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College Men's Health

An Overview and a Call to Action

Copyright © 1998, 1999 by Will Courtenay, PhD, LCSW

An earlier version of this article originally appeared in the Journal of American College Health in May, 1998 (Vol. 46, No. 6, pp. 279-290) Copyright © 1998, Heldref Publications

 

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For men of college age, the risks of disease, injury, and death are far greater than for women of the same age group, yet college men's health concerns receive little attention from health professionals. This article discusses college men's health risks, men's failure to adopt health-promoting behaviors, their propensity to engage in risky behaviors, their beliefs about manhood, their attitudes concerning their own vulnerability, and their limited knowledge about health. Men's socialization as boys provides a framework for understanding why many college men have adopted unhealthy lifestyles. How masculinity and stereotypes about manhood influence the health services provided for men are outlined. We need to both stress the importance of providing gender-specific health behavior interventions and programs and encourage future research into the specific needs of these young men.

Will Courtney

Men in the United States, on average, die 7 years younger than women and have higher death rates for all 15 leading causes of death. Men's age-adjusted death rate for heart disease, for example, is 2 times higher than women's, and the death rate for cancer is 1a times higher. Men are also more likely than women to suffer severe chronic conditions and fatal diseases, and to suffer them at an earlier age. Under age 65, for instance, nearly three of four persons who die from heart attacks are men. Furthermore, men's health shows little sign of improving. For example, men's cancer death rates have increased more than 20% over the past 35 years, while the rates for women have remained unchanged during the same period.

Disease, injury, and death rates are unavailable for college students specifically. A general profile of college men's health can only be inferred from the risks of this approximate age group. Among 15- to 24-year-olds nationally, more than three out of every four deaths each year are male. Among adolescents, males are more likely than females to be hospitalized for injuries. Fatal injuries account for over 80% of all deaths among 15- to 24-year-old men, and three out of four unintentional injury deaths in this age group are male. Young men of this age are also at far greater risk than women for sexually transmitted diseases (STDs). Heart disease deaths are nearly twice as high for men as for women in this age group, and cancer deaths are 1a times as high. [1] Most of these deaths, diseases, and injuries are preventable.

Despite the tremendous loss that these statistics represent, policymakers and health professionals alike have paid very little attention to men's health risks, or to their greater risk of premature death. While health science of this century has frequently used males as subjects, research typically neglects to examine men and the health risks associated with men's gender. The consistent, underlying presumption in medical literature is that what it means to be a man in America has no bearing on how men work, drink, drive, fight, or take risks. Regarding the health concerns of college men in particular, little has been written, aside from a few articles addressing specific health issues, such as STDs, testicular cancer, and men's mental health. Even in studies that address risks more common to college men than women, the discussion of men's greater risks and of the influence of men's gender is often conspicuously absent. No author to date has examined the broader context of college men's health. Despite this dearth of literature, men's health was recently ranked by American College Health Association members as their fifth top priority for continuing education.

This paper provides an overview of college men's health. It identifies the health risks of college men, explores various explanations for their poor health status, and recommends interventions to improve their health. (An academic journal article version of this paper, available on the author's Web site, provides full citations for the data referred to here. Whenever possible, the paper relies on data from college samples are discussed. When no such data exist, research on adolescent males and men in general is used to identify health concerns that need further examination among college men.)

Major Contributors to College Men's Risks

Failure to Adopt Health Promoting Behavior

The gender gap in longevity has widened steadily since 1920, when women and men lived lives equal in length. Unless women's lives have become considerably less hazardous, this increasing gap suggests that there is nothing natural, inevitable, or biologic about men's shorter life span. Although a number of genetic and biologic factors may contribute to the difference, they do not explain it. Additional factors, such as access to care, economic status, and race, also influence health and longevity. Many health scientists contend that personal health behaviors are the most important of these factors-a belief supported by a wealth of data. An independent scientific panel established by the U.S. government recently evaluated thousands of research studies in cooperation with the Public Health Service and concluded that an estimated one half of all deaths in the United States could be prevented through changes in personal health practices.

Gender is one of the most important determinants of health behavior. Research consistently shows that men engage in far fewer health-promoting behaviors and have less healthy lifestyle patterns than women. Research reviewing national data and hundreds of large studies has revealed that men of all ages are more likely than women to engage in over 30 controllable behaviors that are conclusively linked with a greater risk of disease, injury, and death. For example, they eat more fat and less fiber; they sleep less; and they are more often overweight than women.

College men, specifically, also engage in far fewer health-promoting behaviors than college women. For example, they consistently score lower on an index of health-protective behavior that includes safety belt use, sleep, health information, eating habits, and exercise. College men are also significantly less likely to practice self-examinations for testicular cancer than college women are likely to practice self-examinations for breast cancer. Furthermore, college men's health-promoting behaviors have been found to decrease over time, while those of college women increase.

The failure among young men in general to adopt health-promoting behaviors increases their risks. For example, although teenage males receive more exposure to the sun, more than twice as many teenage females use sunscreen regularly. Young men also reapply sunscreen less frequently and use lower SPF protection. There is no evidence that these findings differ for college students. Only one poorly designed study appears to have addressed sunscreen use among college students. This study found that far lower percentages of college men than women use sunscreen. For example, nearly twice as many college women use sunscreen with SPF 15 when exposed to the sun for a least one-half hour, and 6 of 10 college men rarely use sunscreen, as compared to 4 of 10 college women. Although this study reported greater sun "bathing" among the sample of college women, "exposure" to the sun is consistently found to be greater among men of all ages. Young men's failure to wear sunscreen when exposed to the sun contributes to their greater risk of skin cancer. The increase in skin cancer among men is higher than that of any other cancer, and two of three melanoma deaths are men. Use of sunscreen in young adulthood can lower the risk of skin cancer by 80%.

Safety belt use provides another example. College men are significantly less likely than college women to wear safety belts either as drivers or as passengers. Wearing safety belts is potentially the single most effective method for preventing injuries from motor vehicle crashes. It reduces the risk of serious injury by up to 52% and reduces the risk of death by 43%. The failure to wear safety belts contributes to the fact that, among 15- to 24-year-olds, over 3a times more men than women die in automobile accidents.

Risk Behavior

Young men also take greater risks than women do.For example, they drive more dangerously. They are far more likely to tailgate and run red lights; or to drive 20 miles per hour over the speed limit, pass in a no-passing zone, or pass two cars at a time on a two-lane road. Nearly one third of adolescent males take risks "for fun" while driving-over 4 times the number of females. Similar findings are reported for college men. At one university, nearly half of the men have operated a vehicle under the influence of alcohol or other drugs, 61% report riding with someone under the influence, and 93% drive above the speed limit. In a very thorough analysis of gender and driving risks among college students, men received significantly higher scores than women for problem driving, which included speeding or reckless driving, moving violations, arrests for driving under the influence, and license suspensions or revocations. Among college students nationally, 2 to over 2a times more men than women have driven after consuming five or more drinks, and 62% of frequent male binge drinkers have driven after drinking.

Men also engage in riskier sexual practices. Among college students, men begin sexual activity earlier in their lives, have more sexual partners, and are more likely than women to have sex under the influence of alcohol or other drugs. College men, for example, are 2a times more likely than women to have had more than 10 sexual partners. Large studies of African American college students have also found riskier sexual practices among men.

In fact, consistent gender differences among college students are found for most health risk behaviors. A wealth of research has shown, for example, that college men are much more likely than college women to engage in risky sports, work, and travel. A recent study of California college students reveals that men are more likely than women to engage in 20 of 26 specific high-risk behaviors, including behaviors related to smoking, drug use, carrying weapons, and physically fighting. Among college students in New Jersey, men are more likely than women to engage in 12 of 14 high-risk behaviors. Recent national data show that more than 1 of 10 college men carries a gun, knife, or other weapon, nearly 3 times the number of women who do; and students who carry weapons are far more likely to drink, and to fight if they binge drink. College men's risk taking compounds the hazards to their health associated with their failure to adopt the health-promoting behaviors discussed above. For example, their dangerous driving habits compound the risk associated with not wearing safety belts. Condom use provides another example. Only one third to one half of sexually active college men use condoms. Even among those at high risk for STDs, three out of four use condoms occasionally or never. Among young gay and bisexual men, a recent study found that one in four is having unprotected anal intercourse-and although the college men in this study were somewhat less likely than their noncollegiate peers to have unprotected sex, the difference was not statistically significant. This widespread failure to wear condoms compounds the risks associated with college men's unsafe sexual practices.

Masculinity

While simply being male is linked with poor health behavior and increased health risks, so is gender, or men's beliefs about "being a man." A growing body of compelling research provides evidence that men who adopt traditional attitudes about manhood have greater health risks than men with less traditional attitudes. For example, a large study of 13- to 19-year-olds reveals that alcohol use and problem drinking is strongly associated with traditional masculinity, and that this association is even stronger than the link between drinking and being male. Findings from a national study of nearly 2,000 young men aged 15 to 19 years, including college men, reveal that traditional beliefs about manhood are associated with a variety of poor health behaviors, including drinking and drug use and high-risk sexual activity. For example, young men who hold these traditional beliefs-such as believing that a guy should be "sure of himself " and not "act like a girl"-have more sexual partners and are more likely not to wear condoms consistently. These associations hold true regardless of expected educational level or race and ethnicity.

Among college students, traditional attitudes about masculinity have similarly been linked with poor health behavior, including smoking; alcohol and drug use; and behaviors related to safety, diet, sleep, and sexual practices. Compared to their less traditionally minded peers, college men who rigidly adhere to traditional notions of masculinity have more anxiety and poorer health habits, greater cardiovascular reactivity in situations of stress. [60] College men who adopt traditional attitudes about manhood experience higher levels of depression, and are more vulnerable to psychological stress and maladaptive coping patterns; furthermore, these men compound their risks because they tend not to seek help from others and underutilize professional services on campus.

Concealing Vulnerability

Men further compound their risks by concealing pain and illness. Suicide provides one example. Throughout the life span, suicide rates are 4 to 12 times higher for men than for women. Suicide rates are staggering for young men. While the rate for the total population has maintained a flat trend since 1946, suicide rates for young adults, aged 15 to 24 years, have increased about 250%. There are no reliable data documenting suicides among college students, nor are there current data to suggest that the risk of suicide differs for college and noncollege men. For this approximate age group, however, suicide is the third leading cause of death, and six of seven suicides are male. Despite this high risk, friends and family consistently report "complete shock" when college men commit suicide. When one college junior shot himself, his mother said she had "no reason to believe" her son would do such a thing. One explanation for people's shock is that college men successfully conceal their vulnerabilities. They are less likely than college women to confide in close friends, to express vulnerability, or to disclose their problems to others. Consequently, others are often unaware when these men are in pain. A psychiatrist interviewing friends and family of a well-liked, successful student athlete who recently committed suicide reported that "no one really knew what [his] feelings were...he seemed to hide them."

This desire to conceal vulnerability can influence college men's decision not to seek care and can affect assessment and diagnosis when they do get care. In fact, they are significantly less willing than college women to seek support in situations where help is needed. A large study of midwestern students found, for example, that college men were less willing than college women to seek help for physical illnesses. Consequently, among first-year college students in one state, more women have made recent medical visits, and twice as many men as women have not made a medical visit in over one year. College men's reluctance to seek help can result in serious delays in treatment. Among one sample of college men, nearly three of four delayed getting help for STDs from 2 to more than 6 months after they developed symptoms. College men are also more likely than college women to delay seeking psychological help. Among depressed college students, men are more likely than women to rely on themselves, to withdraw socially, and to try to talk themselves out of depression. College men's self-reliance and denial of pain can contribute to others' inattention to their health needs. For example, their responses to depression foster the widespread belief that college men do not get depressed. In fact, studies based on the results of psychological testing consistently find no significant gender differences in diagnosable depression among college students. Despite this strong evidence, survey research based on students' self-reports rather than on psychological tests typically leads to the false conclusion-as reported in one recent study-that depression is a "more critical" health problem for college women.

Perceived Invulnerability

Despite their high risks, the vast majority of American men actually believe that their health is "excellent" or "very good" and report better health than women. Men are also less likely than women to perceive themselves as being at risk for illness or injury. One national study recently found that greater percentages of men than women perceived less risk for each of the 25 health problems examined; and men's gender remained a significant predictor of low perceived risk when controlling for level of education. Men, including young men, perceive themselves as less susceptible to skin cancer than women do and underestimate the risks associated with sun exposure; the one study that has examined perceived skin cancer risk among college students also found that men perceived less risk than women. Similarly, college men perceive significantly less risk associated with the use of cigarettes, alcohol, and other drugs than do college women; they are also more likely than college women to underestimate the risks associated with involvement in physically dangerous activities. In fact, college men are consistently found to perceive less risk than college women for a variety of health threats.

Similar gender differences in perceptions are found for driving risks and for automobile accidents. Adolescent males are more likely than females to expect no consequences-such as a citation, crash, or injury-to result from their more frequent reckless driving. Among college students in one well-constructed study that examined 15 risky driving behaviors, men scored significantly lower in their perception of risk than did women. For example, they perceive as much less serious not using a safety belt, drinking and driving, and not making a full stop at a stop sign. In fact, this study concluded that, compared to college women, college men possess a particularly lethal combination of perceptions that compounds their risk: an exaggerated sense of their own driving skill and the perception of less risk associated with a variety of dangerous driving habits. These beliefs are inconsistent with the finding that, in California for example, men are at fault in nearly 8 of 10 automobile accidents and 2 of 3 injury crashes; and, as noted above, nearly four of five young adults who die in automobile accidents are men. Although comparisons of the driving patterns of college and noncollege men are unavailable, there is no reason to believe that differences exist, particularly given the ample evidence of risky driving among college men.

Men also differ from women in their perceptions of sexual health risks. Based on a variety of behaviors, including sex under the influence of drugs and number of sexual partners, men of all ages nationally are much more likely than women to be at high risk for STDs and HIV. Eighty-six percent of all STDs occur among those under age 30. Recent national data reveal that, based on their sexual histories, 60% of men under age 30 are at medium to high risk, 2a times the number of women; and of particular relevance here, that higher education is positively associated with greater STD risk. The most recent statistics also show that the group at highest risk for HIV are 13- to 25-year-olds. Currently, 8 out of 10 of those infected with HIV are men, and men represent nearly 9 of 10 deaths attributable to HIV. A recent review shows that the prevalence of HIV infection among college students has been 0.20% since 1990. College men who have sex with men have the highest rate of infection-from 1.3% to 2.6%. However, it has been noted that many heterosexual college men may also be at risk for STDs and HIV, due to their high-risk sexual practices. In fact, between 1990 and 1995, HIV infection increased 189% among heterosexuals, compared with 12% among men who have sex with men. Among those aged 13 to 25 years, over one third are infected through heterosexual contact.

Despite these statistics, many researchers have found that college men perceive less risk for HIV than do college women, although some have found either no gender differences or mixed results. However, college men have been found to report little concern even when their actual risk for STDs and HIV is high. In one study, three out of four college men believed that their risk of HIV was either low or extremely low despite their high-risk sexual behavior. This belief in their own attitude of invulnerability prevents college men from changing their behavior. Perceived susceptibility among college students is linked with positive changes in risk behaviors, with rare exceptions. Unrealistic perceptions of risk-including the belief that only men who have sex with men, intravenous drug users, and prostitutes contract STDs and HIV-may explain why knowledgeable college students continue to engage in high-risk sexual behaviors.

Perceptions of invulnerability are associated not only with sexual health risks, but with health risks of many kinds. In one very thorough study, for example, perceived susceptibility to skin cancer and sun damage emerged as the strongest predictor of teenagers' use of sunscreen. Similar studies have yet to be conducted with college students. Perceived susceptibility is also associated with men's failure to adopt positive health behaviors, such as testicular self-examinations. Detected early, testicular cancer is highly curable. However, about half of men with testicular cancer are not diagnosed until it is in an advanced stage, when it is fatal or disabling. Although college men are among those at highest risk for testicular cancer, studies have found that three of four do not know how to perform a self-exam, and only 8 to 14% do so regularly. Because these tumors grow quickly, monthly exams are recommended, and without self-exams or medical visits, early detection is unlikely. College men's sense of invulnerability can undermine their practice of self-exams. In one recent study of college students, fear of developing cancer was among the best predictors of men's practice of testicular self-exams.

Health Knowledge

Research shows that men-including college men-are far less knowledgeable than women about health in general and about specific diseases, such as cancer, STDs, and risk factors for heart disease. For example, studies consistently find that women, including college women, know significantly more about skin cancer, sunscreen protection, and the harmful effects of sun exposure. College men also know significantly less about self-examinations for testicular cancer than college women know about self-examinations for breast cancer. Most recent studies of college students' knowledge have examined risk factors for HIV and AIDS. While gender differences are not found consistently in these studies, when differences are found, college men are less knowledgeable than college women. Most college men have had relatively little experience with the health care system and may lack even basic health information, such as how to make an appointment. In one study of men at a midwestern university, more than one of five had health problems that they needed to discuss, but they did not know whom to discuss them with.

Men's ignorance about health matters can increase their risks. For example, lack of health knowledge is a major contributor to delays in seeking care for cancer symptoms. Health knowledge is also associated with health-promoting behaviors, such as sunscreen use and self-exams. Although the influence of knowledege on sunscreen use has not been researched among college students specifically, young adults with knowledge about skin cancer and sunscreen use are more likely than those with less knowledge to take precautions in the sun and to use sunscreen frequently. Similarly, a national study found that those who are least knowledgeable about STDs-and these are primarily men-are nearly half as likely as those with more knowledge to look for signs and symptoms and, among those at high risk, are less likely to practice safer sex consistently. Men with less knowledge are also less likely to feel comfortable telling their doctor they have an STD, or to have talked to a health professional about risk assessment, getting tested, or prevention. One review of research concluded that knowledge is also an important determinant of positive change in sexual risk behaviors related to AIDS. Among college students, however, this finding is not consistent. Several studies have linked knowledge with decreased HIV risk among college students; however, knowledge alone is not necessarily sufficient to promote safer sex practices.

The Health Effects of College Men's Socialization

Men's unhealthy attitudes and behaviors are not surprising in light of their socialization. Young men and boys receive many contradictory messages about health while growing up. A health professional might encourage a young man to seek help when he needs it; yet research repeatedly shows that parents, other adults, and peers all discourage boys from seeking help-and ridicule and punish them when they do. Similarly, health education campaigns attempt to teach young men that it is wrong to be violent, yet they are encouraged to use aggressive force in sports, the military, and business. Television programs are 60% more likely to portray boys using violence than girls, and they further demonstrate that violence is an effective means for men and boys to attain their goals. Boys are also encouraged to fight. Three out of four Americans believe that it is important for a boy to have a few fistfights while he is growing up. Not surprisingly, nearly one in seven college men in California has been in a physical fight in a recent year.

Young men also receive mixed messages about drinking. While health professionals encourage abstinence, young men grow up in a society that consistently conveys the message to them that drinking is part of being a man. A review of research examining representations of alcohol in various forms of media reveals an unmistakable link with masculinity. The authors also provide compelling evidence that "advertisers further the association between alcohol and masculinity by interjoining their products with athletic events and by strategically placing ads in magazines and television programs with predominantly male audiences." Indeed, Sports Illustrated-the magazine read most by young men-has more alcohol (and tobacco) advertisements than any other magazine. And, like television beer commercials, these advertisements conspicuously equate drinking with being a man, taking risks, and facing danger without fear.

Given these findings, it is not surprising that problem drinking is much greater among college men than women. The most recent data from the Core Alcohol and Drug Survey reveal that, on average, college men consume nearly 7 drinks per week, 2a times the amount that women consume. College men are also 2a times more likely to consume 10 or more drinks per week and 6 times more likely to consume 21 drinks. Nearly one half of college men, compared to less than one third of college women, binge drink over a two-week period. Even when using a gender-specific definition of binge drinking, with fewer drinks required for women to meet this definition, half of college men compared to 39% of college women nationally are binge drinkers; 23% and 17%, respectively, are frequent binge drinkers. Furthermore, frequent college binge drinkers are 7 to 10 times more likely than their nonbingeing peers to have unprotected sex or to get injured. These findings reflect the consistent trends demonstrating that college men are more likely than college women to drink alcohol, to drink more of it, and to drink more often.

College men's alcohol use can be devastating to their well-being. Compared to college women, they are invariably found to experience more negative consequences of drinking, including impaired driving and physical injury. They are 8 times more likely than women to visit their college health service for alcohol-related injuries. Driving drunk is the leading cause of death for those under 25 years old, and the vast majority of those who die are young men; as noted above, college men are much more likely than college women to drive drunk. A large study of students in New Jersey reveals that sexually active college men who drink are also at increased risk for STDs and HIV. Among young adults in general aged 15 to 24 years, 10 times more men than women die from drowning; up to half of these men had been drinking shortly before they drowned.

Young men receive mixed messages about the use of tobacco as well. While public health campaigns attempt to convince young men not to use tobacco, other influences attempt to convince them differently. As noted above, Sports Illustrated is both the magazine most often read by young men and the one with the most tobacco advertisements. Men are also far more likely than women to receive tobacco industry promotional items. Not surprisingly, significantly more men than women currently smoke-28%, compared to 23%-and declines in smoking are occurring among women but not men. Among older teenagers, the decline in smoking since 1980 is also greater for females than for males.

Statistics on tobacco use among college students are not entirely consistent. The most recent national data from the Core Alcohol and Drug Survey show greater percentages of tobacco use among college men than women at all levels of frequency of use during the last 30 days, including 15% and 11%, respectively, who had used tobacco daily. Previous national data showed that the prevalence of cigarette smoking specifically was only slightly greater for men. Among differing colleges and regions, findings vary. Some studies have found that more women than men smoke, but the differences are never significant; other studies report that significantly more men smoke. This research, however, rarely examines specific smoking habits, which are more dangerous among men. For example, men in general smoke more cigarettes per day, inhale more deeply, and are more likely to smoke cigarettes without filter tips and cigarettes that are high in tar and nicotine. Among students in one state, for example, 43% of the men who smoked consumed two or more packs per day-as compared to only 20% of women who did.

Research shows that a common marketing strategy of tobacco companies is to link the use of tobacco products-particularly smokeless tobacco-with virility and athletic performance and to target young men in particular. In fact, smokeless tobacco consumption has nearly tripled since the 1970s, and among young men, use has increased between 250 and 300%. Most smokeless tobacco use is initiated in the teenage years, particularly during college. Twenty-two percent of college men nationally, compared to 2% of women, use more than half a can of smokeless tobacco per week. Male college athletes are twice as likely as nonathletes to use chewing tobacco. Consequently, while most cancers occur later in life, oral cancers are increasingly being diagnosed in younger persons; among 12- to 17-year-olds nationally, smokeless tobacco lesions are found in 3% of males compared to .1% of females. Oral cancers kill nearly twice as many men as women.

Men and boys also receive contradictory messages related to physical activities and sports. Despite public health efforts to foster cautiousness, a review of research shows that boys learn at home, at school, and on television to take more physical risks than girls. Not surprisingly, college men are far more likely than college women to engage in sports that are physically dangerous-such as mountain climbing, scuba diving, parachuting, hang gliding, and body contact sports. Men, including college men, also take greater risks in sports than women-even in sports such as skiing. Consequently, men have a higher rate of ski injuries than women. Men also take greater risks on their bicycles. Males of all ages account for 85 to 90% of all bicycle-related deaths and for 80% of the over 14,000 bicycle injuries in California alone each year. Nine of 10 bicyclists killed were not wearing helmets, which reduce the risk of head injuries from crashes by 85%. The amount of riding that men do does not explain these differences. Taking into account use patterns and exposure, the risk of fatal bicycle injuries for men is 5a times greater than that for women.

Compared to women, men also engage in less healthy forms of physical activity. Women are more likely than men to engage in light to moderate exercise-the type that experts agree and research shows is optimal for the body's well-being. Women place greater value on exercising for health, and they adhere to more regular exercise patterns, engaging primarily in aerobics or walking. In contrast, men in general are far more likely to engage in body contact sports, such as football or basketball, that can lead to injury. For example, football accounts for nearly one-half million injuries annually and was responsible for 13 high school and college student deaths in a recent year. Some young men also use anabolic steroids in an attempt to attain cultural ideals of the muscular male physique. The unprescribed use and abuse of steroids is a relatively new phenomenon. It occurs most often between the ages of 18 and 25, particularly among young men engaged in athletics. According to the most recent national data, 1.2% of college men report having used steroids in the last year. In California, 2% of college men report steroid use; this amounts to over 300 men on the University of California, Berkeley, campus alone. Studies have associated steroid use with changes in physiology, and with behaviors and perceptions among adolescent users that are consistent with psychological dependence. Furthermore, college men who use steroids are far more likely to also use other drugs, including marijuana, cocaine, tobacco, and alcohol; nearly three of four users report arguments or fights as a consequence of their use and nearly half report being hurt or injured.

The Influence of Gender and Stereotypes on Service Provision

Stereotypes about men and boys are deeply entrenched in society. These stereotypes contribute to the invisibility of men's health risks and to men's poor health behaviors. The very attitudes and behaviors that increase men's risks are often considered normal and to be expected; "Boys," we say, "will be boys." Stereotypes contribute to strongly held societal beliefs that men and boys are stronger, tougher, and more robust than women and girls, beliefs that are consistent with men's own perception that they are invulnerable. Boys are exposed to these stereotypes from infancy. When people are told that an infant is male, regardless of its actual gender, they are more likely to believe that it is "firmer" and "less fragile" than when they are told that the same infant is female. Health professionals are not immune to stereotypic perceptions. For example, gender role stereotypes influence the diagnostic decisions of mental health clinicians, and diagnoses are often made on the basis of whether or not patients conform to traditional gender roles.

The consequences of these stereotypes can be damaging to men's health. One recent large and well-constructed study found that mental health clinicians were significantly less likely to diagnose depression in men than in women; in fact, they failed to diagnose nearly two thirds of the depressed men. Consequently, more women are treated for depression, and these higher treatment rates-along with studies relying on self-reports, such as the college survey cited above-have contributed to a cultural perception of men's immunity to depression. This perception endures despite suicide rates-which are indexes of depression-that are, as noted, as much as 12 times higher for men. The finding that depression is undiagnosed in many men is particularly relevant for college health professionals. As noted above, there are no significant gender differences in diagnosable depression among college students. Undiagnosed depression in young men may contribute to their extraordinarily high rates of suicide.

Gender can influence the quality of care that college men receive from health professionals in other ways as well. Despite their high health risks, an extensive review of research has revealed that men in general receive less information and fewer, briefer explanations in medical encounters than women receive. Among college students, men are less likely to be questioned about tobacco use in medical visits. Consistent findings of gender differences in physician and patient communication have led to the recent conclusion by leading health communication researchers that these findings "may reflect sexism in medical encounters, but this may act to the advantage of female patients, who have a more informative and positive experience than is typical for male patients."

Designing Gender-Specific Interventions

As the preceding section suggests, the importance of gender-specific interventions cannot be overstated. College health service providers need to address gender stereotypes that can influence their interventions with college men. Furthermore, women and men have very different health needs, as is illustrated by research utilizing the Stages of Change model. This model identifies six discrete stages of change that individuals move through in changing behavior, as well as interventions proven to be effective at each stage. The six stages are precontemplation, contemplation, preparation, action, maintenance, and termination. Precontemplators typically deny their problems or unhealthy behaviors. Contemplators, in contrast, recognize their problems and begin to seriously think about solving them. An extensive body of research utilizing this model shows that women are far more likely than men to be contemplating changing unhealthy behavior or already maintaining healthy habits. What these women need most is assistance in identifying the causes and consequences of their behaviors, help in considering the pros and cons of changing, or support in maintaining their healthy lifestyles. Men, however, are far more likely than women to be precontemplators and to not be maintaining healthy lifestyles. What precontemplators need most in order to adopt healthier behavior is increased awareness of their problems and education to help them to begin to consider change. Interventions that neglect to take these differences into account or to apply the stage-specific interventions are likely to fail. Men who do progress from precontemplation to contemplation double the probability of successfully changing their behavior.

Recent studies of college students provide additional support for designing gender-specific interventions, such as the need for gender-specific safer sex education. Research has shown that factors such as future awareness and imagining symptoms used to decrease sexual health risks are more effective when used with college men than with college women. It was also recently suggested that because college men are particularly disinclined to seek help, college health professionals need to provide outreach to campus locations where large numbers of men congregate, such as athletic departments, sports events, ROTC, and campus police, as well as academic departments such as business and economics. A gender-sensitive approach to college health could similarly address college men's reluctance to seek help and their tendency to conceal vulnerability by providing the means for them to seek help anonymously, such as health-related telephone hotlines or electronic mail and chat lines.

College men's lack of routine health care makes any contact with a male student an important opportunity for education, assessment, and intervention. A contact made through an acute care visit or campus outreach, for example, may well be the only encounter a college man will have with any health professional for a very long time. Unfortunately, too few strategies for maximizing these contacts have been developed. Nor have strategies been developed for addressing college men's health in general. For example, the preceding discussion suggests that college men's greatest health risks are preventable and the result of controllable behaviors. Interventions need to be designed in order to help college men change modifiable behaviors that are increasing their health risks. Similarly, the fact that women typically visit college health services far more often than men is not simply "natural." Early in their lives, young women are taught the importance of regular exams. Similarly, men need to be taught the importance of receiving periodic evaluations, and of taking personal responsibility for their health.

A clinical practice guideline was recently developed for health professionals who work with men. [52, 166-168] It integrates both psychosocial and medical research on men and masculinity, along with evidence demonstrating the effectiveness of specific interventions. This practice guideline identifies behavioral and psychosocial factors that affect the onset, progression, and management of men's health problems, and outlines specific recommendations for addressing these factors when treating men. The specific interventions and communication strategies of the guideline have been outlined elsewhere and address, for example, the importance of increasing college men's health knowledge in order to foster healthy behavioral change; the need to increase college men's perceptions of vulnerabilityæand to remind clinicians not to overlook men's potential disabilities, such as depression; the need to encourage college men to identify and seek help from sources of support, such as friends and health professionals. Talking with college men about how their behaviors influence their own well-being is a non-threatening means of introducing more challenging discussions about how their behaviors influence the well-being of others: discussions about sexual assault, partner abuse, and drunk driving, for example. Also developed recently is the Health Risk Inventory (HRI). This instrument for measuring health risk assesses 54 factors that influence health, including respondents' attitudes and beliefs. Several studies are currently underway on college campuses utilizing the HRI. Additional strategies and materials need to be developed to assist clinicians, counselors, and educators in working with college men to reduce their health risks.

Implications for Future Research

Several additional implications for future study can be drawn from the preceding discussion. Although researchers have long examined relationships between biologic sex and health practices, very few attempts have been made to move beyond the use of biologic sex as an independent or control variable and to explain what it is about gender, exactly, that influences health. Why do college men engage in more health risk behaviors than college women? As has been noted elsewhere, unhealthy behaviors frequently co-occur in clusters. The interaction of these behaviors often compounds men's health risks, as discussed above. Rather than representing a collection of discrete and isolated activities, these clusters may represent organized constellations of behaviors. However, as other authors have noted, little is currently known about constellations of health-related behaviors practiced by individuals, and even less is known about the psychosocial mechanisms that mediate these behaviors. As discussed above, one mediating factor is men's attitudes about manhood. It has been theorized elsewhere that men and boys actually use unhealthy behaviors to demonstrate manhood; proving that they are "real" men by consuming large quantities of alcohol, for example, or by attempting to drink and drive. Research utilizing constructs and measures that assess the endorsement of traditional beliefs about manhood would be a promising method for testing this theory. Including such measures in studies examining the health risks of college students would assist in differentiating risks among subpopulations of college men. Outcome research is needed to measure the effectiveness of any gender-specific interventions, materials and resources designed to improve men's health.

Research is also needed to examine the questions posed by the preceding discussion-questions such as whether increasing perceptions of skin cancer risk will increase college men's use of sunscreen. Further research is needed to determine how race, socioeconomic status, and sexual orientation influence the health of college men, and how their risks compare to those of noncollege samples. Contrary to popular assumptions, educational level, socioeconomic status, and race are not necessarily indicators of young men's health behavior, and as identified above, college students' health behaviors can in fact be significantly worse than the behaviors of their nonacademic peers. Ultimately, a national system for tracking injuries and deaths among students in United States colleges and universities must be developed for accurate epidemiologic comparisons of students and nonstudents, as well as for identifying gender differences in health-related college attrition. Research must also examine the many as yet unexplained paradoxes of gender and health. Why, for example, are suicide rates in this age group 7 times higher for young men-even though college women are far more likely to consider suicide? Why are college men less likely to be questioned about their health risks in medical visits? The overview of college men's health presented in this paper suggests that research addressing these questions is warranted-and long overdue.

Will Courtenay is one of the few consultants in the United States whose work directly confronts the impact of manhood on menís health. He is the director of Menís Health Consulting, which he founded to educate the public about the health effects of our beliefs about manhood ó and to help men live longer, healthier lives.

Courtenay has specialized in working with men since the late '70s. He received his Ph.D. from the University of California at Berkeley and is a Licensed Clinical Social Worker. He is also a psychotherapist in private practice in San Francisco and Berkeley, California.

As a researcher, Courtenay studies the ways attitudes about manhood influence the health risks of men and boys. He develops all of the educational materials and services that Menís Health Consulting offers to men ó and to employers, parents, educators, policy makers, and health professionals.

He is a contributor to professional journals and is currently writing a book entitled Better to Die Than Cry: Confronting the Menís Health Crisis in America.

An academic version of this article, with full citations, is available at the Men's Health Consulting Web site. It originally appeared in the Journal of American College Health in May, 1998 (Vol. 46, No. 6, pp. 279-290) Copyright © 1998, Heldref Publications


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