Masculinities and Mental Health Help-seeking Among Men in Marginal Communities

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While gender and global mental health discourses have focussed on women, it is also important to interrogate how masculinities influence mental health and wellness of both men and women across the world. As gender relations are constituted by the interactions of both masculinities and femininities, alienating one during study and policy design and implementation is likely to result in weaker outcomes. In this paper, I particularly examine the connections between conformity to hegemonic masculinity norms and mental health help-seeking behaviour with a focus on young men in marginalised communities. I begin by briefly discussing academic studies detailing interactions between men and mental health — and how sex and gender play a role in the interactions. Then, I highlight and define key psychological and sociological frameworks that seek to explain how masculinities develop and how they interplay with mental health. I argue that both adherence to and the conflict that comes from non-adherence to hegemonic masculinities — dominant forms of masculinity — not only increase incidence of mental ill-being, but they also inhibit help-seeking behaviour among men. I also argue that this is exacerbated by the low-income setting men in marginalized communities find themselves in and the lack of focus on men in Gender and Development discourses. However, I argue, western, biomedical epistemologies and treatments of mental ill-being — like psychotherapy, psychiatry and pharmacotherapy — have not adequately adapted and cared for mental health needs of men in marginal populations and more indigenous, nuanced approaches that are sensitive to both cultural context and socio-economic determinants are likely to be more effective.

Firstly, it is important to define and distinguish between sex and gender — before analysing how both influence incidence rates and experiences of mental wellness and ill-being. While sex is primarily biologically defined through aspects such as anatomies of the reproductive system or differences in hormonal make-ups, gender is socially constructed through the roles assigned to different individuals based on the cultural understanding of what is masculine or feminine (Addis & Mahalik, 2003). Multiple studies have shown that both sex and gender influence individuals’ mental illness experiences and help-seeking behaviours. For instance, a study by Jenkins & Good (2014) showed that the incidence of alcohol use disorders is seven times higher among men than among women while depression and migraines incidence rates among women are twice and thrice higher among women than among men, respectively. Suicidal ideation has also been observed to be higher among women, even though death by suicide tends to be higher among men, primarily because men tend to attempt suicidal methods that are more lethal (WHO, 2002). Similar sex differences have been observed across various age groups: a WHO report (2002) points out that young boys tend to display aggressive and anti-social behaviours more than girls; adolescent girls tend to have higher prevalence of depression and eating disorders than adolescent boys and even though incidence rates for Alzheimer’s disease are similar across sex, women’s overall higher life expectancy means that more elderly women live with the neural degenerative illness than elderly men (ibid). While the prevalence rates may seem clear cut across sex lines, the underlying causes for these differences are complex and multi-dimensional. For instance, the higher incidence rates of drug-related disorders among men have been shown to relate to uncontrollable events such as bereavement and job insecurity as well as the socialisation not to express emotions in other ways (ibid). The socialization process and the social milieu people occupy impact both their experiences of mental wellbeing and help-seeking behaviours — and are thus worth paying close attention to.

To a significant extent, expressions of masculinity are learnt through gender-role socialization as boys and men grow. Male gender role socialization is the process by which male individuals evaluate and adapt their behaviour and attitudes in accordance with male gendered norms which are influenced by culture, socio-economic background, race and other factors (Mahalik et. al, 2003). Psychological literature reviews identify two major models to describe how masculine role socialization occurs: masculinity ideology and masculinity gender role conflict (GRC) (Addis & Mahalik, 2003). Masculinity ideology refers to the beliefs that one has about what it means to be male; it is a measure of endorsement and internalization of cultural norms and values on masculinity (ibid). While these ideologies vary across cultures and individuals — and even within individuals over time and across contexts — it is common for certain ideologies to be perceived as powerful and normative. On the other hand, masculinity GRC is defined as “a psychological state in which socialized gender roles have negative consequences for the person or others when rigid, sexist, or restrictive gender roles result in personal restriction, devaluation, or violation of others or oneself” (O’Neil et. al, 2016, p 12). For example, even though men’s experiences of GRC (from, say, teasing from peers for not acting tough enough or being passed for promotions for not acting competitively) has been linked to higher levels of mental distress, it has also, counterintuitively, been linked to less willingness to seek psychological help — which in a sense hurts their wellbeing (Good & Wood, 1995). Beyond psychological studies — which are usually limited by small samples of participants who are mostly young, white, college-attending students in western countries — other fields with more sociological lenses such as gender studies and masculinity studies have been theorizing the development of masculinities and their ramifications. An influential concept in these fields is hegemonic masculinity which, drawing from analysis of patriarchal power dynamics in societies, is defined as the dominant notion of masculinity in a particular historical context” (Connell, 1987). Hegemonic masculinity is perceived as normative, “the most honored way to be a man” and usually legitimizes the subordination of women to men. While most men veer off these stereotypical conceptions of hegemonic masculinity, it is common for individuals to worry about the perceptions of others who might view them as unmanly for their deviations from the norm. Nonetheless, hegemonic masculinity as a concept has been used to study gender dynamics in a variety of contexts and organizations. Relevant to the current paper, for instance, Kupers (2005) conducted a study that showed that men in US prisons tend to display an exaggerated form of hegemonic masculinity that values toughness and inhibition of emotionality; this, in addition to a plethora of other institutional factors, leads to resistance to common treatments of mental illness such as psychotherapy by many of the male prisoners.

The mental health treatment gap — the difference between people who need mental health care and those who actually receive it — has been heavily documented and debated in the past several decades especially with the emergence of the global mental health movement. According to WHO (2018), while 14% of the global burden of disease is attributed to mental, neurological and substance use disorders, most of the people affected — 75% in many low-income countries — do not have access to the treatment they need. Scholars such as Mills (2016) have argued that the mental health treatment gap argument is limited as it does not account for access to indigenous forms of care in most Low- and Middle-Income Countries (LMICs) or seek to address key social determinants of distress. Even in contexts where mental health services such as counselling are available, their underutilization is quite common. This underutilization has been observed to be higher among men — who according to Kessler, Brown, and Broman (1981) are less likely to seek help when experiencing the same level of distress as women. Even more worrisome and relevant to the current essay, men from minority groups such as African Americans or immigrants seek psychological help less than other men (Chandra et al., 2009). Partly, this is explained by lack of access to mental health services and the requisite economic facilities such as health insurance, but it is partly explained by more reluctance to seek treatment and higher levels of stigma associated with seeking mental health services. As Addis and Mahalik (2003) point out, help-seeking tasks like relying on others and recognizing and labelling an emotional problem often run counter to the masculinity scripts men are given on the importance of self-reliance, physical toughness and emotional control. Vogel et al (2011) also found that men who endorse traditional gender role norms such as independence and emotional control at all costs tend to have a negative view of help-seeking as they view it as a threat to their idealized masculinity. Part of the negative attitudes, they argue, is mediated by social stigma towards seeking help by others as well as self-stigma by the individual men. Social stigma in help-seeking contexts, as the name suggests, is the negative association that other people attach to mental illness and help-seeking. Conversely, self-stigma us the internalization of the negative perceptions, leading one to view themselves as inferior or weak for seeking such help (Pederson and Vogel, 2007). Multiple psychological studies (e.g. Mansfield, Addis and Courtenay, 2005; Magovcevic and Addis, 2005) show that self-stigma is more salient among men who report higher levels of GRC. Therefore, more men are disinclined to disclose their distress and seek help. While Vogel et. al. (2011) replicate the findings with a more diverse set of male participants from different ethnicities and sexual orientations, the participants are still all North Americans and other forms of help-seeking outside psychotherapy which might be more appropriate in other countries are not considered. A key weakness of these discourses on the underutilization of mental healthcare resources is their framing of mental healthcare resources as exclusively western, biomedical therapies. This framing often crops out other methods of seeking care which men in these communities might find more culturally appropriate, effective and in line with their epistemologies of the world.

For men in low income communities, the hindrances help-seeking and access to mental health care discussed above are exacerbated by other socio-economic determinants of psychological distress. For example, inability to provide for one’s –and their family’s — basic needs and physical safety clearly leads to more psychological distress. Moreover, inequality across and within countries has been shown to correlate with mental illness even in wealthy countries (Global Health Watch, 2011). For instance, the high suicide rates among small-scale farmers in rural India have been linked to unfair competition, rising prices, erratic weather, and heavy debt (ibid). Other negative conditions that people in marginal populations faces such as structural discrimination and conflict are not only likely to yield higher levels of mental distress, but also affect their ability and resources to cope or recover from such circumstances. Yet, as we’ve seen above, men in these marginalized communities are less likely to seek mental healthcare in forms such as counselling. According to an editor of an anthology detailing experiences of members of Black, African, Minority and Ethnic (BAME) communities in the UK, the mental health system in the UK is not designed for these communities. She cites, for instance, how the diagnostic criteria are based on what is normal for the western world and the lack of representation of people from these communities among counselling professionals in the system who are likely to have shared experiences, hence understand them better (Samara, as quoted in Kankhwende, 2018). Psychotherapy may also be seen as a de-politicization of the social determinants underpinning the mental distress itself. As Mills (2016) argues, some of the signs of distress are normal human reactions to living in the socio-economic milieu that these communities inhabit and recommending psychotherapy and medication of such reactions constitutes a “pathologization of normal sadness”. For men in marginalized communities and LMICs, they face an additional hurdle as they are often framed in development and global mental health discourses as the causes of the problem — never the victims of dysfunctional systems. White (1997) points out how men either do not appear in gender and development discourses or appear as “hazy background figures” who are usually depicted as lazy, violent and individualistic: putting their own desires for alcohol before their family’s needs. This depiction, often with imperialistic tropes and undertones, is stereotypical — in that it doesn’t represent the traits of majority of the men in these communities — and detracts from the more critical discussion on the social-economic conditions that lead to mental distress among the men themselves and how this often manifests itself in ways that affect other members of their families and communities. It also curtails conversations of the appropriate remedies to both the mental distress among the men as well as the social determinants that underpin it.

Furthermore, psychotherapy and pharmacotherapy themselves are centred in a neo-liberal, commoditized form of care that might not appeal to men in marginalized communities whose values are more community-based or spiritually-oriented. Thrift and Sugarman (2018) point out that counselling psychologists are professionally incentivized to frame problems as arising from individuals. This is problematic as it masks the social and political contributors to mental illness that operate on a communal or structural level and places the blame on the individual. As such, this pathologization of sadness allows them to recommend their own services as solutions. Similar arguments have been made against pharmaceutical companies. Mills (2016) notes how big pharmaceutical companies use connections with NGOs in LMICs to offer free samples — thus promoting the dominance of the biophysical approach to mental health care and raising questions of consent. Institutionalized psychiatry, where most of the miniscule of mental health budgets in LMICs are spent, has a long history of abuse and neglect. As such, it is not surprising that people in these countries are likely to resist seeking help there.

This raises the question: what does all this understanding of both men’s help-seeking behaviour and its relation to masculinities as well as the challenges that socio-economic determinants of men’s mental health in marginalized communities pose to biomedical methods of intervention like psychotherapy and psychiatry imply for better, more effective approaches to the challenge of achieving mental wellbeing for these men? Generally, these implications fall into two broad categories: 1) ways that the biophysical and psychological methods of care can be adapted to fit the mental health needs and preferences men in these communities and 2) embracing a broader conception of mental care that include indigenous, communal and spiritual approaches as well as addresses the socio-economic determinants of mental distress. Adapting the biophysical and psychological methods may take a plethora of approaches such as ensuring that there is diversity in the professional care teams and including input from a variety of voices when developing diagnostic criteria and treatment options. This is likely to improve levels of trust in these systems of care. Also, while it is difficult to reverse decades of socialization into hegemonic notions of masculinity that hamper help-seeking among men, psychological studies such as (Vogel et. al, 2011) recommend interventions that mitigate mediating factors such as social stigma and self-stigma. An example of this is reframing the belief that seeking help is a sign of weakness — but rather is a sign of strength — because it takes courage to acknowledge and confront a problem. It might also include encouraging use of more personal platforms such as websites or call lines where privacy is more guaranteed. Also, masculinity gender role conflict may make men less inclined to discuss their emotions with others, including professionals, and thus framing the discussions as thought-based (not emotional-based) has been shown (Robertson et.al, 2015) to improve attitudes towards psychological interventions. Also, Robertson and team’s report recommends adopting outdoors, social and active methods that men are likely to find more empowering. On a broader scale, the limitations of psychological and biophysical approaches, implies interrogating the socio-economic determinants of mental distress and seeking to tackle them as well as finding ways to understand and employ indigenous and communal methods of dealing with mental distress. This also means including men in marginal communities and listening to their voices in a more nuanced manner in both development and global mental health discourses.

In conclusion, this essay has demonstrated that hegemonic masculinities have a significant and negative impact on mental health help-seeking behaviour among men — more so among men from marginalized communities and in LMICs. This is even more pronounced when dealing with biomedical treatments of mental distress. The lack of focus on men’s mental health as it relates to development and indigenous forms of alleviating mental distress means there is a dearth of research in this area — which is an interesting area for future research projects. I have also shown the weaknesses in copy-pasting bio-medical epistemologies and treatments into marginalized communities without considering the cultural, historical and socio-economic contexts men in these spaces inhabit. Finally, I have suggested some ways that both biomedical and indigenous approaches for dealing with mental distress can be adjusted to fit needs and contexts of men in these marginalized communities and LMICs.

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