To effectively address the mental health problems of boys and men, clinicians must recognise the gender-specific stressors, needs and clinical presentations that have been often overlooked in research and practice. In this brief article, some of the main mental health challenges commonly experienced by boys and men are reviewed within a clinical and developmental perspective, to inform mental health practice through recommended clinical guidance.
Critical issues in the mental health of boys and men
Men exhibit suicide rates that are 3–7.5 times higher than those among women across all ages, highlighting the need for a detailed analysis of the gender-specific risk factors influencing suicidality and related mental health problems in males (Otten Reference Otten, Tibubos and Schomerus2021). Lower reported rates of depression in men than in women may stem from men’s tendencies to hide emotional struggles and a lack of recognition of how depression manifests in men, which often includes externalising symptoms (e.g. irritability, aggressiveness) rather than internalising symptoms (e.g. worry, rumination, anhedonia) (Bilsker Reference Bilsker, Fogarty and Wakefield2018). Furthermore, men tend to resort more frequently to maladaptive coping strategies such as avoidance through alcohol misuse and denial, indicating significant gender-based differences in coping mechanisms and emotion regulation (Nolen-Hoeksema Reference Nolen-Hoeksema and Hilt2006). Although empirical studies on adaptive coping strategies of males are scarce, the available evidence suggests that supportive relationships, problem-solving through practical solutions, and cognitive reframing are perceived as preferred coping tendencies by males (Whittle 2015).
The development of psychopathology in boys and men
Developmental neurobiological risk factors
Sex hormones are potential candidates through which epigenetics have an impact on gender-specific mental health problems. For example, during the prenatal and postnatal periods, testosterone surges exert distinctive changes in male brain morphology and in the maturation of developing neuroendocrine systems of stress regulation. It seems that the rate of development of emotion-processing and stress-regulating attachment systems (e.g. limbic structures) is slower in male infants than in females (Schore Reference Schore2017). Even before birth, some neurodevelopmental pathways may be shaped by sex-specific susceptibility to environmental exposures (e.g. hormonal impact on stress reactivity), which, owing to sex-related neurodevelopmental optimal timings and hormones, are likely to be more detrimental in males. Specifically, this is the case for in utero exposure to androgen disruptors, which may impair the maturation of the amygdala, as androgen receptors are more abundant in males (Bingham Reference Bingham, Gray, Sun and Viau2011; Cunningham Reference Cunningham, Lumia and McGinnis2012).
Masculinity, emotion regulation and psychopathology
The enormous variability between genders in experiencing and coping with emotions might be influenced by sociocultural factors, such as socialisation of emotions. For example, boys are more likely than girls to see their emotional expression of fear and sadness minimised or invalidated by their parents (especially fathers), contributing to a sustained learning of maladaptive emotion regulation strategies (e.g. suppression); inversely, negative dominant emotions (e.g. anger, hostility) seem to be more reinforced in boys and have an enduring impact in men (Berke Reference Berke, Reidy and Zeichner2018).
The gendered socialisation of emotions (which reflects cultural prescriptions on gender-appropriate emotional experiences, expressions and behaviours – i.e. gender norms that conflate masculinity with toughness, competitiveness and emotional control) adversely affects the mental health of boys and men by reinforcing cognitive schemas of masculinity that discourage acceptance of vulnerability and emotional expression (Berke Reference Berke, Reidy and Zeichner2018). Consequently, men often perceive emotions such as shame and fear as threats to their masculinity, leading to maladaptive emotion regulation strategies (e.g. denial, suppression). This avoidance pattern exacerbates psychological distress and contributes to a cycle of mental health difficulties, where anger and aggression become a primary defence mechanism, preventing men from constructively processing emotions deemed unmasculine (Bosson 2019). It is noteworthy that research has revealed a positive association between adherence to rigid notions of masculinity and maladaptive coping behaviours (e.g. alcohol misuse, health risk behaviours, self-reliance rather than help-seeking) and alexithymia (Berke Reference Berke, Reidy and Zeichner2018).
A brief note on social media and mental health
Although more studies are needed, current research suggests that social media consumption is associated with more depression and anxiety, and less well-being in young people (Ahmed Reference Ahmed, Walsh and Dawel2024). Studies suggest that more time spent on social media (>3 h per day) is longitudinally related to a higher risk of mental health problems (Riehm Reference Riehm, Feder and Tormohlen2019). Additionally, evidence suggests that social media may harbour content that promotes rigid scripts of masculinity (e.g. unattainable norms of manhood based on financial and sexual success), which tend to target boys and young men longing for identity and community (Botto Reference Botto and Gottzén2024). In some cases, this social media consumption promotes misogynistic narratives to explain perceived personal failures, which ultimately and paradoxically further exacerbate loneliness and psychological distress in young men (Sparks Reference Sparks, Zidenberg and Olver2024).
Implications for mental health practice
Biopsychosocial factors unique to boys’ and men’s mental health call for a gender-specific approach when conducting clinical assessments, case formulations and therapeutic interventions (American Psychological Association 2018). Clinicians should therefore be mindful of the following guidance for improving adherence and treatment outcomes when working with boys and men. This has been gleaned from the literature and is summarised in Box 1.
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Conduct gender-sensitive psychoeducation about the detrimental effects of rigid beliefs of masculinity (e.g. toughness, stoicism, invulnerability) on self-care. Specifically with boys, examine the impact of male-directed social media content that promotes rigid masculinities and misogyny (i.e. the manosphere) and regulate social media consumption as a therapeutic target (e.g. agreeing on a maximum of 3 h per day of social media use and learning to refrain from stress-inducing content that conveys inflexible beliefs of masculinity and reinforces ‘other-blame’ coping).
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Explore traumatic memories or current situations of being put down, shamed or ignored, and how these collide with unrealistic expectations tied to manhood (e.g. dominance and control over internal and external events) and generate subsequent psychological distress.
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Look for gendered presentations of potential depressive symptoms (e.g. irritability, aggressiveness, auto-pilot functioning, isolation and physical symptoms as presenting complaints) in the patient.
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Assess the risk of suicidality thoroughly, even when the patient rationalises and/or minimises his suffering (especially when substance misuse is likely to be co-occurring) and, in the case of boys, when (cyber)bullying is present.
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With older adolescents and adults, include sexual health as a core feature of mental health and target sexual distress in a comprehensive case formulation that addresses rigid beliefs about masculinity (e.g. sexual drive and performance as markers of masculinity) as perpetuating factors.
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Encourage the development of interpersonal relationships, including male support networks, characterised by emotional validation and social connectedness, to reduce loneliness and social threat-based responding (e.g. avoidance, acting out).
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Reinforce self-care by reframing the meaning attached to gendered health behaviours (e.g. seeking mental health support as a committed action towards being the family provider and a strong role model to their children, instead of a sign of weakness).
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Share treatment plans with the patient using strategies typically preferred by males (e.g. solution-focused frameworks) and metaphors with positive masculinity connotations (e.g. courage as an attribute to deal with vulnerabilities; the therapeutic process as being akin to physical training; super-hero narratives to motivate boys confronting ‘inner demons’).
Checklist of core evidence-based clinical guidance
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Facilitate the functional deconstruction of rigid beliefs about masculinity; examine the duration and content of social media consumption
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Explore traumatic memories, particularly those that are shame-focused
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Look for depressive equivalents, such as aggressiveness or irritability
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Assess suicidality risk
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Address sexual health issues, including irrational beliefs about pleasure and dysfunction
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Promote male support groups and connectedness
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Reframe self-care initiatives in a gender-valued manner
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Co-develop mental health strategies that are male positive
Data availability
Data availability is not applicable to this article as no new data were created or analysed in this study.
Acknowledgements
C.C. is very grateful to Professor Dr Cristina Canavarro and to Professor Dr Ana Paula Matos for their enduring supervision, including on topics that inspired this paper.
Author contributions
S.A.C. and C.C. were equally responsible for the conceptualisation, drafting and critical review of the manuscript.
Funding
This work was partially funded by national funds from FCT (Fundação para a Ciência e a Tecnologia, I.P.), under the Individual Call to Scientific Employment Stimulus (ref. 2021.01871.CEECIND; https://doi.org/10.54499/UIDP/00730/2020) awarded to S.A.C. It was also supported by the Center for Research in Neuropsychology and Cognitive Behavioral Intervention (UIDB/PSI/00730/2020), University of Coimbra.
Declaration of interest
C.C. is a member of the BJPsych Advances editorial board and did not take part in the review or decision-making process of this article.
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