Understanding adolescent mental health: the influence of social processes, doing gender and gendered power relations

Authors


Address for correspondence: Evelina Landstedt, Department of Health Sciences, Mid Sweden University, Holmgatan 10, Sundsvall 85170, Sweden
e-mail: evelina.landstedt@miun.se

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.

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-Setäläet al. 2002, Fergusson and Woodward 2002). Existing 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-Setäläet 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, 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 female-dominated).

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.

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.

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.

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

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.

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.

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.

Figure 3.

A continuum illustrating the experienced mental health impact of the performance subcategories ranging from positive to negative influence

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 self-confidence, 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 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.

Figure 4.

A continuum illustrating the experienced mental health impact of the responsibility subcategories ranging from positive to negative 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 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:   You are supposed to hang out with your friends and be a good student

Caroline: and exercise

Linda:   and work

Caroline: 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 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 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 self-esteem 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 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 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 mental health should acknowledge the influence of gender relations, as well as social and psychosocial factors.

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.

Ancillary