Your gender, your practice
A factor that is often overlooked when considering the therapeutic relationship with male patients is the role of a practitioner’s gendered attitudes and beliefs. The way GPs interact with a male patient’s unique version of masculinity, based on their own ideas of what a man can and should be, may have implications for what eventuates in a consultation. Importantly, these beliefs are not fixed but often stem from the GP’s own gender development and generational and cultural context. We suggest these may require purposeful consideration and discussion. In a study of GPs, practitioners were found to be complicit in inadvertently reinforcing traditional masculinity norms among help-seeking men.32 Men who presented as stoic or emotionally detached were found to garner more respect from doctors, which by extension served to reinforce these qualities as typical and expected of men.
Beliefs and biases held by some practitioners about masculinity and appropriate gendered behaviours may impact on the way they approach male patients. For instance, if a young man presents with depressive symptoms, it is imperative that the practitioner does not accidentally perpetuate any of the patient’s underlying beliefs or stereotypes that help-seeking reflects weakness, dependence and powerlessness and is incompatible with masculinity, in an attempt to align with him. Practitioners are encouraged to forward the narrative of help-seeking as indicating strength and self-betterment, and to normalise and reinforce this health-seeking.
Assessment and diagnosis
For men who make it into a GP’s surgery, evidence suggests that the way they experience and express their distress may make it difficult for practitioners to detect and diagnose depression.33,34
Men may express their symptoms of depression through externalising symptoms. These include:
- emotion suppression
- anger or aggression
- drug and alcohol use
- risk-taking and impulsivity
- somatic symptoms (e.g. sleep disturbance, headaches and sexual concerns).
These responses to distress can be socially condoned and understood as traditionally masculine coping behaviours, in the sense that men are thought to be socialised to take risks and resolve conflict through anger or aggression.35 The term ‘male-type depression syndrome’ has been used to describe this range of depression symptoms among men incorporating an externalising phenotype, although debate regarding a specific male depression phenotype continues.36
However, others suggest that perceived pressures on men to rigidly restrict emotional expression, or to ‘act in’ and try to resolve their issues alone, can build over time, labelled ‘the big build’.9 Depletion of the resources to suppress emotion and negative affect can then trigger externalising expression or acting out.
Screening and diagnostic criteria
Diagnostic criteria or generic screening measures for depression fail to capture the externalising symptoms described above.37,38 For instance, the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) incorporates irritability and outbursts of anger as potential criteria for major depressive disorder in children. However, the DSM-5 inexplicably drops these symptoms from the criteria for depression in adults, despite evidence for the co-occurrence of anger in men experiencing mood problems.5