Not to be sniffed at: Why the 'man flu' deserves serious attention

It’s time we stopped teasing men when they complain about catching a virus. Clinicians say they need to be listened to, as they are less likely than women to visit their GP or local pharmacist

Men are less likely to report being sick when their symptoms are dismissed as ‘man flu’. Picture: iStock

YOU might feel a little woozy or low energy before you retire for the evening, or maybe you wake up and the realisation hits you that you have a sniffle, a blocked nose, a heaving chest, or a sore throat.

All this can be accompanied by a cough, a pronounced desire to not move from under the covers unless you migrate to the couch, and a strong requirement for a hot cup of tea, possibly with added Lemsip.

But the diagnosis is typically issued by a close family member, be it partner, parent or child: “Man flu, is it?”

Ah, yes, the seasonal wonder that is man flu: The myth, the legend… the reality? For all the scepticism and accompanying eye-rolling, there is still debate over ‘man flu’. As cyclical as the illness itself, so come the news stories, some casting doubts on the veracity of man flu, others backing the view that it is something tangible.

The contemporary debate began with research by Kyle Sue, a clinical assistant professor of family medicine in Newfoundland and a rural GP. In 2017, he was interviewed by the British Medical Journal (BMJ) about a research paper he wrote titled ‘The science behind man flu’.

“When it comes to viral response infections, it seems that men have a weaker immune response, therefore have longer-lasting symptoms, worse symptoms, higher hospitalisation rates, higher mortality rates, and the higher the testosterone, it seems, the worse the immune response, whereas, in women, it seems the higher the estrogen, the better the response,” he said.

Sue added that women slow down when they begin to feel ill while men tended to push through, worsening the situation.

“The evidence does point to there being some biological basis to it,” he said, conceding that there would also be a sociological element.

“It does seem that when any of us get the man flu, we seem to be completely debilitated,” he said, adding that “there are still a lot of questions that are unanswered.”

Weaker immunity

Mark Jordan, a community pharmacist in Balla, near Castlebar, in Co Mayo, says, “Anecdotally, and through some notable studies over the last decade, there is conflicting evidence of man flu’s existence. Through these studies, both for and against and through my observations as a pharmacist, I can understand why men might find themselves in a situation where their symptoms appear and feel more severe than they may observe in their partners.

“There is some evidence that a man’s immune system may not be as robust as a lady’s. In my opinion, and if true, this is likely impacted by lifestyle choices more typical of men, like diet and other factors, such as less sleep. These will limit recovery time, antibody production, and subsequently protection.”

Man flu is a pop cultural reference point. It has regularly been the butt of jokes, often good-natured. A prime example is an online video skit posted in 2018 by the Mill Pharmacy in Coolaney in Co Sligo. In it, ‘Joe and Mary Soap’ tell an interviewer about their experiences of man flu, with Joe describing having ‘a red nose... I constantly had a wet tissue in my pocket..’ and getting ‘only seven or eight hours’ sleep a night...’ Can women get the man flu, Mary is asked. ‘Oh God, no,’ she responds instantly.

The post was the idea of pharmacy owner Hilary Dolan, who admits: “I sometimes can be too smart for my own good.”

The skit came about because of the sheer number of women coming into the pharmacy to secure paracetamol and other treatments for their ailing male family member.

“Even the men themselves, if they were coming in, you’d [ask if it’s] ‘man flu’ and they’d say ‘man flu is the worst’,” she says.

All that said, she believes that men can be slow to take pre-emptive steps to avoid or mitigate against illness, such as vitamins or folic acid, and that women’s tolerance for pain and discomfort seems to be higher than that of their male counterparts.

Social conditioning?

Sue’s original BMJ article prompted a round-robin of responses, some supportive, others less so. For example, professors and researchers from Stockholm University argued that while the original research paper was “an entertaining read”, they wrote: “We think that man flu is more likely due to men communicating their symptoms differently from women, rather than having different immune functioning.”

Christopher Manlow, consultant in emergency medicine, responded by saying the original article “panders to pejorative views of male health and is sexist”.

It’s a view echoed by Dr Phil Kieran, GP and Irish Examiner columnist. “I think man flu is a misandrist concept,” he says.

“We can’t, as a society, encourage men to be more emotionally vulnerable, physically responsible, and less toxic, and then demean and belittle them, as a group, when they express illness.

“I have met plenty of men who feel very sorry for themselves and take to the bed when sick, and plenty who just get on with what needs doing. I have seen roughly the same proportion of these responses in women, too, so, overall, I don’t think the concept has any value or relevance.”

Jordan, who is also a PSI council member, says: “Regardless of man flu’s existence, as a pharmacist and patient advocate, I find myself concerned that where we trivialise even lesser conditions, like colds, in men’s health, it may have a downstream effect on their readiness and willingness to come forward when more serious conditions present.

“Conditions specific to men, such as prostate or testicular cancers, often go undiagnosed and, therefore, untreated, which, in turn, affects clinical outcomes when they eventually come forward. We want all patients to feel comfortable and confident discussing health issues, colds included.

“The psychology and messaging around men’s health has shifted in a positive direction in previous years, and though many of us are happy to laugh our symptoms off, the fact remains that men still ignore symptoms longer than women and often take more time to present to a health-care professional. Maybe it’s time to change direction on colloquial language to match messaging, empowering all patients, regardless of gender.”

Kieran does not see any evidence of man flu as a distinct entity. “I do notice that some men are much slower to listen to their bodies and rest when they start to get sick,” he says.

“This frequently results in them becoming sicker than they should have. This is likely influenced by toxic expectations that ‘men don’t really get sick’, so by the time they accept that they are sick, they have run themselves into the ground. This is more common in men, though, and I certainly see plenty of women guilty of the same thing.”

A testosterone issue?

Just last month, as the summer ebbed away and we entered cold and flu season, the New York Times was on the case. An article titled ‘The Truth about ‘Man Flu’’ featured Sabra Klein, a professor of molecular microbiology and immunology at Johns Hopkins University, who pointed out that, “Women often produce or mount greater immune responses”, and that their immune cells are faster at detecting foreign invaders, like viruses or bacteria. This difference may be attributable to females having two X chromosomes while males have one. At the same time, testosterone appears to inhibit some aspects of immune functioning, like antibody production, whereas oestrogen boosts it.

Yet, before the male half of the global population can say, ‘We told you so,’ there is more research: A December 2022 study published in the Journal of Psychosomatic Research carried the blunt title, ‘Man flu is not a thing’.

The Austrian authors of the study referred to man flu as a “pop-cultural description”. They found, instead, that while women recovered faster from acute rhinosinusitis (ARS) than men, women also reported a higher subjective symptom burden.

In contrast, men reported a slower subjective symptom improvement over time. Ultimately, the researchers said: “Our data did not support the hypothesis of ‘man-flu’.”

In Coolaney, Hilary Dolan is debating whether to update the man flu video. The original one was clearly popular and received no negative feedback, not even the men.

“Nobody was going ‘poor us’,” she says.

Yet, as (man) flu season comes around again, Kieran believes that the key point is that men listen to what their bodies are telling them.

“I do think society is getting a bit better at encouraging men to express their health concerns, but the generations of ‘not worrying about myself’ in men will take a while to go away fully,” he says.