becomes an issue. But there are still lads dying of testicular cancer because they did not get treatment in time when this disease now has an almost 100% survival rate.

We have to have strategies in place to pick up men as they enter their 30s and 40s. When they find that they are not as young as they used to be and their growing waist size (what used to be seen as "middle-aged spread") extends toward the danger mark of 40 inches--above which they are at a high risk of developing diabetes, hypertension, high cholesterol, and the many cancers that are related to obesity (Sattar, 2003).

There is also a need to find ways of targeting men from the Black and South Asian communities and to be more aware of their health and the specific problems they face; for example, a man from the African-Caribbean community is three times more likely to develop prostate cancer (Haynes & Smedley, 1999), while a South Asian man is between three and six times more likely to develop diabetes, depending on his country of origin (Department of Health, 1999).

How do we get all men to be more proactive in seeking help? A case in point is that millions of pounds have been spent on developing thrombolytic drugs (the clot busters that are given when you have had a heart attack to break down the clot). These need to be given within the first six hours of the onset of the problem, but a significant number of men do not make that time frame. When I conducted my study on men with chest pain (White & Johnson, 2000), a typical story was of the man waking in the night and going downstairs so as not to disturb his partner and waiting until morning before suggesting making an appointment to go to the doctor's office. Or the man who has a second heart attack and, because it wasn't in the same place, does not believe it can be another infarction.

Now prostate cancer is the most common cancer in men, but we still have men in their 50s, 60s, 70s, and beyond experiencing the symptoms and putting it down to old age. We have men suffering the problems of erectile dysfunction, too embarrassed often to mention it to their partners, which has led to marriage breakdown when treatment is available. More important, whereas once it was understood to be mainly psychological in origin, it is now seen as the sentinel marker for many health problems, including cardiovascular disease (Jackson, 2004; Solomon et al., 2003).

Perhaps one way to reach men is the International Men's Health Week that runs up to Father's Day, which is now almost global and is having a marked effect on both men's and practitioners' awareness of men's health. Another way is to develop male-orientated services and deliver information in ways that are more male-friendly. The success of the Haynes Manuals (Banks, 2002, 2004) is a case in point and the award winning Malehealth website is another (malehealth.co.uk).

CONCLUSION

So where are we now? If you look at the data on men, their health is certainly problematic. If you look at the evidence base, it is incomplete. If you look at our theoretical understanding of the issues, it is still unclear. But when you look at the practice, you see changes occurring. Clinicians are realising that the old systems seem to be failing many men and new approaches are required. Academics are turning towards men's health, out of their natural curiosity about a new area and also because the importance of the task is beginning to sink home. This encompasses the whole of society, for whatever affects the health of men also affects women as well as many other aspects of life, such as employment, crime, education and sports, to name but a few.

The first challenge facing those of us working in the field of men's health is to recognise that it is a "field." It has its own developing theory base, it covers a distinct subject area, and there are a growing group of academics, practitioners and organisations working in the area. As with any new field, it needs to be researched, debated, and campaigned for.

Research into the causes of disease, therapeutics, and the skill of clinicians in diagnosis and disease management should be synthesised with social research into men's health beliefs and behaviour. This in turn needs to be translated into developing health policy that is more sex and gender conscious along with education programmes for health professionals and men themselves.

This is no idle endeavour. It is not rhetoric for the sake of some academic whim. There are serious concerns about the state of men and their health, and we are obligated to ensure that we take whatever steps we can to tackle what could be the biggest health issue of the 21st century.

Editor's Note: This is the inaugural public lecture of Alan White, Professor of Men's Health at Leeds Metropolitan University in England. It was given on the occasion of the university's bestowal of a Personal Chair in his name in recognition of Professor White's work in the field of men's health. It is presented much as delivered as an address, with only minor changes.

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ALAN K. WHITE

Leeds Metropolitan University

Leeds, U.K.

Correspondence concerning this article should be addressed to: Prof. Alan White, Centre for Men's Health, Leeds Metropolitan University, Queen Square House, Leeds, LS2 8AF, UK. Electronic mail: [e-mail].