Across a broad range of indicators, men report poorer health than women. Although men in all socioeconomic groups are doing poorly in terms of health, some especially high-risk groups include men of low socioeconomic status (SES) of all racial/ethnic backgrounds, low-SES minority men, and middle-class Black men. Multiple factors contribute to the elevated health risks of men. These include economic marginality, adverse working conditions, and gendered coping responses to stress, each of which can lead to high levels of substance use, other health-damaging behaviors, and an aversion to health-protective behaviors.

The forces that adversely affect men’s health are interrelated, unfold over the life course, and are amenable to change.

This section provides a brief overview of the health status of men in the United States and compares it with that of women. Making these gender comparisons in no way denies or minimizes the historic and ongoing systems of exploitation that have adversely affected women in general and women of color in the United States,4–6 or the pressing need to reduce health and social inequalities for women.7 Women continue to be disadvantaged on multiple social dimensions, and women of color continue to experience disparities for multiple indicators of health.8,9 Nonetheless, the health status of women provides a potentially achievable benchmark for the health of men in contemporary society.

Age-adjusted mortality rates for the 15 leading causes of death in the United States for the year 1999 reveal that, except for Alzheimer’s disease, men have higher death rates than women.10 For both African Americans and Whites, the 2 racial groups for which these data are available, men have death rates that are at least twice as high as those of women for accidents, suicide, cirrhosis of the liver, and homicide.

Contrary to the view that men die younger than women but women have higher levels of illness than men, national data on morbidity suggest a more mixed pattern. Slightly more women (9.4%) than men (8.8%) report that they are in fair or poor health, and comparable numbers of men (12.6%) and women (12.4%) report activity limitations due to chronic disease.11 In contrast, the prevalence of hypertension is 1.2 times higher for men than women, and the incidence of cancer is 1.3 times higher for men than women.11

TABLE 1 —Age-Adjusted Death Rates (per 100 000) for Men (M) and Women (F) Aged 25 to 64 by Years of Education, 1998

Men who belong to racial and ethnic minority populations are another high-risk group. The term “crisis” has been used to characterize the markedly elevated rates of morbidity, disability, and mortality of minority men compared with their White counterparts.14 These disparities are especially marked for African Americans. It is also noteworthy that the pattern of gender differences in mortality and morbidity is consistent for African Americans and Whites.10,11 African Americans have poorer health than the rest of the US population and are exposed to a broad range of social and environmental factors that adversely affect their health. However, both minority men and women are exposed to adverse pathogenic characteristics linked to SES and minority status. The health profile of men suggests that additional health risks are linked to masculinity as well.

The Pitt County, North Carolina, study of African Americans also reported a weak association between SES and hypertension in combined analyses of men and women.18 Intriguing gender differences were noted between SES and risk factors. SES was inversely related to self-rated ill health, cigarette smoking, alcohol consumption, high economic strain, and low emotional and instrumental support for both men and women.18,19 However, while SES was inversely related to stress for African American women, it was positively related to stress for African American men.18,19 This elevated level of psychosocial stress among middle-class African American men may contribute to their increased hypertension risk.20

The stressors faced by middle-class African American males may also account for the pattern of suicide risk. For both African Americans and Whites, rates of suicide are much higher for males than females. Over the past 2 decades, the suicide rate has remained relatively stable for White men but has strikingly increased for young African American men.21 Several studies have found that while SES is inversely related to the suicide rate for Whites, it is positively related to the suicide rate for African American males.22–25

Three factors may underlie the higher level of stress and its adverse consequences on middle-class African American men. First, exposure to racial discrimination is an added burden faced by middle-class African American men, and these perceptions of discrimination are stressors that can adversely affect physical and mental health.26,27 There is a positive association between perceptions of discrimination and education among African Americans, and African American men report higher levels of chronic and acute discrimination than African American women.28

Second, middle-class status is often recent, tenuous, and marginal for African Americans.29–31 College-educated African American are 4 times more likely than Whites to experience unemployment.32,33 Middle-class African Americans have markedly lower levels of wealth than Whites of similar income34 and are often active in the provision of material support to poorer relatives. They are also less likely than Whites of similar income to translate their higher economic status into desirable housing and neighborhood conditions.35 Not surprisingly, one recent study found that while suburban residence was associated with lower mortality risk for Whites, it was predictive of markedly elevated mortality risks for African American men.36

Third, expectations that are unfulfilled because their investment in education has not provided parallel gains in income may be a unique source of stress and alienation for African American men.23,31 Educational attainment is an important indicator of lifetime economic opportunities, with higher levels of education being associated with higher wages, higher family income, and lower unemployment.33 Over the last several decades, educational attainment has increased for African American males and other Americans. Although racial disparities in education still exist, there is only a narrow gap in educational attainment between African American and White men aged 25 to 29.33 However, African American men have experienced less success than others in translating higher education into improved economic circumstances. At every level of education, minority men earn lower levels of income than Whites, and differences in pay between Whites on the one hand and African Americans and Hispanics on the other are larger for men than for women.33

Moreover, trend data indicate that although African American men’s earnings rose relative to those of White men between the early 1960s and the mid-1970s, the trend reversed in the mid- to late 1970s, and African American men’s relative pay declined over the next 2 decades.33 The relative pay of collegeeducated African American men compared with White men fell by more than 10 percentage points between 1979 and 1997, while college-educated Hispanic men lost little ground and earn more than collegeeducated African American men.33

What are the factors responsible for the higher rates of morbidity and mortality among men? Beliefs about masculinity and manhood that are deeply rooted in culture and supported by social institutions play a role in shaping the behavioral patterns of men in ways that have consequences for health. Men are socialized to project strength, individuality, autonomy, dominance, stoicism, and physical aggression, and to avoid demonstrations of emotion or vulnerability that could be construed as weakness.37,38 These cultural orientations and structural opportunities combine to increase health risks.

Men are overrepresented in a broad range of stigmatizing social conditions, such as incarceration, homelessness, unemployment, and institutionalization for substance use and severe mental illness, that reflect social exclusion and separation from the labor market. Eighty-nine percent of the over 600 000 jail inmates and 94% of the 1 million prisoners in state and federal penitentiaries are men.40 Men are also more likely to be homeless, and to be homeless for longer periods of time than women.41,42 Individuals who have less education, who have mental health and substance abuse problems, and who had been incarcerated also tend to be homeless longer than persons without those characteristics.42 Over 1 million clients received treatment at drug or alcohol treatment facilities in the United States in 1998, and 69% of them were men.40

Over the last 50 years, the unemployment rate has been twice as high for African American men as for their White counterparts, and the unemployment rate for African Americans and Hispanics tends to rise more during economic recessions.33 During the last half of the 20th century, labor force participation rates (employed or actively seeking work) declined in general for men and markedly for African American men.33 Among men aged 16 to 24, African Americans are 2.4 times as likely, and Hispanics are 1.8 times as likely, as Whites to be neither employed nor in school.33

Current trends suggest that the challenges for men with employment security are likely to worsen. The share of workers who are employed by temporary agencies has been growing in recent years, and the number of poverty-level and low-wage jobs is also on the increase.43 Relatedly, there is a global expansion of precarious employment.44 Precarious employees are part-time and temporary workers, workers subject to organizational change (workplace restructuring, downsizing, privatization, and corporatization) that leads to job losses and job insecurity, workers in outsourcing and home-based arrangements, and employees of small businesses.

Between 1973 and 1996, these changes in the nature of work led to stagnation or decline in the wages of men in the bottom two thirds of the income distribution, even as overall per capita income was increasing.45 Importantly, precarious employment is associated with worsening occupational health and safety in terms of injury rates, disease risk, and hazardous exposures.44 Poor African American and Hispanic men are also employed disproportionately in jobs with higher rates of layoffs and lower rates of reemployment after job displacement.21

Research reveals that unemployment and job insecurity are associated with elevated rates of stress, illness, disability, and mortality.40 Some of these effects are evident as soon as employees perceive that their jobs are threatened, with persons who are laid off reporting higher levels of stress, illness, and disability than those who keep their jobs.43 A study in Harlem showed, for example, that men who were not employed, who had a history of not having steady work, and who had a history of homelessness were more likely to be hypertensive and more likely to smoke than men who worked full-time and who had steady work.17

Health status changes for men following the collapse of the Soviet Union in 1991 dramatically illustrate how economic marginality can adversely affect health. In the wake of increased inflation, unemployment, and reduced wages,46 life expectancy for men in Russia declined by 6 years between 1991 and 1994.47 The increases in mortality were largest for middle-aged urban males in manual occupations and for those with the lowest levels of education.47

The specific conditions of work that are more likely to lead to poor health are the combination of high job demands with little control over them49 and the combination of high levels of effort with low levels of reward.50 Persons who have low occupational status at work often face elevated levels of stress in nonwork contexts as well.51 Moreover, the combination of these 2 sources of stress with other risk factors, such as social isolation and poor diet, can lead to altered functioning of neuroendocrine stress pathways that can adversely affect health.51

Stressors and the negative emotional states created by them can also lead to health behaviors such as impaired sleeping patterns, decreased physical activity, increased substance use, and the consumption of more food than usual, all of which can increase the risk of chronic diseases.52 In the Whitehall Study, good health practices were positively associated with occupational grade, but health behaviors accounted for only a small part of the variation in heart disease risk for men.51 In contrast, perceptions of control in the workplace accounted for more than half of the variation in the incidence of heart disease.53

Desirable occupational opportunities are differentially distributed by race. Relatively high percentages of White and Asian men are employed in managerial and professional occupations, while African American, Hispanic, and American Indian men are overrepresented in lower-skilled and lower-paid occupational categories such as operators, fabricators, and laborers.33 Since the 1970s, earnings for low-skilled men have deteriorated markedly. The African American, Hispanic, and American Indian men who are overrepresented at the low end of the earnings distribution have also been disproportionately affected by the earnings decline.33 The jobs in which low-SES men in general and minority males in particular are disproportionately concentrated are jobs that are characterized not only by low levels of income but also by high levels of stress (high demands and effort with low control and rewards).

Minority men also tend to be concentrated in jobs that pose high levels of exposure to pathogens in the physical environment. For example, agriculture is one of the most hazardous employment sectors for occupational injuries and deaths, and agricultural employers are exempted from many government workplace regulations that apply to other industries.54 Men in general, and Hispanic men in particular, are overrepresented among hired farm workers in the United States. Sixty percent of farm workers earn so little that their families live in poverty. Similarly, even after education and job experience are adjusted for, employed African Americans are more likely than their White counterparts to be exposed to occupational hazards and carcinogens.55,56

Cultural scripts that contribute to gender differences in responses to stress also lead to gender differences in specific types of illness. Although there are no gender differences in the overall prevalence of psychiatric disorders, women in many societies have higher rates than men of internalizing disorders (feelings are focused on self) such as depression and anxiety, while men have higher rates than women of externalizing disorders (emotions are expressed in outward behavior) such as alcohol, drug abuse, and antisocial behavior.60

Substance use (tobacco, alcohol, other drugs) is one externalizing coping response to high levels of stressors. People often turn to alcohol and drugs to escape adversity and numb the pain of negative social and economic conditions. Research from animal and human studies indicates that stress is a major contributor to the initiation of substance use and to the continuation of addiction to alcohol and other drugs, as well as to relapse.61 Exposure to stress may also underlie the pattern of racial differences in substance use over the life course. African American adolescents have lower levels of use of marijuana, alcohol, cigarettes, and binge drinking than Whites and Hispanics.62 However, although African American adolescent substance use begins at later ages, once initiated, heavy use continues for a longer time.21 The transition to adulthood for African Americans may be associated with heightened awareness of restricted opportunities that may lead to increased levels of stress in early adulthood and maladaptive patterns of coping.

The greater proclivity of men to use alcohol and drugs as a strategy to cope with stress is costly to them individually, as well as to their families and society. A comprehensive report on substance abuse outlined several reasons why it is America’s number one health problem.63 First, alcohol is a central cause of premature mortality and a major contributor to deaths from cirrhosis of the liver, accidents, suicide, and homicide—the causes of death where gender differences are most marked. Alcohol is responsible for almost half of cirrhosis deaths, traffic fatalities, and other accidents.

Second, the use of illicit drugs also has a marked effect on the health of men, especially minority men, through deaths directly related to illegal drugs, as well as through associated conditions such as HIV/AIDS, hepatitis, tuberculosis, falls, motor vehicle accidents, and homicide. Third, in addition to being a serious financial drain on a family, substance abuse is also a major cause of family problems, including divorce, separation, marital violence, child abuse, emotional and adjustment difficulties for children, and the increased risk of children, especially boys, becoming a substance abuser as an adult.

Fourth, substance use has a major impact on increasing health care costs. It is estimated that 25% to 40% of all general hospital patients are hospitalized because of complications related to alcohol use. Fifth, substance use is also a major determinant of crime. At least half of all persons arrested for major crimes such as homicide, theft, and assault were using illegal drugs at the time of their arrest and about half of the persons convicted of violent crime were under the influence of alcohol or drugs at the time the crime was committed. Finally, substance abuse often leads to lower levels of income and occupational mobility. Moreover, compared with Whites, African American and Hispanic adolescents and adults experience higher levels of the negative mental, physical, and social consequences of substance use even when their overall levels of use are lower than or similar to those of Whites.62

Men also tend to have lower levels of adherence to medical regimens than women.64 These differences are pronounced for vulnerable subgroups of men. Compared with their higher-SES peers, low-SES men have lower levels of health information, and individuals dealing with high levels of stress tend not to make prevention and management of chronic disease a priority.52,65 Moreover, high levels of stress have been shown to reduce the efficacy of many pharmacological agents.66 Not surprisingly, African American men aged 18 to 49 have the lowest rates of awareness, treatment, and control of hypertension of all age, race, and gender groups in the United States.64

Health care institutions and practitioners also respond differently to men and women. For example, in the emergency room, men with depressive symptoms (inconsistent with gender norms) are more likely to be hospitalized than women with the same symptoms, and women with antisocial behavior or substance use problems are more likely to be hospitalized than men presenting these symptoms.60 In addition, compared with Whites, minority men and women receive less intensive and poorer-quality medical care for a broad range of medical conditions.67

There are also large gender differences in the typical medical encounter. Health care providers spend less time with men than women; provide them with fewer services, less health information, and less advice; and are less likely to talk about the need to change behaviors to improve health.37 One study found that physicians were 3 times more likely to routinely provide instruction to age-appropriate women on breast selfexamination (86%) than to age-appropriate men on testicular self-examination (29%).68

The forces that affect the health of adult men often begin early in childhood. Early childhood exposure to poor social and economic conditions not only adversely affects child health and growth, but it sets the child on a low education and economic trajectory that increases the risk of poor physical and mental health in adulthood.71 For example, high rates of unemployment, poverty, violent crime, incarceration, and homicide among African American adult males reflect the cumulation of disadvantage at multiple transition points during their development.

Iron deficiency, fetal alcohol exposure, low birthweight, and exposure to lead are examples of conditions during infancy and childhood that contribute to poor health by placing the child on a trajectory of poorer cognitive functioning and low educational performance.21 There are marked SES and racial/ethnic differences for all of these factors. The experience of early abuse is another risk factor in childhood and adolescence that has pervasive adverse consequences. Abuse in childhood predicts poorer school achievement in childhood and adolescence and lower educational and occupational attainment in adulthood.72 Adolescent victims of abuse have lower educational aspirations and efforts as well as lower educational attainment, occupational status, and earned income as adults compared with individuals who did not experience abuse.72 Moreover, victimization in adolescence is predictive of future violent and nonviolent criminal behavior and substance use.72

Thus, growing up poor is associated with multiple adversities that lead to less readiness for school and poorer school achievement. There is little variation in parents’ expectations and aspirations for their children, even in the most economically disadvantaged neighborhoods.73 However, there are large variations in the availability of resources and in parents’ knowledge and expertise in navigating the social system to maximize opportunities for their children. There are also large variations in the quality of schools.74 High-risk children are more likely than others to attend poor-quality schools in disadvantaged neighborhoods where their vulnerabilities are further reinforced. These schools have more deteriorated buildings, fewer qualified teachers, more limited curricula, little serious academic counseling, fewer connections with colleges and employers, and higher levels of teen pregnancy.

These conditions can give rise to peer pressure against academic achievement and in support of crime and substance use. This combination of student and school characteristics leads to higher rates of dropping out of school and inadequate preparation for college and the labor market for those who remain in school.71 The path toward lower socioeconomic attainment and poor health status is further exacerbated by the structure of the labor market. In the last 4 decades, there has been a large out-migration of high-pay, lower-skilled jobs from the urban areas where poor African Americans are concentrated.75,76 The absence of employment opportunities for males leads to high rates of male joblessness, and prospects of low earnings in the legal job market can enhance the attractiveness of illegal activities.

Research reveals that the economic marginalization of African American males (high unemployment and low wage rates) is the central determinant of the high rates of female-headed households among African Americans.77–80 In 1960, two thirds of African American children were living with both parents, compared with 38% in 1999.81 In contrast, 82% of Asian children, 78% of non-Hispanic White children, 63% of American-born Hispanic children, 73% of foreign-born Hispanic children, and 55% of American Indian children lived with both parents in 1999.82 Male labor market earnings are the largest source of household income in the United States.33 Thus, the combination of low earnings for African American males with low pay for African American women leads to high rates of poverty for African American children.

Research reveals that levels of supervision of children are lower in single-parent households.80 For both African Americans and Whites, being raised in a single-parent home is the key determinant of increased risk of juvenile delinquency and participation in violent crime.80 Moreover, compared with children raised by 2 parents, those raised by single parents are more likely to grow up poor, drop out of high school, and be idle during their late teens and less likely to enroll in college.83

McLoyd and Lozoff21 further indicate that marked increases in African American male violence in recent decades coincided with increases in unemployment, the percentage of young African American male high school dropouts with no reported earnings, the use and trafficking of crack cocaine, and declines in the real earnings of young African American males, absolutely as well as relative to Whites. These processes unfolded in areas of concentrated poverty that were created by larger societal policies,84 at the same time that there was a shift in federal drug policy and a decline in federal spending on drug treatment.21 Moreover, aggressive and discriminatory mandatory sentencing of African American males for drug crimes85 removes a high proportion of African American men from the community and keeps them from providing economic and social support to families and children. A criminal record, in turn, reduces the chances for future employment.

Thus, racial differences in crime, unemployment, and single-parent households are not driven by differences in family values but by lifelong interactions of coping responses with restricted access to good neighborhoods, schools, and employment opportunities.

The health status of men is linked to the nature of social organization and of economic opportunity in society. Many of the stable and relatively universally noted differences between men and women are not biologically inevitable but are importantly shaped by social arrangements. For example, the higher prevalence of symptoms of depression and anxiety among women than men is reversed when men and women are not in their traditional roles. Wives who are employed have lower depression and anxiety scores than their husbands, and when women or men earn less relative to their spouses they experience more symptoms of depression and anxiety.60 Similarly, although women are generally better at providing social support than men, men who are the primary providers of child care exhibit social support skills that are comparable to those of women.86

A broad range of solutions are available to address some of the challenges facing men in our society in general and vulnerable men in particular. Improving the health of future generations of men and women will require improving the economic circumstances of men. This must include enhancing the quality of educational institutions and reducing educational failure in elementary and high schools. Investments to enrich the quality of neighborhood environments are also central to any comprehensive strategy that seeks to ensure that no child is left behind.84 The research reviewed here indicates that the employment of men can have ripple effects on the economic and social well-being of men, as well as their families and communities. Employment initiatives should emphasize human resource development through education and training so that individuals are provided with the basic skills that are necessary for meaningful employment opportunities in a rapidly changing technological environment. These public and private training initiatives must include efforts to retool the currently unskilled and to create better job ladders for the least skilled.45

International comparisons suggest that much can be done to provide economic and social support to vulnerable families and children.87 Although Sweden has rates of single-parent households similar to those of the United States, the provision of support has broken the strong link evident in the United States between family structure and childhood poverty.87 These investments have long-term beneficial effects for society. A comparison of the United States and Canada (both with high rates of child poverty) with Sweden (with low child poverty) revealed that the level of verbal and quantitative skills for the least well-educated adults in Sweden is markedly superior to that of their counterparts in the United States and Canada.88

Efforts to improve the conditions of work, enhance employee participation in decisionmaking, and redesign workplaces to reduce injuries can also improve men’s health. Research reveals that a broad range of strategies have been effective in reducing occupational stress, although these interventions are more effective among those with higher occupational status.89

The decline in the prevalence of iron deficiency among US infants is one example of how public health policy has had a dramatic impact on improving outcomes for children. The use of iron-fortified formula for bottle-fed babies, the provision of iron-fortified formula in the federal government’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the encouragement of breastfeeding (the iron in breastmilk is readily absorbed) have had a dramatic impact in providing more iron to most American children.21 However, targeted intervention efforts are still needed for the most vulnerable groups. Although iron deficiency has declined over time, the reduction for Whites (tenfold) has been much larger than that for African Americans (fourfold).21 Similarly, federal regulations prohibiting lead in house paint and gasoline have had a dramatic impact in reducing lead levels in US children.21 The research on iron deficiency also illustrates the long-term consequences of at least some early exposures even if corrective steps are taken. Ten years after the initial treatment for chronic severe iron deficiency in infancy, those children that had been deficient still had lower test scores during adolescence.21

Increased educational outreach efforts targeted to men are also required. Historically, many health promotion campaigns have been targeted to women.37 A recent Harlem study highlighted the need for more health education.17 Although only 12% of men indicated that they had ever been diagnosed with hypertension, assessment of their blood pressure levels revealed that 32% of the men were hypertensive. Educational outreach must include enhancing men’s awareness that at least some culturally supported norms of masculinity can lead to health-damaging orientations and behaviors. Efforts to redefine the cultural meaning of manhood in positive ways will require parallel changes in cultural institutions and social structures to reinforce positive health behaviors in men over the life course.

Effective educational and clinical intervention activities must be culturally appropriate in terms of both interpersonal and technical aspects of care. For example, African Americans and low-SES persons with symptoms of heart attack are more likely than Whites and their economically favored peers to delay going to a hospital for treatment.90 One contributing factor to patients’ delay in taking action, and providers’ misdiagnosis, is that African Americans and low-SES individuals are less likely than Whites to present with the classic symptom of myocardial infarction—chest pain—knowledge of which came from studies of middle-class White men. African Americans are more likely than Whites to report dyspnea as a presenting symptom, and both patients and providers need to be educated about the significance of this symptom.

The evidence reviewed here indicates that the living and working conditions of men in general, and the added burdens of minority men, have harmful effects on their health. Public health practitioners and policymakers need an enhanced appreciation of the magnitude of the health challenges faced by men. Optimal upstream interventions require the awareness that since the major factors affecting men’s health risks are socially determined, they can also be socially ameliorated.

Preparation of this report was supported by grant MH 59575 from the National Institute of Mental Health, the Kellogg Foundation, and the John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health.

I am grateful to Car Nosel, Han Nah Kim, and Trisha Matelski for research assistance and preparation of the manuscript.