I was visiting friends with two young children when Ruthie, their 7 year old daughter, asked if I wanted a tour of their home. Honored, I followed her lead. Soon she brought me to her brother's (who was 4) room, "...this is Jack's room, don't be scared, there are a lot of swords and other weapons", she said. When we got to her room I saw dolls, stuffed animals, and a play area with a little table set with tea cups. When I caught up with Jack he wanted to play 'swords' (fashioned from sticks and household utensils) with me.
Ruthie was verbal, relational and reflective. Jack was physical and competitive.
My friends were both accomplished professionals and had not bought their son toy-store weapons or let him play video games famous for their killing and violence. They did buy dolls their daughter had asked for. Yet, their children, both lively and smart, were gender stereotypes! Will boys be boys, and girls be girls (in most instances)?
What's going on here? And what does it mean for men's mental health and therapies that seek to engage them? And how can we assist those men affected by mental and addictive conditions to recognize problems and seek help, without the stigma and shame that so often occur?
Last year The Huffington Post introduced Stronger Together to advance understanding and effective care for mental disorders, including depression. This year we will focus on men's mental health.
The World Health Organization (WHO) reports that women are far more likely to be diagnosed with depression than men, even when a similar clinical picture presents before a trained clinician. Is this bias, stigma? And what can be done?
The Huffington Post, and I, approach this important topic recognizing that commenting on sex/gender differences can sink even as prominent a person as Dr. Lawrence Summers (when he was President of Harvard University). We want to be clear in stating that population or individually based differences do not, and should not, limit any person, woman or man, from achieving success in work or relationships. Even physically, for the first time in history, two women recently graduated from Army Ranger training where strength and endurance are exceedingly challenged. But differences exist and need to be understood if opportunities are to be equitable.
There can be significant differences in not only the numbers of men and women affected by mental disorders, how these conditions appear clinically, the course of disorders over time, and in treatment approaches -- and these differences can (and do) make a difference.
MRI and other highly sensitive imaging (e.g., PET scanning) of the brain, for example, including reports of cerebral volume and circuits, are revealing - as are hormonal studies of the sexes. They may have implications for developing and delivering gender-specific approaches to a number of mental health conditions, including depression, PTSD, substance use disorders, and psychotic conditions like schizophrenia. While what we know about the brain, cognition, feelings and behavior remains very rudimentary (and is likely to change), social scientists and educated readers need to keep an open mind about what we know and can do today.
For example, fetuses with XY chromosomes (boys) are exposed to far higher levels of male hormones (especially testosterone, and also vasopressin and Műllerian Inhibiting Substance, MIS) in utero as early as nine weeks; levels peak again in puberty and are far greater than in those with XX chromosomes (girls). In contrast, females produce very different levels of estrogen, progesterone and oxytocin (the bonding and 'cuddling' hormone). Testosterone and other androgens influence brain development in a number of ways. Greater exposure to androgens is associated with differences in brain structures like the amygdala (the fear center and where emotional memory can be formed); the hippocampus (which influences learning and long-term memory); parts of the prefrontal cortex (associated with judgment and control); and there is evidence of variations in grey matter (cells) brain volume between the sexes.
One result is that manual and cognitive skills can differ between boys and girls. Males (even monkeys not exposed to cultural influences as are humans) selectively prefer toys like trucks that can be moved through space and that lend themselves to activity, including gross physical movements. Males prefer different colors than females. Females do better than males in tests that measure recollection as well as in more precision motor tasks. There are also differences in behaviors consistent with many of the brain differences described above. Empathy, which is higher on average in females than males, can be reduced by exposure to testosterone in utero; and a genetic condition (congenital adrenal hyperplasia) that increases male hormone production beginning before birth) is associated with reduced empathy.
In a very funny yet smart website called Man Therapy we see the site host seeking comfort by holding a tape recorder to his ear that plays the revving sounds of a big-engine car. Other parts of the site are more serious but may not be more revealing of a man's nature.
Stress responses appear different as well between the sexes. These may relate to the amygdala and the hippocampus, as well as to neurotransmitters like serotonin. Females may be more resilient than males when faced with chronic stress, which we know to be a factor in many psychiatric and medical illnesses including depression, PTSD, hypertension, diabetes and autoimmune disorders.
Addictions (substance use disorders) appear highly linked with brain dopamine, the "pleasure" neurotransmitter. There are notable differences in dopamine in people who develop addictions as well as in changes in this neurotransmitter's activity after exposure to substances of abuse like cocaine, stimulants and ecstasy - as well as in behavioral addictions like gambling. Dopamine and its release may be increased by estrogen, making females more at risk for addiction. These differences suggest treatment approaches that may be different for men and women.
Females, as well, may have greater prefrontal cortex volume, especially in the ration of the cortex to the size of amygdala section of the brain. This may provide them with more capacity for behavior control and suggests cognitive and motivational approaches to problem behaviors. This finding, as well, may be present in people with schizophrenia, and make for different presentations and course of the illness in women than men.
Grey-white matter sex differences (white matter provides connectivity for cells and brain regions) may account for why females are better multi-taskers and why males do better on highly task-oriented activities. Words mean more to females than males, which may relate to greater bilateral verbal brain centers. These differences may help in thinking about and fashioning cognitive therapy approaches.
We read, in a companion, lead by HuffPost Editor Lindsay Holmes, that there are some differences in the prevalence and presentation of different mental disorders around the world. We also need to appreciate how different cultures and age groups regard mental disorders, and the resulting biases and discrimination that is well known to occur.
Extending what we know from brain science, and public mental health, into everyday practice is critical - and not an easy or small step.
Cognitive approaches in therapy, for example, will need to consider different mental skill sets among men and women. Men are drawn to solving problems, especially those that require motor and spatial skills; how can we use that in gaining their attention and trust? Targeting neurotransmitters, by various methods including hormonal administration, will need to build on what is known of their differences between the sexes. The need for men to contain feelings and protect against shame related to feeling inferior, "not quite a man", may be ingrained in the amygdala and hippocampus and thus will need the 'right' approach: A good example is offered in the Opinion Pages of the New York Times in Therapy for Tough Guys (COUCH).
Evolutionary biologists and geneticists will remind us that differences are not only important; they are essential for species survival and adaptation. Vive La Différence, in fact, may be quite right in saluting (in this case, gender) differences; these need to be recognized, understood and used in everyday life and in fashioning approaches that are clinically useful and help reduce stigma about men's (and women's) mental health problems. That's what we aim to do as The Huffington Post focuses on men's mental health.
Cahill L, Why sex matters for neuroscience. Nature Reviews. Neuroscience 7 (6): 477-84, 2006
McCarthy, MM, Arnold, AP, Reframing sexual differentiation of the brain, Nature Neuroscience, Vol 14, #6, June 2011
The Male Brain, Brizendine, L, Harmony/Random House, NY 2010
Vosgrove, K, Mazure, C, Staley, J, Evolving Knowledge of Sex Differences in Brain Structure, Function and Chemistry, Biol Psychiatry, 62:847-855, 2007
Cahill, L, His Brain, Her Brain, Scientific American, 292(5):40-47, 2005
Hines, M, Gender Development and the Human Brain, Annual Rev of Neuroscience, 34:69-88, 2011
Christov-Moore, L, Simpson, EA, Coude, G, et al, Empathy: Gender effects in brain and behavior, Neuroscience and Biobehavioral Revs, 46:604-627, 2014
Koscik T, Bechara A, Tranel D, Sex-related functional asymmetry in the limbic brain, Neuropsychopharmacology, January 2010
Ackermann S, Spalek K, Rasch B et al., Testosterone levels in healthy men are related to amygdala reactivity and memory performance. Psychoneuroendocrinology 37 (9): 1417-24, 2012
The opinions expressed herein are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Dr. Sederer's book for families who have a member with a mental illness is The Family Guide to Mental Health Care (Foreword by Glenn Close) -- is now available in paperback.
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