Masculinity Adherence Could Influence Veteran PTSD Care

Elizabeth Neilson, PhD

Adhering to traditional traits associated with the socially constructed idea of masculinity may be further burdening military veterans with PTSD.

A new assessment from investigators at the Michael E. DeBakey Veterans Affairs Medical Center in Houston shows that common masculinity traits including the suppression of emotions, stoicism, and self-reliance were positively associated with heightened PTSD severity.

The research, led by Elizabeth Neilson, PhD, of Morehead University, may better inform clinicians and psychiatrists addressing trauma-related burdens through psychoeducation.

PTSD is currently a rampant issue among the military veteran population, as Neilson and colleagues noted the estimates range from 11% to 45% of all recently returning veterans reaching diagnostic criteria. And despite a gamut of evidence-based treatments existing for the psychiatric condition—including a processing of patient fear, shame, and guilt—a majority of veteran patients are likely to avoid care, or ultimately receive less benefit than civilian peers.

As such, investigators were interested to assess the influence of traditional masculinity ideologies—social concepts frequently followed by US veterans of both genders—were influencing PTSD symptoms, patients’ decisions to seek help, and the overall treatment of PTSD.

“Although previous reviews have found that traditional masculinity ideology is associated with poorer mental health functioning, no previous review has focused exclusively on the association between traditional masculine ideologies and PTSD among veterans,” they wrote.

Neilson and colleagues assessed data from 17 studies involving 3500-plus military veterans from the last 25 years. Their criteria included relevant research into the association between traditional masculine ideal adherence and trauma-related symptoms. Of all observed trials, just 1 included both male and female participants.

Among studies to report demographic data, mean patient age ranged from 29.07-67.4 years, and racial/ethnic diversity varied even greater—from 8.2% non-White patients in one trial, to 84% in another.

Overall, investigators observed an association between traditional masculinity ideology and PTSD symptom severity when compared to violations of masculinity ideology. Patients who engaged in traditional masculine norms were at greater risk for treatment dropout.

The most consistent finding in their meta-analyses was the association between emotional stoicism or “toughness” and PTSD-related constructs such as self-stigma and self-efficacy.

“Veterans who report a strong identification with military culture and the emphasis on emotional stoicism may be at greater risk to develop PTSD than those who do not,” Neilson and colleagues wrote.

Their findings also showed a trend of patients exhibiting “hypermasculinity” following traumatic events—which they explain as veterans following a compulsion to reaffirm their masculinity following a perceived loss of control during trauma. Hypermasculine behavior can manifest as risky sexual decisions, violence, and aggressive activities.

“The drive to affirm masculinity may contribute to veterans’ post-service risk for substance abuse, sexually transmitted infections, and legal involvement,” investigators wrote.

In a statement related to the study’s findings, Neilson noted the American Psychological Association (APA) 2018 voluntary guidelines advising that therapists weigh the discussion of masculine ideology and its impact on male expectations when treating male veteran patients.

“It would not surprise me if some clinicians are already considering how a veteran’s masculinity ideology contributes to their PTSD symptomology and treatment engagement,” she said. “Consistent with APA’s recommendations, I suggest that clinicians discuss beliefs and adherence to traditional masculinity ideologies with the patients. This information is important for conceptualizing patients’ mental health and identifying specific behaviors to target in treatment.”

Investigators emphasized the multifaceted concept of masculinity and how veterans are able to flexibly shift their concept and conformity to its ideologies, based on their background and experiences. They advised that clinicians reinforce adaptive and flexible displays of masculinity, in a way to bolster trauma-focused care.

Future investigations could look into the influence of traditional masculinity ideology adherence on treatment outcomes, as well as how differing concepts and expressions of masculinity influence PTSD outcomes.

“Such research may generate results and clinical recommendations that enrich the implementation and dissemination of PTSD prevention and treatment programs, thus reducing the longstanding impact of PTSD for veterans,” investigators concluded.

The study, “Traditional Masculinity Ideology, Posttraumatic Stress Disorder (PTSD) Symptom Severity, and Treatment in Service Members and Veterans: A Systematic Review,” was published online in Psychology of Men and Masculinities.