Are Some Axis II Disorders More Prevalent in One Gender than Another?
Seth Grossman
Carrie Millon
Sarah Meagher
Rowena Ramnath
With
so many varied and insidious sources of potential gender bias in the diagnosis
of personality disorders that overlap and interact with each other, it is
nearly impossible to untangle real differences from artifacts. Bias can enter
the equation at any point from the DSM
diagnostic criteria themselves, to the
clinicians who diagnose patients, to the populations sampled in our empirical
research, all generated and maintained within the context of an overarching
biased and often misogynistic culture. Where do we begin an attempt at sorting
out all of these potential sources?
One
body of evidence to consider when pondering this question of bias in diagnosing
personality disorders is the prevalence rates of different categories of
disorders in both males and females. The DSM-IV
(APA, 1994) reports that certain
personality disorders— namely, antisocial personality disorder—are more
frequently diagnosed in males while borderline, histrionic, and dependent
personality disorders are more frequently diagnosed in females. Hartung and
Widiger (1998) compiled findings from a variety of sources to determine that more
males are diagnosed as paranoid, schizoid, schizotypal, antisocial,
narcissistic, and compulsive; and more females are diagnosed as borderline, histrionic,
and dependent. Other studies have reported roughly equal numbers of males and
females diagnosed as schizotypal personality disorder. However, it seems as
though males possess more eccentric/odd symptoms and females possess more ideas
of reference, magical thinking, and social anxiety (Roth & Baribeau, 1997).
One
often-cited criticism in these prevalence figures is that we have very biased
samples of patients. We take samples of convenience at hospitals, the VA,
prisons, and the like and generalize the numbers to clinical populations and
nonclinical populations alike. We have done a fairly poor job of seeking out
representative samples to gather reliable prevalence statistics.
Surprisingly,
overall, both men and women are equally as likely to receive a diagnosis of a
personality disorder (Kass, Spitzer, & Williams, 1983). An equal prevalence
of personality disorder diagnoses across gender as a whole does not preclude
the existence of gender bias. Hartung and Widiger (1994) suggest that there is
a very real possibility that either men or women may in fact have more
personality pathology. Should it be a goal of psychologists to have equal
numbers of women and men diagnosed as personality disordered? More
specifically, should it be a goal that equal numbers of men and women be diagnosed
in each category? Widiger (1998) argues that “the purpose of the DSM-IV is to provide an accurate classification of psychopathology,
not to develop a diagnostic system that will, democratically, diagnose as many
men with a personality disorder as women” (p. 98). While this may be true, it
does not excuse the profession from investigating and correcting the potential
sources of bias that are contributing the differences we are observing under
our current system.
One
consideration that adds more complexity to the issue includes the empirical
evidence that has been amassed to suggest that there is a systematic failure on
the part of the diagnosticians in adhering to the clinical criteria set forth
in the DSM when making diagnoses (refer to Widiger, Corbitt, &
Funtowitz, 1994, for a more comprehensive review of this literature). For
example, a study by Ford and Widiger (1989) found that clinicians diagnosed
females with histrionic personality disorder when they failed to meet DSM criteria for the histrionic personality disorder and instead
met criteria for antisocial personality disorder. Further, when clinicians were
asked to individually assess each of the DSM
antisocial and histrionic criteria, the
sex of the patient had no effect. Ford and Widiger assert that this is evidence
to suggest that the problems lie not in the criteria themselves, but in
clinicians’ failure to adhere to the guidelines.
Other
evidence supports this contention of a problem at the level of diagnostic
labels, not necessarily in the diagnostic criteria. Sprock (2000) used a method
derived from the act-frequency approach to have undergraduate students generate
behavioral examples of DSM histrionic personality without regard to sex or sex roles.
Then, she had a sample of psychologists and psychiatrists rate the
representativeness of the symptoms for either histrionic criteria or histrionic
personality disorder. She discovered that “feminine” behaviors were rated as
more representative of histrionic personality disorder and somewhat more representative
of the histrionic criteria than “masculine” behaviors, supporting the same
notion that Ford and Widiger argued: The female sex-role is more related to the
label than to the criteria. These same arguments can be made for dependent personality disorder,
which includes many traditionally feminine qualities such as putting other
people’s needs above your own or relying on a husband to provide an income and
home.
These
differences in the prevalence rate for females are hardly a one-sided bias on
the part of the DSM. It is just as easily arguable that there are male stereotyped
behaviors to be found in criteria for personality disorders. For example, the
narcissistic personality disorder contains criteria that are traditionally
ascribed to healthy male functioning such as an inflated sense of
self-importance, a preoccupation with fantasies of unlimited success and power,
possessing a sense of entitlement, lacking empathy, and assuming an arrogant manner.
Traditionally socialized male characteristics can be seen in the criteria for antisocial
personality as well, such as deceitfulness, impulsivity, aggressiveness as
evidenced by getting into physical fights, and irresponsibility (APA, 1994).
While
neither side of the debate would likely argue that these criteria mirror
sex-typed behavior, they would argue as to the significance of this fact. Many
feminists would argue that labeling women as personality disordered is an act
of punishing women for conforming to the very criteria we ask them to conform
to (Landrine, 1989; Walker, 1994). They argue that women are actually in a
double bind. If they do not act in a manner that is deferential, dependent, and
sexually provocative, they risk becoming social outcasts. If they do, they are
branded “mad” or “disordered.” Landrine (1989) asserts:
The purposes of masquerading
gender roles as madness may be (a) to locate falsely within persons all of the
ludicrous cognitive and behavioral limitations that actually reside in gender roles
and stratification so that (b) to direct our attention—not to changing gender
roles or to eradicating gender stratification—but to changing individuals
through therapy and to eradicating their ostensible personal problems. (p. 332)
Or
worse, it is a way to label victims of sexual abuse or domestic violence as
“sick” rather than placing the blame on the perpetrators of these crimes.
Given that a huge percentage of women diagnosed as personality disordered
have histories of sexual and physical abuse, this argument is convincing
(Brown, 1992).
Others
(including Widiger, Corbitt, & Funtowitz, 1994) argue that just because
these disorders are founded on a biased society that encourages some of these
characteristics does not negate the fact that in these extreme forms of
expression, they are pathological. If we conceptualize personality disorders as
lying on a continuum rather than as categorical, it is justifiable that at these
extreme ends, the behaviors, whatever their original source of motivation, are
disordered.
There
is empirical support for this notion that several personality disorders are
exaggerations of normal socialized sex-typed behaviors. Landrine (1987, 1989)
proposes what she calls a social-role
hypothesis that posits:
Each
personality disorder represents the role/role-stereotype of the specific status
group (Sex X Social Class X Marital Status Group) that tends to receive that
diagnosis most often, such that the personality disorder categories as a whole
represent the role/role-stereotypes of both sexes. Thus, women might receive
certain diagnoses more often than men—and vice versa— because the category on
question is by and large equivalent to their role.
Based
on this social-role hypothesis that a personality disorder might be
differentially assigned to males or females when the description is consistent
with gender-role stereotypes, Rienzi and Scrams (1991) argued that clinically
untrained people should be able to accurately make this distinction as well. If
assigning these diagnoses to men and women is a social construction, non-clinicians
should fall as victim to these biases as psychologists. In their study of
university students, they asked students to assign gender to six descriptions of
DSM-III-R personality disorders. Significant agreement was found, with
paranoid, antisocial, and compulsive personality disorders being viewed as male
and dependent and histrionic personality disorders viewed as female. In another
study along this same vein, Rienzi, Forquera, and Hitchcock (1994) asked
undergraduates to assign either a label of male or female to gender-ambiguous
vignettes and found a similar bias to labeling the narcissistic vignette as a
male and the dependent vignette as female.
Another
line of research lends an additional slant on this argument. Some theorists have
hypothesized that histrionic personality disorder and antisocial personality
disorder are actually “expressions of the same latent disposition” (Hamburger,
Lilienfeld, & Hogben, 1996, p. 52). What we observe superficially are only
the gender-stereotyped behaviors of the same underlying pathology. As Widiger
and Spitzer (1991) argue, the differences we see in the distribution of
personality disorders may be due to etiological factors such as different sex
hormones that influence the final expression of pathology. Histrionic and
antisocial personalities may be an example of such an effect. They may both
represent expressions of the same pathology, and we are misconceptualizing them
as two separate entities because their superficial expressions (the symptoms
they outwardly express) are different.
Yet
another area of the literature to contemplate when considering gender bias in
diagnosing personality disorders is the area of criminal behavior. The once
hard-and-fast rule that men display more criminal and antisocial behavior is
rapidly changing. Historically, female crime rates have been incredibly small
and considered an aberration. In the late 1890s, Lombroso proposed what he
called the “masculinity hypothesis” to explain women who committed crimes. He
believed that excessive body hair, wrinkles, and an abnormally shaped head were
all outward signs of the female criminal. Perhaps because of Lombroso’s belief
that female criminals are masculine-like and, therefore, somehow unnatural, it
has been widely believed that female criminals are somehow sicker than male
criminals. Lombroso even quotes an Italian proverb, “Rarely is a woman
wicked, but when she is she surpasses the man,” which illustrates this
belief (Lombroso & Ferrero, 1916, p. 147). Clearly, the prototype for an
antisocial was considered
a
male antisocial. A female antisocial is somehow only a poor cousin to the prototype
or “real” antisocial.
Conclusions
After
weighing all perspectives and sources of evidence, it is clear that there are
problems on multiple levels. Our conceptualizations are fuzzy, our samples are
biased, our measures are biased, and our clinicians fall prey to their own
biases. The question of what to do is even more difficult to address. At the
theoretical level, we have great room for improvement. A logical place to start
is at the DSM level. However, tales of how DSM
committees work are horrifying (see
Caplan, 1991, for details on how the self-defeating personality diagnosis was
retained in the DSM). What we put faith in as an unbiased and scientific system
for diagnosing mental disorders is often a very political and even random set
of criteria. To add further fuel to the fire, the vast majority of DSM authors and committee members on personality disorder
workgroups have been male. Eighty-nine percent of DSM-III personality disorder workgroup members (8 of 9) were male, 84%
for DSM-III-R (32 of 38), and 78% for the DSM-IV (7 of 9; Widiger, 1998). Future revisions of the DSM need to draw on the resources of a far wider clinical base than
the 1,000 individuals involved in the production of the DSM-IV. Additionally, if our clinical samples are biased, as a
community, we need to make the investment in solid epidemiological research to
determine real prevalence rates, even if we are using our flawed diagnostic
criteria. It is difficult to obtain a clear picture of where to fix a problem if
we do not know how pervasive the problem is.
The
fairly convincing evidence that clinicians do not adhere to the existing
criteria when making diagnoses is also troubling. How to tackle these failures
is a complex issue. Perhaps raising awareness of biases is a first step. If
clinicians have taken the time to introspect a little on why they assume
histrionics are female and narcissists are male, they may pause to consider
alternative diagnoses. The DSM-IV
contains only one sentence about this
issue buried within the general discussion of personality disorders:
Although
these differences in prevalence probably reflect real gender differences in the
presence of such patterns, clinicians must be cautious not to overdiagnose or
underdiagnose certain Personality Disorders in females or in males because of
social stereotypes abouttypical gender roles and behaviors. (APA, 1994, p. 632)
Perhaps
another solution would be to include reminders throughout the DSM, for example, in the histrionic section: “If a female client is
presenting with X, Y, and Z symptoms, make sure to consider a diagnosis of
antisocial personality disorder as well.” While these suggestions are merely
stopgap measures to address the larger issues of how our diagnostic criteria
and, on a grander scale, our entire mental health system are biased against women,
they are a step toward ameliorating the negative effects such biases can have
on our mental health.
References
Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.Read Also
Histrionic Personality Disorder, Case vignette (1)
Histrionic Personality Disorder, Case vignette (2)
Histrionic Personality Disorder, Case vignette (3)
Antisocial Personality Disorder, Case vignette (1)
Antisocial Personality Disorder, Case vignette (2)
Antisocial Personality Disorder, Case vignette (3)
Rarely Is a Woman Wicked . . .!!??
Histrionic Personality Disorder, Case vignette (2)
Histrionic Personality Disorder, Case vignette (3)
Antisocial Personality Disorder, Case vignette (1)
Antisocial Personality Disorder, Case vignette (2)
Antisocial Personality Disorder, Case vignette (3)
Rarely Is a Woman Wicked . . .!!??
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