Written submission from Dr Rob Whitley (MHM0027)
Executive Summary
My name is Dr Rob Whitley and I am an Associate Professor of Psychiatry at McGill University in Canada. I am a British Citizen who was born and raised in the United Kingdom. I completed my doctoral degree at King’s College London before moving to Canada. I am submitting this evidence as I am an expert on men’s mental health, making many significant contributions to the field. For example, I guest edited a special issue of the Canadian Journal of Psychiatry about men’s mental health, which was published in September 2018. In April 2017, I gave an invited presentation at the European Parliament on the topic of male suicide and I was a key-note speaker at the 2017 Australian National Male Health Conference in Sydney. I also write a popular monthly column on men’s mental health for Psychology Today entitled ‘Talking About Men’, as well as a regular column on men’s mental health for the Huffington Post. I have also written occasional columns on men’s mental health for the National Post and the Province.
2.1 Publicly-available statistics indicate that men experience significantly higher rates of certain mental health outcomes than women. This includes high-rates of Substance-Use Disorder (SUD), Attention-Deficit Hyperactivity Disorder (ADHD), and perhaps most worryingly, suicide. For example, the most recent report from the Office of National Statistics (ONS) indicates that 75% of completed suicides were made by men. Indeed, around 12 men per day take their own life in the UK. These figures are highest in middle-aged men between 40-60.
2.2 Evidence suggests that men are much more likely to develop SUD than women. Several studies indicate that men are around three times as likely to frequently consume illegal drugs in comparison to women. Similarly, men are over twice as likely to misuse alcohol compared to women. Research indicates that men make up around 70% of drug related deaths, with single white men at particular risk. This includes deaths related to fentanyl and opioids.
2.3 Several studies indicate that men have significantly higher rates of mental disorders categorized in DSM-5 as ‘neurodevelopmental disorders’. These studies suggest that the male to female ratio of ADHD diagnosis is around 2:1. Males are also significantly more likely to be diagnosed with Autism Spectrum Disorder (ASD) with a UK study indicating that the prevalence of ASD in men is 1.8% compared to 0.2% for women. This mirrors figures from other countries.
2.4 Numerous epidemiological studies indicate that men have lower rates of depression than women. However many have started to question whether these differences are real or artefactual consequences of measurement and reporting bias. For example, some studies indicate that men commonly experience a form of ‘masked depression’ that is not captured by traditional diagnostic instruments and measurement scales.
2.5 Despite all this, much research indicates that men significantly underutilize health services in comparison to women. Some studies indicate that women are about twice as likely to visit a general practitioner in comparison to men. Likewise, only around 30% of mental health service users are men, with men significantly more likely to avoid visiting a mental health clinician.
3.1 Many men’s mental health campaigns focus attention on men’s supposed silence and reticence to discuss problems. These often take an accusatory tone, leading to a harmful narrative that blames and berates men for their mental health woes. This approach is known as victim-blaming in public health, and is studiously avoided in women’s mental health campaigns, where social context is often-acknowledged as a key determinant of mental health. I discuss this victim-blaming approach, and the associated harms in a recent article for Psychology Today.
3.2 This narrow one-dimensional approach is not based on the latest scientific evidence. This latest evidence suggests that a range of social factors heavily influence the mental health of men and boys. These social factors are often considered in public health research, however they tend to be ignored in current debates and discussion about the mental health of men and boys. I argue in a recent editorial for the Canadian Journal of Psychiatry that we must move beyond victim-blaming to better consider these social determinants of men’s mental health.
3.3 Myself and colleagues recently published a review paper in the Canadian Journal of Psychiatry that summarizes the evidence surrounding these social determinants of men’s mental health. I discuss the most prominent in separate sub-sections below, namely (i) occupational/ employment issues; (ii) family/ divorce issues; and (iii) adverse childhood experiences.
Unemployment, Occupational and Educational Issues
3.4 Unemployment, redundancy and economic precarity are risk factors for adverse mental health outcomes in adult men including suicide, substance abuse and depression. Interestingly, research indicates that unemployment and redundancy can have a greater impact on the mental health of men in comparison to women. This may be because men traditionally link their self-identity, self-esteem and self-worth with their work and bread-winning abilities. Work also provides men with social status, income and resources. As such, loss of employment can leave affected men bereft of a sense of pride, purpose and meaning in life; all of which are essential to psychological strength and resiliency. In short, being a ‘failed bread-winner’ is bad for men’s mental health. As such, policies and interventions that foster male employment will beneficially affect mental health, and should be an integral part of male mental health promotion efforts.
3.5 Men make up the vast majority of people working in dangerous and dirty jobs such as fisheries, agriculture, construction, military and law enforcement. Such dangerous positions frequently lead to disability and injury. This can lead to the development of post-traumatic stress disorder, as well as prescription of pain-killing medications, which can be addictive. Moreover, such employment often involves shift-work, unsocial hours and frequent relocations. This can lead to social isolation and separation from families and friends. All of the above can contribute to suicidal behaviour and substance abuse. As such, micro-level and macro-level occupational health policies and interventions should be developed and targeted to support men’s mental health (i) while in the work-place itself and (ii) when transitioning out of the workplace due to injury, disability or discharge from the armed services.
3.6 Notably, statistics suggest that men are increasingly employed in low-wage and low-skilled jobs in comparison to women. For example, data from the Organisation for Economic Co-Operation and Development shows that men aged 15 to 19 are much more likely to be ‘not in employment, education or training’ (NEETs) in comparison to their female counterparts. This contributes to much higher rates of ‘failure to launch’ in young men compared to young women. As such, myself and other scholars are arguing for reform to the education system, to make it more male friendly and equip male students for the new knowledge economy. Such measures could have a positive impact on the mental health of men and boys.
Family Issues and Divorce
3.7 Evidence suggests that divorce and romantic breakup are strong risk factors for mental illness and suicide in men. Indeed, research indicates that divorced and separated men experience higher rates of depression and suicide in comparison to divorced women. One study indicates that divorced men are roughly twice as likely to report depressive episodes following a divorce than divorced women, while other studies indicate that male suicide increases post-divorce.
3.8 The negative influence of divorce on men’s mental health has been attributed to numerous factors. A key factor is the loss of social support and emotional connectivity. Several studies indicate that divorced or separated men report a significant drop in social support compared to divorced or separated women. This is consistent with sociological research indicating that women tend to have larger circles of family and friends whereas men tend to rely largely on their partner and nuclear family for emotional support. Thus, the loss of a partner can be particularly hard, as can the loss of any children in a custody battle.
3.9 Indeed, evidence suggests that loss of custody and a negative experience in family court are some of the most stressful aspects of divorce for men and have been implicated in both substance abuse and suicide. Like employment loss, loss of custody can leave many men feeling bereft of purpose and meaning in life, often navigating a difficult, shocking and surprising transition alone. As such, reform of family law may have a positive impact on men’s mental health.
Adverse Child Experience
3.10 Much evidence suggests that adverse childhood experiences can lead to short-term and long-term psychological and physical health consequences in males and females alike. Sadly, child abuse is common amongst boys and girls; however, some types of abuse are more prevalent in boys than girls (and vice-versa). While sexual abuse tends to be more prevalent in females, physical abuse tends to be higher in males.
3.11 Research indicates that males and females tend to respond differently to child abuse. Abused girls are more likely to display traditional mental health symptoms such as suicidal ideation, self-harm and disordered eating. Such symptoms can be identified through conventional mental health assessments, leading to targeted treatments. In contrast, abused boys are more likely to display a constellation of behaviours including delinquency, disruption, aggression, binge-drinking and risk-taking. Such ‘externalizing’ behaviours are often considered character issues rather than mental health issues by parents, educational institutions and society as a whole.
3.12 Interventions that reduce adverse child experience will have a positive impact on boys’ mental health, as well as a knock-on effect on men’s mental health as these boys grow into men. Furthermore, support services for adult victims of childhood abuse should be expanded. This may mean more specific mental health services and interventions that are targeted at the mental health of men and boys per se, a point expanded upon below in section 4 below.
4.1 The current mental health system offers two main modalities of healing: medication and ‘talking therapies’. However, University of Missouri Professor Amanda Rose has conducted considerable research comparing male and female orientations to talking, concluding that males often ‘don’t see talking about problems to be particularly useful…men may be more likely to think talking about problems will make the problems feel bigger and engaging in different activities will take their mind off of the problem’.
4.2 Indeed, much research suggests that many men prefer action-based modalities of healing over talk-based modalities. This includes regular exercise, which has been shown to effectively reduce depressive symptoms. Likewise religious and traditional healing can be effective in improving men’s mental health, especially for minority and immigrant men. Some action-oriented mental health services specifically target men, including ‘men’s sheds’. These are places where isolated and lonely men can go to create, repair or make things; finding solace and support in the process. The men's shed motto contains much wisdom: 'men don't heal face-to-face, they heal shoulder-to-shoulder'. Early evaluations indicate that these maybe an effective intervention.
4.3 In other words, much research indicates that there is no one-size-fits-all solution vis-à-vis men’s mental illness. For some men, face-to-face talking can lead to helpful comfort and support: ‘a problem shared is a problem halved’. For others, it can lead to painful brooding and rumination: ‘do not reopen old wounds’. For the latter, action-based modalities of healing may be more effective. As such, an inclusive mental health system must offer a variety of modalities of healing in addition to medication and ‘talking therapies’. Clinicians can then offer different choices and work with the grain when interacting with individual male patients.
5.1 Much research indicates that there is a societal ‘empathy gap’ between men and women. This means that there is a lack of empathy for men and men’s issues, whereas there is an intense empathy for women and women’s issues. This lack of empathy can contribute to stereotypical notions that men are violent and threatening, leading to the ‘demonization of men’ in various sectors of society, including the health, education and the legal system.
5.2 It has been hypothesized that this ‘empathy gap’ and subsequent ‘demonization of men’ is due to persistent stereotypes portraying women as victims and men as villains. Indeed, my own research indicates that media portrayals of women with mental illness tend to be much more empathic and sympathetic than those of men with mental illness, which tend to be harsh and punitive. This can perpetuate negative images of men, which can shape wider societal attitudes.
5.3 This empathy gap manifests itself in various other ways. Research from the U.S. indicates that men receive 63% longer sentences than women when convicted of the same crime. In an article for Psychology Today, I outline how black men can be particularly blamed and targeted in this regard, resulting in much higher rates of miscarriages of justice for black men. Similarly, international research shows a lack of sympathy and associated services for male victims of domestic abuse, even though men make up a substantial proportion of domestic abuse victims.
5.4 The empathy gap and the demonization of men also manifests itself in parliamentary reports. For example, the European Parliament Committee for Women’s Rights and Gender Equality recently produced a report entitled ‘promoting gender equality in mental health and clinical research’. This report was adopted by the European Parliament in plenary in February 2017. I wrote an article noting that only two paragraphs out of 163 are devoted to men’s mental health.
5.5 Worse still, the report appears to be driven by ideology rather than evidence. High rates of suicide in men are blamed on unproven factors such as ‘masculinity which may encourage suppression of emotions or resort to anger’ (p6). More bizarrely, mental illness in women is blamed on husbands, with the report declaring that ‘men do not devote themselves sufficiently to household tasks and bringing up daughters and sons, causing many women to suffer from depression, anxiety and stress’ (p18).
5.6 It is my sincere hope that the Women and Inequalities Commons Select Committee avoids the approach of the European Parliament and bases its recommendations on evidence rather than ideology, especially the evidence presented in this submission.
To conclude, I argue that we need a paradigm shift in the way we frame, discuss and treat the mental health of men and boys. We need to acknowledge that men can suffer health inequalities, manifest in high-rates of suicide, SUD, ADHD and service non-utilization. Further, we need to address the social determinants of men’s mental health- including occupational, educational and legal factors. Moreover, we must diversify mental health services to make them more attractive to men, offering more choice within the system. Finally, we need to close the empathy gap and stop the demonization of men as a class of people. If you require any further information, please do not hesitate to contact me at robert.whitley@mcgill.ca and I would be delighted to assist.