Looking Back: Masculinity and mental health - the long view

Ali Haggett gives a historical perspective
As a medical historian engaged in research on the history of men’s mental health, it is striking how little research exists on the ways in which men have coped with professional and personal pressures. The literature on male psychological and emotional disorders is equally sparse. Why this history has been so poorly recorded is a matter for considerable debate. 
As the authors of the introduction to this special feature have noted, scholars of gender studies have broadly tended to assume a male norm and focus consequently on ‘femaleness’ and differences from the norm, while academic historians (and feminist historians in particular) have focused repeatedly on deconstructing the well-versed ancient association between women and ‘madness’. Some continue to argue that men are simply much less likely to be affected by mood disorders and that women are more naturally predisposed to such conditions (Freeman & Freeman, 2013). Statistically, women do appear to suffer more frequently from depressive and anxiety disorders, featuring more regularly in figures for consultations, diagnoses and prescriptions for psychotropic medication. This has been consistently so since the 1950s, with current figures suggesting that women are approximately twice more likely to suffer from mood disorders than men (WHO, n.d.). 
However, my research suggests that the statistical landscape reveals only part of the story. We know that 75 per cent of suicides are currently among men, and we can trace this trend back historically to data that suggests this has been the case since the beginning of the 20th century (Watts, 1966; Wilkins, 2009). Alcohol abuse, a factor often related to suicide, is also significantly more common in men, who are more than twice as likely to become alcohol dependent than women (Wilkins, 2009). This trend too is well-established and is a consistent theme throughout the studies of general practice morbidity that emerged during the late 1950s (Bancroft & Watts, 1959). 
The subject of help-seeking for psychological disorders certainly seems to be an area that presents particular challenges to masculinity, complicated by the fact that when men do seek help from medical practitioners they often present with somatic or psychosomatic symptoms that may have an underlying emotional cause. It is therefore highly likely that male cases of depression and anxiety disorders are under-diagnosed (O’Brien et al., 2005; Wilkins, 2009). Family doctors practising in the 1950s noted that women tended to present with symptoms of low-mood, anxiety, lack of motivation and sadness (which, for the most part were easy to recognise), whereas men were more likely to present with somatic symptoms, including a range of ill-defined disorders affecting the stomach, digestion, sleep and general well-being (Royal College of General Practitioners, 1956–1958). 
So it appears that the reluctance of men to speak about their own illness and the broader collective silence that surrounds the emotional world of men has a long history. However, interestingly, it is by no means a ‘continuous’ one. I will suggest that alternative constructions of masculinity observable in earlier times resulted in very different approaches to nervous disorders and symptoms of depressive illness. History can indeed tell us much about the origins of dominant forms of masculinity, and perhaps we might look to earlier periods and alternative constructions of masculinity to cultivate healthier ways of expressing emotional distress.
Georgian sensibility and the Victorian ‘stiff upper lip’
Although there is now widespread acceptance among social scientists and historians that masculine traits are not essential attributes, but that they are in large part socially and culturally constructed, it is the familiar image of the tough, stoic male that remains the dominant or ‘hegemonic’ masculinity in the developed Western world. 
However, historically, the inhibition of emotionality is by no means a constant or immutable male trait. During the Georgian period (1714–1830), for example, advances in scientific and anatomical knowledge from the practice of dissection suggested that the central nervous system was fundamental to understandings of the body. There was widespread discussion about how it worked, and physicians thought that many diseases and afflictions were connected in some way to it. This resulted in a new interest in nervous disorders, which were thought to affect men and women alike. Among Georgian society, the individuals thought to be most seriously affected by ‘nervous distempers’ were those from the cultured, well-to-do classes, who were considered to have a more refined nervous system, which was more prone to collapse. Nervousness among the higher social strata was commonly accepted and seen as a sign of ‘good breeding’. 
The display of emotion among men in this period was not associated with sexual practice or effeminacy. Being ‘manly’ meant different things in Georgian Britain; primarily being virtuous and wise. Male emotionality therefore crossed no inappropriate boundaries nor brought undue negative attention. As a consequence, men were quite comfortable looking inwardly and being reflective about their own physical and psychological experiences. 
During this period, an explosion of nerve doctors and medical treatises emerged providing advice on remedies and lifestyle. The physician George Cheyne, for example, published a text entitled The English Malady in 1733, in which he described symptoms of melancholy, lowness of spirits, insomnia and agitation. These, he argued, were common in wealthy people and had several causes, most notably the pace of new modern life, luxurious living and immoderate lifestyle. In the book, he urged people to take up what he called a ‘low regimen’, meaning a temperate lifestyle. Cheyne’s own experience informed his writing, for he suffered himself from many of these symptoms, including headaches, lowness of spirit and disturbance of appetite. Many of his case studies focused upon men. By demarcating nervous distempers as unique to the cultured classes, physicians were able to disassociate themselves from the lower social orders. That ‘good blood and bad nerves went hand in hand’ was broadly manifest in the attitudes and associations of society and shaped the ways in which people viewed themselves in sickness and in health (Micale, 2008).
Scholars have long shown how the huge social and cultural changes of the Victorian period (1837–1901) that followed resulted in new gender constructions and ideas about what it was to be a man or a woman. However, it is only more recently that historians have begun to explore the ways in which these changes, and the consequent stigmatisation of male emotionality, impacted upon male mental health (Micale, 2008). 
By the mid-19th century, Britain had become the world’s leading industrial nation, and it is hard to overstate the scale of changes wrought by industrialisation and imperialist pursuit. British ascendency in the world required the projection of ‘power’ and ‘control’; qualities that did not fit well with a notion of male nervous instability. More generally, the preceding intellectual movement – the Enlightenment – had espoused a range of values that were increasingly seen as excessively liberal and egalitarian. Women, for example, had begun to fight for equal rights in suffrage, divorce and inheritance. The 19th century was in many ways a backlash to this liberal Enlightenment thinking, and on a range of levels a period of social and cultural conservatism emerged. Industrialisation itself promoted the division of labour by sex and heavy factory work, mining and construction became distinctively ‘male’ environments, while symbolically, women became ‘angels in the house’. This term was coined in 1854, by Coventry Patmore, in a poem of the same title. It was used increasingly to describe women who embodied the perfect Victorian ideal of the dutiful wife and mother. 
At the same time, these social changes were bolstered by the evolutionary theories of Charles Darwin and Herbert Spencer that emphasised core differences between men and women (Darwin, 1859; Spencer, 1864). Women were thought to be biologically inferior to men, dominated by their reproductive systems and prone to irrationality. Men, in contrast, were considered to be rational, ‘restrained’ beings. 
Other factors duly reinforced these developments. The rise in Protestant religious enthusiasm, for example, favoured personal values of will-power, obedience and fidelity. Christian ‘manliness’ meant being a good husband and father, leaving little room for emotional self-expression. Within European medicine and psychiatry, the study of human sexuality emerged, promoted by individuals such as Iwan Bloch, Richard von Krafft-Ebing, Maunus Hirschfeld and Havelock Ellis (Hall, 2000). This new ‘science’ of sexology began to investigate and regulate sexual practices, and attempts were made to define ‘normal’ and ‘abnormal’ sexual behaviour. Consequently, the notion that homosexuality was deviant behaviour resulted in anxieties about homo-social affection and its potential association with effeminacy. The values put forward by the British military and the public school system also notoriously fostered strict morality, stoicism and the ‘stiff upper lip’.

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