Why men’s health?

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KEYWORDS:

• Testosterone
• men's health
• COVID-19
• infection

The question of why a new international focus on men’s health was never more poignant than currently in the time of a new pandemic caused by the COVID-19 virus. The early and mid-term data from this infection have shown that men are especially likely to be victims of COVID-19. A recent study in Frontiers in Public Health analyzed the early experience in China where the pandemic began[1]. The data reported by the authors showed that the likelihood of contracting the virus were similar in both genders, men were 2.4 times more likely to die from COVID-19 that their female counterparts irrespective of age and comorbidities. Similarly, men were more likely to have severe problems from their illness than women. This is not surprising, however, as similar gender disparity was found in disease severity and mortality in the SARS outbreak. Globally, men are 60% more likely than women to suffer severe illness or death from COVID-19 [2]. Why this gender disparity? Are men truly the weaker sex? Are there other areas that favor women over men in the health setting? What are the sociological ramifications of men’s illness and early death? What international efforts are underway to change the plight of men? These and other questions in men’s health remain controversial and answers yet poorly documented.

Women have had consistently longer life expectancies than men with the average gap being more than 5 years in the United States and similar gaps globally [3]. The trend to improved life expectancy has continued for the past 60 years except for a small loss of progress for middle-aged white US men in the 1990s. The gender gap while variable has been persistent since maternal child birth deaths have decreased in the 1930s. The exact causes of this gender gap remain elusive and have many theories both environmental and genetic. This difference for the current pandemic has been seen in other infection scenarios. In the 1918 influenza pandemic, men were more likely to die than women and in the tuberculosis outbreaks of the late nineteenth and early twentieth centuries, men were twice as likely to succumb to the infection as women[4].

Several theories have been put forward for the differences in response to infection by men and women. Covid-19 seems to have a strong interaction with the human ACE2 receptor. This receptor has an essential role in virus to cell entry. The ACE2 gene is on the X-chromosome. Women can be heterozygous compared with men who are hemizygous for the ACE2. There are also, genes involved in inflammation that are located on the X-chromosome. The X chromosome is well known to contain many immune-related genes responsible for innate and adaptive immune responses to infection. As a result of these immune-related genes of the X-heterozygous female, there may exist a mosaic advantage with a higher sex-related difference resulting in a gender advantage, further favoring them in counteracting the progression of the COVID-19 infection [5]. Endocrine theories have also been presented to explain women’s advantages in infection resistance. Sexual dimorphism in immunity has been reported in both innate and adaptive immunity. Testosterone appears to have an immunosuppressive effect while estrogen has an immunoenhancing effect on the immune system. Further, females tend to have higher levels of serum IgM and have an enhanced ability to form antibodies. Testosterone has been reported to decrease antibody production, Fc receptor expression, inducible nitric oxide synthase mRNA expression, and eosinophil degranulation while estrogen increases these immune responses[6].

Other immune system advantages include enhanced production of immune cells. As a result, females experience a lower incidence of viral and bacterial infectious diseases than males. Females from multiple species have a more active immune system than males [7].

There may, also, be sociological factors that favor more infections in men. In China, Europe, and the US, men are more likely to be smokers damaging their lungs and predisposing them to more morbidity from pulmonary infection. Men are also more likely to be employed as first responders and ‘essential’ workers such as bus drivers, EMT, , and emergency room providers. Finally, a Gallup poll found that men were less concerned about the COVID-19 pandemic than their female counterparts, perhaps leading to more risk-taking behaviors [8].

The problems for men and their health are not isolated to infection and pandemics. There are many other factors that place men at a comparative disadvantage for health and longevity [3]. The concept of men as the stronger sex is clearly misplaced. Mortality rates for the leading causes of death in the US are disproportionately higher in males [3]. Heart disease is the leading killer of both men and women, but occurs as much as 15 years earlier in men, in the most active time of their employed lives. Similarly, men are more likely to suffer from hypertension, hyperlipidemia, and smoking, all risk factors for cardiac disease. Men are, also, more likely to be affected by air pollution as they are more commonly employed in industries associated with outdoor activities and heavy industry. These risks as well as genetic predispositions increase the frequency of early cardiac disease.

Men are, also more likely to be involved in trauma, both in their employment and in their outside activities. In 2018, there were 4,837 male and 413 female occupational injury deaths in the United States [9]. This higher incidence of trauma is emblematic of the higher risk-taking behavior of men. Suicide attempts are more common in women, but more successful in men. Indeed, successful suicide has a greater than 4:1 prevalence for men. The age-adjusted suicide rate in 2018 was 14.2 per 100,000 individuals. In 2018, men died by suicide 3.56 times more than women. The rate of suicide is highest in middle-aged white men who accounted for 69.67% of suicide deaths in 2018. In 2018, firearms accounted for 50.57% of all suicide deaths [10]. Homicides are starkly more likely in men with a large prevalence for minority men. In the US, almost 80% of homicide victims are men [11]. Similar statistics are reported globally.

Risk-taking behavior is far more prevalent in young males ages 18–35. This time has been characterized as a time of increased competitive and aggressive behavior and termed the ‘young male syndrome.’ This age is associated with not only increased mortality but also increased risks of injuries including head injuries [12]. This risk-taking behavior continues throughout men’s lives with most injuries from combat, crime, and competitive sport among males. Other risks including cigarette use, drug use, and alcohol abuse are more common amongst men. There is a 3:1 self-reported prevalence in marijuana use of men to women [13].

Access to and use of health-care services is less among men in most population-based studies. Similarly, women are more likely to use primary care services, while men are more likely to use emergency room and hospital-based services suggesting that healthcare planning is more likely among women [14]. In 2001, 33% of men had no regular physician compared with 19% of women and 24% of men had not seen a physician in the past year in comparison with 8% of women. In the same survey, 20% of men said that if sick they would seek help and 17% said that they would wait a week or longer to seek help. Minority men fared even worse and were twice as likely to have no physician[15]. Part of the issue for men accessing healthcare may be cultural, as children are taken regularly to their pediatrician during childhood, but as adults, women see their gynecologist for contraception and obstetrician for childbearing whereas men lack the continuity of healthcare and are only accessing healthcare for single disease or event management.

Is a focus on the health of men important to society and what can be done to facilitate improving the healthcare and health of men? While many have written that men’s health is less important than other groups and that to support men’s health would be to sacrifice the healthcare of women and children, the process of improving the healthcare of men has more than just and effect on the man, but rather has a profound impact on the spouse, children, and society [15]. Widows have been shown to be three times as likely to live in poverty as married women and the duration of widowhood increases the frequency and depth of poverty. This trend has been shown to be persistent over many decades and has continued with the most recent US data[16].

It is evident that men are an important part of society and have impact on themselves, their spouses, and family. By improving attention to men’s health in addition to women’s and children’s health, there could be a reduction in healthcare costs by preventing chronic and advanced disease while reducing time lost from work, disability, and financial stresses on the family. The answer to ‘Why Men’s Health’ then is clear. Improved men’s health benefits all of society.

Declaration of interest

The contents of the paper and the opinions expressed within are those of the authors, and it was the decision of the authors to submit the manuscript for publication.

Reviewer disclosure

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.