Gender stereotypes are fixed ideas about men’s and women’s traits and capabilities and how they should comport themselves, based on their biological sex. A classic study conducted in 1970 with male and female therapists showed that stereotypically masculine traits were perceived as more socially desirable than stereotypical feminine attributes, and therapists’ view of a healthy adult correlated highly with stereotypical male traits but not female traits. Though this study was conducted almost 50 years ago, popular culture and media suggest these stereotypes are, at times, still endorsed and relevant today. For example, in film, male characters with mental health conditions may be portrayed as deep thinkers or geniuses, whereas female characters with mental illness are often seen as overly emotional or “crazy.”
How gender stereotypes influence mental health diagnosis and treatment
Because our mental health diagnostic system is a product of our culture, cultural stereotypes can introduce bias in the way we conceptualize mental health problems. Bias can manifest in the diagnostic constructs themselves, the diagnostic criteria, and/or the application of diagnostic criteria. Gender bias can also manifest in standardized tests because constructs and/or criteria are biased or a test or items on the test may have different measurement properties such that scores do not mean the same thing for males versus females. Using non-probability samples also can bias prevalence estimates associated with various disorders (such as using clinic samples).
It is important that gender stereotypes and bias be distinguished from true sex (biologically-based) and gender (shaped by experience/environment) differences. Sex and gender differences in mental health disorders reflect differences in biogenetic or environmental factors that contribute to the development, escalation, or course of a disorder. For example, a large body of evidence indicates that there is greater prevalence and severity of anxiety and trauma-related disorders in women compared to men. This holds true in the military population where anxiety disorders were 1.4 times more often diagnosed in active duty service women compared to men and service women are at a higher risk for post-deployment posttraumatic stress disorder (PTSD) than men. There is strong evidence that female hormones may play a significant role in these sex differences.
Examples of gendered diagnoses and stigma
Mental health stigma prevents help-seeking and can be compounded by gender bias. Alcohol use disorders are highly stigmatized and are considered more masculine than feminine diagnoses. Traditionally, it has been more stigmatizing for women to receive an alcohol use disorder diagnosis compared to men. However, the negative effects of alcohol appear sooner and are more severe in women versus men, and common stressors in the military such as combat exposure and deployment may increase the rates of alcohol use disorder in female service members, thus it is particularly important for women to receive timely treatment. Women with children may feel particularly stigmatized given that motherhood may be a large part of their identity, thus they may avoid treatment for fear of losing their children.
Borderline personality disorder (BPD) is another example of a gendered diagnosis. BPD is diagnosed more frequently in women than in men (adjustment and personality disorders are more than twice as often diagnosed in active-duty service women compared to active duty men), and it is the most stigmatized personality disorder. Research shows that clinicians were significantly more likely to assign BPD to women and PTSD to men when given identical and equal numbers of diagnostic criteria for each disorder. Such bias is concerning given that a diagnosis of PTSD attributes external events and situational factors to the disorder, whereas a diagnosis of BPD tends to attribute the disorder to internal, dispositional factors, increasing patient self-blame and stigma.
For female service members, such issues may be further complicated by military gender stereotypes and stigma of being a woman in the military. For example, some female service members perceive the need to excel beyond the expected competencies for males. Others have reported that seeking mental health care was difficult while serving and reflected poorly on their careers because of an attitude that women do not belong in the military. A recent study conducted with female veterans in community-based clinics in rural areas portrays additional hurdles faced by military women. The women had experienced sexual harassment and ridicule, sexual assaults, and combat. However, when they were referred for mental health treatment (usually by medical personnel) they reported feeling that, because of negative attitudes about women in combat, they were “not really combat veterans” and sometimes felt stigmatized by providers who exhibited lack of interest in their military experiences. There was also a sense of being “marked” and appearing “weak” once they sought mental health care.
How can we avoid gender bias in diagnosis and treatment?
The goal of therapy is to identify patient problems and provide treatment that will reduce distress and improve the quality of their lives. If problems are missed or misdiagnosed, patient well-being is compromised, and there is potential for increasing patient distress. Gender bias may occur because gender is a feature of a clinician’s stereotypes or prototypes. If a clinician bases diagnoses on a comparison of patients to stereotypes or prototypes, those diagnoses may have low validity. The tendency to assign a certain diagnosis more frequently in women and low concordance between a patient’s symptoms and traditional gender characteristics are other sources for gender bias. Reasons for misdiagnosis may include loose interpretation of diagnostic criteria, reliance on personal assumptions, and confirmation bias.
Clinicians can reduce the potential for gender bias, and misdiagnosis in general, by using a comprehensive and systematic diagnostic process to aid clinical judgment which incorporates these elements:
Diagnostic checklists (when structured diagnostic interviews are not possible) to help increase diagnostic accuracy
Evidence-based assessment using well-established, validated measures
Consideration of patient deficits and strengths –
Facilitation of informed choices – help patients advocate for themselves. For example, help facilitate patients with injuries or medical conditions that lead to anxiety and depression to make informed health care choices to mitigate the female stereotypes about submission and agreeableness. Provide resources and encourage patients to partner with their providers and ask questions about medications and medical treatment
Learn more about the impact of gender stereotypes on mental health diagnosis and treatment in my presentation from the National Departments of Veterans Affairs and Defense (VA/DOD) Women’s Mental Health Mini-Residency.
Skopp is a research psychologist at the Psychological Health Center of Excellence West at Joint Base Lewis McChord in Tacoma, WA. She is also an affiliate associate professor at the University of Washington (UW) Department of Psychiatry and Behavioral Sciences. Her expertise is in military psychological health research.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.