Males and Mental Health Stigma

Over a year ago, I had the privilege to sit along with 24 notable experts in mental and men’s health to discuss the behavioral aspects of mental health in the American male, particularly assessing depression and anxiety. One in five adults (an estimated 43 million people) experience a mental illness in the United States every year (National Institute of Mental Health [NIMH], 2019). Although both men and women are affected by mental illness, it is oftentimes overlooked in males. The overall prevalence of mental illness in men is typically lower (Substance Abuse and Mental Health Services Administration ([SAMHSA], 2018). However, mental health among men often goes untreated because they are far less likely to seek mental health treatment than women. Depression and suicide are ranked as a leading cause of death among men. Six million men are affected by depression in the United States every single year. Men (79% of 38,364) die by suicide at a rate four times higher than women (Mental Health America [MHA], 2020). They also die due to alcohol-related causes at 62,000 in comparison to women at 26,000. Men are also two to three times more likely to misuse drugs than women (Center for Behavioral Health Statistics and Quality, 2017). These statistics are troubling because they reinforce the notion that males are less likely to seek help and more likely than women to turn to dangerous, unhealthy behaviors.

Even with the various mental health treatment modalities available, there is a disproportionate difference between the number of males experiencing mental health disorders and those seeking treatment. Mental health, particularly among men, has gained momentum in becoming the “other” silent killer. Why is this? When defining the problem, the topic and role of stigma elicited responses from many of the experts invited to the Behavioral Health Aspects of Depression and Anxiety in the American Male (BHADAAM ¹ ; Giorgianni & Brott, 2019) conference held by the Men’s Health Network. One of the areas where wide agreement among experts arose was the thought that stigma is an extreme barrier to those needing mental health treatment. This editorial presents some of the sociocultural aspects of men’s acculturation to stigma related to mental health issues with emphasis on the influences of culture and traditional masculine norms. In addition, recommendations exploring stigma targeted at underrepresented groups are discussed.

What is Stigma?

Stigma can be complex and prevalent. For these reasons, I have provided some definitions to frame the discussion. Mental health–related stigma is an umbrella term that includes social (public) stigma, self-stigma (perceived), professional stigma, and cultural stigma. Social stigma refers to the negative attitudes toward and disapproval of a person or group experiencing mental health illness rooted in misperception that symptoms of mental illness are based on a person having a weak character. These perceptions can lead to discrimination, avoidance, and rejection of persons experiencing mental illness. This is usually the type of stigma that is discussed most often. Self-stigma is the internalization of social stigma, in that the person with the mental illness feels shame about his or her symptoms. Professional stigma assumes that health professionals transfer and reinforce stigmatization of their clients, while cultural stigma comprises the various ways that individual cultures interpret mental illness (Cerully et al., 2018; Hack et al., 2020; Holder et al., 2019). I highlighted these terms so that we can conceptualize the various lenses in which stigma exist.

Culture is a person’s beliefs, values, and norms within a given racial or ethnic group. It impacts certain ideas and behaviors and directly relates to the meaning that people attach to their illness. Culture also affects whether people seek help, what type of help they seek, and their coping style and support. Social norms guide socially acceptable behavior and form the framework that guides how people experiencing mental illness internalize public attitudes that may lead to embarrassment and shame. For example, mental health illness is considered a taboo topic in the Black community. Those experiencing mental health issues are often considered weak, broken, and not strong enough. In fairness, the Black community has been the casualty of the medical industry, dating back to the Tuskegee experiment where many African American men were misled into being injected with syphilis when they thought they were receiving free health care. Hence, distrust of the health-care system still exists. As a result, you may see that those ascribing to the Black culture may find it difficult to accept a mental health problem or diagnosis and seek help. Because of culture stigma, underrepresented persons are left to find mental health treatment and support alone, if at all. Because cultural influences have an impact on perceptions of mental health, understanding the role of culture in mental illness is important in developing strategic initiatives to improve the negative effects of mental health illness.

Masculine Norms

American men are subjected to a culture where the standards of masculinity are literally killing them. One of the factors that contributes to the underuse of seeking professional help is masculinity norms. Masculine norms are the social rules and expected behavior associated with men and manhood within a given culture (Milner et al., 2018). Traditional masculinity or hegemonic masculinity is a subset of masculine norms that accentuate certain expressions of masculinity and invoke some men’s power, dominance, and privilege over women and some men. Toxic masculinity closely aligns with certain expressions of hegemonic masculinity. Toxic masculinity is the demonstration of masculinities that are enforced by restriction in behaviors (e.g, crying, fear) based on gender roles that amplify existing power structures that favor the dominance of men. Toxic masculinity may lead to difficulty in expressing emotions, which is seen often. If we evaluate the expectations of boys, there is a lot of aggression and violence. Boys are acculturated to play rough and are often allowed to break the rules. The phrase “boys will be boys” is normalized by these notions. Adherence to these rigid masculine norms may lead to

• worsening of depression and anxiety

• abuse of substances

• greater health risk (e.g., cardiovascular and metabolic disease)

• issues with dating and interpersonal intimacy

• issues with interpersonal violence

• increase in overall psychological distress

• discouragement in seeking help

• homophobia

Recommendations for the Marginalized

Below are some key recommendations on progressing toward a society that is attuned to the health disparities that are experienced by underrepresented groups in health-care settings as well as changing the social cultural norms.

• Mental health providers should review the APA Guidelines for Psychological Practice with Boys and Men (2018) to explore the complexity of masculinity and work with males.

• Develop policies for providing mandatory cultural competency training to physicians in medical school and not just primary care settings.

• Develop and implement public stigma reduction campaigns.

• Diversify the pool of mental health providers in urban and rural areas.

• Increase diverse role models of positive masculinity.

Mental health–related discrimination has a negative impact on limiting mental health–care access, help-seeking behaviors, and initial treatment for those experiencing mental illness, therefore contributing to increased morbidity and mortality rate of those experiencing mental illness.

Manhood needs to be redefined. There must be transformation in changing the American culture in which males are more comfortable expressing themselves. It would also be remiss of me not to mention the risk factors that exist in situations such as the COVID-19 pandemic, in which boys and men who may be experiencing a mental health problem are vulnerable to the isolation that COVID-19 creates. This isolation may potentiate the precursors of mental illness, therefore adding to the significance of overcoming and leveraging the barriers to the access of mental health resources among those who are less likely to seek professional help.