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1University College London, WC1E 6BT London, UK
2Barnet, Enfield and Haringey NHS Mental Health Trust, NW1 0PE London, UK
*Corresponding Author(s):taanvi.ramesh@nhs.net (Taanvi Ramesh)
| History | Submitted: 30 July 2023 | Accepted: 04 September 2023 | Published: 30 December 2023 |
| Copyright: | ©2023 The Author(s). Published by MRE Press. |
Men’s prisons are theorised to perpetuate, if not heighten, masculine ideals. Research indicates that prisoners have high rates of mental health difficulties, but treatment uptake is low. This empirical study aimed to understand the prevalence of conformity to masculine norms amongst prisoners and how this shapes, and relates to, experiences of psychological distress and help-seeking. We hypothesised that conformity to masculine norms would be negatively correlated with help-seeking intentions and positively correlated with psychological distress. A mixed-methods approach was used with prisoners recruited from a Category C men’s prison in the UK. In Part 1, 109 prisoners completed three questionnaires assessing conformity to masculine norms, psychological distress and help-seeking intentions. Correlation analyses and group comparisons were conducted to determine associations between variables. In Part 2, semi-structured interviews were conducted with 6 prisoners who participated in Part 1. Reflexive thematic analysis was used to develop themes and sub-themes to understand how masculinity shapes experiences of distress and help-seeking in prison. As hypothesised, Part 1 found a negative correlation between conformity to masculine norms, particularly Emotional Control, and help-seeking intentions, as well as a positive correlation between conformity to masculine norms and psychological distress amongst prisoners. Thematic analysis in Part 2 highlighted themes of Holding it in, Image and perception and Control for prisoners. These findings support the understanding of prisons as environments where masculinity is performed, highlighting a distinction between public and private spaces where individuals’ conformity to masculinity is performed differently and highlighting some spaces where expression of vulnerability is permitted. Findings are discussed in relation to previous research, highlighting clinical implications and future directions for research.
Cite this article
Taanvi Ramesh, Michael Mercieca, Helen Valerie Curran, Jarrod Cabourne. Exploring masculinity, experience of distress and help-seeking within a UK male prison.Journal of Men's Health,2023,19(12):87-98 DOI:10.22514/jomh.2023.134
1. Introduction
Research has consistently found that men within the general population are significantly less likely than women to receive treatment for mental health difficulties [1, 2, 3]. While the reasons for reluctance to help-seek are multifaceted [4, 5], research has consistently found that there is an association between conformity to masculine norms and reluctance to seek help for psychological difficulties [6, 7], as well as an association between conformity to masculine norms and increased psychological distress [8, 9].
R. W. Connell characterizes four types of masculinities, one of which is hegemonic masculinity, defined to be the idealized pattern of masculinity in patriarchal societies, whereby men are positioned as dominant and women as subordinated [10]. As hegemonic masculinity denotes an unequal gender relationship [11], in Western society, it is typically characterized in opposition to femininity, resulting in the endorsement of a lack of emotional expression and concealment of psychological distress to avoid being seen as weak. Masculine socialization toward stoicism, interpersonal dominance, and self-reliance often leaves men ashamed of, and resistant to, being vulnerable and seeking help for psychological difficulties [12].
Although prisons may reflect the cultural and social norms of their “host society” [13], characteristics of the prison environment itself (e.g., a single-sex environment governed by a rigid regime) also results in a particular manifestation of these norms [14]. Prisons housing men are recognized to be environments underpinned by ideologies and discourses endorsing hegemonic masculinity [15]. Although in a men’s prison, dominance over women is less salient, hegemonic masculinity also acknowledges dominance in relation to other men [11]. Within the framework of hegemonic masculinity, there exists a hierarchical structure of masculinity where men who embody certain valued traits are considered superior to those who do not, leading to the marginalization of men who do not conform to these norms. The perpetuation of adherence to hegemonic masculinity is acknowledged to be facilitated not only through the hierarchical structure within the male prison population [16], but also preserved by the actions and behaviour of staff within such settings [17]. While research has highlighted that there may be a more nuanced picture of masculinities that contribute towards men’s help-seeking behaviours in relation to health [18], the specific context of the prison environment may be one where norms associated with hegemonic masculinity are a more salient influence on health help-seeking behaviours.
Research highlights the elevated rates of mental health difficulties among prisoners compared to the general population—male prisoners are significantly more likely than men in the general population to experience psychosis, depression, comorbid substance misuse disorders, Post-Traumatic Stress Disorder or have a Personality Disorder diagnosis [19, 20, 21]. However, considerable evidence suggests low rates of identification or treatment of these difficulties [22, 23].
The conceptualization of men’s prison environments as those that endorse and perpetuate hegemonic masculinity, may be of relevance when considering why male prisoners with mental health difficulties seldom access and receive treatment. This study’s overarching aim was to explore whether living in an environment that perpetuates, or at least does not actively discourage, ideologies of emotional suppression and self-reliance (not solely for the purpose of acceptance but also for the purpose of protection) could have a significant impact on men’s help-seeking behaviour in relation to psychological distress. A mixed-methods approach was employed in order to first understand the prevalence of adherence to norms of hegemonic masculinity and how this correlates with self-reported distress and help-seeking, to establish if similar patterns exist to those found in research conducted with populations outside prisons (Part 1), followed by a more in-depth exploration of the enactment of hegemonic masculinity within the prison environment in relation to managing psychological distress and seeking help for this (Part 2).
For Part 1, on the basis of Mahalik, Wong and colleagues [6, 7], we hypothesised that there would be a negative correlation between conformity to masculine norms and likelihood of help-seeking amongst male prisoners, meaning that prisoners conforming more with masculine norms would be less likely to seek help for emotional difficulties.
On the basis of Wasylkiw, Shea and colleagues [8, 9], we also hypothesised that there would be a positive correlation between conformity to masculine norms and self-reported psychological distress amongst prisoners, indicating that prisoners conforming more with masculine norms would experience higher levels of psychological distress.
For Part 2, the overarching research question was “How does masculinity shape experiences of psychological distress and help-seeking within a prison environment?”.
2. Methods
2.1 Setting
This research was conducted between August 2021 and March 2022 in a UK Category C men’s prison for adult male sentenced prisoners, during the Covid-19 pandemic.
2.2 Part 1
Part 1 of the study was cross-sectional, with quantitative data collected at a single time-point.
2.2.1 Participants
Participants were recruited through a combination of voluntary sampling and opportunistic sampling. All prisoners within the establishment were invited to participate to aim to get a representative sample. Additionally, in order to maximise participation, questionnaires were distributed to prisoners while they were in the Healthcare waiting room. 121 male prisoners took part in the study. 12 respondents were excluded due to missing data, resulting in 109 participants, with a mean age of 41.5 years old (Standard Deviation (SD) = 12.2, Range = 20–77 years). The majority of participants reported their ethnicity as White (69.7%, n = 76) and most respondents (78.7%, n = 37) reported being sentenced for only one offence. See Table 1 for details of prisoner participant demographics.
| Variable | Prisoners | |
| Participants (n) | 109 | |
| Age (yr) | ||
| M (SD); Range | 41.5 (12.2); 20–77 | |
| Wing—N (%) | ||
| Main Residential Wings | 24 (22.0%) | |
| Enhanced Prisoners Wing | 12 (11.0%) | |
| Substance Use Rehabilitation Wing | 14 (12.8%) | |
| Vulnerable Prisoners Wing | 59 (54.1%) | |
| Ethnicity—N (%) | ||
| White | 76 (69.7%) | |
| Black | 15 (13.8%) | |
| Asian | 8 (7.3%) | |
| Mixed/Multiple | 6 (5.5%) | |
| Other Ethnic Group | 1 (0.9%) | |
| Not reported | 3 (2.8%) | |
| Number of Offences—N (%) | ||
| 1 | 37 (78.7%) | |
| 2 | 7 (14.9%) | |
| 3 | 0 (0.0%) | |
| 4 | 3 (6.4%) | |
| Type of Offence—N | ||
| Theft Offences | 15 | |
| Drug-Related Offences | 14 | |
| Sexual Offences | 11 | |
| Violent Offences | 11 | |
| Weapons-Related Offences | 4 | |
| Vehicle-Related Offences | 3 | |
| Recall | 2 | |
| Other | 3 | |
| Time in custody so far (mon) | ||
| M (SD) | 22.4 (23.1) | |
| Range | 1–93 | |
| Time at current establishment (d) | ||
| M (SD) | 144.8 (186.3) | |
| Range | 1–997 | |
| Time left in custody (mon) | ||
| M (SD) | 7.2 (5.4) | |
| Range | 1–33 | |
| SD: standard deviation. |
2.2.2 Measures
Participants completed a demographics questionnaire and three self-report questionnaires measuring constructs of masculinity, psychological distress, and help-seeking intentions.
The most widely used and well-validated measures assessing constructs related to masculinity fall into three categories: (1) those assessing role conflicts and stressors associated with masculinity (e.g., Gender Role Conflict Scale [24]), (2) those assessing agreement with traditional male norms (e.g., Male Role Norms Inventory [25]), and (3) those assessing personal adherence to norms of hegemonic masculinity (e.g., Conformity to Masculine Norms Inventory [6]). For this study, as it was of interest to measure participants’ personal, internal adherence to masculine norms of hegemonic masculinity, rather than their agreement with masculine norms or the degree of conflict experienced within their gender role, the Conformity to Masculine Norms Inventory (CMNI) [6] was chosen. The CMNI examines the degree to which an individual conforms to a validated set of masculine norms of hegemonic masculinity. The version of the CMNI used in this study was the CMNI-46 [26], which has 46 items, with the output of 9 factor scores and a total score. The nine subscales are: Emotional Control, Winning, Playboy, Violence, Self-reliance, Risk-taking, Power over Women, Primacy of Work, and Heterosexual Self-presentation. Items involve identifying the degree to which one agrees with a given statement (e.g., “I tend to keep my feelings to myself”) using a 4-point Likert scale ranging from 1 (Strongly Disagree) to 4 (Strongly Agree), giving a maximum possible score of 138. The CMNI has been validated cross-culturally with diverse samples of men (e.g., gay men [27] and Asian American men [28]).
For this study, it was of interest to measure overall psychological distress, rather than a specific category of distress (e.g., depression, anxiety etc.). The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) [29] is a 34-item measure of psychological distress, with four domains. The four domains are Wellbeing, Functioning, Problems and Risk, with the output of the measure being a total score, a total score minus risk, and a score for each of the four domains. The CORE-OM requires respondents to indicate how frequently over the last 7 days they have experienced the statement described (e.g., “I have felt overwhelmed by my problems”), using a 5-point Likert scale, ranging from 0 (Not at all) to 4 (Most or all of the time), giving a maximum possible score of 136. The measure has been well-validated across diverse samples and is commonly used within clinical settings in the UK.
The General Help-Seeking Questionnaire (GHSQ) [30] assesses help-seeking intentions and has been validated across multiple samples [31]. Intentions are measured by listing a number of potential help sources and asking participants to indicate how likely it is that they would seek help from that source for two specified problems (“a personal or emotional problem” and “experiencing suicidal thoughts”) on a 7-point scale ranging from 1 (extremely unlikely to seek help) to 7 (extremely likely to seek help). The specific sources of help listed can also be modified to be appropriate to the particular research objectives. For this study, listed help-sources included: Partner, Friend, Parent, Relative, Mental Health Professional, Phone Helpline, Doctor, Chaplaincy and Other (to be specified). The listed help-sources for prisoner participants included additional options for Prison Officer and Other Prison Staff.
2.2.3 Statistical analysis
All statistical analyses were conducted using IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp., Armonk, NY, USA). The Shapiro-Wilk test of normality was conducted on all relevant variables, indicating that some data (e.g., subscales of measures and some demographic data) was not normally distributed. This indicated the need for use of parametric and non-parametric tests, depending on the particular associations being investigated.
A mixture of multivariate Pearson and Spearman’s correlation analyses were used to investigate the stated hypotheses, exploring associations between CMNI-46, CORE-OM and GHSQ scores (total and subscales). Exploratory subgroup analyses exploring associations between demographic data and CMNI-46, CORE-OM and GHSQ scores were conducted using Spearman’s correlation analyses and Analyses of Variances (ANOVAs).
2.3 Part 2
All participants for Part 2 were recruited from those who had taken part in Part 1 of the study and had indicated an interest in taking part in a follow-up interview.
2.3.1 Participants
93 (85%) prisoners volunteered to participate in Part 2 of the study. Due to the spread of CMNI-46 scores, this sample was divided into two groups, those scoring either above or below the median. Five participants were randomly selected from each group; however, due to the impact of Covid-19 on access to prisoners, only three participants from each group were able to be interviewed. All prisoner participants who were approached agreed to engage in the interview, resulting in a total of six participants. See Table 2 for participant demographics.
| Participant | CMNI score relative to median | Age | Ethnicity | Wing | Time in custody (mon) | Offence category |
| 1 | Above | 35 | Black Caribbean | Main residential | 21.5 | Drug-related |
| 2 | Below | 40 | Black Other | Vulnerable prisoners | 30.6 | Sexual |
| 3 | Above | 22 | Black Caribbean | Main residential | 20.1 | Drug-related |
| 4 | Below | 38 | Asian Indian | Enhanced prisoners | 11.0 | Drug-related |
| 5 | Above | 32 | White British | Enhanced prisoners | 46.8 | Drug-related |
| 6 | Below | 28 | White British | Enhanced prisoners | 50.9 | Violent |
| CMNI: Conformity to Masculine Norms Inventory. |
2.3.2 Procedure
All participants engaged in a semi-structured interview with the lead researcher, after providing informed consent. Given the topic of masculinity and mental health, semi-structured interviews were chosen over other methods (e.g., focus groups) to ensure confidentiality and prevent participants from being influenced in their answers due to perceived negative social consequences. A semi-structured interview schedule was developed, based on the research question and in line with good practice methodological guidelines [32]. The questions were refined based on collaboration with the research team and two prisoners, who were Healthcare Representatives for their respective wings. All interviews were recorded and transcribed manually. Interviews were conducted in confidential rooms within the prison grounds with prisoners and they were reimbursed with food goods from the prison restaurant.
2.3.3 Reflexive thematic analysis
Interview transcripts were analysed using Reflexive Thematic Analysis (RTA) [33], which emphasises identifying, analysing and interpreting patterns of meaning across qualitative data. During the analysis process, the researcher took a Critical Realist approach [34], which acknowledges the ways in which participant experiences, and the meanings they construct, are impacted on by the wider social context. In line with the Critical Realist approach, and given that the data from the first part of the study indicated a wide range of scores on the CMNI-46, RTA allowed for the use of a slightly less homogenous sample (i.e., those who scored lower and those who scored higher compared to average scores) to be able to have a dual focus on commonalities, but also unique individual experiences. Additionally, this approach does not warrant a large sample size in order to reach saturation, as the emphasis is on understanding participants’ unique experiences in relation to the research topic.
Braun and Clarke’s [35] six step guide to conducting thematic analysis was followed: (1) all transcripts were read through in full prior to starting coding in order to familiarise the researcher with the data; (2) initial codes were generated for the entire dataset by the lead researcher. Inter-rater reliability of codes was explored, with a subset of two transcripts simultaneously coded by a second researcher. After coding transcripts, both researchers came together to discuss codes and possible themes, assessing for inter-coder reliability; (3) all codes were sorted into potential themes; (4) themes were reviewed, refined and sub-themes were identified; (5) themes and sub-themes were finalised and grouped; (6) the analysis was then written up, including extracts from the data to demonstrate the identified sub-themes.
2.3.4 Reflexivity
Reflexive Thematic Analysis (RTA) emphasises the need for an awareness of the contribution of the researcher to how meanings are constructed throughout the research process, acknowledging that the researcher is a part of the research process and understanding of the data [33, 34]. The researcher was a young, Asian British, middle class woman, whose knowledge of the prison environment was based on professional experience, working in multiple male custodial establishments. The researcher engaged in a bracketing interview with an impartial colleague who has no connection to work within prison services, to allow for reflections on how their perspective and experiences impacted their approach to the research and the assumptions held about the link between masculinity, mental health and help-seeking within the prison environment. It was acknowledged that due to the researcher being female, while interviewing male participants, this will have impacted the participants’ answers to questions to some degree; there are likely to have been things shared that would not have been shared with a male researcher, but also things that may have been withheld due to the researcher being female.
2.4 Ethical considerations
All participants were given an information sheet for both parts of the study. Within the prison environment, confidentiality is a particularly salient issue and participants were informed that only the lead researcher would have access to the original questionnaires and recordings of the interviews, and that the dataset would be completely anonymised if it were to be shared with other members of the research team or written up and disseminated. Written informed consent was sought and participants were informed that they were free to withdraw from the study within 2 weeks after participating.
Prisoners were informed within the participant information sheet that any disclosures related to risk to self or others would be escalated and managed in the same ways as is usual within custody (e.g., opening an Assessment, Care in Custody and Teamwork). It was also agreed that, for any prisoners who scored over 2 points for the questions around risk to self, names would be given to a member of the Health and Wellbeing Team, to ensure that the relevant person or team working with them was made aware of possible risk to self and could follow this up.
All data gathered within the study was stored according to the Data Protection Act 2018 and anonymised prior to leaving the prison site (i.e., all identifiable information was removed). Data was stored safely and confidentially so that it was only accessible by the lead researcher.
3. Results
3.1 Part 1
3.1.1 Exploratory analyses of demographics
Prisoners’ reported age was negatively correlated with both CMNI-46 total score (rS = −0.368, p < 0.001, n = 103) and CORE-OM total score (rS = −0.204, p = 0.024, n = 103), indicating that older prisoners were less conforming to masculine norms and reported experiencing less distress. There was also a significant difference between mean CMNI-46 total scores between wings—F (1, 108) = 4.4, p = 0.006—with prisoners on main residential wings scoring the highest (mean = 65.9, SD = 14.9, n = 24) and prisoners on the “Vulnerable Prisoners” (VP) wing scoring the lowest (mean = 52.5, SD = 17.1, n = 59).
3.1.2 Prevalence of conformity to masculine norms
The mean total CMNI-46 score for prisoners was 56.8 (n = 109, SD = 17.7, Range = 84.0). Relative to other subscales, prisoners scored highest on the Emotional Control subscale, which includes items such as “I never share my feelings” (mean = 1.6, SD = 0.7) and lowest on the Power over Women subscale, which includes items such as “Women should be subservient to men” (mean = 0.5, SD = 0.5).
3.1.3 Correlational analyses between masculinity, distress and help-seeking
As hypothesised, there was a significant positive correlation between CMNI-46 total score and CORE-OM total score (rS = 0.445, p < 0.001, n = 109), indicating that individuals who scored higher on the masculinity measure reported increased levels of distress. As hypothesised, there was also a significant negative correlation between CMNI-46 total score and GHSQ total score (r = −0.472, p < 0.001, n = 109), indicating that those who scored higher on the masculinity measure were significantly less likely to seek help. Additionally, there was a significant negative correlation between CORE-OM total score and GHSQ total score (rS = −0.362, p < 0.001, n = 109), indicating that those who self-reported most distress were least likely to seek help.
Of the CMNI-46 subscales, almost all subscales were significantly positively correlated with the CORE-OM total score (see Table 3), indicating that almost all subscales of the CMNI-46 likely contributed to the overall positive correlation between the CMNI-46 and CORE-OM. Both the CMNI-46 total score and the GHSQ total score were significantly correlated with all subscales of the CORE-OM, positively and negatively, respectively.
The GHSQ total score was most strongly correlated with the Emotional Control subscale of the CMNI (rS = −0.614, p < 0.001, n = 109), indicating a strong link between conforming to the norm of Emotional Control and being reluctant to seek help. The GHSQ total score was also significantly negatively correlated with the Risk-taking, Violence, Self-reliance and Heterosexual Self-presentation subscales (see Table 3 for all correlations).
| CORE-OM Total | Wellbeing | Problems | Functioning | Risk | GHSQ Total | GHSQ 1 | GHSQ 2 | |
| CMNI-46 Total | 0.445*S | 0.313*S | 0.400*S | 0.511*P | 0.345*S | −0.472*P | −0.515*P | −0.372*S |
| Winning | 0.265*S | 0.229*S | 0.268*S | 0.239*S | 0.182S | −0.096S | −0.136S | −0.075S |
| Emotional Control | 0.377*S | 0.272*S | 0.308*S | 0.452*S | 0.263*S | −0.614*S | −0.628*S | −0.553*S |
| Risk-Taking | 0.248*S | 0.111S | 0.219*S | 0.251*P | 0.234*S | −0.337*P | −0.364*P | −0.261*S |
| Violence | 0.276*S | 0.207*S | 0.207*S | 0.313*S | 0.323*S | −0.408*S | −0.428*S | −0.366*S |
| Power Over Women | 0.210*S | 0.113S | 0.200*S | 0.200*S | 0.219*S | −0.008S | −0.064S | 0.018S |
| Playboy | 0.156S | 0.122S | 0.121S | 0.179S | 0.167S | −0.067S | −0.093S | −0.042S |
| Self-Reliance | 0.394*S | 0.284*S | 0.360*S | 0.438*S | 0.231*S | −0.495S | −0.532*S | −0.437*S |
| Primacy of Work | 0.036S | 0.005S | 0.125S | −0.061S | 0.020S | 0.142S | −0.118S | 0.125S |
| Hetero-sexual Self-Presentation | 0.293*S | 0.257*S | 0.232*S | 0.342*S | 0.192S | −0.216*S | −0.242*S | −0.195*S |
| CORE-OM Total | −0.362*S | −0.403*S | −0.319*S | |||||
| Wellbeing | −0.307*S | −0.334*S | −0.269*S | |||||
| Problems | −0.259*S | −0.295*S | −0.231*S | |||||
| Functioning | −0.477*P | −0.521*P | −0.397*S | |||||
| Risk | −0.277*S | −0.308*S | −0.245*S | |||||
P: Pearson correlation, S: Spearman’s correlation; *Significant at the 0.05 level. GHSQ: General Help-Seeking Questionnaire; CMNI: Conformity to Masculine Norms Inventory; CORE-OM: Clinical Outcomes in Routine Evaluation-Outcome Measure. |
3.1.4 Summary of quantitative analyses
The findings from Part 1 of this study highlight that associations between conformity to masculine norms, self-reported psychological distress and help-seeking for men in prison mirror those observed within community populations. Prisoners conforming more with masculine norms were significantly more likely to report higher levels of distress and a reduced likelihood of seeking help for distress. In particular, the masculine norm of Emotional Control was found to be most strongly associated with a reluctance to seek help.
3.2 Part 2
Thematic analysis of the prisoner interview transcripts (n = 6) identified three themes of: (1) Holding it in, (2) Image and perception and (3) Control, with seven subthemes. Overall, prisoners highlighted that emotional suppression is typically employed as a way of managing distress, with over half the sample describing a reluctance to seek help. Prisoners spoke about needing to consider how they are perceived by their peers, with the expression of emotion being viewed as a weakness and the potential consequences of this being particularly threatening within the prison environment. They also highlighted a lack of agency and the need to heavily rely on others while in prison. Prisoners identified peer support as crucial to supporting their ability to manage their distress, highlighting that some vulnerability can be permitted with trusted others in private spaces. Comparisons across participants were examined and the frequency of themes across all participants are presented in Table 4.
| Themes | Subthemes | Frequency |
| Holding it in | ||
| Don’t ask for help | 67% | |
| Suppress it to cope | 83% | |
| Image and perception | ||
| Showing emotion is weakness | 67% | |
| Threat and judgement | 100% | |
| Peer support | 100% | |
| Control | ||
| No agency or choice | 100% | |
| Having to rely on others | 67% |
3.2.1 Theme 1: Holding it in
All prisoners spoke about having to hold emotions in whilst in prison and some described this as being specific to the prison environment. Emotional suppression was described as an effective and necessary coping strategy and there was discussion about avoiding seeking help for emotional difficulties in prison. The fears that prisoners held about how they were perceived by other prisoners were linked to why emotional suppression and avoidance of help were employed as strategies.
3.2.1.1 Subtheme 1: Don’t ask for help
Most prisoners spoke about negative attitudes towards seeking help within prison, linking this with masculine ideals of autonomy and self-reliance. Some identified the negative perception from other prisoners if they were to seek help in prison. This was linked to ideas around being perceived as weak, which threatens masculine ideals of strength (as highlighted in other sub-themes—“Threat and judgement” and “Showing emotion is weakness”), but was also described as heightened within a prison environment where men are surrounded by other men, who are strangers to them.
P2: I was contemplating going to mental health and all of that kind of stuff and he goes: “I beg you not to do that, don’t do it”. I didn’t understand why he was telling me not to do it, but I’m glad he did.
They spoke about trust as a crucial factor in relationships to be able to feel that seeking help would actually be helpful. Prisoners distinguished between help for practical things and help for emotional difficulties, stating that they would be much more likely to seek help for the former than the latter. They noted that promises made by staff often do not materialise (or take a long time to) and this leads to feeling frustrated, let down, invalidated and misunderstood. These experiences are seen as indicative that others do not care about them, leading to a withdrawal from re-attempting to seek help to avoid feeling the same way again.
P6: In jail… if you ask this stuff and they say yeah, and it don’t happen, it’s a bigger let down.
P5: You don’t have a thing where you can just open up to officers… Like they don’t really care to be honest… they just want to get their job done and go home.
Most prisoners acknowledged that there are some sources of support within the system, but there was a sense that there was not enough support or that the support on offer was not adequate (e.g., long waiting times).
3.2.1.2 Subtheme 2: Suppress it to cope
Prisoners spoke about suppressing emotions as a way of managing their distress whilst in prison and highlighted this as different to how they would cope in the community. While this sub-theme was strongly linked to the sub-theme of “Showing emotion is weakness”, prisoners also highlighted other relevant factors linked to the prison environment—e.g., the physical confinement of being in prison was linked to an increased building of emotional pressure due to isolation from loved ones and not having as much outlet as they would do outside of prison. They spoke about how emotions feel much more intense in prison and things feel exaggerated, which means that emotions could more easily become overwhelming. Suppressing emotions was described to be a necessity rather than a choice (in order to not feel overwhelmed), but also was a way of maintaining some control in an environment where this is lacking, linking in with the theme of “Control”.
P1: Because if you think about it and feel it while you’re in here, then…it feels twice as much because we’re stuck inside… I have to be busy… then it’s easier for me ‘cause then I don’t have to stop and think.
Most prisoners spoke about distraction being the most helpful coping mechanism in prison and linked this to enabling them to not have to think about things that were distressing them. Multiple prisoners noted that they were delaying their processing of emotions until they were released and were able to access more coping mechanisms to support this processing, highlighting the unique nature of the prison environment as a significant barrier to emotional processing.
3.2.2 Theme 2: Image and perception
Prisoners spoke about the importance of maintaining an image while in prison, as a way of communicating to others that you are strong, resilient and cannot be taken advantage of. They discussed how the way in which you are perceived by others whilst in the prison environment can impact significantly on your safety and dignity. Prisoners spoke about needing to portray a certain version of themselves when out on the landing surrounded by unfamiliar men, but noted a distinction between this and private conversations between trusted others.
3.2.2.1 Subtheme 1: Showing emotions is weakness
All prisoners spoke about a strongly held belief that showing emotions is an indication of weakness, which they equated with not being a man. Although this was an idea that applied whether inside or outside prison, it was evident that the prison environment was a place where the risks associated with being perceived as weak were significantly heightened and portraying strength and resilience was essential to maintain a sense of safety and to be able to survive prison.
P2: I can’t allow you to see a weak version. This is prison, I have to just be able to show strength. I can’t do that if I’m going to be emotional, I can’t…It’s not happening.
Additionally, it was noted that when referring to “emotions” as weak, this did not apply to certain emotions, namely anger and frustration. Prisoners spoke about the acceptability of expressions of anger, perhaps as this emotion endorses masculine ideas of dominance and strength and alerts others to threat in order to ensure safety, unlike emotions like sadness or anxiety.
P1: It’s like… Men being men… Most of the people in here feel like if you talk about your feelings, then it makes you softer or you look like less of a man or you don’t look as tough. Then they don’t end up talking about it… unless they’re angry. That’s about the only emotion that you will see from most of the prisoners, it’s anger.
This sub-theme linked strongly with the sub-theme of “Suppress it to cope”, as prisoners spoke about emotional suppression being their behavioural response to this belief that showing emotions indicates weakness. Most participants used the word “soft” when referring to showing emotions, which is a term often equated with femininity, highlighting that not only do prisoners feel they have to adhere to masculine norms, but also that they must avoid and distance themselves from being perceived to be in proximity to femininity.
3.2.2.2 Subtheme 2: Threat and judgement
Almost all prisoners spoke about the fear of negative judgement from others (most often, men), which they linked to the ability to keep oneself safe from emotional or physical harm in prison. It was highlighted that to keep oneself safe, it is necessary to perform masculinity as a communication to other prisoners of strength and resilience, in order to prevent others from seeing vulnerabilities that may be exploited or targeted (e.g., being bullied).
P3: So yeah, like basically you have to act more of a man in jail because you don’t want people to start thinking like “oh yeah I can go and bully this guy”.
All prisoners spoke about feeling judged by other people and identified fear of judgement as a barrier to expressing emotions or asking for help, both from officers and from peers. The ways in which prisoners described feeling judged were linked to being judged as weak or soft, or being judged as not manly enough.
P1: It’s just like a masculinity thing. Like I don’t want to make myself sound soft when I’m with a male officer because then he might tell another male officer and it’s just an ongoing thing.
Prisoners spoke about judgement as particularly threatening if coming from another man, as opposed to a woman. They linked judgement to negative consequences, with the consequences of judgement from other prisoners being related to a loss of social status within the prison hierarchy, while judgement from staff may result in confidentiality being broken. Prisoners also spoke about experiencing judgement more generally, not directly related to their masculinity; for example, feeling judged by staff members and the general public due to their offending behaviour or the nature of their offence.
3.2.2.3 Subtheme 3: Peer support
Prisoners noted that safety is possible in certain contexts and with certain people. Prisoners spoke about the importance of finding support from other prisoners, who they have built relationships with during their time in prison. Almost all prisoners spoke about the importance of their relationship with their cellmate while in prison, as a source of emotional support.
P4: I think your cellmate is a part of your journey. He’s a part of your prison journey.
They discussed the importance of finding people who they can trust to confide in, but acknowledged that this process is not easy due to the risks of threat and judgement, as highlighted in the previous sub-theme.
P1: There’s two people on the wing now… I don’t mind confiding in them or talking to them and then we’ll confide in each other and make sure everyone’s alright.
Prisoners identified a distinction between the version of themselves that is presented out on the landing when amongst other prisoners—i.e., putting on a brave face—compared to the version of themselves behind closed doors, where expression of some vulnerability may be permissible, depending on who is with them.
P6: Yeah, it’s good. It’s good to speak to somebody, get off your chest and then knowing that’s just somebody there who’s listening and cares for you as well… Then as soon as that door opens, we’ll leave it there.
Prisoners highlighted that they would usually still not share everything with even their most trusted peers, again linked to previous sub-themes of fear of judgement and being perceived as weak. They discussed how feeling cared for by other prisoners has often been crucial to them getting through a difficult time, which links in with the previous sub-theme of “Don’t ask for help”, where prisoners identified often feeling that other people do not care about them. They noted that they would not trust most other prisoners, but if trust is built over time, then this can be possible with particular individuals.
3.2.3 Theme 3: Control
Prisoners spoke about experiencing a lack of control over their day-to-day lives while in prison, as well as feeling they have no choice or any sense of autonomy. Comparisons were made with life outside prison, where prisoners discussed having control over their lives as a very important factor in supporting them to manage their emotional difficulties and find ways of coping. Prisoners discussed how, when in prison, they have to become reliant on other people (staff and family/friends outside), which feels difficult as this is an unfamiliar position for them to be in.
3.2.3.1 Subtheme 1: No agency or choice
All prisoners identified that they did not feel they had any control, choice or agency in their day-to-day lives in prison. They described autonomy in the outside world as very important to them and some perceived autonomy to be a central character trait of theirs, perhaps linked to ideas about men being in charge of themselves. This was strongly linked to the sub-theme of “Don’t ask for help”, as many prisoners spoke about feeling that they need to manage things themselves rather than seek help from others for difficulties.
P2: Just get on with it. You’re forced to accept everything that goes on. I have to just… How can I put it? Take it on the chin? And get on with it. I don’t have a choice.
Prisoners described feeling frustrated by the lack of control that they experience while in prison and some spoke about feeling left powerless and in a position of submission (rather than the traditional masculine position of dominance), which they linked to further negative emotional experiences. Prisoners spoke about feeling that they are forced to not only accept their situation, but also accept the emotional impact of their situation. Avoidance of seeking help and managing things alone may be one way in which prisoners feel they regain control in an environment where they lack it.
3.2.3.2 Subtheme 2: Having to rely on others
Most prisoners discussed the difficulty of having to rely on staff members or family and friends outside to do things for them. These ranged from more minor things (e.g., getting toilet roll) to more significant things (e.g., departments effectively communicating to ensure support following a bereavement; family sending money in). Again, this linked in with masculine ideas around autonomy and self-reliance, as highlighted in the previous sub-theme, but also acknowledged frustrations when the desired tasks do not happen.
P3: Like for instance, one time I asked for toilet roll he [officer] said “Ah, it’s Friday… I wanna go home and go out”. I’m like… if I could get my own toilet roll I would get it myself… It’s like just little things like that.
There was particular acknowledgement of the dynamic between prisoners and officers, with multiple prisoners highlighting the difficulty in having to rely on officers (for very basic things) who they often feel do not care about them or their wellbeing. It was also evident that reliance on officers for small and basic needs was a reminder to prisoners of the power dynamic between prisoners and officers, with officers in the position of dominance, which is a position that, outside of prison, prisoners are often used to being in.
P6: We asked an officer “can we get the hoover… to hoover the rug?” And they said “there’s no hoover on the wing”. Then we went down to the office and the blonde woman there, we said “miss is there a hoover on the wing?” And she said “yeah it’s in the office”. And when we walked past with the hoover, we said to the guy “why didn’t you get the hoover out?” and he said “ah I couldn’t be bothered to move”. That’s an officer. Yeah, I mean so he will never get asked for anything off me again.
This sub-theme was connected to the sub-theme of “Don’t ask for help”, as prisoners spoke about how negative experiences with staff—e.g., where staff chose not to help them with something—impacted significantly on their impression of that staff member and the likelihood of them asking for something from that same staff member again. Additionally, this linked in with the prior highlighted distinction between practical help and help for emotional difficulties; prisoners spoke about feeling that if they could not rely on staff for practical support, then they would not rely on staff for emotional support.
4. Discussion
4.1 Overview
The findings of this study replicated findings from community-based samples, confirming a significant association between increased conformity to masculine norms, increased psychological distress and reduced likelihood of help-seeking amongst male prisoners. The size of effects found in this study are higher than those found in a previous meta-analysis [7], suggesting that this association may be elevated for prisoner populations. While this study found that prisoners reported similar levels of overall conformity to masculine norms when compared with general population prevalence rates [8, 36, 37, 38], when considered in conjunction with the qualitative data from interviews, a distinction between internal conformity to masculinity and displayed conformity to masculinity whilst in the prison environment is evident. Interview data highlights that while prisoners may be able to be more free from the restrictions of hegemonic masculinity in private spaces with trusted peers, when outside of their cells and amongst other men, the fear of judgement from their peers and lack of agency experienced while in prison result in prisoners performing masculinity in order to appear “strong” to others and regain a sense of control.
4.2 The relationships between masculinity, distress and help-seeking in prison
The findings in this study are in line with the theory of Gender Role Conflict (GRC), which is defined as “a psychological state in which gender roles have negative consequences or impact on the person or other” [39]—i.e., that men experience negative personal and relational consequences when the restrictiveness and rigidity of male gender roles are incompatible with the demands of a relevant situation. For prisoners, increased personal alignment with masculine norms may elevate the level of distress experienced due to the loss of important masculine norms, such as autonomy, control and dominance. It is also important to acknowledge that this may be additive to the elevated level of distress that prisoners already experience, relative to the general population, linked to both environmental prison-related factors and individual-level factors [40]. This may explain the strong link found between increased conformity to masculine norms and elevated psychological distress amongst prisoners, which is higher than effect sizes reported in a previous meta-analysis [7].
Additionally, this study found that younger participants both conformed more with masculine norms and also reported increased levels of distress. While it is acknowledged that the salience of social acceptance during adolescence and early adulthood is crucial in impacting on the importance placed upon adhering to normative gender roles [41, 42], future research may seek to explore the role of age in the relationship between conformity to masculinity and elevated distress amongst prisoners, which may in turn impact on help-seeking intentions.
4.3 The external performance of masculinity
Prisoner interviews clearly highlighted that how distress and help-seeking are experienced in prison is shaped significantly by the need to create and maintain an outward image of oneself as more in line with masculine norms, which does not necessarily predicate the presence of internalised conformity to these norms. The distinction between internal and displayed conformity to masculine norms may explain why although the literature has theorised prisons to be hypermasculine environments, the findings in this study indicate similar prevalence of conformity to masculine norms amongst prisoners compared to the general population. The construct being measured by the CMNI-46 is internal conformity to masculine norms (through private, anonymised self-report), rather than the externalised performance of masculinity that is captured within the interview data.
From interview data, the notion of emotional expression as an indication of weakness was consistent, which is linked to a range of associated risks. While this is consistent with the literature on men’s perceptions of emotional expression and mental health difficulties [43], prisoners shared that their way of portraying themselves differs when they are outside the prison environment, highlighting the magnifying impact of prison. This suppression of emotional expression may partially explain the sizeable evidence that indicates that mental health difficulties amongst prisoners are rarely identified or treated [22, 23].
Michalski [44] theorizes that as prison environments often strip men of most of their forms of economic and political power, this leads to social status becoming a more significant priority as this is a prisoner’s main way of accessing power and privilege, with the acquisition of status as being dependent on men competing to solidify their reputation as a “real man” [45]. As prisoners highlighted in their interviews in the present study, this leads to those who are less successful at competing in this performance of masculinity being bullied, exploited, ostracized or assaulted. In line with Michalski’s theory, prisoners’ loss of autonomy and control whilst in prison may also link to an increased desire to find ways to regain control of their circumstances, which may involve controlling the way they are perceived by others or controlling their emotions through suppression. Prisoners also importantly highlighted that although expression of vulnerability did not feel possible in a public space (e.g., while out on the wing), it was partially permitted to occur behind closed doors (e.g., in their cells) with particular trusted peers and this was a crucial source of support for prisoners. This aligns with findings from research in schools, acknowledging that homosocial relationships are complex and nuanced, with homosocial relationships in some contexts (e.g., public) maintaining hegemonic masculinity norms, while homosocial relationships in other contexts (e.g., private) can invite and allow engagement more with caring masculinities [46].
4.4 Limitations
There are a few limitations of this study worth acknowledging. The context of the research being conducted during the global pandemic (Covid-19) impacted both on data collection and generalisability of findings. For example, self-reported distress may have been elevated at this time due to increased restrictions in prisons. Replicating this research when Covid-19 is no longer as much of a threat to health and society will be important to ascertain whether these findings remain relatively stable, or were specific to the context of the pandemic.
Another limitation of this study is the specific context and location of the establishment within which the research took place—i.e., located in a diverse London borough, only houses male prisoners who have been sentenced and have been deemed to meet the risk threshold warranting residence in a “Category C” establishment. While this study has investigated individual experiences of masculinity, distress and help-seeking, similar results may not be found in another establishment which may have a different culture or house a population with different demographics (e.g., in a less diverse area of the country or within a remand prison). Future research should seek to replicate these findings across multiple sites, with a larger sample size of both prisoners, using volunteer sampling, in order to address the limits of generalisability.
While qualitative research does not aim for generalisability, as small samples preclude representativeness, it is important to consider that some participants may have been more willing to engage in an interview compared with others, particularly in the context of the research topic. Participation in research may be thought to be similar in some ways to seeking help and it is possible that similar barriers may be present for both. It will be important for future research that aims to replicate these findings across other establishments to consider recruitment methods for qualitative interviews carefully in order to attempt to facilitate participation from those who may be less likely to come forward.
4.5 Implications of this research
This study identifies the need for a shift in the culture of prisons. For prisoners, loss of agency and control—while an inevitable element of the prison setup—results in an increased need to assert masculine values in other ways, leading to increased performance of masculinity through emotional suppression, pursuit of social status and reluctance to seek help. While these are issues observed across the masculinity literature, in prisons, the associated risks of not presenting an image that is in line with masculine ideals are magnified and mental health difficulties are elevated compared to the general population [19, 20, 21]. Therefore, it is of utmost importance for prisoners to feel able to express their emotions and receive support where needed for any emotional distress particularly as prisoner mental health has been linked to likelihood of reoffending [47]. Initial research findings support the use of sports-based interventions as a way of increasing awareness of mental health, coping skills and attitudes towards help-seeking for male prisoners who may be reluctant to engage with more “traditional” psychotherapeutic interventions [48, 49, 50]. These interventions may be less stigmatised within the prison environment and may be deemed more acceptable or appealing to male prisoners. Given the findings of increased endorsement of masculine values amongst younger prisoners, these types of interventions may be especially relevant for those in Young Offender Institutions (YOIs) or younger individuals residing within adult establishments.
Initial research has explored the presence of caring masculinities amongst prisoners, which is characterized by men embracing values of care and interdependency, and has highlighted that the culture of the establishment must endorse and promote caring masculinities further in order for this to be permitted within relationships between prisoners [51]. Given the highlighted importance of peer support amongst prisoners from this study, increased provision of peer-to-peer support networks within prisons should be considered and prioritised, rather than just focusing on interventions with professionals, alongside the promotion of a culture that endorses caring masculinities (e.g., through this being modelled by male staff within the establishment).
While some research has highlighted factors that facilitate help-seeking in prisons (e.g., the expected response from a particular help-source, perceived skill of the help-source and confidentiality) [52], the impact of masculinity should be considered more explicitly within future research, as this may link closely with the underlying drivers of these responses (e.g., expected response and confidentiality may be linked to perceived judgement from the help-source, which may be amplified for seeking help from male staff or peers). These findings indicate the need for further research to explore whether, specifically for men residing in custody, masculinity plays a partially mediating role between self-reported distress and help-seeking attitudes, or whether other variables explored in the general population literature—e.g., stigma [53] may play a mediating role. Additionally, it is important to consider the provision of mental health services in prisons and the reality of accessing help (i.e., long waiting lists, limited staff resource), which likely impacts significantly on the likelihood of men in prison seeking help, regardless of the impact of masculinity.
5. Conclusions
While studies have explored the links between conformity to masculine norms, psychological distress and help-seeking amongst samples of males, this is the first study to examine this in the context of a male prison environment. This study found a significant correlation between conformity to masculine norms and help-seeking for psychological distress, indicating that prisoners conforming more to masculine norms, particularly of emotional control, are less likely to seek help for psychological distress. Interview data supported the understanding of prisons as environments where masculinity is performed, highlighting a distinction between public (e.g., when visible in prison) and private (e.g., in the cell or with trusted peer groups) spaces where individuals’ conformity to masculinity differs and expression of some vulnerability can be permitted. The clinical implications of this study provide the prison and probation services (HMPPS), and those working within them, with a greater understanding of the barriers to seeking help, expressing emotions and the impact this has on prisoners. Additionally, it identifies the need for a shift in the culture of prisons to combat some of these barriers linked to masculinity.
Future research should seek to identify whether the findings of the present study are generalisable to other establishments and whether the culture of prisons in the UK is universal or if there are nuances between different establishments, e.g., based on geographic location, security category, age of prisoners (e.g., YOIs) and gender of prisoners. For example, research on the impact of masculinity in women’s prisons may be of interest to explore how this presents differently and could provide further helpful insight into the role of the environment of prisons in endorsing masculine values, regardless of gender of prisoners, and therefore inhibiting emotional expression and help-seeking behaviour. Additionally, some establishments have embedded trauma-informed ways of working more than others—e.g., including the offer of reflective practice and/or supervision for prison officers; research in these establishments to determine how these ways of working have impacted on the prison culture will be important. Further study around the explicit relationship between masculinity, distress and help-seeking in prison, with consideration of any possible mediating variables, such as self-stigma, should be explored.
Availability of data and materials
Full datasets available on request.
Author contributions
TR, JC and HVC—designed the research study. TR—performed data collection and analysed the data, with MM—second-coding the interviews for the thematic analysis. TR and JC—wrote the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The study received ethical approval from HMPPS National Research Committee (NRC reference: 2021-061). Signed informed consent was sought for all participants.
Acknowledgment
Not applicable.
Funding
This research received no external funding.
Conflict of interest
The authors declare no conflict of interest.
