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It has been decades, but Rahn Bailey, M.D., can still remember what his eighth-grade football coach told one of his teammates whose hand was injured after it got caught between two helmets during a play. “Stick it in the mud,” Bailey recalled.
“That speaks to this idea that boys and men are bigger and stronger, and they’re supposed to be able to deal with the pain,” said Bailey, APA’s minority/underrepresented trustee, the assistant dean of clinical education at the Charles R. Drew University, and chief medical officer of Kedren Health Systems Inc. in Los Angeles. “I think experiences like that stay in people’s psyches the rest of their lives. The idea that men must be hypermasculine hurts us because, ultimately, it means we don’t do the things we should, from a treatment standpoint, to get the care we need.”
According to the American Foundation for Suicide Prevention, men died by suicide at 3.56 times the rate of women in 2018. Yet women are more than twice as likely to be diagnosed with depression than men. Maybe, Bailey hypothesized, that disparity is because men are underdiagnosed for illnesses like depression. “Men may experience depression just as much as women, but our capacity to diagnose and capture it is missing,” he said.
Examining Masculinity and Suicide
Daniel Coleman, Ph.D., M.S.W., an associate professor at the Graduate School of Social Services at Fordham University, and colleagues examined the association between high traditional masculinity and the risk of death by suicide using data from Add Health, a nationally representative study of individuals from adolescence into adulthood. They published their findings in JAMA Psychiatry in April 2020.
Add Health began in 1995 with 20,745 adolescents, and in 2014, the participants were matched with death records from the National Death Index. Because the study does not specifically include a measure of masculinity, Coleman and his colleagues instead looked at 16 attitudes and behaviors that are presumed to distinguish men and women (such as not crying, not being emotional, fighting, or risk taking), and generated a probability score of the individual’s tendency to align with his or her gender’s traditional role. The participants who scored 73% or higher on the masculinity probability score were classified as having high traditional masculinity.
There were 22 deaths by suicide among the participants, 21 of whom were men. Men with high traditional masculinity were 2.4 times more likely to die by suicide and 1.45 times less likely to report suicidal ideation than men who did not have high measures of traditional masculinity.
Coleman noted that the findings need to be replicated, which he and his colleagues are currently working to do, but the study confirms what many health professionals suspect: Men who exhibit strong signs of traditional masculinity are at greater risk for death by suicide.
“The beliefs about yourself and other people, as well as the emotions and achievements that high traditional masculinity imply, become a restricting psychological factor,” he said. “When they’re under stress, traditionally masculine men don’t have very flexible or strong coping skills.” Suicide becomes an option in which they can preserve their views of themselves as masculine while escaping whatever stressors they’re experiencing, he continued.
Measuring Harmful Masculinity
Another study published last August in Preventive Medicine pointed to an association between harmful attitudes about masculinity and violence perpetration, depression, and suicidality.
The study set out to measure how harmful masculinity is associated with poor health outcomes and the use of violence, said Elizabeth Miller, M.D., Ph.D., an author of the study and director of adolescent and young adult medicine at UPMC Children’s Hospital of Pittsburgh.
Miller and her colleagues conducted a secondary analysis of data from a 2016 survey of 3,673 men aged 18 to 30 years from the United States, the United Kingdom, and Mexico. The survey was conducted by Kantar TNS, a global data company, and sought to determine the prevalence of harmful masculinity characteristics among young men. The online survey took about 20 minutes to complete and included the Man Box Scale, which was developed from several decades of research on assessing men’s personal beliefs about masculinity. The survey also included items from the Patient Health Questionnaire-2 to assess depression, one item to assess suicidal ideation within the past two weeks, and items to measure past-month violence-related outcomes.
The Man Box Scale asked participants to mark their agreement (along a four-point scale) with statements such as “In my opinion, a man who talks a lot about his worries, fears, and problems shouldn’t get respect” and “In my opinion, men should use violence to get respect if necessary.” The researchers included 17 of the Man Box Scale’s statements in their survey.
The researchers found that men who had high Man Box scores had significantly higher odds of perpetrating verbal, online, and physical bullying and sexual harassment. Men with high Man Box Scores also had a higher risk for depression and were up to two-and-a-half times more likely to experience suicidal ideation.
Treating Hypermasculine Men
Bailey has written at length about the diagnosis and treatment of depression in African American men. While studying the topic, he made grand rounds in Mississippi. “It’s the heart of the South, where men are men, and it’s difficult as psychiatrists to get our patients to understand or have insight into their own psychological vulnerabilities or their risk factors for clinical depression,” he said.
“Men are people, too, and people tend to laugh when you say that, but it’s true,” he continued. “Often, because of hypermasculinity, some men—but not all, of course—may be more likely to accept a somatic or medical diagnosis like hypertension or asthma, but not a psychological or brain-based disorder.”
Once men are diagnosed, Bailey said, they’re less likely than women to continue with follow-up care and more likely to self-medicate with alcohol or other substances. All too often, untreated clinical depression causes some individuals to grow sullen, isolated, and internalize their problems, while others externalize their depression, sometimes through violence.
Bailey recently published a book on domestic violence, Intimate Partner Violence: An Evidence-Based Approach, as a resource for health professionals who may encounter victims or perpetrators of domestic violence. Often, intimate partner violence involves a perpetrator who has untreated and undiagnosed clinical depression, he said.
“The person you’re most likely to hurt when you’re having an episode of violence is someone close to you or home with you,” he said. “Hypermasculinity implies: There’s something about me that has to be stronger than you, and whatever the exchange is, I have to win.”
While he worked in Houston for about a decade, many of Bailey’s patients were men who felt more comfortable meeting in a nonclinical space, like a café, than in his office. He found that his patients often wanted to downplay their feelings and imply that they did not have a psychiatric condition. Treatment is further complicated by hypermasculinity because it prevents some men from getting their psychiatric medications filled. “Taking the medications would be an admission internally that they have a problem they can’t fix on their own,” Bailey said.
Some notions of masculinity preventing men from talking about their mental health start young, Bailey said. “You’re indirectly taught to be tougher, stronger, bigger, more masculine, and not to show vulnerabilities. We have to teach our boys that it’s OK to need help sometimes.”
The Add Health study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The study by Coleman and his colleagues received no outside funding.
Miller’s study was supported by the National Center for Advancing Translational Sciences and the National Institute on Alcohol Abuse and Alcoholism. The original Man Box study was funded by Axe Unilever. ■