We have all heard some version of the story: A middle-aged man begins acting like a teenager, buys a flashy new sports car, and gives up a long-term marriage to be with a much younger woman. The notion of men reliving their teen years at midlife is a well-worn stereotype, played out in novels and movies. Some men have difficulty accepting the realities of midlife. But studies show the majority do not experience a “middle-age crisis.” Midlife is more often a period of transition than a crisis. Real and unique challenges do emerge at middle age, and most men adjust.^1,2

For many men, middle age marks the first adult experience of physical vulnerability. These men may notice their stamina is slightly diminished, and they have more difficulty rebounding from strenuous physical activity and late-night partying. Men who are aware will recognize that they can no longer consume large meals without physical consequence.

They may notice a gradual widening of the waistline and subtle changes in sexual functioning.³

Midlife typically marks a time of reflection upon a life half completed. People at midlife look back on what they have achieved, or not achieved, in work and family life. For some men, this life period marks a career peak. For others, the newness, excitement, and drive they experienced through work in the second and third decade of life have worn off. Or “burn-out” may have set in. Still others may face the realization of missed career goals in light of the success of their peers.¹

Divorce and the death of a parent are unfortunate milestones that many middle-aged men face. These events provoke reflection and often a new awareness that everything has an end. that life does not go on forever. When accepted and sorted out, these painful events can foster psychological growth and role changes.¹

Viewed from a chronological perspective, 32 to 38 years of age is the average midlife point for men. However, the midpoint differs depending on the person, cohort, and race (e.g., the average life expectancy of African American men is nearly eight years less than that of the general male population).¹ Another view of middle age is from a “stage-of-life” perspective, in which specific external and internal changes occur during a general time frame. In this case, middle age is typically identified as 40 to 60 years of age.¹

Psychological development

Psychologically, the task at middle age is to guide the next generation. This often occurs through successful parenting. Or it can happen in other ways that result in the creation of something for the next generation. For some men, this means mentoring children or younger men and women in work or social situations. It involves actions that make a positive difference for the future, whether through affecting others or taking care of what will be left behind, such as a viable planet for future generations.

Generativity is the term used to denote mastery of this stage of life. A sense of “caring” and obligation toward others is central to generativity. Those who fail to achieve generativity are stagnant. They regress to earlier stages of development and are self-indulgent, as in the case of the stereotypical middle-aged man who runs off with that younger woman. For the stagnated man, these actions may be attempts to avoid feeling empty, unhappy, and unfulfilled.⁴

New ways of thinking about the psychological development of men include an understanding of relatedness to others. The capacity for intimacy is the foundation required for the later development of a solid sense of one’s self.⁵ The experience of intimacy must begin early in life. It derives from a close, secure, and loving relationship with primary caregivers. Intimacy in early life includes having one’s dependency needs met and leads to feelings of security and trust in others even when they are not present. The child who experiences intimacy can separate when the time is right developmentally.

Successful separation and individuation are needed to develop a strong sense of self or identity. However, they do not occur successfully unless a strong early bond is achieved with caregivers. Additionally, the importance of separation is overly emphasized in male developmental theories. Little boys are too often expected to be independent of their mothers from an early age. As a result, grown men may have difficulty being close and intimate with women.⁵

For many boys, there is an overemphasis on what they are able to “do.” As adults, these men are uncomfortable just being with a loved one or dealing with others’ emotions. Instead, there is a tendency to “fix” things. Sometimes for boys, early experiences of being loved and feeling special become connected with achievement rather than their own individual uniqueness. Regardless of early male socialization, men, like women, possess the potential for empathy.^1,6

To some degree, the American cultural ideal of masculinity restricts men from experiencing a full range of emotions and activities. “Manhood” encompasses competition, risk-taking behaviors, emotional stoicism, and rejecting femininity. The role of the man in the family is often restricted to provider and protector.⁶ Verbalization of feelings may be difficult for men. They often are taught to suppress feelings other than aggression and anger. Expression of grief, sadness, or powerlessness may feel humiliating and therefore be suppressed.⁶ Middle age presents the real vulnerabilities of being human. If a man can accept these vulnerable parts of himself, this period of life offers the opportunity for him to discover a gentler side. He can recognize that this does not take away from his strength and manliness.¹

Psychological influences on health and behavior

To a large extent, diseases affecting middle-aged men can be prevented by changing behaviorial patterns.³ By middle age, unhealthy lifestyles, such as poor eating habits, smoking, risk-taking behaviors, and physical neglect, are well-established. These behaviors begin to take a toll on the middle-aged body. In the service of being stoic and not complaining, the middle-aged man may ignore pain and other signals of physical problems. It’s not surprising that men spend less time with healthcare providers than women do.⁶

Men’s risk-taking behaviors have dire consequences on health and mortality.³ Although middle-aged adults are much less likely to sustain physical injuries than teenagers and young adults, men of all ages are still at greater risk than women. The incidence of head and spinal cord injuries are greater for men than women. The number of firearm-related injuries is substantially greater for men.⁷ About twice as many men as women die in traffic accidents.³ Risk-taking behaviors that result in injuries have been linked to the ideal of masculinity, in which boys learn to externalize emotions through “acting out.”⁶

Oral habits such as overeating and tobacco use serve as coping mechanisms. They may temporarily negate uncomfortable emotions, such as anxiety, or fill up feelings of emptiness. Smoking is the most dangerous behavioral risk factor for death and disease.^3,8,9 Quitting — extremely challenging but doable — can substantially reduce death rates associated with diseases such as lung and throat cancer and emphysema. Stopping smoking also brings about an increased quality of life: the ability to more fully enjoy flavors and tastes and increased physical stamina and endurance.³

Obesity is the next major risk factor for disease and death. The likelihood of developing Type 2 diabetes exists even for those who are only somewhat overweight.³ Hypertension increases the risk of cerebral vascular accidents and is twice as likely in those who are overweight.⁷ Elevated serum lipid levels and high total and LDL cholesterol are associated with being overweight and lead to atherosclerosis and cardiovascular disease.³ The chance of developing cancer (e.g., colon, prostate, and gallbladder) also increases when weight is in the unhealthy range. Arthritis can develop from carrying too much weight.⁸ Poor self-image, shame, and humiliation are common psychological repercussions. Quality of life is likely to be diminished.³ Being overweight has emotional, behavioral, and biological origins and ill consequences. It is of particular concern for men at middle age, since there is already high risk for heart disease just by being male and turning 45, when risk increases significantly.³

Some people are predisposed to being obese. Genetics and resting body metabolism play a role.⁹ Regardless, the ever-present availability of high-calorie foods in the U.S. diet makes maintaining a healthy weight difficult for most. Although it is not easy to do so, eating patterns and activity level can be changed.

Becoming aware that a weight problem exists is the first step. A common determination of appropriate weight can be made using the body mass index. (A BMI calculator is available at www.cdc.gov/nccdphp/dnpa.)

A rough determination is waist measurement. A man with a girth greater than 40 inches is generally overweight.³ Extra fat around the waist is a greater risk for heart disease than fat anywhere else in the body.³

Awareness of eating habits is critical to weight loss. One should be conscious of what satiation feels like and aware of when, how much, and under what circumstances eating occurs. Some people find it helpful to keep an eating diary to heighten awareness and make connections between mood states and eating behaviors. Emotions associated with eating are highly individual. Psychotherapy may help uncover underlying psychological/emotional issues.

Experts recommend eating a variety of foods and avoiding fad diets.³ Saturated fats (most notably transfats or hydrogenated oils), simple sugars, and processed foods should be limited, and protein consumed in moderation. Liberal helpings of fruits and vegetables are advised. Reading food labels and reducing portion sizes should become a habit. Most will find it difficult to change habits. Weight problems in the United States have been linked to ever increasing serving sizes in restaurants and the omnipresent availability of food. Men and their loved ones need to be understanding and not expect instant behavioral changes.¹⁰ To be effective, long-term weight loss needs to be gradual.^3,10

Regular and consistent exercise must be incorporated into a weight loss/maintenance plan. Like a diet, exercise should not be punishing. Success is probable when activity is incorporated into lifestyle (incidental exercise). Examples include using the stairs instead of the elevator and washing one’s own car. The surgeon general recommends 30 minutes of brisk exercise daily at least five days a week.^3,10

Problem drinking is another behavior that is more common in men than women. Complicated psychological, biological, and social factors underlie alcohol abuse and the more serious illness, alcohol dependence. Alcohol is often used as a socially acceptable outlet for men to deal with emotions.⁵ In addition to wreaking havoc on personal relationships, excessive alcohol damages every organ in the body. Liver disease is one of the most common and debilitating complications of heavy alcohol use.³

Suicide is a tragic behavior disproportionately higher for men than for women. While depression rates are greater for women, men are four times more likely to complete suicide. Current literature suggests that rates of depression in men are actually higher than previously believed. Depression has been overlooked in men because men tend to suppress feelings of sadness.¹¹ More commonly manifested are anger, irritability, and use of alcohol or illicit drugs to mask feelings.⁵

Testosterone and middle-aged men

The term “male menopause” may be gaining popularity but it is a misnomer.⁹ The decline of testosterone in men is actually a gradual process that continues into old age. It is unlike the precipitous drop of estrogen in women at menopause that occurs at middle age.⁹ Most men have adequate amounts of testosterone to father children into their eighth and ninth decades.³

There’s no question, testosterone is a vital hormone for men. The most potent of the male hormones, or androgens, it has wide-ranging effects. Male characteristics such as muscle mass, hair growth, libido, erections, and sperm production are the consequence of testosterone. The deep voice acquired at adolescence results from thickening of vocal chords — also the effect of testosterone. Testosterone even influences the production of red blood cells. Some behaviors, such as aggression, seem to be linked to testosterone.³

Testosterone is produced in the testes. The process begins in the brain, where the hypothalamus produces gonadotropin-releasing hormone (GnRH), which acts on the pituitary gland, which in turn secretes two hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Better known for their effects on the ovaries, FSH and LH are instrumental in the action on the testes. LH triggers testosterone production, and FSH acts along with testosterone in stimulating sperm production.³ That which is considered a normal testosterone level is quite broad. Levels range from 270 to 1,070 ng/dl (nanograms per deciliter), an 800-point difference. The highest levels are reached just shortly before age 20, and levels begin to fall around 40.³

The FDA has approved testosterone to treat hypogonadal conditions (e.g., Klinefelter’s syndrome) and cancers and infections of the pituitary glands. Testosterone replacement is critical in treating these illnesses.^3,9 Testosterone is available by injection, orally, and through a patch or gel. Risk of impaired cholesterol metabolism and liver damage is greater from the oral form. Injections are every two to three weeks. Fluctuations in levels of the hormone, which may cause mood swings, are a problem with injections. Patches and gels provide a more steady release.¹¹

Although men receiving testosterone replacement therapy report feeling more energetic and younger, the long-term effects of supplemental testosterone are unknown. There is a possible risk for prostate cancer, which is testosterone-dependent. Excessive production of red blood cells (polycythemia) also may occur, increasing the chance of cerebral vascular accidents. Potential for interference with liver functioning and cholesterol metabolism also exists.⁹ Further, synthetic testosterone suppresses the body’s production of testosterone and therefore may be a problem when the hormone is discontinued.¹¹ Given the possible adverse effects, testosterone supplementation is a serious endeavor and should be done under the careful monitoring of a healthcare provider experienced in this area of medicine.

Erectile dysfunction at midlife

About 40% of men age 40 to 60 have some problem achieving an erection.¹¹ Although the chance of erectile dysfunction increases somewhat with age, the problem is more often a result of diseases that damage the blood vessels and nerves rather than age or low testosterone levels.³

The penis is like a large artery; damage to blood vessels impairs the ability to have an erection. Diabetes, hypertension, and arteriosclerosis are major culprits. These problems are often associated with obesity. The man with a 42-inch waist is nearly 50% more likely to have erectile problems than the man with a 32-inch waist. Medication can also be responsible (e.g., ACE inhibitors, alpha blockers, antidepressants).³ If a man can have an erection at night during sleep, but not with his partner, the problem is psychological. Anxiety is the most common issue.³

Generally, the most effective approach is to address the underlying cause of the erectile problem. Assessment of lifestyle and medication regime is necessary.³ When the problem is a lack of desire from stress or depression, a psychological assessment may be indicated. Tension or distance in a relationship can cause psychological strain on the man’s ability or desire to perform sexually. Couples therapy or sex therapy can be beneficial in resolving underlying relational problems and fostering intimacy.

When medication is responsible but cannot be discontinued or a causal medical problem cannot be resolved, erectile dysfunction medication may be an option.³ General knowledge of erectile functioning is necessary to understand how ED medications work. A receptive state of mind, adequate testosterone, and healthy arteries, veins, and nerves are needed for an erection. Nitric oxide is needed to transmit messages between nerve cells that in turn relax smooth muscles. Nitric oxide signals cells in the arteries to produce the chemical cyclic guanosine monophosphate, which increases blood supply to the penis, thus creating an erection. Nitric oxide also stimulates another chemical, phosphodiesterase-5, which functions in stopping the erection after a certain period of time. Viagra (sildenafil citrate) and other ED drugs generally work by inhibiting PDE5.²

Viagra dosages range from 25 mg to 100 mg prn about one hour before sexual activity (maximum dose once daily). Headache is the most common adverse effect. Due to its hypotensive effects, Viagra should never be used within 24 hours of taking nitrates (nitroglycerine). Men with heart disease should discuss the safe use of ED medications with their healthcare provider.³

Middle-aged men who do not have erectile dysfunction may feel pressure to perform sexually and be tempted to use ED medications to enhance sexual performance. With the growth of direct-to-patient marketing of medications and omnipresent advertising, many functional men are curious about ED medications. It may be necessary to clarify that these medications are not aphrodisiacs.

Body image, baldness, and the middle-aged man

Male pattern baldness (androgenic alopecia) is not a disease.² Still, it is troubling for many middle-aged men. Because adopting a healthy lifestyle will not stimulate hair growth, feelings of helplessness may ensue.¹²

Male pattern baldness starts between ages 17 and 40. It typically begins at the hairline on the forehead or the crown of the head. By age 50, half of men have some hair loss. Hair loss is partly genetics, inherited from either father or mother. Testosterone also plays a crucial role.

To understand balding, one must know about hair growth. There are two phases, growth and resting. Balding involves a shortened growth phase and a longer resting phase. When the growth period is shortened, hair is finer and less tightly attached to the scalp. The follicles become smaller as a result of the shortened growth period. Over time, the rate of loss varies. It can slow down or speed up over the years. The actual hair follicles never disappear.^3,12

Two medications are approved for male pattern baldness. Minoxidil, a hypertensive drug marketed under the name Rogaine for hair loss, is sold over the counter in a topical form for hair growth. It increases the length of the growth phase. It is more effective for bald spots than a receding hairline. Application twice a day is required. Finasteride (Propecia) is an oral medication that interferes with the effects of testosterone on the hair follicles.¹²

Some men opt for hair transplants, which involve having hair follicles moved from one area to another. Sporting a shaved head is another alternative.¹²

Be aware of and sensitive to the issues that affect your middle-aged male patients. The knowledgeable nurse will have a tremendous impact. Whether with a patient or with a husband, partner, father, or son, the potential for intervention through identifying problems and risk factors, and promoting psychological and physical health is far-reaching.