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Men ‘as they are’
As we all know, the average man thinks about sex every 7 seconds. Or is it every 17 seconds? Or every 52 seconds? Perhaps it's every 2 minutes, or 9 minutes or 20 minutes. A Google search will find you all these ‘facts’ repeated thousands of times with very great certainty. You will even find the confident assertion that when the average man does think about sex he does so for the suspiciously precise duration of 1 minute 50 seconds. The academic literature offers rather more measured observations on this matter and – because the subject is one that presents a number of obvious challenges to the researcher – it tends also to couch its findings in rather less specific terms. Across all ages, for example, it is suggested that around half of men may have sustained thoughts about sex once a day.1
Whether you go for the popular stereotype or the learned analysis however, you can be sure of one thing – and that is that men think about sex itself much more often than they think about their sexual health. In fact, to be precise, men think about sexual health with only 0.19 times the frequency with which they think about actually having sex. Scientists have proved this.
In 2003, the Men's Health Forum (MHF) conducted a series of focus groups with young male students and young male soldiers about their attitudes to sexual health.2 At the end of the process, we concluded that these young men in quite different settings were similar in many ways:
“They are quite likely to leave discussion of contraception with a new partner to the last desperate fumbling moment. They know it is ridiculous even to think it but they believe they can make an educated guess about whether a woman is likely or not to have an STI [sexually transmitted infection]. They regard it as unlikely that they might have an STI themselves without their knowing it. Even when they try, they may find it impossible to conceptualise the potentially negative consequences of their immediate behaviour.”
This may sound pessimistic, but conversely:
“Many of these young men anticipated that their attitudes would change and develop as they got older … they would eventually settle down into a stable relationship and have a family … they recognised that they are young now and their understanding of being young is likely to involve experimentation, misjudgements, mistakes and some degree of irresponsibility.”
These findings suggest the importance of services designed to engage with men ‘as they are’, rather than as we might like them to be. It is easy to assume that people are internally motivated to maintain good health and to seek treatment when things go wrong. This is often not the case. Difficulty in facing up to the need to seek help occurs with all health problems and may be more commonly a male trait. A recent randomised postal survey conducted by the MHF found, for example, that 22% of men compared to 14% of women agree that “I would rather not know if something was seriously wrong with me”.3 This generalised reluctance is compounded by a problem already very familiar to sexual health professionals: there are greater cultural barriers to help seeking in their field than any other (except perhaps, arguably, mental health).
Men and women
The young soldiers and students referred to above also remind us that in sexual and reproductive health, the beliefs and behaviours of the sexes are uniquely linked. By not using a condom, for example, a man may pass on a chlamydial infection to a woman. Perhaps neither partner considered the risk of an STI at the time and perhaps neither will experience symptoms sufficiently serious to seek treatment. The physical burden of pelvic inflammatory disease that may result will be borne by the woman alone. If, though, she suffers the further misfortune of becoming infertile, then the ultimate outcome may well affect a man too – her husband or long-term partner who hoped to become a father.
Another example of this interconnection is to be seen in increasing research evidence that significant numbers of men are infected with the human papillomavirus (HPV) virus.4 HPV is associated with some relatively uncommon cancers in men but it is, of course, a much greater threat to the health of women because of its role as the major cause of cervical cancer and its association with other less common cancers of the female reproductive system. HPV infection is believed to be associated with 5% of all cancers worldwide, the majority of them in women.5 There are complex clinical, epidemiological and ethical issues to be debated, but it seems probable that mass vaccination of boys would make an important contribution to reducing morbidity and mortality in women.
Older men and sexual health
But sexual health is not just a concern for young people. The issue of older men's sexual health is one of particular interest to the MHF at the moment. National Men's Health Week in 2012 will be taking the prevention, diagnosis and treatment of cardiovascular disease (CVD) as its theme. Not a sexual health issue? Well, there is very clear evidence of an important association between the incidence of erectile dysfunction (ED) and CVD, the most common cause of male deaths in the UK. A recent meta-analysis of 12 large-scale studies found that by comparison with men who do not have ED, men who do have it were half as likely again also to have CVD.6 The theory is that the arteries supplying the penis become narrowed by atherosclerosis in parallel with the coronary arteries.
If this is the case, then ED, which often becomes evident sooner, becomes an important marker for the potential presence of CVD. This is a powerful argument for general practitioners (GPs) and sexual health practitioners to make sure that patients presenting with ED are offered the option of tests for CVD (and also, of course, for health professionals to discuss sexual health with male CVD patients).
ED may also have a role helping to identify those older men at risk of contracting an STI. Another recent study in the USA found that men aged over 40 years who have been prescribed pharmacological treatment for ED (e.g. Viagra®) are more than twice as likely as men who have not had such a prescription to need treatment for an STI, particularly HIV. Interestingly, men prescribed medication for ED were also likely to have had higher rates of STIs in the 12 months prior to the commencement of their ED medication. This suggests the possibility that older men who engage in riskier sexual behaviour are more likely to seek treatment for their ED. Although the reasons why this should be so are not entirely clear, the authors were prompted to observe that:
“Use of ED drugs by middle-aged and older patients may serve as a simple screening tool for physicians to use in identifying those patients who may benefit from reminders about safe sexual practice.”7
Helping older men to think about their sexual health is no easy task however. A broadsheet newspaper ‘comment’ piece discussing public attitudes to male sexuality argued recently that older men face the risk of being labelled as “lechers” or “dirty old men” simply for remaining sexual beings.8 Yet we know that sexuality is important to many older people, male and female, and that most people remain sexually active well into later life. A detailed study in the USA in 2002, for example, suggested that 83% of men aged 57–64 years and 38% of men aged 75–85 years had had at least one sexual experience with a partner in the preceding 12 months, in most cases within the context of a long-term relationship.9 The same study found that sexual activity in older people of both sexes is also (and perhaps not surprisingly) associated with self-reported good health.
In other words, a continuing interest in sex is not only pretty much par for the course, it is also sufficiently good for you that it should be celebrated, even – dare we say it – encouraged. The problem is that the public reticence to acknowledge this positive view of older men's sexuality may inhibit men's willingness to seek help and advice with sexual problems. This is a self-perpetuating and thoroughly damaging state of affairs, given that most studies suggest that ED affects somewhere between 30% and 40% of men aged over 50 years.10 11 Even GPs may be subject to this popular ambivalence about older people's sexuality; a series of interviews with GPs in Sheffield found that they “held preconceived notions about older people's sexuality” and very often felt “uncomfortable” about discussing sexual matters with older people. They were “responding to stereotypes of later life sexuality, rather than the reality of older people's experiences”.12
Men and help-seeking
Although the reasons are not fully understood, most data for most disease areas suggest that men are less adept than women at looking after their own health. This is a partial explanation for men's greater likelihood of dying earlier. Data also suggest that, in broad terms, men tend to use health services less effectively than women. This may be more likely because some health services are inadvertently organised in such a way that they are better at engaging with female users. These things can be changed if we begin to recognise that men's poorer health is an inequality and should be tackled as such by health planners. Men's sexual health, as we have seen, can be an important indicator of other aspects of men's physical health. We have also seen that we cannot achieve optimum sexual health for either sex unless we engage the other in the process.
I began this article flippantly by suggesting that men think about their sexual health rather less frequently than they think about the sexual act. In an ideal world, we might hope to reach a level of public and professional understanding where it is entirely normal to think of the two together, without stigma, embarrassment or value judgements. We can only achieve this by ensuring that we understand men's attitudes and behaviours in relation to sex and sexual health, and by working to deliver services in such a way that men's needs and sensibilities are properly taken into account (Box 1).
Box 1 Action points for health professionals
▶ In general, men may be less motivated to seek advice, help or treatment than women. Where there is lower uptake by men, service providers should examine whether redesigning the service could close the gap between the sexes.
▶ It is important to provide services for young men ‘as they are’. This does not mean condoning irresponsible behaviour but it does mean accepting that it commonly occurs.
▶ Don't forget that older men (and older women) may have an active sex life that is important to them. They may welcome the chance to talk about sexual problems and anxieties.
▶ Older men who seek help for erectile dysfunction should also be considered for checks in relation to cardiovascular disease.
▶ Older men who are using medication for erectile dysfunction might benefit from a reminder about safer sexual practices.
Competing interests None.
Provence and peer review Commissioned; internally peer reviewed.
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