International Men's Day 2022: An expert guide to men’s mental health, gender gap and societal expectations

November 19 is celebrated as International Men's Day with the aim of shining a spotlight on issues that impact men. There is perhaps none more than the issue of mental health which is being increasingly acknowledged as a global health concern. According to World Health Organization (WHO) estimates, 25 per cent of the global population will suffer from neurological or mental disorders in their lifetimes. Mental health conditions have only been aggravated during the pandemic owing to the rise in stressors, and disruptions in mental health services, with WHO estimates indicating the increase in both depressive and anxiety disorders to be more than 25 per cent. Treatment, although available, isn't sought by nearly two-thirds of people affected by a known mental disorder due to stigma, leading to preventable deaths.

Amidst the global mental health crisis, it is helpful to note how it impacts different demographics. Due to the patriarchal norms and expectations, there are few emotional outlets for men and they are reluctant to seek help which leads to a difference in manifestation of mental distress in different genders. Gender and culturally sensitive mental health services are essential to recognise and treat mental disorders appropriately. We spoke to three mental health practitioners, Dr. Vinod Kumar, psychiatrist and head of Mpower-the Centre in Bangalore, Nikita Sulay, clinical psychologist at Mpower-the Foundation in Mumbai, and Dr. Ambrish Dharmadikari, adult psychiatrist and assistant vice president of clinical operations and rural initiative at Mpower, who draw upon their diverse expertise and experiences with patients to further our understanding of the gender disparity in mental health.

Excerpts from the interview

What role does gender play in mental health?

Sulay: Mental health more or less impacts genders equally, however there are gender difference studies that indicate that certain disorders are likely to affect one gender over the other. It is also interesting to see that females tend to internalise emotions which generally leads to signs of depression, loneliness or withdrawal. On the other hand, men are more likely to externalise emotions which can be seen in forms of aggression, impulsivity, and disruptive behaviour. It is also observed as per a study published in the American Psychological Association that women tend to be diagnosed more frequently with disorders such as depression and anxiety, while men get diagnosed with substance use and antisocial disorders.

In the Indian context, how damaging are cultural and patriarchal norms to men's mental health?

Sulay: In the Indian context, we often see that men are taught to be tough, the breadwinners and protector of the household. Any sign of vulnerability is looked down upon which results in inhibiting emotional expression. This means that men are less likely to seek mental health services compared to women. There is a clear demarcation in the patriarchal norms that men cannot be emotional and vulnerable. This has a detrimental effect as emotions are basically energies, and these energies either get repressed or come out in uglier forms. Various issues stem up from men's inabilities to process emotions such as domestic violence, substance abuse, vandalism, bad parenting, increased suicidal risk and psychosomatic issues. We need to teach children from a very young age to identify and process emotions effectively.

Help-seeking behaviour is a major determinant of mental well-being. What all impacts men's help-seeking behaviour?

Sulay: In my clinical practice, I have observed that I tend to have twice more female clients compared to males. Men tend to hesitate or are less compliant towards therapy. Some aspects that could impact men's health seeking behaviours are:

1. Stigma surrounding mental health concerns in society.

2. The typical masculine behaviour is that men do not need help, and can be self-reliant.

3. The belief that they can delay treatment and self-medicate.

4. Denial of the issues and indulgence in unhealthy coping mechanisms such as substance or aggression.

5. Normalisation of various problems in the society, in many cultures it is considered normal for a man to have anger issues or consumption of substances.

How do the patterns of psychological distress and disorders vary in men?

Dr. Dharmadikari: Our mind has an algorithm or order of thoughts, behavioural patterns or emotions. Disorder is when any of these dysfunctions. Distress is concerned with how we interact with the environment. We experience distress in case of adverse events or situations.

Dr. Kumar: What we see in practice and which is evident in research demonstrates that there is a clear difference in the presentation to clinicians of mental health issues. In women there is a much larger representation of what we call as neurotic disorders like depression and anxiety based disorders compared to men. Emotional distress is experienced in a very different way in men, as they have a tendency to externalise their distress. This presents in the form of conduct disorder or antisocial personality disorder. And of course, substance misuse. In my own clinical practice, I have seen various manifestations and shades of this. What is interesting is that men who tend to be the macho or bravado type of personalities do tend to get in touch with their own vulnerabilities when they are older and more aware of their own physical frailties and diminishing sexual libido, etc. and that is when the neurotic experiences and neurotic presentation of the emotional distress becomes more evident.

What are the prominent reasons behind these differences?

Dr. Kumar: The issue of gender differences in the experiences of mental health disorder is a very interesting one. There has been a lot of research done in recent times on this. In summary, there are multitude of reasons why there is a difference starting from the psychoanalytical perspective of how the experience of your biological sex defines your existence. And then, of course, the socio-cultural aspect of gender definition and gender role identification defines one's functioning and purpose in life, depending on the culture and the society one lives in.

The challenges of bearing the reproductive function leads to women enduring an undue amount of biological stress. In the context of going through menarche and the hormonal roller coaster ride of the typical menstrual cycle, bearing the physical brunt of pregnancy and delivery, and of course, the difficulties associated with menopause. This leads to a greater amount of depression and other anxiety based disorders in women of childbearing age.

Generally, men are assigned with the role of being the breadwinner and women are assigned the role of being the carer and nurturer, as a consequence men are culturally not allowed to display their emotional distress and issues as freely as the female sex is permitted to do so. Obviously, this is a very complex observation and various other causes define the final experience of these at an individual level.

Dr. Dharmadikari: The difference lies in the social and cultural understanding of society. In rural areas, when an earning member of the family or a man experiences mental health issues, they are swiftly provided help and other support like medicines. Women on the other hand are subjected to non-medical adjustments.

The opposite is also prevalent where men are known to hide or not actively seek help for common mental health disorders due to ego or not wanting to seem weak. Some men think that if they admit to mental health problems they will appear as weak or will be perceived as unfit to provide for their families. Therefore, milder symptoms of common mental health disorders often go unnoticed among men. Society's taboo that men cannot or should not cry puts men under immense pressure or stress to not be forthcoming with their mental health problems. This also leads to men resorting to anger as one of their main outlets for distress. Cultural rather than gender differences can often be attributed to the difference between the way men and women deal with their mental health problems.

Can men present different symptoms for the same mental health issues?

Dr. Dharmadikari: The societal structure can result in the same symptoms being presented differently. In underprivileged or rural areas, emotions are often internalised and presented in a physical nature. Whereas educated people tend to verbalise their emotions.

Are there any gender-focused prevention and treatment efforts that are adapted and can improve the efficiency of care?

Dr. Dharmadikari: All mental health issues can equally affect all genders. However, men suffering from mental health issues can have far-reaching economic consequences for families in a patriarchal society where men usually earn. Awareness or sensitisation on mental health by educational institutions or NGOs can help make mental health more inclusive. Society needs to work towards creating an environment where men can seek help freely, comfortably express themselves and address their mental health issues. Making mental health care more accessible to both men and women by integrating care services in primary or community health centres will be impactful.

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