Guidelines on Men and Boys: Oh Boy


Let’s face it. When men are compared with women on a variety of psychological and physical health parameters, men pretty much lose across the board. Women outlive men, indeed, in every age group, death rates for men exceed those for women. In 2018, women in the US lived on average a whopping five years longer than men (81 vs. 76 years), though the US ranked only 53rd of 220 nations or territories in terms of overall life expectancy. Nor is the difference limited to humans. In practically every mammalian and avian species, females live longer than males, though in a few species of seals, birds, ungulates, and wild dogs, males have a small edge (shout out to you, all you he-African buffalos and tundra swans!)

In comparison to women, men engage in more risk-taking behavior, consume more alcohol, are more likely to use more tobacco and other substances, and get diagnosed with ADHD more frequently. Men also experience more behavioral disorders in childhood and adolescence, where we develop a pattern of externalizing behaviors that not only bring us to the attention of the wrong type of people but also lead us to ignore internal cues that modulate psychological health. As a sex, we are, in a word, a mess.

Why? That is a bit unclear. Some believe that men have been socialized into patterns of riskier behavior and psychological myopia, are unable to admit to perceived personal deficits, and generally possess an unhealthy level of bull-headedness. Others point out that since intersex differences are so pervasive among species, there are genetic and hormonal advantages to being female. But no matter whether you blame tobacco, tiki bars, or telomeres, the picture is grim for carriers of the XY chromosomal pattern.

These findings provide a somewhat dreary prolegomena (at least if you’re a male) to the recently published APA Guidelines for Psychological Practice with Boys and Men. Although the authors of this guideline note that while, somewhat paradoxically, gender privilege rests with males (particularly, in our society, European-American males) and men for many years provided the normative basis that underlay many descriptions of human behavior (all psychology was, in essence, “male” psychology, because women were often ignored when normative assumptions about behavior were being formulated), men have been socialized into gender role stereotypes that are distinctly unhealthy. This is compounded by things like gender biases in therapy and a greater burden of stigma directed at males who express psychological vulnerability.

The authors of the guidelines then go on to provide input in 10 general areas that, in their opinion, can positively affect men and how they engage in therapy. They urge understanding that while men express certain common behaviors as a group, there are many different masculinities based on social, cultural, and contextual factors. They note that myriad factors affect the expression of masculine identity: social, economic, gender, ethnicity, sexual orientation, immigration and ability variables, to name but some.

As you might expect, this exegesis did not go down well with certain factions in the blogosphere and among the chattering classes. The guideline’s authors were very rapidly taken to task for targeting the traditional American male for extinction in an ominous attempt at “Soviet”-style social engineering. They were clinical psychologists waging a “pseudotherapeutic war” (as opposed, I presume, to a therapeutic war?) against traditional masculinity, patriarchy, male stoicism, and rigid gender norms, according to another commentator. Many seem to have read no further than the byline as it is clear to them that APA has been mortally compromised as a scientific authority, having been taken over by leftist culture warriors. Get rid of traditional masculinity and you’ve emasculated the American male. Without traditional masculinity, how would we have won World War II? (that commentator did not, sadly, examine the question of whether WWII would ever have occurred if we’d understood traditional masculinity a little better).

Such responses are to be expected. It is unreasonable to presume that a report that deals with issues of gender and sexuality, including homosexuality and transgender issues, could be released into the overwrought, tweet-fueled atmosphere of the modern agora without kicking up quite a fuss. Issues that many of us view as innocuous, such as a discussion of patriarchy, may become unexpectedly controversial, for example, among those who believe that ‘traditional’ masculine family roles are rooted in Biblical precepts. In other words, the guidelines provide ample ammunition for those who want to view them in terms of challenges to prevailing social mores.

We are in an era when many privileges are being re-examined, so construing the guidelines as a part of this shouting match is pretty much inevitable, but it’s not necessarily something we need to spend too much time on. Let’s accept that such guidance cannot be promulgated without attracting a certain amount of negative attention, and instead focus on the substance of the guidelines. What do they say, and is it of value to the clinician? Here are a few examples from the 10 recommendations in the guidelines.

The first four of the guidelines remind us that masculinities are a social construct, and that many such constructs exist, sometimes in spaces that compete with one another. It also reminds us that gender (as distinct from, but in the same manner as, sexual orientation) is a nonbinary construct. Men may exhibit elements of “traditional” masculinity, but many must continually negotiate between what are perceived as societal norms and their individual identities, particularly if they possess social or ethnic minority status. Privilege is real and carries with it not just societal advantages but psychological vulnerabilities. Thus, our World War II hero, fresh from taking the beachhead, might have gone home to the arms of his wife or girlfriend, as most did, or his same-sex lover, as the predictable minority of WWII combatants did (see Alan Berube’s WWII history “Coming Out under Fire”). Courage, though selective and inconsistent (sometimes you have it, sometimes you don’t) is universal and not specific to masculinity. But it is often confused with traditional masculine identities. Overall, I think we would rate these four guidelines as pretty sound advice: Don’t presume that the patient in front of you is as he first appears. His identity and perhaps struggles have been defined by multiple, possibly conflicting constructs.

Guideline 5 exhorts the clinician to assist fathers to succeed in that complex and challenging role. According to the literature cited in the guideline, most men in our society are fathers, and most don’t think they are very good at it. Although parenthood often brings out the best in men (reduced substance intake, enhanced perception of responsibility and closer spousal relations), many are flummoxed about how to be a parent, understandable since most parenting literature and social support systems are aimed at mothers. The majority of fathers still have traditional roles of being the higher income earner and provider in families and don’t always succeed in blending this with good parenting. What do the authors recommend? Help dads be dads. Expose them to resources and strategies aimed at enhancing their effectiveness as fathers. Help them negotiate the complex demands of being the principal economic supporter and simultaneously an involved, responsive parent.

Guideline 6 provides some straightforward recommendations regarding schooling males. Inasmuch as educational success is a strong predictor of numerous desired outcomes (e.g., vocational and social success) and given that elementary education is challenging for many boys (more boys than girls are diagnosed with ADHD, experience disciplinary problems, and otherwise struggle in school) this guideline has particular importance. Clinicians are urged not to make knee-jerk diagnoses of ADHD, but instead look at the externalizing behaviors that may be mistaken for it. Help educators and administrators devise effective anti-bullying strategies, including effective interventions for bulliers. Help teachers develop boy-centric academic strategies that treat certain externalizing behaviors as strengths rather than deficits.

Guideline 7 deals with a central component of modern masculinity: Violence. While most males are not violent, most violence is perpetrated by males, including violence directed against the self —males are more likely than females to end their lives by suicide. Males who have been the victims of violence in childhood are more likely to perpetrate domestic violence in adulthood. The origins of such violence are, as the authors note, multifactorial and difficult to parse out. Nevertheless, common factors such as adverse childhood experiences and socialization towards aggressivity can be identified and effective interventions developed. But, as Guideline 8 addresses, all is for naught if the documented reluctance of males to seek help cannot be overcome. Getting men as a group to be more open to medical and psychological assistance is difficult, and well beyond the powers of a single profession. But stigma can be effectively, if not completely, addressed often by other men who have experienced it. Senior military commanders acknowledging their struggles with PTSD and the need for psychological assistance provide powerful leadership examples, as Army Brigadier General Donald Bolduc provided in disclosing his own struggles.

I don’t have space to dissect all of the Guidelines in detail. You can access and read them online, which is worth the read. In general, I found them to be thoughtful, inclusive, and helpful in my thinking about how to approach men’s psychological difficulties. Remember that these are guidelines, not edicts. They point the way towards better practice, they do not dictate it. As was the case with the publication last year of APA’s Guidelines for treating PTSD, they are likely to be misconstrued as more prescriptive than they are intended to be. And yes, they do challenge some societal constructs, and in doing so bring controversy. But I think it is our job as psychologists not only to continually augment our knowledge base, but to help others in solving problems that transcend the individual. We can assist in steering the discussion in more rational directions. We can acknowledge the shortcomings in our knowledge base and our own biases in presenting the data we choose to support our arguments—and in doing so help others engage in constructive discussions. Such an approach may not sell newspapers or generate “likes” on social media, but perhaps more than anything it’s what we need at the present moment.

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