Introduction

A common social problem and a major public health challenge in the Nordic countries is mental ill-health, and several previous studies show that mental ill-health is on the rise, particularly among young adults. Girls and young women suffer from mental ill-health to a greater extent, but it is also growing among boys and young men. There is a link between expressions of mental ill-health and limiting gender norms. Masculinity norms negatively impact the health of men in the form of an increased risk of suicide, non-health-promoting behaviours, poorer social support, substance abuse, and a variety of high-risk behaviours in traffic and workplaces for example. Boys and men sometimes also exhibit different symptoms of mental ill-health than do girls and women, which means that it is not always detected and that they do not get the right help and treatment. Mental ill-health risks leading to aggression, self-destructive behaviours, and violence towards oneself and others. More broadly speaking, conditions in schools and workplaces can affect young men’s health, and the reverse is also true: that young men’s ill-health and destructive masculinity norms can affect their future educational choices and their establishment in the labour market.

A number of national studies show that mental well-being has deteriorated in most groups over the past ten years, across both women and men and different age groups. Several studies, including the Norwegian commission of inquiry Jenterom, gutterom og mulighetsrom (NOU 2019: 19), show that mental ill-health is on the rise, in particular among young people. The Norwegian investigation also highlights that the extent of mental ill-health is often measured by self-assessment in surveys, and that it is mainly girls and young women who rate their mental health as poor. At the same time, boys and young men are overrepresented in the death by suicide statistics. In the report Inequalities in mental health in Sweden (2022), the Public Health Agency of Sweden shows that mental health is not equal and that certain groups – homosexual and bisexual, recipients of financial assistance, unemployed young adults, single mothers and persons with disabilities – are particularly vulnerable. Even at an early age, there is an unequal distribution of mental health issues depending on the socioeconomic status of the family. For example, children and young people who are less well-off more often report mental ill-health and psychosomatic illnesses. Mental problems can subsequently develop into more serious mental illnesses, which can have consequences in adulthood. Other factors, such as the country of birth and level of education of their parents and the type of family in which a child grows up, also affect the mental health of children and adolescents.

There are gender differences in health, and the report Inequalities in mental health (Public Health Agency of Sweden, 2019) shows that younger boys (0–12 years) have both more and other forms of mental health problems than girls. For example, boys exhibit more neurodevelopmental problems and externalising symptoms than girls. Girls, on the other hand, have a higher incidence of eating disorders and internalising symptoms such as psychosomatic disorders, depression and anxiety. Analyses of Swedish patient data show that boys between the ages of 7 and 17 are diagnosed with mental disorders in specialised outpatient care more often than girls, but between the ages of 18 and 24 the opposite is the case.

It is difficult to identify men’s and boys’ mental health issues in time because they generally seek help less often, and at a later stage than women and girls (Swedish Association of Local Authorities and Regions, 2018). A research overview of the sub-goal Equal health in Sweden’s gender equality policy highlights in particular medical research concerning masculinity and ill-health (Swedish Gender Equality Agency, 2021), and shows that school performance and how much parental leave is taken has links to men’s ill-health long-term.

A number of international studies compiled by the Public Health Agency of Sweden in the report Is the COVID-19 pandemic affecting the mental health of the population? indicate that mental ill-health has increased during the pandemic. The results of these studies indicate that young adults are feeling less mentally well. They also show that there is a connection between mental ill-health and sociocultural patterns with regard to gender expression (SOU, 2014).

Distance teaching that has been widespread across the Nordic countries also has gendered implications. Specifically, studies indicate that deficiencies in teaching and the quality of schooling disadvantage boys in particular, as they are more in need of special support in schools – a need that has been difficult to meet during the pandemic. Overall, the pandemic has affected mental health in the community negatively in both the short and long term.

In this report, the focus is on self-assessed mental health, i.e. research where the person’s own experience and subjective assessment of their health constitute the research material. Objective assessments of health made by the health care system have been systematically excluded from this overview.

To discuss the concept of ill-health, we need to start from the concept of health. The easiest way to look at health is that a person without disease is healthy, that is, that health is the absence of disease (Sartorius, 2006). Health is more than absence of disease as defined by Boorse in the 1970s (Boorse, 1977).  However, in the perhaps most widespread definition of health, the World Health Organization (WHO) problematises this definition: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948). The WHO definition takes a holistic approach to health and well-being and includes physical, mental and social aspects. Physical health refers to physical capabilities and functional levels; mental health includes emotional health and well-being; and social health can be described as the degree to which the individual has well-functioning social networks, and at the societal level how well they are able to participate in society’s organisations. The WHO definition describes a kind of ideal state of health and this definition has been criticised as utopian and impossible to achieve. Nordenfeldt (1991) contributed an additional perspective with his action-oriented approach to health. This approach emphasises the ability of individuals to achieve their goals, provided that these goals are realistic and achievable. Nordenfeldt argued that there must be a balance between the individual’s ability to act and their goals, and that a person who cannot achieve their goals has some form of ill-health. This definition has a strongly individual perspective, which can be contrasted with a public health science definition. The Public Health Agency of Sweden is tasked with regularly monitoring public health in Sweden and underlines the importance of good health on equal terms. The Agency emphasises that “good public health means that health is as good and as equal as possible across different groups in the community. The health of the population is shaped by an interaction of factors – from individual hereditary factors to lifestyle habits, living conditions and circumstances” (Public Health Agency of Sweden, n.d.). This perspective thus means that ill-health cannot be understood solely in relation to individual goals and the individual’s ability to act. Social structures that shape the individual's circumstances can stand in the way of achieving their goals, but also contribute to ill-health or the reverse – to better health. Most definitions describe some kind of relationship between the individual and the social context, as for example in Randell (2016), which describes health in the context of young men, such as feeling good in body and mind and having access to relationships of trust.

The WHO has also formulated a more specific definition of mental health as a state of mental well-being where each individual can realise their potential, cope with ordinary stresses, work productively and contribute to the society in which they live. According to the WHO, mental health is thus not the same as the absence of mental illness. A report on ill-health from Forte: the Swedish Research Council for Health, Working Life and Welfare (Vingård, 2015) discusses the WHO definition: “deviations from this ideal state would appear to be part of everyday life. In cases where these deviations, or disturbances, are short-lived and/or mild, they are seen in most cultures as part of life, while more tangible effects on well-being lead to what is commonly described as ill-health” (Vingård, 2015:1). The problem with a very broad and inclusive understanding of mental ill-health is that it includes everything from mentally impaired well-being to serious mental illnesses. More everyday ‘normal psychological’ conditions that may be due to difficult situations or stresses in life get mixed in with serious and/or more permanent conditions. The Swedish National Board of Health and Welfare (2019) writes in a report that mental ill-health can be a temporary state of worry, low mood or sleep problems, but the term is also used to describe mental illnesses such as anxiety or depression. What characterises all mental ill-health is that it affects our well-being and makes us function differently than usual.

Health and mental health are thus multifaceted concepts that individuals experience on a sliding scale, from excellent health or excellent mental health to very poor health or ill-health, where the different aspects of health –mental, social and physical – are interrelated and influence each other. Mental ill-health can give rise to different types of physical problems that are experienced as being physical, which makes establishing clear boundaries between mental and physical ill-health very difficult. Health and ill-health are often discussed in terms of psychosomatic disorders. These can include feeling down or having difficulty sleeping. It is not always possible to clearly identify the origins of ill-health or whether the body or the person's mental state is the cause. They are interconnected.

In recent years, reports from the Public Health Agency of Sweden and other documents that deal with health have generally noted a shift from an ill-health perspective to a health perspective, as well as an increased use of salutogenic, preventive and health-promoting perspectives. A salutogenic perspective means focusing on what factors cause and maintain health more than what causes disease. All in all, with a broad concept of ill-health that encompasses social contexts and attaches importance to societal norms and the way society is organised, changes in education and training systems and the labour market, as well as a focus on young people who are often facing crucial decisions about their future educational and career choices at this time of life, young men’s mental health problems emerge as a complex problem. But education and training and the workplace can also be the cause of mental ill-health and offer health promotion, depending on a number of factors, while unemployment and being outside the education and training systems can also lead to mental ill-health. Where education and training and the workplace are strongly gender-segregated, it is also important to get a perspective on the relationship between mental ill-health and masculinity.

Men’s perceived health is paradoxical. In countless studies, men report better subjective, self-assessed health than women and are also less likely to experience that they have health problems and to seek help for them. At the same time, boys and men have a higher rate of death by suicide, even though girls and women attempt suicide more often than boys and men (Kimmel, 2010; McLoughlin, Gould, & Malone, 2015). The suicide rate, especially among teenage boys aged 15–19 and among young adult men, is a problem in the Nordic countries and in the rest of the world (Breland & Park, 2008; Kõlves & De Leo, 2016). Studies show that men are more likely to adopt an unhealthy lifestyle, expose themselves to dangers and risks, and are at greater risk for all leading causes of death (Courtenay, 2003; Courtenay & Keeling, 2000; Oliffe et al., 2010). This pattern is also evident in teenage boys, who in studies rate their health higher than teenage girls do (Ciarrochi, Deane, Wilson, & Rickwood, 2002; Johansson, Brunnberg & Eriksson, 2007; MacLean, Hunt & Sweeting, 2013). At the same time, more boys have more neurodevelopmental diagnoses and difficulties such as attention deficit, hyperactivity or behavioural disorders that can lead to impulsive behaviour and the need for support in school. Boys and men are more often involved in accidents, and they are more likely to be both the perpetrators and victims of violence than girls and women. Young men also generally have an increased risk of accidents and violence, and teenage boys are much more likely than girls to engage in high-risk behaviours (Boyle et al., 2011).

Masculinity norms can have a significant impact on the mental health and well-being of teenage boys and young men. Traditional masculinity norms often emphasise traits such as control, self-reliance, and toughness, which can cause young men to conceal their emotions and avoid seeking help for mental health problems. Boys’ lower propensity to seek help compared to girls is known from previous research (Granrud, Bisholt, Anderzèn-Carlsson & Steffenak, 2020; Wirback, Forsell, Larsson, Engström & Edhborg, 2018). In addition, societal expectations of what it means to be a ‘real young man’ can lead to feelings of shame and inadequacy for young men who do not fit into or comply with these norms, which can make them feel even less well mentally. Having to bear the burden of your own difficulties without having anyone to turn to can result in increased stress, anxiety and depression, which ultimately risks leading to suicide. It is important to demonstrate alternative masculinities to young men to promote their mental health and well-being, and to challenge and redefine the kinds of traditional masculinity norms that can be harmful to young men’s health.

The concept of masculinity was developed to analyse how norms for men are maintained by maintaining differences between men as a group and women as a group in various ways, and through hierarchies within men as a group, where those who do not act in accordance with the masculinity norms are subordinated (De Visser, Smith & McDonnell, 2009; Messerschmidt, 2009). Using the concept of masculinity in the plural means acknowledging these hierarchies within men as a group and that power is often exercised within the group by defining subordinate positions as ‘feminine’. Masculinity is constructed in multiple arenas and homosocial narratives are a way to assert masculinity (Vaynman, Sandberg & Pedersen, 2020). The term ‘homosociality’ refers to how men identify with and understand their social position in relation to other men. Homosociality can explain why it may be experienced as shameful to seek help and show weakness, since this is linked to ‘being feminised’. Given this emphasis on homosociality, it is easy to imagine that young men who violate heteronormative expectations and orient themselves sexually toward other men are exposed to various forms of physical and psychological violence, discrimination and threats. In comparison with many others, the Nordic countries are streets ahead in certain areas of equality, but the reiteration of hegemonic masculinity norms in the Nordic countries still excludes and still identifies non-white, non-heterosexual and disabled men as ‘other’ (Egeberg Holmgren, 2011).

Masculinity norms are embedded in society’s norms, and these norms, although they are constantly developing and changing, shape and contribute to young men’s health and health behaviours; thus, individual and structural factors interact in complex ways (Robertson, 2007; Thorpe & Halkitis, 2016). Thus, masculinity norms can be limiting for boys’ and young men’s health even though masculinities are constantly changing and allowing for new, more health-promoting masculinities to be created.

Over the past fifty years, the Nordic countries have experienced a shift in gender roles, changing family structures and the development of new social norms. These are still changing, especially when it comes to family policy and taking parental leave. Men are expected to take both a productive responsibility in the labour market and an increased reproductive responsibility at home. These dual expectations are termed ‘dual emancipation’ (SOU 2014). A strong emphasis on gender equality can sometimes lead to confusion for young men trying to manage and live up to what are often very narrow gender roles that society permits them to take on. To be a teenage boy and feel the pressure to be both masculine and strong in a traditional way, and at the same time sensitive and caring, can be experienced as challenging (Randell, Jerdén, Ohman, Starrin & Flacking, 2015). Masculinity norms can be understood at the individual level as creating a sense of security, which makes the issue of masculinity norms and ill-health even more complex. An interview study about young men in Reykjavik has reported that changed masculinity norms, permeated by gender equality norms, are seen as a common goal. Young men are strongly influenced by the gender equality discourse and welcome changes in behaviour patterns (Jóhannsdóttir & Gíslason, 2018). At the same time, they say that they feel uncertain when they describe what has changed and what has remained stable in what is expected of them as men. There are clear indications that masculinity is now more broadly defined than previously, that more things are now ‘allowed’.

Loosening up masculinity norms can lead to better mental health, if it means a greater opportunity to express oneself about one’s feelings. Bearing the burden of your own difficulties without having anyone to turn to can result in increased stress, anxiety and depressiveness, which ultimately risks leading to suicide. Different masculinities and expressions of emotion are strongly intertwined and how a person handles their emotions in everyday life is crucial for well-being. Having self-esteem, access to relationships with trusted others, and having the courage to resist traditional masculinity norms without losing status contributes positively to teenage boys’ well-being. Researchers and professionals who come into contact with young men need to take into account the complexity involved in assessing their health, since norms, values, relationships and gender constitute its social determinants (Randell, 2016).

Social class and socio-economic status are also very important factors for mental health. There are studies that indicate that the hegemonic norms affecting young men from the working class can be countered through education. In an education and training context where there is relational support, young men can benefit from this support, and be strengthened in terms of their well-being (Roberts, 2018; Ward, 2018). One study shows that masculine identities and capacity for caring in young men who have experience of difficult relationships or drug problems in their lives can also be positively influenced by close and caring relationships with their mother or other female relatives (O'Dell, Brownlow, & Bertilsdotter-Rosqvist, 2017). Furlong (2009) also emphasises the importance of intergenerational relationships and points out that how well young adults fare is dependent on a ’joint enterprise’ between the child and its parents.

Society’s norms have become more permissive when it comes to sexuality, sexual identity and expression, gender and relationships, but there are still strong heteronormative norms in society. Even quantitative research which lacks a problematising approach to gender categories is part of this norm reproduction. Given these current societal norms, it can be difficult for young people who identify as non-binary to be open about this identification. Openness and visibility for LGBTI people has helped break down traditional gender norms and led to greater variation in masculine positions. However, studies show that people outside the heteronorm still face challenges that affect their health negatively. Ill-health among transgender and non-binary young people is cause for concern, and shows that there is a need for greater attention to this matter.

A number of studies show that adolescents who identify as transgender or non-binary have multiple and complex health challenges. In addition, the number of young people and young adults suffering from gender dysphoria is increasing. A Swedish study (Durbeej et al., 2021) among teenagers shows that adolescents who identify as non-binary constitute a vulnerable group when it comes to mental health, but at the same time also exhibit a greater willingness to exert influence and be involved in municipal policy issues such as social policy development, education and training, municipal services and drug and alcohol policy than cis gender people (25.3% versus 38.0%). Adolescents who identify as non-binary have a higher risk of mental health problems and report more truancy than cis gender people (36.5% versus 49.6%) (see also Gisladottir, Gronfeldt, Kristjansson, & Sigfusdottir, 2018; Vehmas, Holopainen, Suomalainen, & Savolainen-Peltonen, 2022).

Personal accounts can provide significant insights into the dynamic and complex creation of sexual identities, providing valuable clues about the person’s vulnerabilities and strengths. The accounts of LBTQ individuals were investigated in a Norwegian study (Synnes & Malterud, 2019). The participants were of different ages and backgrounds. The study shows that they had all experienced minority stress related to their sexual orientation, with a significant impact on their identity, even when significant others were encouraging and supportive. These accounts indicate that personal resilience and sympathetic environments can support mental health and counteract the negative effects of these kinds of processes that contribute to minority stress such as heteronormativity and subtle microaggression.