The effects of hair loss in European men: a survey in four countries
European Journal of Dermatology. Volume 10, Number 2, 122-7, March 2000, Cas
Author(s) : D. Budd, D. Himmelberger, T. Rhodes, T.E. Cash, C.J. Girman, Department of Epidemiology, Merck Research Laboratories,
BL 1-7, 10 Sentry Parkway, Blue Bell, PA 19422, USA. firstname.lastname@example.org.
Summary : Despite the high prevalence and the accepted psychological aspects of
male pattern hair loss, few have characterized the effects of hair loss in representative
samples of men in different countries. A representative sample of households in 4
European countries (France, Germany, Italy and the United Kingdom) was contacted by
an interviewer and resident males 18-40 years of age (n = 1,717) completed a
questionnaire designed specifically to evaluate attitudes to hair loss. The questionnaire
was comprised of 78 questions translated and pilot-tested using standard methodology
into each local language. Questionnaires queried about self-rated hair loss, satisfaction
with hair appearance, noticeability of hair loss to others, and bother, concerns and
perceptions about hair loss, as well as general physical health (the SF-12
questionnaire) plus three additional questions about mental health. The self-reported
degree of hair loss in men was statistically significantly associated (p < 0.001) with all
hair-loss specific effects measured, except “limiting job opportunities”. The impact of
hair loss was generally consistent in the four countries surveyed, although less
pronounced in the United Kingdom. Age was significantly correlated with hair loss (rs =
0.34, p < 0.001). Men with greater hair loss were more bothered, more concerned about
looking older due to their hair loss, and less satisfied with their hair appearance. Male
pattern hair loss has significant negative effects on hair-loss specific measures in men
18 to 40 years of age in France, Italy, Germany and the UK. The degree that hair loss is
perceived as noticeable to others appears to be a significant contributor to these
Keywords : androgenetic alopecia,
Androgenetic alopecia, or male pattern hair loss (MPHL), is a common condition that
has been reported to affect 29-40% of men between 18 and 59 years of age [1-3].
Despite the accepted psychological effects of MPHL, few studies have been conducted
to investigate and quantify this relationship. Of those which have been reported [4-6]
most have relied on selected samples of men seeking medical attention for their hair
loss and may not be representative of the general population. In addition, many of the
earlier studies that investigated the psychosocial effects of MPHL used scales that are
not specific to this condition. However, these global psychological measures may not be
sensitive enough to detect meaningful effects in men with hair loss.
Using measures specific to hair loss, Cash et al.  documented the negative
psychological effects of hair loss on men and women in a US survey of patients seeking
treatment for androgenetic alopecia, compared to female control patients. These results
were supported by a recent study conducted in men recruited from a community near
Dayton, Ohio , which found that men with hair loss are significantly more distressed,
self-conscious and dissatisfied with their hair appearance relative to men without hair
loss. However, no studies using measures specific to hair loss and population sampling
methodology have been conducted to investigate the effects of hair loss on men in the
general population of various European countries.
This study was designed to address this void by using measures specific to the
problems and concerns expressed by men with hair loss  and a sampling
methodology that included men representative of the general population in four major
European countries (Germany, France, Italy and the United Kingdom).
Materials and methods
Randomly selected samples of men 18 to 40 years of age were surveyed in each
country. This survey was a part of a larger omnibus survey that is routinely conducted in
the UK and Italy every 2 to 4 weeks. The demographic characteristics of the sample in
each country were comparable to that of the general population in that country. A
personal interviewer identified participants, and the respondent then completed a
questionnaire in his primary language without any assistance from the interviewer.
The questionnaire was initially developed in the United States in American English to
evaluate the impact of hair loss on men's health-related quality of life. The instrument
was translated from American-English into French for use in France, German for use in
Germany, Italian for use in Italy and British-English for use in the UK using the standard
forward-backward method [9-11]. Prior to data collection, each translated version of the
questionnaire was pilot-tested for comprehension  with 10 men in each country.
Men rated their hair loss using a categorical scale with seven responses: "a full head of
hair", "only a little hair loss", "some hair loss", "moderate hair loss", "a good bit of hair
loss", "a lot of hair loss", and "I am bald". In addition, men circled the classification that
they felt best matched their hair loss pattern, using the Norwood/Hamilton scale [1, 2].
Men were also asked questions that were specific to hair loss, including previously
validated measures  of satisfaction with their hair appearance (on top of their head,
frontal hairline, and overall), degree of bother due to hair loss, extent of concern about
aging, and perceived noticeability to others . A "hair loss distress" domain score was
calculated as the sum of responses to questions regarding bother and concern about
looking older due to hair loss, whereas a domain score for thinning/shedding included
three questions pertaining to shedding while grooming . Demographic data,
respondent's medical history and data about hairstyle, hair color, hair length and family
history of disease were also collected. Other questions, identified as most relevant in a
previous survey , were included on an exploratory basis to investigate the relationship
between hair loss and worry about appearance and relationships, helplessness, self-
confidence and self-consciousness, preoccupation, impact on social life and job
opportunities, and other pertinent areas specifically related to hair loss. The response
scales of these questions were modified to better conform to the rest of the present
survey. Additionally, data were collected about men's awareness of hair loss products
and remedies, such as surgery, drug therapy, wigs, and hair styling.
Respondents were categorized into one of the four groups based on their self-reported
degree of hair loss: "a full head of hair", "a little hair loss", "some hair loss" or "moderate
hair loss", and finally, "a good bit of hair loss", "a lot of hair loss" or "bald".
Differences among men with various degrees of hair loss were assessed using general
linear models (GLM) . Covariates in the model included marital status (never
married, married/cohabitating/widowed/divorced), age (18-25, 26-30, 31-40), education
level (¾ high school, > high school), and interactions of hair loss and age. Analyses
were performed separately for each country. Bonferroni adjustments for multiple testing
were made for all statistical tests . Spearman rank correlations were used where
appropriate to investigate relationships between individual variables.
A total of 1,717 men with varying degrees of MPHL were surveyed in France (n = 502),
Germany (n = 508), Italy (n = 383), and the UK (n = 324). The average (± SD) age of
participants was 29.3 (± 6.4) years and age distributions were comparable among
countries. About half of the men had never been married (51.2%) and half were
currently married or cohabiting (47.7%). Marital status was fairly consistent among
countries, except that fewer men in the UK had never been married (34.6%) and more
were married or cohabiting (59.9%). Overall, 30.1% of the men had completed college
or graduate school; differences between countries probably reflect the different
educational systems. The majority of participants worked full-time (75%) or part-time
(5.7%) and 8.0% were students.
Slightly more than half of the participants (53.5%) in the survey reported that they had a
full head of hair and few men (8.8%) reported more than moderate hair loss (Table I).
The degree of self-reported hair loss was highly dependent upon patient age (r
p < 0.001). Of men under 20 years of age, 81.3% reported that they had "a full head of
hair", but only 35.2% of men 35 years or older reported "a full head of hair" with about
30% reporting at least "moderate hair loss".
Among men reporting hair loss, the average (± SD) age at which they began to notice
hair loss was 23.9 (± 6.8) years of age; however, men in Italy reported a significantly
lower age at which hair loss began (20.8 years), compared to the other countries (24.6-
25.6 years); (p = < 0.01).
For all four countries, mean scores for the shedding/thinning domain increased with
increasing degree of hair loss (p < 0.0001) (Fig. 1a). These increases were typically
independent of age except in France (p < 0.005) where 18-25 year old men reported
higher shedding/thinning scores than either the 26-30 or the 31-40 year old men (mean
± s.e.: 6.1 ± 0.30, 5.3 ± 0.28, 5.3 ± 0.23 respectively).
Mean scores for the hair loss distress domain also increased with increasing degree of
hair loss in all four countries (p < 0.002) (Fig. 1b). The increase in distress was
independent of age for France and Italy. For Germany, the distress domain scores were
generally greater in younger men, decreasing slightly with increasing age (mean ± s.e.:
4.1 ± 0.33, 3.5 ± 0.19, 3.2 ± 0.14 for men 18-25, 26-30 and 31-40 respectively).
However in the UK, men 26-30 reported the highest distress scores with the older men
(31-40 years) reporting the same average level of distress as the younger men. Hair
loss distress in all countries appeared to be driven mainly by the question pertaining to
how bothered they were by their hair loss rather than concern about looking older due to
hair loss. Marital status and education level were generally not related to the hair loss
distress domain, although a consistent relationship between education and hair loss
measures was found for men in the UK (p < 0.05). Likewise, the degree of bother due to
hair thinning increased with increasing hair loss in all countries. The degree of concern
about looking older due to hair loss also increased with the degree of hair loss, except
in the UK where the relationship was not significant.
Perceived noticeability of hair loss to others was highly correlated with self-reported
degree of hair loss in all four countries (r
= 0.73-0.83). Overall, 98% of men with a "full
head of hair" reported that hair loss was "not at all" or "slightly" noticeable while 75% of
the men who reported "a lot of hair loss" or "I am bald" reported that their hair loss was
"very" or "extremely" noticeable to others. In addition, perceived noticeability to others
was strongly related to the satisfaction measures and degree of bother in each country
= 0.58-0.60). Overall, perceived noticeability to others was somewhat more strongly
related to bother (r
= 0.58) than degree of hair loss (r
= 0.51). As with the other hair loss
specific measures, perceived noticeability also increased with increasing degree of hair
loss independent of age for all countries (p < 0.0001) (Fig. 1c).
In all four countries, men with greater hair loss reported significantly less satisfaction
with their hair appearance (hairline in front, hair on top of their heads, and hair in
general) than men with less hair loss (p < 0.0001).
The exploratory analyses of measures of worry, helplessness, self-consciousness,
preoccupation and impact on social life yielded results similar to those presented
previously. Men with greater self-reported hair loss reported significantly greater
negative effects for all measures except "opportunity in your job" (Table 3). As with
previous results, "perceived noticeability to others" was significantly indicative of greater
negative effects for most of the measures.
The general health measures, SF-12 physical (PCS-12)  and mental (MCS-12)
domains and the MHI-5 , were not related to self-reported hair loss and were not
significantly different from published norms for men in the United States between the
ages of 18 and 34 [16-17].
Although less than 12% of men 18 to 40 years of age reported that they had "a good bit
of loss" or greater hair loss, significant negative effects of hair loss were reported for
men surveyed who reported any degree of hair loss. Men who reported greater hair loss
expressed less satisfaction with hair appearance, a greater degree of bother due to hair
loss and more concern about growing older. In addition, men with greater hair loss
appeared to be more worried, less self-confident and, in general, to have more negative
effects specific to their hair loss than men who reported less hair loss. Even men
reporting only "a little" or "some" to "moderate" hair loss showed significant negative
effects of hair loss relative to men without hair loss.
Although others have documented the negative effects of hair loss on men, this is the
first study to document the consistency of such effects across cultures. Generally,
trends in the negative effects of hair loss on men 18 to 40 years of age were similar in
France, Germany, Italy, and the UK. In addition to the degree of self-reported hair loss,
"perceived noticeability to others" was found to be significantly related to most hair-loss
specific measures. Men who perceived their hair loss as more noticeable to others were
less satisfied with their hair appearance and more bothered by their hair loss. This
variable captures the person's self-conscious awareness of their hair loss. Demographic
characteristics were generally not associated with the hair-loss specific measures.
Unlike the findings from a community study conducted in the US  that surveyed men
up to 50 years of age and another former survey , we did not consistently find that
younger men were more negatively affected by their hair loss. It is unknown whether
this stems from the lack of a true effect or if it simply reflects perceptual and cultural
differences among countries. As in previous studies, the general health measures, SF-
12 physical and mental domains and the MHI-5, were not related to self-reported hair
loss. Such measures are often too general and too broadly based to detect important
relationships within specific medical conditions [18, 19]. On the other hand, disease-
targeted measures such as the hair loss specific items in these surveys, focus on
aspects that are affected by a specific condition, and can be used to identify important
concerns of patients with certain conditions and to measure important changes after
In a previous study by Cash , a greater proportion of men with hair loss reported
negative effects of hair loss than men with no hair loss. This finding was also true for
men who were not seeking care for their hair loss . Our findings also suggest that
men with hair loss, the vast majority of whom are not seeking treatment for hair loss, are
more negatively affected in terms of distress, bother, concern, self-consciousness and
dissatisfaction with hair appearance than men with a lesser degree of hair loss. This
finding was relatively consistent in the different countries. The random sampling process
used in these studies helps minimize the selection bias associated with studying men
seeking treatment, and better characterizes relationships of these effects and hair loss
in the general community. However, men who are seeking treatment, by definition, are
probably most affected by their hair loss, and may respond to these instruments quite
differently. While treatment-seekers are understandably more distressed by the
condition they seek to remedy, nonclinical samples of community men also exhibit
significant levels of concern and body image discontent.
Given that the surveys were cross-sectional, no causal inferences can be made. The
degree of hair loss for men who refused to participate is unknown, and hence, it is
difficult to speculate the magnitude of non-response bias, if any. However, participants
in each country appeared to be fairly comparable to the nation-wide demographics of
men in this age group. It should be noted that substantial regional differences exist
between and even within cultures in terms of perceptions about health and medical
conditions. Despite attempts for cross-cultural validation to achieve linguistically
equivalent instruments, the translated questionnaires could elicit a different response
due to differential interpretation or perceptions by participants in the different countries.
Hence, caution should be used in interpreting any differences among countries.
This study is the first large survey conducted in representative samples of men in four
separate European countries using hair-loss specific measures to assess how the
average man is affected by their hair loss. Male pattern hair loss appears to have
significant negative effects on men 18 to 40 years of age in France, Italy, Germany and
the UK. The degree that hair loss is perceived as noticeable to others appears to be
highly related to these negative effects.
Article accepted on 14/10/99
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