Gender Bias In Diagnosis: Background
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There was controversy over whether or not certain disorders (in this case Personality Disorders) represent
actual differences between males and females or whether they are reflective of the stereotypes and biases
of society and clinicians.
Hpd – histrionic – over-emotional, provocative, shallow
Apd – antisocial – lack of empathy, callousness
Previous research suggested that there is sex-bias in diagnosis: Warner (1978) found that the same case was
more likely to be judged as having HPD than APD if the 175 mh professionals thought the patient was
female, as opposed to male (described as female hpd=76% of time, if male= hpd 49% and apd 41%). These
diagnoses were selected from a list of 8 possible.
This research has been criticised as possibly reflective of a) actual differences in prevalence and b) reflective
of the fact that as more f than m have been diagnoses with hpd, the base rate (i.e. the figures that already
exist) show this bias, and clinicians are basing judgements on these base rates.
Ford and Widiger: Sex Bias in the Diagnosis of Histrionic and Antisocial Personality Disorders
Journal of Consulting and Clinical Psychology, 1989, vol 57 (2), 301-305.
Aims:
To assess whether sex differences in the diagnosis of APD and HPD could be explained by base rate. differences
To assess whether the more explicit and specific criteria of the DSM-III prevent sex bias.
Sample:
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Randomly selected from the National Register of Health Services Provides in Psychology with a
geographical focus on the South Eastern United States.
381 responses to mail out (34%, 43% when adjusted for undeliverable etc.)
Final selection of 354 mental health professionals
15.6 yrs average experience
Generally balanced spread of clinical perspectives/experience
Procedure
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Given one of 9 case studies
Either: m+neutral, i.e. no clear hpd or apd diagnosis, f+neutral, unspecified+neutral, m+hpd, f+hpd,
unspecific+hpd, m+apd, f+apd, unspecified+apd
The neutral case histories had no clear diagnosis, whereas the apd or hpd met the diagnostic criteria. It
was established prior to the study that there were no gender specific criteria in either hpd or apd lists.
Results
If diagnosis is based purely on diagnostic criteria the males an females should have been equally as likely to receive
diagnosis of hpd in the hpd condition. If base rates or stereotypical bias affect the diagnosis then we would expect
more hpd female diagnoses even when criteria are the same for the male and female conditions.
Histrionic cases:
M: correctly diagnosed 44% of the time, F: 76% of the time
Antisocial cases:
M: 42% correctly, F: 15% correctly
% of histrionic diagnoses (incorrect diagnoses) in the APD category for females: 46%
%. of antisocial diagnoses (incorrect diagnoses) in the HPD category for males: 33%
Conclusions:
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The DSM-III’s explicit criteria do not guarantee objective diagnosis of HPD and APD.
Gender influences the diagnosis of APD and HPD, with females more likely to be diagnosed as histrionic
and males more likely to be diagnoses as antisocial, when all other factors are controlled for.
Base rate judgments are not the best way of explaining the biases as they usually only occur when the
information is ambiguous – the HPD and APD lists were unambiguous as rated by 88 psychologists.
Tendency not to diagnose males with HPD and a tendency to diagnose females with HPD.