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Mind Your Head

Men, boys and mental well-being


The physical health of men in the UK is poorer than the physical health of 6. Health
women. Mental health seems to be the reverse; women are markedly more Even very serious physical illness or disability does not necessarily
likely to suffer from a mental disorder. An examination of some of the broader damage an individual's capacity for enjoying mental well-being - although
indicators of mental distress however, suggests that many men who may have chronic pain and mental illness are known to undermine mental well-
no formal diagnosis of a mental health problem may nevertheless be struggling being. Chronic pain is bad for the mental health of both sexes but it is
to cope. For example, men are far more likely to become alcohol dependent, probable that men cope with chronic pain less well than women. Men are
to misuse drugs and to go missing from home. Men are also far more likely to less likely to be diagnosed with depression but a potential explanation for
take their own lives. this is that depression is less easily recognised in men. Black men are
much more likely to be diagnosed with a psychotic illness and to
There is a growing international interest in the idea that the conditions for greater experience some of the most unpleasant aspects of treatment in
happiness - or "mental well-being" - at both population and individual levels can psychiatric hospitals.
be deliberately created. Some commentators have even argued that happiness,
rather than economic growth, should be the driving objective of all government *
policy. This idea has not previously been examined in relation to gender. If we
were to construct a society in which people had the maximum chance of feeling Mental well-being depends on a highly complex range of interacting
mentally well, would the necessary conditions vary between men and women? factors, some of which are significant enough to be embedded in culture
This report looks specifically at this question in relation to men. and tradition, others of which are small enough to be within the capacity
of the individual to change. Many of these factors affect men and
Six aspects of life are considered. Five of these are recognised within the women differentially, and some are specific to men. Men's mental well-
literature on mental well-being as being of particular significance. The sixth, being as a whole is poorly understood and seriously under-valued. The
"School" has been added to enable consideration of the issues relating to aim of this report is to open a debate - not to offer a short cut to the
boys. solutions. Nevertheless, we are confident in five recommendations:

1. Family Public policy should aim to improve men's mental well-being.

Socialisation of boys within the family is an important factor in creating Numerous examples exist of ways in which existing policies,
"traditional" male attitudes. It is believed that some such attitudes may be statutory services and legislative systems militate against the
damaging to men's mental well-being. A strong father/son relationship achievement by men of mental well-being. The question should be
increases the likelihood of a boy growing up to enjoy positive mental health. asked of current and planned policy in any field whether it acts
Stable, long term adult relationships are protective of men's mental health. directly to undermine men's mental well-being. If the answer is
"yes", the policy should change.
2. Financial circumstances
Having the financial wherewithal comfortably to meet the daily necessities of There must be greater recognition of male-specific indicators
life is an important precursor of mental well-being. Money may be at its most of emotional distress.
important as a determinant of mental well-being when it functions as a marker There is increasing evidence that men are less likely to be diagnosed with
of comparative status in relation to other people. The greater the gap depression because male-specific symptoms may not be taken into
between rich and poor in a developed society, the greater the chances of account. Wider indicators of unhappiness in men (heavy drinking, drug
poorer mental and physical health in the population as a whole. All these misuse, "challenging" behaviours of various sorts) may not be regarded
principles probably apply to men and women equally. as potential indicators of emotional distress at all and may not, in any
event, elicit a sympathetic response.
3. Work
Experiencing satisfaction at work is an important predisposing factor for
Services must adapt to meet men's needs more effectively.
positive mental health in men. One of the reasons for this is the importance
The issues are not easy to resolve, but men who "present" in the kinds
of "breadwinning" as a cultural indicator of the "male role". This situation can
of "non-traditional" circumstances highlighted above need to be helped to
however, be a double-edged sword. Lack of job satisfaction; work-related
find services that address their emotional and psychological needs.
stress; pressure to work long hours; and unemployment are all damaging to
mental well-being and are more likely to affect men than women.
Mental health promotion aimed at men and boys should take
4. School account of "traditional" masculinity.
Boys - especially boys from Black and minority ethnic communities - are doing Men may seek "masculine" solutions to problems of emotional distress.
less well at school than girls. This is likely to hinder their chances of growing Approaches to improving mental health that rely on messages perceived
up to experience positive mental health. Young gay men are particularly as "feminine" - for example, preparedness to "open up" or admitting to
vulnerable to bullying, which can have a direct and negative impact on their vulnerability - run the risk of failing to be effective with men.
mental health.
A national initiative is needed to help men achieve mental
5. Community and friends well-being.
The concept of "social capital" is an accepted means of considering people's The issue that emerges most clearly is how little is really known about
sense of "connectedness" to each other and to wider society. There is an the most effective ways to help men achieve positive mental health. We
established correlation between low social capital and greater risk of mental must analyse what is currently known, disseminate good practice,
health problems. Men almost never score better than women on measures of develop new approaches and - most importantly - instigate a
social capital - and on a number of specific indicators, they consistently score comprehensive pro-active strategy for the improvement and maintenance
markedly less well. of positive mental health in men.
Introduction (in terms that relate to individuals) as “mental well-being”
and “positive mental health”. This report aims:
• to explore the kinds of social and cultural
It is well established that the physical health of men is
circumstances that increase the likelihood of mental
poorer than the physical health of women. There is no well-being;
established consensus about the extent to which this
disparity is the inevitable consequence of biological • to look at the structural changes necessary to achieve
differences between the sexes but it is widely accepted those circumstances
that biology explains only part of it at most. By extension • and to examine the known obstacles.
then – even though the exact reasons are not known -
men’s physical health is much poorer than it need be.
This report does this strictly in regard to men and,
wherever possible, without recourse – now that the broad
Mental health on the other hand, appears to present us case has been stated - to making comparisons between
with a different challenge. At any one time, 20% of men and women.
women are believed to be suffering from a mental health
problem, compared with 14% of men1. Neurotic disorders As has already been demonstrated, it is not possible to
in particular (anxiety, depression, phobia and obsessive consider the route to achieving mental well-being in men
compulsive disorder) are much more commonly diagnosed
without drawing attention to the problems that currently
in women than men.2 In 2003 the Department of Health exist. It is also necessary to highlight the inadequacy of
made a commendable attempt to recognise that women current policy where that is a factor. Taking such an
have mental health needs that are specific to their gender approach is unavoidable but the overall intention of this
with the publication of a strategy document3 intended to
report is to look forwards not backwards. By concentrating
help services become more sensitive to womens needs. on men and the masculine experience in this way we are
doing something new. It is hoped that the publication of
Without in any way diminishing the importance of women’s this report will begin a much wider public debate about this
mental health however, it is worth noting that an important issue and start the process of identifying the
examination of the broader indicators of emotional and specific steps that need to be taken to maximise men’s
psychological distress suggests that the bigger picture is opportunities for good mental health.
rather more complicated than it seems at first sight:
• 75% of people who kill themselves are men.4 It is further hoped that this report will contribute to the
• 73% of adults who “go missing” are men. 5 developing understanding that in order to improve public
• 90% of rough sleepers are men. 6 health overall, we need to recognise that men and women
often experience the world differently. “Gender sensitive”
• One man in eight is dependent on alcohol (men are approaches are required in order to achieve greatest
three times more likely than women to become effectiveness. Because an individual’s sense of “gender” is
alcohol dependent). 7
inextricably linked to his or her sense of self, this is
• Men are more than twice as likely to use Class A arguably more true for the achievement of mental well-
drugs. 8 being than for any other aspect of health.
• 78% of drug-related deaths occur in men.9
• Men make up 94% of the prison population 10 - and
72% of male prisoners suffer from two or more
mental disorders (compared with 5% of men in the
general population). 11
• 46% of male psychiatric inpatients (compared with
29% of female patients) are detained and treated
compulsorily .12
• 84% of children excluded from school are boys. 13
• Boys are five times more likely to be diagnosed with
ADHD (attention deficit hyperactivity disorder) than girls.14
• Young men are significantly more likely than young
women to emerge from the education system with
lower levels of qualification 15.

Many of these statistics are surely markers of forms of

disadvantage that are specific to males. If nothing else, it
seems very clear that many men and boys are struggling
to cope – and often without necessarily coming to the
attention of established mental health services. 1
Mental Health Foundation.
Mainstreaming Gender and Women's Mental Health
Office for National Statistics
But this is not a perverse competition between the sexes 5
Research by the University of York for the National Missing Persons Helpline
to see which is the worse off. It is surely one of the Crisis.

Alcohol Concern.
functions of a civilised society to attempt to create the 8
British Crime Survey 2002
conditions in which all of its citizens – male and female – 10
Home Office
Social Exclusion Unit
are offered the greatest opportunity to experience 12
Healthcare Commission
contentment, joy and peace of mind. This short report is Department for Education and Skills

Mental Health Foundation.
concerned with these objectives, expressed henceforward 15
Department for Education and Skills

Background with a 50% lower risk of death from cardiovascular
disease10 is just the latest of a long line of studies over
many years to confirm evidence for this link. A settled and
An extensive literature has developed in recent years that contented nation would be a healthier nation in more ways
reflects the growing interest among academic than one.
psychologists in the nature and experience of happiness.
Some of this work has concentrated on methodological
issues such as developing objective measures of At the same time, periods of unhappiness within the
individual lifespan are inevitable and no-one expects that
happiness. There has also been interest in the balance
between the various interacting factors that impinge upon things could be otherwise. It is also the case that definitions
the likelihood of experiencing happiness (e.g. genetic of conditions like depression, anxiety and stress (that might
inheritance, cultural context, the influence of upbringing be seen as the enemies of happiness and well-being), do
vary across time, within cultures and according to individual
and so on). Some researchers have made particular
attempts to compare different countries and historical perception and circumstances. In other words, it is not
periods, or to quantify the benefits of happiness for always clear where the line is to be drawn between the ups
individuals and societies1, 2. and downs of a real life lived in the real world and
unhappiness experienced as pathology. Even psychotic
illness, which most people would agree is distressing,
One of the ideas that has emerged is the paradox that while frightening and demanding of treatment, is not beyond the
individual wealth and overall living standards have increased bounds of cultural acceptability at certain times and in
significantly in all western nations in the last fifty years, certain places. There are many familiar examples of figures
levels of happiness have – broadly - either remained static or of social and historical importance whose contributions have
declined. During the same period, the incidence of common seemed inseparable from their suffering delusions or
mental health problems like anxiety and depression has addiction, or extremes of elation and depression.
risen, as have markers of a discontented society such as
violence in public places, substance misuse, family
breakdown and the decline of community activity3, 4. Poorer To try to characterise “mental well-being” or “positive
nations meanwhile, manifest levels of happiness perfectly mental health” therefore, is to grasp at a fairly slippery
object. At the same time, mental well-being is recognised
comparable with those that are materially much better off.
with absolute ease at an individual level – so much so, that
attempts to put the idea into words seem almost fatuous.
Some academics and commentators involved in this field Probably everyone knows when they experience some
have consequently taken the view that happiness (rather combination of those good feelings (loving and being loved,
than economic growth) should be the goal of all public peace of mind, contentment, joy, optimism and so on) that
policy 5. There is, to be sure, debate about whether this is make up a sense of mental wellness. This common-sense
best achieved by tackling large structural factors or by understanding is undoubtedly the one that informed the
encouraging individuals to think and behave differently but thoughts of those members of the public consulted in the
such an approach certainly sounds like it would find public production of the Health White Paper. It also informs the
favour; research has consistently shown that the majority of rest of this report. Happiness is “self-evidently good”11 and
people see the search for “happiness” as the central purpose (in the words of the American Declaration of Independence)
of life6. There is also – and inevitably - some academic the pursuit of it is an “inalienable right”.
debate about the precise definition of the central concepts.
There is little doubt however, that happiness, or some
recognisable degree of it, is a fundamental characteristic of The most influential UK proponent of the idea of
positive mental health or mental well-being. establishing well-being as an objective of public policy has
been the economist, Professor Richard Layard. Layard’s
analysis of the present state of knowledge suggests that
The importance of this subject was highlighted earlier this there are seven clearly identifiable factors that influence
year with the publication of the Health White Paper, Our people’s likelihood of achieving a sense of well-being.
Health, Our Care, Our Say7. Extensive consultation of the Those factors are:
general public prior to publication found that “a focus on
• Family relationships
mental well-being” ranked second only to regular preventive
health checks among people’s priorities for the NHS. • Financial situation
Government has recognised the interest of health providers • Work
and health consumers in this matter by the publication of a • Community and friends
number of documents intended to encourage good practice
• Health
and appropriate provision. In particular, Standard One of
• Personal freedom
the National Service Framework for Mental Health 8 requires
the NHS to “promote mental health for all”. The National • Personal values
Institute for Mental Health in England (NIMHE) has recently
made explicit the benefits to the nation of working to This report takes the first five of these factors in turn and
enhance mental well-being: explores the issues within each of them that might be
The skills and attributes associated with positive mental thought of as having particular resonance for men and the
health lead to improved physical health, better quality male experience. Because this report is concerned with
of life, reduced crime, higher educational attainment, the mental well-being of boys as well as men, we have
economic well-being and personal dignity.9 taken the liberty of adding an additional factor – that of
“School” - to Layard’s original framework.
The case that happiness and mental well-being are
strongly associated with better physical health is especially The last two factors in Layard’s list (“Personal freedom”
well established. Recent research linking optimism in men and “Personal values”) list are not addressed in this report.

This is not because they are judged to be less important. Family Relationships
Simply, it is that because they are more to do with wider
ideological and philosophical considerations, they do not
sit quite so comfortably with the intention of this report, Perhaps the most important issue with regard to family
which is to explore the implications for individual men of relationships is the belief that traditional gender roles are
the idea that we might prioritise mental well-being as a created and perpetuated by socialisation (the idea that boys
matter of public policy. It would undoubtedly be extremely and girls are treated differently within families and brought
interesting, in a different context and with more space, to up to exhibit different attitudes, behaviours and
explore the connections between masculinity, individual expectations). Socialisation is a particularly important factor
value systems and perceptions of personal freedom. in relation to the debate about men’s mental well-being
because of the widely held belief that some of the damaging
tendencies seen more commonly in men (e.g. a relative lack
Within the framework outlined above, it is also the of emotional expressiveness, poorer “help-seeking skills”, a
objective of this report to pay particular attention to the tendency to “act out” emotional distress in a damaging way)
issues for men from Black and minority ethnic have their roots in the way boys are raised.
communities (BME men) and gay men – groups whose
likelihood of achieving mental well-being cannot be
separated easily from the experiences of their particular The academic evidence on this point is not entirely
communities. unequivocal however. It suggests that while socialisation is
unquestionably a real and influential phenomenon in
emotional development, gender differences in achieving
Clearly, shortage of space means that it is not possible to do mental well-being depend on a combination of factors that
any of these things exhaustively and this report makes no also includes biology and personality, and is greatly
claim to do so; nor does the publication of this report seek influenced by national culture and social context (i.e.
to imply that pursuing the achievement of mental well-being people’s emotional responses depend on the circumstances
for men is of greater importance than pursuing the same in which they find themselves at the time)13, 14 . These factors
objective for women. It is the consistent experience of the are interwoven in a highly complex way and remain largely
Men’s Health Forum however, that the specific relationship inseparable in terms of their relative importance.
between masculinity and any given health issue is almost Furthermore – and unhelpfully for our present purposes -
always under-recognised and imperfectly understood - and most work on gender differences has focused on moods and
as a result is rarely taken into account in the development behaviours that are perceived as negative and accounts less
of policy and services. This has consequences for men that well for differences in positive mental health15.
are specific, tangible and almost invariably damaging.

Nevertheless, it is beyond dispute that boys, by and large,

Layard himself suggests that gender is not a very are encouraged to minimise the expression of hurt (“big
significant variable in whether or not an individual is boys don’t cry”) and are allowed greater leeway in the
happy, pointing out that “in nearly every country men and expression of externalised emotions like physical aggression
women are roughly equally happy” 12. This is not the same and anger 16. It therefore seems highly probable that paying
of course, as saying that the factors that would need to be attention to the way boys are socialised at home has the
changed to achieve higher levels of well-being are the potential to increase their chances of achieving positive
same for women and men. In fact, they are likely to be mental health when they are grown into men.
very different - as will be seen from the demonstrable
differences in the various manifestations of male and
female distress and men’s different experience of the Socialisation also commonly assumes that boys are likely
factors that Layard considers to be of greatest importance. to grow up to be heterosexual, a popular notion that
makes life more difficult for boys who become aware that
they are gay and which also limits the range of “gender
appropriate” behaviours, social roles and relationships that
young boys or men of any sexual orientation are
comfortably able to express in adulthood17. On this latter
point, it is interesting to note that in a series of interviews
with men (of all sexual orientations) diagnosed with
depression in adulthood, several recalled that showing
vulnerability in adolescence resulted in them being called
“‘sissies’, ‘poofs’ or ‘gays’” 18.

A second crucial issue in considering what kinds of family

relationship are more conducive to positive mental health
in men and boys, is the role of fathers – particularly in
relation to the upbringing of sons. There is good evidence
that where fathers are actively engaged in the process of
supporting and nurturing boys, those boys are will grow up
in greater likelihood of enjoying a happy and rewarding
life. This can be measured by both positive and negative
indicators. Adolescent boys who have a strong paternal
bond are – for example - less likely to become involved in
petty crime 19. Likewise, boys who have supportive fathers
are more likely to do well in school20 – and higher
educational achievement is correlated with a greater
likelihood of enjoying positive mental health 21.
Further evidence for the value of positive engagement by Financial situation
fathers for the future well-being of their sons has also been
found “in reverse”. A large scale study of fathers who
suffered depression in the postnatal period found a clear It is a central tenet of the work on the psychology of
link with adverse emotional outcomes in children of both happiness, that increased wealth tends to have only a
sexes at age three and a half, and noted a “striking” modest effect in making people happier. This is for two
association with behavioural problems specifically in sons reasons frequently demonstrated by research but which
(an outcome that has not been consistently observed in can only be summarised here in the simplest of terms.
studies of postnatal depression in mothers) 22.
The first is that, beyond a certain level, measurable
According to research in the USA, in families where fathers happiness ceases to increase in parallel with income – that
have greater involvement with their children, those is to say, a kind of “tipping point” exists which is denoted
children tend to display less gender-stereotypical (very broadly) by the income level at which the daily
behaviour 23 which, as we have seen, may have benefits for struggle to attain the basic prerequisites of a comfortable
boys in terms of achieving mental well-being. In light of life no longer dominates the activities of the individual.
this it is encouraging to note that fathers’ involvement in The second is the process of “adaptation” which is widely
the care of under-fives increased from an average of fewer recognised in the literature and suggests, among other
than 15 minutes per day in the 1970s to two hours per day things, that “there is a tendency for transitory satisfactions
(one third of all child care) by the late 1990s 24. eventually to give way to indifference or even
dissatisfaction”32. In other words, there is (to use the
academic phrase) a “hedonic treadmill” which causes
Fathers do not always live with their children of course. people who become wealthier eventually to need to seek
One child in four is being brought up in a lone parent more wealth again in pursuit of the shifting and elusive
household, and nine out of ten of such households are goal of greater happiness.
headed by the mother25. The break up of the family does
not, of itself, necessarily prevent fathers from playing a
positive and supportive role. Many separated fathers These issues point at a complex relationship between
maintain a strong commitment to the welfare of their money and mental well-being – a relationship complicated
children and where that happens, the children tend to be still further by the importance of relative deprivation. It
more settled and better adjusted26. In the light of what is has been observed in numerous studies that people tend
known about the benefits for mental well-being of boys to be made more unsettled and dissatisfied by their status
however, it is a pressing cause for concern that the in relation to others than by their objective
Millennium Cohort Study suggests as many as four in ten circumstances33. Furthermore, Richard Wilkinson has
children being brought up by their mothers have no demonstrated convincingly that, in the developed world, it
contact at all with their fathers27. is more egalitarian societies (where the gap between rich
and poor is narrower) whose citizens enjoy better physical
and mental health 34. This principle holds good regardless
The third important issue in relation to family relationships of the economic prosperity of the nation overall.
is the benefit to the man himself. Evidence from many
countries has demonstrated strongly and consistently that
a stable, long term relationship is among the most Preoccupation with relative status may therefore reduce
important predisposing factors for positive mental (and the likelihood of achieving mental well-being in individuals
physical) health in men. This effect applies to marriage by creating a cyclical pressure to keep pursuing greater
more so than cohabitation but both states significantly out- wealth (perhaps to no very great benefit in terms of
perform the various alternatives28. Layard attributes this enjoying life) while simultaneously increasing the
very simply, to the abiding power of love29. At the same likelihood of poor health at population level by
time, divorce and separation are common causes of perpetuating wide differences in economic status.
unhappiness 30. This latter is somewhat more true for
women than men - although a massive unmet need for Although these general principles apply to men and women
emotional support for men who have experienced the break alike, the implications for men are profound and specific.
up of a family relationship has been demonstrated by Most of the associated issues however, are inseparable
MensLine Australia. This nationwide service - the first of its from men’s relationship to the world of work and are dealt
kind in the world – uses a specifically “male-centred” with in the section on “Work” below, which should be read
approach. Its success (more than 400,000 calls since its with the context outlined above in mind.
inception in September 2001) has given the lie to the idea
that men prefer to “shut down” emotionally or “soldier on
regardless” at times of emotional distress 31.
Financial situation: summary of key points
Having the financial wherewithal comfortably to meet the daily necessities of life
Family relationships: summary of key points is an important precursor of mental well-being. Beyond that, the relationship
between increased wealth and increased happiness is nowhere near as
Although there are other factors involved, socialisation of boys within the family straightforward as is popularly supposed - in particular, the pursuit of increased
is an important factor in creating "traditional" male attitudes. It is believed that wealth as a proxy for increased happiness may be self-defeating. Money may be
some such attitudes (broadly connected with the tendency to repress emotion) at its most important as a determinant of mental well-being when it functions as
may be damaging to men's mental well-being. A strong father/son relationship a marker of comparative status in relation to other people. However, the greater
increases the likelihood of a boy growing up to enjoy positive mental health. the gap between rich and poor in a developed society, the greater the chances of
Stable, long term adult relationships, particularly (but not exclusively) marriage, poorer mental and physical health in the population as a whole. All these
are protective of men's mental (and physical) health. Men in emotional distress principles probably apply to men and women equally - although for reasons
may be more likely to seek support than is commonly assumed if the services are explored in the following section, the implications of these insights may have
provided in the right way. particular importance for men.

Work currently work over seven hours unpaid overtime every
week. Most of these people are likely to be men. Many of
these extra hours are worked unwillingly; studies
Despite the major social changes of the past few decades conducted by the TUC suggest that almost half the UK
in relation to gender roles, men remain very much more workforce would like to work fewer hours, with 10% willing
likely than women to work full time; 94% of male to accept a reduction in pay to do so41.
employees work full time compared with 57% of female
employees35. As is well known, men also earn more than
Apart from the obvious link with reduced job satisfaction
women (18% - 40% more on average) and are more often
represented at higher levels in management structures36. and work-related stress, long working hours also militate
It is clear therefore that in most “traditional” family against those family relationships that (as we have seen)
situations the man remains the main breadwinner (70% of may be crucial for the development of positive mental
health in future generations of men. It is particularly
children are being brought up by a male/female couple).
For many men, this necessitates a predominant interesting to note in this context, that fathers
commitment to work. implementing their right to request flexible working
patterns under the 2002 Employment Act are more likely
than mothers to have their requests turned down by their
Of course, the statistics relating to comparative income and employer and more likely to have their cases fail on appeal
employment status are usually - and entirely correctly - to an Employment Tribunal42.
cited as evidence of continuing discrimination against
women. It is however, possible simultaneously to
Finally, it is perhaps worth reminding ourselves that the
understand them as directly bearing on the mental well-
being of men. Work and “providing” are, on several familiar reverse of long working hours – unemployment – is also a
levels, an established cultural delineator of masculinity and well known predisposing factor for loss of mental well-
being. The Health Development Agency’s review of the
the “male role” - and there is no doubt that for many men,
their work confers significant benefits not only in terms of evidence 43 concluded that:
personal income and power but also (as we shall see) in . . . . there is a strong association between
relation to their mental health. But that does not, by any unemployment and psychological and psychiatric
means, mean that work predisposes all men to a greater morbidity . . . . Upon re-employment, there appears to
sense of well-being. Work and our cultural perception of be a reversal of these effects.
who should be doing it, can also be a trap.
The strong connection between work and masculine status
There are various reasons for this. First of all, the very that has already been described, also means that the loss
centrality of work in men’s lives has the effect for many, of of employment affects men’s sense of well-being more
making their mental health a function of their experience damagingly than it does that of women44.
at work. For some this is a very good thing. An important
meta analysis of the relationship between job satisfaction
and mental health has established conclusively that
positive job satisfaction is significantly correlated with Work: summary of key points
positive mental health 37. The same study suggests Far more men than women work full-time. Experiencing satisfaction at work is an
however, that the failure of a job to provide satisfaction important predisposing factor for positive mental health in men. One of the reasons
may predispose the individual to anxiety and depression. for this is the importance of "breadwinning" as a cultural indicator of the "male role".
This situation can however, be a double-edged sword. Lack of job satisfaction;
work-related stress; the pressure to work long hours; and unemployment are all
Moreover, even the most satisfying job can become damaging to mental well-being and, for numerical reasons, are more likely to affect
burdensome if the demands exceed the worker’s capacity men than women. All these factors have further "knock-on" effects that may
to cope. The association between stress at work and loss compound the negative effect on men's mental health. Loss of work status is also
of mental well-being is an obvious one, to the extent that more harmful to the mental well-being of men than to that of women.
“work-related stress” is itself a commonly accepted mental
health problem. Estimates vary but it is accepted that
around half a million people may be suffering from
psychological problems associated with their work at any
one time. A major study commissioned by the Health and
Safety Executive in 2004 suggested that men were
significantly more likely than women to experience most of
the factors associated with predisposing workers to work-
related stress, such as lower levels of support from peers
and manager; higher levels of demand; and lack of
understanding of their role38. Work-related stress is also
comprehensively associated with numerous chronic
physical health problems, doubling the risk in men, for
example, of heart disease and diabetes39. Chronic ill health
is, in turn, a factor in loss of mental well-being (see later
section on Health).

It should be further noted that men in the UK work the

longest hours in Europe; 27% of men with full-time jobs in
the UK work more than 48 hours a week (compared with
11% of women) and 11% of men work more than 60 hours
a week40. The TUC estimates that 5 million people
School Community and friends

Layard’s seven component framework does not include The phrase “social capital” is often employed to
people’s experience of school as a factor in the likelihood encapsulate the extent to which any given society
of their achieving positive mental health. This is not an demonstrates the capacity for social “connectedness”
omission - his approach concentrates largely on adult among its citizens, and engagement between its citizens
perceptions of happiness - but because this report is and civic processes50. It is broadly accepted that the
concerned with the mental well-being of boys as well as greater the level of social capital, the lower the likelihood
men, it seem appropriate to address the issue briefly here. of that society experiencing social dysfunction and the
greater the chances of better physical and mental health
for its citizens. Although much of the early research
The matter that commands most immediate attention is
underpinning the theory of social capital was undertaken
that boys in England are doing consistently less well at all
in the US and Italy, the ideas are widely accepted to be
levels in school than girls - for example, in 2005, only 52%
relevant for most countries in the developed world.
of boys achieved 5 A-C grade GCSEs compared to 62% of
girls 45. 84% of those pupils who are excluded from school
are boys. There has been a great deal of interest in recent years in
understanding social capital in the UK context – indeed,
the tenth Health Survey for England in 2000 made an
These discrepancies are even more marked once ethnic
examination of social capital one of its central objectives.
origin is taken into account. Black and Asian pupils (with
An analysis of that survey’s findings 51 concluded that for
the exception of those of Indian and Chinese origin) are
two of the seven measures of social capital that it
doing less well than white pupils. These differences in
investigated - social support and levels of trust in other
achievement can be explained by higher levels of
people - there was a significant correlation with “self-
deprivation in the case of most Asian communities but for
assessed health” and objective measures of mental health.
Black Caribbean pupils, low achievement greatly exceeds
In other words, the lower the level of social support and/or
that which could be accounted for by the deprivation
the lower the level of trust in other people, the greater the
experienced by those pupils (measured by eligibility for
likelihood of poor self-assessed health and/or poor mental
free school meals). Likewise, Black Caribbean boys are
twice as likely as White boys to be categorised as having a
behavioural, emotional or social difficulty, and Black pupils
are three times more likely to be permanently excluded This relationship between measures of social capital and
from school than White pupils (as are Gypsy/Roma health held equally true for both men and women. It is
pupils)46. Most of these excluded pupils are boys. notable however, that while men and women tended to
score equally on five of the seven measures of social capital
(contact with friends; trust in other people; participation in
This is important because there is a modest but clear
social activities; experience of neighbourhood problems;
correlation between educational achievement and mental
and access to services), men were markedly more likely to
well-being. This correlation may partly be explained by
score lower than women on the other two – contact with
higher educational achievement increasing the chances of
family and levels of social support.
obtaining a more satisfying job 47. In any event, it seems
at least probable that educational provision as it is
currently structured is not contributing as well as it might “Social support” in this context was indicated by the level
to the development of positive mental health in boys and of physical and emotional engagement between the survey
men – particularly perhaps, for men in BME communities. respondent and his or her family and friends, measured
using an established scale. 67% of women reported that
they felt fully supported and encouraged in this way,
Finally, for obvious reasons, being a victim of bullying at
against only 55% of men. At the other end of the scale,
school is strongly associated with a loss of mental well-
17% of men reported a severe lack of social support,
being and indeed, poorer achievement. By and large,
compared with 11% of women. This is a particularly
victims of bullying are evenly distributed between the
important finding because – as explained above - lack of
sexes (as are perpetrators, incidentally)48. One group
social support was one of the clear correlates of risk for
specifically of boys however, is particularly vulnerable to
poorer mental health.
bullying; half of all gay men report having experienced
homophobic attitudes in school – from staff as well as
fellow students. 45% were victims of bullying directly This rather dispiriting situation in regard to men’s
related to their sexuality. In all, 65% report “ownership” of social capital is borne out by other
experiencing problems of one kind or another at school research. A study commissioned by the Health
in association with their sexuality – problems which Development Agency 52 and based on an analysis of
show a direct correlation to poorer mental health49. different data (the British Household Panel Survey) came
to similar conclusions (that there are significant
connections between some measures of social capital and
mental and physical health) and noted that while men
School: summary of key points appeared more likely to be active in organisations, they
are, by comparison with women:
Boys - especially boys from some BME communities - are doing less well at
school than girls. Boys are also far more likely to be excluded from school. Both . . . . more likely to have low contact with friends, low
these factors have the potential to hinder their chances of growing up to neighbourhood attachment and low social support.
experience positive mental health. Young gay men are particularly vulnerable to
A third study53 concluded:
bullying, which can have a direct and negative impact on their mental health.
. . . . it seems that women have more social capital
than men in all key dimensions.
Information about social capital in men in the UK, broken Health
down by ethnic group is not easily available incidentally,
but the following paragraph highlights that there are
significant differences between communities. Caution Richard Layard makes the point that good health is not
must therefore be employed in applying generalisations necessarily a prerequisite of mental well-being58. This
across the population as a whole. observation – perhaps, at first sight, rather surprising – has
been supported in numerous studies over the years. People
. . . . Blacks have the lowest scores on neighbourhood
consistently demonstrate a good ability to adapt to the
attachment but the highest scores in social networks.
physical limitations imposed by illness or injury (although
By contrast Pakistanis and Bangladeshis have the
the evidence in the case of diseases which cause
lowest scores in both social network and civic
deterioration over a protracted period is more equivocal)59.
engagement. The Chinese and Indians have poor
scores at social networking in the wider community
although the Indians seem to enjoy very good Two specific manifestations of poor health - chronic pain
neighbourly relations. The Chinese have high scores at and mental illness - are however (as Layard also points
civic engagement. . . . . Whites do not have the highest out) a different matter. Both are known to undermine
or lowest scores in any of the three types54. mental well-being

Why men have lower levels of social capital in general, has In the case of chronic pain, no academic research is really
not been specifically explored and it seems probable that needed to illuminate the reasons why this should be so.
the reasons are complex and multi-factorial. Certainly, Again, there is not the space here to explore this issue in
there is no space to look into this matter in detail here. detail but, in the present context, it is particularly worth
Earlier research however has identified a very broad noting that recent research has indicated that men and
“catch-all” possibility – that men exhibit a lower capacity women may experience pain differently and that:
for intimacy in relationships than women. Some very Women, many experts now agree, recover more
significant caution is needed before regarding this quickly from pain, seek help more quickly for their pain,
generalisation as an explanation but researchers have and are less likely to allow pain to control their lives.
consistently noted that: They also are more likely to marshal a variety of
Disclosure and “really knowing” each other is more resources - coping skills, support, and distraction - with
characteristic of women’s friendships, while doing which to deal with their pain 60.
things together is more characteristic of men’s
In other words, although chronic pain diminishes the
capacity of both sexes to feel mentally well, it may be a
Interestingly a recent study by the Mental Health greater threat to men because of men’s widely
Foundation dealing explicitly with the idea that, for many acknowledged status as poorer users of health services and
people, the use of alcohol may function as “self medication” their reduced access to support (see previous section).
for “low-lying mental health or mood problems”, has found
men markedly more likely than women to use alcohol in
Mental illness is, rather obviously, and almost by definition,
order to be able to “fit in socially” 56. This potentially
an enemy of mental well-being. As was made clear at the
suggests that men may find membership of a social
outset, it is not the primary purpose of this report to look
community more difficult to achieve than women. Where
at mental illness and mental illness services. There are
there is a strong male community however, there is
some very particular male-specific aspects of this subject
evidence that membership of that community is protective
however, and this is a good opportunity to address four of
at least of physical health. Evidence for this has been found
them at least.
in research in gay communities where:
One of the most successful correlates of successful
behaviour change (in relation to the prevention of HIV The first is the matter of depression. It is a paradox that men
infection) . . . . is attachment to an organized gay are three times more likely than women to take their own
community57. lives but only half as likely to be diagnosed with depression.
Some observers have speculated that this may be because
the internationally recognised symptomatology for
depression may incline towards a view of the disease that
Community and friends: summary of key points emphasises a “feminine” presentation. There are several
aspects to this idea, but the most important is that “anger
Using the concept of "social capital" is an accepted means of considering people's
attacks” in particular, and “acting out” in general, are more
sense of "connectedness" to each other and to wider society. There is an
established correlation between low social capital and greater risk of mental common in men but may not be recognised as indicators of
health problems. Men almost never score better than women on measures of depression. Indeed, these symptoms may actually militate
social capital - and on a number of specific indicators, they consistently score a against a sympathetic response from health professionals (or
good deal less well. Although the degree of risk to mental health is broadly the anyone else for that matter). This problem of under-
same for both sexes for any given indicator of lower social capital, men are diagnosis may be exacerbated by depressed men’s greater
nevertheless at greater risk because more such indicators apply to them. One likelihood of appearing (if they appear at all) in a clinical
possible explanation for men's lower levels of social capital is in men's perceived
setting with an ostensible physical problem, while women
lower capacity for intimacy in relationships.
may be more likely to directly identify emotional distress as
the concern for which they are seeking help61, 62.

This is a complex issue, but the important and emerging

lesson may be the pressing need to find ways of both
identifying and treating depression that take account of

culturally dominant ideas of masculinity. A recent study with a mental illness at some point in their lives
based on detailed interviews with men diagnosed with (typically depression and anxiety), and that a similar
depression has summarised the issue in regard to proportion potentially had a current problem (using
treatment thus: the “GH12 score” – an established measure of mental
. . . . it is important for men with depression to health). 27% of respondents had attempted suicide
reconstruct a valued sense of themselves and their own and 30% had self-harmed. These are much higher
masculinity as part of their recovery . . . . For example proportions than among men in the population as a
rather than seeing depression as making one powerless, whole. The study attributed these indicators of poor
some men conceptualised it as an heroic struggle from mental health to:
which they emerged a stronger person63. The impact of negativity when coming out, isolation,
difficulties in school and work related to sexual
orientation and homophobia in society . . . .
The second is the particularly negative experience of
mental health services by men from black and minority
(BME) communities. The Department of Health’s “Inside Interestingly in light of the previous discussion in this
Outside” report acknowledged that: report of social capital however, the study identified the
There does not appear to be a single area of mental “key factor” as “the absence of someone to talk to”70.
health care in this country in which black and minority
ethnic groups fare as well as, or better than, the Finally, there is the very high level of mental illness among
majority white community64. prisoners – 94% of whom, as we have seen, are men. Up
to 90% of prisoners may have a mental health problem of
The troubled relationship between mental health service some kind71 and male prisoners are five times more likely
providers and the BME community, was also explicitly than men in the general population to kill themselves72 (and
conceded to have been an important factor in the death of this is in a setting where suicide is expressly guarded
David Bennett, a Black psychiatric in-patient who died while against). There are proportionately far more Black men in
being restrained in 1998 65. The Inquiry recognised that: prison than in the population as a whole (although fewer
South Asian men) and Black men tend to receive longer
. . . . institutional racism has been present in the
mental health services, both NHS and private for many
Assessment and treatment services for prisoners are widely
acknowledged to fall well below those for the rest of the
On March 31st 2005, a national census was conducted of
population. There is furthermore, a clear association between
almost 34,000 inpatients receiving care in publicly funded
the likelihood of a man ending up in prison and his having
mental health facilities in England and Wales66. The figures
experienced some of the life experiences listed elsewhere in
are complex because of the numerous routes of admission
this document as being damaging to mental well-being:
to psychiatric hospital but admission rates of Black men
were shown to be “three or more times higher than the Compared with the general population, prisoners are
average”. Black men were also 25% – 38% more likely to thirteen times more likely to have been in care as a
have been compulsorily detained and treated under the child, thirteen times more likely to have been
Mental Health Act; almost twice as likely to have been unemployed, ten times more likely to have been a
referred to mental health services by the police or the regular truant . . . . six times as likely to have been a
courts; more likely to have been placed in seclusion during young father . . . .74
their time in hospital; and more likely to have been placed
in a medium or high secure ward. Black Caribbean men Prisoners are also much more likely to have very low
were almost one third more likely to have experienced educational attainment and to have been excluded from
“control and restraint.” school as boys.

Estimates vary, but Black men born in Britain are very Again, constraints of space prohibit more detailed
much more likely to be given a diagnosis of schizophrenia exploration of this matter but it is worth noting that one of
than the general population 67. This high incidence of acute the most respected research and development
psychotic illness is not mirrored among men in the organisations in the field, The Sainsbury Centre for Mental
Caribbean however, which suggests that there may be Health, in outlining its “Vision for 2015” offers the
some specific aspect of the Black British male experience following:
that contributes either to higher incidence or inappropriate
Offenders with mental health conditions will, where
diagnosis, or both 68. There is furthermore, some evidence
appropriate, be diverted from prison; and those who
that the incidence of schizophrenia in all BME communities
are in prisons will be offered equivalent care to that
(i.e. not only Black communities) increases in direct
which is offered outside, or transferred promptly to an
proportion to the imbalance between White and non-White
appropriate NHS secure bed75.
residents (i.e. the smaller the local BME community, the
higher the incidence of schizophrenia in that community69)
– a finding incidentally, which also suggests the potential It is also very important to note that, in general terms,
protective effects of community (see “Community and people with severe and enduring mental health problems
friends” above). are among the most socially excluded in society, being
significantly more likely, for example, to experience
problems finding work and in access to education. This
The third issue is the similarly increased risk of
group is consequently much more likely to experience
mental health problems among gay men. A recent
rooted economic deprivation 76. Similar problems affect men
survey of young gay men in Northern Ireland found
who act as carers for those with mental health problems, or
that over a third of respondents had been diagnosed
for an elderly relative with dementia - almost one third of
those caring for a relative (usually a spouse) with dementia
may be men. Caring for a relative in these circumstances
is known significantly to increase the risk of depression and
loneliness 77. All of these "knock on" factors affecting both Three themes will have become evident by this point. The
those with long term problems of mental functioning and first is that mental well-being depends on numerous
those who care for them are, as we have already seen, interacting factors. Some of these factors are of very
independently associated with loss of mental well-being. significant scale and are deeply rooted in social, cultural
and political infrastructures. Others are small enough to be
within the capacity of the individual to address. These
factors are entangled in such a way that it is difficult (and
Health: summary of key points perhaps unhelpful) to separate them out. The second is
Even very serious physical illness or disability does not necessarily damage an that many of the most important factors differ considerably
individual's capacity for enjoying mental well-being. There are however, two in their effect between men and women. It is clear indeed,
areas of personal health - chronic pain and mental illness - that are known to that some of these factors are entirely specific to men.
undermine positive mental health. Chronic pain is bad for the mental health of The third is that the issue of men’s mental well-being is at
both sexes but it is at least probable that men cope with chronic pain less well present not very well understood - and its importance is
than women. Men are less likely to be diagnosed with depression but a potential seriously under-valued.
explanation for this is that depression is less easily recognised in men, rather that
depression is less common in men. If this is so, it may mean that large numbers
of depressed men are not getting the support and treatment that could enable There is therefore, much more work to be done. The
them to go on to enjoy positive mental health. Black men are much more likely to recommendations that follow are based on the evidence as
be diagnosed with a psychotic illness and to experience some of the most
it has been presented in this report – but that there is
unpleasant aspects of treatment in psychiatric hospitals. Gay men are much
more likely to suffer from depression and anxiety than the male population as a further evidence to be found is not in doubt. The problem
whole. Both these phenomena may be attributable to the experience of being part is that the evidence exists in disparate forms and has
of a minority community and experiencing discrimination. Prisoners (the never been systematically explored. Indeed it could be
overwhelming majority of whom are men and proportionately more of whom are argued that a question has been raised here that is rarely
Black) tend to have very poor mental health. Long term mental illness also asked in any context:
increases the risk of experiencing other factors known to damage mental well-
being, both for the those affected and for men who act as carers to others. What can be done to enhance the capacity of men to
experience happiness, contentment and peace of
These recommendations seek to address this question.

1. Public policy should aim to improve men’s

mental well-being.
It is of concern that some existing public policy actively
militates against the attainment of mental well-being in
men. Under most of our five headings we can observe
examples of this phenomenon. For example, pressure
from employers for staff to work long hours is
commonplace; both employers and Employment Tribunals
are more likely to refuse requests by men for flexible
working hours; poor mental health is very common among
prisoners but services are widely acknowledged to be
inadequate; education services are failing to make the best
of our boys and young men. There is plenty of scope for
improvement in simply asking whether current policy in
any field is failing to improve men’s mental health or
worse, is acting directly to undermine it. If the answer is
to either question is “yes”, then the policy should change.
This seems a modest and obvious starting point.

2. There must be recognition of male-

specific indicators of emotional distress.
As we have seen, there are strong arguments that the
“presentation” of emotional distress is different in men.
This may lead to its under-recognition and consequently to
an absence of support and treatment. A good example, as
suggested earlier, is the debate about whether the
symptomatology for depression should be recognised as
different in men. It is further probable that a number of
difficult social behaviours that are far more common in
men - from heavy drinking, to “going missing” in its
various forms, to a greater propensity for physical violence
– are often potential indicators of emotional distress.
These are culturally challenging ideas but they shed light
on areas of concern that need to be further researched and
more widely understood.

3. Services must adapt to meet men’s needs The publication by the Department of Health of
more effectively. guidance for mental health practitioners on effective
working with women (Mainstreaming Gender and
Services are not presently structured so that men who
Women’s Mental Health, 2003) demonstrates a
present in the “non-traditional” ways highlighted above are
willingness to recognise gender as an important and
enabled access to the right kinds of help. At its most basic
relevant factor in this field. That document indeed,
level, this might be a problem for the GP who suspects his
makes this very point in its introduction by confirming it
or her male patient’s recurring “bad back” is actually a
“provides a strong evidence base” for “the need for
symptom of anxiety but who simply has no time to discuss
gender sensitive and gender specific services”. The
the matter in the depth that would be required. More
National Institute for Mental Health in England (NIMHE)
problematically, it might be manifested in the lack of support
also has an established work programme on “Gender
for emotionally damaged men in prison; the challenges
and Women’s Mental Health”.
posed by boys from dysfunctional family backgrounds who
misbehave in school; or the acknowledged structural
problems in providing a fully integrated service for men who Both the Department of Health guidance and the NIMHE
have a “dual diagnosis” (a combination of substance abuse “workstream” concentrate largely on provision for female
problems and mental illness). mental health service users. This present report has
argued for a focus on the wider community and on the
importance of prioritising mental wellness in men as an
4. Mental health promotion aimed at men objective of policy in all fields. Nevertheless, both the
and boys should take account of principle (the need for gender sensitivity) and the area of
“traditional” masculinity. concern (mental health) are the same. A national initiative
Research and project work in other areas of health has of comparable status is required that could further develop
demonstrated the value of communicating with men in a way the first four recommendations in this section and begin to
that resonates with the male “world view”. In other words, address some of the other important questions raised by
speaking to men “as they are” - not as we might wish them this report, such as:
to be (i.e. as if they were as receptive as women to the idea • How do we best provide support for parents in raising
of prioritising personal health). For a variety of reasons, it is boys?
can be difficult to face up to this idea. It may however, be • How can we help men develop communication and
particularly important to do so in the field of mental well- relationship skills ?
being, where, as we have seen, the sense of self is so closely
• How can employers be encouraged to consider men’s
linked to the capacity to feel mentally well.
mental health in the workplace?
• Could the Australian “Mensline” model work in the UK?
The research on depression highlighted in the section on
• What needs to be done to improve boys’ performance
“Health” for example, demonstrates the need that some men
at school?
have to acknowledge and celebrate the traditionally positive
virtues of masculinity (such as “strength”, “resilience” and • Can “male-friendly” community settings be used to
“facing the challenge”) as part of the process of regaining reach out to men in need of emotional support?
their mental health. There is surely a lesson here for those • How can we deal with the significant inequalities
working to deliver health education and to improve health at associated with this issue, such as those affecting gay
the population level. Schools – for example – need to place men and men from BME communities?
work on boys’ emotional health within the PSHE (personal, • How can we best protect male carers and men with
social and health education) curriculum in the context of long term mental health problems from the further
boys’ sense of their developing masculinity. Public health damaging effects of social exclusion?
departments should aim to develop male-specific marketing
techniques and work in partnership with organisations that
offer access to men in male-friendly environments. Primary
care should aim to create an atmosphere that men find
supportive and welcoming. The aim should be not only to
encourage a greater willingness to disclose problems and
seek help, but also to acknowledge - and maximise the value
of - those traditional components of masculinity that hold the
potential to strengthen mental health.

5. A national initiative is needed to help men

achieve mental well-being.
The issue that emerges most clearly from this report is an
overarching one; that of how little is really known about the
most effective way to help men achieve positive mental
health. This is despite the very significant evidence – as was
observed at the outset – that many men are struggling with
emotional distress. Time and effort needs to be given to
analysing what is currently known; searching out and
disseminating examples of proven good practice; developing
approaches that tackle the existing problems effectively;
and – most importantly of all – developing a comprehensive
“cross-cutting” strategy focusing on the improvement and
maintenance of positive mental health in men.

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The mission of the Men’s Health Forum (MHF) is to provide an
Published by:
independent and authoritative voice for male health and to tackle the
issues affecting the health and well-being of boys and men in England and
The Men’s Health Forum
Tavistock House
Our vision is a future in which all boys and men in England and Wales Tavistock Square
have an equal opportunity to attain the highest possible level of health London WC1H 9HR
and well-being. We aim to achieve this through:
• Policy development JUNE 2006
• Research
• Providing information services Tel: 020 7388 4449
• Stimulating professional and public debate Fax: 020 7388 4477
• Working with MPs and Government
• Developing innovative and imaginative projects Web:
• Professional training
• Collaborating with the widest possible range of interested organisations
and individuals The MHF gratefully acknowledges the
support of the editorial group members who
• Organising the annual National Men’s Health Week advised on the various draft versions of
“Mind Your Head”.
The Men’s Health Forum (MHF) makes comparisons between men’s and
women’s health only when it is unavoidably necessary to do so. We do not
advocate shifting attention away from female health or re-allocating Registered Office as above.
resources from women to men. Moreover we do not believe that women’s
health should function as a “gold standard” for men’s health – the MHF is A registered charity
committed to improved health for both men and women. (No 1087375).

A company limited by guarantee

The Forum’s mission, vision, values and beliefs statement can be read in (No 4142349 - England)
full at: