Abstract

Mental health problems have great international health relevance. From a multifactorial nature, the health conditions considered here as suffering are influenced by social elements such as the construction of masculinity, notwithstanding the evident increasing criticisms and struggles against male sexism. Given this setting, the paper addresses male mental distress and its care, based on a literature review, according to BVS research, and considering the 2010-2020 period. Twenty-two papers were selected from the research. The results of the study were organized into these categories: Characteristics/Particularities of men’s mental distress; Access/Way of seeking help by men in distress and approach/Care of men in mental distress. We can conclude that there is a need for more visibility for the relationship between masculinity and suffering and their care specificities, considering the existence of an apparent silent crisis, the right of men (as people) to care, and the possible contribution, albeit indirect and modest, of addressing men’s distress to the fight against machismo.

Key words:
Men; Masculinity; Mental Health

Introduction

Currently, unique, sometimes called identity agendas, such as feminist/anti-machismo struggles, anti-racist movements, and against LGBTphobia, have been highlighted in the public arena. However, they have been accompanied by so much criticism about possible limitations related to their specific focus and conservative reactions to the status quo, but also formulations that seek to understand and connect elements that establish true networks of oppression and inequality, such as the notion of intersectionality, crossing gender, ethnicity, and class¹1 Hirata H. Gênero, classe e raça: interseccionalidade e consubstancialidade das relações sociais. Tempo Soc 2014; 26(1):61-73.. In this setting, and considering, for now, the issue of gender relationships, it is not too much to remember the profoundly harmful effects of machismo and some of its primary expressions, the symbolic and concrete violence. It is no coincidence that, amid the COVID-19 pandemic, women, for example, have an increased risk of suffering domestic violence.

In what may seem a paradoxical movement, this paper seeks to address another facet of this issue: the “side” of men, particularly their mental distress. Although machismo mainly targets women, we understand that men are also, to some extent, affected by it. This is because internalizing hegemonic masculinity models can be linked both to the production of distress and particularities (often understood as barriers) in expressing and recognizing such distress.

While relatively recent, the recognition of the influence of masculinity in the processes of illness did not occur in contemporary times. Such influence was already recognized²2 Courtenay WH. Constructions of masculinity and their influence on men's well-being: a theory of gender and health. Soc Sci Med 2000; 50(10):1385-1401. in the 1970s, which is considered the starting point for studies on men and health, albeit with poorly elaborated notions influenced by feminist theories. In the following decades, we could observe growth in studies and discussions about the particularities of men’s health. The 2000s saw the emergence of the WHO publications highlighting the importance of implementing health policies targeting the needs of this population³3 World Health Organization (WHO). Boys in the picture. Genebra: WHO; 2000;. While an essential step at the national level, the approval of the National Comprehensive Men’s Health Care Policy⁴4 Brasil. Ministério da Saúde (MS). Departamento de Ações Programáticas Estratégicas. Política nacional de atenção integral à saúde do homem. Brasília: MS; 2008. is criticized for its apparent focus on urological issues⁵5 Hemmi APA, Baptista TWF, Rezende M. O processo de construção da Política Nacional de Atenção Integral à Saúde do Homem. Physis 2020; 30(3):e300321..

This work aims to explore the complex relationship between masculinity and mental distress. However, before doing so, adopting the understanding of Gomes’ work, we should clarify that we understand the construction of the hegemonic pattern of masculinity from a relational perspective of gender, in which social patterns expected of men and women emerge to differentiate them, becoming norms that tend to be stereotyped and internalized by people⁶6 Separavich MA. A saúde do homem em foco. Interface (Botucatu) 2011; 15(38):957-962..

In turn, mental distress in the contemporary world is linked to several factors, including those related to the implications of neoliberalism on ways of life urged to make themselves based on the company, forging themselves as supposed self-entrepreneurs, impelled to seek often unstable self-realizations, in an individualizing movement and dissolution of social ties⁷7 Dardot P, Laval C. A nova razão do mundo: ensaio sobre a sociedade neoliberal. São Paulo: Boitempo; 2016., to which we add, especially in countries with marked social inequality, material precariousness and difficulty in maintaining primary living conditions.

When looking at mental health-related data, a higher prevalence of Common Mental Disorders (CMD) is identified⁸8 Costa JSD, Menezes AMB, Olinto MTA, Gigante DP, Macedo S, Britto MAP, Fuchs SC. Prevalência de distúrbios psiquiátricos menores na cidade de Pelotas, RS. Rev Bras Epidemiol 2002; 5(2):164-173.^,99 McManus S, Meltzer H, Brugha T, Bebbington P, Jenkin R. Adult psychiatric morbidity in England, 2007: results of a household survey. London: National Centre for Social Research; 2009. in women. However, a higher likelihood of false negatives is observed among men when performing mental health screening tests¹⁰10 Mari JJ, Williams P. Misclassification by psychiatric screening questionnaires. J Chron Dis 1986; 39(5):371-377.. Furthermore, men are substantially more susceptible to suicide than women, and an underdiagnosis of these conditions in the male population is alleged¹¹11 Bilsker D, Fogarty AS, Wakefield MA. Critical Issues in Men's Mental Health. Can J Psychiatry 2018; 63(9):590-596., considering that CMDs are usually associated with suicide. This short-sighted recognition may occur because men tend to associate illness with weakness and have more incredible difficulty expressing anxieties and feelings of sadness than women¹⁰10 Mari JJ, Williams P. Misclassification by psychiatric screening questionnaires. J Chron Dis 1986; 39(5):371-377.. Thus, they may be more resistant to reporting emotional symptoms to interviewers. Moreover, it is speculated that even when suffering is manifested, singularities of men’s distress can represent a barrier to recognition by health professionals¹⁰10 Mari JJ, Williams P. Misclassification by psychiatric screening questionnaires. J Chron Dis 1986; 39(5):371-377..

Given this situation, this review aimed to characterize men’s mental distress and explore elements of their care.

Methods

We decided to carry out an integrative literature review that captures, recognizes, and synthesizes the production of knowledge on a particular subject or theme¹²12 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008; 17(4):758-764.. The research was carried out in June 2020 and included works published in the last ten years (from 2010 to 2020) in the Virtual Health Library (BVS) Brazil, as it is a database with a high degree of indexation of Brazilian and global health journals. The guiding questions of this review were: “What are the peculiarities of men’s mental distress?” and “How are professional approaches to men’s mental distress implemented?” The following descriptors were used: men; masculinity; psychological distress; mental health and stress, psychological. These were arranged with the following combinations: (men OR masculinity) AND (“mental health”; OR “psychological distress” OR “stress, psychological”). The inclusion criteria established were: an approach to men’s mental health (gender perspective) and language (English, Portuguese, and Spanish). Exclusion criteria were no access to the paper; approach in the context of a specific illness (except for mental disorders); addressing specific subgroups of men (for example, men working in specific settings and age groups such as older adults or adolescents). Our reading of the papers included allowed us to define three categories of approaching the theme: Characteristics/Particularities of mental distress in men; Access/Way of seeking help by men in distress and Approach/Care of men in mental distress. Around them, the main study findings and discussions were addressed, with gender relationships as a background.

Results and discussion

A total of 345 works were found in the first phase of the research. First, the titles of the papers were read and, based on the previously mentioned inclusion and exclusion criteria, 306 works were excluded. Then, after reading the abstracts, ten papers were excluded (mainly because they addressed specific subgroups). Finally, after reading the papers in full, 22 papers were included (Figure 1). Chart 1 consolidates the papers included, their respective authors, year, and place of publication concerning the previously described thematic categories. Among the works that make up the results of this review, eight are literature reviews, seven are observational studies, four are secondary data analysis, two are trials, and one is an open letter. Of the observational studies, six used qualitative methods, and only one used a quantitative method. The data of six of these seven works were based on individual interviews and one from a focus group. None of the works included were carried out in Brazil. Chart 2 shows the sorting of paper by thematic category and country of publication.

Characteristics/Particularities of mental distress in men

From the papers included in the research, we observed that, while a particular confluence was noted in the authors’ findings regarding the higher prevalence of conditions such as substance abuse and disorders related to men’s impulsivity, there are questions regarding the lower prevalence of common mental disorders¹¹11 Bilsker D, Fogarty AS, Wakefield MA. Critical Issues in Men's Mental Health. Can J Psychiatry 2018; 63(9):590-596.^,1313 Affleck W, Carmichael V, Whitley R. Men's Mental Health: Social Determinants and Implications for Services. Can J Psychiatry 2018; 63(9):581-589.. Affleck et al.¹³13 Affleck W, Carmichael V, Whitley R. Men's Mental Health: Social Determinants and Implications for Services. Can J Psychiatry 2018; 63(9):581-589. highlight the discrepancy between the prevalence of depression in men - which is significantly lower than in women - and the incidence of suicide - substantially higher in this population - as a possible indication of the underdiagnosis of depressive disorder and this is because, as pointed out by the authors, most cases of suicide are associated with depression. Furthermore, the authors point out that men are less likely to recognize mood-related symptoms due to non-compliance with dominant notions of masculinity. They seem to tend to react differently than women when faced with psychological stress. The authors argue that men seem to engage in alcohol abuse, exaggerated risk-taking, and violence due to a phenomenon described in psychoanalysis as “acting-out”. This reaction is potentially harmful and seems to contribute to mental distress not being recognized by health professionals¹¹11 Bilsker D, Fogarty AS, Wakefield MA. Critical Issues in Men's Mental Health. Can J Psychiatry 2018; 63(9):590-596.. Thus, this review shows that the discrepancy between suicide and depression data in men, the possible limitations in recognizing psychological distress, and role-playing behaviors seem to lead to what some authors have pointed out as the “silent crisis” of mental health of men¹³13 Affleck W, Carmichael V, Whitley R. Men's Mental Health: Social Determinants and Implications for Services. Can J Psychiatry 2018; 63(9):581-589..

In the national context, an observational study carried out in Pelotas (not included in the results of this research due to the year of publication) showed at least one allegedly minor psychiatric disorder in 26.5% of women and 17.5% of men¹⁴14 Lima M, Soares BGO, Mari JJ. Saúde e doença mental em Pelotas, RS: dados de um estudo populacional. Rev Psiquiatr Clín 1999; 26(5):225-235.. Also, some Brazilian authors claim that dominant gender patterns can lead men to silence health issues¹⁵15 Schraiber LB, Figueiredo WS, Gomes R, Couto MT, Pinheiro TF, Machin R, Silva GSN, Valença O. Necessidades de saúde e masculinidades: atenção primária no cuidado aos homens. Cad Saude Publica 2010; 26(5):961-970. (which is aligned with the idea of “silent crisis”) and lead women to talk and complain more about emotional issues. However, some argue that differences in prevalence are not necessarily produced by underdiagnosis in the male population. Ludermir et al.¹⁶16 Ludermir AB. Desigualdades de classe e gênero e saúde mental nas cidades. Physis 2008; 18(3):451-467., for example, point out that such differences can result from gender inequalities, which can adversely impact the mental health promotion of women, who tend to suffer from double shifts and the persistent devaluation in the labor market. We consider that machismo affects society as a whole, which leads to evident deleterious effects on women’s lives and adversely affects men’s mental health. Thus, we understand that recognizing the higher prevalence of mental disorders in women does not exclude the possibility of unrecognized distress in men.

Although men seem to suffer “in silence”, evidence shows that they do not suffer alone. An analysis of data from the 2002 U.S. National Survey on Drug Use and Health found that men who committed domestic violence reported untreated mental health needs twice as much as those who did not¹⁷17 Lipsky S, Caetano R, Roy-Byrne P. Triple jeopardy: impact of partner violence perpetration, mental health and substance use on perceived unmet need for mental health care among men. Soc Psychiatry Psychiatr Epidemiol 2011; 46(9):843-852.. Furthermore, from interviews with men from Mexico and the U.S., Fleming et al.¹⁸18 Fleming PJ, Patterson TL, Chavarin CV, Semple SJ, Magis-Rodriguez C, Pitpitan EV. Are men's misogynistic attitudes associated with poor mental health and substance use behaviors? An exploratory study of men in Tijuana, Mexico. Psychol Men Masc 2018; 19(2):314-318. showed that depressive symptoms were associated with misogynistic attitudes. While the temporal and causal relationship between depressive symptoms and misogynistic attitudes cannot be assertively defined due to the study’s exploratory nature, the authors of this study believe that a better understanding of this relationship can lead to positive outcomes in both men and women.

We do not intend to hold male perpetrators of domestic violence accountable by describing the possible relationship with mental distress but rather to discuss a potential (and relevant) positive impact of the men’s mental health approach that transcends the relief of distress.

Despite having noticed a tendency among authors to relate hegemonic patterns of masculinity to adverse effects on men’s mental health¹⁵15 Schraiber LB, Figueiredo WS, Gomes R, Couto MT, Pinheiro TF, Machin R, Silva GSN, Valença O. Necessidades de saúde e masculinidades: atenção primária no cuidado aos homens. Cad Saude Publica 2010; 26(5):961-970.^,1616 Ludermir AB. Desigualdades de classe e gênero e saúde mental nas cidades. Physis 2008; 18(3):451-467.^,1919 Boettcher N, Mitchell J, Lashewicz B, Jones E, Wang J, Gundu S, Marchand A, Michalak E, Lam R. Men's Work-Related Stress and Mental Health: Illustrating the Workings of Masculine Role Norms. Am J Mens Health 2019; 13(2):1557988319838416.^,2020 Milner A, Shields M, King T. The Influence of Masculine Norms and Mental Health on Health Literacy Among Men: Evidence from the Ten to Men Study. Am J Mens Health 2019; 13(5):1557988319873532., there was also a tendency that can be understood as relativization or even opposing that vision²¹21 Whitley R. Men's Mental Health: Beyond Victim-Blaming. Can J Psychiatry 2018; 63(9):577-580.

22 Wong YJ, Owen J, Shea M. A latent class regression analysis of men's conformity to masculine norms and psychological distress. J Couns Psychol 2012; 59(1):176-183.

23 McKenzie SK, Collings S, Jenkin G, River J. Masculinity, Social Connectedness, and Mental Health: Men's Diverse Patterns of Practice. Am J Mens Health 2018; 12(5):1247-1261.

24 Keohane A, Richardson N. Negotiating Gender Norms to Support Men in Psychological Distress. Am J Mens Health 2018; 12(1):160-171.^-2525 Shafer K, Wendt D. Men's mental health: a call to social workers. Soc Work 2015; 60(2):105-112.. We highlight the work carried out by Wong et al.²²22 Wong YJ, Owen J, Shea M. A latent class regression analysis of men's conformity to masculine norms and psychological distress. J Couns Psychol 2012; 59(1):176-183. who, from a multidimensional perspective of the construction of masculinity, identified that compliance with certain norms in specific subgroups of men could be associated both positively and negatively with psychological stress - it has to be said that the subgroup called “detached risk-takers”, which is in general per more sexist and patriarchal norms, had greater psychological distress.

Again, in the sense of perceiving the constructions as multidimensional, McKenzie et al.²³23 McKenzie SK, Collings S, Jenkin G, River J. Masculinity, Social Connectedness, and Mental Health: Men's Diverse Patterns of Practice. Am J Mens Health 2018; 12(5):1247-1261. studied the establishment of social connections by men and the mobilization of support networks. The authors identified diverse patterns, and while some respondents showed more instrumental and less emotionally collaborative forms of relationship, others displayed positive social connection patterns for emotional health. In this sense, the warning made by Shafer and Wendt²⁵25 Shafer K, Wendt D. Men's mental health: a call to social workers. Soc Work 2015; 60(2):105-112. stands out so that traditionally perceived masculine attitudes are not automatically deemed unfavorable since, from the authors’ perspective, some of these characteristics, such as being “action-oriented” and “goal-focused” could be useful in the treatment. Also, in this direction, Whitley²¹21 Whitley R. Men's Mental Health: Beyond Victim-Blaming. Can J Psychiatry 2018; 63(9):577-580. highlight a phenomenon described as “victim-blaming”, in which men are blamed for acting per masculinity standards, attributing distress to this behavior and disregarding the complex phenomenon involving the social context and health determinants. This view is understood as simplistic and reductionist, and transcending it seems to be a need when thinking about the care of men in mental distress²⁴24 Keohane A, Richardson N. Negotiating Gender Norms to Support Men in Psychological Distress. Am J Mens Health 2018; 12(1):160-171..

Access/Way of seeking help by men in distress

Despite recognizing the intersections between issues related to the particularities of men’s mental distress and the way of seeking help, some of the studies included in this review directly address the access or way of seeking help by men in distress. The study conducted by Keohane and Richardson²⁴24 Keohane A, Richardson N. Negotiating Gender Norms to Support Men in Psychological Distress. Am J Mens Health 2018; 12(1):160-171. stands out, who, based on focus groups whose participants were men at higher risk for suicide or who played the role of community “gatekeepers”, made relevant observations concerning seeking, receiving, and providing help. The researchers noted that men invariably considered the effect of psychological issues on masculinity. Cultural norms such as repressing emotions and maintaining “firmness” in the face of adversity were very much alive among the participants. Acknowledging or admitting the problem was seen as the most difficult first step. We also observed that seeking help depends on good connections made in the family environment, at work, and in sports, and that, while men also recognize themselves in the role of “helpers”, they showed fear of not having the necessary helping capacity.

Also, men generally seek help for mental issues less than women²⁶26 Buffel V, Van de Velde S, Bracke P. Professional care seeking for mental health problems among women and men in Europe: the role of socioeconomic, family-related and mental health status factors in explaining gender differences. Soc Psychiatry Psychiatr Epidemiol 2014; 49(10):1641-1653.^,2727 Parent MC, Hammer JH, Bradstreet TC, Schwartz EN, Jobe T. Men's Mental Health Help-Seeking Behaviors: An Intersectional Analysis. Am J Mens Health 2018; 12(1):64-73. and some men subgroups tend to access help less than others. Parent et al.²⁷27 Parent MC, Hammer JH, Bradstreet TC, Schwartz EN, Jobe T. Men's Mental Health Help-Seeking Behaviors: An Intersectional Analysis. Am J Mens Health 2018; 12(1):64-73. observed, from the application of questionnaires to a sample of American men, that seeking help (defined in the study as contact with mental health or social service professional in the last 12 months) was higher among white, homosexual, single, older adults with more prominent depression. Authors of a study carried out in several European countries pointed out that socioeconomic factors influence the demand for health services. However, authors argue that, although the social roles of men and women influence access, this impact varies by country studied²⁶26 Buffel V, Van de Velde S, Bracke P. Professional care seeking for mental health problems among women and men in Europe: the role of socioeconomic, family-related and mental health status factors in explaining gender differences. Soc Psychiatry Psychiatr Epidemiol 2014; 49(10):1641-1653..

As already mentioned, no studies carried out in Brazil were found in this review. However, we should highlight works that, while not explicitly exploring the ways men seek care in the context of mental distress, investigated the theme of seeking care more broadly, allowing, to some extent, a dialogue with the findings of this review. For example, Cunha et al.²⁸28 Cunha RB, Rebello LEFS, Gomes R. Como nossos pais? Gerações, sexualidade masculina e autocuidado. Physis 2012; 22(4):1419-1437. showed that the men studied considered prevention and body care as the main ways to self-care. However, they recognized that the self-care habit has not yet been incorporated into male culture. On the other hand, Figueiredo²⁹29 Figueiredo W. Assistência à saúde dos homens: um desafio para os serviços de atenção primária. Cien Saude Colet 2005; 10(1):105-109. highlights that, while there is, in fact, an idea that the low presence of men in PHC services is associated with the devaluation of self-care by this population, men tend to prefer to use other services such as first aid or pharmacies, which are places where the author believes demands are answered more objectively²⁹29 Figueiredo W. Assistência à saúde dos homens: um desafio para os serviços de atenção primária. Cien Saude Colet 2005; 10(1):105-109..

Therefore, in the national context, besides possible issues related to male identity are also those related to the organization of health services. We should recognize, then, that political and cultural change (with the deconstruction of hegemonic ideals of masculinity) should not be passively observed by those working in the health sector. Instead, these professionals should perhaps incorporate the values of this change in their practices and in the organization of the service itself, paying attention to what eventually appears as a barrier for men and seeking to create strategies to circumvent them, expanding reception mechanisms without, however, being mere adequacy to men’s rationale.

Approach/Care of men in mental distress

Reading the works addressing care for men in mental distress, we identified that considering particularities and adapting the approach of professionals is relevant³⁰30 Seidler ZE, Rice SM, Dhillon HM, Herrman H. Why it's time to focus on masculinity in mental health training and clinical practice. Australas Psychiatry 2019; 27(2):157-159.

31 Parent MC, Hammer JH, Bradstreet TC, Schwartz EN, Jobe T. Men's Mental Health Help-Seeking Behaviors: An Intersectional Analysis. Am J Mens Health 2018; 12(1):64-73.^-3232 Roy P, Tremblay G, Duplessis-Brochu É. Problematizing Men's Suicide, Mental Health, and Well-Being. Crisis 2018; 39(2):137-143.. For example, Seidler et al.³⁰30 Seidler ZE, Rice SM, Dhillon HM, Herrman H. Why it's time to focus on masculinity in mental health training and clinical practice. Australas Psychiatry 2019; 27(2):157-159. claim that the more “gender-competent” a health professional is, the better she/he can respond to men’s psychological and clinical challenges. The diverse and complex masculinity expressions seem to be related to health as they can influence how help is sought and engaging with treatment³⁰30 Seidler ZE, Rice SM, Dhillon HM, Herrman H. Why it's time to focus on masculinity in mental health training and clinical practice. Australas Psychiatry 2019; 27(2):157-159.. Thus, the authors argue that masculinity should be part of the “mental health” curriculum. In this sense, Patrick and Robertson³³33 Patrick S, Robertson S. Mental health and wellbeing: focus on men's health. Br J Nurs 2016; 25(21):1163-1169. underscore the importance of nurses recognizing the particularities of men’s mental distress and providing gender-sensitive interventions. In the same vein, Cheshire et al.³⁴34 Cheshire A, Peters D, Ridge D. How do we improve men's mental health via primary care? An evaluation of the Atlas Men's Well-being Pilot Programme for stressed/distressed men. BMC Fam Pract 2016; 17:13. describe the Atlas project, a pilot program that aimed to approach more gender-sensitive general practitioners, among other things. Robertson et al.³⁵35 Robertson S, Gough B, Hanna E, Raine G, Robinson M, Seims A, White A. Successful mental health promotion with men: the evidence from 'tacit knowledge'. Health Promot Int 2018; 33(2):334-344. showed that the more sensitive to the gender issue, the more respectful and less judgmental, the better the facilitator’s effect on men’s expression of emotions and communication.

Besides adapting health professionals, some studies mentioned adapting services or the approached environment¹⁸18 Fleming PJ, Patterson TL, Chavarin CV, Semple SJ, Magis-Rodriguez C, Pitpitan EV. Are men's misogynistic attitudes associated with poor mental health and substance use behaviors? An exploratory study of men in Tijuana, Mexico. Psychol Men Masc 2018; 19(2):314-318.^,3232 Roy P, Tremblay G, Duplessis-Brochu É. Problematizing Men's Suicide, Mental Health, and Well-Being. Crisis 2018; 39(2):137-143.. Robertson et al.³⁵35 Robertson S, Gough B, Hanna E, Raine G, Robinson M, Seims A, White A. Successful mental health promotion with men: the evidence from 'tacit knowledge'. Health Promot Int 2018; 33(2):334-344. showed that creating a safe environment where men can feel relaxed and comfortable is important. The authors emphasize that most services are predominantly attended by women, making it unattractive for men³⁵35 Robertson S, Gough B, Hanna E, Raine G, Robinson M, Seims A, White A. Successful mental health promotion with men: the evidence from 'tacit knowledge'. Health Promot Int 2018; 33(2):334-344.. Similarly, Ogrodniczuk et al.³⁶36 Ogrodniczuk J, Oliffe J, Kuhl D, Gross PA. Men's mental health: Spaces and places that work for men. Can Fam Physician 2016; 62(6):463-464. described initiatives to transform environments to make them more welcoming and receptive to men with depression and suicidal ideation. These findings align with the conclusions of authors of studies carried out in Brazil, such as that of Figueiredo²⁹29 Figueiredo W. Assistência à saúde dos homens: um desafio para os serviços de atenção primária. Cien Saude Colet 2005; 10(1):105-109., mentioned above, which highlights the feminization of national PHC services.

However, it seems relevant to us to mention that because health services are perceived as “feminized” does not shift the responsibility for the low demand of men solely to these services. The resistance of these men is also seen as a reflection of the hegemonic social constructs of masculinity, which make the presence in “feminized” environments uncomfortable.

Concerning approach strategies, two of the studies included mention the importance of normalizing the distress experiences of men³³33 Patrick S, Robertson S. Mental health and wellbeing: focus on men's health. Br J Nurs 2016; 25(21):1163-1169.^,3737 Such E, Burton H, Copeland RJ, Davies R, Goyder E, Jeanes R, Kesterton S, Mackenzie K, Magee J. Developing a theory-driven framework for a football intervention for men with severe, moderate or enduring mental health problems: a participatory realist synthesis. J Ment Health 2020; 29(3):277-288.. “Gender-transformative” approaches that aim to reinforce positive aspects of masculinity³²32 Roy P, Tremblay G, Duplessis-Brochu É. Problematizing Men's Suicide, Mental Health, and Well-Being. Crisis 2018; 39(2):137-143.^,3838 Seidler ZE, Rice SM, Dhillon HM. Get angry or get even: Finding balance in the discussion of masculinity and mental health. Aust N Z J Psychiatry 2019; 53(11):1122. were also mentioned. Finally, concerning ways of approaching, we observed that physical exercise was used as a strategy to promote mental health in men³⁹39 Seaton CL, Bottorff JL, Jones-Bricker M, Oliffe JL, DeLeenheer D, Medhurst K. Men's Mental Health Promotion Interventions: A Scoping Review. Am J Mens Health 2017; 11(6):1823-1837. in seven of the 14 studies included in a systematic review. In the same vein, Such et al.³⁷37 Such E, Burton H, Copeland RJ, Davies R, Goyder E, Jeanes R, Kesterton S, Mackenzie K, Magee J. Developing a theory-driven framework for a football intervention for men with severe, moderate or enduring mental health problems: a participatory realist synthesis. J Ment Health 2020; 29(3):277-288. and collaborators showed that intervention through physical exercise could have therapeutic effects on men’s mental health as it fosters social connection, identity security, normalization of experiences, and affectivity³⁷37 Such E, Burton H, Copeland RJ, Davies R, Goyder E, Jeanes R, Kesterton S, Mackenzie K, Magee J. Developing a theory-driven framework for a football intervention for men with severe, moderate or enduring mental health problems: a participatory realist synthesis. J Ment Health 2020; 29(3):277-288..

It must be pointed out, however, that the very multifactorial nature of human distress - understood here as destabilizing a set of elements or worlds (past, present, familiar, and secret)⁴⁰40 Cassel EJ. The nature of suffering and goals of medicine. New York: Oxford University Press; 1991. - makes a complete response of case-specific approaches such as, for example, physical activity or those that can be performed at the individual care level, unlikely. In this sense, it seems appropriate to reiterate that machismo can be, for men, one of the causes of distress (when they have to be providers or strong, for example) and an obstacle to facing them (no space for mediations and reflexivity). Finally, we highlight that distress experiences and manifestations are not homogeneous. Social differences can establish different distress configurations, and coping can vary depending on the reality and the subject.

While being a risk, the approach to male mental distress is not bound to victimize or absolve men eventually. We understand that this is not the case. However, we should remember that people deserve to have access to care in the face of distress and that, while not necessarily structured around machismo, distress and care can be a way of accessing subjective processes and producing “dialogues” that favor, albeit indirectly, the setting and experience of other possibilities of masculinity.

Final considerations

While using a single database in the bibliographic research, this study indicates that hegemonic patterns of masculinity seem to be part of the complex genesis of men’s distress and impact on care for this public. It seems reasonable to assume that the possible under-diagnosis of common mental disorders in men pointed out in other countries is also a reality in Brazil. This is because we understand that the patterns of masculinity in Brazilian society, the exacerbated socioeconomic inequality, and the dismantling of social protection devices are combined and enhanced and can influence mental distress.

Recognizing the harmful effects of sexism on men themselves should not mean taking away the responsibility of those who often use their macho social structure to oppress and rape women. Therefore, the care of men in mental distress should not nullify the public debate to combat gender inequalities and may represent a small contribution, depending on how it operates, for its complex and challenging deconstruction. The elements brought up in this paper point to the need for this theme to be the target of more research, with different approaches and settings, which becomes even more relevant in the national context, as no papers published in Brazilian journals were found in this review.

References

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