They're overweight, over-stressed and never go to the doctor. In the first part of a six-week guide to men's health, Rob Stepney examines why men ignore the warning signs; 'Men tend to have less emotional involvement, perceiving their bodies as machines which occasionally need fixing. It is more difficult for men to take on the sick role, which conflicts with society's stereotype of male behaviour'
When Lewisham's first Well Man clinic opened a year ago, the provision of free condoms was the lead item in leaflets advertising the service. The offer of a general health check, thought to be something of a turn-off for men, was well down the list. But the hundred or so men who attended the Friday evening clinic over its first six months have brought the idea of a personal MOT to the top of the publicity agenda.

The Lewisham experience shows that some men are not averse to the kind of check-up long familiar to women. Nevertheless, it is a telling point that the Well Man clinic was established as a result of pressure from women.

"We run large Well Woman clinics," says Lindy Bashford, manager of the Lewisham Open for Men initiative. "We found women saying they wished something similar was available for their partners, who they felt wouldn't see a doctor until they were actually ill. In response to that we closed an under-utilised family-planning session and diverted money into the Well Man service."

The men of Lewisham are privileged. Their clinic is one of only five in the country. And this is despite the fact that the Government's document on the state of the public health, published four years ago, identified the reduction of illness among men as a national priority.

Men may not have a clinic to go to once they have woken up to the fact that their bodies are not self-servicing, but they do have the advantage of birth: there are 105 boys born to every 100 girls. From then on, however, the survival stakes are firmly stacked against them. Birth defects are more common among males and the life expectancy of a boy is a good five years less than that of a newborn girl. One reason for the higher rate of premature death is biological: men lack the oestrogen that seems to protect pre-menopausal women against heart disease. But much of the damage is self-inflicted.

The widest gap in death rates occurs between the ages of 15 and 30 - a period when men are more than twice as likely as women to die. Accidents, suicide and (to a lesser extent) Aids are the factors most responsible. Accidental death, frequently associated with drink and driving, reflects what Dr Ian Banks, a Northern Ireland GP, describes as a "James Dean attitude to self-preservation". Risk-taking is a traditional male trait. But the high and rising rate of suicide among young men, which accounts for one in five deaths in this age group, is more difficult to explain.

"We suspect it is due to factors that are mostly psychologically conditioned," says Dr Banks. "Women are better than men at expressing depression and so turn less to suicide. They also have a social network allowing them to discuss their emotions." Denied other avenues of expression, men's negative feelings are more likely to find outlet in aggression, alcohol and drug abuse, and, ultimately, in suicide.

A second bulge in male mortality occurs between the ages of 55 and 70, when a lifetime's smoking shows up as lung cancer, as well as continued high rates of heart disease. But the gender gap in mortality at these ages is likely to narrow over the next decade. The proportion of men smoking has fallen to around 30 per cent, little more than the figure for women. The trend in male lung-cancer deaths is now downward, while that for women is rising steadily. On the other hand, excessive drinking is more than twice as common among men as women.

It is not just a propensity for risk-taking and high living that contributes to ill health and early deaths. Men simply resist seeking medical advice. Even when family planning and pregnancy are discounted, women use GP services far more frequently than men. Women consult about means of prevention; and they consult early with problems. Most men, it is believed, are reluctant to report symptoms that conflict with a self-image of strength and fitness, and have difficulty accepting the loss of control that follows the admission of illness. A recent study from the University of Exeter suggests such ideas are deeply rooted. Among 12-year-olds, twice as many boys as girls say they would not discuss a health problem with anyone.

"Men and women have different perceptions of health," says Peter Williamson, of the East Midlands Men's Health Network. "Men tend to have less emotional involvement, perceiving their bodies as machines which occasionally need fixing. It is more difficult for men to take on the sick role, which conflicts with society's stereotype of male behaviour."

These problems are well reflected in last year's publication The Crisis in Men's Health, produced by five men who came together in 1991 to form a men's health awareness project. "We are so detached from our feelings and bodies that we don't notice the danger signals," they write. "Hiding from the messy, physical reality of their lives, many men focus their energy on external goals in the public sphere." Where men do pay attention to their bodies, they do so in a simplistic way. "Working out at the gym, body-building and jogging can become quick-fix activities which have their own dangers," the report argues.

Gay men may have something to teach the wider male world about maintaining health. "Many gay men find it easier to express personal needs and seek help quickly either within their community or from health services. They also have a more effective social support network," says Peter Williamson. This instinct towards openness has been amplified by 15 years' experience of dealing with HIV and Aids; and the gay community could act, and arguably already has acted, as a catalyst for change in the health attitudes of male society as a whole.

For the moment, though,seeking help is still seen as unmanly. "I'm here because my wife said I should come," is not an uncommon preface to GP consultations. But, according to Dr Banks, even when a man does manage to get himself to a doctor, his overall health may still be disregarded. Male doctors, he argues, are the worst proponents of men's health.

"If a woman comes into surgery with a sore ear but the conversation turns to cancer, it is normal for the doctor to examine the woman's breasts and to teach her self-examination. If a man comes in with a sore ear, unless he specifically wants you to examine his testicles for signs of cancer, that will not happen," Dr Banks says. "In effect, the male doctor colludes with a male patient in not doing a commonsense check."

GPs are now being encouraged to undertake some forms of routine screening with male patients. "When a woman comes for a smear or advice on contraception, we would routinely measure blood pressure and do a dipstick test for sugar in the urine," says Dr Andrew Surawy, a GP from Battersea, south London. "But we would now suggest such opportunistic screening with many men."

At last, then, interest in men's health may be moving away from the commercial. The saturation of the women's cosmetics and health market made men an obvious target and three men's health magazines, Men's Health, Maxim and XL, combining advice with glossy fashion and workouts and even recipes, have sprung up in the last year. Men's Health, which is upping publication from the current six to 10 issues a year, now has a greater emphasis on genuine health matters, rather than body image, and late next month BBC TV and radio begin a season of programmes on "The Trouble with Men". The interest targeted at, and generated by, white middle- class males is being replaced by a grass-roots interest in men's health. The Men's Health Networks taking hold across the country are as likely to be found in Chesterfield and inner-city Glasgow as in leafy suburbia.

This new broad-based interest, coupled with changes in GP attitudes towards health promotion, may do something to tilt men towards better health. But wider social factors are set to thwart improvements. First, evidence suggests that men who live alone (especially the divorced) suffer more ill-health than those who live with a female partner. With rising rates of family break- up, more men than ever are sailing solo through much of their lives. Second, employment trends are not conducive to better health. While one in 10 men has no job at all, many of those in work do the job of two. "Excessive employment demands promote physical and psychological ill-health and discourage early action to resolve problems," says Dr Surawy, who has noticed increasing levels of stress in the past few years among his male patients. "With a work culture in which only the fittest survive, no one will admit to weakness."

Meanwhile, in a society which has not yet accepted that breadmaker can be as valid a male role as breadwinner, evidence continues to accumulate showing that lack of a job destroys masculine self-esteem and undermines health. Dr Tony Delamothe, deputy editor of the British Medical Journal, has a long-standing interest in poverty and illness. "To the effects of unemployment itself you have to add those of deprivation," he says. "The holes in the safety net are getting bigger. Many men pay the price of increasing social inequality with their health. Some are paying for it with their lives."

'The Crisis in Men's Health' is obtainable from Community Health UK, 6 Terrace Walk, Bath BA1 1LN (01225 462680).