A tapestry of oppression

Now that men's mental health is beginning to receive the specific attention it deserves (Wilkins & Kemple, 2011) this is a good time to draw lessons from developments in related fields. The study of women's mental health has been advanced through gender analysis, and we suggest this perspective can also help us understand and respond to the mental health needs of men. The gender system impacts on men as well as women, it is underpinned by processes that define males and females as different and that provide the justification and conditions for their inequality. Gender is potent because of its centrality to identity and the high level of interaction between women and men. 

Yet despite a long-standing and productive endeavour exploring the relevance of gender inequality for women's mental health (Baker-Miller, 1971; Williams & Paul, 2008; Women's Resource Centre, 2013), this concept is largely absent from the rapidly growing literature on men's mental health. Instead attention is directed to the mental health implications of manifestations of gender inequality such as gender differences, roles, lifestyles, and relationships. 

As a power structure, gender inequality interacts with other systems of inequality including those founded on class, race, ethnicity, age and sexuality – so even though the male gender confers certain privileges, many men do not have privileged lives and fall within disadvantaged groups for other reasons. There is some willingness to consider how social inequalities impact the mental health of those groups of men who can be defined as disadvantaged in these ways (e.g. Robinson et al., 2011; Samaritans, 2013). 

In this article, we counter the pervasive assumption that men only accrue advantages from the gender system and that there are no detrimental effects; and we look at how gender inequality interacts with other dimensions of privilege and disadvantage.

Inequalities are mad making

The ways that inequalities can affect the mental health of people who are socially disadvantaged are well known; potential mediating factors include poverty, deprivation and discrimination. The implications for public health and therapy are not difficult to formulate. For example, policies can target the reduction of childhood poverty, and troubled clients can be offered therapies to help them deal constructively with the psychological consequences. 

More elusive are the mental health implications of the ideologies that deflect attention from inequalities, and support their paradoxical existence in a democracy where legislation and political rhetoric supports social equality. Justification and explanations for the existence of inequalities are woven into the fabric of our society and tolerated as part of normal everyday life, whilst open scrutiny and opposition is discouraged. This lack of transparency poses a significant threat to mental health; it is difficult for individuals who are harmed by inequalities to make sense of their experiences. 

To illustrate, a young man who has a deep-rooted commitment to being strong in the face of difficulty and loss, and whose family and friends share this gendered expectation, may not be able to fathom his responses to the death of someone significant. He is denied access to helpful words, explanations, social support and validation. Instead his struggle to survive may precipitate him into the criminal justice system or reliance on alcohol and drugs, or may be read as signs of madness by himself, his family and professionals alike.

In the last 40 years much has been written about how gender analysis can inform mental health work with women (Women's Resource Centre, 2013), and to some extent men from disadvantaged groups (Robinson et al., 2011; Samaritans, 2013). Men from disadvantaged minority groups are in fact particularly vulnerable to having their experiences named for them by those who have more power. In contrast, very little has been written that considers the implications for men positioned as privileged. Yet white middle-class men are not spared mental health difficulties; furthermore they may encounter particular difficulties decoding their experiences in the absence of the understandings, solidarity and support that can be gained from belonging to a disadvantaged social group. 

At this point it would be easy to be distracted by a comparative analysis, to try to quantify which groups of men are most under siege in terms of their mental health; this is not helpful. The main challenge is to map the links between social inequalities and mental health and gain understanding of the complex intersections of privilege and disadvantage. Below are some of the key issues that need consideration. 

Becoming male 

Psychologists have been major contributors to the study of gender socialisation (Fine, 2010). Right from the enthusiastic 'colour coding' of young children to remind everyone, including them, of their gender categorisation (Eliot, 2010), beliefs, expectations and attitudes about what it is to be a man and a woman give substance to the gender system. Indeed there are indications that gender socialisation has become increasingly robust as legislative barriers to equality have been removed.  

Socialisation continues to encourage women to develop characteristics and competencies that suggest they are not well suited to exercising power, but which are compatible with a position of subordination. These include being useful and pleasing to others, compliant and uncomplaining. In contrast men continue to be socialised to develop psychological characteristics that are consistent with the exercise of power (Connell, 2011; Seguino, 2007). Global capitalism and nationalism benefit from the defining features of masculinity, such as competition, acquisition, bravery and domination, and when required large numbers of the right sort of people can be delivered to military life (Sjoberg & Via, 2010). 

However, while shaping men's identities and lives in this way may serve the collective interests of some groups; this is at considerable cost to the mental health of individual men. The central requirement of hegemonic masculinity which is crucial for perpetuating the gender system – that men are strong, tough, winners and providers – has important mental health ramifications. 

To begin with, there is good evidence that gender socialisation places heavier constraints on males than females. Men are being trained to be powerful and to take power, and the greater cultural value attached to 'masculine' compared to 'feminine' interests and behaviours means that more tolerance is shown to women who stray from what is expected. This is nicely illustrated by the comparative value of 'sissy' and 'tomboy'. Young men inhabit a world where being described as 'gay' or 'like a girl' is a taunt rather than an observation or compliment; where the rapid commodification and commercialisation of all things male – including appearance – makes being 

a 'real' man completely unrealistic; not least because of their limited access to power. Young men are under pressure to give up physical affection from their parents; to demonstrate their independence and capacity to thrive without emotional and physical intimacy (Floyd, 2000). They also have to negotiate the world of shifting relationships without many of the skills young women are expected to develop; men tend to have fewer close friends than women and to feel less well connected to their communities. It should not be surprising then that young men exposed to the full force of the unreasonable and unrealistic expectations of masculinity should be at risk of: depression, psychosis and suicide; becoming reliant on drugs and alcohol; retreating into the fantasy worlds of sex and power provided by new technology; and of feeling entitled to having their sexual needs met by young women (Harland, 2008; 2009; Sanders, 2011).

The common thread of masculinity also exists in a nexus of other social inequalities, and is modified by material and social processes (Connell, 1995; Robertson, 2007). The hierarchal ordering of these variants of masculinity then positions men from black and minority ethnic (BME) groups and other disadvantaged categories as subordinate and marginalised. Such subordination involves cultural stigmatisation, which means that BME men are marginalised from full participation in society with devastating psychological sequelae (Robinson et al., 2011). It is known that groups who are in lower societal hierarchies suffer from greater psychological difficulties; that this is associated with a greater risk of psychiatric hospitalisation is unsurprising (Fernando & Keating, 2009). 

While all men may recognise something of their own experience in this brief outline, most negotiate the constraints and contradictions of masculinity without serious harm to themselves or others. This suggests there are also protections against the insults of gender inequality. The most obvious is being valued for who you are rather than for how well you approximate the caricature of a 'real' man. Unconditional love in early life and safe, valued, relationships in later life are likely to be especially important in this respect. Being male may also confer other protections such as opportunities, money and the power to define rather than be defined. Yet such advantages are not equally shared by all men. The majority of BME men are not in positions of power and lack the resources (e.g. economic) that can help other men to benefit from male hegemony.

Men's lives

Evidence is gradually being pieced together about the mental health risks embedded in the gendered lives of men. Given the mental health significance of trauma, it is relevant to consider the extent to which violence and trauma are gendered in origins and implications. 

Male dominance is not only based on a hierarchy of men over women, but some men over other men. From childhood, men are required to engage in power struggles to establish pecking orders; bullying, violence and fear of violence play a significant role in these power struggles (Addis & Cohane, 2005; Harland, 2008). Racial violence is still a common feature in the lives of BME men: race attacks count for four fifths of hate crime in which 80 per cent of the perpetrators are white men (Chapline et al., 2011). 

Seen from this perspective it becomes clear that men's violence against women is linked to men's violence against other men and also to the internalisation of violence; to violence against the self. Male power is also exercised through emotional and sexual abuse; the victims include men as well as women. It also needs to be recognised that women's resistance towards, and rage against, their lived experience of gender inequality is not always self-directed. It can take forms that harm the psychological well-being of the individuals they live with, for example, through the misuse of their relational and emotional power (Williams et al., 2008). The complexities of interpersonal violence and abuse played out in the context of gender and other inequalities needs to be acknowledged and charted.

Unfortunately, thinking, practice and service responses are commonly influenced by the dichotomous assumption that survivors are female and perpetrators are male. The belief that men are too strong and tough to be victims protects gender inequality at men's expense. This is the context within which victimised men make sense of their experiences; which invites them to conclude that if they didn't stop it happening they must be weaklings, or wimps. Damage and harm to men is hidden and minimised when the complexity of gender-based power relations are ignored. This also happens when the sexual exploitation of young men by older women, and violence against men from women is treated as comedy, and when it is considered normal for young men to experience violence on the streets.

The domestic and work roles that have traditionally provided men with opportunities to feel powerful are also changing. Evidence is accumulating about the toll on men's mental health of unemployment, redundancy, economic loss and relationship breakdown; problems that are typically felt more keenly by men than women, partly because the directive to be 'strong and powerful' is often translated into being a 'provider' (Samaritans, 2013). It is also important to remember that these risks are not evenly distributed amongst men: for example, young black men are particularly vulnerable. They generally have higher rates of unemployment, live in poorer housing, report poorer health and have lower levels of academic achievement, higher rates of exclusions from schools and overrepresentation in prison statistics (Becares, 2013; White, 2002). The well-documented relationship between perceived racism and mental health (Karlsen et al., 2005) is exacerbated by the social disadvantages experienced by BME men (Erens et al., 2001, Robinson et al., 2011).

Commercially driven solutions to men's feelings of powerlessness are traps that prevent rather than enable them to build meaningful connections with their fellow humans. Included here would be using alcohol and drugs, including steroids, and boundless opportunities to identify with powerful protagonists in online games and pornography. Many culturally specific solutions, such as gang membership, are also high-risk, because of the invitation to categorise some men as bad and to socially marginalise and reject them. Indeed following the case of Christopher Clunis – a black man with a diagnosis of schizophrenia who killed Jonathan Zito in 1992 – simply being a BME man experiencing mental health difficulties may be sufficient to trigger the stereotype of 'big, black and dangerous'. 

Within the constraints of the gender system it isn't only feelings of powerlessness that are hard for men to acknowledge. Other feelings such as fear, shame, sadness and vulnerability are inconsistent with hegemonic masculinity. Acknowledging and expressing such taboo feelings can be inhibited by the dread of being diminished – of being 'unmanly'.  This isn't simply a private matter. Reponses of family and friends can be crucial in giving, or denying, a man permission to be real. This isn't as easy as it sounds – vulnerable men can unsettle gender relations. As one young woman memorably remarked about her partner, 'I'd rather he hit me than cried'. Anger and aggression are not the only 'manly' ways of surviving, other ways include reliance on drink or drugs and other distractions, hyperactivity, risk taking as well as suicide and psychosis. It is common for such behaviours to be labelled as normal, bad or mad and for their origins in unacknowledged distress to be unexamined.

We invite you to reflect on the ways that manifest behaviour may be rooted in efforts to survive life's difficulties and trauma within the constraints of masculinity, and to not be content with superficial explanations, especially when they ignore the existence of gender inequality. 

Service responses

It is widely recognised that the mandate to be 'tough' and 'strong' can prevent men communicating vulnerability and from seeking informal and professional help (Addis & Mahalik, 2003). However, it would doubtless be easier for men to overcome this reticence if there were unequivocal evidence that mental health services had something to offer them; that they really could be helped to decode their 'signs and symptoms' of psychological harm and to move forward in their lives. Unfortunately, gender inequality is not only a determinant of men's mental health, but also of the ways that services respond, or fail to respond to these needs.

For example, when mental health staff in training are asked to explain why women are usually centre stage in discussions about gender and mental health they consistently say it is because men are supposed to be strong and not have mental health problems. The strength of this unhelpful belief is demonstrated by its paradoxical existence in services where large numbers of men are in treatment. The pernicious effects of the gender system are also evident in the assumptions and practices of inpatient mental health services. For example, a common problem for service managers is that the majority of inpatient staff would rather work with men than women; men are typically less keen to talk about their needs and emotional lives and hence place fewer demands on hard-pressed staff. Furthermore, anxieties about evoking feelings of powerlessness and distress in men can result in staff being reluctant to engage them in therapeutic conversations. Recognising the risk to masculinity of feeling vulnerable and out of control, staff collude with men in keeping their emotions and thoughts under lock and key rather than providing the safety they need to talk. It seems that the private constraint many men experience when it comes to talking about their difficulties is paralleled by professional reticence to acknowledge and respond to men's mental health needs. The mental health needs of men in these kinds of settings are likely to remain unknown and unmet. The uncontested workings of gender inequality are manifest in this collusion of silence. 

Conclusion

Gender inequality is interwoven with other dimensions of oppression and needs to be the starting point for building knowledge about men's mental health difficulties and shaping service responses to their needs (Williams & Miller, 2008). We all have significant stories to tell about our lived experience of gender and other inequalities, and this recognition needs to inform the help offered to men with mental health needs as well as women. Professionals need training and support to become effective gender-informed practitioners who are aware of the opportunities and limitations of their practice and service contexts. 

It is also important to learn from those exceptional services that have an explicit commitment to working with men from an inequality-informed perspective. Some examples are described later in this issue by our colleagues Kingerlee et al.  

This is a public health matter for which we are all accountable through our participation in the systems and practices that sustain inequalities. Increased awareness of the harm caused to men as well as women will make change more possible. The case for change is strengthened by the recognition that liberating women from restrictive gender roles and gendered oppression is inextricably bound up with liberating men from the same things. It is not a zero sum game; though it is mainly men (often particular groups of men) who control the money, cultural power and political authority needed for this to happen. 

Jennie Williams is Director, Inequality Agenda [email protected] 

David Stephenson is an Associate Mental Health Worker, Barnet, Haringey and Enfield Mental Health NHS Trust [email protected]

Frank Keating is Senior Lecturer, Royal Holloway University of London Frank. [email protected]  

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