Testosterone Poisoning or Terminal Neglect? The Men's Health Issue


Research Paper 22 1995-96

Richard Fletcher
Consultant to the Law and Public Administration and Social Policy Groups

Contents

Major Issues

Introduction

How Is Men's Health?

Who Is Doing What In Men's Health?

The Development Of Men As A Legitimate Target Group

The Men's Health Movement and Other Myths

Is There A Backlash? The Proudfoot Case (Proudfoot and Ors. v ACT Board of Health & Ors. (1992))

Prostate Cancer Screening And Men's Health: A Case Study

Concerns About Boys

The Task Before Us

The Role Of The Commonwealth

Endnotes

Major Issues

Men's Health has become an issue of concern for men and women in the community and for a significant number of health professionals. The figures on male death rates, illness and mental health reveal a pattern of poor health sufficient to justify special attention. However, the longer term trends, which reveal a dramatic improvement in key areas of men's health, make it clear that no "crisis" is occurring. There is, however, a pressing need for a clearer understanding of the factors which have contributed to the poor health profile for males compared to females. Some of these factors, and the longer term implications, are set-out below.

  • Statistics on excess male mortality have been available for many years. Media and political assessment of the statistics has, until quite recently, been clouded by misconceptions. This may have led to a tolerance within the community and by health planners of the obvious contradiction in death rates as a marker of health status and the lack of action in identifying men as a legitimate target for health care programs.
  • One deeply entrenched and convenient explanation for the poor health profile for men is that it is due to biological factors. There are important biological differences between men and women but this should be irrelevant to a willingness to improve the health status of males as well as females.
  • There are a variety of factors which impact on men's health. Young adult males, in particular, engage in behaviour and lifestyles which are hazardous. For example, analysis indicates that a recent epidemic of heroin use in England was almost entirely related to males. Ironically however, the majority of males rate their health as good or excellent. There is a view that men, particularly in the working-age group, are socialised to report fewer illnesses although they have the same level of serious chronic illnesses as women.
  • When reporting on men's health, the media has a tendency to portray any calls for targeting of men in terms of gender warfare and to fuse the men's health issue with a perceived men's health movement. This is unhelpful and unwarranted. The reality is that calls for a greater awareness of men's health as an important social and political issue have also come from close female relatives of men. It is acknowledged that the 1992. Proudfoot case, which was grounded in a claim that programs of funding for women's health discriminated against men, did produce a backlash effect, at least in some quarters. A more co-operative approach has now emerged.
  • One significant need for men is to be better informed. The interconnected clinical, economic and public health issues surrounding prostate cancer screening is illustrative of the need for men and women to be better informed not only of this serious ailment but of the whole area of health and health care.
  • The Commonwealth has a role to play and the Draft National Men's Health Policy (released on 18 January 1986) is an important start in identifying the longer-term responsibilities which will require fundamental changes in many, if not all of its health related programs. The whole process, from staging a National Men's Health Conference to submitting a policy to the Australian Health Minister's Council in 1996 will have taken one year. This is in stark contrast to the 14 years between the first National Women's Health Conference and the National Women's Health Policy released in 1989.

Introduction

The mortality rate for males in any given age group is higher than that for females. Young men, for example, are involved in more fatalities arising from accidents, suicides and drug dependency. Older men die from heart disease and many common cancers at higher rates than do women. There is, however, some good news in that, over the last few decades, male deaths from many of these conditions have declined substantially.

This paper is not a male v female study nor is it a pitch for greater health resources for men at the expense of existing programs for women. The paper seeks to collect a number of points which are relevant to the emergence of a very important debate - the men's health issue.

In any event, comparisons based simply on the distribution of financial resources overlook the need to examine entrenched views such as whether men's poor health is biological, or whether men are socialised to ignore vital symptoms.

Some improvements in men's health have been obtained by increasing the awareness of a healthy life style. Further improvements can be expected from a more open discussion of issues such as prostate cancer and head injury.

There is also the need to expose the myth that the men's health issue has been placed on the national agenda by a "men's health movement". Some of the key advocates for greater attention to this issue are women whose involvement has been generated by concern for close male relatives.

The release of a Draft National Men's Health Policy by the Commonwealth Government on 18 January 1996 is a welcome but belated recognition of the importance of this issue to the nation as a whole.

How Is Men's Health?

The most recent national health survey (1989-1990), asked men to rate their health as poor, fair, good or excellent. Overall, 80.1% of men rated their health as good or excellent, a figure slightly higher than that for females (78.3%).(1) While the limitations of self reported health data are well known, it is clear that overall, men (as well as women) feel that they benefit from the generally high standard of health care and living conditions found in Australia.

Of course there are groups within the male population who do not enjoy good health. Younger men reported better health than older men with 10.6% of men aged 18-24 rating their health as poor or fair compared to 43.8% of men aged 65 and over. Low income males in the 25-64 age group are more than twice as likely as high income males to report their health as fair or poor (27.5% compared to 10.2%). Aboriginal and Torres Strait Islander organisations have made repeated claims for better health services and for attention to social factors such as unemployment, discrimination and land use, which affect their health. Aboriginal and Torres Strait Islander men have a life expectancy 16-18 years less than non indigenous men.

Recently, however, the evidence of male excess mortality and morbidity across the whole population has been accepted as requiring action on the basis that health services (including health promotion) should be addressed to those in need.

At the 1995 National Men's Health Conference, Mathers, from the Australian Institute of Health and Welfare, presented a summary of the health differentials between Australian males and females. He considered the standard markers of health status, mortality, morbidity, risk factors and health service utilisation.(2)

Mortality

From birth to 14 years, boys have a death rate 35% higher than the age standardised (3) rate for girls. Boys predominate across all the major causes of death: complications of pregnancy and childbirth (30% higher), congenital abnormalities (11% higher), cot deaths (34% higher), respiratory disorders (45% higher) and injury (76% higher).

Young men have an overall death rate almost three times that of young women. Motor vehicle traffic accidents and suicide, the leading causes of death, were 3.2 times and 4.2 times higher respectively for males. Deaths due to drug dependence were 88% higher for males and cancer deaths were 59% higher.

The death rate for men of working age (25-64) is nearly double that for women. The only major cause of death where men in this age group do not have a higher rate is genitourinary system (bladder, urinary tract and genitalia) deaths which were 29% higher for women. Among the major causes of death, a broad comparison between men and women in the 25-64 age group reveals the following higher rates for men: coronary heart disease (253% higher), suicide (251% higher), lung cancer (220% higher), motor vehicle traffic accidents (170% higher), stroke (33% higher).

For older men, over 65 years, the death rate was 61% higher than the age standardised rate for women. These men had higher rates for all major causes of death including the genitourinary system. Some major causes of death were lung cancer (387% higher), suicide (286% higher), bronchitis/emphysema/asthma (196% higher) and stomach cancer (139% higher).

Morbidity

For illness , the picture is more complex. In some areas males have higher rates, in others they seem to do considerably better than females.

Boys report significantly more serious chronic illness and recent illness than girls. Boys have more respiratory and mental illness whereas girls have more skin conditions. Working age men report fewer days of reduced activity and less use of health services than females. They also report fewer illnesses although the same level of serious chronic illness. Older males report higher rates for deafness (104% higher), bronchitis/emphysema (73% higher) back problems (55% higher), and heart disease (30% higher). For a range of illnesses, from headaches and varicose veins to arthritis and hypertension, women report up to 50% higher rates.

Risk factors

Working age and older men, according to self report, have significantly higher rates than women of all the risk factors: smoking, risky drinking, overweight, high blood pressure, inactivity and high serum cholesterol.

Medical, hospital and other health consultations

Apart from the 0-4 year old group, women and girls receive more medical services per capita than men and boys. Working age women report 40% more hospital episodes, 16% more outpatients visits, 24% more dental visits and 25% more other health professional visits than working age men. The gap in medical consultations and hospital use is widest in the adult years 15-54. This is partly due to reproductive related services for women.

Mental health

Until recently, the accepted view was that women had higher rates of mental illness than men. Recently it has been demonstrated that while adult women experience more anxiety, depression and eating disorders, men experience more alcohol and drug abuse and antisocial behaviour. Among children, boys have higher rates of mental illness than girls, but this is reversed for adults, so that the overall rates are similar.(4)

The good news

It is tempting to interpret the figures in the proceeding sections as a "crisis" in the health status of men. But a consideration of trends reveals a dramatic improvement in a number of areas. Lung cancer deaths, the biggest cause of cancer death in men, have been declining since about 1980. As the proportion of men smoking continues to fall, deaths from this cancer are expected to decline even further. Male deaths from Coronary Heart Disease (CHD) have been falling since the 1960s. Heart attack deaths, the major contributor to CHD, are declining at an annual rate of 4% in men (compared to 2.7% in women). Stroke mortality is declining at about 4.5% for both sexes. Alcohol consumption continues to fall. Between 1989 and 1994 the number of standard drinks per day for men fell from 1.8 to 1.3 (still higher than women on 0.4 standard drinks per day). The proportion of men drinking at hazardous levels fell from 15% in 1989 to 9% in 1994.(5) An even more striking improvement has been demonstrated for road deaths. Between 1968 and 1992 the age standardised death rate for males fell from about 45 per 100,000 population to about 15 per 100,000.(6)

So, is it biology?

The dramatic changes in deaths and illness over the last twenty years are one of the strongest arguments against ascribing men's poor health to biological factors. However, the idea that biological factors will eventually be discovered for all our bodily ills, given enough time and effort, is deeply entrenched in the discussions of health and illness in Australia. So it is hardly surprising that genes or testosterone are commonly invoked to explain men's health status. On a global scale, there is support for the biological weakness of males since for a variety of cultures, from all continents, males have higher death rates. As well, across species from nematodes (worms) to mammals, male longevity is inferior in almost every case. Of course important biological differences between the sexes are acknowledged in the medical literature. In relation to heart disease, for example, it is accepted that women's oestrogen levels pre-menopause have a protective effect while men's tendency to store fat around their waists instead of their hips, as women do, is now thought to partly explain men's higher rate of CHD. But, as indicated above, men are also more likely to smoke and drink, and to eat more fatty foods than women. Ian Ring, Head, Epidemiology and Health Information Branch, Queensland Health, summarised the relation between the biological and social explanations as:

The picture I have in my mind of what has been happening over the last 50 years is one of biologically inferior males trapped by nature, social roles and cultural myths into patterns of behaviour that have had a particularly devastating impact on their health. The behaviours that they have selectively adopted have been those that are associated with the major causes of death and chronic illness in the 20th century and the health system has been largely ineffective in reducing these differentials and indeed has made inadequate attempts to do so.(7)

In the following sections, an approach to the issue of men's health is suggested which recognises that there are important biological differences between men and women but holds that these differences are irrelevant to our willingness to try to improve the health status of men as well as women. Equally important is the simultaneous recognition that while males have been the focus of much health research and health service resourcing, males have not benefited from this attention because "maleness" has been invisible to health planners and professionals.

Who Is Doing What In Men's Health?

Nurses and other health professionals have initiated community based, male-specific programs which fall into two main areas: health awareness and domestic violence. Programs attempting to raise male awareness of health issues commonly include the following topics: stress, heart disease, cancer, exercise, smoking and diet. These programs are often short, sometimes just a single session, and have targeted local men or, more rarely, specific groups such as unemployed men. Few of these programs have been evaluated or documented and, since the courses tend to depend on the enthusiasm of the initiator, there is little development or linking between areas. Nevertheless, since the late 1980s, when these programs first appeared, they have proliferated across Australia. A National Men's Health Forum held in 1994 in Burnie, Tasmania, using local resources attracted 120 participants from all states except the Northern Territory.

Courses for perpetrators of domestic violence are sometimes based in specialised domestic violence services but many are run thorough community health centres or welfare agencies. Their development has been controversial and, like the health awareness courses, evaluation and networking have proven difficult.(8)

Over the same period, general practitioners have become increasingly vocal in advocating attention to males' health needs. The June 1990 "Men's Health" edition of the Australian Family Physician journal asked: "Men's Health - is there a problem?". By 1993 the second "Men's Health" issue described a new "medical entity" of men's health as "evolving from a pure concern with the distinctly male apparatus into a concern for the total person and how that person's belief systems and approach to the world are interacting with health and disease."(9) Subsequently, male-specific general practices have opened in Sydney and Melbourne, Victorian general practitioners have developed a "Being a Bloke" education kit for rural general practitioners and clinics for men's sexual difficulties have been established in every major city.

Aboriginals and Torres Strait Islanders have also identified "men's health" as a separate service delivery issue. In 1992, health workers and Aboriginal groups from the Pilbara region of Western Australia held a Men's Health Conference.(10) A year later, Aboriginal men representing all major groups across the Northern Territory met to demand attention to Aboriginal men's health needs. In some areas, Aboriginal men's health clinics have been initiated to parallel the existing women's health clinics run in isolated communities.

At the national level, campaigns using sophisticated marketing techniques have also been directed to "men's health". In the cancer area, Apex, a 'male' organisation, used a video and rubber 'practice testicles' to initiate discussion of testicular cancer in its branches across Australia during 1992-93. (11) In 1993, Merck Sharp & Dohme (Australia) Pty. Ltd. set up the Prostate Disease Awareness Committee (PDAC) to publicise the issue among men. (The issue of prostate disease is described in the case studies below).

Research conducted among Newcastle steelworkers in 1992 led to the development of a uniquely male oriented weight loss course. Ten thousand men in Australia have now completed the basic six week course under the trade name Gutbusters, (pers. comm. Egger 1995). A recent evaluation study found significant waist reduction over 2 years.(12) Dietitians in community settings in several states have since begun similar male specific weight loss courses under other names.

The Development Of Men As A Legitimate Target Group

During the 1980s there were precursors to the discovery of men's health in the 1990s. At the South Australian conference, Linking Men's Services held in Noarlunga in 1986, research was reported showing men used community health services at only 50% the rate for women and a typology of male clients was suggested.(13) In Sydney, Thelma Robinson, director of the NSW Community Safety Division of the National Safety Council, circulated her report Being Male is A Safety Hazard documenting the excess male deaths and hospitalisations from NSW figures. The Noarlunga conference findings had little effect outside of South Australia however and Thelma Robinson found her paper dismissed as "interesting". Neither event made headlines or stirred public interest.

Public discussion of men certainly took place in Australia during the 1980s. But the emphasis on men's psyche, rather than their physical health prevented major health developments for men from being recognised as "male" health issues. The new Occupational Health and Safety legislation and the Drug Offensive for example, initiatives of great benefit to men's health, were discussed as "workplace" or "community" issues.(14)

By contrast, the report Men and Mental Health released at the 1995 National Men's Health Conference, marks a break with the popular psychology approach to men's health since it considers the effects of war, stress and family breakdown within a public health framework rather than the individual therapy framework of the popular press.(15)

An epidemiological, or public health perspective however does not ensure that men's health is recognised as an area of need. From the mid 1980s, in response to an international interest in the broad issues of health promotion, Australian government reports began to consider the issue of equity in the broad context of health status and well being rather than the narrow treatment framework of hospital care and medical services. The report of the Better Health Commission, Looking Forward to Better Health, was published in 1986. It included proposals for achieving higher levels of equity in health in Australia but made no reference to males as a group.(16) Three years later the Australian Health Ministers Advisory Council's Health Targets and Implementation (Health For All) Committee produced the Health For All Australians report. Three major areas of inequality were nominated: Aboriginality, socioeconomic status, and gender. For gender it noted:

There are also quite remarkable gender differences in health status in this country. Men in Australia die from nearly all non sex-specific leading causes at much higher rates than do women, although women consult doctors more frequently for all causes except injuries. These differences in health status largely reflect the prevalence of preventable factors.(17)

But while the committee could point to the emerging new national plan for Aboriginal health, and the National Women's Health Policy being formulated, and the committee itself took action to develop health goals and strategies for older people and migrants, for men it simply noted:

There have been no formal efforts to develop goals, targets or national strategies for the health of men in Australia.

This is surprising given the importance accorded mortality rates in evaluating health status. As professor Stephen Leeder, a leading public health advocate explained:

..when I consider which statistics have media and political impact, I can think of none more powerful. Excess mortality is a concept everyone can grasp. Our fierce Australian egalitarianism leads us immediately to conclude that something unfair is going on if one community group has a higher mortality than another.(18)

Two related, but separate ideas may explain the tolerance among health planners of the contradiction between death rates as a marker of health status, and their lack of action in targeting men.

A fundamental concern both of the original World Health Organisation (WHO) health resolutions and the Australian reports and programs generated in response, was that health inequalities (i.e. health status differences) be reduced. Australian reports and programs embraced this goal, but made an important distinction between "inequality" and "inequity".

In the European Region's response to the 1977 WHO resolution, from which Australian documents took much of their direction, the distinction is made between inequality as unfairness, termed inequity and inequality as "unequal in a purely mathematical sense". Inequalities which are not unfair may be due, for example to biological factors, or to "freely chosen" health damaging behaviour such as "participation in certain sports and pastimes."(19)

This distinction has provided, in the Australian context, a way of acknowledging that males have markedly poor health in some areas while continuing to overlook males as a suitable target group. In the Health For All Australians report for example, the question is presented "Why do women report more health problems yet live longer than men?" And then an answer is offered. "This paradox can be explained in terms of the differences in types of illnesses they report. The chronic conditions that men report are more likely to be those also causing high mortality."(20)

In practice, maintaining the boundary between behaviours which are "freely chosen" and those which are imposed is not straightforward. The European WHO document notes:

Promotion of health damaging products may be targeted at certain groups such as young working class men and alcohol advertising...This puts them under greater pressure than others to consume these products. (21)

Similarly confused attempts to separate inequity and inequality occur in Australian documents.(22) And some Australian commentators have been more dismissive of this distinction maintaining that "inequalities always have externally imposed, unfair causes".(23)

A second difficulty in targeting men is the assumption that men's health is being taken care of (not an unreasonable assumption).(24) This view is not canvassed in national public health documents, but was made explicit in the recent charge that the Canberra Women's Health centre was unfairly discriminating against men (Proudfoot's case(25)). This case was heard before Justice Wilson in the Human Rights and Equal Opportunity Commission in 1991 and 1992. The general features of the hearing are discussed later.

An important, though unintended, feature of this case was the public testimony of senior health bureaucrats. Dr Stephen Duckett, then Director of Policy and Planning for the Health Department of Victoria, gave evidence on behalf of the respondents (ie. women's health) about the general approach to planning services. On being asked if, in planning health services, men's needs were set beside women's needs and a judgement made, he replied:

...one would hope that existing services are meeting someone's needs and if they're not meeting women's needs they're presumably meeting men's needs.(26)

It is unusual for such background thinking to be on the public record but this assumption, if widely held by health planners, would help explain the invisibility of men's poor health for so long.

By 1993, the revised national health targets, set out in Goals & Targets for Australia's Health in the Year 2000 and Beyond, with minimal discussion of equity, included males as a priority target group in several categories, such as suicide, motor vehicle injury, skin cancer and heart disease.(27) The most recent Better Health Outcomes for Australians (1994), breaking with the distinction between inequity and inequality altogether, included males as a priority population under the social justice category for injury.

In parallel with this increasing national recognition of males' needs, regions in Queensland and Western Australia, and Area Health Services in NSW have included males as a priority group. South Australia is planning a "Men's Health Policy" for release early in 1996.

At the national level, a Draft National Men's Health Policy was released on 18 January 1996. It identifies four action areas:

  • a national education strategy for schools and community organisations
  • an information strategy promulgating best practice in men's heath and developing benchmarks for assessing men's health initiatives
  • research into men's health related behaviours and men's needs and
  • an extensive consultation process with men and male organisations.

The Men's Health Movement and Other Myths

While there undoubtedly are parallels in the development of "men's health" and "women's health" (with a 20 year time lag), there are also important differences. The development of women's health as a separate health care issue has been grounded in women's public dissatisfaction with existing health care services.(28) The National Women's Health Policy report of 1989 acknowledged important precursors to the policy: the resurgence of the women's movement in Australia, the United Nations Decade for Women, the National Agenda for Women and the 1975 and 1985 national women's health conferences.(29) The situation for males is not comparable.

A 1995 Morgan poll found that only 37% of the men questioned were concerned that men's health issues were not being properly addressed.(30) Males' satisfaction (or dissatisfaction) with existing health care is rarely discussed in the medical literature. But there is no reason to assume a hidden dissatisfaction. A 1994 community survey of 400 Pilbara males found levels of satisfaction with health practitioners ranging from 82.3% for surgeons to 86.5% for general practitioners to 100% for chemists and nurses.(31)

The lack of sweeping dissatisfaction with existing health services should not be taken to suggest that men's health is simply a media fabrication without substance. The wide ranging programs described above have not been concocted by journalists. But the media portrayal of men's health activity, while certainly an important factor in public awareness of the issue, has portrayed this interest and activity in a stereotyped and inaccurate way.

One pervasive notion is that a "men's health movement" with connotations of aggrieved men demanding justice, is the driving force behind the appearance of men's health as a public issue. This is not an altogether unreasonable assumption since the development of women's health did arise from second wave feminism. However it is an incorrect portrayal in the case of men's health.

In many community health centres, in hospitals, and in the bureaucracies it is females (often nurses) who have been advocating, investigating and promoting awareness of men's health issues. Given the predominance of females in health work this is not surprising. But the differences with the development of women's health should be noted. Many proponents of men's health have been long-standing advocates for women's health. It was the Kalgoorlie Women's Health Centre, for example who initiated the first men's health awareness night in that area. In South Australia it was a feminist researcher who first documented men's poor attendance at community health centres. In Newcastle it was a lecturer specialising in women's health who first introduced a men's health topic into nursing courses. It should also be noted that many men are very supportive of women's health services. The 1995 Morgan poll cited above found that 87% of the men surveyed were in favour of specific women's health services. This is not the situation portrayed by journalists looking for a "war of the sexes" story.

A recent cover story in Time magazine is a case in point. Although the Time journalist was advised when writing the article that women were important advocates and provided with examples of women who had initiated key men's health programs, the picture conveyed by the story was that it is men who are now taking action. A corollary of the conflation of the men's health issue with a men's health movement is that men's health and women's health are seen as mutually hostile and incompatible. So that any attention to men must be at the expense of women. This idea was reinforced in the Time story with a quote from Eva Cox, representing the feminist position: "the poor dears are getting worried about their balls and they want to be victims too".(32)

But the evidence from around Australia is clear on this point. It wasn't men who first "worried about their balls", it was the close female relatives of the men. The discovery of testicular cancer as a public issue came from a mother whose son was diagnosed with testicular cancer and became dangerously ill. When she looked around the Health Promotion Unit where she worked, there was not a single pamphlet on the topic. As her son recovered she lobbied for funds to develop a resource alerting men to the issue. The Monkeys Check Theirs, Do You? kit has since been distributed nationally through Apex. There are parallels in the UK. There it was a nurse whose partner had testicular cancer who advocated and lobbied for health promotion specifically targeted at young men.

Another common belief is that men's health claims should be modelled on the early development of women's health. It is often assumed for example that not only will men be the foremost advocates of men's health but that they will seek "men's health centres" along the lines of the alternative women's health centres of the 1970's. Where this has been attempted, as on the NSW Central Coast, it has not lead to the provision of new services but to conflict with existing service providers and disillusionment among supporters. The general practices which have been set up recently to offer specialist services to men have not been alternative in the sense of emphasising non-medical treatments.

Is There A Backlash? The Proudfoot Case (Proudfoot and Ors. v ACT Board of Health & Ors. (1992))

The fear of some women's health advocates, that the discovery of men's poor health status constitutes a thinly disguised grab for resources, is understandable.(33) Some of the publicity advocating men's health makes just this claim (as well as blaming feminists for men's plight). The February 1994 Penthouse article 'Men's Health Scandal' led off:

Thirty years of feminism may have stressed the need for an equal society, but female gains have been at the expense of Australian male health care. An old feminist slogan says: "We don't want a bigger slice of the cake - we want the whole damn bakery." In terms of health, women have taken "the whole damn bakery" while men enjoy the crumbs.(34)

A more formal argument against women specific health services, with potentially more serious implications, was made by Dr Proudfoot, principal adviser to the Therapeutic Goods Administration of the then Commonwealth Department of Health, Housing and Community Services. Dr Proudfoot, acting in a personal capacity, filed a complaint in 1990 in the Human Rights and Equal Opportunity Commission alleging that the Commonwealth and ACT governments funded projects which discriminated against men on the ground of gender and were therefore illegal, under Section 22 of the Sex Discrimination Act 1984. The projects, which came under the National Women's Health program included the consultations held by the ACT government into women's health needs, the ACT Women's Health Service ( a clinical service for women) and The Canberra Women's Health Centre (a voluntary information, education and referral service for women). These services were, the complainants argued, discriminatory because men could not access them, because men's health was worse than women's and because the services addressed problems common to men and women. Gynaecological and reproductive services were not included in the complaint. The respondents argued that even if it was found that discrimination had occurred, the projects were lawful because of sections 32 and 33 of the Act. Section 32 exempts services which, by their nature, can only be provided for one gender. Section 33 exempts any act designed to ensure that persons of one gender have equal opportunities with the other. By the time of the hearing before Sir Ronald Wilson, two other men had filed related complaints and all three were heard together. However it was Dr Proudfoot who provided the substance of the arguments.

Two features stand out from the transcript of the hearing. Not only were the complainants ill prepared, but they were arguing against women's health rather than for men's health. The exchanges recorded in the transcript are marked by their futile negativity. The complainants did attempt to show that Australian men had worse health than women, relying heavily on evidence of higher mortality of Australian men, but they were not advocating equivalent men-specific health services. Their aim was to dismantle the existing women's health services, so that no case was made as to how men's health might be improved, save the suggestion for redistributing funds from women-specific to general health services. Since women-specific services account for only 1% of the total health budget, this was a weak argument, even assuming that the case for men's needs being greater than women's could be made.

The Proudfoot case centred its inquiry on how to decide which gender has better health status. This question is relevant to a variety of health resource debates but it is, arguably, an inappropriate course of inquiry to take unless it is recognised that more than one measure of the factors comprising health status must be examined. Further, the use of such measures is not free from criticism. For example, quality of life (or as it is sometimes expressed in literature - Quality of Life Year or QUALY), and years of life, are separate concepts but they are sometimes taken together. For disease-specific outcomes there is some agreement, but deciding between quality of life outcomes for different diseases has not proved possible. Unfortunately this is precisely the area pertaining to men's versus women's health. What is required is some way to establish a preference between, say, 'x' years with arthritis, a condition common among women, and losing 'y' years due to premature cardiovascular death, or living 'z' years with severe brain damage, the statistically common situation for men.

A major difficulty is in deciding who to ask to indicate a preference. Are those who suffer from the condition in the best position to decide? Is it professionals with a range of experience? Or those who may know someone who might suffer from it? The method chosen for estimating preferences in this case might well have profound effects on the outcome.(35)

In summing up Justice Wilson dismissed all the complaints. He held that the consultation initiatives to identify women's needs were not unlawful and that the Women's Health Service and the Womens' Health Centre were protected by sections 32 and 33 of the Act respectively.

He also noted:

Notwithstanding the mortality and morbidity statistics, women were significantly disadvantaged in their personal well being and hence in their health. There were many socio economic pressures - poverty, child care, single parenthood, lower wages, domestic violence, sexual violence, depression, drug addiction etc - quite apart from child bearing and menopause which impact on the health of a significant number of women in Australia. Their situation warranted special measures. (36)

Effects of the case

One effect was to generate a "backlash" tag for those advocating attention to men's health. While there are small pockets of supporters for this approach, attacking women's health in the name of men's health, the vast majority of those pursuing "men's health", as argued above, come from a more positive framework.(37)

As a reasoned consideration of the health needs of men and women, the case was a poor model. By their application to the Human Rights and Equal Opportunity Commission, the complainants marked their hostility to women's health as more important than their advocacy of men's health. As Justice Wilson noted in passing, "It would be a strange way of meeting the unmet health needs of one sex to dismantle the services already provided to meet the health needs of the other sex".

To their credit, advocates for women's health have, for the most part, not used the Proudfoot case as an excuse for ignoring the self evident health needs of men. A co- operative approach is emerging which recognises the value to women's health of having men's gender acknowledged as an important consideration in health care debates.(38)

Prostate Cancer Screening And Men's Health: A Case Study

In 1990 a Cancer Council briefing on major cancers was conducted in Newcastle. After spending some time on Breast, Cervical and Skin Cancer the presenter came to the page in the flip chart headed "Prostate Cancer". The presenter glanced at the heading, then, as he flipped over the page, he joked "Well we all know about men and fingers don't we?" Everybody laughed and the presenter moved on.

In 1996 such cavalier treatment is unlikely. Prostate cancer has become part of the general health debate carried on in the community and through the media. Reports of the 1994 controversy over breast cancer funding, for example, highlighted two areas for comparison, AIDS and the "male" diseases, prostate and testicular cancer. While the AIDS lobby was cited as a precedent in politicising the health research process, prostate and testicular cancer were offered as the logical comparison for evaluating priorities and funding. This two way contest between breast and the "male" cancers was not simply media inventiveness. The then Minister for Health, Senator Richardson, in responding to criticism over breast cancer funding said it was tragic that 2600 women died annually of breast cancer but 2300 men died each year of testicular and prostate cancer. He also said that breast cancer research received $1.5 million annually, or 10% of the cancer research budget, and the male diseases received about $300,000 but the media did not focus on the male disorders because they were not "fashionable".(39)

In lobbying terms, prostate cancer is poised to become fashionable. The statistics on death and risk are easily conveyed and the differences in research funding for breast cancer and prostate cancer appear stark. On the other hand, the reasons for lack of screening are not easily sloganised. A recent Lancet article pointed out that, compared to breast cancer, we know little about the natural history of prostate cancer, the adequacy of the screening tests or the efficacy of early treatment. The author concluded that even to commence a trial of prostate cancer screening would be unethical at this stage, and called for open discussion of the issues.(40) Letters to the Lancet in response revealed disagreements among medical experts and researchers over the measurement of survival rates, the evidence of testing efficacy, the ability of clinicians to identify potentially harmless cancers, and the statistical models used in previous studies.

The complexity of the arguments and the lack of consensus surrounding prostate cancer screening preclude a straightforward response to suggestions for aggressive strategies for detection. At the same time, a number of recent developments in Australia make the climate for championing prostate cancer particularly auspicious.

The perception that men in Australian society are in crisis seems to be common among media workers. This means that health issues framed as "male issues" are likely to receive considerable coverage. In addition, a well resourced Prostate Disease Awareness Committee has been set up with a grant from Merck Sharp & Dohme (Australia). The American parent company, which sponsors similar groups in other countries, manufactures Proscar (Finasteride) a prostate shrinking drug used in the treatment of Benign Prostatic Hyperplasia (BPH). This condition is an enlargement of the prostate and is very common in men over 50. Where enlargement is detected, about 15 to 20 percent of those cases warrant treatment, usually surgery. The percentage increases significantly as men age. The committee, which is managed by Edelman Medical Communications, includes representatives from the Australian Kidney Foundation, the Combined Pensioners and Superannuant's Association and the Returned Services League of NSW. It has broad educational aims and is preparing a video based presentation on prostate disease to be shown by health workers to men across Australia. While the committee does not advocate screening for prostate cancer, (and Merck Sharp & Dohme (Australia) have no direct financial interest in PSA screening), their enthusiastic publicising of prostate disease inevitably raises the question of cancer. While 90 per cent of enlarged prostates might prove to be benign, men understandably wish to know if their prostate is one of the other 10 per cent.

What happens if prostatic diseases do become "fashionable"? One consequence, if the breast cancer foundation established in the May 1995 budget is a precedent, will be separate funding for prostate cancer research. This is likely to be opposed by medical researchers as replacing scientific merit with lobbying. However the research funding debate may be overshadowed by the problems, suggested above, which will be caused by an increase in the general awareness of prostate disease.

Prostate screening tests

The use of screening tests for detecting cancer has been a major point of debate in the medical literature. As well as discussion of individual tests, there has been tension between mass screening of an asymptomatic population and case detection in asymptomatic patients seeking a health check. In the former, clear guidelines have been established to justify the expenditure of public money and to ensure that potential benefits outweigh the risks. In the clinical setting with individual patients, however, general practitioners or specialists may well operate on the basis that the earlier a cancer is found the better (and their patients may be convinced that "earlier is better" applies absolutely to all cancers). Recognising this dilemma, the Medical Journal of Australia published Australian Cancer Society guidelines for cancer related health checks as a special supplement to the September 1985 edition.(41) At that time no methods of early detection for prostate cancer were recommended, due to lack of evidence. But since then pressure has been mounting to recommend mass screening for prostate cancer, or at least to follow the American Cancer Society guidelines in recommending that annual Digital Rectal Examinations (DRE) be offered to men over 40 years requesting a health check.(42)

Other tests are available for detecting prostate cancer. Two of the most common are Prostate Specific Antigen (PSA) and Trans Rectal Ultrasound (TRUS). But neither they, nor DRE, are particularly accurate. The Digital Rectal Examination for example, has a positive predictive value (the probability of disease in somebody with a positive test result) of only 0.17 to 31 percent.(43) This means that a high proportion of men thought initially to have cancer will, after further investigation, be found to be cancer free. Since a positive result at screening will require further investigation, and because it is difficult to predict which prostatic cancers will progress, finding the cancer may not benefit the patient. A decision analysis of treatment of men with asymptomatic prostatic nodules in general practice found that the men would be worse off if the prostatic nodule found on screening were evaluated and treated.(44) However DRE, which is cheap and non-invasive may be the least likely candidate for inappropriate use since social attitudes may inhibit widespread rectal examinations. The taking of a PSA blood test and the TRUS are likely to be more acceptable. Sladden and Dickinson have estimated that screening costs using these tests for the 1.5 million Australian men over 50 could be as high as $300 million dollars per year.(45) A figure, it should be noted which is 20 times the total existing cancer research budget.

Unfortunately, the potential conflict between a newly alerted public wanting to know if they have cancer and a properly cautious scientific community will not be solved through researching the effectiveness of the tests. The scientific gold standard required in such cases is provided by randomised control trials. Such trials are underway but, of necessity, require many years to complete. The European trials, testing different combinations of screening, will not be complete until the year 2000.

In the past, health authorities have been able to contain the use of screening tests by issuing guidelines to GPs and refusing to sponsor government funded mass screening. But the context of public health debate has changed. As noted above, our health culture is now one where men's health is highly visible and where articulate groups are promoting prostate awareness to a receptive public. We can see a possible future in developments in the United States. There, the proportion of patients with newly diagnosed prostate cancer who had the PSA test rose from 5.8 percent in 1984 to 68.4 percent in 1990.(46) Increasingly however, the combination of political, consumer and commercial pressures is sidestepping the scientific community to encourage testing with DRE and PSA in men without symptoms. Senate Minority leader Bob Dole was diagnosed with prostate cancer and has recovered. He sponsors a touring Bob Dole Prostate Cancer Detection Unit staffed by volunteer urologists and physicians which screens up to 2000 men at each site.(47) Free screening is also provided at other sites across the United States during Prostate Cancer Awareness Week (PCAW). This week has become the largest cancer screening program in the United States. Since 1989 an estimated 2 million men had been screened. The December 1992 issue of the Saturday Evening Post contained a tear out Christmas present centrefold - a gift certificate for a PSA test from the doctor of your choice.

For those hoping that Australian health policy would never be prey to such folly the recent developments in breast cancer funding must provide food for thought. The Commonwealth decision to establish a breast cancer foundation, bypassing the established NH&MRC review process, was made in the face of opposition from the Australian Medical Association, the Royal Australian College of Physicians, the Australian Cancer Society and prominent researchers and clinicians, including those working in the breast cancer area.(48) The announcement of the funding was made at the same time that a national Breast Cancer Week was announced.

Although our health system is based on different principles, the possibility is that older men who are wealthy or in positions of influence (General Norman Schwartzkopf, who was treated for prostate cancer, served as national PCAW chairman in 1994) will be favourably disposed to suggestions for specific research into prostate cancer. When a Perth businessman was diagnosed with prostate cancer recently, he began, with the help of local urologists, to raise money for research into prostate cancer. Within three years they had raised over $3 million dollars purely from business associates.

But breast cancer may also provide a positive model. The revised health promotion guidelines for breast cancer suggest that skilled counsellors be provided to women to assist with the unravelling of a complex health decision process. This concept could be borrowed for men concerned with prostate disease. Where the breast cancer advice was to be offered in relation to treatment (and the treatment decisions for men are not exactly simple either) the notion could be extended to cover all aspects of screening. On a larger scale the provision of spokespersons to advocate on behalf of men's health interests has not, to date, been seen as necessary. After all, most urologists are male. But without suggesting any inadequacy on the part of urologists, the idea that male medical specialists could speak on behalf of all Australian men flies in the face of current understanding of consumer rights. There are groups available. Apex and Rotary have been providing health education outside Cancer Council guidelines. They could be invited to join a co-operative educational approach to men's health. Male organisations, such as those represented on the prostate awareness committee, with little experience in health advocacy could be resourced and skilled to adequately represent men in health debates.

Concerns About Boys

The title "Men's Health" should be taken to include males of all ages. For boys, there is a growing awareness that both academically and socially, they are lagging behind girls. In recent years at the NSW Higher School Certificate girls have outperformed boys overall as well as in five of the six Key Learning Areas (boys are doing better in just one, mathematics). Girls also out perform boys in literacy at every level. Boys on the other hand, excel at being suspended from school (male/female ratio, 3:1), being convicted of drink driving (7:1), being killed through injury (2:1), committing suicide (4:1), binge drinking (1.5:1) and being referred for emotional and behavioural disorders (10:1).(49)

NSW led the world when it initiated a parliamentary inquiry into boys' education. The publication of the government report,(50) and the recent publication of Boys in Schools,(51) documenting initiatives in boys education in four states, have focused on the connection between schooling and the construction of masculinity. By "construction" is meant the way boys build a male identity for themselves from what is offered by schools, parents and society. The discovery of boys' education as an issue is both separate from, and overlapping with, men's health. As an issue of public concern it has a different, though parallel history. Like men's health, boys' education was first flagged not by governments or by senior bureaucrats but by front line teachers and parents worried about their sons. Like men's health, an initial reaction was to paint the expressions of concern for boys as a backlash, but the weight of public distress, and the common sense nature of the evidence that all is not well with boys, has meant that schools are actively rethinking their approach to boys and dragging their bureaucracies with them.(52)

The Task Before Us

The task for men's health is clearly different from that facing women in the 1970s. There is no widespread community anger to harness and replacing the few existing female health executives with males would not improve male health status. Rather, the understanding of men's health by those already in positions of influence needs to be addressed. Health planners and service providers have to be persuaded that neither men's nor women's health is superior, but that men's health merits closer attention. Men's organisations have to be resourced and encouraged to actively represent men and boys' views and interests. And men and boys have to be invited to join the dialogue on men's health, not simply by talking with professionals, but by talking with each other.

The Role Of The Commonwealth

At the time of writing the immediate steps to be taken by the Commonwealth have largely been taken. The Draft National Men's Health Policy was released on 18 January 1996. The four areas: education, information, research and consultation are the appropriate domains to be developing. It is also appropriate that the draft policy does not specify the precise topics for research, or the themes for educational development. The whole process, from staging a National Men's Health Conference to submitting a policy to the Australian Health Minister's Council in 1996 will have taken one year. This is in stark contrast to the 14 years between the first National Women's Health Conference and the National Women's Health Policy released in 1989.

Long term implications

An example of the shift in thinking implied by men's health was given at the first British men's health conference, Men's Health Matters, held in July, 1995 in London. Professor John Strang, Head of The Addiction Unit, The Maudsley Hospital, was asked to speak at the conference. Having agreed, he went to the data on heroin addicts, an area he had already analysed in terms of gender, but hitherto always looking for issues likely to affect females. He found, to his surprise, that the 2.5/1 male/female ratio in addicts was not due to a bias in male oriented treatment provision as was commonly assumed. Heroin overdose deaths, time to treatment, arrests and hepatitis B rates all indicated a genuine male excess. Furthermore he found that the recent epidemic of heroin use in England was almost entirely related to males. The male to female rate, which had been steady at 2.5/1 for ten years was now 3.5/1. The possibility that this might be a peculiarly male epidemic had not been raised in the discussions he had attended. He then asked: "How could we have failed to spot this gender effect? Are we still failing to explore powerful gender based protective factors?"

Revamping Commonwealth activities, in all likelihood, will begin with revelations such as this. Individuals working in drug abuse, workers compensation, road safety, welfare provision, housing, urban development, rural assistance, etc will begin advocating for attention to men. What will follow will involve research, some of it basic. Essentially, research of a quite practical nature will be required because a fundamental aspect of recognising male gender in such services is recognising the need to engage men in a discussion about their needs. The general research question is "What structures and processes will help men to discuss their needs with each other in order to clarify what these are, and then, how can these needs be articulated into the design and delivery of appropriate services?" This question is already being posed in the most obvious health area of prostate disease, as discussed above, but it is equally applicable to Commonwealth activities which fall outside of the health portfolio but which impact on men's health.

A personal dimension for politicians and staff(53)

Like most men in Australia, male politicians and male staff reading this paper will not have been encouraged to think of "men's health" as personally relevant. Equally likely, male politicians and male senior staff will think of their health as fairly good, but perhaps with concern for symptoms of prostate enlargement, high stress levels and elevated risk factors for heart disease. They will also, statistically speaking, be likely to have had some personal experience of relationship breakdown, in the role of husband, son, father, etc. and to know someone affected by drug abuse and domestic violence. They will undoubtedly have some memories of risk taking as a younger man.

It could be argued that an important task for the Commonwealth will be to assist these men to bring their personal knowledge's into the public arena in a way which validates the importance of men discussing health. This is not a call for public disclosures of personal information or for male politicians and other staff to be models of "sensitive new age guys" ("sensitive new age cowpersons" in rural areas). But it does suggest that males in leadership positions are not immune from the traps of social roles and cultural myths for males which Ian Ring described earlier.

In a variety of ways, through the development of men's health, Commonwealth programs will be asking men in the community to make changes. Men will be asked to make special efforts to resist harmful social pressures, including the pressure of what other men might think, and to re-evaluate the male identity they have developed which underpins their behaviours. It seems only fair to ask the designers and proponents of these programs to do the same.

Endnotes

  1. Australian Bureau of Statistics 1989-90 National Health Survey Lifestyle and Health Australia Catalogue No. 4366.0
  2. Mathers C. 'Health differentials between Australian males and females: a statistical profile'. Keynote address to the National Men's Health Conference 10,11 August 1995. Melbourne. These indicators, from mortality to health service utilisation, are the accepted sequence for comparing the health status of different groups. See for example the biennial health reports from the Australian Institute of Health and Welfare. Mortality is listed first as the most objective indicator, objective in the sense that the fact that someone is dead, in most cases, is not in dispute. And while there is variation, doctors are legally bound to register a cause of death in each case. However reliance on mortality and morbidity data has been criticised by women's health advocates as ignoring women's (often ignored) health needs. See for example Redman S, Hennrikus DJ, Bowman JA, Sanson Fisher RW. 'Assessing women's health needs'. Med J Aust 1988;148:123 27. This issue is taken up in the section on the Proudfoot case below.
  3. 'Age standardised' means the raw numbers have been adjusted to allow for different numbers of males and females in each age group in the population.
  4. Jorm AF, ed. 'Men and mental health: reference document'. Canberra: National Health and Medical Research Council, 1995.
  5. Australian Institute of Health and Welfare. Australian Health Indicators Bulletin, December 1994. No 2.
  6. Australian Institute of Health and Welfare. Australia's Health 1994. Canberra: AGPS, 1994.
  7. Ring I. Inequalities in health: the challenge for the nineties. The 1992 Elkington Oration. Brisbane: Epidemiology and Health Information Branch, Queensland Health, 1992.
  8. Frances R. Programs for men who are violent in the home. Melbourne: Department of Criminology The University of Melbourne, 1994.
  9. Clearihan L. Australian Family Physician 1993;22:1317.
  10. Health Department of Western Australia. Men's health: a Pilbara review. Port Hedland: Health Department of Western Australia, 1992.
  11. Webster P, Patterson M, Chin V, Sharp R. Testicular cancer self examination: report to the Apex foundation. Apex Foundation, 1992.
  12. Egger G, Bolton A, O'Neill M, Freeman D. 'Effectiveness of an abdominal obesity reduction program in men: The Gutbusters 'Waist Loss' Program' Int J Obes (in press)
  13. 'Linking Men's Services: a conference on men's issues and services in South Australia'. 7th & 8th March 1986. Noarlunga Health Services.
  14. The acceptance of 'men as norm' in health research and service delivery is two edged. It is now being recognised, with hindsight, that men are poorly served by a health system which assumes that male identity is irrelevant to health issues and that men and boys are doing fine. But equally important is the recognition, first argued by feminists but now accepted by mainstream researchers, that because males were taken as the norm, research, funding and treatment regimes were preferentially directed at males. The feminist critique of standard practice in medicine and health is voluminous. A recent (though US based) account is given by Nechas E,Foley D. Unequal Treatment.New York: Simon & Schuster, 1994 For an Australian summary article see Broom D. 'Masculine Medicine, Feminine Illness: gender and health' in: Lupton GM, Najman JM, eds. Sociology of Health and Illness Melbourne: Macmillan, 1989. For mainstream concurrence see for example Petticrew M, McKee M, Jones J. 'Coronary artery surgery: are women discriminated against?' B M J 1993; 306:1164 6 and on funding see Melbourne District Health Council. 'A sliver not even a slice: a report of a study of expenditure on women and health research'. Melbourne: Melbourne District Health Council, 1990
  15. See footnote 4.
  16. Better Health Commission Looking forward to better health. Vol 1 Final report. Canberra: AGPS, 1986.
  17. Health Targets and Implementation (Health for All) Committee to Australian Health Ministers 1988. Health for all Australians, report to the Australian Health Ministers Advisory Council and the Australian Health Ministers Conference Canberra: Australian Government Publishing Service, 1988.
  18. Leeder S. Warning: 'Death statistics can be a health hazard'. Med J Aust 1991; 155:357 8.
  19. Whitehead M. 'The concepts and principles of equity and health'. Health Promotion International 1991;6:21728.
  20. Health Targets and Implementation (Health for All) Committee to Australian Health Ministers 1988. Health for all Australians report to the Australian Health Ministers Advisory Council and the Australian Health Ministers Conference Canberra: Australian Government Publishing Service, 1988. .
  21. See footnote 19.
  22. Commonwealth Department of Health, Housing and Community Services. Towards Health for All and Health Promotion. Canberra: AGPS, 1993.
  23. Leeder S, Grossman J. 'A din of inequity' (editorial). Aust J Public Health 1991;15:24.
  24. Council on Ethical and Judicial Affairs American Medical Association. 'Gender disparaties in clinical decision making'. JAMA 1991;266:55962.
  25. See page 16 in this document. (Proudfoot & Ors v ACT Board of Health & Ors (1992) EOC 92-417).
  26. Transcript of proceedings. Tuesday 4th February 1992. Human Rights and Equal Opportunity Commission. Canberra: Auscript, 1992.
  27. Nutbeam D, Wise M, Bauman A, Harris E, Leeder S. Goals and targets for Australia's health in the year 2000 and beyond. Report prepared for the Commonwealth Department of Health, Housing & Community Services. Canberra: Australian Government Publishing Service, 1993.
  28. Yew L. Need JA. 'Women's health needs'. Med J Aust 1988;148:110 2.
  29. Commonwealth Department of Community Services and Health. National women's health policy. Canberra: Australian Government Publishing Service, 1989.
  30. Medical Benefits Fund of Australia. MBF Healthwatch Survey III Men's Health Issues. Sydney: MBF, 1995.
  31. Pilbara Public Health Unit Men's Health Project, Report, September 1994 Pilbara Public Health Unit 1994.
  32. Smith R. 'The Weaker Sex', Time Australia December 12, 1994:56 61.
  33. Moore R. 'Targeting men's health - what does it mean for women's health?' Healthsharing Women 1994; August September:5 6.
  34. Norman J. Men's health scandal. Penthouse 1994; February:34 36,96,98.
  35. This is a brief summary of an enthusiastic debate with direct policy implications. See for example Packwood B. 'Oregon's bold idea' Acad Med 1990:632 3. A more pragmatic measure than QALY's is the DALY. It still has problems but see The World Bank. World development report 1993: investing in health New York Oxford University Press, 1993.
  36. Proudfoot & Ors v ACT Board of Health & Ors (1992) EOC 92-417 at p. 78,984
  37. The People's Equality Network in Victoria and some 'men's rights' organisations in Western Australia seem to be taking this line.
  38. Dorothy Broom, who testified for the respondents in the Proudfoot case has recently been proposing a new approach to men's health for women's health advocates. See Broom D. 'Rethinking gender and drugs'. Drug and alcohol review 1995; 14:411 15.
  39. Newcastle Herald 1994; Febuary 22:3 But see note 14 above. In cancer as in every other health area it is men's diseases which have, overall, received more attention even though the funding was not tagged as 'men's health'.
  40. Adami H, Baron JA, Rothman KJ. 'Ethics of prostate cancer screening trial'. Lancet 1994;343:958 60.
  41. Fleming WB. The cancer related health check up. 'A guide for medical practitioners'. Med J Aust 1985;143 (special. supplement)S33 S40.
  42. American Cancer Society. 'Defining and updating the American Cancer Society guidelines for the cancer related check up: prostate and endometrial cancers'. CA 1993; 43:42 6.
  43. Chodak GW, Schoenberg HW. 'Progress and problems in screening for carcinoma of the prostate'. World J Surgery 1989;13: 60 4.
  44. Mold JW, Holtgrave DR, Bisman RS, Marley DS, Wright RA, Spann SJ. 'The evaluation and treatment of men with asymptomatic prostate nodules in primary care: a decision analysis'. J Family Pract 1992 ;34:561 68.
  45. Sladden M, Dickinson J. 'Effectiveness of screening for prostate cancer'. Aust Fam Phys 1993;22 :1385 92.
  46. Mettlin C, Jones GW, Murphy GP. Trends in prostate cancer care in the United States, 1974 1990: 'Observations from the patient care evaluation studies of the American College of surgeons commission on cancer. CA Cancer' CLIN 1993; 43:83 91
  47. SerVass C. 'Men: don't sit on the problem' Saturday Evening Post 1992; November/December :50 55,97 99.
  48. Ragg M. The Australian 22/4/1994:11
  49. Fletcher RJ. Boys education strategy 1995? Newcastle: University of Newcastle, 1994.
  50. NSW Government Advisory Committee on Education , Training and Tourism. Report on the inquiry into boys' education 1994.
  51. Browne R, Fletcher R, eds. Boys in schools Sydney: Finch, 1995.
  52. Just as in the men's health debate, the media instinctively reach for a battle of the sexes metaphor in reporting boys' troubles. But as well, the schooling debate is skewed by an elitist concern with university entrance scores. School teachers and parents are particularly concerned with the majority of boys who will not be going to university, who lack of motivation to do just about anything, or who harass girls and attack each other. Media reports however emphasise the tertiary entrance score differences, which, in any case, are minor compared to the differences between high and low socioeconomic groups or between indigenous and non indigenous students.
  53. Women are also complicit in the construction and reinforcement of cultural myths about males and masculinity, so female politicians and staff will have a role to play in developing a new Commonwealth culture which recognises male gender too. But many women will be already familiar with the notion of integrating their personal knowledge with their work related knowledge and historically it has been women, rather than men, who have argued for gender to be a public issue. Experience in the community has shown that when a gender issue is addressed to 'people' or 'staff' the women readily respond while the men see it as a 'women's issue'. Finally, males predominate among politicians and senior staff, hence the address specifically to males.

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