There is a perception that women are more likely to experience common mental disorders than men. Statistically, women do appear to suffer more frequently from depressive and anxiety disorders, featuring more regularly in primary care figures for consultations, diagnoses and prescriptions for psychotropic medication. This has remained consistent throughout the post-war period; current figures suggest that women are approximately twice more likely to suffer from common mental disorders than men. However, recent research initiatives undertaken by organisations such as the Men’s Health Forum, Mind, CALM and Samaritans suggests that the situation is less clear-cut. Homelessness, alcohol abuse and drug addiction are, for example, more common in men. 73% of adults who go missing are men; 90% of rough-sleepers are men; and men make up 94% of the prison population. Most worryingly, the Department of Health’s Statistical Update on Suicide (2015) suggests that 78% of all suicides are among men. Adult men under the age of fifty are considered to be a specific group ‘at risk’ and men aged between 39 and 49 are now the group with the highest suicide rate. The male suicide rate has increased significantly since 2007, while female rates have remained relatively consistent. Increasingly, research also suggests that when men do seek medical help, psychological distress in men presents in different ways. They report physical symptoms such as digestive disturbances, headaches, insomnia and musculo-skeletal pain. Their symptoms may have an emotional cause, but are not recognised within conventional approaches to diagnosis of mental illness.
Questions about whether or not women really are more prone to psychological illness have been hotly debated among psychologists, social scientists and historians. Some researchers have begun to question the reliability of current data on gender and mental illness, arguing that most large-scale epidemiological surveys rely on self-reporting. This increases the likelihood that women will feature more commonly than men in the data, since men are less likely to recognise, express or report psychological symptoms. Most epidemiological surveys continue to exclude physical and psychosomatic presentations of illness, focusing instead on classic symptoms of low mood and anxiety. If we continue to adhere to the tightly defined markers determined by the prevailing biological model of mental illness, men’s mental illness will continue to be neglected.
Following the publication of the previous coalition government’s strategy document No Health Without Mental Health (2011), mental wellbeing began to attract much-needed publicity. The recent Independent Mental Health Taskforce findings (2015) and the collective cross-government strategies for preventing suicide in England, Wales, Scotland and Northern Ireland, all highlight the importance of preventing mental ill-health in the first place as a core theme. Men are identified in this literature as needing specialist engagement. However, prevention strategies must involve much greater financial and philosophical commitment to ameliorate many of our most pressing social problems such as drug and alcohol abuse, isolation, long-term unemployment, debt and divorce – problems which often impact most seriously upon men. Additionally, without underestimating the important role biological psychiatry plays in the treatment of some mental illness, there is much evidence to suggest that the prevailing biomedical model of mental illness excludes a wide range of symptoms more often seen in men. Greater emphasis upon the role of sociocultural factors in disease, alongside the promotion of a holistic, interactionist model of mental health would do much to improve detection of psychological disorders in men before they reach the point of crisis.
The enduring cultural association with femininity and irrationality stems from ancient Hippocratic medicine which held that if an adult woman was not sexually active, her uterus would rise within the body cavity seeking ‘gratification’, causing a range of symptoms understood as hysteria. This theory was surprisingly resilient, despite developments in anatomical knowledge that questioned such possibilities. Supernatural and demonic theories of madness waxed and waned during the centuries leading to the early modern period (around 1500-1800), when hysteria was included once again within the ‘medical’ sphere. Although ‘melancholy’ men appear in these texts sporadically, it was not until the late seventeenth and early eighteenth centuries that men occupied a more prominent position in the story. As I pointed out in an earlier Opinion Article, ‘Men, mental health and suicide in the UK: The importance of the long view’, (November 16th 2015), and as the historian Mark Micale has shown, the increasing use of cadavers and advances in the technique of dissection led to new understandings of the body’s central nervous system. This resulted in new interest in nervous disorders, which were thought to affect men and women alike. During the Georgian period (1714-1830), the individuals thought to be most seriously affected by ‘nervous distempers’ were those from the cultured, well-to-do classes, who were considered to have a more refined and fragile nervous system. Nervousness among the higher social strata was commonly accepted and seen as a sign of ‘good breeding’. The display of emotion in this period was not associated with homosexuality or effeminacy – being ‘manly’ in Georgian Britain primarily meant being virtuous and wise. Male emotionality, therefore crossed no inappropriate boundaries and men were quite comfortable looking inward and being reflective about their physical and psychological experiences.
The Victorian period that followed ushered in a host of social and cultural changes. Bolstered by the evolutionary theories of Charles Darwin and Herbert Spencer, this period witnessed the emergence of new constructions of male and female. Women became viewed as biologically inferior to men, dominated by their reproductive systems and prone to irrationality. Men, in contrast, were considered to be rational ‘restrained’ beings. By the mid nineteenth century, Britain had become the world’s leading industrial nation. British ascendency required the projection of ‘power’ and ‘control’ – qualities that did not fit well with a notion of male nervous instability. Industrialisation itself promoted the division of labour by sex. Heavy factory work, mining and construction became distinctively ‘male’ environments, while symbolically, women became the ‘angels in the house’. Additionally, within European medicine and psychiatry, the study of human sexuality emerged. In this new field, homosexuality became pathologised, fuelling anxieties about male effeminacy and emotional openness.
Accounts of female insanity have largely dominated the medical literature from this period onwards. The one important exception has been the psychological and psychosomatic symptoms of trauma in combat. Unexplained and troubling symptoms of trauma have featured in all major combat zones, dating from early accounts of cerebro-spinal shock during the Napoleonic Wars; cardiac exhaustion during the Boer War; shell shock during the First World War, through to more recent experiences of gastric disorders during the Second World War and Post Traumatic Stress Disorder in modern times. Male trauma in war has rightly attracted much interest among scholars and culminated in an extensive literature on the topic; however, much less attention has been focused on the experiences of ordinary men outside the extraordinary sphere of military combat. So how might a longer history inform current debates about gender and mental health within today’s medical and policy arenas?
Prevention is at the core of all recent reports, documents and strategies for improving mental health in the UK. The WHO document Preventing Suicide, A Global Imperative (2014) opens with the words of Director General, Dr Margaret Chan who reminds us that suicides are preventable, and that the burden of suicide weighs not only on the health sector but on society as a whole. Increasingly it is acknowledged that the origins of much mental ill health can be found in social circumstances, for example: in poverty, exclusion, unemployment and relationship breakdown. Although these circumstances impact negatively on both sexes, men are more likely than women to develop maladaptive coping behaviours – particularly in the form of heavy drinking, which is often closely related to suicide. We know that this is in large part due to the longstanding and unhelpful association between mental illness and ‘weakness’, which leads to men’s reluctance to discuss emotional difficulties with others. If we are serious about prevention of mental illness, and in particular the prevention of male suicide, there needs to be much greater willingness to examine the negative effects of specific social circumstances on men.
The extraordinary disadvantage and oppression faced by women in recent history has made it politically sensitive to articulate concerns about masculinity and the male role. Since the mid twentieth century, the emphasis of enquiry into mental illness and life experience has understandably been placed routinely on the particular types of stress experienced by women. Men were discussed tangentially as workers within class structures, as youths, or as ‘problems’, but less frequently as husbands and fathers or male individuals. Over the last twenty years, there has been growing academic interest in men and masculinities, which has produced a rich body of research. Academics working in the field of men’s health, for example, have noted that divorced men have higher rates of mortality, substance abuse and depression. Additionally, they are at a disadvantage when it comes to social support networks, since they are less likely to live with their biological children and are more likely to suffer the loss of emotional support from former friends and peers. Yet a review of the literature suggests that the topic of men’s wellbeing after divorce has been overwhelmingly neglected.
Similarly, a major report, Sick of Being Unemployed: The Health Issues of Out of Work Men and How support Services are Failing to Address Them, by the charity Men’s Health Forum, suggests that unemployment causes serious long-term physical and psychological problems. Although this applies to both sexes, men are more likely to suffer adverse effects than women. Due to the strong cultural association between work and masculine identity, unemployment is likely to affect men’s sense of wellbeing more acutely, and, once again, men are more likely to engage in behaviour, such as problem drinking, which puts health at risk. Most worryingly, the report suggests that unemployment may double, or even treble, the risk of male suicide. Within the context of the current recession, over two and a half million men were made redundant between 2008 and 2013 and it is probable that this group experienced a decline in health during this period. Historically, there has long been an association with suicide and periods of economic decline. Data from the early twentieth century shows that indices of serious mental illness and suicide rates rise within a year of increasing unemployment and that rates of chronic physical illness (such as cardiovascular disease) also rise correspondingly. Research undertaken on data from the interwar period to the late twentieth century suggests that economic instability increases the likelihood of immoderate life habits, the disruption of social networks and major life stress, leading to morbidity and mortality. However, despite the existence of a century of evidence, there appears to be no decisive move towards preventive action to protect men during economic recession.
Within the workplace in Britain, there has been a long history of underestimating numbers of men affected by mental illness and a failure to focus on effective preventive programmes. Historically, debates about the health of workers have primarily focused on concerns about productivity. Specific physical and chemical hazards and on ways of improving rates of absenteeism have been foregrounded. Since the Second World War, data on workers affected by mental illness has been wholly misleading, since men have tended to present with somatic (physical) disorders that often masked an emotional cause. GPs have been reluctant to disclose psychological disorders and substance abuse on sickness certification due to the stigma associated with these conditions. Historically, men tend to be reluctant to partake in workplace health investigations and have been less likely to report sickness if faced with the prospect of the loss of wages. The structure of occupational health in Britain has compounded the situation. As historians such as Vicky Long have noted, the failure to provide a state industrial medical service in tandem with the creation of the NHS in 1948, resulted in a lack of preventive health measures, a reliance on scientific discourse, and a focus on specific occupational diseases. It was feared that an independent industrial health service would exacerbate the shortage of manpower in the NHS. Little incentive existed for employers to establish services to promote health and wellbeing when the NHS existed to treat sick and injured employees. Most of the workforce was employed in non-industrial settings or by small firms, where occupational health was virtually non-existent. In the industrial arena a system was developed of technical experts and engineers who were employed to ensure the safety of the working environment. Opportunities to identify and observe male psychological illness at work were therefore almost certainly obscured by the political agendas of workplace health and compounded by a construction of masculinity (particularly in the heavy trades) characterised by toughness and the importance of not appearing ‘weak’.
Dame Carol Black’s report, Working for a Healthier Tomorrow, published in 2008, nearly sixty years later, suggests that many of these key challenges remain. Among them, she noted that GPs are still insufficiently equipped to offer patients advice about sickness certification – and the stigma of a psychological diagnosis remains. However, most importantly, Black observed that:
Detachment of occupational health from mainstream healthcare undermines holistic patient care. A weak and declining academic base, combined with the absence of any formal accreditation procedures, a lack of good quality data and a focus solely on those in work, impedes the profession’s capacity to analyse and address the full needs of the working age population.
Shortly after the release of Black’s report, researchers from the men’s health charity Men’s Health Forum warned that these findings had potentially serious consequences for men who spend more of their lives in the workplace and are much less likely than women to make use of almost all other forms of primary health provision. In their policy briefing paper, the authors noted that the NHS should begin to find ways of delivering services to men more effectively than has been the case in the past.
In terms of the primary prevention of mental illness and promotion of wellbeing, one arena that offers real opportunity is working with schools and young people. In theory, the current provision of personal, social, health and economic (PSHE) education delivered in schools provides space for the exploration of a wide range of topics, including gender identity, mental health and wellbeing. There should be significant opportunities within the scope of these sessions for teachers to challenge some of the damaging perceptions that have grown up around masculinity and emotional expressiveness. History is uniquely placed here to illustrate how gender is not ‘essential’ or fixed, but instead time and culture bound. History can tell us much about the origins of dominant forms of masculinity and we could develop imaginative ways of encouraging children to look to earlier periods and alternative constructions of masculinity, to cultivate healthier ways of expressing emotional distress.
However, the report of the House of Commons Education Committee (2015) has recently exposed inconsistencies in the provision of PSHE among schools, with 40% of provision requiring improvement. The Committee stated that there was an overwhelming demand for PHSE, and that it should be given statutory status. However, in their view, there was a mismatch between the claims of commitment from the Government and the steps taken to improve it. In February, demands for statutory status – put forward not only by the Education Committee, but also by a long list of parliamentary committees, the Children’s Commissioner and the Chief Medical Officer – were nevertheless rejected by the Government, leading the PSHE association to declare the situation ‘an appalling failure’.
If, as the longer history and the recent Task Force Report suggest, much mental ill-health stems from social problems such as poor housing, poverty, divorce, unemployment and difficult life experiences, there must be more focus and financial commitment upon the primary prevention of mental illness and the broader determinants of good mental health.
Since the middle decades of the twentieth century, there has been increasing confidence in curative medicine and the treatment of mental illness has been largely dominated by biological psychiatry. This has been the case particularly in the UK, where the practice of psychoanalysis was less influential than it was in the USA. Despite attempts during the mid-twentieth century to promote the importance of constitutional and social factors in disease by the social medicine and ‘biopsychosocial’ movements, the divide between prevention and cure has never fully been bridged. Only a small number of general physicians recognised the potential of holistic practice and traditional ideas were exceptionally difficult to challenge. The dominance of the biomedical approach (underpinned by the notion that the mind and body are distinct from each other) has done much to impede the detection of male psychological illness. Doctors who were more sympathetic to a holistic, person-centred approach were more skilled in communicating with patients, and consequently more successful in recognising atypical signs of psychological distress. However, by the late 1970s, it was widely acknowledged that most family doctors were not well equipped to deal with psychological disorders and many of the social problems that presented in practice. A model of medicine which focused more seriously on health issues in cultural, social and economic context, would place greater emphasis on the social causation of disease and the cultural construction of gendered behaviour that is so intimately connected with mental disorders. Historically, the longstanding cultural association with women and mental illness has exacerbated clinicians’ propensity to diagnose psychological disorders more readily in women than in men. The World Health Organisation’s paper Gender Disparities in Mental Health (2011), states explicitly that gender stereotyping continues to compound difficulties associated with the identification and treatment of mental illness. The report concludes that reducing gender disparities in mental health involves looking beyond mental illness as a disease of the brain and requires mental disorders to be socially contextualised.
In the detection of mental health disorders and in the management of diagnosed conditions, engaging with the emotional lives of men in the twenty-first century appears to be no less problematic than it was over fifty years ago. Recent research has shown that much distress is routinely unrecognised because many men struggle to locate the language of expression. Alexithymia (the inability to express emotions) is increasingly considered to be an aspect of the ‘post Victorian’, normative model of masculinity, and as such, poses a major barrier to men seeking therapy. Recent research also suggests that many mainstream services have failed to engage with men effectively over wellbeing and that modern services might be ‘inherently feminised’ because of the disproportionately low number of men working in frontline mental health service provision.
A number of important themes emerge from current academic research on male wellbeing. Firstly, there is evidence that men are more likely to disclose mental health problems and suicidal thoughts if they have access to a safe, appealing (and non medical) space. Pre-crisis management is essential in the detection of signs of distress, and informal settings such as sports venues have provided the opportunity for positive health interventions. Online and telephone provision of support has also proved successful in allowing the anonymity some men require to open up. Yet challenges remain. Should practitioners confront or exploit familiar notions of ‘stoic’ masculinity in order to persuade men to think about their mental health? Initiatives that are delivered in traditionally male spaces such as sports venues, may reinforce the very ‘masculine’ ideals from which we aim to move away.
Historically, the failure to recognise mental health issues in men has been the result of a complex range of factors from within medicine, the workplace and wider society. The longstanding cultural association with women and mental illness is unhelpful and has led both to an unwarranted association between femaleness and irrationality, and to a serious underestimate of numbers of men who suffer from emotional and psychological difficulties. Undiagnosed depression is thought to contribute significantly to numbers of male suicide and men are still known to be less likely to recognise depressive disorders and less likely to seek medical help for symptoms. The clear policy message is that there must be serious and long-term commitment to prevention and support services. Conclusions from history, and from recent studies, suggest convincingly that reliance on the medical model is insufficient and that medicine, society and culture need to change. There is undoubtedly an important role for biological psychiatry and psychotropic medication; however, there should be a greater focus on understanding the broader social and cultural determinants of good mental health. A serious commitment to the prevention of mental ill-health, in both sexes, will require targeted interventions to foster emotional literacy during early years; to provide support during difficult periods such as unemployment and divorce; and to focus on specific high-risk groups (for example, ethnic minorities and LGBT communities). The recent literature also identifies a need for further professional training – for clinicians and others working in the field – to raise awareness about gender and socialisation.
History should play an important role in three key ways when informing policy and practice in relation to men’s mental health and male suicide. Firstly, it offers the opportunity to challenge existing perceptions about gender and mental health, by exposing, uncovering and perhaps ‘normalising’ male mental illness. Secondly, history helps us understand and explain the many complex reasons why, in the modern period, male psychological distress has been so hard to detect, offering insight about how we might cultivate change. And thirdly
history offers novel opportunities in schools, sports venues and doctors’ surgeries, to educate men about alternative masculinities – such as the ‘introspective male’ of the eighteenth century. As such, it provides a powerful tool for challenging the inevitability of certain negative health-related beliefs and behaviours. Historians are well-placed to work alongside psychologists, health scientists and policy-makers to facilitate change, supported by evidence from the longer view.
M. H. Brenner, ‘Mortality and the national economy: a review and the experiences of England and Wales’, Lancet (1979), 2, 568-73.
Ali Haggett, A History of Male Psychological Disorders in Britain, 1945-1980 (Basingstoke, Palgrave Macmillan, 2015).
Roger Kingerlee, Duncan Precious, Luke Sullivan and John Barry, ‘Engaging with the emotional lives of men’, The Psychologist, 26, June 2014.
Vicky Long, The Rise and Fall of the Healthy Factory: The Politics of Industrial Health in Britain, 1914–60 (Houndmills: Palgrave Macmillan, 2011
Mark Micale, Hysterical Men: The Hidden History of Male Nervous Illness (Cambridge MA, Harvard University Press, 2008).
Linda Morison, Christina Trigeorgis and Mary John, Are mental health services inherently feminised? The Psychologist, 26, June 2014.
S. Robertson, A. White, B. Gough, M. Robinson, A. Seims, G. Raine and E. Hannah, Promoting Mental Health and Wellbeing with Men and Boys: What Works? (Leeds Beckett University and Men’s Health Forum, 2015).
David Wilkins, Untold Problems: A Review of Essential Issues on the Mental Health of Men and Boys (London, Men’s Health Forum, 2010).
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