I will first give some background on the post title. The oath of Hippocrates is an ethical code formulated in ancient Greece that describes how a doctor/medical professional should engage with his/her patients. Obviously, the original document is no longer applicable to Western medicine, however modern interpretations of this oath still hold an important role in Western medicine, and most medical students are taught some modern version of this oath. You can read more about it here: https://en.wikipedia.org/wiki/Hippocratic_Oath

The following modern interpretation is an example that comes from a philosophy book written in 1987, the one I put in bold are the ones that I think were violated by the guidelines:

Source: Bulger, R. A dialogue with Hippocrates and Griff T. Ross, M.D. In Bulger R, ed. In Search of the Modern Hippocrates. Iowa City: University of Iowa City Press; 1987:253.

In this post, I claim that the APA guidelines on men and boys, violate the modern version of this oath, and that they give men a rational reason to distrust therapy and mental healthcare.

Link to the APA guidelines: https://www.apa.org/about/policy/boys-men-practice-guidelines.pdf

There is a commentary on youtube about them by someone who works as a therapist and a researcher in psychology:

https://youtu.be/Dx8SMZeyXUw?si=1Ry3ghupequdLkXI

After the guidelines were released multiple academics working in the field of psychology called out the document as harmful, for example:

https://www.christopherjferguson.com/Men%20and%20Boys%20Guidelines.pdf

This paper argues the following points:

1)The guidelines overstated the harm of traditional masculinity:

One early meta-analysis (Whitley, 1985) suggested somewhat complex relationships, with masculine traits overall associated with positive mental health outcomes for both men and women. One more recent meta-analysis, cited in the guidelines (Wong et al., 2017) found only weak associations between traditional masculinity and either negative or positive mental health outcomes, with most bivariate effect sizes well below the r = .20 threshold sometimes advocated for interpreting a finding as practically or clinically significant (Ferguson, 2009). Bivariate effect sizes generally overestimate the strength of evidence as they lack theoretically relevant controls. A request for the raw data for this meta-analysis was, unfortunately, not returned. As such, it was not possible to verify the results of this meta-analysis, nor conclusively examine for publication bias. Another meta-analysis examining masculinity and PTSD (Kaiser et al., 2020) conceded that, for some outcomes, relationships became non-significant when controlling for confounders. They didn’t report effect sizes for multivariate relationships, so it was difficult to ascertain whether other effect sizes had been reduced to triviality even if remaining “statistically significant”. The authors also seemed to suggest that studies applying theoretical controls were quite uncommon. The current article reanalyzed the data from this meta-analysis using the basic effect size data in their Table 1.8 Using Comprehensive Meta-analysis, results indicated some publication bias, reducing the observed effect of (random effects) r = 0.215 to about 0.195. Rean alyzing the results with p-checker in ShinyApps with the PET/PEESE procedure, suggested publication bias adjusted the effect size down to .158. It must be recalled that these are bivariate effects, and it appears from the author’s narrative that including theoretical controls reduces this effect size further. As such, these effects are not strong evidence for the hypothesis traditional masculinity impacts PTSD rates. There are reasons to think that such weak effect sizes, particularly based on bivariate correlations, likely are an upwardly biased source of evidence. First, as noted, the inclusion of theoretically relevant controls appears to reduce these effect sizes. Second, demand characteristics are likely evident in many of the studies. It is likely obvious from questions being asked what the hypothesis of the study is in many cases. Such demand characteristics coupled with single responder bias (Baumrind et al., 2002) can inflate effect size estimates. Third, the researchers’ own expectancy biases can inflate effect size estimates.

But how strong is the evidence linking traditional masculinity to negative outcomes? The practice guidelines do cite a large number of articles (albeit more often reviews than original studies) in support of their conclusions. However, this raises several important questions. First, what were the effect sizes of these studies (particularly controlling for other variables)? Second, what was the internal and external validity of these studies? Third, is their evidence for publication bias or researcher expectancy effects? In this regard, the current article focused initially on several metaanalyses which appeared relevant, although they were few in number.

One early meta-analysis (Whitley, 1985) suggested somewhat complex relationships, with masculine traits overall associated with positive mental health outcomes for both men and women. One more recent meta-analysis, cited in the guidelines (Wong et al., 2017) found only weak associations between traditional masculinity and either negative or positive mental health outcomes, with most bivariate effect sizes well below the r = .20 threshold sometimes advocated for interpreting a finding as practically or clinically significant (Ferguson, 2009). Bivariate effect sizes generally overestimate the strength of evidence as they lack theoretically relevant controls. A request for the raw data for this meta-analysis was, unfortunately, not returned. As such, it was not possible to verify the results of this meta-analysis, nor conclusively examine for publication bias. Another meta-analysis examining masculinity and PTSD (Kaiser et al., 2020) conceded that, for some outcomes, relationships became non-significant when controlling for confounders. They didn’t report effect sizes for multivariate relationships, so it was difficult to ascertain whether other effect sizes had been reduced to triviality even if remaining “statistically significant”. The authors also seemed to suggest that studies applying theoretical controls were quite uncommon. The current article reanalyzed the data from this meta-analysis using the basic effect size data in their Table 1.8 Using Comprehensive Meta-analysis, results indicated some publication bias, reducing the observed effect of (random effects) r = 0.215 to about 0.195. Rean alyzing the results with p-checker in ShinyApps with the PET/PEESE procedure, suggested publication bias adjusted the effect size down to .158. It must be recalled that these are bivariate effects, and it appears from the author’s narrative that including theoretical controls reduces this effect size further. As such, these effects are not strong evidence for the hypothesis traditional masculinity impacts PTSD rates. There are reasons to think that such weak effect sizes, particularly based on bivariate correlations, likely are an upwardly biased source of evidence. First, as noted, the inclusion of theoretically relevant controls appears to reduce these effect sizes. Second, demand characteristics are likely evident in many of the studies. It is likely obvious from questions being asked what the hypothesis of the study is in many cases. Such demand characteristics coupled with single responder bias (Baumrind et al., 2002) can inflate effect size estimates. Third, the researchers’ own expectancy biases can inflate effect size estimates.

2)The guidelines ignore evidence for biological inputs into gender identity and masculinity

Guideline 1 of the guidelines states that “Psychologists strive to recognize that masculinities are constructed based on social, cultural, and contextual norms.” However, it is not clear that this guideline is based in careful, nuanced, and objective analysis of the complex data on gender identity and masculinity, as opposed to an ideological statement of sociopolitics. This section of the narrative presents masculinity as entirely socially constructed, particularly as part of systems of oppression. The issue of gender identity is a very complex one, but also a politicized one. It is not uncommon to hear refrains such as “gender is a social construct” which reflects a sociopolitical worldview rather than a scientifically well-established fact. Although it is beyond the scope of this paper to review this evidence in detail, considerable evidence points to neurological processes underpinning gender identity, particularly as related to the hypothalamus (e.g., Berglund et al., 2008; Garcia et al., 2011; Savic et al., 2017). Exposure to sex hormones in utero appears to play a key role in the development of gender identity (Roselli, 2018) as well as traditionally masculine behavior (Auyeung et al., 2009). I note here the distinction between sex, which I refer to as a propensity to produce gametes (sperm or ova) whereas gender identity is one’s own sense of being male and female. Although many make a distinction of one (sex) as biological the other (gender identity) as social, the data appear to indicate that, in fact, both have significant biological inputs that must be understood in any discussion of gender. Likewise, for issues of traditional masculinity (whether in boys or girls), evidence suggests significant hereditary components (e.g., Knafo et al., 2005; Verweij et al., 2016) as well as for stereotypical gender-role expectations (e.g., Cai at al., 2016). To be clear, the point is not that sociocultural factors play no role in the development of traditional masculinity. Rather that the development of traditional masculinity involves complex interactions between biological and environmental factors and the guidelines clearly missed an opportunity to discuss these fully. That the guidelines chose to ignore these data altogether, pre senting masculinity as defined entirely (if by omission) by sociocultural factors, is a significant exclusion. Withholding this information does not help clinicians understand masculinity in a broader biosocial context. By presenting masculinity as the consequence of oppressive gender norms imposed by society, the guidelines also encourage therapists to chal lenge and undo traditional masculinity in patients who express it. This opens up a tricky line of thought insofar as it may implicitly give permission to therapists to enforce their own sociopolitical worldviews as they relate to the politics of gender onto patients when this may not be advantageous to the patient’s therapy

3)Deemphasis on male agency

Much of the narrative of the guidelines portrays men as buffeted and shaped by social forces outside their control, inherently lacking agency and victimized by these forces. The quote on page 7 “By the time he reaches adulthood, a man will tend to demonstrate behaviors as pre scribed by his ethnicity, culture, and different constructions of mascu linity” is an exemplar of this phenomenon, though such language is common throughout the document. Such language arguably infantilizes men and encourages the therapist to see their goal as fixing masculinity or changing men in ways that are desired by the authors of the guide lines but may not be consistent with the treatment goals of men them selves as they seek therapy. This approach also causes the guidelines to make basic errors of fact and to otherwise engage in speculation without solid data. For instance, the authors claim (page 15) that media and violent media specifically reinforce linkages between traditional masculinity and aggression. However, recent research, particularly from preregistered open science studies, has called into question any link between media violence and aggression (e.g., Drummond et al., 2020; Savage & Yancey, 2008). Nor does there appear to be a solid basis to suggest masculinity is shaped by media in any non-trivial way (the sources cited by the guidelines are two non-empirical books). This statement would greatly benefit from sup port from preregistered, open science studies with non-trivial effect sizes, which appears to be entirely lacking. At one point (page 7) the guidelines claim “African American boys and men who feel they cannot abide by hegemonic masculinity standards construct standards of their own, which can take the form of gang behavior, cool pose, and unique dress codes” a highly speculative and potentially racist claim that Black American boys so aspire to and envy White masculinity that they turn to gangs or ethnic dress to compensate. In most cases of therapy, helping clients achieve a sense of agency, including direction over therapeutic treatment goals themselves, is a key element. It is not implied that the authors of the guidelines had any intent to work against this. However, the language throughout the guidelines appears to suggest male clients may be unaware of social forces influencing them, replacing these social forces with ideologically driven goals that may neither be desired by the male client, nor even in their best interest. For instance, on page 7, the authors invite clinicians to administer self-report surveys such as the Male Role Norms Inventory, the Male Role Attitudes Scale, or the Conformity of Masculine Norms Inventory in order to “… discover the benefits and costs of their gendered social learning …” However, though often used in research, the clinical utility and validity of these scales is unclear for use in practice. The guidelines appear to place exploration of the meaning of masculinity at the center of therapy, though it is unclear under what circumstances therapists should do so. Given how central this argument is to the guidelines (in fact central to Guideline 1), it is unclear whether this guideline is truly in the best interest of the male client or the un doubtedly good-faith social engineering project of the authors themselves. In some cases, of course, male clients may want to explore the meaning of masculinity. But no data is provided to suggest this is a common concern among male clients. Nor is there any consideration of when such goals may cause harm (particularly if the therapist adopts a rigidly non-traditionalist conception of masculinity) or may simply distract from treatment goals the client is actually concerned about. As such, the argument is that a.) therapists should allow clients to take the lead on expressing whether they want to consider masculinity as a construct as part of their therapy and b.) therapists should be aware of any biases they may hold regarding traditional masculinity.

4)Stereotyped and prejudicial language

Guideline 1 begins by stating, “Clinician awareness of one’s stereo types and biases against boys and men is a critical dimension of multi cultural competence.” This is, of course, entirely true. However, the guidelines themselves arguably are filled with stereotyped and hostile depictions of traditional masculinity that contradict this worthwhile statement. It is this issue that may actually dissuade many men and boys (and their families) from seeking treatment even if they might otherwise have benefited from it. Arguably, much of the language in the guidelines describes tradi tional masculinity as something almost monstrous. For example, page 10, “Additionally, traditional masculinity ideology encourages men to adopt an approach to sexuality that emphasizes promiscuity and other aspects of risky sexual behavior … Indeed, heterosexual men’s adher ence to traditional, sexist aspects of masculinity has been connected to sexual assault perpetration.” The guidelines sometimes add the word sexist in as a qualifier, although this is likely to appear as a descriptor of “traditional” rather than a unique category distinct from traditional masculinity. Arguably, most traditional men would be surprised to learn that they are more likely to endorse sexual assault, transmitting STDs, unplanned pregnancies, the perpetration of hate crimes, and causing depression in their life partners. Nor is the evidence presented by the C.J. Ferguson guidelines in regard to these claims persuasive, built mainly as it is on self-report surveys, sometimes of college students, with few controls for unreliable responding, weak effect sizes and absence of preregistration or other open science practices, though the guidelines also generally cite non-empirical reviews more than is perhaps desirable. Another concern is that some of the studies cited by the guidelines confuse traditional masculine values with gender role conflict which is specifically negative (e.g., Breiding et al., 2008). We might reasonably expect dissatisfaction with one’s performance in one’s gender role to correlate with negative outcomes, but this is distinct from the suggestion that traditional male values are associated with negative outcomes. The failure of the guidelines to make this distinction appears critical. Not including the references, “violence” is mentioned 37 times in the 20-page guidelines (“violent”, a further 14 times). Naturally, violence is an important issue to consider given that men are overrepresented both as perpetrators and victims of violence. However, the topic of violence is not dealt with in a specific section but returns throughout the guidelines. Though likely unintentional, this reinforces the stereotype of men and traditional men specifically as inherently violent, even as the guidelines do try to clarify that not all men are violent. The guidelines, when talking about domestic violence, largely portray this issue as male per petrators and female victims, once again ignoring considerable data that, in this specific realm, evidence suggests gender parity in incidence and motivation of perpetration (Desmarais et al., 2012). Even if the authors don’t accept the evidence for gender parity at face value, it is certainly true that men are sometimes abused by female partners. By ignoring this, the guidelines enforce, rather than detract from, gender stereotypes in ways likely to harm male clients, particularly those whose abuse victimization may be waved off as inconsequential due to this stereotyping. One defense of this approach is that the guidelines are not discussing men as individuals but rather operationally defined constructs such as “traditional masculine ideology.” Yet, this argument is a selective abstraction that would likely be unsatisfying were such constructs applied to other identities involving race, gender, sexual orientation, etc. Further, if a construct such as traditional masculine ideology is problematic, individuals identified as high in this construct have the potential to be stigmatized and stereotyped with significant potential to cause harm. And individuals in the general public are unlikely to be alert to the selective abstraction, differentiating between individuals and constructs.

5)Narrow theoretical/ideological focus

One of the concerns that emerged from the controversy in January 2019 was that the theoretical focus of the guidelines too narrowly derived from feminist and intersectional theory. This perception did not appear to be strongly disputed by either the APA or the guidelines au thors. This raises several questions, specifically the degree to which practice guidelines should hew to a specific sociopolitical worldview, the degree to which a single theoretical perspective should be prioritized over others, and whether feminist-informed therapy is the best modality for clinical work with men and boys. Perceptions that the guidelines were constructed under feminist theory could be inaccurate. To gain clarity on this issue, four of the five main authors of the guideline draft were contacted. Their responses varied somewhat but, overall, appeared to confirm that feminist and intersectional theory provided the main theoretical structures for the guidelines. In sensitivity of saving space, I have made the personal communications available at: https://osf.io/g946y/ This returns us to the question of whether it is wise for practice guidelines to hew to a single theoretical worldview. The answer is that if there is a solid bank of research (particularly preregistered, open science research with non-trivial effect sizes) to support a particular theory or therapeutic modality over others, then this may be justified. However, the guidelines provide no evidence to suggest that viewing therapy for men and boys through a feminist/intersectional lens is superior to other worldviews, therapeutic modalities or even a theory-neutral approach. The opposing concern is whether viewing therapy with men and boys mainly through a feminist/intersectional lens may cause harm to men and boys. This may occur in two ways: first, by misinforming therapists such that they focus on treatment goals and modalities that are not consistent with the needs of their male clients (as opposed to larger sociopolitical views) and second, that adherence to a single worldview may discourage many male clients from seeking therapy in the first place. The guidelines may unintentionally promote stereotypes of men and traditional men in particular. The guidelines may also generally come across as an ideological rather than as a therapeutic or scientific document. For instance, the guidelines, at least 4 times, refer to either society or masculine role norms as “patriarchal”. The word privilege appears 13 times (not including references) in the guidelines. Some version of “intersectional” appears approximate 8 times (not including references) in the guidelines. Arguably, this puts a lot of pressure on clinicians to see men and boys through these lenses. However, it is un clear that, say, the out-of-work coal miner, struggling to provide for his family and feeling suicidal is going to benefit from a discussion of his privilege, or an examination of how patriarchy has shaped his perceived role in the world. This is not to say there is a clear linear relationship between biological maleness and traditional masculinity, far from it. But there is little evidence that the approaches advocated in the guidelines would be useful for the very real concerns of men, whether traditional or not. At very least, for practice guidelines to have such a narrow theo retical focus, clear empirical work should be provided that would sup port this focus. Unfortunately, that is not yet forthcoming. Once again, this raises the question of who the guidelines are for … men and boy clients or those who earnestly wish to reshape society around a feminist/ intersectional perspective. The other issue is whether the wording of the guidelines is likely to dissuade men and boys (and also many women and girls) from seeking therapy because the guidelines will suggest therapists find allegiance with a worldview at odds with patients’ own. One potential irony of the guidelines is that they appear to highlight traditional men as particularly needing therapy, yet do little to either attempt to understand, speak to, or express an attempt to understand the traditional worldview (and by doing so, arguably violate their own first guideline). It was foreseeable that the wording of the guidelines would be received poorly by many individuals, particularly more traditional in dividuals, perhaps sabotaging the very intent of the guidelines to pro vide better services for men and boys.9 The controversy that erupted in January 2019 was quite predictable as is the perception that this con troversy likely has resulted in less trust among men, particularly tradi tional men, and less help-seeking behavior by the same. Again, to be clear, it is not meant to entertain the notion that the authors had any thing but good faith, a desire to present their worldview honest and earnestly, with the hopes of helping as many men and boys as possible. However, it’s also time to acknowledge that the guidelines have likely done more harm than good and should be immediately reassessed.

I'm arguing that these issues with the guidelines, violate the ethical principles I earlier highlighted in bold. The use of ideology and stereotypes instead of science-based medicine undermines the competency of the healthcare professional, and interferes with the best interest of the patient. Furthermore, the focus of these guidelines fails to appreciate the different value systems of male patients and instead turns therapy into conversion therapy, where patients need to be converted into the value system of the therapist, rather than focusing on the wellbeing of the patient. It is intirely unsuprising that this alienates potential male patients, or male patients that are just starting therapy for the first time, thus exacerbating existing mental health issues in the male population.

As long these kinds of attitudes are so pervasive that they can be published by the most important and official organisation of psychology in the US and stay up for multiple years, men avoiding therapy can be seen as a rational decision to protect their own wellbeing and unless this is adressed, saying American men don't seek help is just a deflection from the real problem.

Edit: some parts of the post suddenly disappeared and are restored