3.2 Depression

• Studies suggest that depression can occur as often in men as in women.
• Doctors are less likely to diagnose men with depression than women.
• Men may not be as able as women to recognise depression when it occurs (Harris, 1995) ‘Hidden’ or unacknowledged depression may also be a factor behind several of the problems we think of as being typically male – alcohol and drug abuse, domestic violence and failures in intimacy.

Unemployment is a major cause of depression and suicide in men.

• One in seven men who become unemployed will develop depression within six months

PTSD Individuals at high risk of developing Post-traumatic Stress disorder include combat veterans, fire-fighters and victims of violence, groups where men are likely to be over-represented.

3.3 Alcohol and substance abuse

• Morbidity for drug and alcohol problems tend to be skewed towards men, with a ratio of 5.1. Men are far more likely to become alcoholic, and to die prematurely of its effects. Approximately three times as many men are admitted for in-patient care as a result of alcoholism . For those arrested for drunkenness, 90 % are men.
• Alcohol and drug use is the major contributory factor in violent crime: 62 per cent of violent offenders were drinking at the time of the crime

3.4 Serious Mental Health Problems

• Men tend to have an earlier onset of schizophrenia and a poorer prognosis than women.
• Men are more likely than women to be diagnosed with antisocial, paranoid and schizoid or schizotypal personality disorders.
• The number of men formally admitted to NHS hospitals in England and Wales under part II of the Mental Health Act (sections 2, 3 and 4) has risen dramatically in recent years. In the ten years up to 2000-01 formal admissions of men in England rose from 8,673 per year to 13,605, while the number of women admitted increased from 8,908 to 11,696. In Wales during the same period the number of men admitted rose from 547 per year to 780, while the figures for women increased from 558 to 763.
• Black men in particular have high admission rates to hospital under section, and are over-represented in secure units. Men from black and minority ethnic groups have far higher rates of compulsory admission to psychiatric hospital than the general population. They are more likely to be treated with drugs and ECT, and are less likely to receive counselling or psychotherapy
• Research suggests that men are more likely to experience childhood disorders, for example, attention deficit hyperactivity disorder and conduct disorder

3.5 Victims of Violence

• Whilst women may be at greater risk of violence in the home, young men are at greater risk of street-violence than any other group.

The British Crime Survey 2001/2 states that the overall risk of being a victim of violent crime is 4 per cent in the general population. However, young men aged 16 to 24 were identified as being most at risk, with 16.2 per cent experiencing a violent crime of some sort in the year Crime

• Men make up 96 per cent of the UK prison population.
• Men are more likely to be given custodial sentences than women for the same offence.
• 58 per cent of remand prisoners have been assessed as having mental health problems.
• 39 per cent of sentenced prisoners have been assessed as having mental health problems.

Antisocial personality disorder is predominantly found in men and usually begins early in life. Men with antisocial personality disorder make up 63 per cent of male remand prisoners in the UK and 49 per cent of sentenced male prisoners10

4 High Risk Behaviour

• Road Traffic Accidents. Men are twice as likely to be involved in road RTAs, as both driver and pedestrian .

• Aids and safe-sex Taking Risks or Taking Responsibility?

Men are involved in almost every case of sexual transmission of HIV; while most sexual transmission is between men and women, at least one in every 10 cases may be the result of transmission between men Four out of every five drug injectors are men. Without men there would be no AIDS epidemic. Male sexual and drug-taking behaviour is dictated by deeply rooted and widespread concepts of masculinity

The findings describing the current suicide risk amongst young men are particularly disturbing. In a very important perspective on this issue a The Samaritans’ report (Young Men Speak Out, 1999, Samaritans) found that only 39 per cent of suicidal young men would consider phoning the Samaritans. The survey found that:

• 67 per cent of suicidal young men say they have nowhere to turn for emotional help
• suicidal young men are four times more likely to smoke and ten times more likely to take an illegal drug to relieve stress
• more than one in three young men would ‘smash something up’ instead of talking about their feelings
• less than one in five young men would ask their father for emotional support
• 78 per cent of depressed and suicidal young men have experienced bullying
• 69 per cent of suicidal young men have experienced violence from an adult
• 50 per cent of suicidal young men have been in trouble with the police compared to 17 per cent of the non-suicidal.

In September 2002 the Government launched a new National Suicide Prevention Strategy for England. The strategy aims to reduce the number of suicides by at least 20 per cent by 2005. It also aims to ensure that local mental health services use assertive outreach teams to maintain contact with the most vulnerable patients. Young men are a particular target. Several writers have argued that the privileged male role imposes expectations about masculinity that may have a serious detrimental effect on the mental health of men themselves, in addition to women and children . At first glance maleness might seem to be straightforwardly health promoting since it offers privileged access to a range of valuable resources. However, closer examination reveals a more complex picture. One of the most pernicious consequences for men of masculinity is the injunction placed upon emotional entitlement. Successful male socialization requires men to be silent and strong, leaving individuals little scope to acknowledge and deal constructively with feelings of vulnerability or powerlessness. Instead men are offered safety through dominance and control of the external world, and survival through the sanctioned means of violence. As Miller and Bell note:… the end product of male socialization is alienation from meaningful intimacy, and objectification of all those who are not me (p.320 ). Masculinity persists in this form because internal and external constraints make it a cultural taboo for men to speak about its costs and because there re advantages associated with male dominance: men have better access to socially valued resources, including money, status and power. Men’s feelings of personal satisfaction (and mental health) seem to be closely tied to the extent to which they believe they are successfully discharging the male script i.e. the acquisition of conquest or entitlements - at work, at play and at home. White, middle-class heterosexual men, may well gain some satisfaction from having fulfilled the male script. ‘… those who have power in the economic realm, where ownership authority, competitiveness, and mental – not physical - labor are valued’.

However, this is made less likely for men who deviate from the cultural and social norms. These will be men who need to reconcile the gap between the expectation of dominance and their experience of powerlessness. ‘Cultural expectations of male and female roles may mean that the frustrations, hopelessness and loss of self-esteem associated with unemployment are felt more keenly by the male partner of an unemployed couple, even if both are seeking work. Again, such feelings are not compatible with good mental health’.

This observation is illustrated by the consistent under-reporting of traumatic experiences14 A considerable number of studies, for example, demonstrate that boy children as well as girl children are made victims of sexual abuse, physical violence and neglect, and that the long-term consequences for both sexes are often ruinous. Reported rates of child sexual abuse amongst males vary considerably. However, in a comprehensive review of studies of sexual abuse in men, Watkins and Bentovin state that “under-reporting of sexual abuse is consistent and universal”. We can best understand this in terms of report defence elements such as shock, embarrassment, fear, stigma, self-blame, and, perhaps, most significantly, simply being male. Within the terms of masculinity the consequences of assault are compounded by a form of psychological emasculation literally implying the loss of masculinity .i.e. the loss of power, and failing to be a man. As one man reported to me, after a particularly severe and brutal rape by three assailants, “ I should have been able to stop it from happening. A real man would have found a way out of that situation”. Any coherent account of men’s mental health must also include an appreciation of the male capacity to harm. ‘Normative’ male behaviour appears, then, to include a high risk of violence within ‘intimate’ settings. This pattern is not, of course, confined to adult relationships alone. The vast majority of offences against children are committed by men Mental health services have, until recent years, rarely considered violence as a central mental health issue, either with regard to its origins or its mental health consequences so disappearing the crucial links and avoiding the unavoidable association that men are its primary perpetrators . It would be difficult to overestimate the prevalence of violence in the home, or the long-term consequences for those exposed to it. Similarly, it would be hard to over-estimate the mental health costs and consequences of domestic violence, or sexual abuse. Both have been strongly linked to the most serious mental health problems challenging services today .

Men cannot be treated as a homogeneous group. As lived realities masculinity is a broad term covering a variety of overlapping ‘masculinities’, in which there can be dominant and dominated, mainstream and marginalised, social groups. These different masculinities emerge, evolve or disappear overtime, and are shaped by social class, age, disability, ethnicity and sexuality. In turn, these have an impact on the range of cultural messages that are available to men in developing their own identities. Within this, there is a need to clarify the relationship of ‘masculinities’, and men’s practices and behaviour. In truth, the male club, at least in Western societies, is hierarchically organised and the consequences can be significant for those, who deviate from ascribed, heterosexual, white, middle-class norms (though there are many male clubs, gangs, orders, parties, professions, organisations and agencies that hold power). A range of disqualifications may apply such as being black, psychiatric labelled, physical disabled, gay, or unemployed. From this, there needs to be a clearer understanding of how these impact on health service policy and its delivery.

5 Training

This account of masculinity and the pattern of mental health issues associated with it poses considerable challenges in reskilling health aswell as mental health workers in working with men. These should be considered in tandem with the training agenda emerging from the Womens Mental Health Strategy1.

A number of core components can be emphasised.

• Like women, the abuse men experience in childhood is rarely recognised or used as a focus for treatment by psychiatric services. Similarly, understandings of social inequality are rarely used as a resource to inform service delivery or service development. For men, this implies the need to challenge silence, and to sensitise clinical assessment and practise to the issues of abuse, violence and harm.
• Male workers need encouragement to work with men and to develop their understanding of mens needs and issues., as outlined here. There is particular need to recognise the different patterns of male distress and the often covert, indirect, destructive, and self-destructive ways these can be expressed.
• Men should not be expected to live up to stereotypical conceptions of heterosexuality and masculinity. Clinicians need to recognise the psychological difficulties that male service users may bring to the clinical encounter and the challenges that male distress may pose to their sense of their own identity.
• Training needs to recognise the potential for ‘damage-doing’ as well as ‘damagdness’ inherent in masculinity. This means being prepared not only working with men as either victims or perpetrators, but that the potential for both can exists side by side.
• Since men have a poor record as users of psychological therapy, it is important to develop creative ways of facilitating access. The establishment of targeted resources for men in the work- place are examples of this. A number of studies have focused attention on work-related environments, such as for those in the Armed Forces, Police Force, Ambulance and Fire Services, railways, violence at work, and schools.
• Health services would benefit from further training to overcome stigma and prejudice associated with a number of male populations. For example:
• Gay men experiencing mental distress may have problems accessing appropriate services such as counselling or psychotherapy, as a number of counselling and psychotherapeutic methodologies pathologise gay sexuality. Recent research reports that between 25 to 60 per cent of gay people seek counselling at some stage in their lives, and that up to 50 per cent of these individuals report discontent with their experiences.

Research suggests that gay men do not feel comfortable accessing primary health care services because they have experienced homophobia within the NHS. Only 25 per cent of those surveyed found their GP’s accepting of their sexuality. Only 4 per cent found mental health services to be gay-friendly. The research suggests that 73 per cent of gay men have experience of stress. In 35 per cent stress was due to their sexual orientation. 12 per cent had attempted suicide, and a further 8 per cent had considered suicide because of their sexual orientation. (For further information, see Mind’s Lesbians, gay men, bisexuals and mental health factsheet.)

• African-Caribbean men are over-diagnosed with psychosis. There is some evidence to suggest that these high rates may be due, at least in part, to misdiagnosis by psychiatrists. Issues such as cultural differences in the expression of distress, concepts of illness, expectations from support agencies, and linguistic needs in a multicultural society can all contribute towards potential misdiagnosis of black men in mental distress.
• Asian men also have a high incidence of compulsory admission to psychiatric institutions, they have high levels of physical treatments, low levels of referral for talking treatments, such as counselling or psychotherapy, and low uptake of after-care services.

6 Conclusion

In conclusion, there is no doubt that we are also witnessing a period of massive and rapid social change in the reconstruction of most aspects of our work, family, and marital lives and the institutional structures that support them. Gender-relations, in various forms, are to be found right at the heart of this. In my view Mental health services should have a keen interest in this and the very real contribution it could make to the reshaping of gender relations for the next generation.

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