Is masculinity really such an obstacle to men seeking help for prostate cancer?

Jan 23

It was very welcome news a few days ago that “NHS prostate enlargement page visits [were] up 1,000% after King Charles' diagnosis”. At the same time, the charity Prostate Cancer UK saw a 97% increase in visits to their online risk checker. So although it is a difficult time for King Charles, at least the publicity is benefitting other men.

But wait a second – we are often told that men are reluctant to seek advice about their health, so then why would a news story about prostate cancer cause a stampede of men to check themselves for cancer symptoms? Let’s explore this conundrum with another real-world example.

Recently, the US Secretary of Defence experienced a “firestorm of criticism” for not disclosing that he was having surgery for prostate cancer. He got a post-operative infection which kept him off work for several days, and the news outlet USA Today made several suggestions for his lack of communication. One suggestion was that men might not talk about prostate cancer because it’s a deeply personal condition, being related to extremely uncomfortable issues such as erectile dysfunction and urinary incontinence. This point couldn’t be more self-evident, and if you doubt it, then think for a moment about how comfortable you would be talking with your father or grandfather about these things.

Clearly there is stigma and shame because prostate cancer may impact a man’s sexuality, fertility, mental health, and everyday quality of life e.g. driving a car, staying active, holding a job etc. Similarly, women feel stigma and shame when something impacts them so personally too e.g. miscarriage. When women talk about these things, they rightly expect people to listen with sympathy and offer help. They don’t expect to have their painful feelings blamed on their femininity – that would be to heap further shame on them, and almost certainly be called out as ‘victim-blaming’.

“…why say masculinity is to blame? This too easily comes across as blaming men, adding to the shame they might already feel about the embarrassing problems related to prostate cancer.”

But the explanation USA Today focused on most regarding the Defence Secretary’s lack of communication was that “men commonly struggle with sharing weaknesses, in part, due to our culture's view of masculinity, even when it comes to important health matters”. In a later section the article continued: "Masculinity is, in part, based on self-efficacy”, and talking about losing control of your bladder or having sexual problems “can really impact men's self-esteem […] it really feels like talking about a very vulnerable part of yourself", which can be shameful and impact self-worth. That makes sense up to a point, but if self-efficacy, self-esteem, vulnerability, shame and self-worth prevent men from talking about health problems, then unless all of these are specifically aspects of masculinity, then why say masculinity is to blame? This too easily comes across as blaming men, adding to the shame they might already feel about the embarrassing problems related to prostate cancer.

The idea that masculinity causes men to neglect their health problems was popularised originally in the US, but has become embedded in many parts of UK academia, government and the media. In fact you could say the idea that masculinity causes men to neglect their health is one of the most pervasive stereotypes about masculinity in our culture today. Even the job description for the new role of Ambassador for Men’s Health talks about“the association between traditional notions of 'masculinity' and a reluctance among men to seek help for physical and mental health needs”, implying that such and association is a given rather than a hypothesis to be properly tested. This is unfortunate because the hypothesis that masculinity has health benefits is routinely ignored in academia, government and the media, and a Men’s Health Ambassador would be in a unique position to do something positive about this.

As stated in Centre for Male Psychology’s submission to the UK government’s inquiry into men’s health: “This popular misconception exists despite evidence that masculinity is either unrelated to preventative health behaviour, or even has a beneficial effect on general health and mental health for men.” The typical explanation is that a masculine sense of self-reliance means that men tend not to seek help because it makes them look weak, but an evaluation of the evidence for this shows this link to be weak.

Let’s put psychological factors, such as masculinity and self-esteem, to one side for a minute, because there are several much more obvious and concrete barriers to men seeking help, none of which are directly caused by masculinity.

“For many men with prostate issues, they don’t notice any symptoms and don’t talk about symptoms because they have never been told by anyone what the symptoms are. [Also] in many cases the symptoms are subtle”.

Let’s first think about the King Charles effect. What does it tell us? It tells us that for many men prostate cancer wasn’t on their radar, until it appeared under their noses as headline news. It also suggests that once it is on their radar, they do something about it. For many people King Charles will be a positive role model, so this might have helped too.

So was the lower number of visits to the cancer symptoms page previous to the King Charles story caused by masculinity, or was it maybe caused by a relative absence of any public information about prostate cancer? For many men with prostate issues, they don’t notice any symptoms and don’t talk about symptoms because they have never been told by anyone what the symptoms are. In contrast, although breast cancer awareness has been the subject of a huge number of large-scale health promotion campaigns since the 1980s, the same is not true for prostate cancer. You can’t blame masculinity for a man not knowing about something he has never heard about.

Perhaps one reason for the lack of discussion of symptoms of prostate cancer is that in many cases the symptoms are subtle (you can check the symptoms here). There aren’t any noticeable lumps. In a small minority of cases there may be blood in urine, be this might go unnoticed too. So even if men talk very freely about prostate cancer symptoms, they might not see any symptoms, thus not see the need to be tested for it.

So why, unlike breast cancer, is there is no routine prostate screening for men? After all, similar numbers of men and women die of these cancers. So although women in the UK receive an invitation for screening by post every three years from the age of 50 to 71, and breast screening has been a basic standard of healthcare for decades, there is no equivalent provision for men regarding prostate cancer.

If we are serious about men seeking help for prostate cancer, not only should there be a systematic screening programme for them, but the screening needs to be effective. It is sometimes said that men are ashamed to have a rectal examination. This is probably true to some degree, and is certainly the source of nervous humour among teens and younger men. However this is less the case for the mature men of the age who are impacted by prostate cancer, and for whom the rectal examination is not a serious barrier. But there are valid concerns that impact men’s willingness to undergo tests. For example, one of the first steps to diagnosis is the prostate specific antigen (PSA) blood test, but it is well known that it is unreliable, and may either miss the presence of prostate cancer, or wrongly suggest prostate cancer is present. Tests such as biopsies can be invasive and painful.

Whether the PSA gives a false positive or not, subsequent treatments may have a major physical and psychological impact on about half of men diagnosed. For example, androgen deprivation therapy (ADT) can lead to temporary and sometimes permanent erectile dysfunction and urinary incontinence as well as other effects, including retrograde ejaculation (‘dry orgasm’) and shortening of the penis, and mental health problems too.

But there is some good news here too: there is currently a clinical trial of improved prostate cancer screening methods, which aims to “provide definitive evidence for the best way to screen for prostate cancer so that, in future, all men at risk will be invited for regular tests”.

When regular effective screening for prostate cancer becomes the norm, I predict that – with access to information - men will attend screenings. In the meantime, I would like to suggest that blaming masculinity doesn’t solve any problems and diverts attention away from exploring realistic solutions. I would suggest that people learn about how masculinity might actually be related to many positive aspects of men, including help-seeking for physical and mental health issues. There is already research evidence out there, though unfortunately also a tangible reluctance for academics to recognise this fact or explore it further, let alone celebrate it.

You can check your risk of prostate cancer in 30 seconds here at the Prostate Cancer UK website. If you want to find out more about male psychology and mental health, see details of the Centre for Male Psychology’s online course.

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