Gender and Mental Health

It’s hard to think of a Hollywood star more successful (he was the highest paid actor in 2020) or more traditionally masculine than Dwayne “the Rock” Johnson. When he was young, he became famous as a college football player and WWF wrestler. But he also suffered from depression. In a 2018 interview he talked about a time when he was “devastated and depressed,” “crying constantly.” In opening up, he said he hoped to encourage others to talk about their mental health. He particularly emphasized how this is a challenge for men, saying “us dudes have a tendency to keep it in. You’re not alone.”

Gender and mental health connect in many ways, and the consequences can be literally life or death. Women are almost twice as likely as men to be diagnosed with depression and attempt suicide 1.5 times as often as men, yet men die by suicide 3.63 times more often than women. Mental health is impacted by biological factors, such as genetics, but it’s also critically shaped by social factors such as our childhood experiences, family dynamics, ability (or inability) to express our emotions, and the community we have available to us — all of which are affected by gender.

Lots of people immediately think of mental illness when they think of mental health. Everyone experiences times of mental health distress (like stress or anxiety), but a condition becomes known as a mental illness when it persists and seriously impacts someone’s life. Mental illness is common; in fact, nearly 50% of people in the US will be diagnosed with a mental illness or disorder at some point in their lifetime. Mental illnesses vary widely, and the degree to which they impact someone’s overall well-being and ability to live their life also varies hugely. More broadly, however, mental health affects everyone. It affects how we think, feel, and act. Good mental health isn’t just the absence of mental illness — it’s the presence of mental wellbeing.

There’s a lot that still isn’t known about mental health. However, it’s clear that gender plays a key role in shaping our mental health, and the complex ways in which gender plays out in our lives can harm - or help - our mental wellbeing.

What shapes our mental health?

Our understanding of mental health is still pretty nascent, and the way our minds work is extremely complicated. Certainly, biology plays a part. It’s long been known that specific mental illnesses may be inherited. At the same time, social factors, context and circumstances — including those around gender — also play a role in shaping our mental health. Recognizing the complex ways in which gendered norms impact our mental health is crucial to be able to address and promote mental wellbeing of people of all genders.

Before we talk about gender and mental health, it’s important to orient ourselves. A lot of research has conflated sex and gender (in other words, assumed that people born biologically female are women or biologically male are men). It’s important to remember that even biological sex isn’t as binary as many people think it is. Most medical research hasn’t accounted for the vast spectrum of sex and gender or the complex ways in which our brains may (or may not) shape our gender, and vice versa. To learn more, see Reimagine Gender’s brief on the differences between sex and gender.

How do gendered expectations impact our mental health?

Certainly, we know that people of different genders seem to have differing mental health outcomes. One reason why is because of the ways in which gender shapes our social experiences.

For example, women are more likely than men to be diagnosed with depression. There are social reasons why women might be more likely to seek care and thus receive a diagnosis (more in the next section on Addressing mental health), but also women experience particular gender-based stressors. Women face greater stress on their time: women do two more hours of housework each day than men, spend nearly twice as much time on childcare as men, and make up the majority of caregivers (which includes not only children but also elderly or disabled family members). Girls and women are more likely to be sexualized from an early age, which harms mental health (and can contribute to illnesses like depression and eating disorders). Girls and women also live with a threat of violence - one in four women in the US will experience intimate partner physical violence, and about one in six women has been the victim of an attempted or completed rape in her life. All of this takes a toll. Of course, this is compounded by other factors of identity. Women who are of a marginalized race, ethnicity, sexuality, or religion. face even more threats and stressors in their lives.

Transgender, non-binary, and agender people often face significant discrimination and trauma, which can harm their mental wellbeing. As many as 40% of transgender adults in the US report having attempted suicide in their lifetime, compared to less than 5% among the overall population. Childhood experiences have important repercussions on our mental health, and nearly one in five respondents to the National Transgender Survey said their family was unsupportive of their gender identity (an additional one in five said their family was neither supportive or unsupportive). Gender dysphoria can cause depression, and gender affirmative-care can be life-saving, so having a supportive family or community is critical to the mental wellbeing of transgender and gender diverse people, especially youth. Transgender, non-binary, and agender people may face discrimination in all parts of their lives, -from school, to work, to healthcare, even day to day casual discrimination. They also are victims of violence at shocking rates. Again, all of this adds up, and is compounded for people who are discriminated against because of other aspects of who they are.

Men’s mental health is also impacted by gendered experiences. If women are more likely to be diagnosed with depression, and more likely to attempt suicide, how is it that men are nearly four times more likely to die by suicide? One factor is the method of suicide. In the US in 2019 just over half of all suicides were committed with a firearm, and about 6 in 10 gun owners are men; it’s also worth noting that among gun owners men are much more likely to keep a loaded gun easily accessible at all or most times. The reasons some men own guns are related to masculinity and the experience of gender.

However, men also face extreme gender-based pressures. More than 70% of both men and women think that in order for a man to be a good partner he needs to be able to support a family financially. Although men have historically had lower rates of unemployment than women, men’s employment was hit especially hard during the 2007-09 recession. Notably, the suicide rate in the US also rose during the recession. Traditional notions of masculinity dictate that men should be strong and stoic, which can keep boys and men from feeling like they can share their emotions, or communicate when they are suffering. When boys aren’t able to express themselves, this can lead to violence and aggression as a means of emotional expression, which can lead to violence later in life as well. Boys and men also experience trauma such as physical and sexual abuse, and are often left unable to talk about it. Men’s friendships may be more likely to rely on shared activities, rather than talking about emotions, family, and relationships — something which has posed particular difficulties during the COVID-19 pandemic, when doing activities together has become less safe. For lots of gendered reasons, men are more likely to serve in the military; - in fact ninety percent of veterans are men. Around 10-20% of veterans experience PTSD (although this varies depending on the conflict, and is very likely underreported). Eating disorders among men have been on the rise - but it’s hard to know to what extent this is due to an actual rise in cases, versus increased reporting because men with eating disorders have traditionally faced a lot of stigma.

Rigid gender norms don’t just hurt men’s mental health; they also make it so men are less likely to seek mental health treatment or care when they are struggling. A lot of men are afraid that their friends or partners will find out, and think less of them. These issues can also be multiplied and exacerbated by other identities, such as age, class, ethnicity and race. Some research shows that Black men are particularly concerned about stigma related to mental health.

Addressing mental health

Mental health as a general topic, and in particular mental health care and treatment such as going to therapy or taking antidepressants, has long been stigmatized. Fortunately, more and more people are talking openly about mental health - driven in particular by younger generations’ openness with the topic. This was true before the pandemic, but certainly the strain put on almost everyone’s mental health by COVID-19 has put a spotlight on the topic.

More and more campaigns have decided to tackle the stigma against mental health, particularly for men. Lots of these have embraced traditionally masculine language or symbols - such as Man Therapy (“Sometimes a man needs a pork shoulder to cry on”); Movember, an organization which encourages men to grow mustaches to raise awareness for men’s health issues, including mental health and suicide; or the Campaign Against Living Miserably’s “Grow a Pair” campaign (grow a pair of ears - “If your mate’s struggling, start listening”). All of these campaigns and resources are trying to use masculinity to reach men while still encouraging men to be more expressive of their emotions, more available to their friends, and guiding them towards professional help if needed.

The gender divide of who does get professional mental health care is stark. In 2019 approximately one in five adults in the US received mental health treatment, including medication, counseling or therapy. Among women, 24.7% received mental health treatment, while only 13.4% of men did. Women are twice as likely to take medication for their mental health and also more likely to receive counseling or therapy. Even among men who are depressed, it’s estimated that only 60% go for treatment, compared with 72% of women. It’s also important to note that these numbers vary widely when one looks at the racial breakdown. White adults are much more likely to receive mental health treatment than Hispanic, Black, or Asian adults. Among transgender Americans, 31% lack access to health care, and there are many barriers to receiving mental health treatment, including poverty, a lack of gender competent therapists and transphobia. More data is needed about non-binary people and access to mental health treatment.

Lots of companies and organizations are trying to make mental health care and therapy in particular more accessible, particularly by leveraging technology to offer remote care options. Social media, apps, and increased media representation have helped a lot of transgender, non-binary, and agender people find community and role models, which has a positive impact on mental health. Some organizations are also trying to meet people where they are, like The Confess Project, which trains Black barbers to be mental health advocates for boys and men in their communities.

Getting effective gender-informed care

If someone does decide to seek mental health care, they’ll still encounter gendered assumptions within psychology and psychiatry. The American Psychological Association didn’t release guidelines specifically focused on psychological practice with boys and men until 2018. More than 60% of psychologists are women, which means some men struggle to find a therapist they feel comfortable speaking with. Again, race and age play a factor here. More than 85% of psychologists in the US are white. As with all people, therapists bring their own gendered biases to work. In 2018 the APA published updated guidelines for psychological practice with girls and women which acknowledged that psychologists often base their ideas about positive mental health “on behaviors that are most consistent with masculine stereotypes or life experiences.”

The symptoms we think of when we think of some mental health disorders, including ADHD and autism, are also shaped by gender. Initial studies which documented these conditions were often conducted with boys, which is why the classic symptom of ADHD is hyperactivity. Girls with ADHD present differently, with attention deficiency being a key symptom. A lot of girls who present with symptoms of inattentiveness are just “written off as dreamy or ditzy.” ADHD may be both under- and over-diagnosed. One expert estimates that half to three-quarters of women with ADHD are un- or under- diagnosed (as many as 4 million women). At the same time, lots of specialists think that the increasing rates of ADHD diagnoses are due to changing social environments for kids - more homework and confined, structured time, less free time and play. Expectations for how kids should behave is gendered, as are the warning signs their parents are taught to watch for. Boys are actually more likely than girls to get counseling now (75% of boys and 65% of girls with mental health problems receive counseling), which is likely driven by the increasing rates of diagnosis of conditions like ADHD and autism among boys. The ways in which our behaviors are socialized also impacts how different mental health conditions might manifest. For example, the socialization of girls and women enables some with autism to hide or mask symptoms. Since doctors have come to better understand the different ways in which girls might present autism, the gender gap between boys and girls diagnosed with autism has dropped hugely, from 8-1 in 1995 to 3-1 in 2010.

Gender-affirming mental health care is more prevalent than it used to be, but many transgender, non-binary, and agender people still have trouble accessing mental health care. Some of this is rooted in the legacy of discrimination faced by gender-diverse people within healthcare (further explored in the next section), and some of it relates to other barriers: in some areas facilities that offer mental health services tailored for gender-diverse people simply don’t exist, and when they do they’re often only in large cities. Medical paperwork and systems are generally not accommodating of anyone who is not a cisgender woman or cisgender man, and there is a lack of specialists focused on mental health for gender-diverse people. The vast majority of mental health specialists who do provide gender-affirming care are themselves cisgender, and not all have been properly trained on gender. Even if they have experience working with gender-diverse patients, they don’t have the personal lived experience of navigating day-to-day minority stress factors that transgender, non-binary, and agender people do. Additionally, transgender people face higher rates than the general population of poverty and unemployment, which can make payment and insurance access insurmountable barriers. With recent attacks on gender-affirming care for transgender children, these barriers to access only grow.

The absence of relevant care

Further complicating the picture, sometimes people are directed to mental health treatment when it is not necessarily what they want or need.

Women are more likely than men to have their reports of physical pain be ignored and dismissed by doctors (this is especially true for Black women). Many women have experiences being told by doctors that their pain is “all in their head” in part because of lasting gendered notions of women as emotional or hysterical. One study in Sweden found that women were more likely than men to be prescribed antidepressants even if they didn’t report depression. Several studies have shown that women were more likely than men to be prescribed antidepressants when reporting physical pain.

Transgender and non-binary people seeking gender-affirmative care such as hormones sometimes have to wait long times and be seen by mental health providers in advance of receiving the treatment they want. One specialist at Michigan Medicine’s Von Voigtlander Women’s Hospital pointed out that although mental health care can be helpful to almost anyone, requirements that transgender people have a mental health care provider before they can receive gender-affirming hormones “wrongly implied that mental health professionals were better equipped than transgender people themselves to determine one’s own gender identity.”

As Ronald Levant, the former head of the American Psychological Association said, “Psychotherapy was originally created by men to treat women.” This means that not only is it not well-suited to the needs of men, but it also has a long, often troubling history with regards to mental health treatment applied, particularly to women, transgender and non-binary people.

Gender and the history of mental health

The history of mental health and psychology and its relationship to gender is definitely too big to explain in a couple paragraphs, but there are a few important things to keep in mind when thinking about how gender and mental health play out in our world today.

It has only been in very recent years that authorities on mental health have stopped classifying being transgender or non-binary as a “disorder.” In 2013 the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) dropped “gender identity disorder” and instead started recognizing “gender dysphoria” - pathologizing not gender identity but rather the experience of not having harmony in one’s gender. It was not until 2017 that Denmark became the first country in the world to remove trans people’s classification as “mentally ill.” Despite these advancements, transgender, non-binary, and agender people still face discrimination and harassment from mental health care providers who treat their identities like an illness.

Mental health care has also historically failed women. The DSM included “hysteria” until the 1980s. Hysteria could be used as a catch-all to explain any experiences of women which psychologists and doctors didn’t understand. In the 1800s women could be confined to an insane asylum based on ‘abnormal’ behavior which might range widely from committing violent acts to having unusual mood swings. This didn’t end in the 1800s. Even in the 1950s women could be committed to mental hospitals for reasons such as ‘not being a good mother’. Insane asylums and mental hospitals also have a long history of being used to essentially incarcerate Black people. Throughout the 20th century, lobotomies were infamously used on White women and Black people of all genders to treat mental illness (real or perceived by doctors). Author Caroline Criado Perez has highlighted that “at least one US psychiatric textbook, still widely in use during the 1970s, recommended lobotomies for women in abusive relationships.”

We’ve come a long way, and mental health professionals today by and large seek to provide safe, affirmative care which actually improves the lives of their patients. Still, it is important as we think about the future of mental health and gender to understand how the past has shaped the legacy of mental health diagnosis and treatment.

In conclusion

Due to COVID-19, people around the world are experiencing extreme stress, isolation, and increased work and caregiving burden - and these mental health stressors are themselves playing out in gendered ways.

It’s more important now than ever that we understand mental health and gender as inextricably linked, and use this understanding to promote better awareness of and accessible, compassionate care for mental health issues.

Gender and Mental Health