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Healthy masculinities and the wellbeing of young men and boys

BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p385 (Published 23 February 2023) Cite this as: BMJ 2023;380:p385

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Encouraging equality starts before birth

Dear Editor

Encouraging equality starts before birth

A prominent feature of masculinity is the suppression of vulnerability. Signs of weakness are shameful to many boys and men, from which follow undesirable traits such as reluctance to seek help, and contempt for frailty in others, both male and female.

A group of 6 year-old girls and boys were listening to the recorded sound of a crying baby. Many more girls than boys spoke kindly to what they assumed was a real infant, while more than twice as many boys simply turned the speaker off. Tracings of heart rate variability suggested that the boys were more anxious; they could not tolerate the infant’s distress (1).

This is one of many studies on male vulnerabilities that I summarised in 'the Fragile Male' (2) in this journal over 20 years ago. From conception onwards the male is at a disadvantage that persists in various forms throughout life. This news came as a surprise to many people, including the international mainstream media. I was ‘famous for 15 minutes’ but, though the paper is still cited in scholarly journals, the message has had little lasting impact.

To begin with, a male fetus is more affected by maternal stress. Four months after the 9/11 attacks in New York the ratio of boys to girls born there was greatly reduced (3). This is the tip of an iceberg of male fragility and harm. Every paediatrician fears more for the survival of premature babies when they are male (4). Boys of mothers with antenatal anxiety at 32 weeks are more likely to become inattentive and hyperactive (5), and maternal postnatal depression affects teenage boys’ academic attainments at GCSE more than girls (6).

While the excess of widows over widowers is well known, there is little public awareness of the greater mortality of boys from all causes, with twice as many deaths due to injury and a steep social class gradient (7). The far higher suicide rate in men (8) is related to a perception that help is not available and that asking for it is a sign of failure (9).

Already by six months girls are more sociable and better at emotional self-regulation (10). The prevailing view that males are tougher than females encourages some parents to give less attention to infant boys, just when they need it more (11). If mothers, fathers and other caregivers and educators understood his extra needs, they could be more patient with a boy’s struggles to hold himself together. Under less social pressure to dismiss anxiety he may then become better able to manage it.

Professionals who care for pregnant women and families with babies and toddlers need to learn about the fragile male. Early intervention starts before birth, preferably in multidisciplinary perinatal care, where stress in pregnant women may not be readily identified without team discussion (12).

A social intervention
A recent major study of the long-term outcome of Sure Start centres for under 5s (13) showed that boys from the most disadvantaged backgrounds made the greatest gains, ten years later. The researchers found a very significant fall in teenage rates of hospital admission for injuries or mental problems. Even without a deliberate focus on their vulnerability, it seems that a collective, easily accessed social programme for families – with expert staff such as health visitors on hand – provides a secure container for the hardest to reach little boys, promoting resilience that may last them into adulthood.

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2. Kraemer S. The fragile male BMJ 2000;321:1609
3. Catalano R, Bruckner T, Marks AR, Eskenazi B. Exogenous shocks to the human sex ratio: the case of September 11, 2001 in New York City, Human Reproduction 2006:21(12):3127-­3131
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8. Thomas K, Gunnell D. Suicide in England and Wales 1861–2007: a time-trends analysis. International Journal of Epidemiology 2010;39:1464–1475
9. Oliffe JL, Broom A, Rossnagel E, Kelly MT, Affleck W, Rice SM. Help-seeking prior to male suicide: Bereaved men perspectives. Social Science & Medicine 2020; 261
10. Malatesta CZ, Haviland JM. Learning display rules: the socialization of emotion expression in infancy. Child Dev 1982;53:991-1003
11. Weinberg MK, Tronick EZ, Cohn JF, Olson KL. Gender differences in emotional expressivity and self-regulation during early infancy. Dev Psychol 1999; 35(1):175-88
12. Kraemer S. Mental health: needs go beyond RCTs. Lancet 2015;385:1831–1832
13. Cattan S, Conti G, Farquharson C, Ginja R, Pecher M. The health impacts of Sure Start. London: IFS, 2021. Available at: https://ifs.org.uk/publications/health-impacts-sure-start (accessed: 12 March 2023).

Competing interests: No competing interests

15 March 2023
Sebastian Kraemer
Honorary Consultant Child and Adolescent Psychiatrist
Tavistock & Portman NHS Trust
120 Belsize Lane, London NW3 5BA