Gender and Psychological Health - Health and Well-Being

The Psychology of Sex and Gender - Jennifer Katherine Bosson, Joseph Alan Vandello, Camille E. Buckner 2022

Gender and Psychological Health
Health and Well-Being

Charles Haley, pictured here in 1992 when he was with the Dallas Cowboys, suffered from undiagnosed bipolar disorder for much of his career. Haley now speaks out publicly on the importance of asking for help.

Source: Getty Images / Focus On Sport / Contributor

Test Your Knowledge: True or False?

· 13.1 Approximately one-quarter (25%) of all people in the United States will meet diagnostic criteria for a mental illness during their lifetime.

· 13.2 In general, men are more likely than women to suffer from alcohol, drug, and other substance use disorders.

· 13.3 Eating disorders only occur in Western cultures.

· 13.4 LGBTQ youth who live in neighborhoods with higher rates of hate crimes against LGBTQ people are more likely to attempt suicide.

· 13.5 Across cultures, men generally report higher levels of happiness and positive emotions than women do.


How Are Mental Illnesses Defined, Classified, and Conceptualized?

· The Diagnostic and Statistical Manual and the International Classification of Diseases

· The Transdiagnostic Approach: Internalizing and Externalizing Disorders

· Journey of Research: Treatment of Transgender Identity in the DSM

What Contributes to Sex Differences in Internalizing Disorders?

· Gender Role Factors

· Abuse and Violence Factors

· Personality Factors

· Biological Factors

What Contributes to Sex Differences in Externalizing Disorders?

· Gender Role Factors

· Personality Factors

· Biological Factors

· Debate: Do Women Suffer From Depression More Than Men?

What Roles Do Sex and Gender Play in Eating and Body Image Disorders?

· Objectification Theory, Body Image, and Eating Disorders

o Links to Women’s Mental Health

o Roles of Media and Culture

· Intersectionality and Eating Disorders Among Women

· Gender Identity, Body Dissatisfaction, and Eating Disorders

· Intersectionality and Eating Disorders Among Men

How Do LGBTQ Statuses Relate to Mental Health?

· Victimization, Discrimination, and Rejection

· Homelessness

· Institutional Discrimination: A Hostile Environment

· Internalized Stigma: Homophobia and Transphobia From Within

What Roles Do Sex and Gender Play in Mental Health Help-Seeking?

· Sex Differences in Rates of Help-Seeking

· Intersectionality and Help-Seeking

What Roles Do Sex and Gender Play in Happiness and Well-Being?

· Subjective Well-Being

· Communion, Agency, and Well-Being


Students who read this chapter should be able to do the following:

· 13.1 Define psychological disorders and explain the major approaches to classifying them.

· 13.2 Analyze the various factors (e.g., gender roles, abuse, personality, and biology) that contribute to sex differences in rates of internalizing and externalizing disorders.

· 13.3 Explain the roles of gender and self-objectification in eating and body image disorders.

· 13.4 Describe the unique mental health vulnerabilities experienced by LGBTQ individuals.

· 13.5 Evaluate the roles of sex and gender in help-seeking.

· 13.6 Understand how sex and gender relate to happiness and well-being.


In 2015, Charles Haley was inducted into the Pro Football Hall of Fame after a career of unparalleled achievements that included five Super Bowl championships. After opening his Hall of Fame acceptance speech with a brief anecdote, an obviously nervous Haley abruptly switched topics: “[My ex-wife] Karen in 1988, she diagnosed me with manic depression … and I never really listened, nor did I step up to the plate and do something about it. My life spiraled out of control for years.” During his years as a pro football player, Haley had a reputation for being volatile, aggressive, and uncooperative. Unable to control his temper and moods, Haley punched his fist through windows, got into physical confrontations with other players, and occasionally alarmed his teammates with bouts of uncontrollable sobbing. Haley’s undiagnosed and untreated mental illness cost him his marriage, got him traded off his team, and threatened to destroy his career on multiple occasions.

Today, Haley talks openly about his diagnosis of bipolar disorder (formerly referred to as manic depression) and his regrets about not addressing his psychological problems much earlier in his life. As a mentor for young athletes, he works hard to destigmatize mental illness and break down the norm of fierce self-reliance that pervades the hypermasculine world of professional sports. Haley implores young men who are struggling with mental illness, “You gotta ask for help.” This message might be a hard one to sell, however. In male-dominated environments—and especially those that value physical strength and toughness—there are powerful pressures against expressing vulnerability and emotional pain. Elite male athletes who internalize hypermasculine norms tend to hold negative attitudes toward both mental illness and help-seeking (T.-V. Jones, 2016). Consider the words of Brandon Marshall, an NFL wide receiver who was diagnosed with borderline personality disorder in 2011 after several years’ worth of high-profile arrests, domestic disputes, and personal conflicts: “Before I [got treatment], if someone had said ’mental health’ to me, the first thing that came to mind was mental toughness and masking pain, hiding, keeping it in. That’s what was embedded in me since I was a kid—you know, never show a sign of weakness.”

Despite the stigma surrounding mental illness among professional athletes, things may be changing for the better. In 2014, Marshall cofounded Project 375 ( to raise awareness and end the stigma surrounding mental illness, particularly for men. He and other professional athletes like Haley, Michael Phelps, Duane “The Rock” Johnson, and Oscar De La Hoya are speaking out publicly about their battles with psychological disorders and the need to seek help (see “22 Male Athletes …,” 2018). However, the stigma of mental illness reaches far beyond the arena of professional sports. Across cultures, male gender role norms of toughness and self-reliance discourage expressions of vulnerability. Men from all races, ethnicities, occupations, and socioeconomic groups who suffer from mental illness may be reluctant to acknowledge and treat it for fear of appearing unmanly (Wong, Ho, Wang, & Miller, 2017). This is especially troubling because of the worldwide prevalence of mental illness. Lifetime rates of mental illness (the percentage of people who will meet diagnostic criteria for a mental illness during their life) range from a low of 12% in Nigeria to a high of 47% in the United States (see Table 13.1; Kessler et al., 2009). In the United States, about 18% of adults and 14% of adolescents experience a mental illness each year (Center for Behavioral Health Statistics and Quality, 2015).

In this chapter, we examine questions about mental illness and health through the lens of gender. What does it mean to have a mental illness, and conversely, what does it mean to be psychologically healthy? What forms do mental illnesses take, and do they differ by sex? Are there sex differences in help-seeking tendencies? In addressing these questions, our primary emphases will be on internalizing disorders (e.g., mood and anxiety disorders), externalizing disorders (e.g., conduct and substance use disorders), and eating disorders. We will also address psychological disorders among people who identify as lesbian, gay, bisexual, or transgender, as they tend to have higher rates of mental illness. To begin, we cover some of the basics of defining and categorizing mental illness. Note that we use the terms mental illness and psychological disorder interchangeably in this chapter.

Table 13.1

The lowest lifetime rates of psychological disorders (percentages of people who will develop a disorder in their lifetime) occur in Nigeria and China, while the highest rates occur in the United States and New Zealand.

Source: Adapted from Kessler et al. (2009).


Defining mental illness is difficult. How do you know whether someone’s behavior is just “quirky” versus a sign of disorder? How can you tell if your feelings are normal sadness versus diagnosable depression? Unfortunately, these questions have no simple answers. Psychologists have debated questions surrounding the definitions, diagnoses, and treatments of mental illness for as long as psychology has existed, and they will likely continue doing so (see the “Journey of Research” for an example). That said, clinical psychologists generally agree that a psychological disorder (or mental illness) is a persistent disruption or disturbance of thought, emotion, or behavior that causes significant distress or impairment in functioning. So, feeling sad and lonely for several weeks after a breakup would not likely qualify as a disorder. However, if a breakup makes you so sad that you stop spending time with friends, lose interest in your hobbies, and become overwhelmed with self-loathing, then you might meet criteria for a disorder.

Psychological disorder (or mental illness) A persistent disruption or disturbance of thought, emotion, or behavior that causes significant distress or impairment in functioning.

The Diagnostic and Statistical Manual and the International Classification of Diseases

Psychologists recognize over 200 distinct psychological disorders, each of which consists of a unique set of symptoms. To describe and classify these disorders, the American Psychiatric Association publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM), a resource text that categorizes disorders based on their primary symptom (e.g., depressed mood, anxiety, and substance use). Another similar system is the International Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization (WHO). Broader than the DSM, the ICD includes not just psychological but also medical illnesses. Both texts are updated regularly to reflect new scientific knowledge and research findings, with the DSM currently in its fifth edition (DSM-5) and the ICD in its 11th (ICD-11).

The Transdiagnostic Approach: Internalizing and Externalizing Disorders

In this chapter, we discuss many specific disorders, such as depression, social phobia, and conduct disorder (see Tables 13.2—13.4 for descriptions of these and other disorders). However, for much of the chapter, we use an organizing framework that combines the depressive and anxiety disorders together into one group (called internalizing disorders) and the antisocial, conduct, substance use, and impulsivity-related disorders into another group (called externalizing disorders). This framework reflects the transdiagnostic approach, which assumes that most psychological disorders are actually different manifestations of a few core, underlying dimensions (Krueger & Eaton, 2015). Rather than viewing depression and anxiety disorders as separate conditions, the transdiagnostic approach views them as different versions of the same heritable tendency.

Internalizing disorders Mental illnesses of mood, anxiety, and disordered eating, in which symptoms are directed inward, toward the self.

Externalizing disorders Antisocial, conduct, substance use, and impulsivity-related disorders, in which symptoms are directed outward, toward others.

Transdiagnostic approach An approach that views most psychological disorders as different manifestations of a few core, heritable, underlying dimensions.

Backed by solid empirical research, the transdiagnostic approach offers a useful organizing frame for this chapter because there are persistent sex differences across the internalizing and externalizing disorders. Internalizing disorders consist of problematic emotions and behaviors that are directed inward, while externalizing disorders consist of problematic feelings and behaviors that are directed outward. What does it mean to direct feelings inward or outward? Generally speaking, symptoms of internalizing disorders include things like low self-esteem, social withdrawal, anxiety, restrained eating, and acts of nonsuicidal self-injury, like cutting oneself. In other words, the sufferer experiences symptoms privately and expresses disturbance largely by blaming and punishing the self. In contrast, the primary symptoms of externalizing disorders include things like aggression, impulsivity, interpersonal manipulation, and drug and alcohol abuse. These acts tend to involve either victimizing others or altering one’s consciousness in a manner that impairs judgment and reduces inhibitions against harm.

In general, women show higher prevalence rates than men do for internalizing disorders, while men have higher prevalence rates than women do for externalizing disorders. One study of U.S. adults found that the effect size for women’s higher levels of internalizing disorders was small (d = −0.23), while the effect size for men’s higher levels of externalizing disorders was medium (d = 0.52; M. D. Kramer, Krueger, & Hicks, 2008). Similar sex differences occur around the globe in Europe, Asia, North and South America, Africa, and the Middle East and across ethnic groups living in the United States (Anderson & Mayes, 2010; Seedat et al., 2009). Moreover, sex differences in internalizing and externalizing behaviors emerge in childhood (Rescorla et al., 2014). In the sections that follow, we consider several different possible explanations for these persistent sex differences.


The psychiatric community’s understanding of transgender people has a long and complicated history, as evidenced by several changes to the Diagnostic and Statistical Manual (DSM) over time. In the medical field, the study of transgender individuals emerged in the late 19th century (Krafft-Ebing, 1886/1998), but it was not until the 1950s that the psychiatric community grew increasingly interested in transgender identity as a psychological phenomenon. This interest was sparked, in part, by the high-profile case of Christine (born George) Jorgenson, an American World War II veteran who underwent genital reconstructive surgery in Denmark in 1952 and transitioned from male to female.

From the 1950s through the 1980s, mainstream psychiatry and psychology viewed transgender identity as a mental illness requiring treatment with psychotherapy (Drescher, 2010). Although the first two editions of the DSM included no reference to transgender identity, many psychiatrists considered it a form of delusional belief stemming from neuroticism, schizophrenia, or confused homosexuality. This mistaken tendency to equate transgender identity with same-sex sexual orientation should be familiar to you from past chapters (especially Chapters 5 and 9).

By the late 1970s, a substantial body of research existed on the topic of transgender identity, allowing for sufficient psychiatric consensus regarding its nature and characteristics. Reflecting this consensus, the DSM-III (American Psychiatric Association, 1980) included two diagnoses of gender identity disorder (GID). One diagnosis was for adolescents and adults (transsexualism), and the other applied to children (GID in childhood). For both disorders, symptoms included an intense and persistent identification with the other sex, a belief that one’s assigned sex is inconsistent with one’s true gender identity, and significant distress caused by the perceived mismatch between sex and gender identity. However, with the publication of the DSM-IV in 1994, transsexualism was removed as a separate diagnosis, and GID was expanded to include cross-sex identification among both children and adults.

Critics of the inclusion of GID in the DSM argue that transgender identity is a natural variation of gender expression and that calling it a “disorder” unfairly pathologizes it (Drescher, 2010). Moreover, some argue that the feelings of distress associated with transgender identities are caused not by the condition itself but by negative and stigmatizing societal reactions to those who do not fit cleanly into the sex and gender binaries (American Psychological Association, 2009b). In fact, recent data support this proposition. A study of 250 transgender adults in Mexico City found that experiences of social rejection and violence related to being transgender strongly predicted psychological distress, whereas feelings of gender incongruence did not (Robles et al., 2016). In contrast, those who advocate to retain transgender identity in the DSM argue that transgender individuals often experience distress associated with inhabiting the “wrong” body and that this distress, by itself, can cause clinical impairment.

Responding to these controversies, the DSM-5 again revised its treatment of transgender identity in 2013, replacing GID with the label gender dysphoria (GD). GD is diagnosed when an individual experiences clinically significant distress because of a “difference between the individual’s expressed/experienced gender and the gender others would assign him or her” (American Psychiatric Association, 2013). In contrast to GID, the definition of GD emphasizes feelings of distress rather than a mismatch between assigned sex and psychological gender. Moreover, prior DSM versions used language that presumed binary gender categories (e.g., “identification with the other gender” [italics included]), while the language used to define GD acknowledges a wider range of nonbinary identities. Finally, unlike GID, the GD label does not include the word disorder. Although these changes represent an important shift in clinical thinking, many still argue that removing transgender diagnoses from the DSM altogether is a necessary step toward destigmatizing transgender identities (Lev, 2013). Considering similar arguments, the WHO removed gender identity disorder from the International Classification of Diseases in 2019, reclassifying it as “gender incongruence” and moving it from the mental disorders chapter to the sexual health chapter (Lewis, 2019).

Christine Jorgenson, pictured in 1954.

Source: Archive PL / Alamy Stock Photo


What factors do you think account for changes over time in how the DSM defines disorders? How can something be a disorder at one point in time but not in another? Why has diagnosing disorders of gender identity been particularly challenging and controversial? Did the DSM-5 get the diagnosis right with gender dysphoria? Do the pros of including the gender dysphoria diagnosis in the DSM outweigh the cons or vice versa? Why?


As noted, internalizing disorders include mood and anxiety disorders (eating disorders are also considered internalizing disorders, but we will discuss these separately). Table 13.2 summarizes several internalizing disorders and indicates the size of the sex difference for each. The internalizing disorders have sex differences ranging from small (d = −0.14) to medium (d = −0.53) in size; the exception is bipolar disorder, which does not show a consistent sex difference. Many factors likely contribute to these sex differences, and we consider several of them here. Note, however, that our focus is on factors that contribute to sex differences in disorder rates, not on factors that cause the disorders themselves.

Gender dysphoria A disorder consisting of clinically significant distress due to the difference between a person’s psychological sense of gender and the gender that others assign them.

Table 13.2

These disorders include depressive disorders and anxiety disorders. As you can see, there are sex differences favoring women for lifetime rates of almost all internalizing disorders (except for bipolar disorder), and effect sizes range from small to medium.

Source: Adapted from Seedat et al. (2009).

Gender Role Factors

There are several ways in which gender roles may contribute to sex differences in internalizing disorders. One early hypothesis, the gender intensification hypothesis, proposed that the pressure to adopt sex-typed traits and behavior intensifies during adolescence, and this contributes to sex differences in depression (J. P. Hill & Lynch, 1983). According to this hypothesis, young people face increasing pressure to adopt traditional gender roles as they enter puberty and prepare for adulthood. For girls, this means adopting stereotypically feminine tendencies, such as emotionality and self-sacrifice—but these traits can foster a helpless coping style that increases depressive tendencies. In contrast, this hypothesis proposes that adolescent boys increasingly adopt stereotypically masculine qualities, such as confidence and independence, that can buffer them from depression. This logic may sound reasonable, but the data do not cleanly support it. It is true that sex differences in depression (and other internalizing disorders, such as anxiety and eating disorders) begin to manifest around puberty, when girls show sharper increases in these disorders than boys (Mendle, 2014). As you read in Chapter 4 (“Gender Development”), however, adolescents in the United States do not appear to undergo an intensification of sex-typed traits (Priess et al., 2009). While increases in male-typed traits during adolescence predict decreases in depression for both boys and girls, adolescent boys and girls in the United States today do not differ much on male-typed traits.

That said, sex differences in certain coping styles can contribute to sex differences in mood and anxiety disorders. Susan Nolen-Hoeksema’s (1991) response styles theory focuses on a coping style called rumination, which involves passively and persistently focusing attention on one’s negative mood. For example, a person who has a ruminative style might think repetitively about how upset they feel after an unsuccessful job interview, dwelling on their flaws and judging themselves for feeling badly. Women tend to score higher than men in the tendency to ruminate when distressed (Tamres, Janicki, & Helgeson, 2002), and rumination correlates with depression, social phobia, posttraumatic stress disorder (PTSD), and generalized anxiety disorder (Nolen-Hoeksema, 2012; Shor, Millon, Chang, Olson, & Alderman, 2017). Thus, women’s greater tendency to cope passively with negative emotions may prolong and amplify their depressive and anxious moods; in contrast, men’s tendency to cope more actively with negative emotions by distracting themselves or doing physical activities may protect them from developing internalizing disorders.

Rumination Passively and persistently focusing attention on one’s negative mood, its causes, and its possible consequences.


Simply documenting that women tend to ruminate more than men does not explain why this occurs. What are some possible reasons for this sex difference in the tendency to ruminate? What have you learned in other chapters of this book (e.g., about gender development or about gendered language, communication, and emotion) that might help explain this difference?


Being exposed to certain forms of benevolent sexism can lead some women to ruminate. Recall from Chapter 6 (“Power, Sexism, and Discrimination”) that benevolent sexism consists of flattering but condescending beliefs about women as morally pure, vulnerable, and needful of protection by men (Glick & Fiske, 1996). While this sort of chivalrous treatment from men may be appreciated in romantic and dating contexts, it can lead to maladaptive outcomes in workplace contexts. For instance, when women receive benevolently sexist messages implying that they need special treatment or assistance in work contexts, they exhibit increases in rumination (Dardenne, Dumont, & Bollier, 2007; Dumont, Sarlet, & Dardenne, 2010). This likely occurs because benevolent sexism is ambiguous—both flattering and insulting at the same time—and these mixed messages may lead women to ruminate about their competence.

A related gender role approach asks whether widespread devaluing of female-type labor (i.e., childcare and housework) contributes to women’s high rates of depression. If this were the case, we should see smaller sex differences in depression in cultures that place more value on female-typical labor. In fact, sex differences in depression are smaller or nonexistent in some subcultures, such as Orthodox Jewish and Amish communities, that honor the homemaker role as a position of great importance (Piccinelli & Wilkinson, 2000). Sex differences in depression also get smaller as gender equality increases within cultures over time. One study of over 72,000 adults in 15 different countries found that increases in nation-level indices of gender equality correlated with decreases in the size of sex differences in depression (Seedat et al., 2009).

Sex differences in depression are relatively small among the Amish, a cultural group in which female-typed, domestic labor is highly valued.

Source: brt COMM / Alamy Stock Photo

Abuse and Violence Factors

Childhood sexual abuse, which disproportionately affects girls, is a traumatic life experience that has profound consequences for mental health. A meta-analysis of 331 independent samples with over 9.9 million participants worldwide found that 18.0% of girls report sexual abuse, compared with 7.6% of boys (Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011). In general, girls and women are more likely than boys and men to experience many types of sexual violence across all cultures, as you will read in Chapter 14 (“Aggression and Violence”). Does exposure to sexual violence contribute to sex differences in internalizing disorders? To some degree, yes. One review concluded that sex differences in childhood sexual abuse can explain up to 35% of the sex difference in adult depression (Cutler & Nolen-Hoeksema, 1991). That said, sexual abuse in childhood predicts adult depression regardless of victims’ sex. Boys may be less likely to experience sexual violence than girls, but when they do, their risk of depression is high.

Having a physical or cognitive disability dramatically increases women’s risk of sexual violence. An analysis of U.S. national crime data found that women with disabilities experienced more sexual violence and more serial victimization (i.e., six or more similar violent incidents within a 6-month period), compared to men with disabilities and to individuals without disabilities (Dembo, Mitra, & McKee, 2018). In turn, women with disabilities report more anxiety, depression, and severe mental distress than do men with disabilities and individuals without disabilities. Thus, an intersectional analysis can shed light on identity factors, such as physical and mental disability status, that place girls and women at greater risk for sexual violence. You will read more about this topic in Chapter 14.

Personality Factors

Sex differences in internalizing disorders may also reflect sex differences in neuroticism, defined as the chronic tendency to experience negative emotions. People high in neuroticism worry easily and describe themselves as “moody” and “blue.” Not surprisingly, neuroticism correlates very strongly with internalizing disorders (Griffith et al., 2010), and women across cultures tend to score higher in neuroticism than men (Schmitt et al., 2017).

Neuroticism The tendency to experience high levels of negative emotions.

Biological Factors

Some research finds that girls and women, as compared with boys and men, respond to stress with more extreme nervous system activity. This elevated stress response then predicts higher levels of depressive and anxious symptoms. Moreover, levels of female sex hormones such as estrogens increase dramatically in puberty, and these hormones enhance the sensitivity of the stress response and heighten young women’s vulnerability to the long-term effects of stress. This may account for the dramatic rise in internalizing disorders often observed among girls in early adolescence (Bale & Epperson, 2015).

Depression is partly heritable, suggesting genes play a role in internalizing disorders (Isler & Nestler, 2018). However, researchers do not find sex differences in the presence of the genes that contribute to internalizing disorders. Instead, sex differences in depression rates may reflect the operation of epigenetic factors. Recall from Chapter 3 that epigenetics is the study of how environmental factors can influence the expression of genes in ways that are heritable. For example, exposure to chronic stressors may alter the manner in which a mother’s genes are expressed (an epigenetic process), resulting in her own depression. These epigenetic changes, however, may then get passed along to the mother’s offspring, increasing their vulnerability to depression (Hodes, Walker, Labonté, Nestler, & Russo, 2017).


Externalizing disorders are characterized by deficits in impulse control; patterns of aggression, violence, or criminality; and substance abuse. Table 13.3 summarizes several externalizing disorders and their sex differences. You can see that men experience each of these disorders more frequently than women do, with effect sizes ranging from small (d = 0.12) to medium (d = 0.66). In what follows, we will cover several factors that may contribute to sex differences in externalizing disorders.

Table 13.3

These disorders include substance use disorders, conduct and antisocial disorders, and attention-deficit disorders. Lifetime rates of these disorders all show sex differences favoring men, with effect sizes ranging from small to medium.

Source: Adapted from N. R. Eaton et al. (2012) and Seedat et al. (2009).

Gender Role Factors

Just as gender roles can help explain sex differences in internalizing disorders, they may also help explain why boys and men display externalizing disorders at higher rates than girls and women. As you read in Chapter 8 (“Language, Communication, and Emotion”), boys learn from an early age to avoid displaying emotions that might make them seem vulnerable, like sadness and anxiety (Berke, Reidy, & Zeichner, 2018). In contrast, parents and other socialization agents typically consider anger a more acceptable emotion for boys to display. Boys may therefore learn to express negative emotions through angry outbursts instead of sad withdrawal.

Another gender role factor is parental discipline. Parents tend to use harsher discipline strategies, such as yelling and physical aggression, with their sons than with their daughters. This may help to explain the higher rates of conduct and antisocial disorders among male youth, because harsh parental punishment predicts aggressive behavior, criminality, and delinquency in youths (Meier, Slutske, Heath, & Martin, 2009). Moreover, inconsistent use of punishment predicts increases in children’s conduct problems over time, but the reverse is true as well: Children who display more antisocial tendencies elicit more inconsistent discipline from parents (Hawes, Dadds, Frost, & Hasking, 2011). Since boys display more antisocial traits than girls (as we will discuss in the next section), boys’ personalities may contribute to sex differences in parental discipline.

Finally, gender role differences in coping may contribute to sex differences in externalizing disorders, particularly substance use problems. Whereas women tend to ruminate when distressed, men more often distract themselves from stress via alcohol or drugs (Harrell & Karim, 2008). Ultimately, this can become habitual and may lead to substance abuse problems. Men also tend to cope via distraction more often than they use other, healthier means of coping with stress, such as seeking social support (Tamres et al., 2002). We will return to this idea later in the chapter, when we discuss sex differences in help-seeking.

To summarize, traditional gender role socialization of boys and men can teach them to suppress vulnerable emotions, behave aggressively, use drugs and alcohol as coping mechanisms, and avoid seeking help from others. To address these potentially harmful consequences, the American Psychological Association (2018) proposed a set of therapeutic guidelines for psychologists who treat men and boys. These guidelines call for therapists to increase their understanding of men’s gender-related problems and strengths; to adopt more intersectional approaches when treating men and boys; to assist male clients in reducing maladaptive, gender-related behaviors (e.g., aggression, substance abuse, suicidality); and to better advocate on behalf of boys’ and men’s mental health. The guidelines have generated controversy, with some arguing that “traditional masculinity” and even men themselves are under attack. However, defenders note that the guidelines are meant to broaden the male gender role in ways that promote mental health (Mull, 2019).

Personality Factors

Impulsivity and effortful control may contribute to sex differences in externalizing disorders. Impulsivity consists of traits such as sensation-seeking, novelty-seeking, and risk-taking, while effortful control consists of persistence, focus, and impulse control. As a group, externalizing disorders correlate with high levels of impulsivity and low levels of effortful control, and both of these personality factors show sex differences. Meta-analyses reveal a large effect size for effortful control (d = −1.01) that favors girls (Else-Quest, Hyde, Goldsmith, & Van Hulle, 2006) and medium effect sizes for sensation-seeking (d = 0.41) and risk-taking (d = 0.36) that favor men (Cross, Copping, & Campbell, 2011). These personality factors predict increases in antisocial and substance use disorders over time (Krueger, 1999), suggesting that they may contribute to the development of externalizing disorders.

Impulsivity A personality factor consisting of traits such as sensation-seeking, novelty-seeking, and risk-taking.

Effortful control The capacity for persistence, focus, and impulse control.

Callous-unemotional traits A personality factor consisting of low levels of empathy, guilt, and warmth.

Another relevant personality factor, callous-unemotional (CU) traits, includes low levels of empathy, guilt, and warmth. These tendencies underlie the aggression, criminal behavior, and lack of remorse often present in conduct and antisocial disorders. Adolescent boys tend to score higher in CU traits than girls (d = 0.52), which may help to explain their increased tendencies toward these disorders (Pihet, Etter, Schmid, & Kimonis, 2015). As noted earlier, boys’ higher levels of CU traits may both elicit and result from inconsistent parental disciplinary practices.


Consider that boys, on average, tend to have lower levels of empathy, guilt, and warmth than girls. Does this sufficiently explain sex differences in externalizing disorders, like conduct disorder and antisocial personality disorder? What factors might help to explain why boys tend to be lower on these traits than girls? What have you learned in other chapters (e.g., about gender development or about gendered language, communication, and emotion) that could help explain these sex differences?

Biological Factors

Recall from Chapter 3 (“The Nature and Nurture of Sex and Gender”) that testosterone masculinizes fetuses in utero, affecting both the structure and function of the brain. One brain region affected by prenatal testosterone exposure, the prefrontal cortex (PFC), may play a role in the development of externalizing conditions such as ADHD and substance disorders. Activity of the PFC contributes to impulse control, emotion regulation, and planning, all of which are relevant to externalizing tendencies. Although the PFC develops gradually throughout adolescence in all children, it tends to develop more slowly in boys than girls. Moreover, exposure to larger amounts of prenatal testosterone predicts lower PFC volume among boys aged 8—11 (Lombardo et al., 2012). Decreases in PFC volume, in turn, correlate with increased vulnerability to ADHD and other externalizing disorders.

Prefrontal cortex A brain region involved in impulse control, emotion regulation, and planning behaviors.

Activity of the prefrontal cortex (PFC) contributes to impulse control, emotion regulation, and planning and may play a role in the development of externalizing conditions such as ADHD and substance disorders.

Source: ©

Dopamine (DA), a neurotransmitter involved in feelings of reward and control of voluntary movement, may also contribute to sex differences in externalizing tendencies. On average, women tend to show enhanced dopamine functioning compared with men, which may protect them against disorders characterized by poor impulse control, such as ADHD and substance abuse (Martel, 2013). Moreover, the dopamine transporter protein (DAT1), which regulates the brain’s use of DA, may play a role in externalizing disorders. Among boys and men, a variant of the gene that codes for DAT1 is linked to externalizing and antisocial behaviors (S. A. Burt & Mikolajewski, 2008). Men may be more likely than women to inherit this genetic variant, which can partially explain their higher rates of externalizing symptoms and disorders.


Depression, the leading cause of disability worldwide, disproportionately affects women: Across cultures, women receive depression diagnoses at twice the rate of men. In this chapter, we consider several possible explanations for why women are more prone to depression than men. But what if the apparent sex difference in depression is not real? In the following debate, we consider this possibility.


Some propose that people of different sexes are equally vulnerable to depression, but they reveal their depression via different symptoms. In other words, depression “looks” different in women and men, and it therefore gets diagnosed at lower rates among men. This perspective proposes that classic symptoms of depression, such as sadness, hopelessness, and low self-worth, are inconsistent with male gender role norms of toughness and invulnerability and that men display depression with male-typed symptoms, such as anger, irritability, alcohol and substance use, risk-taking, and aggression (Addis, 2008). What do you notice about these symptoms? Typically classified as externalizing symptoms, these are not considered symptoms of depression (an internalizing disorder). Thus, the “male-type depression” perspective argues that some externalizing behaviors and symptoms should not be seen as distinct from depression because they reflect male-typical expressions of depression.

In support of this perspective, some research shows that depressed male patients report more anger and aggression, less impulse control, and more substance use than depressed female patients do (Cavanagh, Wilson, Caputi, & Kavanagh, 2016; Winkler, Pjrek, & Kasper, 2005). Moreover, a gender-inclusive depression scale that measures both traditional symptoms (e.g., depressed mood, indecisiveness) and male-typed symptoms (e.g., anger, substance use) shows similar rates of depression among men and women (30.6% of men vs. 33.3% of women) in a nationally representative sample (L. A. Martin, Neighbors, & Griffith, 2013).

Links between depression, suicide, and sex also support the notion of a male-type depression. Depression increases people’s risk of suicide by 20% (E. C. Harris & Barraclough, 1997), and although adolescent girls attempt suicide more frequently than boys (Krysinska, Batterham, & Christensen, 2017), men disproportionately die from suicide. Men, especially young men, account for close to 80% of deaths by suicide (Murphy, Xu, Kochanek, Curtin, & Arias, 2017). How can we reconcile the fact of women’s higher depression rates with men’s higher suicide rates? The male-type depression hypothesis offers a possible solution by suggesting that at least some of men’s increased risk of suicide may reflect depression that goes undiagnosed.


Decades of research point to higher rates of depression among women than men, and this sex difference emerges across nations and cultures. The notion of a male-type depression that looks different from traditional depression is problematic for several reasons. First, accepting the premise of a male-type depression requires that we change the definition of depression. Clinical psychologists identify a specific set of symptoms that characterize major depressive disorder, and these symptoms clearly occur more frequently among women than among men. Sex differences in depression rates may go away when we include aggression, risk-taking, and substance use in our definition of depression—but in doing so, the thing we call depression loses some of its meaning.

On a related note, if men display externalizing symptoms such as aggression, risk-taking, and substance abuse, then the simplest diagnosis is that they have an externalizing disorder. It is unnecessarily complicated to assume that these symptoms reflect a “male-type depression” that is different from typical clinical depression.

Finally, at least some of the symptoms of male-type depression do not occur more commonly among men than women. One large-scale study of people with major depression found that women were more likely than men to experience clinically significant levels of irritability and anger attacks associated with their depression (Judd, Schettler, Coryell, Akiskal, & Fiedorowicz, 2013). This raises questions about whether irritability and anger should be included among the male-type depression symptoms.

Having heard both sides of the debate, which arguments do you find more convincing, and why? Is it possible that both perspectives hold some truth? What do you think is the best way to define major depressive disorder? This question will only become more important with time as rates of depression continue to climb.


The gender paradox of suicide refers to the fact that girls and women more frequently exhibit nonfatal suicide behavior, such as suicidal ideation, suicide attempts, and nonsuicidal self-injury, while boys and men more frequently die from suicide in almost all countries (Krysinska et al., 2017). This may reflect sex differences in the suicide methods commonly used, with boys and men being more likely to use violent means such as firearms. There may also be sex differences in the problems that predict suicidality. For men, work problems, financial problems, substance use problems, and relationship dissolution are stronger predictors of suicide. For women, problems with children, depression and anxiety, and obesity more strongly predict suicide (Branco et al., 2017; R. Evans, Scourfield, & Moore, 2016; Krysinska et al., 2017). For LGBTQ youths, peer bullying and family rejection are often precursors to suicide (Wolff, Allen, Himes, Fish, & Losardo, 2014).

How do you know if you or someone you know is at risk? Suicidality can be difficult to detect accurately, even for experts, but there are some clear warning signs. If someone threatens to kill themselves, actively looks for ways to kill themselves (e.g., tries to attain a weapon or pills), or talks or writes about suicide or dying, this signals a need for immediate help from an expert (such as those at the National Suicide Prevention Lifeline: 1-800-273-8255). Other warning signs include feelings of hopelessness or purposelessness, feeling trapped like “there’s no way out,” withdrawal and social isolation, dramatic mood changes, agitation, changes in sleeping patterns (either unable to sleep or sleeping all the time), and reckless or risky behavior (Rudd et al., 2006). For more information on suicide and how to prevent it, visit


In the United States, approximately 4.93% of women and 2.22% of men meet diagnostic criteria for an eating disorder at some point during their lives (Duncan, Ziobrowski, & Nicol, 2017). Eating disorders (summarized in Table 13.4) are serious medical conditions that affect both psychological and physical health. For example, of all mental illnesses, anorexia nervosa has the highest mortality rate (Arcelus, Mitchell, Wales, & Nielsen, 2011), and it carries a 23% increase in risk of death by suicide (E. C. Harris & Barraclough, 1997).

Gender paradox of suicide A pattern in which girls and women more frequently exhibit nonfatal suicide behavior (suicidal ideation, suicide attempts, and nonsuicidal self-injury), while boys and men more frequently die from suicide.

Girls and women are between 1.75 and 3 times more likely to experience eating disorders than boys and men (Hudson, Hiripi, Pope, & Kessler, 2007). Moreover, certain populations are especially vulnerable to developing these disorders. Both anorexia and bulimia occur more frequently in Western than non-Western cultures and among adolescent and young adult women more frequently than older women (Smink, van Hoeken, & Hoek, 2012). That said, eating disorders in non-Western and older samples (of both women and men) are more common than previously thought (Mangweth-Matzek & Hoek, 2017; Pike & Dunne, 2015). Rates of eating disorders are also higher among transgender than cisgender people (B. A. Jones, Haycraft, Murjan, & Arcelus, 2016), and gay men have higher eating disorder rates than straight men, although rates between gay and straight women do not differ (M. B. Feldman & Meyer, 2007). Athletes in aesthetic sports, such as gymnastics, dancing, and figure skating, also show elevated rates of eating disorders (Joy, Kussman, & Nattiv, 2016).

Table 13.4

While lifetime rates of eating disorders show sex differences that favor women, with small to medium effect sizes, muscle dysmorphia is almost exclusively diagnosed in men. Although women do suffer from this disorder, valid estimates of its rates among women cannot be calculated.

Source: Adapted from Hudson, Hiripi, Pope, and Kessler (2007).

Note: aWe cannot calculate effect sizes for muscle dysmorphia because population rates are not available.


Most research on body image and eating disorders focuses on girls and women. However, researchers today are paying more attention to eating disorders in boys and men. Male eating disorders may be underdetected because the symptoms tend to differ by sex. Whereas girls and women often strive to lose weight, boys and men use risky means to gain muscle mass, including taking supplements, growth hormones, and steroids. One national sample of U.S. adolescents found that 17.9% of boys reported being “extremely concerned” with their weight and physique, and this group also showed higher rates of drug use and depression (Field et al., 2014).

Risk factors for eating disorders include troubled relationships with parents, early sexual abuse, low self-esteem, perfectionism, chronic pressure to be slim, and body dissatisfaction. While these risk factors can help identify which individuals are likely to develop eating disorders, they are not by themselves explanations for eating disorders. Fortunately, objectification theory offers a framework for understanding and evaluating both eating disorders and a subtype of body dysmorphic disorder called muscle dysmorphia that affects men more often than women.

Objectification theory The theory stating that being socialized within a cultural context that objectifies the female body encourages girls and women to internalize an outsider’s perspective on themselves and engage in self-objectification.

Objectification Theory, Body Image, and Eating Disorders

Objectification theory argues that being raised within a sociocultural context that routinely objectifies and sexualizes the female body has consequences for female mental health. To be objectified is to be “treated as a body (or collection of body parts) valued predominantly for its use to (or consumption by) others” (Fredrickson & Roberts, 1997, p. 174). Objectifying others means seeing them as less than fully human. Objectification theory notes that, as compared with the male body, the female body is more commonly objectified, via media images that sexualize the female form as well as through common daily experiences (e.g., street harassment, unwanted touching, and appearance-related comments). In turn, objectification teaches girls and women that their worth depends more on their appearance than on their actions or accomplishments. It also teaches girls and women to internalize an outsider’s perspective on their physical selves, resulting in a chronic preoccupation with their appearance. This constant self-objectification increases young women’s risk for body dissatisfaction, eating disorders, depression, and substance use problems (Carr & Szymanski, 2011; Moradi & Huang, 2008).

Self-objectification Defining the self in terms of how the body appears to others instead of what the body can do or how the body feels.

In an early demonstration of objectification theory, Fredrickson and colleagues randomly assigned women to try on either a swimsuit or a sweater in front of a full-length mirror and then measured women’s feelings of body shame and the number of cookies that they ate as part of a supposed “taste test” (Fredrickson, Roberts, Noll, Quinn, & Twenge, 1998). Women who were self-objectified by wearing the swimsuit reported more body shame than those wearing the sweater, and self-objectified women also consumed fewer cookies than sweater-wearing women. A follow-up study showed that trying on a swimsuit had no effect on men’s feelings of body shame or eating behaviors. Similar effects have been found in other experiments, demonstrating that self-objectification increases women’s shame about their appearance and decreases their self-esteem (Moradi & Huang, 2008).

Links to Women’s Mental Health

Self-objectification correlates with a wide range of negative mental health outcomes. Across dozens of studies that control for factors such as age, race and ethnicity, body weight, personality, and other risk factors, self-objectification consistently predicts higher levels of eating disorder symptoms (e.g., restricted eating and disordered eating behaviors), lower self-esteem, more depressive symptoms, and reduced psychological well-being (Lindner & Tantleff-Dunn, 2017; Moradi & Huang, 2008).

According to some theories, feelings of body shame drive these links between self-objectification and negative mental health outcomes. That is, chronically evaluating their physical appearance leads women to experience more body shame, which, in turn, increases their vulnerability to eating disorders, depression, low self-esteem, and substance abuse. Other theories also consider whether social comparisons drive the links between self-objectification and negative outcomes (see Figure 13.1). According to these theories, self-objectification leads women to compare their bodies with their peers’ bodies. Social comparisons then predict body shame, which predicts eating disorder symptoms (Tylka & Sabik, 2010).

Being raised in a culture that routinely objectifies and sexualizes the female body can encourage women to take an outsider’s perspective on their own appearance.

Source: ©

Of course, because the data linking self-objectification with eating disorders are largely correlational, we cannot draw causal conclusions from them. However, studies that use longitudinal designs to track changes over time find similar links between these variables (B. A. Jones & Griffiths, 2015), and these designs allow for somewhat more confidence regarding causality. Moreover, by linking body image problems and eating disorders to a larger sociocultural cause (i.e., regular exposure to media images and experiences that sexualize women’s bodies), objectification theory can explain why these disorders occur more often among women than men. On that note, we will next consider the role of the media more fully, especially as it pertains to cultural differences in objectification.

Figure 13.1 Path From Self-Objectification to Eating Disorders

Source: Adapted from Tylka and Sabik (2010).

Social comparisons Comparisons between the self and another person on a specific dimension.


With the widespread use of social media, there is increasing focus on the mental health consequences of “sexting”—sending and receiving nude or sexually provocative personal photos via phone or Internet. The research findings are complex and depend on factors such as age and consent. In a study of Hong Kong college students, sexters (compared with nonsexters) reported higher levels of body shame (suggesting objectification) but also more comfort with nudity (suggesting body positivity; Liong & Cheng, 2019). In a large-scale study of over 40,000 adolescents (aged 12—17), sexting was associated with substance use, anxiety and depression symptoms, and risky sexual behavior (Mori, Temple, Browne, & Madigan, 2019). Consent is relevant here because sexts can be sent under pressure, forwarded without consent, and unwanted by those receiving them, which takes sexting into the realm of cyberbullying and exploitation. In fact, sending sexts under pressure and receiving unwanted sexts are associated with higher levels of psychological distress among adolescents (Gassó, Klettke, Agustina, & Montiel, 2019). These data are correlational, though, so we cannot assume that sexting is the cause of any associated outcomes.

Roles of Media and Culture

Objectification theory was initially proposed and tested within Western contexts. Reflecting this, 85.5% of all participants in studies of self-objectification have been women from Western cultures including the United States, Australia, and Canada (Loughnan et al., 2015). Do the assumptions behind objectification theory apply similarly to the experiences of women from other parts of the world? According to the theory, the mass media, which include social networks, magazines, television, Internet, and films, are a primary way that people are exposed to objectified (thin, flawless, and sexualized) images of women. And, in fact, young Western women who use more social media, especially social network sites and magazines, also report higher self-objectification (Slater & Tiggemann, 2015). But media depictions of women’s bodies vary widely across cultures, reflecting differences in religion, values, gender equality, and economic and political systems. Do the media objectify women in non-Western cultures to the same degree as they do in Western cultures? It seems not. For instance, magazines in Asian countries (such as China, South Korea, Singapore, and Taiwan) show relatively few models in a nude, partially nude, or sexual manner (Frith, Shaw, & Cheng, 2005; M. R. Nelson & Paek, 2005).

Given cultural differences in media depictions of objectification, are there cultural differences in self-objectification? One study compared the prevalence of self-objectification tendencies across six different countries (the United States, Australia, Italy, India, Pakistan, and Japan) and the United Kingdom (Loughnan et al., 2015). Women scored higher in self-objectification than men did overall, and some interesting cultural differences emerged as well: People in the United States, United Kingdom, and Australia self-objectified more than those in Italy, Japan, Pakistan, and India. Thus, self-objectification tended to be higher in Western cultures than in non-Western cultures, which may help explain the lower rates of eating disorders in non-Western cultures.

Cultural differences in self-objectification may be changing, however, as people in non-Western countries get exposed to more Western media and values such as materialism. In one study of young Chinese women, materialism predicted self-objectification tendencies (Teng et al., 2017). Another study measured self-objectification among two generations of women (mothers and daughters) in Nepal, a country that spent much of its history (until about the mid-1980s) cut off from Western influences. While both generations of Nepali women were lower in self-objectification than U.S. women, Nepali daughters were higher in self-objectification than their mothers (Crawford et al., 2009), perhaps reflecting their increased exposure to Western, objectified representations of women. On a more positive note, body image activists are consistently working to undermine these objectified representations of women in the media (see Sidebar 13.5).


Body image activists work to combat the harmful consequences of objectification. In 1996, Connie Sobczak and Elizabeth Scott founded The Body Positive, an organization that teaches people to love and appreciate their bodies through programs that promote healthy eating and self-care and decrease body shame ( In 2016, Taryn Brumfitt released the documentary Embrace, which aimed to combat the global epidemic of body-loathing ( Perhaps the most well-known advocate for the cause is the singer-rapper Lizzo, who infuses body positive lyrics throughout her work. In her song “Juice,” Lizzo sings: “If I’m shinin’, everybody gonna shine (yeah, I’m goals) / I was born like this, don’t even gotta try (now you know).” This activism may be paying off, since the body dissatisfaction of girls and women has decreased gradually over the past several decades (Karazsia, Murnen, & Tylka, 2017).

Does exposure to Western media increase non-Western women’s eating disorder vulnerability? To answer this question, Anne Becker and her colleagues assessed the prevalence of eating disorders among groups of school girls in a Fijian village both 1 month after and 3 years after Western television was first introduced to the area in 1995. After 3 years of Western television exposure, the percentage of young Fijian women who displayed clinical levels of eating disorder symptoms had more than doubled from 12.7% to 29.2% (A. Becker, Burwell, Herzog, Hamburg, & Gilman, 2002).

Lizzo performs in Milan, Italy, in 2019.

Source: MARKA/Alamy Stock Photo

Again, all of the findings summarized here are correlational, so we must interpret them with caution. However, the data suggest that the (largely) Western tendency to objectify and sexualize women’s bodies can at least partially explain sex and culture differences in body dissatisfaction and eating disorders. If so, then we might see increases in eating disorders around the world as the influence of Western culture continues to increase.

Note, however, that not all researchers agree that exposure to thin, idealized images of women affects body image and eating disorders. For example, Christopher Ferguson (2013) argues that while this type of media imagery might affect some (but not most) girls and women, other factors, such as genes, also influence eating disorders. The issue is far from settled. One meta-analysis found small to moderate relationships between exposure to thin, idealized images and body image concerns and eating behaviors (Grabe, Ward, & Hyde, 2008). Another meta-analysis found little to no relationship between women’s exposure to thin media images and body image (Holmstrom, 2004). Yet another meta-analysis found little evidence that exposure to muscular images influences men’s body satisfaction (Ferguson, 2013). In light of this mixed evidence, Ferguson concluded that nature and nurture combine to shape eating disorder outcomes: Women with preexisting body dissatisfaction and/or genetic tendencies toward eating disorders are the ones most likely to suffer negative consequences of exposure to idealized media images.

Intersectionality and Eating Disorders Among Women

Eating disorders were once viewed as primarily affecting White women, but recent studies paint a different picture. A literature review published in 2009 found that White women were more likely than Black, Latina, and Asian American women to develop anorexia, while rates of bulimia and binge eating disorder were comparable across racial and ethnic groups (Cachelin, Dohm, & Brown, 2009). These data are summarized in Figure 13.2. A more recent, large-scale study of U.S. high school students found very similar rates of disordered eating behaviors (e.g., excessive fasting, forced vomiting, abusing laxatives) among Black (20.4%), Latina (29.2%), and White (21.4%) girls (Beccia et al., 2019).

If rates of some eating disorders are similar across racial and ethnic groups, what about the risk factors? This question is important because understanding the risk factors can help clinicians develop interventions and treatments for eating disorders among diverse groups. Interestingly, research suggests that certain racial and ethnic identities can protect against eating disorders in some ways but also create unique vulnerabilities in other ways. For instance, thin ideal internalization, or the belief that an ultrathin body is ideal for women, predicts eating disorders among White women. On average, however, Black women tend to score lower in thin ideal internalization than White, Latina, and Asian American women. Moreover, among women of color, having a stronger ethnic identity—a sense of connectedness to one’s racial or ethnic group—weakens the link between thin ideal internalization and eating pathology (Rakhkovskaya & Warren, 2014). This suggests that a stronger ethnic identity can buffer women against some types of eating concerns.


Figure 13.2 Eating Disorders Among U.S. Women

Source: Adapted from Cachelin, Dohm, and Brown (2009).

Ethnic identity A psychological sense of connectedness to one’s racial or ethnic group.

At the same time, women of color face a unique source of body shame not shared by White women: racial discrimination. Some research finds that more frequent race-based mistreatment predicts body shame, which predicts eating disorder symptoms among Latina women (Velez, Campos, & Moradi, 2015). Similarly, in a large, nationally representative sample of Black adults, perceived racial discrimination predicted increased rates of binge eating disorder among Black women but not Black men (Assari, 2018). Thus, the links between risk factors (e.g., thin ideal internalization, body shame, discrimination) and eating pathology among women of color are complex, and more research is needed on this topic.

Gender Identity, Body Dissatisfaction, and Eating Disorders

Transgender people are especially vulnerable to developing eating disorders. On average, transmen and transwomen have higher levels of body dissatisfaction and more disordered eating behaviors than their cisgender peers (B. A. Jones et al., 2016). For transgender people, body dissatisfaction may result when certain body parts or physical features remind them of their assigned sex, which differs from their gender identity. In such cases, individuals may use excessive dieting or other disordered eating practices to suppress physical features associated with their birth sex or to accentuate body features consistent with their gender identity. These practices can then lead to eating disorders. Note that body satisfaction often increases, and disordered eating decreases, among transgender individuals after they undergo genital reconstructive surgery or hormone treatments. One study found that genital surgery, chest surgery (removal or enhancement of breast tissue), and hormone treatment all led to decreases in transgender adults’ perceptions of being misgendered (viewed or referred to as the wrong gender) by others (Testa, Rider, Haug, & Balsam, 2017). In turn, having their gender identity affirmed by others led to increases in body satisfaction and decreases in eating disorder symptoms among both transwomen and transmen. We will return to the topic of mental health and transgender identity in a later section (“How Do LGBTQ Statuses Relate to Mental Health?”).

Intersectionality and Eating Disorders Among Men

In the United States, as many as 28%—43% of men report dissatisfaction with their overall appearance (Fallon, Harris, & Johnson, 2014). Of course, not all men who report body dissatisfaction will have an eating disorder, but men who internalize media ideals of male bodies, men with social anxiety, and men with poor impulse control are at heightened risk of developing eating disorder symptoms (Dakanalis et al., 2015). Men of color may also experience a heightened risk of eating disorders: A large-scale study of U.S. high school students found higher rates of disordered eating (e.g., purging, excessive fasting, abusing laxatives or diet pills) among Black male adolescents (13.4%) and Latino male adolescents (12.4%) compared to White male adolescents (8.1%; Beccia et al., 2019). Unfortunately, men’s eating disorders may go undiagnosed more often than women’s because men are more likely to stigmatize themselves for needing psychological help (Griffiths et al., 2015).

One eating disorder that affects men at growing rates is muscle dysmorphia, an obsessive preoccupation with increasing muscularity and maintaining low body fat (W. R. Jones, 2010). Sometimes referred to as “bigorexia,” muscle dysmorphia affects men almost exclusively (see Table 13.4) and may reflect increasing (and unrealistic) social pressures for men to obtain a physique characterized by high muscularity and low body fat. Just as exposure to objectified images of women’s bodies can heighten women’s feelings of body shame, exposure to objectified images of men’s bodies can increase men’s body shame. However, the underlying body image concerns that drive body shame tend to differ for women and men. While women may feel shame about not being thin enough, men may feel shame about not being muscular enough (Murnen & Karazsia, 2017; Nagata et al., 2019).

Muscle dysmorphia A body image disorder characterized by an obsessive preoccupation with increasing one’s muscularity and maintaining low body fat.

Can objectification theory shed light on men’s problems with muscle dysmorphia? Even though researchers developed this theory to illuminate how objectification affects women, some theorists argue that it can also explain men’s body image concerns, especially due to increasing cultural objectification of the male form (Davids, Watson, & Gere, 2019). In fact, the same processes seem to underlie both women’s and men’s reactions to objectification. Greater exposure to idealized images of men’s bodies encourages men to self-objectify, which increases their body dissatisfaction and heightens their vulnerability to body image disorders (Moradi & Huang, 2008).

Men may develop an obsessive preoccupation with increasing the size of their muscles while maintaining low body fat, a condition termed muscle dysmorphia.

Source: ©

Objectification theory may be especially useful for understanding the development of eating and body image disorders among gay men, who experience stronger pressures to conform to physical attractiveness standards than heterosexual men do. Gay men, compared with heterosexual men, report lower satisfaction with their bodies and muscles (Frederick & Essayli, 2016) and greater self-objectification, drive for thinness, and disordered eating symptoms (Martins, Tiggemann, & Kirkebride, 2007; Siever, 1994). Similar to women, gay men are regularly objectified by men within a patriarchal context, and gay men, relative to straight men, report feeling more objectified by others and more judged based on their appearance (Frederick & Essayli, 2016). In a replication of the swimsuit study described earlier, researchers objectified gay and heterosexual men by making them wear a pair of Speedo briefs (Martins et al., 2007). Their findings showed that, while the clothing manipulation did not affect heterosexual men’s body image, self-objectified gay men scored higher in body shame than gay men who were not self-objectified. Thus, the root of body image problems may not be objectification by itself but objectification by the male gaze, which refers to a voyeuristic and sexual mode of viewing others that reflects men’s patriarchal power.

Male gaze A mode of viewing others that is voyeuristic and sexual and that reflects men’s patriarchal power over women and other objectified individuals.


This section focused on how the tendency to objectify people’s bodies leads to unhealthy outcomes. Suppose you were in charge of a campaign to protect young people from the harmful effects of objectification. What shape would your campaign take? What factors do you think would be the most powerful in countering the effects of objectification? How would your strategies differ, if at all, when addressing female versus male objectification?


Sexual and gender minority (i.e., LGBTQ) individuals display heightened risks of mental illnesses and symptoms including depression, anxiety disorders, alcohol and substance abuse problems, self-injury, and suicidality (Becerra-Culqui et al., 2018). What might account for these differences in the rates of mental illness? As you may recall from Chapter 12 (“Gender and Physical Health”), minority stress theory proposes that belonging to a stigmatized group can create stressors unique to the minority experience (I. H. Meyer, 2003). These stressors, which include rejection, harassment, abuse, discrimination, and internalized stigma, combine to increase people’s vulnerability to all types of mental illness. Here, we will consider several factors that contribute to sexual and gender minority stress.

Victimization, Discrimination, and Rejection

The stressors of victimization (e.g., bullying and threats) and discrimination (e.g., restricted opportunities and denial of services) disproportionately affect LGBTQ people. Sexual minority and gender-nonconforming youths and adults who experience more victimization and bullying also report more depressive symptoms, suicidality, anxiety and PTSD symptoms, and substance use disorders (Burton, Marshal, Chisolm, Sucato, & Friedman, 2013; Crissman, Stroumsa, Kobernik, & Berger, 2019; N. R. Eaton, 2014).

For LGBTQ people, victimization sometimes occurs at the hands of close family members, including parents. Unlike racial and ethnic minority individuals, LGBTQ individuals often come from families in which close relatives do not share their minority status. Accordingly, they experience a heightened risk of being treated as outcasts or rejected by parents or family. Sexual minority adults who experienced more parental rejection of their sexuality (e.g., disparaging comments and anger) during adolescence also report higher rates of attempted suicide, depression, illegal drug use, and risky sex than their peers who experienced less parental rejection (C. Ryan, Huebner, Diaz, & Sanchez, 2009). Similarly, higher levels of family rejection in response to coming out as transgender predict higher rates of attempted suicide and greater substance abuse among transgender adults (A. Klein & Golub, 2016).

While an absence of parental rejection is good, an abundance of parental acceptance is even better. Strong, high-quality parent—child relationships, characterized by connectedness, support, and warmth, can buffer LGBTQ youths from the negative consequences of sexual minority stress. Across dozens of studies, LGB young adults who reported more parental support and more positive, warm relationships with their parents in adolescence were less likely to use substances, experience depression, and show suicidal tendencies (Bouris et al., 2010). In fact, one study found that positive connections with parents and family were the single best protector against suicidal behavior among both LGB and heterosexual adolescents (M. E. Eisenberg & Resnick, 2006). Less research examines the outcomes of parental acceptance among transgender youths, but what little there is suggests similar benefits (C. Ryan, Russell, Huebner, Diaz, & Sanchez, 2010; Valentine & Shipherd, 2018). The importance of positive family relationships for all youths, regardless of sexual orientation and gender identity, cannot be overstated.

Between 30% and 40% of all homeless youth identify as LGBTQ. Here, residents of the Wanda Alston House, a shelter for homeless LGBTQ youth in Washington, D.C., gather in a common area.

Source: Getty Images / The Washington Post / Contributor


Relative to heterosexual and cisgender youth, LGBTQ youth are at an increased risk of homelessness. Some estimate that LGBTQ teens make up 30%—40% of the 1.7 million homeless youth in the United States (Choi, Wilson, Shelton, & Gates, 2015), despite representing only 5%—7% of the youth population. Furthermore, a disproportionately large number of homeless LGBTQ youth are Black and Latinx and thus may experience stress related to multiple intersecting, marginalized identities. Young people become homeless for a variety of reasons, including parental neglect, abuse, and family conflict, but LGBTQ youth are especially likely to be evicted by parents or to run away to escape abuse. Moreover, homelessness takes a disproportionate toll on the mental health of LGBTQ youth. For example, homeless LGB youths suffer more depression, anxiety, conduct problems, and substance use problems compared with both homeless heterosexual youths and non-homeless LGB youths (Rosario, Schrimshaw, & Hunter, 2011).

Institutional Discrimination: A Hostile Environment

So far, we have primarily considered minority stressors that involve direct mistreatment from others. However, minority stressors can exist on a larger scale, reflecting environmental conditions that can impact psychological health. One study found that LGBT youths who lived in neighborhoods with higher rates of violent LGBT hate crimes had more suicidal ideation and attempted suicide more frequently compared with both heterosexual youths exposed to LGBT hate crimes and LGBT youths exposed to non-LGBT-based violent crimes (Duncan & Hatzenbuehler, 2014). Moreover, LGB adults who live in states that do not provide legal protections based on sexual orientation experience disproportionately high rates of mood and anxiety disorders (Hatzenbuehler, Keyes, & Hasin, 2009). Findings like these indicate that living within a “hostile” environment can impair the mental health of sexual and gender minority individuals, perhaps by arousing chronic feelings of anxiety, worry, and hopelessness.

Internalized Stigma: Homophobia and Transphobia From Within

Ironically, sometimes minority stress can come from inside. As you may recall from Chapter 9 (“Sexual Orientation and Sexuality”), internalized homophobia consists of self-directed antigay attitudes held by sexual minority individuals. Similarly, internalized transphobia refers to self-directed antitransgender attitudes held by transgender individuals. These occur when people internalize the negative, devaluing attitudes and beliefs held about their group by the surrounding culture. Internalized stigma then produces conflicts and stress that can manifest as mental health problems. For instance, internalized homophobia predicts depression, anxiety, and substance abuse problems, with small to medium effect sizes (d = 0.26), among the LGB population (Brubaker, Garrett, & Dew, 2009; Newcomb & Mustanski, 2010), and internalized transphobia predicts depression and suicidality among transgender adults (Breslow et al., 2015; Tebbe & Moradi, 2016). These links may occur because internalized stigma predicts both an increased reliance on unhealthy coping strategies (e.g., denial, self-blame, substance use) and a decreased reliance on adaptive coping strategies such as self-acceptance, support-seeking, and confronting homophobia (Kaysen et al., 2014).

Internalized homophobia Self-directed antigay attitudes held by sexual minority individuals.

Internalized transphobia: Self-directed transphobic attitudes held by transgender individuals.

Sexual minority individuals who belong to more than one disadvantaged group may suffer even greater levels of internalized stigma. Some findings indicate that internalized homophobia is higher among Black and Latinx than White sexual minority individuals (O’Leary, Fisher, Purcell, Spikes, & Gomez, 2007). This may occur because LGB people of color can internalize both homophobia and racism, which increases their vulnerability to psychological distress (Szymanski & Gupta, 2009). This makes sense from the perspective of minority stress theory: The condition of double stigma—being a member of more than one stigmatized group—should be doubly stressful.


Why do you think some individuals internalize negative attitudes about their sexual orientation or gender identity? What aspects of a person’s environment, upbringing, or personality might make them more inclined to internalize stigmatizing attitudes about their group? Conversely, what factors might protect LGBTQ individuals from embracing negative, self-directed attitudes?


Sex Differences in Rates of Help-Seeking

On average, men are less likely to seek help for mental health problems than women are, just as men are less likely to visit doctors for physical health issues (see Chapter 12, “Gender and Physical Health”). This sex difference depends on a couple of factors, however. First, the type of help provider makes a difference. Sex differences in help-seeking for mental health problems from medical doctors and informal sources (e.g., self-help groups and spiritual providers) are consistently large, but sex differences in help-seeking from mental health professionals (e.g., psychotherapists and social workers) are relatively smaller. This pattern emerges across several large, nationally representative studies of adults who meet diagnostic criteria for mental illnesses in the United States and Europe (Kovess-Masfety et al., 2014; Susukida, Mojtabai, & Mendelson, 2015). Men are thus far less likely than women to bring up emotional or mental health problems during routine doctor visits, which can be an important first step toward getting help. Second, the type of symptoms that people experience can make a difference: Sex differences in use of mental health services may be larger for anxiety problems than for depression problems (Mackenzie, Reynolds, Cairney, Streiner, & Sareen, 2012). Finally, although men with mental health problems seek less help than women, women also underutilize professional services. One study found that fewer than 40% of U.S. women who met diagnostic criteria for a mood or anxiety disorder in the past year sought help for it (Susukida et al., 2015). The tendency to underutilize psychological help services clearly does not apply just to men.

That said, many researchers seek to understand—and thereby close—the gender gap in mental health help-seeking. Much of this research focuses on how the male gender role suppresses help-seeking. Seeking help for emotional pain involves expressing emotions and making oneself vulnerable, behaviors that are inconsistent with male role norms of toughness, self-reliance, and stoicism. Men who conform more strongly to these male role norms and who endorse more traditional gender ideologies also tend to hold more negative attitudes toward seeking mental health help (Berke et al., 2018; Gerdes & Levant, 2018). The surrounding context can also play a role in whether or not people seek help for emotional problems. Male-dominated and hypermasculine environments, such as competitive sports and the military, tend to press for self-reliance and mental toughness and discourage vulnerability and help-seeking. Think back to the stories of Charles Haley and Brandon Marshall that opened this chapter. Socialized from an early age within the tough world of football, both Haley and Marshall resisted seeking help until their mental health problems almost destroyed their careers. Community type (rural versus urban) may also play a role in mental health help-seeking. Men from rural communities less frequently seek help for emotional problems than do men from urban communities, likely because of the strong norms of tough, self-reliance that are especially salient in rural areas (Hammer, Vogel, & Heimerdinger-Edwards, 2013). Note that these norms of toughness and self-reliance, especially in masculine and male-dominated environments such as the military, suppress mental health help-seeking in both women and men alike (Clement et al., 2015).

Military norms of toughness and self-reliance may discourage people from seeking help for mental health problems.

Source: ©


As we mentioned in the chapter opening, Charles Haley and Brandon Marshall both work to destigmatize mental illness and encourage men to seek help when needed. Do you think their efforts are likely to be successful? Why or why not? Are messages about the importance of help-seeking more likely to be effective if they come from stereotypically tough male role models? What steps would you take to increase people’s use of mental health services?

Intersectionality and Help-Seeking

As we noted earlier, women do not necessarily seek mental health help when they need it, and Black women may be especially unlikely to do so. Even when controlling for access to insurance, Black women in the United States are less likely than White women to use mental health services (Manuel, 2018). One explanation for this is that when Black women need psychological support, they often prefer seeking it from friends, family members, and pastors rather than from mental health professionals (Ward, Clark, & Heidrich, 2009). Another explanation for Black women’s underuse of mental health services lies in the strong Black woman (SBW) schema, a set of beliefs and attitudes about what it means to be a Black woman. According to the SBW schema, Black women are strong, selfless, resilient, and able to persevere despite oppression and financial hardship (Abrams, Hill, & Maxwell, 2019). Although the SBW schema can be a source of strength and self-efficacy for Black women, it may also hinder their tendencies to seek help because it encourages self-reliance and emotional self-control in the face of stressors. Consistent with these ideas, Black women who more strongly endorse the SBW schema are also less willing to acknowledge psychological problems and less open to seeking professional psychological help (Watson & Hunter, 2015; Watson-Singleton, 2017). Thus, unique features that arise from the intersection of gender and racial identities may influence help-seeking tendencies.

Strong Black woman schema A set of beliefs about Black women as being strong, resilient, and able to persevere despite oppression.


Thus far, we have devoted most of this chapter to discussions of mental illness. But what about psychological health? What does it mean to be mentally healthy? Here, we consider two prominent models of mental health and the roles that sex and gender play in each.

Subjective Well-Being

Psychologists who study happiness often examine a variable called subjective well-being (SWB). SWB refers to both short-term experiences of positive emotions and longer-term, global judgments of life satisfaction, meaning, and purpose (Diener, Oishi, & Tay, 2018). Given that women suffer from higher rates of depression than men do, we might suspect that men are higher on SWB than women, but the evidence does not support consistent sex differences in SWB (Batz-Barbarich, Tay, Kuykendall, & Cheung, 2018). One study that measured the predictors of SWB in 50 countries found no sex differences across cultures either in happiness or in the factors that predicted happiness (Lun & Bond, 2016). Moreover, women and men report similar frequencies of positive emotions, although women report stronger intensities of positive emotions than men do (Lucas & Gohm, 2000). Thus, despite having a higher propensity for depression, women do not report being less happy than men in general.

Subjective well-being People’s feelings of both short-term positive emotions and long-term sense of satisfaction, meaning, and purpose in life.

That said, some sex differences in SWB emerge when we examine the role of economic factors cross-culturally. One study measured sex differences in people’s belief that they were living “the best possible life” (a variable that captures the life satisfaction element of SWB) in seven different world regions. Across the globe, women reported greater SWB than men in both middle-income and high-income countries. Men had slightly higher SWB than women, however, in the poorest countries, where women are generally less empowered and more economically dependent on men (Graham & Chattopadhyay, 2013).

Of all the factors that seem to have a substantial and lasting influence on happiness, sex and gender do not seem to play much of a role. Some factors that we cannot control, such as genes and personality, contribute to happiness levels, but so do more controllable factors. People can try to increase their happiness by developing satisfying social relationships, maintaining good physical health and regular exercise, practicing kindness and gratitude, and helping others selflessly (Lyubomirsky, 2008). As shown in Figure 13.3, a meta-analysis of the effects of positive psychology interventions—such as practicing optimistic thinking, writing about gratitude, and thinking about positive experiences—found that these practices tend to increase well-being and decrease depression, with small to very large effect sizes (Sin & Lyubomirsky, 2009). Fortunately, with sufficient time and resources, people can cultivate such practices.


Figure 13.3 Positive Psychology Interventions

Source: Adapted from Sin and Lyubomirsky (2009).


Although women and men do not differ much in overall happiness, it is possible that the sources of happiness differ across sex. Think about the things that make you happy. Can you think of sources of happiness that might differ for women and men? As a researcher, how would you test this?

Communion, Agency, and Well-Being

Rather than focusing on subjective feelings of happiness and life satisfaction, some researchers instead conceptualize well-being as a balance between communion and agency (Wang, 2016). This idea has roots in Sandra Bem’s (1974, 1975) earlier thesis that psychological androgyny (possessing high levels of both male-typed and female-typed traits) predicts positive psychological health outcomes. As discussed throughout this book, communion refers to qualities that connect and orient people to others (e.g., warmth and generosity), and agency refers to qualities that distinguish people from others and orient them toward the self (e.g., independence and assertiveness). These dimensions are relevant to gender roles because men are typically expected to display agentic traits, and women are expected to display communal traits. Not only do these dimensions underlie sex-typed traits, they also underlie common gender stereotypes (recall the stereotype content model that we discussed in Chapter 5, “The Contents and Origins of Gender Stereotypes”).

As we discussed in the previous chapter on physical health, extreme and dysfunctional versions of agentic and communal traits—referred to as unmitigated communion and unmitigated agency—are associated with deficits in well-being but for different reasons. Unmitigated agency, which consists of extreme self-reliance and negative views of others, correlates with interpersonal difficulties, poor-quality relationships, and a lack of social support from others. Unmitigated communion, characterized by overattentiveness to others and neglect of self, correlates with low self-esteem and a lack of personal autonomy (Helgeson, 2012). Thus, if children undergo sex-typed socialization in which parents and other socialization agents encourage them to embody the unmitigated version of either agency or communion, they may be less likely to experience positive mental health.


Unmitigated agency can make it difficult for people to seek social support when they need it the most, such as after a cancer diagnosis. In one study of men who survived prostate cancer, unmitigated agency predicted more depressive symptoms, worse mental health, and more intrusive thoughts about cancer 14 months later (Helgeson & Lepore, 2004). Not surprisingly, higher scores on unmitigated agency also correlated with having fewer sources of social support to assist men with coping. In contrast, men who were higher in healthy agency had more social support and better outcomes over time.

In one test of these ideas, Yi Wang (2016) proposed that optimal mental health is associated with balanced authenticity, which refers to a healthy middle ground between the needs for self-focus and other-focus. People with balanced authenticity reap the benefits of both agency and communion. In support of this perspective, people who scored higher on a measure of balanced authenticity also scored higher across several indices of personal mental health (e.g., subjective well-being, self-esteem, feelings of competence) and social connectedness (e.g., positive relations with others, empathic concern for others, perspective taking). Thus, one form of optimal mental health involves being able to move flexibly between “feminine” and “masculine” tendencies. Looking forward, perhaps the growing tendency to move beyond the gender binary will have new implications for how gender relates to mental health. It will be interesting to see where research on this important topic takes us next.


· 13.1 Define psychological disorders and explain the major approaches to classifying them.

Psychological disorders (mental illnesses) are persistent disruptions or disturbances in thought, emotion, or behavior that cause significant distress or impairment. Both the American Psychiatric Association and WHO publish reference manuals that define and classify psychological disorders. While the American Psychiatric Association’s reference text (the DSM) describes over 200 distinct disorders, the transdiagnostic approach proposes that most of these disorders reflect different manifestations of a few core, heritable dimensions. These dimensions include the internalizing disorders (which consist of symptoms directed inward, toward the self) and the externalizing disorders (which consist of symptoms directed outward, toward others).

· 13.2 Analyze the various factors (e.g., gender roles, abuse, personality, and biology) that contribute to sex differences in rates of internalizing and externalizing disorders.

Internalizing disorders, which include mood, anxiety, and eating disorders, are cross-culturally more common among women than men, with small to medium effect sizes. Explanations for this sex difference vary, and each one likely accounts for some portion of the overall effect. Gender socialization may teach girls and women to cope passively with negative emotions (ruminate), and traditional labor divisions restrict women to a smaller number of socially devalued, home-based roles. Girls and women—and especially those who have physical or cognitive disabilities—experience sexual violence at higher rates than boys and men, and this can contribute to sex differences in depression. Women the world over also tend to be higher in neuroticism (negative emotionality) than men, and girls and women demonstrate a more reactive physiological response to stress. These factors can increase women’s vulnerability to internalizing disorders, especially during adolescence.

Externalizing disorders, including impulse control, attention, conduct, antisocial, and substance disorders, are cross-culturally more common among men than women, with medium effect sizes. This sex difference may reflect the operation of multiple factors. Boys often learn to display anger instead of sadness or fear, and parents tend to discipline sons more harshly than daughters. Men are more likely than women to use drugs and alcohol to cope with negative emotions, and they may have personality traits (high impulsivity and callous-unemotional traits and low effortful control) that render them vulnerable to externalizing tendencies. Boys also tend to have lower brain volume in an area of the brain that regulates impulse control (the prefrontal cortex) and may be more likely to inherit dopamine irregularities that underlie poor impulse control.

· 13.3 Explain the roles of gender and self-objectification in eating and body image disorders.

Women develop eating disorders (e.g., anorexia nervosa and bulimia nervosa) more frequently than men, while men develop muscle dysmorphia more frequently than women. Eating disorders have a genetic component, but other factors contribute to their development as well. Objectification theory posits that repeated exposure to objectified, idealized, and sexualized images of women’s bodies causes women to engage in self-objectification, which then predicts body dissatisfaction, eating disorders, low self-esteem, depression, and substance use problems. Although men are not immune from self-objectification, Western media are more likely to depict women in an objectified manner, which may partially explain why eating disorders occur more frequently among Western women. Increases in self-objectification and eating disorders are observed, however, in non-Western cultures that undergo increasing exposure to Western media (e.g., Nepal and Fiji).

In the United States, Black women are less likely than White women to internalize the thin ideal, and women of color with stronger racial and ethnic identities may be buffered from some types of eating disorders. However, experiences of racial discrimination can contribute to body shame and eating disorders among women of color. Transgender individuals display heightened levels of body dissatisfaction and eating disorders, but these symptoms often subside after genital reconstructive surgery or hormone treatment. Rates of muscle dysmorphia among men are on the rise, possibly due to increasing portrayals of highly muscular male images in the media. Gay men experience a relatively high frequency of body image issues, possibly because they—like heterosexual women—are especially likely to be targets of the male gaze, a sexualized and voyeuristic way of viewing others that reflects patriarchal power.

· 13.4 Describe the unique mental health vulnerabilities experienced by LGBTQ individuals.

LGBTQ people have higher levels of internalizing and externalizing disorders than heterosexual and cisgender people. Minority stress theory proposes that belonging to a stigmatized group creates unique stressors that heighten vulnerability to mental illness. Some stressors experienced by LGBTQ people include discrimination, physical and verbal victimization, parental and family rejection, homelessness, threatening environmental conditions, lack of legal protections, and internalized stigma. Parental acceptance and support offer a considerable buffer against the negative effects of minority stress.

· 13.5 Evaluate the roles of sex and gender in help-seeking.

Men seek help for mental health problems from medical doctors at much lower rates than women, but sex differences in help-seeking from mental health professionals are smaller. Sex differences in help-seeking may also differ depending on disorder type (e.g., anxiety vs. depression). Most people with mental health problems, regardless of sex, fail to seek adequate help for these problems. Men are especially unlikely to seek mental health help if they endorse male role norms of toughness and self-reliance or if they occupy male-dominated, hypercompetitive environments. Black women who more strongly endorse views of Black women as strong and resilient are also less likely to seek professional mental health assistance.

· 13.6 Understand how sex and gender relate to happiness and well-being.

There are few consistent sex differences in people’s subjective well-being, which consists of positive emotions and feelings of life satisfaction. Women report more negative emotions than men, but they do not consistently report lower happiness than men. In general, the factors that predict happiness seem to be similar for women and men. Approaches to health that focus on communion and agency propose that optimal well-being reflects a balance between these dimensions. Being too extreme on agency (unmitigated agency) can undermine well-being by reducing relationship quality and social support, while being too extreme on communion (unmitigated communion) can lead to self-neglect and low confidence. People high in balanced authenticity—a middle ground between self-focus and other-focus—tend to score highest in both personal mental health and connectedness to others.

Test Your Knowledge: True or False?

· 13.1. Approximately one-quarter (25%) of all people in the United States will meet diagnostic criteria for a mental illness during their lifetime. (False: Almost one-half [47%] of all people in the United States will meet diagnostic criteria for a mental illness during their lifetime.) [p. 471]

· 13.2. In general, men are more likely than women to suffer from alcohol, drug, and other substance use disorders. (True: Sex differences in these types of disorders are in the medium effect size range.) [p. 473]

· 13.3. Eating disorders only occur in Western cultures. (False: While eating disorder rates tend to be lower in non-Western cultures, increasing exposure to Western, objectified representations of women correlates with increased eating disorders among women in non-Western cultures.) [p. 486]

· 13.4. LGBTQ youth who live in neighborhoods with higher rates of hate crimes against LGBTQ people are more likely to attempt suicide. (True: LGBTQ youth who have not personally experienced hate crimes are more likely to attempt suicide if they live in neighborhoods with higher rates of LGBTQ hate crimes.) [p. 495]

· 13.5. Across cultures, men generally report higher levels of happiness and positive emotions than women do. (False: There are not persistent sex differences in the amount of happiness that women and men report.) [p. 499]

Descriptions of Images and Figures

Back to Figure

The graph is described as follows:

The horizontal axis shows the eating disorders in Black, White, Latina, and Asian women.

The vertical axis shows the percentage from 0.0 to 4.0 in increments of 0.5.

The given percentages are:

1. Anorexia Nervosa:

1. Black women: 0.14%

2. White women: 1.50%

3. Latina women: 0.12%

4. Asian women: 0.12%

2. Bulimia Nervosa:

1. Black women: 1.90%

2. White women: 2.30%

3. Latina women: 1.91%

4. Asian women: 1.42%

3. Binge Eating Disorder:

1. Black women: 2.36%

2. White women: 2.70%

3. Latina women: 2.31%

4. Asian women: 2.67%

Back to Figure

The graph is described as follows:

The vertical axis shows Depression and Well-Being in Self-Administered, Group-Administered, and Individual Therapy.

The horizontal axis shows scores from minus 2 to 2 in increments of 0.5.

The given scores are:

1. Depression:

1. Self-Administered: minus 0.18.

2. Group-Administered: minus 0.63.

3. Individual Therapy: minus 1.39.

2. Well-Being:

1. Self-Administered: 0.41.

2. Group-Administered: 0.72.

3. Individual Therapy: 1.15