Sociology of Health & Illness Vol. 31 No. 7 2009 ISSN 0141–9889, pp. 962–978
doi: 10.1111/j.1467-9566.2009.01170.x
Understanding adolescent mental health: the influence
of social processes, doing gender and gendered power
relations
Evelina Landstedt, Kenneth Asplund and Katja Gillander
Gådin
Department of Health Sciences, Mid Sweden University, Sundsvall, Sweden
Abstract
Despite a well-documented gender pattern in adolescent mental health, research
investigating possible explanatory factors from a gender-theoretical approach
is scarce. This paper reports a grounded theory study based on 29 focus groups.
The aim was to explore 16- to 19-year-old students’ perceptions of what is
significant for mental health, and to apply a gender analysis to the findings in
order to advance understanding of the gender pattern in adolescent mental
health. Significant factors were identified in three social processes categories,
including both positive and negative aspects: (1) social interactions,
(2) performance and (3) responsibility. Girls more often experienced negative
aspects of these processes, placing them at greater risk for mental health
problems. Boys’ more positive mental health appeared to be associated with
their low degree of responsibility-taking and beneficial positions relative to
girls. Negotiating cultural norms of femininity and masculinity seemed to be
more strenuous for girls, which could place them at a disadvantage with regard
to mental health. Social factors and processes (particularly responsibility),
gendered power relations and constructions of masculinities and femininities
should be acknowledged as important for adolescent mental health.
Keywords: femininity, masculinity, focus groups, mental health, gender
Introduction
This paper explores the interaction of social processes in adolescents’ everyday life and
mental health, focusing on the links between adolescent mental health, gendered power relations and constructions of masculinities and femininities.
Despite a well-documented negative trend and consistent gender pattern describing adolescent mental health, the knowledge base regarding possible explanations for these observations is limited, and there is a lack of research in which gender analysis is applied. There
is a growing consensus that, in general, mental health problems have increased among
youth over the past 20 years (Berntsson and Köhler 2001, Collishaw et al. 2004, Fombonne
1998). The World Health Organisation, among others, has highlighted adolescent mental
health as a significant public health issue (Kolip and Schmidt 1999). Poor mental health
during adolescence has negative consequences for adolescents and is a risk factor for mental
illness in adulthood (Aalto-Setälä et al. 2002, Fergusson and Woodward 2002). Existing
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Understanding adolescent mental health
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research, which is mainly quantitative, shows a distinct gender pattern after the age of 13
years; different problems afflict boys and girls, and girls generally report more mental
health problems than boys. Relative to girls, the situation for boys during adolescence is
more stable (Hankin et al. 1998, Torsheim et al. 2006, West and Sweeting 2003). Depressive
symptoms and anxiety are twice as common among girls as boys (Aalto-Setälä et al. 2002,
Ge et al. 1994, Hankin et al. 1998) and teenage boys score higher on self-esteem scales than
do girls (Tomori et al. 2000). In terms of suicide, mortality by suicide is higher among boys,
while self-harm and suicide attempts are more common in girls (Wannan and Fombonne
1998).
Explanatory models regarding gender differences in adolescent mental health have predominantly focused on individual factors, such as hormones or genetics (Angold et al. 1998)
or psychological characteristics (Nolen-Hoeksema et al. 1999, Piccinelli and Wilkinson 2000).
In contrast, sociological and public health research explore the relations between the social
circumstances that people live in and the risk of mental health problems (Horwitz 1999). Public health and socio-cultural health research has found that girls’ and boys’ different experiences and exposures in terms of stress, violence, cultural norms, workload, and high strain
may contribute to the elevated levels of mental health problems observed among girls
(Gillander Gådin and Hammarström 2005, Siegel et al. 1999, West and Sweeting 2003).
Gender-theoretical framework
Gender is conceptualised as an individual characteristic and a fundamental organisational
principle in society. Gender can be theorised as a social and cultural construction of sex in
diverse images of masculinities and femininities, and a power relation (Connell 2002). Structural patterns in these gender relations and positions construct a dynamic, yet consistent,
hierarchical structure in which men and boys collectively possess higher status, resources,
and power than women and girls. Gendered division of power at different societal levels is
characterised by dominance, coercion, advantage, as well as discursive expressions and
practices (Connell 1987). In contrast to the biological category of sex, gender is not something we have - it is something we do in social practice. Doing gender is a set of practices
informed by constructions of masculinities and femininities that are both shaped by, and
reshape, structures in society (Connell 2002, West and Zimmerman 1987). Although there
are multiple representations of femininity and masculinity, girls and boys are encouraged to
adopt dominant constructions and norms in terms of gendered beliefs and behaviours
(Paechter 2006).
The interaction between gender and health among adults has been explored regarding
gendered living conditions, such as division of labour, domestic violence, income, sexual
violence, risky behaviour, health-care systems, and the distribution of power and resources
(Annandale and Hunt 1990, Courtenay 2003, Doyal 2000). Studies on adults have suggested that gender inequality contributes to depressive symptoms in women and that it is
relevant to highlight the links between gendered power relations and mental health (Chen
et al. 2005, Stoppard 2000). According to Gillander Gådin and Hammarström (2005) only
a few studies have explored the interaction of power relations, gendered living conditions
and mental health in adolescents.
Aim
The aim of the study was twofold: (1) to explore what 16- to 19-year-old students perceive
as significant for adolescent mental health and (2) apply a gender analysis to the findings,
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and examine the interaction of gender relations, gendered living conditions and mental
health in adolescents.
Methods
The present study is part of a larger research project that also includes a questionnaire
study partly based on the present findings. Qualitative methods were chosen in order to
acquire a deeper knowledge about young people’s experiences (Patton 2002) The present
study relies on principles of constructivist grounded theory suggested by Charmaz (2005,
2006). The systematic, yet reflexive process of gathering rich data and performing the analysis were found to be appropriate, given the aim of the study. Furthermore, we acknowledge
that the analyses are social constructions; the abstracted understandings grounded in data
are contextually and theoretically situated and emerge from the researcher’s interactions
within the field and interpretations of the data (Charmaz 2005).
Focus groups
The choice of focus groups was motivated by the method’s potential, through discussions
and interactions in the groups, to generate rich data and to capture cultural norms and
shared experiences in a social context (Kitzinger 1994, Morgan 1996). We were interested in
the dominant discourses to which the adolescents related regarding mental health and the
living conditions that they believed influenced mental health. Furthermore, focus groups
may generate a feeling of confidence among the participants and reduce the power asymmetry in relation to the researcher (Kitzinger 1994).
Design and sample
The study was systematically designed to generate a reflexive process of data collection and
analysis. Participants were recruited from schools in six towns of various sizes in rural and
urban areas in a county of northern Sweden. All students in each school class approached
were asked to participate and the groups were self-selected, as discussed by Kitzinger
(1994). This implies that some of the groups were established peer groups.
In order to obtain broad variation in experiences, participants were recruited with the
goal of obtaining a sample with maximum variation (Patton 2002). At first, six focus
groups were recruited from a selection of school classes representing different age groups
and educational programmes (theoretical, vocational, male-dominated and femaledominated).
After initial analysis of data, theoretical sampling (Charmaz 2006) was used and recruitment of another three groups was carried out because of perceived gaps in the data or
issues we intended to further explore. We recruited, for example, additional groups from
theoretical educational programs and female-dominated school classes. Seven of the nine
groups were then interviewed a second time. Of the two groups that were not interviewed
twice, participants in one group declined further participation and the participants in the
second group declined for practical reasons. Follow-up focus groups made it possible to
revisit earlier discussions and gave the participants the opportunity to address additional
topics. In order to broaden the background of the participants and further enrich the data,
another 13 focus groups were carried out. Twelve of the focus groups were conducted with
male groups, 13 with female groups and four groups were gender mixed.
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Characteristics of the sample
The choice of single sex groups was based on two main arguments: first, as Morgan (1996)
argues, homogenous groups are preferable, as this facilitates a confident context. Secondly,
we assumed that the impact of asymmetric gender-based power relations would be less present in single sex groups than in mixed gender groups, as suggested by Gillander Gådin
(2002). The students were asked to form single-sex groups. We did not, however, intend to
exclude anyone who wanted to participate, and therefore included four mixed groups
according to the students’ requests. The focus groups comprised three to eight students.
The limited number of participants in the smallest groups occurred for practical reasons or
was a result of drop-outs. As described above, the total sample varied in terms of age and
socioeconomic and demographic characteristics. Specific personal data were not collected
on an individual level.
Procedure
The interviewer (EL) was a 27-year-old ethnic Swede who had experience working with
adolescents as a social worker. In approaching and interacting with the participants she was
sensitive to her position in terms of age, gender and socio-cultural aspects. The methods
used by the interviewer in an attempt to reduce expected distance and power asymmetry
included showing interest in the participants and in a responsive manner, adjusting her way
of speaking (e.g. wording of questions or accent).
The focus groups were conducted in the participants’ schools, lasted 60-120 minutes and
were tape-recorded and transcribed verbatim. In order to generate a common point of
departure for the following discussion, the participants were asked to reflect upon what they
thought about and associated with the concept of ‘mental health’. Following this, the question ‘what do you think is important for adolescent mental health?’ was asked. The discussions were intended to be broad, and centred on the topics raised by the participants. The
interviewer was guided by different themes such as friends, school, family, future plans, and
relationships. According to the principles of constructivist grounded theory (Charmaz
2006), the content of the discussions was to some extent adjusted as the study proceeded
and new insights regarding processes influencing mental health were achieved. Nevertheless,
the main structure of the discussions was consistent throughout the study.
Analysis
The material was initially read through several times in order to obtain a comprehensive
picture of the data. Line-by-line coding was then carried out to conceptualise ideas. Identified patterns or similarities influenced the focus of later focus groups as well as the coding
process. Consequently, a constant comparative method was developed early in the analysis
process to facilitate simultaneous involvement in data collection and analysis (Charmaz
2006). Preliminary broad categories were constructed by selecting relevant codes using a
process of focused coding. In order further to synthesise the data and deepen the analysis,
the properties of the categories were specified by axial coding. Focused interpretations
guided the theoretical coding in which the categories and the relations between them were
further scrutinised and specified (Charmaz 2006). The social interaction, performance and
responsibility categories were then revised and confirmed against the data by deductive
analysis.
As a final step of the analysis process, workshops were held with both teachers and
student groups in other settings. These discussions shed new light on the results as they
emphasised slightly different aspects. Yet, the outcome of these seminars confirmed the
appropriateness of the derived categories.
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Responsibility
Social interaction
Performance
Figure 1 A model of the three main categories and how they are interconnected. The interplay, which
is mainly expressed in the responsibility process, is illustrated by overlaps of the social interaction and
performance processes
Ethical considerations
The study was approved by the ethical research committee at Mid Sweden University as
being in accordance with ethical standards. Participants were given verbal and written information about the study and flyers with contact information in case they felt the need for
professional support. The participants were gently reminded to reveal only what they
desired to disclose in the discussions and to treat each other respectfully.
Results
Mental health was understood as an emotional experience and described as ‘how you
feel’ in terms of self-esteem, stress, confidence and experiences of humiliation. According
to the focus groups, mental health was mainly associated with negative aspects, distress
or illness. When discussing important influencing factors, the participants emphasised
the significance of social and psychosocial factors and circumstances, which in the analysis were conceptualised in three categories of dynamic social processes: (1) Social interaction; (2) Performance; and (3) Responsibility. The processes are constituted by
experiences, relationships, situations, circumstances, and actions jointly expressed by
both girls and boys. The dynamic dimension of each category is represented by a
continuum illustrating a range of positive to negative mental health influences. As illustrated in Figure 1, the categories are interconnected and the interplay is mainly
expressed in the process of responsibility, which is why it is presented at the end of the
findings section.
Social interaction
The social interaction process includes aspects such as good relations with others, respect,
interactions in peer groups, risk of receiving disrespectful treatment, and assault. As shown
in Figure 2, the subcategories represent positions of experienced mental health impact on
a continuum ranging from positive to negative influence. According to the participants,
various aspects of supportive relations with others contributed to good mental health, while
destructive social interactions such as assault and violence represent the negative mental
health influence. Joking – contradictory social interaction in the mid-section of the continuum – partly overlaps with the other two subcategories and includes situations, interactions,
and treatment by others that were ambiguously experienced as having both potentially positive and negative effects on mental health.
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Understanding adolescent mental health
Positive relations
with others
Joking contradictory
social interaction
967
Assault
Figure 2 A continuum illustrating the experienced mental health impact of the social interaction subcategories ranging from positive to negative influence
Positive relations with others
Both boys and girls emphasised the importance of positive, supportive relations with others
based on reciprocity, understanding, and respect.
If you didn’t have any friends, what would you do then? And my family, it’s important, and girlfriend and school mates.
The positive mental health outcomes of good relations with others were exemplified as happiness, self confidence and joy. Relationships with friends, family, teachers, and classmates
were expressed as fundamental for mental health. Such relationships were expressed as significant in terms of support, general company, and having someone with whom you could
talk. The participants underscored how mental well-being, to a large extent, depends on
trust, perceived respect, and appreciation for who one is: ‘It’s important to be well treated,
to be seen by others, and to have somebody to trust’.
Joking - contradictory social interaction
The subcategory of joking represents experiences of factors on the mid-section of the
mental health influence continuum. It comprises the contradictory situations and interactions of joking that were identified as having restraining consequences that may make
the person insecure in situations or among people they expect to be supportive.
Described as a rough language of jargon and actions, joking was seen as a behaviour
that would be considered rude or insulting outside the context of a peer group. The participants explained that joking was mainly a way of interacting, bonding, and defining
membership within a peer group. As mentioned above, having friends was linked to
good mental health. On the other hand, the content of the jokes could be mean and
potentially insulting, which could result in negative mental health-related feelings of
shame and humiliation. Hence, joking was expressed as sometimes contradictory and
restraining. According to some participants, joking could affect people mentally depending on how they already felt, as expressed by a 17-year-old boy: ‘I don’t care if somebody says something demeaning to me as a joke, but if you have low self-esteem and
are sensitive, it can be worse’.
Furthermore, although joking represents a method of peer recognition, it was described
as mainly practised by dominant boys targeting more submissive peers. Two girls discussed
their experiences of joking and how it made them feel unsure of themselves:
Anne: Joking can get out of hand.
Frida: Exactly, sometimes I don’t feel comfortable to take action against it ’cause I
can’t tell whether it was directed at me or not.... But people laugh so it’s a kind
of humiliation through humour. You don’t know whether to get angry or
laugh, but you still feel insulted.
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Assault
Negative aspects of social interactions include assault and disrespectful treatment by others.
Assault was exemplified by bullying, violence, threats, sexual harassment, injustice, and
social exclusion. Such forms of treatment and behaviour could be both direct, obvious
actions and more elusive forms of assault. One example of the latter was social exclusion,
the spreading of rumours, and comments in school hallways: ‘They [other girls] can make
loud comments about your clothes. They pretend to whisper but they want you to hear
what they say’.
According to the participants, assault was associated with mental health in terms of humiliation, worry, anxiety, fear, stress, and insecurity. It could also negatively affect mental health
via the potential for worsened school performance due to a loss of focus and self-worth.
The participants’ narratives showed that assaults were a part of their everyday life and
could influence their mental health regardless of whether they were directly exposed to it or
not. One girl shared her experience of a hostile environment: ‘I was not bullied, but I saw it
everywhere around me. You had to make yourself invisible to avoid bullying. I didn’t feel
safe there’. Another girl reflected on the risk of sexualised violence: ‘You know that you
can get raped. It can happen anywhere. It’s in the newspaper every week. I’m afraid’.
Girls and boys had somewhat different experiences of assault. Some boys said that various violent situations between boys were common. This does not imply that violence and
harassment were constantly present, but that they were events that the boys referred to as
part of their daily life. Both girls and boys perceived that girls were exposed more to sexual
harassment and sexualised violence. Sexualised and harassing name-calling was experienced
by both boys and girls, but the most commonly expressed scenario was that of boys harassing girls or other boys. In several groups, girls described incidents of pawing, name-calling,
sexual invitations, sexual rumours, grabbing of their genitals, and comments about attractiveness or sexuality. A 16-year-old girl explained her experiences: ‘I can never tell what
he’s going to be like. One day he’s the nice classmate, and another he’d threaten me and
grab me between my legs’. Sexual harassment and fear of sexualised violence were experienced as restricting girls’ space of action, as they avoided perceived risky situations or
areas.
Performance
Both girls and boys strived for respect and appreciation through various forms of performance, but this appeared to be particularly important for the girls. The presence and scope
of demands and expectations were highly relevant factors for mental health in relation to
both satisfaction and stress. Performance comprises achievements related to school and
leisure time activities, as well as expectations about appearance and behaviour. The latter
are conceptualised as ‘gender performance’ in this study: efforts to look and behave according to gender-specific norms. Performance processes were experienced as having both positive and negative impacts on mental health. As shown on the mental health influence
continuum (Figure 3), these were represented as encouraging success and demands.
Encouraging
success
Demands
Figure 3 A continuum illustrating the experienced mental health impact of the performance subcategories ranging from positive to negative influence
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Encouraging success
The positive aspects of the performance category can be summarised by the importance of
encouraging success in terms of reassurance and praise. Examples of this were reaching
goals, receiving compliments, or gaining appreciation and recognition for something they
had done. Both boys and girls emphasised the significance of positive results on exams or in
leisure time activities. Such encouraging success influenced mental health in terms of better
self-esteem, self-worth, confidence and happiness. Reassurance from teachers was expressed
as of great value. When discussing what can be done to improve adolescent mental health,
one boy burst out: ‘Give us more appreciation. Let us know when we do something good
or perform well.’
Regarding gender performance, the participants said that compliments and reassurance
about their attractiveness could be positive for their self-esteem and general mental health.
It could contribute to a feeling of confidence, as one girl explained: ‘Because, if you know it
[that you look good], you can relax, kind of’. The boys, however, appeared to pay less
attention to the importance of attractiveness, although a few boys mentioned it: ‘It makes
you happy if somebody gives you compliments about your looks, but I don’t care so much
about it’.
Demands
Experiences of stress, anxiety, and fear of failing in relation to demands, expectations and
workload were common. Such demands concerned leisure time activities, gender performance, popularity, and school achievements. Several students explained the difficulty associated with performing well in school when feeling low, and that pressure or disappointing
results could cause stress, shame, low self-worth and anxiety. Both boys and girls recognised that girls experienced greater pressure. The participants also expressed a close association between performance and self-confidence:
Jenny: I think girls put a greater pressure on themselves. Maybe it’s easier for guys
to feel confident....
Sara: Exactly, they get treated differently and learn that they are good, sort of….
Felicia: It feels like we have to prove we’re good all the time.
This gender pattern does, however, have exceptions. Some boys experienced stress and anxiety regarding demands related to school performance and leisure time activities. They were
afraid to disappoint their parents or themselves. In addition, it should be noted that not all
girls experienced great workloads or difficulties in finding time to relax.
Experiences of demands regarding gender performance were mostly mentioned by girls.
Some girls expressed expectations regarding how to look and behave as a girl: ‘I feel embarrassed if I am not pretty’. Boys also reflected on norms of girls’ appearance: ‘It seems like
girls often have bad self-esteem and feel bad about their bodies. TV and media put pressure
on them to all look the same. Guys don’t care about their looks as girls do’.
Gender performance was relevant in relation to expectations of how to behave and look.
Several girls used similar words to explain how they were very tired of being – and feeling
expected to be – pretty, nice, happy, and sweet. Gendered expectations about selfconfidence, possibilities, and hindrances were expressed as follows by an 18-year-old girl:
‘Girls are more reserved to say they have good self-esteem and like themselves. It’s easier
for boys to be pushy and say it. They want to be macho, sort of ’.
Despite the exception of one boy who said he could feel low when attending school
without first getting his hair done or wearing clothes that he liked, most boys neither
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experienced nor reflected on gender performance-related pressure as negatively affecting
mental health. On the other hand, both girls and boys described how norms, such as being
cool and macho, might negatively affect boys. For example, open expressions of feelings by
boys seemed to be perceived as potentially negative for mental health. One boy expressed it
thus: ‘Imagine crying at school, it would be horrible! I would be called a wimp for ages! It’s
like an unwritten rule for boys not to show their feelings’.
Some groups of girls discussed how boys who do not talk about their emotions might feel
even worse. According to the boys’ narratives, however, they were confident discussing their
feelings with close friends, families, or partners. Expressions of emotions in public situations
appeared to be unacceptable for boys and perceived as a risk factor for bullying or other
forms of negative responses.
Responsibility
According to the focus groups, reflections on the links between mental health and diverse
experiences of responsibility were common. The participants’ experiences, conceptualised in
the responsibility category, include integrated aspects of the social interaction and performance processes. This is illustrated in Figure 1 where these categories partly overlap the
responsibility category. Positive and negative aspects of the social interaction and performance processes can both reinforce and have easing effects on each other, which is exemplified in the subcategories. As observed with the other two categories of influencing
processes, responsibility is a dynamic process. The subcategories represent factors and
circumstances existing on a continuum shown in Figure 4, ranging from positive to negative
mental health influence.
Low degree of responsibility
The adolescents considered a low degree of responsibility-taking as being positive for mental health which they exemplified as confidence, independence and feeling relaxed. A low
degree of responsibility-taking was exemplified as ignoring or not responding to demands
and things for which one is expected to take responsibility. One boy illustrated it as: ‘Sometimes I let things pass when there’s too much to do at school. I just relax and hope for the
best.’ Both boys and girls said that boys took on less responsibility than girls. One boy
explained this behaviour as an old habit or a general societal trend: ‘Guys take less responsibility in society than girls. They have better self-confidence just because they are guys and
have been favoured. They kind of feel they are better.’
Some girls, on the other hand, expressed a wish to ‘let things go as they [boys] do’ so that
they could also feel more relaxed. Some girls discussed how less responsibility-taking
regarding achievements in school ‘would make it easier.’ It was, however, also perceived as
risky behaviour: ‘I wouldn’t feel that I did my best. I cannot take that risk’.
According to the quotes presented, confidence, which was previously presented as an
expression of good mental health, seems to be required for practising a low degree of
Low degree of
responsibility
Efforts to
obtain balance
Burden
Figure 4 A continuum illustrating the experienced mental health impact of the responsibility subcategories ranging from positive to negative influence
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responsibility-taking. Those who already feel confident may potentially feel less obligated to
take responsibility and can allow themselves to take on less responsibility. Hence, motives
for limited responsibility-taking may be grounded in experiences of receiving reassurance
without the need to constantly perform well in order to prove that they are good enough.
Future plans and expected financial status were also mentioned in relation to low degree of
responsibility-taking. One girl reflected upon experiences of gendered life circumstances:
‘Guys don’t have to study as much as we have to. They will get a better wage in the end
anyway’.
Efforts to obtain balance
The efforts to obtain balance subcategory clearly reflects the integration of social interaction and performance processes. The participants described how they took responsibility in
order to gain control of and find balance between different parts of their lives.
Tina:
Caroline:
Linda:
Caroline:
You are supposed to hang out with your friends and be a good student…
…and exercise…
…and work…
…and spend time with your boyfriend….
The informants did not consider this responsibility-taking a problem as long as they felt
they were in control and confident. Balance between positive and negative experiences of
social interaction and performance was of great importance for obtaining such control.
Many negative experiences regarding relations with others could be balanced by receiving
a corresponding amount of performance-related confirmation. On the other hand, low
self-esteem in relation to school performance could result in greater susceptibility to
assault and lack of social support. Efforts to balance these factors were expressed as
closely related to establishing priorities in life, priorities that seemed gendered and experienced differently by girls and boys. Some boys said that if they had to establish priorities,
they would prioritise their leisure time activities over homework. ‘School is important
because there’s where we are. But the leisure time is more important. It’s what I live and
long for’. In contrast, several girls maintained that they could not trivialise school: ‘I have
to set up plans when to see my friends. I hardly see them when there is too much to do in
school. One cannot skip homework’. The gender pattern in these matters was, of course,
not as simple as this description. There were stories told that reflected the opposite experience. Some boys, for example, said that they felt stressed when trying to balance their
responsibilities regarding school achievements, relationships and sports performance.
Burden
Responsibility was also experienced as burdensome and, thus, negative for mental health.
This was most commonly exemplified by experiences reinforcing negative effects of social
interaction and performance: ‘There is so much to take responsibility for. It can be hard if
you have problems at home or in school’.
The subcategory of burden is related to demands, which were previously presented in
the performance category. Demands, however, mainly concern those demands related to
achievements while burden also comprises pressure linked to relations with others. It
was relatively common among girls, and some boys, to experience stress and anxiety
due to many and high demands, as well as expectations to perform well and maintain
good relationships with their family, partner, and friends. Several girls experienced stress
and frustration as a consequence of their burdens: ‘I get stressed and irritated by all
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the demands and expectations but I don’t show it. I don’t want to drag others down.’
Experiences of guilt were also apparent: ‘It is not good if I put pressure on my boyfriend when I’m angry with my parents. I get aggressive sometimes and feel guilty
about it’.
Worry and anxiety about the future could increase responsibility in a burdensome way.
The students talked about how this produced feelings of guilt and inadequacy. Several participants expressed feeling of stress and pressure regarding their education, potential careers,
and economy-related issues. The following excerpt illustrates a discussion that occurred in
several female groups:
Anna:
There is so much I want to do, get a good job, family, house… there is not
enough time. I feel pressure from people around me, to see me grow up, be
successful, become the perfect wife with the perfect husband...
Jasmine: It’s so stressful! I want to have an education first and have kids before 30
and get married and…
As presented, responsibility is a complex social process that may be forced upon young
people and, therefore, experienced as controlling and stressful. However, responsibility was
not always perceived as burdensome as long as the participants felt in control of the situation.
Discussion
On the results
This study found that the dynamic processes of social interaction, performance, and responsibility were linked to adolescent mental health. In line with Horwitz’s (2002) reasoning we
highlighted the experienced positive and negative mental health-related consequences of the
social processes. Boys and girls underscored the same factors and conditions as being
important for mental health, but experienced them somewhat differently. Some findings are
in accordance with previous research investigating possible determinants of adolescent mental health: for example, the significance of peer and family support (Armstrong et al. 2000,
Kraaij et al. 2003), loneliness (Brage and Meredith 1994), pressure in school (West and
Sweeting 2003), and bullying and sexual harassment (Gillander Gådin and Hammarström
2005, Kaltiala-Heino et al. 2000). The forthcoming gender-theoretical interpretation of the
findings will focus on experiences of gendered power relations and doing gender, and how
it can be linked to adolescent mental health.
Experiencing gendered power relations
Within the field of public health research, positive health is widely known as being associated with beneficial status and power positions, while subordinated groups in terms of
poverty, ethnicity, gender, or socioeconomic status possess worse health status (Baum
2003, Brown and Harris 1978, Marmot 2007). The subcategories of assault, joking,
demands and burdensome responsibility comprise aspects of gendered power relations, as
conceptualised by Connell (1987). For example, violence and various forms of harassment
and assault can be considered as different means of exercising dominance and power
(Kenway and Fitzclarence 1997). Exposure to violence and harassment increases the
risk of mental health problems among teenage boys and girls (Schraedley et al. 1999,
Sundaram et al. 2004). In accordance with previous studies (Romito and Grassi 2007), our
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Understanding adolescent mental health
973
findings indicate that boys exercised more and experienced more physical violence and
verbal abuse (in terms of joking) than girls, who outlined more experiences of sexualised
assault. It appears that aggressive and abusive behaviour is a part of reconstructing
hierarchies and adjusting to cultural definitions of masculinity (Kenway and Fitzclarence
1997). The associations between power relations, masculinity, and health have been
explored by Courtenay (2003), who recognised the emotional and psychological costs of
the stress and violence needed to maintain male hierarchies among young boys. At the
same time, such practices provide tools to claim power, influence, and status, which have
been found to be associated with positive mental health (Courtenay 2000, Gillander Gådin
and Hammarström 2000).
Regarding girls’ experiences, apart from being victimised to a larger extent and an awareness of the risk of sexualised assaults, a greater negative influence on girls’ mental health
may be linked to their generally less empowered situation relative to boys (Gillander Gådin
and Hammarström 2005). With reference to the categories of performance and responsibility, both boys and girls expressed the view that boys are favoured in society and could benefit from their gendered position in terms of mental health. One possible illustration of
discursive power, as conceptualised by Connell (1987), is the process of responsibility.
Responsibility was experienced as controlling but also possible to reject by those, mainly
boys, who already felt confident and recognised, without the pressure of ‘proving’, their
worth. Hence, being a boy seems to imply fewer experiences of factors capable of eliciting
negative mental health, which, in turn, might strengthen boys’ position in terms of power.
The girls’ narratives mainly illustrate perceived disadvantages that might place them at a
greater risk for mental health problems.
Doing gender
In their gender performance, or doing gender as theorised by West and Zimmerman (1987)
and Connell (2002), the informants negotiated gendered expectations and norms by adjusting to or challenging dominant constructions of femininity and masculinity. Our findings
indicate that doing gender, in complex ways, could impart both benefits and disadvantages
in relation to mental health. Some girls expressed a complex balance between a desire and a
resistance to look and behave according to gendered norms and expectations. Adjusting to
a perceived widely-accepted practice of femininity was identified as a means of gaining reassurance, which they expressed as significant for mental health in terms of encouraging success. At the same time, the findings indicate that they experienced the practice of femininity
as demanding, controlling, and stressful, and thus as risk factors for mental distress. These
findings are consistent with a study performed by Tolman et al. (2006) discussing how
adjustments to stereotypical feminine ideals are culturally and socially communicated to
young women as strategies for success in society in terms of ‘passing’ as attractive and
respectable women. Such benefits, however, can be diminished by the perceived negative
mental health implications of adherence to femininity (Tolman et al. 2006). The wish to
‘pass’ might also be motivated by potentially negative experiences associated with crossing
norm and expectation boundaries. Polce-Lynch and co-workers (2001) identified lower selfesteem among girls who did not adhere to stereotypical feminine ideals regarding body
image. With reference to Connell (1987) and Stoppard (2000), the adoption of culturally
and socially dominant norms of femininity can also be seen as an adjustment to a less
powerful position which, as discussed above, is associated with a risk of mental health
problems.
The boys did not explicitly express negative feelings regarding gendered expectations
or gender performance. In contrast, girls and boys associated the practice of masculinity
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974
Evelina Landstedt, Kenneth Asplund et al.
with self-esteem, confidence, and positive mental health, as exemplified in the categories
of performance and responsibility. These findings are in line with those of Annandale
and Hunt (1990), whose study identified an association between femininity and
relatively poor health and between masculinity and relatively good health. As discussed
by Courtenay (2000), it appears that boys’ practice of dominant masculinity can promote positive mental health and strengthen boys’ position over girls and marginalised
boys.
Some boys did, however, mention potential negative responses (e.g. being ridiculed for
atypical masculine behaviours, such as expressing emotions). Consistent with Paechter
(2006) and Courtenay (2000), our findings indicate that crossing boundaries and distancing
oneself from hegemonic masculinity (as described in demands regarding gender performance) may imply giving up power and jeopardising their position in a male hierarchy,
which seemed to be a risk related to mental health.
In line with previous research (Polce-Lynch et al. 2001, Siegel et al. 1999), the boys in the
present study experienced fewer demands and less pressure regarding attractiveness than
girls. This can be protective against mental distress since a negative body image is associated with depressive symptoms and other forms of mental health problems among both
boys and girls (Allgood-Merten et al. 1990, Siegel et al. 1999).
The negotiation of dominant norms of masculinity and femininity was evident in experiences of performance-related demands. Girls seemed to negotiate a discourse underpinned by their own and others’ expectations of achieving good results. They seemed to
doubt their own capacity and expressed dissatisfaction with their accomplishments, which
both boys and girls recognised as negative for mental health. Crossing boundaries of
such achievement-focused femininity was expressed as risk-taking. In accordance with
these findings West and Sweeting (2003) discuss how educational stressors and pressure
to achieve and maintain a feminine identity might increase the risk for mental health
problems. In contrast, both boys and girls said that boys were confident and aware of
their advantage, although they practised less responsibility-taking. Boys seemed to experience a decreased need to perform well and did not express competing demands such as
future work-family balance. West and Sweeting (2003) reflect upon this in terms of a
‘laddish culture’, which, paradoxically, can protect against mental distress. Being a girl,
on the other hand, seems to imply greater responsibility-taking, which can be interpreted
as adjusting to the dominant constructions of femininity (Skeggs 1997). Understanding
responsibility as being a gendered phenomenon does not imply that all boys practise limited responsibility-taking and that all girls perceive it as burdensome. Our gender analysis
does, however, suggest that responsibility can be a disadvantage for girls and an advantage for boys in terms of mental health.
On the methods
The grounded theory approach and focus groups appear to have served the study well.
However, there are limitations to be discussed. We believe that self-selected single-sex focus
groups facilitated an open discussion. On the other hand, power relations and hierarchies
within the groups could have restrained some participants from speaking out or bringing
up certain topics. For example, the fact that discussions about gender performance-related
demands were rare in the male groups does not necessarily mean that the boys in the study,
or boys in general, never reflect on it. Discussing the disadvantages of being a boy can
perhaps be a sensitive issue and perceived as a risk in a group of boys. Another possible
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limitation associated with self-selected and single-sex groups is that the familiarity can imply
that some things are not discussed since they are taken for granted or are perceived as
potentially sensitive or taboo. As suggested by Morgan (1996), individual interviews are an
alternative way of accessing deeper and more personal experiences. Additionally, we are
aware that the participants’ experiences might have differed because of socioeconomic
status, sexual orientation, age, ethnicity, or other social positions and identities. Such
variations were not extensively investigated in this study. Regarding single-sex groups, we
observed that the discussions in the gender-mixed groups were less relaxed and deep in
comparison with the single-sex groups. Despite the presented limitations, we argue that
utilising self-selected single-sex groups was a suitable method for the aims of the study.
Research bias may have been unintentionally communicated to the adolescents. We do,
however, believe that the interviewer’s awareness and experience of working with adolescents may have contributed to a trustful atmosphere. Furthermore, in accordance with
Kitzinger (1995), we argue that the use of focus groups was an appropriate method since the
discussions provided the researcher time to acclimatise to the participants’ ways of speaking.
Regarding the size of the groups, our experience was, in line with the reasoning of Morgan
(1996), that having few participants in the groups was appropriate, given the somewhat
sensitive topics discussed. The largest groups, comprising eight participants, experienced
greater difficulties in terms of interaction and the possibility of all members’ participation.
Based on the description provided of the settings and methods used, the reader can judge
the transferability of the study, as discussed by Seale (2002). In addition, the transferability
is strengthened by the fact that some of the findings are consistent with previous research.
Hence, we believe that the findings could be transferable to young people in similar contexts. One issue to be considered is whether the results and conclusions would be applicable
in other settings, for example, a bigger city or a rural area. A follow-up questionnaire
study, which was partly inspired by this study, will make it possible to quantify some of the
results obtained herein, and thus further assess their generalisability.
Conclusions
The present study suggests a model in which significant factors for adolescent mental health
are represented by the dynamic processes of social interaction, performance, and responsibility. There was a gendered pattern associated with experiences of positive and negative
aspects of these processes where girls experienced more negative aspects. Experiences of
responsibility seem to play a significant role, and further investigations regarding the interaction between responsibility, gender, and mental health are needed. In order to better
understand the gender pattern in adolescent mental health, it is necessary to highlight the
impact of experiences of gendered power relations and the ways in which young people do
gender through constructions and reconstructions of femininities and masculinities. The
present study sheds new light on how girls and boys experience disadvantages and benefit
from their positions and practices, and how this can influence mental health. Boys’ experiences of gendered power relations, for example, are likely to be beneficial for their mental
health. Negotiating cultural norms of femininity and masculinity seemed to have more negative consequences for girls, which might place them at a greater risk of mental health
problems.
In addition, qualitative methods have the potential to generate valuable knowledge based
on the adolescents’ own perceptions and experiences of complex relations and social phenomena. Finally, health promotion programmes aimed at reducing inequities in adolescent
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Evelina Landstedt, Kenneth Asplund et al.
mental health should acknowledge the influence of gender relations, as well as social and
psychosocial factors.
Address for correspondence: Evelina Landstedt, Department of Health Sciences, Mid Sweden University, Holmgatan 10, Sundsvall 85170, Sweden
e-mail: [email protected]
Acknowledgements
We thank the County Council of Västernorrland for financial support. We also thank the staff at
the participating schools for their co-operation and valuable support. Finally, we are sincerely
grateful to all participants for sharing their experiences and thoughts.
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