August 22, 2008
Osteoporosis in Older Men: Feelings of Masculinity and a ‘Women’s Disease’
By Solimeo, Samantha
Osteoporosis is a metabolic bone disorder characterized by low bone density and associated with atraumatic fractures, pain, disability, long-term-care placement, and premature mortality. The condition is an important public health issue for all older adults, but the construction of osteoporosis as a "women's disease," and men's behavior in response, may limit the efficacy of current screening and treatment options for men. Though men are indeed at risk for osteoporosis, it does occur primarily among postmenopausal women, with the therapeutic interventions, educational outreach, and screening programs thus aimed primarily at women. The positive trends seen among at-risk womenimproved healthcare utilization and health outcomes for osteoporosis-are not evident among at-risk men. Men themselves rarely recognize their risk of osteoporosis, and behaviors associated with masculine gender identity may constrain them when it comes to preventive behavior to avoid osteoporosis and to recognize the disease if it does appear. Attention to men as a risk group and to the behaviors associated with masculine gender identity must inform research and practice related to osteoporosis.
EFFECTS ON QUALITY OF LIFE
We know that osteoporosis has negative consequences for interpersonal relationships and overall quality of life among older female sufferers (Gold, 1996, 2001, 2003). Women with the disease have difficulty performing recreational and home-keeping activities from which they derive identity, and they often experience feelings of role loss and of premature aging, as well as shame or embarrassment, stress, anxiety, and depression (Gold, 1996,1999; Gold and Roberto, 2000; Penrod, 2000; Roberto and Gold, 1997,2002; Roberto, Gold, and Yorgasen, 2004; Roberto and Reynolds, 2001). But we do not know the ways and extent to which osteoporosis similarly affects the quality of life for men.
The gendered nature of social roles and activities in later life would suggest a qualitative difference in how men feel about and adapt to osteoporosis. Although literature on the epidemiology and treatment of male osteoporosis is thin, recent study of men's knowledge about osteoporosis and feelings of self-efficacy in relation to it, as well as studies of the relationship between gender performance and health behavior, illustrate how men's experience of osteoporosis most likely will differ from that of women and identify areas for future qualitative and intervention research.
MEN'S VULNERABILITY TO A WOMEN'S DISEASE'
Several studies have demonstrated that men have little knowledge of risk factors for osteoporosis, have inadequate calcium consumption, and engage in alow levd of weight-bearing exercise (Ailinger et al., 2005; Sedlak, 2000; Tung and Lee, 2006). In addition, the incidence of osteoporosis and related fractures in men is increasing because more men now live past the seventh decade of life, and the prevalence may continue to grow with the proportion of our population that is over the age of 70 (Nguyen et al., 1996, p. 259; Fande and Francis, 2001). But men's own health and illness behavior is not the only reason that men are vulnerable to osteoporosis. Even in the presence of fractures, osteoporosis in men is underdiagnosed and infrequently treated. In a study of male HMO members over 65 years of age, treatment for osteoporosis was infrequent (Feldstein et al., 2005). Among those who were treated for fractures, less than 2 percent had their bone density measured, and almost 70 percent of men with vertebral fractures received no osteoporosis-relatcd treatment (Feldstein et al., 2005).
These data reveal a missed opportunity to decrease the vulnerability of men to subsequent fractures, disability, and premature death. In comparison to women, men with osteoporosis experience vertebral body and hip fractures more often; have higher post-fracture mortality, higher rates of disability and institutionalization; and are diagnosed later in the disease, after a fracture has occurred (Campion and Mariac, 2003; Pande and Francis, 2001; Vondracek and Hansen, 2004).
MASCULINITY AND SYMPTOMS OF OSTEOPOROSIS
Osteoporosis is commonly referred to as a "silent disease" because the disease process is unapparent until a painful fracture or measure of bone density brings it to the fore. Despite public perception of osteoporosis as a disease that affects only postmenopausal women, men have the potential to exhibit a majority of risk factors for the disease. Of the nineteen risk factors identified by the National Osteoporosis Foundation (NOF) (2007), only three are specific to women, and of the twelve risk factors identified by the National Institutes of Health Consensus Panel (cited in Stone and Lyles, 2006, p. 67), only two are specific to women.
Risk factors for men include the following: history of smoking or alcohol use, low bone mineral density, family history of fracture, low body mass index, smaller stature, older age, low dietary calcium, vitamin D insufficiency, lack of weight-bearing exercise, low testosterone, history of prior fracture, and the use of corticosteroids and certain cancer-related medications (Anderson and Cooper, 1999; Bilezikian, 1999; NOF, 2007; Kirk and Fish, 2004; Nguyen et al., 1996; seeman et al., 2004; Skmenda et al., 1992; Vondracek and Hansen, 2004).
Men are physiologically less vulnerable to osteoporosis than are women, but prevention among older men is precluded by their lack of awareness of their susceptibility to this condition. A survey-based study of knowledge about osteoporosis across gender and age found that older adults perceived greater susceptibility than did younger people and that women in general felt more susceptible than did men (Johnson et al., 2007).
However, an educational intervention targeting men demonstrated that men's knowledge of osteoporosis could be improved, but that this improvement did not translate into engagement in prevention behaviors (lung and Lee, 2006). Such research reveals the relevance of gender and the necessity that it be taken into account when planning osteoporosis prevention and intervention.
The rules for gender performance-how individuals express masculinity or femininity-differ by age, race, social class, and other axes of social stratification, and while the consequences of behavior that does not follow these rules are less severe for older people than for younger people, gender performance does influence the health and well-being of older adults.
Men may actively avoid what might be construed as "healthy" behavior and purposely engage in risky behavior (Courtenay, 2000). Some forms of male gender performance pose special challenges for practitioners working in osteoporosis prevention. Back pain, a potential indicator of vertebral fractures, may be construed by men as something they ought to withstand rather than treat, as expressed ability to tolerate pain without complaint is seen as a masculine trait (Courtenay, 2000; O'Brien, Hunt, and Hart, 2005). Efforts to raise awareness among men about their risk of osteoporosis may be stymied by a reluctance to utilize preventive services that is common among men. Men may equate use of Healthcare services with weakness and thus actively avoid physicians (O'Brien, Hunt, and Hart, 2005; Mahalik, Burns, and Syzdek, 2007).
Similarly, the stigma many older men experience in being labeled as men with a "women's disease" can deter some from seeking treatment and from recognizing the risk factors they may possess (Feldstein et al., 2005; Resnick, Wehren, and Orwig, 2003).
It is also important to consider the ways in which age intersects with gender performance, as older men negotiate a set of cultural expectations that differ from those of their younger counterparts (Courtenay, 2000; Gough, 2006). In a study by O'Brien and colleagues, older men were more likely to seek medical care than were younger men, and the comments of older men articulated a tension between the genderdriven pressure to "wait things out" and their age-related concern that they may put themselves at risk of injury by waiting. Men who had lived through a serious disorder such as prostate cancer represent exceptions to the gender norm of healthcare avoidance, and both groups-older men and men who had survived a serious disorder-acknowledged the need for and sought preventive care (O'Brien, Hunt, and Hart, 2005).
Thus, men do not uniformly avoid care, but they utilize services via a "hierarchy of threats to masculinity" (O'Brien, Hunt, and Hart, 2005, p. 514). Unfortunately, osteoporosis is most likely positioned at the very bottom of this hierarchy: The condition is commonly symptomfree, it is construed as something of concern to postmenopausal women, and men do not consider it to be life threatening.
A RESEARCH AGENDA
Seeman and colleagues' (2004) essay provided a road map for building the scientific basis for understanding osteoporosis in men. Many of the gaps they identified are emerging as major lines of research, but others remain unaddressed. As the literature on osteoporosis in men becomes deeper, broader, and more sophisticated, we have a unique opportunity to integrate gender performance into our understanding. The following questions should be included in a research agenda:
* In what ways do age, race, ethnicity, and sodoeconomic status combine to differentially influence the incidence of osteoporosis in men? * How do men interpret the symptoms of osteoporosis, and how do these interpretations influence their health behavior?
* In what ways does the condition affect men's identity? Do specific problems related to osteoporosis, such as back pain, affect identity differently for men than for women? Do socioeconomic and cultural factors contribute to the poorer osteoporosis-related outcomes seen among men as compared to women?
* Does adherence to osteoporosis medications differ by gender?
* Given the relationships between testosterone and osteoporosis and between testosterone and gender identity, how do testosterone medications and androgen-deprivation therapy affect men's identity?
* Where do men with osteoporosis locate the disorder among their "hierarchy of threats"?
* Does osteoporosis-related quality of life differ by gender?
* What are the beliefs of healthcare professionals concerning osteoporosis screening and treatment in men?
Recent scholarship emphasizes the importance of measurement of bone density and pharmacotherapy to the health and survival of men at risk for osteoporosis (Schousboe et al., 2007). The issues surrounding osteoporosis among men may be an analog to the history of cardiovascular disease among women.
An analogous situation can be seen in consideration of cardiovascular disease, long considered a "men's disease," for which research and practice historically focused on middle-aged and older men. The extent to which women were at risk of the disease was long underrecognized, contributing to poorer outcomes for women. More recently, more attention has been paid to the incidence of the disease in women.
Recent calls for a men's health movement, the development of new journals dedicated to the study of men's experiences, and feminist scholarship exploring the intersection of masculinity and age have moved gender into the forefront of gerontological research. These developments have produced exciting new work exploring how gender performance relates to health behavior. In the case of osteoporosis in men, gender and health scholarship have yet to be fully integrated.
Men are indeed at risk.
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Samantha Solimeo, Ph.D., M.P.H., is a postdoctoral fellow, Aging Center, Duke University Medical Center, Durham, N.C.
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