Gender roles – ‘masked depression’

Gender role theory sees gender in terms of the cultural and historical ways in which biological sex differences are played out at the individual and social level. As cultural constructs, gender roles rarely provide an accurate description of any individual man or woman; rather, they are social lenses (Bem, 1993) through which men and women perceive themselves and each other. Roles are learnt through processes of socialisation – such as modelling (copying) one’s parents – which means that gender roles self-perpetuate and come to constitute material reality. For example, family law often deals with cases of child abuse and domestic violence, and requires its legal professionals and their clients to deal unemotionally with the facts of the case – no matter how upsetting these may be (Pond & Morgan, 2005). Successful professionals are those that can negotiate the system by the use of reason while keeping any sentiment private, which proliferates a particular way of being a professional. This creates what we might call the ‘role’ of a legal professional and illustrates how aspects of that role may be learnt (e.g. through rewarding professionals that stick to the facts) as a function of the structure (such as the ‘factual’ requirements of evidence in court) in which the role is enacted. Presumably, given the right context anyone can enact any role, which means that men can enact male and female roles, and women can enact female and male roles. Epidemiological sex differences in the symptoms of depression may be evidence not of a different type of depression but of ways of expressing or coping with depression that are appropriate to a particular gender role.

The male and female roles are understood as norms that individuals aspire to and enact differently. An individual can adhere strictly to one role (masculine or feminine), weakly to both roles (androgynous), strongly to both (undifferentiated) or to neither (ambiguous). Although the definition of a particular role may be culturally dependent we can presume that because gender roles are self-perpetuating through processes of socialisation they are rarely subject to substantial change. For issues of mental health and illness the coping style of each gender role is particularly apt. In gender role theory, the feminine style of coping is to deal with the emotion associated with the stressor (emotion focused), whereas the masculine style is to deal directly with the stressor (problem focused) (Li et al, 2006). Feminine, emotion-focused coping is associated with higher levels of depression than masculine problem-focused coping (Compas et al, 1988; Ebata & Moos, 1991). However, the research on sex differences mentioned above suggests that diagnostic criteria fail to include a male depressive syndrome, which may mean that depressive symptoms in masculine, problem-focused individuals have remained hidden. Indeed, Good & Wood (1995) point out that the masculine role is antithetical to recognising and expressing depression and to utilising emotion-focused interventions such as psychotherapy. For example, seeking help might be interpreted as incompetence and dependence (Mo"ller-Leimku"hler, 2002), and research has shown that individuals who adhere to the masculine role have negative attitudes towards using counselling services (Good & Wood, 1995). This has led some to theorise a disorder of masked depression, where the reduced affect is, for example, manifest in physical symptoms (Kielholz, 1973). Interestingly, associating masculinity with mental ill health has been important for the antisexist men’s movement (e.g. the male role leads men to be violent to women) and for an antifeminist backlash (e.g. the male role damages men and privileges women), and this has been taken up in gender role theory with little recourse to empirical evidence. Regardless of whether masculine individuals are more likely to experience depression it is important to note that if they do, it seems that they will be less likely to recognise it as depression and to seek help.

The gender role theory approach to men and depression suggests that services could be redesigned to target masculine, problem-focused individuals. In addition, services could adopt practices to help men with depression challenge gender role norms, which would theoretically leave them better able to recognise and accept help for their own depression. Although gender role theory does acknowledge possible differences between men, it relies on a fundamental opposition between male and female. This risks overemphasising gender when other factors, such as class and ethnicity, may be more important. In particular, gender role theory largely focuses on women or, when focusing on men, is based on affluent White US college students, who are unlikely to reflect the diversity of men with depression.

The list of gender role characteristics shown in Table 1Go, predominantly from the 1970s, may seem dated and difficult to take seriously. However, the point is that if we cannot take historical gender role characteristics seriously then current gender role research may suffer the same fate. Indeed, a review (Choi & Faqua, 2003) of factor analytic studies validating the definitive gender role psychometric measure – the Bem Sex Role Inventory (BSRI; Bem, 1974) – suggests that the understanding of masculinity and femininity in gender role theory is insufficiently complex. Another difficulty with gender role theory is that it seems to conceptually confuse gender norms with an individual’s behaviour, which could result in potentially unhealthy male role norms being seen as ‘normal’ things for men to do.

Hegemonic masculinity – ‘depression enacting gender’

Connell’s (1987) concept of hegemonic masculinity is perhaps the most popular approach to gender in academia at present. Like gender role theory, hegemonic masculinity focuses on the social, rather than biological, aspects of gender. Gender is understood as something that is actually done by people. Thus, if men regularly do something in a certain way – such as waking early, being last to leave work, working at home in the evening – and this is accepted by both men and women it becomes a masculine feature, a masculinity. Gender is multiple, as practices may construct many ways of being a man, and historical, as these ways of being a man change. Power is particularly important -  ‘hegemony’ refers to insidious processes of domination where the majority of people come to believe that particular ideas are not only natural but are for their benefit. Different masculinities must therefore compete to define what it is to be a man, and the dominant masculinity in any particular context is not simply the one that forces itself on people but the one that is so socially ingrained that it is almost impossible to imagine anything else. Hegemonic masculinity must also compete with other identities such as femininity, class and age. Consequently, masculinities are not always dominant and are instead subordinate to another identity. As hegemonic masculinity is defined in particular contexts, it can never be fixed and must instead be continually reworked as people move through their lives. Sex differences in the symptoms of depression may be evidence of underlying and common gendered practices.

Enacting depression could be part of enacting gender. Indeed, being depressed would seem to be unmasculine. In an interview-based study involving men who had been diagnosed with depression but were well enough to participate in the research, Emslie et al(2005) found that the recovery process was talked about as successfully renegotiating a masculinity. Thus, actually being depressed would constitute a failure to be masculine. Nevertheless, for a few of the men Emslie et al interviewed, the isolation and loneliness of depression were incorporated as signs of their difference (as more sensitive and intelligent) from others, which seems to suggest that actually being depressed would reaffirm their own masculinity.

As so few men are diagnosed with depression it is important also to look at depression-related practices in non-clinical samples. A focus group study that sought a diverse sample of men from both clinical and non-clinical populations looked at how they talked about seeking help for physical and mental health problems (O’Brien et al, 2005). The authors found considerable resistance to talking about mental ill health, particularly among young men, for whom masculinity appeared to require being strong and silent about emotions.

Masculinity can be practised by both men and women, which means that women need to be included when considering depression in men. Brownhill et al(2005) conducted focus groups with a non-clinical sample of men and women and found that the important difference was not how depression was experienced but how it was expressed. Their study seems to suggest that depression is part of an inner emotional world that is contained, constrained or set free by gendered practices. The ‘big build’ (Fig. 1Go) is the descriptive model Brownhill et al developed to explain how masculine practices in relation to depression result in a debilitating trajectory of destructive behaviour and emotional distress. These practices start as avoidance, numbing and escaping behaviours that may escalate to violence and suicide. The point seems to be that there is no difference in the depression men and women experience but that there are important differences in how depression is ‘done’ or enacted in terms of masculinities or femininities.

From the research on depression and hegemonic masculinities, it might be suggested that the destructive behaviours such as violence in intimate relationships, substance misuse and suicide are ways of ‘doing’ depression that enact particular masculinities. Further, current mental health practices in the diagnosis and treatment of depression might be seen as enacting femininities. From the concept of hegemonic masculinity, depression in men is not masked but is often visible in abusive, aggressive and violent practices; nor are these behaviours a sign of a male form of depression -  women can ‘do’ masculinity and may cope with their depression in similar ways. The point for service provision is that depression may underlie wider issues of mental health (such as substance misuse) and criminal behaviour.

Although hegemonic masculinity may offer clinicians a more nuanced view of their clinical practices and how their clients act out their difficulties, it fails to offer any specific treatment possibilities.

To date, the research on hegemonic masculinity and depression has utilised focus group and interview methods. As masculinity is understood in terms of constantly recurring practices, research needs to adopt methods that identify and study depression-related practices as they occur in real life. Studies have already looked at how masculinities are achieved through destructive behaviours such as crime (Messerschmidt, 1993) and hooliganism (Newburn & Stanko, 1994), and it would be interesting to explore them for depression.