Men's Health Concerns Sourcebook, 6th Ed.

Part One

Men’s Health Basics

Chapter 1

Sex-Specific Health Differences

Chapter Contents

Section 1.1—Differences in Men’s and Women’s Health: An Overview4

Section 1.2—Why Women Live Longer than Men10

Section 1.3—Alcohol Use and Risks to Men’s Health14

Section 1.4—Sex Differences in Substance Abuse17

Section 1.5—PTSD Study: Men versus Women20

Section 1.1

Differences in Men’s and Women’s Health: An Overview

This section contains text excerpted from the following sources: Text under the heading Sex and Gender is excerpted from Sex and Gender, NIH News in Health, National Institutes of Health (NIH), May 2016; Text under the heading How Gender and Sex Influence Health and Disease is excerpted from How Sex/Gender Influence Health and Disease (A–Z), Office of Research on Women’s Health (ORWH), National Institutes of Health (NIH), February 12, 2015. Reviewed June 2019.

Sex and Gender

Are you male or female? The answer to this seemingly simple question can have a major impact on your health. While both sexes are similar in many ways, researchers have found that sex and social factors can make a difference when it comes to your risk for disease, how well you respond to medications, and how often you seek medical care. That is why scientists are taking a closer look at the links between sex, gender, and health.

Many people use the words sex and gender interchangeably, but they are distinct concepts to scientists.

Defining differences: Sex is biological. It is based on your genetic makeup. Males have one X and one Y chromosome in every cell of the body. Females have two X chromosomes in every cell. These cells make up all your tissues and organs, including your skin, heart, stomach, muscles, and brain.

Gender is a social or cultural concept. It refers to the roles, behaviors, and identities that society assigns to girls and boys, women and men, and gender-diverse people. Gender is determined by how we see ourselves and each other, and how we act and interact with others.

There is a lot of diversity in how individuals and groups understand, experience, and express gender. Because gender influences our behaviors and relationships, it can also affect health.

Influences on health: Sex and gender play a role in how health and disease affect individuals. There was a time when we studied men and applied those findings to women, but we’ve learned that there are distinct biological differences between women and men, explains Dr. Janine Austin Clayton, who heads research on women’s health at the National Institutes of Health (NIH). Women and men have different hormones, different organs, and different cultural influences—all of which can lead to differences in health.

As scientists learn more about the biology of males and females, they are uncovering the influences of both sex and gender in many areas of health.

For instance, women and men can have different symptoms during a heart attack. For both men and women, the most common heart attack symptom is chest pain or discomfort. But, women are more likely than men to have shortness of breath, nausea and vomiting, fatigue, and pain in the back, shoulders, and jaw. Knowing about such differences can lead to better diagnoses and outcomes.

Men and women also tend to have different responses to pain. The National Institutes of Health-funded researchers recently learned that different cells in male and female mice drive pain processing. Without studying both sexes, we wouldn’t know if we’re taking steps in the right direction toward appropriate clinical treatment for men and women, Clayton says. Our differences also affect how we respond to medications, as well as which diseases and conditions we may be prone to and how those diseases progress in our bodies. For example, women metabolize nicotine faster than men, so nicotine-replacement therapies can be less effective in women.

Attention to addiction: Scientists are finding that addiction to nicotine and other drugs is influenced by sex as well. When it comes to addiction, differences in sex and gender can be found across the board, says Dr. Sherry McKee, lead researcher at an NIH-funded center at Yale University that studies treatments for tobacco dependence. There are different reasons men and women pick up a drug and keep using a drug, and in how they respond to treatment and experience relapse. Sex also influences disease risk in addiction. For example, women who smoke are more susceptible to lung and heart disease than men who smoke.

One NIH-funded research team has detected some of these differences in the brain. In a recent study, 16 people who smoke—eight men and eight women—underwent brain scans while smoking to create movies of how smoking affects dopamine, the chemical messenger that triggers feelings of pleasure in the brain.

These brain movies showed that smoking alters dopamine in the brain at different rates and in different locations in males and females.

Dopamine release in nicotine-dependent men occurred quickly in a brain area that reinforces the effect of nicotine and other drugs. Women also had a rapid response but in a different brain region—the part associated with habit formation. We were able to pinpoint a different brain response between male and female smokers, a finding that could be useful in developing sex-specific treatments to help smokers quit, says lead study researcher Dr. Kelly Cosgrove, a brain-imaging expert at Yale University.

Finding better ways to help men and women quit smoking is important for everyone’s health. More than 16 million Americans have diseases caused by smoking. It is the leading cause of preventable death in the United States.

Autoimmune disorders: Scientists have found sex influences in autoimmune disorders as well. About 80 percent of those affected are women. But, autoimmune conditions in men are often more severe. For instance, more women than men get multiple sclerosis (MS), a disease in which the body’s immune system attacks the brain and spinal cord. But, men seem more likely to get a progressive form of MS that gradually worsens and is more challenging to treat.

Not only are women more susceptible to MS, but women also have many more considerations in the management of the disease, especially since it often begins during childbearing years, says Dr. Ellen Mowry, a specialist who studies MS at Johns Hopkins University.

There are a lot of unanswered questions when it comes to the study of sex differences in MS and other autoimmune disorders, Mowry explains. Researchers can learn a lot by studying women and men separately and together, considering possible risk or predictive factors that may differ based on sex or gender, and working collaboratively with other scientists to improve the likelihood of detecting these factors.

How Gender and Sex Influence Health and Disease

Research on sex and gender differences—research that spans basic studies on cells to large, clinical trials involving thousands of patients—aims to understand health differences between males and females at all levels. The knowledge will improve health for both women and men.

Arrhythmias

As an electrically controlled organ, the heart beats when a wave of electricity courses through heart muscle in a defined regular path. Any disruption of this path of conduction, called an arrhythmia, causes the heart to beat irregularly. An arrhythmia can be very mild, even undetectable, or serious and fatal. Sex and gender differences are known to affect heart rhythms. Here are some examples.

Certain medications, including the allergy drug Seldane and the gastrointestinal drug Propulsid (both of which have been taken off the market in the United States) trigger a potentially fatal heart arrhythmia more often in women than in men.

A 2009 study showed that women are more likely than men to have complications from implantable cardiac defibrillators, devices that monitor heart rhythms and deliver shocks when needed to restore a normal heartbeat.

Although men are more likely than women to experience a usually mild condition known as atrial flutter (heart palpitations), surgical treatment (ablation) of this arrhythmia affects women and men differently, according to a 2013 study.

Cardiovascular Risk

For the most part, an individual has direct control over whether she or he will develop heart disease, by managing behaviors that raise or reduce the chances that heart disease will take root in their body. National Institutes of Health-funded medical research that goes back decades has defined a core set of cardiovascular risk factors that individuals can manage with the help of a doctor. The risk factors include smoking, high cholesterol and triglycerides, high blood pressure, diabetes, and being overweight or obese.

Yet, even though everyone should pay attention to these risk factors that affect heart health, the risks differ between women and men in various ways that appear subtle, but can be very significant.

In women, aspirin reduces risk of ischemic stroke, whereas in men, low-dose aspirin therapy reduces risk of heart attack.

Cholesterol plaque in women may not build up into major artery blockages, but instead spreads evenly throughout the artery wall. This means that artery blockages can be more difficult to diagnose in women, who may not have outright symptoms but are still at high risk for heart attack.

Influenza

Influenza, more commonly called the flu, is a viral infection of the nose, throat, and lungs. Flu symptoms may include muscle aches, chills, cough, fever, headache, and sore throat. Research is underway to find out why the flu virus and vaccine affect men and women differently. For example, women are more likely than men to have severe flu symptoms. Men with high levels of testosterone produce fewer antibodies in response to the flu vaccine compared with men with low testosterone.

Lupus

Lupus is an autoimmune condition that causes inflammation and damage to various organs. Common symptoms include extreme fatigue, painful or swollen joints (arthritis), unexplained fever, skin rashes, hair loss, and kidney problems. Lupus develops slowly, with symptoms that come and go. The most common type, systemic lupus erythematosus, usually appears in the mid-teens, 30s or 40s. Women are more likely to get lupus than men, and African American, Hispanic, Asian, and American Indian women have a higher lupus risk than white women. Here are examples of how lupus can differ in women and men:

Although more women than men get lupus and a related disorder, systemic sclerosis, men are more likely to have more severe disease.

In contrast, women are more likely than men to develop lupus-related urinary tract infections (UTIs), hypothyroidism, depression, esophageal reflux, asthma, and fibromyalgia (FM).

Among children and adults with lupus, males are at greater risk than females for kidney injury, kidney failure, and kidney-related death.

Researchers have found a lupus-related gene (called "IRAK1") on the X chromosome, which may help explain why women get the disease more often than men.

Osteoarthritis

Osteoarthritis (OA) is a condition that accompanies aging, as the body’s bones and joints suffer wear and tear with time and lots of use. It is painful, and there is no cure. OA remains the leading cause of chronic disability in the United States, and it disproportionately affects postmenopausal women (PMW). Current treatment generally involves a mix of exercise, lifestyle modification (such as weight loss), and pain relievers. Researchers are hard at work looking for new clues about how to prevent and treat osteoarthritis. It is more common among women than men in every age group, but there are subtle differences worth knowing about.

The severity of OA is usually significantly worse in women than it is in men.

Black women and black men with OA are much less likely to undergo total knee replacement when compared to white men.

Stroke

A stroke is sort of like a heart attack in the brain. Strokes occur when blood flow to a part of the brain suddenly stops, starving brain cells of the oxygen they need to live. Clogged arteries can cause a so-called ischemic stroke, in which fat and cholesterol form plaques in artery walls, allowing less blood to flow through freely.

While some of the risk factors for stroke are the same in men and women, such as family history of stroke, high blood pressure or cholesterol, smoking, and being overweight, certain aspects of stroke are unique to women. Researchers have identified several sex/gender differences, such as these:

While men have a higher risk of stroke than women in general, women are usually older when they have strokes, and they are more likely to die of strokes than men.

Women have a poorer quality of life (QOL) after a stroke than men.

Women with a history of preeclampsia during pregnancy are 60 percent more likely to have a nonpregnancy-related stroke later in life.

Women who suffer from migraines with visual components like flashing lights have a higher risk of having an ischemic stroke.

Vision Disorders

Vision disorders affect women disproportionately both in the United States and throughout the world. But in addition to affecting vision, eye changes can signal the presence of other conditions, especially autoimmune diseases such as lupus and rheumatoid arthritis (RA). Ocular manifestations of thyroid disease may be the first characteristic symptom that brings a woman to a physician’s office to seek treatment. Here are some examples of how vision disorders affect women and men:

Dry eye affects twice as many women than men over 50 years of age. Dry eye disease affects QOL, interfering with routine activities such as reading, working on a computer, and driving a car.

Cataracts that cloud the eye’s lens are more likely to occur in women than in men. In developing countries, women are less likely than men to receive cataract surgery.

Brain-imaging studies of people with migraines, intense headaches that are twice as common in women than men and that often affect vision, have reported sex-specific patterns.

Adult women experience about 25 percent more uncorrected visual impairment due to refractive error, which impedes the ability to focus, compared to adult men.

Section 1.2

Why Women Live Longer than Men

Why Women Live Longer than Men, © 2017 Omnigraphics. Reviewed June 2019.

According to statistics compiled by the United Nations, women typically live 4.5 years longer than men worldwide. In 2013, the global average life expectancy for women was 71 years compared to 66.5 for men. This pattern has been observed in every country in the world, and it has held true the entire time that reliable birth and death records have existed.

Although social and lifestyle factors are believed to play a role in adult mortality rates, evidence suggests that biological and genetic factors are also involved. Significantly, studies have found sex-related differences in life expectancy among other primates—female gorillas, chimpanzees, and orangutans consistently outlive males of their species as well. By studying the various factors that may account for increased female longevity, scientists hope that they will identify ways to help both men and women live longer, healthier lives.

Biological Factors

Biologists have put forth a number of theories to explain why women live longer than men. Some of the major genetic and biological factors they believe may contribute to increased female longevity include the following.

Women carry two X chromosomes, while men have one X and one Y chromosome.

This biological difference means that men are more vulnerable to genetic mutations that can cause life-threatening health conditions. Whereas women may avoid the expression of genetic diseases by relying on a normal gene on the other X chromosome, men lack a second copy of the defective gene.

Women’s bodies tend to be smaller in size than men’s bodies.

Since larger people have more cells in their bodies, they may have a greater tendency to develop harmful cellular mutations. In addition, larger bodies use more energy, which creates wear and tear on organs and tissues and may increase the rate of long-term damage.

Women’s immune system function declines at a slower rate than men’s.

All people’s immune function gradually declines with age. But, blood samples of healthy people have shown that the normal loss of white blood cells—which help protect the body from infection—occurs faster in men than in women. As a result, women may enjoy protection from illness to a more advanced age.

The male hormone testosterone may increase disease risk later in life.

Testosterone, which is secreted by the testicles, is the hormone primarily responsible for the development of male sex traits, such as deep voices and hairy chests. Although testosterone contributes to male strength and virility, it may also increase men’s risk of developing cardiovascular disease and cancer later in life.

A modern analysis of records from nineteenth-century Korea revealed that eunuchs (men whose testicles are removed before puberty, and thus have significantly lower lifetime exposure to testosterone) lived an average of 20 years longer than typical Korean men and were far more likely to reach their hundredth birthday.

The female hormone estrogen may decrease disease risk later in life.

Estrogen, which is produced in the ovaries, is the hormone primarily responsible for female sex traits, such as breast development and menstruation. In contrast to testosterone, estrogen appears to protect against disease. Estrogen has antioxidant properties, meaning that it helps eliminate harmful chemicals that may cause cell damage. Studies have shown that when the ovaries are removed from female animals, the animals experience an increase in disease risk and a decrease in longevity.

Women develop heart disease a decade later than men.

Heart disease is the leading cause of death for both men and women in the United States. But, partly due to the protective effects of estrogen, which helps control cholesterol and prevent plaque formation in the arteries, women tend to develop heart disease 10 years later than men. In fact, women’s risk of heart disease only begins to increase after menopause, when the production of estrogen declines. In addition, more than 4 times as many men as women smoke worldwide, and smoking is a major contributor to heart disease. Another theory to explain the delayed onset of cardiovascular illness in women is that women’s heart rate tends to increase during the second half of the menstrual cycle. Some researchers claim that this increase offers the same health benefits as moderate exercise.

Lifestyle Factors

In addition to biological differences between men and women, studies have also suggested that sociological and lifestyle factors may contribute to women’s longer lifespan. Some of the main factors that are believed to influence mortality rates include the following.

Men are more prone to risk-taking behavior.

According to the U.S. Centers for Disease Control and Prevention (CDC), unintentional injuries are the third-leading cause of death for American men. For women, on the other hand, unintentional injuries rank sixth. Scientists point out that the frontal lobe of the brain develops more slowly in males than in females. Since this part of the brain is involved in calculating risks and behaving responsibly, men are more likely to exhibit dangerous or risky behavior than women of the same age. As a result, studies show that men are less likely to wear seatbelts and more likely to drive aggressively and be involved in motor vehicle accidents.

Women have stronger social networks.

Men are often socialized to hide their emotions and keep their concerns bottled up inside. For women, however, it is more culturally acceptable to express emotions and confide in friends or family members about sources of worry or stress. Studies have shown that strong social connections can decrease a person’s risk of dying by 50 percent. Men can experience the protective nature of social ties by getting married—studies have also shown that married men tend to be healthier and live longer than single men.

Women take better care of their health.

Another contributing factor to women’s longevity is that they tend to take better care of their health. Men often ignore or deny symptoms of illness and avoid seeking medical attention. In fact, studies have shown that men are 24 percent less likely than women to have visited a doctor within the past year.

References

Bergland, Christopher. Why Do Women Live Longer than Men? Psychology Today, July 8, 2015.

Innes, Emma. Women Live Longer than Men Because Their Immune Systems Age More Slowly, MailOnline, May 15, 2013.

Levine, Hallie. 5 Reasons Women Live Longer than Men, Health.com, October 13, 2014.

Zeilinger, Julie. The Real Reason Women Live Longer than Men? Huffington Post, August 3, 2013.

Section 1.3

Alcohol Use and Risks to Men’s Health

This section includes text excerpted from Fact Sheets—Alcohol Use and Your Health, Centers for Disease Control and Prevention (CDC), January 3, 2018.

Alcohol Use and Your Health

Drinking too much can harm your health. Excessive alcohol use led to approximately 88,000 deaths and 2.5 million years of potential life lost (YPLL) each year in the United States from 2006–2010, shortening the lives of those who died by an average of 30 years. Further, excessive drinking was responsible for 1 in 10 deaths among working-age adults between the ages of 20 and 64. The economic costs of excessive alcohol consumption in 2010 were estimated at $249 billion, or $2.05 a drink.

What Is a Drink?

In the United States, a standard drink contains 0.6 ounces (14.0 grams or 1.2 tablespoons) of pure alcohol. Generally, this amount of pure alcohol is found in:

12 ounces of beer (5 percent alcohol content)

8 ounces of malt liquor (7 percent alcohol content)

5 ounces of wine (12 percent alcohol content)

1.5 ounces of 80-proof (40 percent alcohol content) distilled spirits or liquor (e.g., gin, rum, vodka, whiskey)

What Is Excessive Drinking?

Excessive drinking includes binge drinking, heavy drinking, and any drinking by pregnant women or people younger than the age of 21.

Binge drinking, the most common form of excessive drinking, is defined as consuming:

For women, four or more drinks during a single occasion

For men, five or more drinks during a single occasion

Heavy drinking is defined as consuming:

For women, 8 or more drinks per week

For men, 15 or more drinks per week

Most people who drink excessively are not alcoholics or alcohol dependent.

What Is Moderate Drinking?

The Dietary Guidelines for Americans defines moderate drinking as up to one drink per day for women and up to two drinks per day for men.

In addition, the Dietary Guidelines do not recommend that individuals who do not drink alcohol start drinking for any reason.

However, there are some people who should not drink any alcohol, including those who are:

Younger than 21 years of age

Driving, planning to drive, or participating in other activities requiring skill, coordination, and alertness

Taking certain prescription or over-the-counter (OTC) medications that can interact with alcohol

Suffering from certain medical conditions

Recovering from alcoholism or are unable to control the amount they drink

By adhering to the Dietary Guidelines, you can reduce the risk of harm to yourself or others.

Short-Term Health Risks

Excessive alcohol use has immediate effects that increase the risk of many harmful health conditions. These are most often the result of binge drinking and include the following:

Injuries, such as motor vehicle crashes, falls, drownings, and burns

Violence, including homicide, suicide, sexual assault, and intimate partner violence

Alcohol poisoning, a medical emergency that results from high blood alcohol levels

Risky sexual behaviors, including unprotected sex or sex with multiple partners. These behaviors can result in unintended pregnancy or sexually transmitted diseases, including human immunodeficiency virus (HIV).

Long-Term Health Risks

Over time, excessive alcohol use can lead to the development of chronic diseases and other serious problems including:

High blood pressure, heart disease, stroke, liver disease, and digestive problems

Cancer of the breast, mouth, throat, esophagus, liver, and colon

Learning and memory problems, including dementia and poor school performance

Mental-health problems, including depression and anxiety

Social problems, including lost productivity, family problems, and unemployment

Alcohol dependence, or alcoholism

By not drinking too much, you can reduce the risk of these short- and long-term health risks.

Section 1.4

Sex Differences in Substance Abuse

This section includes text excerpted from Gender Differences in Primary Substance of Abuse across Age Groups, Substance Abuse and Mental Health Services Administration (SAMHSA), April 3, 2014. Reviewed June 2019.

National data consistently show that sex is an important factor to consider when examining patterns of substance abuse, such as overall prevalence rates and substances of choice. For example, males are more likely than females to report marijuana and alcohol use, whereas females are more likely than males to report nonmedical use of prescription drugs. Also, differences in substance abuse patterns among men and women vary by age. Data from the 2011 National Survey on Drug Use and Health show that men 18 years of age or older have almost twice the rate of substance dependence as adult women, but among youths between the ages of 12 and 17, the rate of substance dependence for both sexes is the same (6.9%). Knowledge of how sex can interact with age and patterns of substance abuse may be useful to those responsible for the design of outreach, prevention, and treatment programs.

The Treatment Episode Data Set (TEDS) collects data on admissions to substance abuse treatment facilities across the United States and can be used to examine differences in primary substance of abuse among males and females by age. TEDS collects information on up to three substances of abuse that led to the treatment episode. The main substance abused by the client is known as the primary substance of abuse. For each admission, data on primary substance of abuse are reported at the time of treatment entry. The analyses in this report are based on TEDS data for 2011.

The Treatment Episode Data Set is a census of all admissions to treatment facilities reported to the Substance Abuse and Mental Health Services Administration (SAMHSA) by state substance abuse agencies. Because TEDS involves actual counts rather than estimates, statistical significance and confidence intervals are not applicable.

Overview and Demographic Characteristics

In 2011, about 609,000 of the 1.84 million admissions to substance abuse treatment were female (33.1 percent), and 1.23 million were male (66.9 percent). No meaningful sex differences were found by race/ethnicity. Specifically, the majority of female and male admissions (66.4 and 58.2 percent, respectively) were non-Hispanic White.

The percentages of female and male admissions that were non-Hispanic Black and Hispanic were similar.

Sex Profiles

No appreciable sex differences were found by primary substances of abuse overall. Alcohol was the most commonly reported primary substance of abuse by female (33.3%) and male (42.3%) admissions. Among females, alcohol was followed by heroin (15.3%), marijuana (14.6%), and prescription pain relievers (13.8%); among males, the next most frequently reported substances were marijuana (19.9%), heroin (15.0%), and prescription pain relievers (7.8%).

Differences in Primary Substance of Abuse

Analyses by sex and age were conducted for the six most commonly reported primary substances of abuse: alcohol, marijuana, heroin, prescription pain relievers, cocaine, and methamphetamine/amphetamines.

Alcohol and Marijuana

Compared with their male counterparts, a larger proportion of female admissions between the ages of 12 and 17 reported alcohol as their primary substance of abuse (21.7 vs. 10.5 percent). This pattern changed among adult admissions. Among admissions between the ages of 25 and 34, a smaller proportion of female admissions than male admissions reported alcohol as their primary substance of abuse (25.9 vs. 36.5 percent). Marijuana was reported as the primary substance of abuse less frequently by females than males among admissions between the ages of 12 and 17 (60.8 vs. 80.7 percent) and between the ages of 18 and 24 (22.1 vs. 33.4 percent). There was no variation by sex in primary marijuana abuse among admissions 25 years of age or older.

Methamphetamine/Amphetamines

The proportions of female and male admissions reporting methamphetamine/amphetamines as their primary substance of abuse were similar across all age groups with the exception of those between the ages of 18 and 24. Specifically, among admissions between the ages of 18 and 24, 8.9 percent of female admissions reported primary methamphetamine/amphetamine abuse compared with 3.7 percent of male admissions.

Prescription Pain Relievers

The highest proportions of primary abuse of prescription pain relievers (e.g., oxycodone) were found among admissions between the ages of 18 to 24 and 25 to 34. In the 25 to 34 age group, 19 percent of female admissions and 12.2 percent of male admissions reported prescription pain relievers as their primary substance of abuse. In terms of the effect size, however, the differences between male and female admissions in these age groups were negligible. The only meaningful difference by effect size between males and females was observed among admissions 65 years of age or older. Within the 65 years of age or older age group, the proportion of female admissions reporting primary abuse of prescription pain relievers was nearly 3 times that of their male counterparts (7.2 vs. 2.8 percent).

Discussion

This report highlights important differences in primary substance of abuse between males and females admitted to substance abuse treatment. These differences were found at various stages of life, from adolescence through older adulthood, particularly for abuse of alcohol, marijuana, methamphetamine/amphetamines, and prescription pain relievers. Although this report does not explain the potential reasons for these differences, it brings awareness to the fact that they exist. This may help inform the design of prevention, outreach, and treatment services for specific sex and age groups across multiple settings, including primary care. For example, other research shows that compared with men, women have been found to initiate use of methamphetamine at younger ages and have a greater vulnerability to methamphetamine dependence due to physiological factors. This research, coupled with the findings in this report, might suggest that age-appropriate methamphetamine prevention and outreach efforts directed towards adolescents and young women in particular may be important in areas with moderate to high rates of methamphetamine use.

Additionally, the findings related to differences in the abuse of prescription pain relievers between older adult males and females may warrant further investigation particularly in the context of older adults receiving medications in general medical settings. Further research is needed to understand who would benefit from programs that target particular sex and age groups compared with sex-specific programs and standard treatment.

Section 1.5

PTSD Study: Men versus Women

This section includes text excerpted from PTSD Study: Men versus Women, U.S. Department of Veterans Affairs (VA), April 18, 2013. Reviewed June 2019.

In the general population, women are twice as likely as men to develop posttraumatic stress disorder [PTSD], noted Dr. Sonja Batten, the U.S. Department of Veterans Affairs’ (VA) Deputy Chief Consultant for Specialty Mental Health. But among recent returnees seeking care at VA, PTSD rates among men and women are the same. Statistics such as these suggest the need to better understand the role of gender [sex] in PTSD, particularly as it may impact our Veterans seeking care.

Researchers at the Department of Veterans Affairs are now taking some initial steps toward understanding this complex subject. To that end, Dr. Sabra Inslicht, a staff psychologist at the San Francisco VA Medical Center and an assistant professor of psychiatry at the University of California, San Francisco recently led a VA study that took a closer look at how men and women learn to fear. Her work was published in the October 2012 issue of the Journal of Psychiatric Research.

Men Are from Mars; Women Are from Venus

If we can learn more about potential gender [sex] differences in the process of fear learning, Inslicht said, it may help us develop more targeted treatments that are geared more precisely to the unique needs of men and women.

For their study, Inslicht and her team recruited 18 men and 13 women who had been diagnosed with PTSD. These participants were all shown various images on a computer screen. Electrodes were attached to their palms, so researchers could measure participants’ physiological response to each image.

After certain images appeared, the test subject received a small electrical shock. Gradually, the test subject came to associate these particular images with something unpleasant. They learned to anticipate the impending shock, Inslicht said. They learned the danger cues. We call this ‘fear conditioning.’

Researchers carefully monitored test subjects’ skin conductive responses—that is, how sweaty their palms got—to measure the body’s stress reaction to the image on the screen.

We discovered that women responded more strongly to the visual cues than men when they saw a particular image that they knew was going to be followed by an electric shock, Inslicht explained. This suggests that women conditioned more robustly than men. In our future work, we’d like to get a better understanding as to why these differences may occur.

Fight or Flight

To some extent, learning to fear is important for survival, the researcher said. When we are threatened by something dangerous, we tend to react with a stress response or ‘fight-or-flight’ response. It helps keep us safe by mobilizing our bodies to either fight or flee a threat, thus enabling us to protect ourselves from harm in dangerous situations.

Inslicht said this fight or flight response, however, can sometimes persist even in nonthreatening situations. For example, she said, "if you witnessed a suicide bombing while on patrol in a crowded marketplace in Afghanistan, you might develop a fear of crowded places. While you’re on patrol and in potential danger, a heightened level of vigilance can be protective. However, if that response persists even after returning home and to a safe place, it can become problematic.

When you’re unable to turn it off in safe situations, the stress becomes prolonged, she continued. This can cause wear and tear on both the mind and the body. When this heightened reactivity starts to negatively impact your daily life, we begin to worry about posttraumatic stress. But, if fear conditioning does in fact occur differently in men and women, then might not the process known as fear extinction also be affected by sex differences?

Fear extinction happens, Inslicht said, when you are gradually exposed to the previously learned danger cues, such as crowds, and you gradually come to realize that the cue will not be followed by a stressful or potentially traumatic event. This results in the diminishing of the fear response. Since extinction learning is believed to be important for recovery from PTSD, a deeper understanding of this process could alter our strategy for how we treat PTSD in men and women.

Much More to Learn

Inslicht said her small study leaves a number of questions unanswered, and that more in-depth research is needed.

For example, all our study participants had PTSD, she said, so we couldn’t arrive at any conclusions regarding whether women, as a general rule, condition more strongly than men do, or whether this difference is found only among women who have already developed PTSD.

Finally, we did not examine what may drive the gender [sex] differences that we found, the researcher noted. For example, there may be biological differences such as particular hormones and neuropeptides that may mediate these effects.

Inslicht said the research community is only just beginning to understand fear learning and extinction mechanisms and their relationship to PTSD.

Ultimately, however, this line of research may result in advances for treatment, she concluded. There may be ways that we can enhance extinction learning—perhaps through medications or with other modifications to existing behavioral treatments.

Chapter 2

Self-Examinations Recommended for Men

Chapter Contents

Section 2.1—Breast Self-Examination24

Section 2.2—Oral Cancer Self-Examination26

Section 2.3—Skin Cancer Self-Examination28

Section 2.4—Testicular Self-Examination30

Section 2.1

Breast Self-Examination

Breast Self-Examination, © 2016 Omnigraphics. Reviewed June 2019.

Many people are not aware that men can develop breast cancer. Males do have breast tissue, however, and malignant (cancerous) cells can develop there—just as they can in any other part of the body. Although less than one percent of all cases of breast cancer occur in males, several factors may increase the risk of male breast cancer, including:

Inherited gene mutations, such as BRCA1 or BRCA2;

Family history of breast cancer;

Exposure to radiation;

High levels of estrogen;

Advanced age (most cases are detected in men between the ages of 60 and 70).

Since early detection of male breast cancer can lead to improved treatment options and prognosis, many healthcare practitioners and cancer-prevention organizations recommend that men with an increased risk of breast cancer perform monthly breast self-examinations.

Breast self-examination is a technique people can use to visually and manually check their own breast tissue for lumps or other changes. People who conduct regular self-exams become familiar with the normal appearance and feel of their breast tissue, which enables them to recognize changes and discover lumps that may require medical attention. Some of the changes that should be checked by a doctor include:

Hard lumps or new areas of thickness, which may or may not be painful;

Discharge of fluid from the nipples;

Dimpling, puckering, rashes, or other changes to the skin;

Changes to the size or shape of the breast.

How to Perform a Breast Self-Examination

Doctors recommend that men at risk of breast cancer perform a regular breast self-examination once per month. It should cover the entire surface area of each breast, from the collarbone down to the abdomen and from the armpit across to the center of the chest. Perhaps the easiest way for men to examine their breast area is in the shower. Using soap and water to create a slippery surface allows the fingers to slide easily over the breast tissue.

The main steps in performing a male breast self-examination are as follows:

Raise your right arm, and place it behind or on top of your head.

Use the pads of the three middle fingers on your left hand to examine your right breast.

Move your fingers in small circles, about the size of a quarter.

Begin under the armpit, and work from top to bottom along the outer part of your breast.

After completing one vertical strip, move over one finger width and begin a new strip, working from bottom to top. Do not lift the fingers between rows.

Check the entire breast area in an up-and-down pattern, as if mowing a lawn.

Repeat the process by using the left hand to examine the right breast.

Gently squeeze each nipple between your fingers to check for any fluid discharge, puckering, or retraction.

After stepping out of the shower and drying off, visually examine your breasts in front of a mirror. They should appear symmetrical in size and shape, and the skin should not show signs of dimpling, puckering, or rashes.

Men who find a lump or notice other changes in their breast tissue during a self-examination should not become alarmed. Around 80 percent of all breast lumps are not cancerous. In addition, most lumps or inflammation detected in male breasts are due to a benign condition called gynecomastia. This condition is commonly associated with the hormonal changes of puberty, but it may also occur as a side effect of certain medications. Still, any hard lumps or other areas of concern should be checked by a medical practitioner.

References

Check Yourself for Male Breast Cancer, MaleCare, 2016.

Stephan, Pam. Male Breast Self-Examination, VeryWell, December 16, 2014.

Section 2.2

Oral Cancer Self-Examination

This section contains text excerpted from the following sources: Text in this section begins with excerpts from Oral Cancer, MedlinePlus, National Institutes of Health (NIH), August 18, 2016; Text under the heading How Oral Cancer Self-Examination Is Done? is excerpted from The Oral Cancer Exam, National Institute of Dental and Craniofacial Research (NIDCR), September 2018.

Oral cancer can form in any part of the mouth. Most oral cancers begin in the flat cells that cover the surfaces of your mouth, tongue, and lips. Anyone can get oral cancer, but the risk is higher if you are male, use tobacco, drink lots of alcohol, have human papillomavirus (HPV), or have a history of head or neck cancer. Frequent sun exposure is also a risk factor for lip cancer.

Symptoms of oral cancer include:

White or red patches in your mouth

A mouth sore that will not heal

Bleeding in your mouth

Loose teeth

Problems or pain with swallowing

A lump in your neck

An earache

Tests to diagnose oral cancer include a physical exam, endoscopy, biopsy, and imaging tests. Oral cancer treatments may include surgery, radiation therapy, and chemotherapy. Some patients have a combination of treatments.

How Oral Cancer Self-Examination Is Done?

An oral cancer exam is painless and quick—it takes only a few minutes. Your regular dental checkup is an excellent opportunity to have the exam.

Here is what to expect:

Preparing for the exam: If you have dentures (plates) or partials, you will be asked to remove them.

Your healthcare provider will inspect your face, neck, lips, and mouth to look for any signs of cancer.

With both hands, she or he will feel the area under your jaw and the side of your neck, checking for lumps that may suggest cancer.

She or he will then look at and feel the insides of your lips and cheeks to check for possible signs of cancer, such as red and/or white patches.

Next, your provider will have you stick out your tongue so it can be checked for swelling or abnormal color or texture.

Using gauze, she or he will then gently pull your tongue to one side, then the other, to check the base of your tongue. The underside of your tongue will also be checked.

In addition, she or he will look at the roof and floor of your mouth, as well as the back of your throat.

Finally, your provider will put one finger on the floor of your mouth and, with the other hand under your chin, gently press down to check for lumps or sensitivity.

Section 2.3

Skin Cancer Self-Examination

Skin Cancer Self-Examination, © 2016 Omnigraphics. Reviewed June 2019.

When potential skin cancers are found and treated early, they can usually be cured. Thus, early detection is thus a major priority. Doctors and cancer-fighting organizations recommend conducting a thorough, head-to-toe skin cancer self-examination every month as a way to help people notice changes in their skin and identify suspicious moles, growths, or lesions that should be checked by a physician.

Medical professionals have developed two main strategies to help people recognize malignant melanoma—the deadliest form of skin cancer—as well as nomelanoma skin cancers, such as basal cell carcinoma and squamous cell carcinoma. These early recognition strategies, the ABCDEs, and the Ugly Duckling sign can be applied by individuals examining their own skin, as well as by healthcare professionals.

How to Conduct a Skin Cancer Self-Examination

Medical practitioners and skin cancer awareness organizations recommend that people conduct a head-to-toe self-examination once per month to check for unusual moles or lesions on their skin. A complete examination should include the following areas:

Face—use a mirror to examine the nose, mouth, and ears.

Scalp—use a blow dryer to expose various sections of the scalp for inspection or ask a friend or family member to help.

Hands—check the palms as well as the backs of the hands, and look between the fingers and under the fingernails.

Arms—begin by inspecting the wrists and forearms, then use a mirror to check the elbows, upper arms, and underarms.

Chest—examine the neck, collarbone, chest, and torso.

Back—using a full-length mirror and a hand mirror, check the back of the neck, shoulders, upper back, and lower back.

Genitals—use a hand mirror to examine the buttocks and genital area.

Legs—inspect the front and back of each leg, including thigh, shin, calf, and ankle.

Feet—check the top and bottom of each foot, as well as between the toes and under toenails.

What to Look for in a Skin Cancer Self-Examination

Most people have ordinary, harmless moles or spots on their skin. Also known as nevi, moles are common skin growths in which pigment cells form a cluster. A typical nevus may appear black, brown, tan, pink, or red. It may be flat or slightly raised, and it may be round or oval in shape. The goal of a skin cancer self-examination is to identify atypical moles (dysplastic nevi) that may be precancerous or cancerous. The two main strategies to help people distinguish between harmless and suspicious moles are the ABCDEs, and the Ugly Duckling sign.

The ABCDEs

The acronym ABCDE is a valuable tool for helping people evaluate moles, spots, and other skin growths. Each letter represents a specific warning sign that a mole may potentially be cancerous and should be checked by a doctor:

A. Asymmetry—benign (noncancerous) moles tend to be symmetrical, meaning that the two halves match; asymmetry is a warning sign for melanoma.

B. Border irregularity—typical moles tend to have smooth, regular borders, while melanomas usually have rough, uneven, notched, or scalloped edges.

C. Color variation—benign moles tend to be all one color, while melanomas often have a number of different shades of brown, tan, black, red, or white.

D. Diameter—benign moles are typically smaller than 6 millimeters in diameter (about the size of the eraser on a pencil), while melanomas tend to be larger in diameter.

E. Evolution—the appearance of common moles tends to remain the same over time, so any changes or evolution in a mole’s size, shape, color, or other characteristics (such as itching, crusting, bleeding, or failing to heal) should be considered a warning sign.

The Ugly Duckling Sign

Although the ABCDEs are helpful in identifying potential skin cancers, even experts may find it challenging to distinguish melanomas from harmless moles that display some of the warning signs. Given the importance of early detection, skin cancer specialists developed a second tool—the Ugly Duckling sign—to aid in screening and diagnosis.

The Ugly Duckling sign is based on the fact that all of the moles on the skin of a specific person tend to resemble one another. Whether a person has a dozen moles or a hundred moles, most will be of a similar shape, color, and size. As a result, part of the skin cancer self-examination should involve comparing each mole to surrounding moles and looking for outliers—or ugly ducklings—that do not fit into the usual pattern. For instance, a mole that stands out because it is larger or a different color than the others should be considered suspicious and checked by a doctor.

References

Do You Know Your ABCDEs? Skin Cancer Foundation, 2016.

Scope, Alon, and Ashfaq A. Marghoob. The Ugly Duckling Sign: An Early Melanoma Recognition Tool for Clinicians and the Public, Skin Cancer Foundation, August 29, 2011.

Step-by-Step Self-Examination, Skin Cancer Foundation, 2016.

Section 2.4

Testicular Self-Examination

Testicular Self-Examination, © 2016 Omnigraphics. Reviewed June 2019.

Although testicular cancer has a relatively low rate of occurrence, accounting for just 1 percent of malignancies in all men, it is the most common neoplasm, or abnormal growth, in adolescent males and young men under 35 years of age. Testicular cancer is easily diagnosable and can be successfully treated, with a high survival rate of more than 10 years in nearly 90 percent of patients. As with most types of cancer, the prognosis is particularly good with early detection. While significant advances have been made in developing treatments for testicular cancer in the last few decades, the benefits of early detection through self-examination have not received much attention, often resulting in delays before medical attention is sought.

Importance of Testicular Self-Examination

In the absence of a standard or routine screening for testicular cancer, the condition is most often detected either by a doctor during a routine physical examination or by an individual during the course of a self-exam. The outlook for testicular cancer depends on whether or not the disease has metastasized to lymph nodes, tissues, and organs, and this underscores the importance of early detection by testicular self-examination (TSE).

Early detection involves the diagnosis of testicular cancer through stages 1 and 2. Stage 1 refers to a localized tumor restricted to the primary site, the testes. Stage 2 is the term for a regional tumor, one that has spread to other areas. An early diagnosis resulting from a self-exam can greatly enhance treatment outcomes and also reduce the side effects commonly associated with chemotherapy, radiation, and surgery.

How to Perform a Testicular Self-Examination

It is important to perform a self-examination every month. This allows you to familiarize yourself with the size, shape, and consistency of your testes and to sensitize you to any abnormality in the future. This also helps you to distinguish the epididymis—a highly coiled duct behind the testis for the temporary storage of sperm—from an abnormal lump or growth. Further, it is quite normal for most men to have testicular asymmetry. Differently sized testes with one hanging lower than the other is a normal anatomical feature and should not be construed as a sign of abnormality.

The ideal time to perform a self-exam is right after a warm shower when the scrotum is relaxed and can be easily drawn back to examine the testicles.

Testicular self-examination is a simple procedure that takes no more than a couple of minutes:

Hold the penis away from the scrotum to enable close examination of the testes.

Hold the testicles between your thumb and fingers and roll gently.

Feel each testicle for any painless lump, usually grain or pea-sized, in the front or sides, taking care not to confuse a lump with supporting tissues and blood vessels.

If you detect any thickening, discomfort, or pain in the testicles or groin, contact your healthcare professional immediately.

Studies show that men often delay seeking medical attention because early symptoms are typically mild, and many men tend to believe that a lump is benign or harmless and may go away on its own. Concerns about loss of sexuality, or sterility, may also get in the way of seeking professional help when an abnormality is detected.

While the majority of scrotal and testicular irregularities may not be associated with malignancy, it is important for all men—especially those who carry a high risk for testicular tumors—to perform regular self-exams. A family history of testicular cancer and previous history of malignant tumors in one or both of the testes are regarded as high-risk factors, as are conditions such as cryptorchidism, a common birth defect associated with undescended testes.

References

How to Perform a Testicular Self-Examination, The Nemours Foundation/KidsHealth®, 2012.

Testicular Examination and Testicular Self-Examination (TSE), Healthwise, Incorporated, June 4, 2014.

SEER Stat Fact Sheets: Testis Cancer, National Institutes of Health (NIH), April 2016.

Chapter 3

Recommended Screening Tests for Men

Chapter Contents

Section 3.1—Screening Tests for Men: What You Need and When34

Section 3.2—Abdominal Aortic Aneurysm Screening36

Section 3.3—Blood Pressure Screening39

Section 3.4—Cholesterol Screening42

Section 3.5—Colorectal Cancer Screening46

Section 3.6—Osteoporosis Screening51

Section 3.7—Prostate Cancer Screening56

Section 3.1

Screening Tests for Men: What You Need and When

This section includes text excerpted from Men: Stay Healthy at Any Age, U.S. Office of Personnel Management (OPM), August 15, 2010. Reviewed June 2019.

Get the Screenings You Need

Screenings are tests that look for diseases before you have symptoms. Blood pressure checks and tests for high cholesterol are examples of screenings. You can get some screenings, such as blood pressure readings, in your doctor’s office. Others—such as a colonoscopy, a test for colorectal cancer—need special equipment, so you may need to go to a different office. After a screening test, ask when you will see the results and who you should talk to about them.

Abdominal aortic aneurysm. If you are between the ages of 65 and 75 and have ever been a smoker, talk to your doctor or nurse about being screened for abdominal aortic aneurysm (AAA). AAA is a bulging in your abdominal aorta, the largest artery in your body. An AAA may burst, which can cause dangerous bleeding and death.

Colorectal cancer. Have a screening test for colorectal cancer starting at the age of 50. If you have a family history of colorectal cancer, you may need to be screened earlier. Several different tests can detect this cancer. Your doctor can help you decide which is best for you.

Depression. Your emotional health is as important as your physical health. Talk to your doctor or nurse about being screened for depression especially if during the last two weeks:

You have felt down, sad, or hopeless.

You have felt little interest or pleasure in doing things.

Diabetes. Get screened for diabetes if your blood pressure is higher than 135/80 or if you take medication for high blood pressure. Diabetes (high blood sugar) can cause problems with your heart, brain, eyes, feet, kidneys, nerves, and other body parts.

High blood pressure. Starting at the age of 18, have your blood pressure checked at least every 2 years. High blood pressure is 140/90 or higher. High blood pressure can cause strokes, heart attacks, kidney and eye problems, and heart failure.

High cholesterol. If you are 35 years of age or older, have your cholesterol checked. Have your cholesterol checked starting at 20 years of age if:

You use tobacco.

You are obese.

You have diabetes or high blood pressure.

You have a personal history of heart disease or blocked arteries.

A man in your family had a heart attack before the age of 50 or a woman had a heart attack before the age of 60.

Human immunodeficiency virus (HIV). Talk with your healthcare team about HIV screening if any of these apply to you:

You have had unprotected sex with multiple partners.

You have sex with men.

You use or have used injection drugs.

You exchange sex for money or drugs, or you have sex partners who do.

You have or had a sex partner who is HIV-infected or injects drugs.

You are being treated for a sexually transmitted disease (STD).

You had a blood transfusion between 1978 and 1985.

You have any other concerns.

Syphilis. Ask your doctor or nurse whether you should be screened for syphilis.

Overweight and obesity. The best way to learn if you are overweight or obese is to find your body mass index (BMI). You can find your BMI by entering your height and weight into an online BMI calculator. A BMI between 18.5 and 25 indicates a normal weight. Persons with a BMI of 30 or higher may