The Impact of Gender Roles on Psychiatric Treatment: In Conversation With Eugene T. Lucas Jr, DNP, CRNP, FNP-BC, APMHNP-BC

CLINICAL CONVERSATIONS

It is time to take a closer look at the intersection of gender, sexual health, and mental health. Psychiatric Times sat down with expert Eugene T. Lucas Jr, DNP, CRNP, FNP-BC, APMHNP-BC, to examine this complex relationship.

Psychiatric Times: How do traditional gender roles impact help-seeking behavior as well as engagement in psychiatric treatment?

Eugene T. Lucas Jr, DNP, CRNP, FNP-BC, APMHNP-BC: Traditional gender roles impact men’s and women’s help-seeking behaviors and adherence to treatment. Men are often socialized to embody stereotypically masculine traits, like having strong, dominant personalities, being leaders, making decisions easily, being in control, and being oriented toward their own goals.¹

This kind of pressure and self-image often prevents them from being honest with themselves and their partners in admitting any difficulty with mental health such as depression, anxiety, or what not. They think they are supposed to just handle it on their own and should not need help or support. For the same reasons, they are less likely to see a psychiatrist and also less likely to stick to any medications over the long-term.

In contrast, stereotypical feminine traits include being gentle, warm, nurturing, sensitive to others’ needs, communally oriented, and generally more accepting. As a result, they tend to be more open to seeking care and adhering to treatment, particularly when facing conditions like anxiety, which women are more likely to struggle with. However, societal expectations around juggling multiple roles—ie, as mothers, partners, workers, and caretakers—can contribute to a lot of stress and angst.

PT: How might pharmacokinetics differ in men vs women?

Lucas: Physiological differences between men and women play a big role in how medications are absorbed, metabolized, and tolerated. Factors such as body weight, body fat distribution, total body water, gastric acidity, liver enzyme activity, and kidney function all differ by sex.²

For example, women have more subcutaneous fats and that will influence the absorption of transdermal medication, because there is a liquid layer that the medication must go through. In general, men have a lot more systemic ability to have pharmacokinetics work with higher doses than women do.

Because of these variables, clinicians should not rely solely on standardized dosing but instead consider doing some baseline lab work (eg, metabolic panels and assessments of kidney and liver function) before initiating treatment. Tailoring medication plans to these differences can reduce side effects and improve adherence.

PT: What are some tips to support men who experience sexual dysfunction as a result of pharmacological interventions?

Lucas: Men struggle with needing help or support in the first place due to societal expectations around masculinity and their own self-image of needing to be strong and self-reliant. If you add in sexual adverse effects from medications, then that is likely going to be a major reason for them to stop taking those medications. This can make adherence to treatment even more challenging with men than it already is.

To support adherence, I often recommend considering alternatives such as bupropion, which generally has fewer sexual adverse effects (although you also want to be cautious if you are using bupropion to treat anxiety as opposed to depression). However, depending on which conditions are being treated, some patients simply do better on selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors. In which case, one strategy can be skipping a dose before planned sexual activity (except for fluoxetine due to its longer half-life).

It is also important to check testosterone levels, as low testosterone can contribute to sexual dysfunction. For some men, therapies like testosterone replacement or PDE5 inhibitors such as sildenafil (Viagra) or tadalafil (Cialis) can be effective.

In all cases, I encourage involving the patient’s partner in these discussions as restoring sexual function after a period of inactivity can sometimes reintroduce dynamics that require communication to manage well.

PT: How do testosterone levels impact psychiatric illness and psychopharmacological treatment efficacy?

Lucas: Testosterone has a major influence on mood and behavior, as it is the hormone that fires up the masculine traits. In the context of psychiatric illness and treatment, it is another variable to watch. In individuals with depression or anxiety, for example, too much testosterone can result in increased aggression. These are also things to consider when using hormone replacement therapy as part of a treatment plan.
We also need to remember there is a range of individuals who receive testosterone replacement therapy (TRT). Potential patients include men with low T levels as well as individuals who are transgender, have gender dysphoria, or are cisgender and have underdeveloped sexual organs.

There are additional factors to consider. For example, an individual undergoing gender transition may have testosterone levels that are normal for their sex assigned at birth but they need more testosterone to develop physically masculine features such as facial hair.

If you have a patient who is receiving TRT, keep a close eye on those hormone levels and frequently assess how they are feeling and behaving. Similarly, work closely with their family to ensure you have a good feel for what is going on.

It is also advisable to collaborate with a urologist so that you are not doing anything to injure liver or kidney function.

There are cases where you would want to avoid testosterone replacement therapy entirely, such as a patient with personality disorder, intermittent explosive disorder, or bipolar disorder.

PT: How might clinicians best address risky behaviors, secondary to a psychiatric disorder, in their male patients?

Lucas: Risky behaviors in male patients often include too much coffee, smoking, binge drinking, illicit drug use, reckless driving, poor sleep hygiene, lack of exercise, and/or unprotected sex. These behaviors not only worsen psychiatric conditions but also put these patients at higher risk for physical harm and legal trouble.

The key is to address these directly as behavioral issues, not just secondary effects of the psychiatric conditions (eg, depression or anxiety). An effective approach is to use behavior support plans in combination with evidence-backed methodologies such as cognitive behavioral therapy, in which present the behavior to the patient, essentially saying, “Here is a behavior you are exhibiting that is not really helpful. How do we work on this particular issue so that it’s helpful to not only you but also to other people?”

In more serious cases, patients may also need referrals to substance use treatment, inpatient care, or regular ongoing therapy.

PT: Globally, suicide rates tend to be higher in men versus women. How can clinicians better identify and mitigate suicidal ideation in men?

Lucas: Men are more likely to die by suicide, often because they tend to use more lethal means such as firearms.³ Many male patients who struggle with suicidal ideation feel that they are failing to meet the previously noted masculine roles that society and they themselves have set. Instead of seeking help, they may experience a sense of nihilism and conclude that ending their lives is the only way to escape the sense of failure or inadequacy. Hostility, irritability, aggression, withdrawal are all warning signs.

The Columbia Suicide Severity Rating Scale is a valuable tool for identifying suicidal ideation. Once identified, clinicians should work with patients to develop crisis plans and highlight sources of meaning and connection, whether family, faith, community roles, or daily responsibilities. Reinforcing a patient’s strengths and helping them reconnect to support systems is critical in reducing risk.

PT: Are there differences in how nonadherence occurs in men versus women?

Lucas: Yes. Societal expectations around gender roles, masculinity, and femininity influence how nonadherence occurs in both groups. If men use a lot of alcohol, for example, that impacts their ability to receive maximum benefits from their medications.⁴ The same can apply with smoking.

Men’s belief in how medications should work, and preconceived ideas they have about “handling” their medications as well as adverse effects, especially sexual adverse effects, also play a big role.

For both men and women, support systems and the relationship with the clinician are important. Do they have a health care professional that they believe in? Is the relationship strong? Is the clinician there to support them when they have difficulties with an adverse effect from the medication, if they need to increase or lessen the dose, or change the medication entirely? All of these factors influence adherence and nonadherence.

PT: For which disorders may men present differently than women?

Lucas: Some disorders present differently or more frequently. For example, research shows women more frequently experience anxiety and eating disorders such as anorexia or bulimia while men have higher rates of substance use disorders, attention-deficit/hyperactivity disorder, conduct disorder, and intermittent explosive disorder.^5-9

There are ways the conditions can present differently. For instance, men with depression are more likely to display anger, hostility, aggression, and substance use rather than the classic symptoms such as sadness, fatigue, sleep issues.¹⁰

In terms of screening tools, the traditional screening tools such as the PHQ-9, GAD-7, and MDQ use the same questions and scoring criteria for men and women. There is the Male Depression Risk Scale, however, which is specifically designed to measure factors associated with depression and suicidality in men and can be used in conjunction with the other tools.

Similarly, the Women’s Health Questionnaire was developed specifically for women and can provide insight in both physical and mental health while evaluating overall well-being in women.

There is also the Self-Reporting Questionnaire-5, which is a gender-neutral tool that can be particularly useful for how easily and quickly it can be used in the underresourced or disadvantaged settings in which women are disproportionately affected by mental health challenges.^11,12

PT: What else do you want your colleagues in psychiatry to better understand and address?

Lucas: I would encourage my colleagues to pay closer attention to the intersection of sexual health and mental health. Sexual health is a major factor in overall well-being, and most individuals consider sex to be a positive part of their lives that alleviate the stressors of the day, allow for emotional release, and fosters a bond with another individual. But this can also have negative consequences if patients or their partners get sexually transmitted diseases, which affect their physical health and also impact their mental health and well-being.¹³

Unfortunately, many patients struggle to discuss these topics openly with clinicians. Men, in particular, often avoid raising concerns about sexual function, sexually transmitted infection risks, or condom use. Generally speaking, women are able to communicate a little better with their partners regarding these matters, and they are quicker and more willing to go to a doctor. However, both sexes would benefit from better sexual education, because men and women do not use protection when they should (eg, oral or anal sex) and are not always aware of the risks.

PT: Thank you!

Dr Lucas is an associate professor and coordinator of the distance education Psychiatric/Mental Health Nurse Practitioner program at Wilkes University.

References

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