Podcast: Examining Gender Differences in Mental Health

Jenn talks to Dr. Roberto Olivardia about the relationship between gender and mental health diagnosis and treatment. Roberto discusses the impacts of stereotyping on mental health, highlights differences in presentation of mental illnesses between genders, and answers audience questions on how to be supportive of kids and their emotional well-being.

Roberto Olivardia, PhD, has been treating patients for the last 20 years since his internship at McLean Hospital. He runs a private practice in Lexington, Massachusetts, where he specializes in the treatment of body dysmorphic disorder, obsessive compulsive disorder, ADD/ADHD, skin picking disorder, and males with eating disorders. Dr. Olivardia also treats patients with other anxiety and mood disorders.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hi folks. So, good morning, good afternoon, or good evening to you, and thank you for joining us about conversations around gender differences in mental health.

So, when preparing for this chat, I wanted to be really cognizant of gender identity. I also really wanted to recognize that there are several more genders than just male and female.

For some additional clarity to start, I actually had pulled a definition from the Council of Europe that explains the differences between sex and gender, just to lay that out for everybody.

So, sex refers to the different biological and physiological characteristics of males and females. That’s reproductive organs, chromosomes, hormones, et cetera.

Gender refers to socially constructed characteristics of women and men. So norms, rules, and relationships between groups of women and men, et cetera.

So, in this conversation with Roberto, we’ll be discussing more of the socially constructed characteristics of women and men when we talk about gender, but because there are some hormonal aspects to mental health as well, we’ll probably be touching on that, too.

That being said, mental health conditions impact all genders, but how they present may differ, so there’s a lot of factors in play. One of them that comes to mind for me is sociocultural forces, so things that are sayings like, “Boys don’t cry.”

That’s a pretty common one. That can actually really impact social and emotional development in kids.

So it’s really important for us as adults to encourage kids of all genders to express emotion and how they’re feeling, to recognize the gender differences that can impact mental health diagnoses and treatment, and how we can help break stigma around kids expressing how they feel in a way that they want to express it.

So, I’m super excited to have Roberto with me to talk all about stereotyping impacts on mental health, the differences in presentation of some mental illnesses between genders, and whatever else comes up in our chat today.

So, if you are unfamiliar with him, I have the distinct pleasure of introducing him. Dr. Roberto Olivardia has been treating patients for the last 20 years since his internship at McLean Hospital. But by the looks of him, you’d think he was just getting out of his residency.

He runs a private practice in Lexington, MA where he specializes in the treatment of body dysmorphic disorder, obsessive compulsive disorder, ADD, ADHD, skin picking disorder, and males with eating disorders.

He also treats patients with other anxiety and mood disorders. So, we’re so happy to see you. Thank you so much for joining me.

And I wanted to start by asking why is it important to address the differences in gender when we’re talking about mental health and mental health conditions?

Roberto: Sure. Well, first, it’s always a pleasure talking with you, Jenn, and being part of this and part of this McLean community.

And I’m glad we’re talking about this, because I think it’s so important to understand, anytime we’re dealing with any kind of condition, we always want to understand how that condition falls into the context of all of these other variables.

I mean, there’s this term called intersectionality that is used that refers to looking at all and how all different variables, whether it’s somebody’s sex, gender, racial group, socioeconomic status, how all of that can basically impact and be impacted by mental health conditions.

And so today we’re focusing on the socially constructed sort of notions of gender. And it is really important, and it’s not one in which we’re saying, “Oh, well this is worse for one than the other.”

It’s more about understanding how, let’s say, if we take something like depression, how depression with somebody who has, with all of the sort of social constructs of masculinity can play out and can express itself.

And, similarly, if somebody ascribes to and feels pressured by all the social constructs of what it means to be a woman and how something like depression can interact and intersect with that, as well as really looking at this from a larger scale as I’m sure we’ll talk about.

Like, understanding how I don’t think we really know the extent to when we talk about prevalence, for example. Studies will show that there’s a higher prevalence of depression, anxiety, post-traumatic stress disorder in women.

You’ll see men who might have higher rates of substance abuse. I challenge all of those things. And I think that we have to sort of look at and understand that these are based on a whole number of variables.

What research is being done, whether research is adequately being done in various genders, who are people volunteering to do these research studies, who’s walking through the therapist door in terms of what we see.

Are our notions of these mental health conditions gendered by nature in such a way that we might think of depression, for example, is just sad, someone who might be sad versus, like, anger might not be correlated in people’s mind with depression.

But I know a lot of male patients I work with who have anger management issues, it’s because they’re depressed. And that’s sort of a more socially acceptable way to convey that, that they have a real hard time with that vulnerability.

So, when we hear these prevalence rates, it can be very, I think, deceiving in that sense. And we know that it can express itself in different ways. I mean, if you take something like depression, for example, okay so studies will show that women are more likely to be depressed.

So, one is that, what does that say to men who are depressed? That there could be something very stigmatizing to them around that. And sometimes for, sort of, reasons that, again, are part of the kind of inherent sexism that occurs in our society.

The idea that being, like, a woman inherently is something that’s shaming to these sort of traditional constructs of masculinity, which of course it shouldn’t be. But that’s sort of what gets embedded in our culture.

But in addition, we have higher substance abuse rates in men. Now, a lot of men, not all men who engage in substance abuse, but a lot of them are self-medicating depression. So are we adequately counting those men?

We know men are four times more likely to take their lives. Women are three times more likely to attempt suicide, but men are four times more likely to take their lives. So clearly, and we know that 90% of people who take their lives are struggling with a mental health condition.

Are we adequately accounting for that? Lots of men, and I’ve seen certainly in therapy don’t even really know that they’re depressed and that might seem odd to people to understand.

But if they can list these symptoms and they could be saying, “I’m tired, I have no motivation. Everything kind of just feels pointless. My libido has crashed.” And I have experienced many times in my practice saying something like, “It sounds like depression.”

And they’ll be like, “Depression? I thought depression is, you’re stuck in bed all day, you can’t get out of bed and you’re crying all the time. That’s not, I feel nothing or I’m just angry all the time. I’m irritated all the time.”

So, those people don’t get counted in. So, I guess I’m using that as one of many examples and we see it in the opposite too. I mean, I’ve seen conditions that are typically associated with boys and men that is often underdiagnosed with women because we’re thinking of the signs almost too gendered in that way.

Jenn: I’d love for you, if possible, to talk a little bit more about your experience with prevalence of conditions between genders, with a focus on, like, what you’ve seen in your own patient populations.

I know, both in terms of research and practice, because your background is studying eating disorders and body dysmorphic disorder in men, but that’s something that tends to go, like, pretty often unaddressed in those populations.

Roberto: Oh, absolutely. I mean, I think that that was, when I started doing that work almost 30 years ago. And I remember as an undergraduate, I went to Tufts University as an undergraduate.

And when I proposed to my thesis committee that I want to do this as a senior honors thesis, where I would put ads in college newspapers to find men, college men with eating disorders, their first response is, “This is interesting, but you should have a plan B because I don’t know if you’re going to get many guys. I don’t know if there are that many people.”

And I didn’t need a plan B, Jenn. I mean, it was, I got deluged by phone calls. And similar, I mean now what we know from studies is that about one in four patients who has an eating disorder or one in four people, I should say, who has an eating disorder are male.

And that, now one in 10 eating disorder patients are male. So there are men who are in the community who struggle with eating disorders who never, ever seek treatment for it.

And I’ve been, because of my area of expertise, I see a lot of boys and men, and particularly with the adult men that I work with, I am often the only person that they have disclosed to.

I mean, they are, some of them are married, some of them have very close relationships, some of them have been in therapy for alcohol abuse or depression and just couldn’t disclose that because of the shame and the stigma of what it means to be a man who struggles with body image issues.

And so I definitely, and then, again, even with eating disorders, I mean, there’s some men who know that there’s a problem, and then I’ve worked with men who might engage, let’s say, in bulimic behavior, binge and purging behaviors.

And when I mention the eating disorder, they’re like, “I don’t have an eating disorder. Like that’s not, I’m just, I eat too much and then it’s too much. And I don’t like the feeling and how I feel. And I feel disgusted and I make myself puke, but that’s not the same thing as the fashion model or the teenage girl.”

And when you’re saying, “No, obviously it’s going to be a different experience for you because you’re a different person than that other person, but it still is categorized that way.”

And so absolutely, I mean, I see, and that’s often one of the biggest obstacles really is to have people sort of move away from these sort of gendered notions and just understand a disorder and know and avail themselves to the treatment.

Jenn: I know you have talked a little bit about behaviors already, but do you have examples of other behaviors that could actually point to a mental health condition, but might be overlooked as being “typical” of a gender?

Roberto: Oh, absolutely. That I think, I mean, if you take something like ADHD, for example, that a lot of times, so you can have, ADHD gets accused of being over, massively over diagnosed.

And what studies and certainly my clinical experience has shown is it’s actually more underdiagnosed. So you have either the boys who are kind of the rambunctious, bouncing off the walls boys, that sometimes could be like, “Oh, boys will be boys.”

And I’ve heard from parents that say, “That might be true, but my kid is a little different.” Like, everyone is saying, “Yeah, all boys are hyper and a little annoying and blurt out answers,” but this is a little bit different.

Now, consequently, ADHD is one of those, I would say, this is one of these gendered conditions that still today you will see boys outnumber girls three to one. That’s not true. I have worked with countless numbers of girls and women.

And now I would say probably in the last five years, we have finally, in the ADHD world, understand that it is just as common. Now, why is that, is there’s more people doing research on girls and women with ADHD.

So you have more research, you have more prevalence data, you have more people coming in saying, “Oh wow.” You have more clinicians that understand how it might express differently in girls.

So, the typical girl with ADHD might not be the rambunctious bouncing off the walls. She might be the daydreamer who’s highly perfectionistic and internalizing all of these symptoms and maybe getting straight A’s in school, but working so hard, like so, so hard to do it and having difficulty with impulsive behaviors.

Like, maybe eating issues or cutting that people might think of as being part of another diagnosis. And so a lot of times when you hear ADHD, I mean, even maybe a couple months ago, I did a consultation with a young woman and, and said, “No, this is very classic ADHD.”

And she said, “Is it ADD or ADHD?” Now it’s all called ADHD. It used to be called, ADD represented the more inattentive type, the H part was the more hyperactive type. But it’s all called ADHD, either inattentive subtype or hyperactive subtype.

But she said, “Oh, I hope I’m just the ADD and not the ADHD.” And I said, “Oh. I’m curious, like, what...” like almost like, “What’s the difference?” She goes, “Oh, the H that’s, like, kind of like boys.”

And this is a woman in her early thirties who’s very egalitarian in the way that she sort of, but it’s still, there’s something about, kind of, what that meaning and how that is for people that still carries a lot of weight.

Jenn: So, if a parent or caregiver is tuning in today and, like, I’m sure that they’ve heard first and foremost, like “Boys don’t cry,” “Suck it up,” “Take it like a man.”

I’ve even been told by some parents that they’re, like, glad they’ve had all boys, because parenting boys is easier than girls.

So, if any of those parents who have heard those things and question them are tuning in, how can they address those stereotypes that are set on kids to help them better express their thoughts and emotions that are more aligned with them as a person and not so much what’s been society’s implication of them as a gender?

Roberto: Definitely. I think, first, is for us to all be aware of what biases we have, like, right off the bat.

I mean, research shows that people will ascribe gendered notions to infants, even when they don’t, if they’re told the infant is a boy, and regardless of whether it’s actually a boy or a girl, people are like, “Oh yeah, he looks so rugged and so tough.”

And if it’s a girl, “Oh, she’s so sweet and so gentle.” And that we have to first recognize what are our biases. And certainly for people who grew up in different generations, they may have been told, “Hey, suck it up. Boys don’t cry. You’re a wimp. You’re this...”

And for girls, like, to show any anger, to show sort of a sense of being tough is like, “Oh don’t.” I’ve worked with women who had, were told by their mothers, like, “No boy is going to be attracted to you. No one’s going to want to marry someone who speaks her opinion too much,” you know, like, kind of...

So you see these sort of boys who tend generally, and again, we’re talking in general terms, externalize their behaviors, girls who tend to internalize behaviors. So, what are our biases for that?

How were we, and it’s not to blame previous generations, it’s understanding that they were all parts of the constructs of how gender was. And I think, gosh, how limited that was. I mean, the idea of a woman even working outside the home was radical, like, at some points in our history.

So we have definitely come a long way and we have a long way further to go. But what comes up in us, and a lot of times with both men and women, if, let’s say, your child is displaying a certain behavior, sometimes it could sort of trigger something in us that could be uncomfortable.

If you’re a father and your boy is crying, sometimes for a lot of men, they remember when they were in junior high school or elementary school and they got bullied for being too sensitive or whatnot. So they’re doing it out of love to say, “Hey, stop crying,” because in their mind, they’re trying to protect their kid from future, being ostracized or whatnot.

And, at the same time, what we need to do is say, “You know what, it’s totally normal, you’re a human being.” When we get upset we cry, and help that child regulate those emotions. It’s not about not feeling them, because we can’t help what we feel, it’s about regulating those emotions.

And, similarly, a lot of times with particularly, like, something like depression and anxiety could sometimes be overlooked in girls because girls have this sort of gender construct of being dramatic and being, hysterical was the word that was used many years ago that was so pathologizing and really invalidating.

How do we move away from that and say, “Oh, wait a minute, there’s real suffering here, there’s real struggle here,” and understanding that there’s obviously behaviors that, I, rather than even looking at them in a gendered way, we can look at them in more developmental ways.

Like, all of us, as teenagers let’s say, are fairly emotional, more emotionally raw, than at other points in our lives. And at the same time, that doesn’t mean that just because somebody is crying all the time, that it’s just even about adolescence. That we have to always explore whether there’s something more.

And at the end of the day, we’re trying to teach all people how to deal with emotions, regulate emotions, accept those emotions and move away from the sort of gendered notion of that.

Jenn: I’m curious, when we’re talking about mental health, it’s important to consider that there isn’t just a biological aspect to some mental health conditions, some of it can actually be with environmental influence or sociocultural.

But I’m curious if your familiar with any risk factors that would be gender specific that might make somebody more susceptible to poor mental health?

Roberto: So, I think definitely when we look at, sort of, these different gender roles, understanding how that then begins to interact with that. So, for example, if I’m working with a mom who struggles with depression.

Now, what we know, and this isn’t true for every household, but for many households, that the moms often carry sort of a lot of the executive responsibilities of, sort of, managing the household.

And research has shown that’s even true in dual earner families. So, even when you have a dad or another mom working and a mom working that a lot of it will still fall on the mom to, sort of, do that.

And, again, we’ve seen some change with that, but, so if I’m working with someone let’s say who struggles with depression and part of my treatment might be, “Hey, take some time for yourself, writing in your journal,” all of these techniques.

And understanding that, oh, but for this person, not only do they have these responsibilities, but part of their depression is that they feel like now they’re failing, so they’re depressed, and then they’re getting depressed that they’re depressed and that they’re failing at sort of their motherly responsibilities.

In the same way that for a lot of men that I work with who, let’s say, if they’re depressed and part of their depression is that they lose their libido. And so their sex drive crashes.

And because part of that gendered notion of masculinity is always being ready for sex and sexual activity, that for men who experience that, it’s even, it’s a real double whammy in a way to them, because now they feel like, “Okay, I’m depressed, and because I’m depressed, I’m failing as a man.”

And what that means to them. So, it’s always important that although we’re trying to sort of move away from these gender constructs, but as a clinician, I’m aware we are living in this world that has these constructs.

And so how we have to understand that through the lens of these different mental health conditions is really important, to sort of, in a way we’re, sort of, integrating.

And I often will integrate these kind of conversations into the work that I do with patients of saying, “Oh, that’s interesting that, how that could look different for you than it does for somebody else.” I mean, and when I’ve worked with people, because we know many mental health conditions have a genetic component.

So, I’ll work with people who might also have siblings, let’s say with ADHD, with depression, with substance abuse issues, but it will manifest differently for a number of reasons, different generation, birth order, age, but gender is one of those.

And sometimes patients will be like, “Oh, I don’t understand why it was so much easier for my brother to deal with this than it is for me,” without really them understanding kind of the nuances of how gender as one of many variables could play a part in making it different. It’s not apples to apples in that way.

Jenn: I mean, that’s also important too, to think about, like, even mental health conditions between, if it was, like, me and one of my sisters, same condition, there’s a spectrum of how severe some of the symptoms are, what the symptoms even are that we’re expressing.

So that’s also really important that it’s not just in gender, there’s going to be some variation in how people experience the same condition, no matter what.

Roberto: 100%. And that’s something I talk about a lot. I mean, with something like birth order, I’m the youngest of three kids, and I’m very close to my siblings, but my brother and I, he’s the oldest, are very, very different personalities.

Now, I think when you’re the oldest, I actually empathize with people who are the oldest in their family, because I think there’s a lot of responsibility with that. Whereas the youngest, I kind of have the safety net of siblings who are six and five years older than me.

So I could kind of get into shenanigans, I’d call them, I’d get into lots of shenanigans because I had that safety net. And parents are tired by the time kid number three comes around. Like, whereas when you’re the oldest, it’s, like, all of this sort of attention is on you.

And I feel like sometimes there’s less room to make mistakes with the oldest child. So, when I’m meeting with someone, that’s absolutely a piece of information that I always want to know, is where do you fall in the birth order?

And then culturally if you’re the oldest, let’s say in the Latin American, like, Hispanic family, like there’s sometimes, especially if there are multiple siblings, it’s an expectation that you are taking on the role of, sort of, parent, what’s seen as, like, parenting responsibilities.

And that’s not, again, I’m not pathologizing. That’s part of culture, in Hispanic culture is, like, you sort of become this helper. The youngest does not take on that role. Like, the youngest is like la-la-da.

It’s almost like my siblings that I joke that we were raised, like, totally differently because of just the circumstance. Now, my sister’s in between us. She can speak to gender notions of being the only girl and what that must have been like for her.

Like, I remember, I mean, my mom, who was a fantastic cook, definitely wanted my sister to know how to make certain things. I wish she had done, I mean, I sort of picked up some of that, but she didn’t make sure that, like, my brother and I knew how to cook.

And that was sort of her gendered notion of, “Oh, well, in order to be in a relationship, like, you have to know...” because that was kind of her in her generation she grew up, she was born in the thirties.

So it was very, very different notion. But how that then plays into how you see yourself period, and then how it intersects certainly with various kinds of mental health conditions is super important.

But, again, even, like, how we name things and how we label things, how we research things. I mean, I know, like, with the eating disorder literature, for example, less than 1% of eating disorder research is devoted to looking at men with eating disorders.

And I’m not saying it has to be 50-50. I’m not saying, but less than 1%? And so, are we surprised that we don’t see as many men, sort of, coming to therapy or talking to their primary care physicians or when we’re not researching as much, you don’t see men maybe represented.

I mean, representation is everything in mental, in all of these mental health issues and neurodiversity to always have men, women, people of different backgrounds so that people can see themselves and be like, “Oh, okay.”

Because it’s not only, “Oh, I’m not the only one who struggles with bipolar disorder or the only one that struggles with borderline personality disorder.”

But for men to see that men can struggle with borderline personality disorder as well, because that’s one of those gender diagnoses as well, that men tend to get more diagnosed with antisocial personality or narcissistic personality disorder when they have all of the symptoms of borderline personality disorder, that they can see that.

And there was an athlete whose name I don’t remember, but I remember a football player who had come out saying he was diagnosed with borderline personality disorder. I thought, “Oh my gosh, that’s fantastic.”

Like just to, not that he was, I mean that he was struggling, but fantastic that he felt comfortable enough to put that out there and give that representation. For women, to see women, let’s say, on the autism spectrum, because that’s something that you would typically, we typically think of with boys.

And for those of you who might know Temple Grandin, who is an outspoken advocate, she has autism spectrum and carries a doctorate in agricultural science. And it’s a fantastic movie, actually, about her, Claire Danes actually plays her.

But she is, being a woman on the autism spectrum was so important to tell girls who, even, like, autism spectrum in girls was wildly under-recognized until fairly recently, I would say.

They might be seen as sort of quirky and odd, but that’s, again, one of those things that we would typically say, “Oh, boys.” And I’m not arguing either that as we’re having this conversation that there aren’t biological differences and whatnot.

But even when we talk about things like hormones, it’s still, I mean, we can, in group differences, maybe say, “Okay, here are these differences that we might see in men versus women, boys and girls.”

But the reality is, is you can take 10 boys or 10 girls, and there could be a spectrum of sort of how hormones, it’s not like every boy has the same testosterone level or every girl has the same, like, it.

So, even when we think of that, we have to be careful not to be like, “Oh okay, the hormones.” And at the same time we know with women who have a menstrual cycle, that they’re, that’s something actually, when you talk about that can get swept under the rug a lot of times, it’s like, “Oh, it’s that time of the month.”

How it’s so invalidating and just pathologizing to assume that just because a woman is upset that, oh, it must be a period.

And for those women who have something called premenstrual dysphoric disorder, certainly I know women I’ve worked with who are on the bipolar spectrum where that menstrual cycle can really sometimes trigger, certain times of the month, trigger hypomanic episodes or really suicidal depression.

We have to understand that biology in the context of their mental health issue without just kind of saying, “Oh, their period,” in this kind of way that really is just not helpful and just really negative language.

Jenn: I know one of the things that we’ve talked about, and especially since you’re so focused on your research, is the dismissive behavior around eating and dysmorphic disorders in those who identify as male.

And I’m really curious, I know you had mentioned it a few times already, but why do you think that they’re so often overlooked? And a follow up question would be, how can we reduce stigma around these conditions in boys and men, especially if you might be finding it hard to either do research, acquire research, or get people to talk about it?

Roberto: Yeah, there’s definitely, I think a lot of it is that, and unfortunately for boys and William Pollack, Bill Pollack, who’s a psychologist who wrote a great book called “Real Boys” in the late, I think 1998.

He’s affiliated with McLean Hospital. He talks a lot about this in his book in terms of the sort of boy code that basically boys and, again, there’s the good news is that the tides are changing in this, but we still have a ways to go. But basically masculinity has often been defined as not to being like a girl.

So yeah, you have, like, to be tough and to be, but it’s really underneath all of these things is to not be like a girl. Don’t be sensitive. Don’t be interested in your body image. Don’t be delicate. Don’t like the color pink.

I mean, like, all of these things that are like, hit like a boy, run like a boy, act, talk like a boy, I mean, all of these things. So, here we have a problem and what that does to boys about, how it teaches them about what it means to be a boy.

And secondly, how damaging it is to see how, what we’re, and when I say we, meaning societally, is teaching them about women and about girls. Like, there’s something so inherently misogynistic about that, like, the idea that being a girl is, like, the worst thing in the world, it’s like, what?

Now, if we’re, again, if we’re defining being like a girl as being more sensitive, which I don’t, see, I never ascribed to any of that. I grew up with a mom who was incredibly nurturing and sensitive and loving and was very fierce and very tough and could tell you where to go if you certainly messed with her kids.

And I had a dad who was very firm, head of, Latino, like, head of the household and had, like, a heart of gold. Like, so to me, it was like, I don’t, I think we even have to move away from, like, being tough is this way, and being sensitive is this way.

It’s like, these are just terms that we use, that you can be a sensitive individual and be tough, like, at the same time and resilient. And you could be interested in drama and be the captain of the football team.

Like, we need to sort of expand these notions, but a lot of times it’s that way of telling people, “Don’t be like this,” and for girls it’s similarly.

I mean, there was the term, like, a tomboy was sort of the phrase when I was growing up with, like, girls who maybe didn’t like pretty dresses and didn’t want to play with dolls, they wanted to get kind of rough and dirty and play baseball and climb trees, and that’s fine. Yeah. I mean.

Jenn: I got that a lot as a kid.

Roberto: Yeah, I mean, my mom, she used to say to me and she’s like, “Yeah,” she was, “I used to love to climb trees and scrape my knees and all.” But what happens is that girls, so even that term tomboy, which I don’t know if that’s, hopefully it’s not used as frequently today, but I found that was always, again, this inherently gendered notion like you’re like a boy.

And certainly when I was growing up in the eight, seventies and eighties, the implication was, “Oh, well, that girl is probably gay,” that people would assume. And not that there’s anything wrong with that.

Again, there’s this inherent misogyny in what we tell people, “Don’t be like a girl ,”and an inherent homophobia in, like, “Oh my gosh, God forbid that you’re gay.” But this idea of, well, why can’t she be a girl who just likes to play baseball or climb trees, period?

Like, why are we even naming it a tomboy? Like, why do we have to categorize that? So, I think we have to start with that kind of language. But that definitely trickles down when we’re talking about mental health issues because part of the work often is, kind of, shattering through those.

And this is, I find the promising thing, Jenn, is that with younger people I work with, I’m definitely seeing this less.

I have absolutely seen a tide start to change, and I think because this generation has really shuffled the deck and having us confront these notions of what we mean by gender and by sexuality and by roles and social constructs and people.

Even people could be like, “Whoa, but it’s so out there, and so,” but you know what, at the end of the day, movers and shakers get us thinking. And I appreciate the sort of younger generation for that.

With a lot of the older people, and when I say older, I’m talking even like over the age of 30, those conversations come up all the time as to what it means and how being a man, being a woman, and how that interacts with these mental health issues that they have is so important.

Jenn: Yeah, I even know I’ve had the conversation with several friends that identify as male who have said, “Yeah, I go to therapy and you’re the only person I talk to about it, because none of my guy friends would understand.”

And sometimes I want to press the issue being like, “Why wouldn’t they get it? What makes you think they’re not in therapy themselves?” But as somebody in their early thirties, it’s, some of those constructs are still there that men shouldn’t seek help for what they’re feeling, they should just suck it up and take it. And-

Roberto: Right.

Jenn: In some ways it’s, like, we’ve made some progress, but we also have so much more progress to make.

Roberto: Oh, absolutely.

And in the ways that when we think as well about, like, something like eating disorders is we talk about the stigma with men and understanding, let’s say with girls and women, how, from a very, very young age, how bodies, like, how female bodies get sexualized, like at such a young age.

Like, boy, and that’s something that is different than boys and girls. And I think in having these kinds of discussions, I mean, I remember when I co-wrote “Adonis Complex,” which is a book that I co-wrote with Dr. Harrison Pope at McLean and Dr. Catherine Phillips, which talks about body image issues and eating disorders and boys and men.

And we got the scathing review from a person in England who said that we were intending to take away and rob women of their place in this space of their battles with their bodies. And we make it very clear in the book, we’re trying to bring the conversation into a more, sort of, including everybody in it so that everybody can eventually be helped and treated for this.

But, similarly, and so just because we’re talking about differences is never saying, “Oh, therefore it’s worse for this person than for that person,” because there are so many factors and variables. And at the end of the day, pain is pain.

And so we never, but I as a clinician have to understand that with girls that from a very young age that, I know in many women in my lives would tell me stories of at five or six being told like, “Oh, once, you know, your breasts come in, oh, you’re going to have to chase the boys off you.”

And, like, at six being told something like that. Boys don’t usually, their bodies are not really, are not sexualized generally in that kind of way. Now with boys’ bodies though, which is important for clinicians to understand, the functionality of a boy’s body, how fast we run, how strong we are is very embedded.

And that’s why with boys, I see just as many boys whose negative body image is around being too skinny than I do boys who are, who are overweight because the boys who are too skinny run the risk of being seen, like, as weak. And unfortunately that gets translated, like a girl.

You’re not as strong, you’re like a girl. So, whereas I’ve never worked with a young woman, who’s like, “Oh, people see me as too skinny and that makes me feel bad,” because society rewards women for that.

So gender, we have to definitely always keep that in mind too, of like, what are the scripts that people hear? And so when now you have an eating disorder and in treatment, I’m telling a patient, “Hey, I’m not saying that looks don’t matter in our society, of course people do discriminate, but we’re trying to, sort of, combat that.”

I have to understand when I’m speaking to a young woman, that she has heard those scripts for her eternity. I mean, everything from how pretty her curls might be to what dress she’s wearing, to scrutinizing in that kind of way, that’s a different experience than it is for boys.

And that’s not to say that again, I work with boys and men who suffer and struggle with these disorders, but it just has a different feel to it. And I think we have to respect those stories of where people come from.

And again, we’re talking just about gender. There are many lenses though of which people could, and certainly interpret that experience.

Jenn: I’m curious from, based on your experience with helping boys and men with so many different mental health conditions, how can people tuning in help normalize those that identify as male seeking mental health help?

Roberto: I think, you know what, even the way that I might talk to men about this, I think, and this is where clinicians, we have to keep a dialogue going, because we have to recognize that there are these constructs there.

I will often say, and this is something that often works with men is, if you identify that here’s this thing we call it, let’s say, we’re talking about depression. Here’s the thing, and it’s getting in the way of you doing what you want to do.

No one wants to live their lives with debilitating depression. And so if going to therapy is, rather than you looking at it as this vulnerability that you’re sort of, because I think for men, sometimes they look at therapy as they’re submitting their power to a therapist.

They’re basically surrendering. And that goes against, again, just like girls bodies get sexualized, boys, I mean, every boy, I could probably say this pretty confidently that if you ask any boy the first time that they were either shamed or told that they did something like a girl or that they did something, or they were too weak, they will remember it.

It just sticks in your mind. Just like many young women that I treat for eating disorders will tell you the first time somebody told them that they were too fat or that their nose looked weird or something like that.

So with these, with a lot of men, I think they look at therapy as a surrender to power in a way that, because boys are also typically raised to be more individualistic and not cooperative and collaborative.

And generally speaking that girls are, there’s more sort of a relational kind of cooperative construct for girls to kind of be, and I don’t know if part of that is the idea of being a mother one day and whatnot, although dads, you have to be cooperative and it’s not that dads shouldn’t get those lessons as well.

So, I think when I frame it to them is, you’re not submitting and surrendering power, in fact, you’re taking control. Like, you’re taking the power in your own hands by saying, I don’t want this thing to get in my way, in an assertive way.

This depression is very inconvenient for me. I’m sort of being a little humorous with them about it. Like, this is inconvenient. We need to get this, at least pushed to the side, if not out the door, because I have stuff that I need to do.

And when I present it that way, it’s amazing how just framing it that way to a lot of men who really have these very tight constructs of being a man and masculine really works for them, really helps them see, “Oh, okay, so this isn’t me being weak,” you know?

And it isn’t being weak. I mean, I feel that way for anybody, that when we go to seek treatment, it is to me an assertive response. It’s something that we’re like, “I’m done with this, like, this isn’t…”

So, although we use terms like, we hit bottom or there’s no way out, at the end of the day to be in that position is not, I see as you take, beginning the first step of taking control of your life with the support of somebody.

And the other framing too is, I’ll often say is, when you decide that you want somebody to support you, that’s you deciding that. So the support is not like, oh, because a lot of times I’ll hear, “Oh, I don’t want therapy to be a crutch for me, or medication.”

I mean, then there’s a whole other discussion we could be talking about just on medication, what a crutch. I’m like, “Well, but what does that mean?” Like, “Oh, like I’m depending on it.”

Like, “Well, but if you are deciding, ‘Hey, I need that.’” And I’m basically delegating a responsibility to you as an expert to help me with that. To me, you will never ever see me, Jenn, do my own taxes. I don’t understand taxes. I fall asleep at even the sight of it.

I mean, it’s like, my own ADHD is in super high play when I meet with my accountant. And I just tell my accountant each time I am so grateful that you do this for a living because there’s no way I could do this.

So I am delegating the responsibility. You just tell me what you need from me and I’ll cooperate and whatnot. And I say, and of course with therapy, it’s going to be more of sort of that cooperative feel.

But I think if people can see it, and particularly men can see it in that way. And then I also work with women who have those constructs as well about being tough.

And I think, again, because there’s just, like, we see with internalized homophobia, there could be a lot of internalized sexism too, like with women who fear that if they are, have traditional sort of female personality characteristics that that’s weak.

And so they feel “Okay, well, I have to be like a man,” which isn’t, well, then what does that mean, again? Like you can be both. So, I’ve worked with women who also have that, “I don’t want therapy to be a crutch because that’s going to make me, like, a damsel in distress.”

I actually was, I remember a patient saying that to me. And I said, “Oh no, you’re not, That’s not, I’m not prince charming here.” I’m here to support you, but you are running the show.

But what I can bring into the picture is an expertise of a certain disorder and certain diagnosis and treatment interventions. But I’m not an expert on you. My work with you is to understand, okay, so you have OCD.

Well, I want to understand how that OCD, I can tell you a lot about OCD, but with your experience as a woman, as maybe a woman of color, as a woman of color who grew up in a rural part of the U.S., your experience of OCD might be completely different than another person’s experience with OCD.

Jenn: If possible, could you speak a little bit about how mental health stereotypes may impact intersex and transgendered people as well?

Roberto: So that, and I think this is where, again, this generation is really kind of challenging us and really looking at these constructs, and challenging us in a good way, of looking at these constructs and understanding what we are talking about when we even talk about, sort of, gender.

And so with trans individuals, with intersex individuals, where there’s so much work that they have to do in terms of even trying to combat, sort of, societal notions of who they are, fight for their own rights and having, sort of, access to resources, it’s no wonder we see such a high rate of depression, of suicide in trans individuals.

We know that they are more likely to be the victims of violence than cisgender individuals. So that experience in and of itself now, when we’re talking about depression, I think it’s important.

Yes, we can look at these symptoms, but let us understand the context of an individual and to say, “Well, wouldn’t I be depressed too, if, I mean, my rights are literally taken,” or not even taken away as if I even had them.

I mean, in some parts you don’t, even the people aren’t granted those rights. If I have to walk outside and fear being killed, on a good day, I’m going to be bullied, but on a bad day, I could be killed. Then we have to, sort of, frame it.

Now, it doesn’t mean that the treatment’s going to be 100% different, but it may be a bit different in that kind of way. I remember, I did this documentary many years ago and it featured people with body dysmorphic disorder and with eating disorders and they featured somebody…

So they had four people. I had not met them. So, they had just interviewed them separately. And they all, three out of the four of them had an eating disorder, BBD, but one of the individuals they profiled was a trans woman who wanted facial feminization surgery.

And I said to the producers, “This is not body dysmorphic disorder, this is something very different.” You have to understand this in, now this was, gosh, this was 20 years ago. So even what, how we talked about trans visibility and trans lives was very different than how we do now.

I said, that’s not, I said, “This is an individual who is a trans woman, and wants to have a body that matches, sort of, that identity.” And I said, “I really don’t think that this should be featured in that.”

They did it anyway. And it really upset me because I felt there was more nuance to that. This isn’t a body, this isn’t the same as the other person they featured who had, was constantly getting breast augmentation surgery and couldn’t get implants that were big enough.

And so we have to sort of understand that, but, again, we’re starting with, we have to do research, we have to understand what that even means. Like, intersex is, like, I have a brilliant nephew who did, he graduated from Brown this past year. And he did his thesis on intersex individuals.

I learned more reading that than I’ve ever heard. I mean, you just don’t hear about it and see about it. My notion of what intersex was, was very different than after I read his thesis. And so, there’s so much we need to learn and ask them about, tell me your experience.

And then when I hear that, and then I know that a mental health issue is also in the picture, how do we then understand that? And at the end of the day, get you the treatment that you need.

Jenn: And I find that sometimes, I find that sometimes people find that challenging to say, tell me what you need, explain to me what it’s like, because they don’t want to put the onus on somebody who already is feeling misunderstood that it’s, like, their responsibility to educate us.

Roberto: Yes.

Jenn: At the same time, if we don’t have the qualitative information that says, this is my experience, this is what I’ve endured, there’s no way for us to continue to understand and work toward having it be more commonly accepted and understood and researched.

Roberto: I’m so glad you brought that up, Jenn, because that’s absolutely true. Because obviously someone who is in any gender nonconforming, whether it’s trans, non-binary, intersex, definitely going to a therapist who has expertise in that area is paramount.

I mean, is really, really important. And to your point at the same time, just because somebody works with trans individuals, that trans identity is intersecting with all of these other identities. And so providing that information of, okay, this is my experience and this is my story will help shape that.

So that, I’m glad you brought that up because it is important for us to do the work. And when I say us as clinicians to read, to take continuing ed, to understand, sort of, this so that when somebody comes through the door and they’re looking for help, that we’re at least coming from some base of knowledge of understanding how all of these things can play a role.

Jenn: Do you think that, I know you’ve mentioned a few times that this youngest generation is significantly more fluid and open and understanding and accepting.

Do you see research possibly trending more toward doing non-binary research instead of having it be classified as boys research and girls research?

Roberto: Yes, I do see it that way.

And I think that’s where, I think with this generation when they go to college, you’ll probably see more theses, and then when some of them go off to grad school, they do dissertations and then become researchers and academia.

That, you’re seeing a lot of colleges now that have, traditionally it’d be like, women’s studies was the department. Now it could be, like, women and gender sexuality studies, or, that is more inclusive to this.

So there’s no doubt there’s more research being done. And it’s, we’re still at an early stage of even understanding sometimes what that means for an individual and what it doesn’t mean.

And then as far as mental health issues are concerned, I think a lot of times it can be this notion of, like, even I know let’s say with girls and with depression that you could hear these sort of gendered notions of, “Oh, well maybe girls are more likely to be depressed because they’re less resilient or less strong,” could be, kind of, this notion, which then, again, makes men who are depressed, be like, “Oh, I don’t want people to think I’m depressed.”

But the reality is that maybe these girls are depressed because being a girl in a certain, in any society, in a certain, especially during a certain time could be really, really tough, and, like, really, and as it is being a man in that way, like.

So, when we look at, again, like something like suicide, now, one of the reasons that we see higher suicide rates in men is that men are more likely to use more lethal means. So, like, firearms account for high, half of suicides, 50% of suicides is through gun suicides.

And men are more likely to use those means. So that can be, in terms of accessibility, but let’s think of the social construct of that. And I’m not saying there’s anything wrong with have, being a responsible gun owner, I’m not taking it from that position.

But certainly as young boys it’s like, the notions of having a gun, everything from those childhood games and action stars, whereas it’s like that, just even that accessibility and that is still seen in this very sort of masculine kind of way.

But it’s in so many things. I was working with a young man who had eating disorder and it started with him being a vegan. And he actually didn’t tell anyone that he was a vegan because he’s like, “Oh, I didn’t want people to think I was going to use this,” expletive term, like “by being a vegan.”

And I said, “Why would people...” he goes, “Oh, because, like, real men eat meat.” Like, and, “I would be seen…” So that’s something that it’s like, it’s gendered to even be a vegan.

And now, granted, it became, it went awry for him where it got very unhealthy, but, there are lots of people who are very healthy, who are vegans. But the idea that that could, that their gender and sense of being a man, would be challenged by that is like, wow.

Like, just understanding how all of this plays together. So, if anything, I hope what people get out of this conversation is more just, kind of, expanding sort of our notion of really including and understanding how these gender constructs can play its role into mental health conditions.

And then when you have, someone has a mental health condition, how looking at it through this one lens, and there are many lenses, but if we’re just focusing on gender, how that could be a different kind of experience.

In the same way, like we see with, like, trauma is another example, that the statistics are just, I mean, so unacceptable. One in four girls will have, some say one in three, one to three to four girls will have an experience with sexual assault before the age of 18.

Now, contrary to what people might think, one in six boys will have a sexual abuse or sexual assault experience before age 18. Now, with girls who are traumatized, what happens is because they’re girls, it almost gets, it becomes too normative in a way.

That it’s like, oh, like this, this happens all the time. In the same way that eating disorders and body, all girls want to be a size zero. And meanwhile, these girls are dying because people think it’s so normative. That’s problematic.

And then with boys who are sexually abused, there’s such, I mean, there’s so much stigma, so much stigma around, especially most offenders, most perpetrators are male. And because we have homophobia in our culture, which, again, has nothing to do with being, with sexual abuse.

But our culture just sees, that homophobia just plays it out. And a lot of the men that I’ve treated who experienced trauma are like, “I don’t know, I don’t want people to think I’m gay, I don’t want people to think I’m weak. I let this…”

I mean, even boys who are sexually abused at five, six, when I treat them as men, they’re like, “Oh, I can’t believe I let that man do that to me.” And I’m like, “You are five.” It’s like, what? These ideas are so…

So we see with both genders and when we’re talking about male and female, because as you mentioned, there are many, but we’re talking male and female, there’s intricacies and nuances in how that plays out in all of those.

Jenn: See, this is why I like to have you. When I have you join my conversations I’m like, Roberto’s my co-host, because you tie things up so beautifully that I could just be like, well, it’s over, thanks folks.

So you, thank you for concluding the conversation so wonderfully. I think we’ve made, as a society, we’ve made so much progress, but we still have so much progress to make.

And you’ve done just such a fabulous job at saying that and navigating that over the last hour when talking about gender. So Roberto, thank you so much for another enlightening conversation.

Roberto: My pleasure.

Jenn: And to anybody who tuned in, this is actually is the end of our session. So, like I always say, be nice to one another, but most importantly, be nice to yourself. So, thanks again, Roberto. And thanks folks. Have a great day.

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Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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