Gender and Mental Health Issues

The Psychology of Women and Gender: Half the Human Experience + - Nicole M. Else-Quest, Janet Shibley Hyde 2018

Gender and Mental Health Issues

“I was eighteen when I started therapy for the second time. I went to a woman for two years, twice a week. She was constantly trying to get me to admit that what I really wanted was to get married and have babies and lead a ’secure’ life; she was very preoccupied with how I dressed, and just like my mother, would scold me if my clothes were not clean, or if I wore my hair down; told me that it would be a really good sign if I started to wear makeup and get my hair done in a beauty parlor (like her, dyed blond and sprayed); when I told her that I like to wear pants she told me that I had a confusion of sex roles.”

Phyllis Chesler (1972), Women and Madness

When psychologist Phyllis Chesler wrote her revolutionary book Women and Madness in 1972, stories like this one were not uncommon. Today, gender bias in diagnosis and treatment of mental health issues is more subtle, just as modern sexism has replaced old-fashioned sexism in many other areas of life. In this chapter, we discuss some of the mental health issues that show lopsided gender ratios in prevalence, the evidence on gender bias in psychotherapy, and feminist therapy. We also consider American Psychological Association guidelines for psychological practice with two marginalized groups: trans people and women of color.


According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), at least five of the following symptoms must be present for at least 2 weeks for a diagnosis of depression:

1. Depressed, sad, empty, or hopeless mood

2. Loss of interest or pleasure in all or nearly all activities

3. Significant increase or decrease in appetite and/or weight

4. Sleeping too much or too little

5. Psychomotor agitation or retardation (e.g., restlessness, being slowed down)

6. Fatigue or loss of energy

7. Feelings of worthlessness or inappropriate guilt

8. Difficulty concentrating or making decisions

9. Thinking about death, suicidal ideation, or even attempting suicide

These are the classic, defining symptoms of depression.

Gender Differences

No matter how you count it, more women than men are depressed. The gender difference is found whether the index is diagnosable depression, people seeking therapy for depression, or even depressive symptoms in samples drawn from the general community. The lifetime prevalence of depression is 15.9% for girls and women but 7.7% for boys and men (Merikangas et al., 2010). A meta-analysis of gender differences in depression using nationally representative samples found that about twice as many women as men are depressed, or d = —0.37 (Salk et al., 2017). At the intersection of gender and ethnicity, these differences were found across ethnic groups in the United States. The meta-analysis included studies from 90 countries, finding that effect sizes in depression vary somewhat, but the same general pattern of gender differences is found across cultures and income levels (Salk et al., 2017).

One important finding about depression is that, across the lifespan, the gender difference changes. In childhood, there appears to be no gender difference in depression. Yet in early adolescence, girls’ depressive symptoms begin to accumulate (Hankin et al., 2015; Salk et al., 2016). In U.S. community samples, a gender difference emerges between 11 and 12 years old, peaks at 16 (d = —0.47), and then decreases and remains stable in adulthood (d = —0.19 to —0.30; Salk et al., 2016; Salk et al., 2017). Adolescence is a challenging time for many youth, but it seems there’s something especially difficult about it for girls.

It was once argued that these higher rates of depression in adolescent girls and women are not cause for concern because the gender difference is an “artifact” rather than a true difference. That is, it seemed possible that, in reality, men and women suffer equally from depression but that women are overrepresented in the statistics, perhaps because they are more willing to admit the symptoms or to seek help for their problems. We now know that the difference is not an artifact, but a true mental health disparity.

We also know that no single factor (for example, stress) accounts for the gender difference in depression. Multiple factors are involved, and different people may become depressed for different reasons. Newer theories of depression, such as the ABC model, must integrate multiple factors to explain gender differences in depression.

The ABC Model

The ABC model is illustrated in Figure 15.1 (Hyde, Mezulis, & Abramson, 2008). The diagram is complex, and we will break it down in the sections that follow.

The ABC model is a vulnerability-stress model. That is, people carry with them different levels of vulnerability to depression. In the presence of stress, those with high vulnerability are likely to become depressed. Someone who does not have high levels of vulnerability might encounter the same stress and not become depressed. The A, B, and C stand for three categories of factors that make someone vulnerable to depression: affective, biological, and cognitive. Let’s consider each of them.

Affective vulnerability.

The A stands for affective (or emotional) vulnerability. Specifically, the focus here is on temperament, which we discussed in Chapter 7. Temperament refers to constitutionally based individual differences in reactivity and regulation. It includes emotional traits that appear early in life and predict later behaviors and psychological problems, such as negative emotionality. Children who are high in negative emotionality tend to become upset, fearful, sad, or tearful more easily than their peers, and they are highly sensitive to negative stimuli. A number of studies have shown that negative emotionality predicts depression in adolescents and adults (Clark et al., 1994; Colder et al., 2002; Newman et al., 1997).

How can the affective factor of negative emotionality explain the gender difference in depression? Although meta-analysis has shown that there is no gender difference in average levels of negative emotionality, there is some evidence that, as a group, girls are somewhat more variable in this trait (Else-Quest et al., 2006). That is, girls display slightly more variability (variance) in negative emotionality so that, even though there is no average gender difference, there are more girls who score in the top 20% for negative emotionality. Those girls with higher negative emotionality are more vulnerable to depression.

Biological vulnerabilities.

The B is for biological vulnerabilities. Here we discuss two potential biological factors—genetics and issues associated with puberty—but there are also others such as epigenetic factors and neurobiological changes.

Figure 15.1 The ABC model of depression explains the emergence of gender differences in depression during adolescence.


Source: From Hyde, Mezulis, & Abramson (2008).

The Human Genome Project has mapped the thousands of genes that constitute the human genome. A dozen or more of these genes have been implicated in depression, many of which have to do with coding proteins that are part of the serotonin system. Serotonin is one of the neurotransmitters involved in depression. Selective serotonin reuptake inhibitors (SSRIs) increase serotonergic activity in the brain and are effective in treating depression (Levinson, 2005).

Much research has focused on a serotonin-related gene called 5-HTTLPR, which has evidence for its importance to depression. The two alleles for this gene are called s (for short) and l (for long), so people may have an s/s, an s/l, or an l/l genotype. In an important study, researchers showed that s is the vulnerability gene and that it interacts with stress to predict depression (Caspi et al., 2003). One stressor they studied was child maltreatment, ranging from no maltreatment to severe maltreatment. The outcome was major depression occurring between ages 18 and 26. Individuals with the l/l genotype were unlikely to experience depression, regardless of whether they suffered maltreatment. Those with the s/s genotype had low rates of depression with no maltreatment, but with severe maltreatment they had high rates of depression. The results, then, show a genotype × environment interaction. While there are some contradictory findings, other researchers have found a similar effect (for a meta-analysis, see Karg et al., 2011). These results are also an example of a vulnerability-stress interaction. The s/s genotype creates a vulnerability, and in the presence of severe stress (child maltreatment), depression is a likely outcome.1

1. In case you are wondering about people with the s/l genotype, they fall in between the s/s and the l/l. That is, under conditions of severe maltreatment, s/l people have a rate of depression that is moderate, falling between the low rate for l/l people and the high rate for s/s people.

As discussed in Chapter 2, feminists have often been critical of biological explanations for gender differences because such explanations tend to promote biological determinism and reinforce a patriarchal status quo (Salk & Hyde, 2012). Do these criticisms apply to this research on gender and depression? For several reasons, we don’t think so. Contemporary genetics research is far more sophisticated than the old-fashioned biological determinism that feminists have criticized. The research does not show, for example, that those with an s/s genotype absolutely will develop depression. Among s/s individuals, even under conditions of severe maltreatment, far less than 100% become depressed. Indeed, these findings and others in contemporary genetics research actually demonstrate the great importance of environment, including stress, in development (Salk & Hyde, 2012).

How can this gene—stress interaction help to account for gender differences in depression? It turns out that men and women are equally likely to have the vulnerable s/s genotype, so the answer may lie in stress. That is, if girls and women experience more stress than boys and men do, that would create a gender difference in depression among those with the s/s genotype. We will return to this important point later.

The sharp emergence of the gender difference in depression occurs around age 12, making puberty a suspect. In particular, researchers have examined pubertal timing, or whether kids are reaching puberty early, on time, or late relative to their peers. That is, pubertal timing is another biological vulnerability. For transgender youth, puberty is especially fraught with challenges, but there are not yet sufficient data to demonstrate precisely how pubertal timing plays a role in their well-being. We currently know much more about the effects of pubertal timing for cisgender youth. Early puberty has often been considered detrimental for cisgender girls (Ge & Natsuaki, 2009; Natsuaki et al., 2015). Consider the girl who develops sexy curves and noticeable breasts at 10 or 11: She is sexualized and teased by her peers and, compared with other girls, is less able to handle it, precisely because she is young and not mature enough to manage such social challenges (see Chapter 7). By contrast, for cisgender boys, early puberty is often welcome good news. These boys grow taller and more muscular ahead of their peers and thus perform better athletically. Nonetheless, meta-analysis indicates that early puberty is positively associated with internalizing disorders (like depression) among cisgender girls (d = 0.19) and boys (d = 0.16; Ullsperger & Nikolas, 2017). Thus, early puberty is a risk factor for depression, regardless of gender.

Cognitive vulnerabilities.

C is for cognitive vulnerabilities. We consider three of them here: negative cognitive style, rumination, and objectified body consciousness.

Negative cognitive style is rooted in the hopelessness theory of depression, formulated by psychologist Lyn Abramson and her colleagues (1989). According to hopelessness theory, a negative cognitive style makes a person vulnerable to depression. Like the ABC model, hopelessness theory is a vulnerability-stress theory of depression.

Negative cognitive style: A tendency to attribute negative life events to internal, global, and stable causes.

Hopelessness theory: A vulnerability-stress theory that a negative cognitive style makes a person vulnerable to depression.

People with a negative cognitive style tend to show a particular pattern of thinking when they experience negative life events (e.g., failing a test, losing a job, getting sick). When negative life events happen to people with a negative cognitive style, they tend to do three things: (1) They conclude that the negative event implies bad things about themselves—that is, they make an internal attribution. For example, after failing a math exam, a student says, “I got the F because I’m stupid” rather than “I got the F because the exam was way too difficult.” (2) They attribute the negative event to global causes. In other words, they believe that whatever caused the negative event is going to generalize to many other areas of their lives (a global attribution). The student thinks, “I’m so stupid, I’m probably going to fail the exams in my other classes, too.” (3) They believe that whatever caused the negative event is going to continue in their lives and create more negative events in the future (a stable attribution). The student concludes, “I’m never going to understand math. I’m just not smart enough.”

In sum, people with negative cognitive styles tend to make internal, global, stable attributions about negative life events. Someone who does this will, in turn, feel hopeless and convinced that there is nothing to be done to stop negative life events from happening.

Research with children under 11 indicates no gender difference in cognitive style (Abela, 2001; Gladstone et al., 1997). Yet research with adolescents shows that girls have a slightly more negative cognitive style (Hankin & Abramson, 2002). Adolescence, then, is when the cognitive vulnerability stage is set for the gender difference in depression to emerge.

Psychologist Susan Nolen-Hoeksema (1991, 2001) introduced a second type of cognitive vulnerability to depression: rumination, which refers to the tendency to think repetitively about one’s depressed mood or about the causes and consequences of negative life events. People who ruminate just can’t seem to get these negative thoughts out of their heads, which predisposes them to depression. One meta-analysis found that gender differences in rumination are very small in childhood (d = —0.14) but swell during adolescence (d = −0.36; Rood et al., 2009). Another meta-analysis found that gender differences in rumination are significant but small in adulthood (d = —0.24; Johnson & Whisman, 2013). Additionally, research has demonstrated that co-rumination—essentially, when peers frequently discuss or rehash problems with one another—helps to explain the emergence of gender differences in depression in adolescence (Stone et al., 2011). That is, adolescent girls are more likely to co-ruminate, which then contributes to the onset, severity, and duration of depressive symptoms that they experience. Girls’ and women’s greater tendency to ruminate and co-ruminate, then, may help explain gender differences in depression.

Rumination: The tendency to think repetitively about one’s depressed mood or about the causes and consequences of negative life events.

A third type of cognitive vulnerability to depression is objectified body consciousness, which was described in detail in Chapter 2. The body surveillance component—a repetitive self-surveillance to make sure that one’s body conforms to cultural ideals—is most relevant here. Longitudinal research shows that body surveillance predicts later depressive symptoms among adolescents (Grabe, Hyde, & Lindberg, 2007). And by age 11, girls score higher than boys on body surveillance (Grabe et al., 2007). Thus, body surveillance and the cultural forces that create it contribute to the gender difference in depression.

Negative life events.

We have described the three categories of vulnerabilities to depression: affective, biological, and cognitive. But these are just vulnerabilities, and a vulnerability-stress theory such as the ABC model also requires stress for the development of a disorder like depression. Negative life events or serious stress are theorized to interact with or activate the existing vulnerabilities to depression, thereby triggering the development of depression. It is well established that negative life events predict depression including, specifically, depression in adolescence (Grant et al., 2004; Monroe & Reid, 2009; Tram & Cole, 2000).

Thus, logic follows that if boys and girls experience similar rates of negative life events but girls are more vulnerable to the effects of those negative life events, a gender difference in depression would emerge. However, it turns out that girls and women actually experience slightly more negative life events than boys and men do (d = —0.12; Davis et al., 1999). According to a meta-analysis of research on major and minor life events, the gender difference was not significant in childhood, but was in adolescence (Davis et al., 1999). The gender difference in adolescence was also larger for appraisals (that is, how unpleasant or stressful the event was) of the event (d = —0.29) rather than just for the occurrence of the event. In other words, compared with their male peers, adolescent girls experience a greater number of negative life events and they report that those events are more stressful.

This meta-analysis lumped together all types of negative life events and may not have given sufficient weight to the really serious events. For example, child sexual abuse is among the most serious and detrimental of negative life events, and girls are more than twice as likely as boys to report sexual abuse in childhood and adolescence (Kendler et al., 2000; see Chapter 14).

Another category of negative life events is peer sexual harassment in the schools, as discussed in Chapter 7. More girls than boys report being victims, and girls are also more upset by such incidents (American Association of University Women, 2011). And a majority of LGBTQ youth report being verbally harassed because of their sexual orientation or gender expression (Kosciw et al., 2014). In sum, peer sexual harassment is more common for adolescents who aren’t straight cisgender boys.

Violence and poverty are additional factors that contribute to depression in girls and women and help to explain the gender difference (Belle & Doucet, 2003; Cutrona et al., 2005; Koss, Bailey, et al., 2003). Gender-based violence was discussed in detail in Chapter 14, but it is clear that the experience of being victimized can lead to depression. Regarding the second factor, poverty has become increasingly gendered. An increasing proportion of those living below the poverty line are women or women and their children, a phenomenon known as the feminization of poverty. In turn, this pattern is related to factors such as the increased proportion of single-parent households headed by women, the inadequacy of child support payments following divorce, and the lack of decent, affordable child care that would allow these women to work at jobs that could bring them to self-sufficiency (Belle & Doucet, 2003). Abundant evidence shows a link between poverty and mental health problems (Belle & Doucet, 2003). Therefore, the feminization of poverty has mental health implications for women.

Feminization of poverty: The increasing trend over time for women to be overrepresented among the poor in the United States.

Research indicates that women who are financially stressed and have responsibility for young children experience more symptoms of depression than other women do. One study found that 40% of the low-income mothers in the sample had sufficient symptoms to be categorized as depressed (Coiro, 2001). It is clear that the higher rates of poverty among women contribute to the higher incidence of depression in women.


We have looked at the three categories of factors—affective, biological, and cognitive—proposed by the ABC model to make a person vulnerable to depression when faced with negative life events. It’s important to remember that no single factor explains the emergence of the adolescent gender difference in depression. Instead, multiple pathways and multiple factors may contribute to girls’ higher depression. For one girl, it may be an s/s genotype combined with a history of childhood abuse or other trauma. For another, it may be a high level of body surveillance combined with a comment from a boy that she looks like she’s gaining weight. While humans are very adaptable and many overcome significant challenges, there are also many ways and reasons that we may develop disorders like depression.

Focus 15.1 The Politics of Psychiatric Diagnosis: Premenstrual Dysphoric Disorder

The American Psychiatric Association publishes a thick book called the Diagnostic and Statistical Manual of Mental Disorders (DSM). The latest edition, DSM-5, came out in 2013. Why is this book important? It contains the listing of all the official labels or diagnoses that psychiatrists and psychologists can give to people’s mental disorders, together with a list of the criteria or symptoms that a patient must show in order to be given a particular diagnosis. Money is involved because, in order for your health insurance to pay for psychotherapy, the therapist must give you an official diagnosis from this book, which then becomes part of your medical record. In turn, a diagnosis from the DSM must be noted in situations such as an application for disability insurance and may exclude you from certain occupations or educational training. A DSM diagnosis may help you gain access to therapy, but it is also potentially stigmatizing.

The DSM-5 contains several controversial diagnoses. One such diagnosis is premenstrual dysphoric disorder (PMDD). (Dysphoria is the opposite of euphoria; dysphoria means unhappiness or depressed mood.) To be diagnosed with PMDD, a person with a female body must display at least five of the following symptoms during the last week of most menstrual cycles during the past year: mood fluctuations, irritability, anger, or increased interpersonal conflict; depressed mood, hopelessness, self-deprecation, or marked anxiety or tension; decreased interest in usual activities; subjective difficulty in concentrating; lethargy or fatigue or lack of energy; marked appetite change with overeating or food cravings; insomnia or hypersomnia; and feelings of being out of control. Somatic symptoms such as bloating, weight gain, breast tenderness, and joint or muscle pain may also be present (American Psychiatric Association, 2013). Many of these symptoms are also present in depression, but a key difference here is timing. Symptoms should improve or even disappear in the first week of the menstrual cycle, only to return again a few weeks later.

Is PMDD an attempt by the American Psychiatric Association to incorporate PMS into its diagnoses? Advocates of the PMDD diagnosis maintain that PMDD is more severe than PMS (Epperson et al., 2012). They also claim that PMDD is very rare—with only 2% prevalence, which is about the same as the prevalence of autism spectrum disorder. Yet skeptics have pointed out several problems with the PMDD diagnosis.

One reason to be skeptical about PMDD is that the scientific evidence backing it is disputed. While the DSM is supposed to contain only diagnoses that have been validated scientifically, there are many social scientists who remain critical of a PMDD diagnosis. For example, there is some concern that PMDD is culture-bound, existing only in certain cultures. If a disorder results from hormonal fluctuations in the female body, wouldn’t we expect women across cultures to experience it? Most PMS research has been done in a small number of Western nations. Research conducted in Hong Kong and mainland China indicates that women there report premenstrual symptoms of fatigue, water retention, pain, and increased sensitivity to cold (Chrisler & Johnston-Robledo, 2002). American women do not report increased sensitivity to cold and Chinese women do not report depression. These findings also confirm the argument that many PMS symptoms are culturally constructed.

There is also a suspicion of drug company involvement (Ali et al., 2010). The pharmaceutical company Eli Lilly developed and owned the patent to the antidepressant Prozac. The patent was about to expire and, with it, huge profits. Eli Lilly repackaged Prozac (fluoxetine) as Sarafem, a treatment for PMDD and, miraculously, PMDD appeared in the DSM at about the same time.

A diagnosis of PMDD might be harmful to women in several ways. For example, a woman who is diagnosed with PMDD might be regarded as emotionally unstable or mentally ill and then denied insurance coverage or custody of her children. As a rule, one should be suspicious of any psychiatric diagnosis that can be applied to one gender only.

What about women who do feel depressed just before their period? Don’t we need a diagnosis for them? There already is one—depression. They can be treated for it, with no need for gender-stereotyped and potentially harmful labels of PMDD.

In sum, there is serious question about the scientific validity of PMDD. Even a process as seemingly innocent as psychiatric diagnosis may involve gender stereotypes and practices that can be harmful to women.

Alcohol- and Substance-Use Disorders

Gender and Alcohol-Use Disorder

Each year in the United States, alcohol causes nearly 107,000 deaths, from car crashes to liver disease (Centers for Disease Control and Prevention, n.d.). Thirty percent of these deaths are among women. In addition to the well-known damage that alcoholism does to women’s day-to-day functioning, heavy drinking increases women’s mortality rates. Chronic conditions such as alcoholic liver disease and cirrhosis, as well as acute conditions such as falls, poisoning, and motor vehicle crashes, are the most common types of alcohol-attributable deaths among women.

In addition, even moderate alcohol intake is linked to an increased risk of breast cancer. About 4% of breast cancer cases are attributed to alcohol use (Collaborative Group on Hormonal Factors in Breast Cancer, 2002). Research indicates that alcohol raises the levels of specific sex hormones that are known to increase breast cancer risk (Dorgan et al., 2001). In addition, long-term alcohol abuse of the kind that occurs in alcohol-use disorder actually shrinks the brain, and the effect is larger in women than in men (Wuethrich, 2001).

We can think of drinking behavior as falling along a continuum from abstinence at one end to dependence at the other, with moderate drinking, heavy drinking, and problem drinking falling in between. As can be seen in Table 15.1, there are gender differences in any use of alcohol, with more men than women consuming alcohol. Alcohol-use disorder is characterized not only by excessive alcohol use, but also by the associated failure to fulfill major role obligations (e.g., work, school, home). As such, alcohol-use disorder can have pervasive and far-reaching impacts. The ratio of men to women with alcohol-use disorder is approximately 3:1. This gender difference is found across nations, although the gender ratio varies somewhat from one country to another (Wilsnack et al., 2009). The gender difference exists across ethnic groups in the United States, but overall rates differ across ethnic groups. That is, American Indians have the highest rates of alcohol-use disorder, followed by Whites, Hispanics, African Americans, and Asian Americans (American Psychiatric Association, 2013).

Alcohol-use disorder: A psychological disorder characterized by excessive alcohol use and associated failure to fulfill major role obligations (e.g., work, school, home).

In short, despite the greater prevalence in men, alcohol-use disorder remains a very serious matter for women. Why did it take so long for scientists to alert us to this issue? One reason is that, as recently as 1995, all-male research samples were still common (Greenfield, 2002). And because alcohol-use disorder is stereotyped as a “masculine” problem, women with alcohol-use disorder stand a good chance of being overlooked.


Source: Data from Substance Abuse and Mental Health Services Administration (SAMHSA; 2014).

Causes of Gender Differences in Alcohol-Use Disorder

Heavy drinking almost always precedes and often predicts the development of alcohol-use disorder, and more men than women are heavy drinkers (Dawson et al., 1995). That then leads to this question: Why are more men heavy drinkers? One possibility has to do with gender roles; in short, women’s drinking is restricted and men’s is encouraged. That is, heavy drinking and drunkenness are more socially disapproved for women than for men (Vogeltanz & Wilsnack, 1997). Therefore, women must limit their alcohol consumption to avoid this social disapproval. Also, men experience more social pressure to drink than women do (Suls & Green, 2003).

Another possibility has to do with how female bodies respond to alcohol. That is, alcohol has greater bioavailability in women than in men, such that, given equivalent doses of ethanol, a woman will experience a higher blood alcohol level than a man, even when body weight is controlled for (El-Guebaly, 1995; York & Welte, 1994). Partly, this has to do with metabolic differences between male and female bodies (Baraona et al., 2001). Women are therefore more sensitive to the effects of alcohol. According to this explanation, women may learn to moderate its use, thereby avoiding becoming problem drinkers.

Predictors of Alcohol-Use Disorder in Women

Many factors may contribute to the development of alcohol-use disorder in women, including genetic factors, a history of childhood adversity, having a mood disorder, and having a spouse or partner who has a drinking problem.

A substantial body of evidence indicates that genetic factors contribute to alcohol problems, although some researchers believe that genetic influence is weaker in women than in men (Hicks et al., 2007). Certainly, it is true that not everyone who has an alcoholic parent will also become alcoholic. Some factors may actually protect such people from developing alcohol use problems. For example, one study found that being in a good marriage protected women who had an alcoholic parent from also becoming alcoholic (Jennison & Johnson, 2001).

A history of childhood adversity is a strong predictor of alcohol problems in women. One especially important factor is childhood sexual abuse. For example, one study with a sample of women with alcohol- and/or substance-use disorders found that 51% had experienced childhood sexual abuse and 39% had been exposed regularly to physical abuse by a parent (Berry & Sellman, 2001). Another study examined adverse childhood experiences (such as physical, emotional, or sexual abuse; physical or emotional neglect; having household members with a history of incarceration, mental illness, and/or substance abuse; and parental discord and violence) and found that such experiences were associated with problematic alcohol and substance use (Dube, Anda, et al., 2002; Dube, Felitti, et al., 2003). Moreover, a higher number of adverse childhood experiences increased the likelihood that a participant developed an alcohol- and/or substance-use problem.

Depression and anxiety are commonly associated with alcohol problems in women (Mann et al., 2004). One question is this: Are the depression and anxiety the cause or the effect? Do they precede or follow alcohol-use disorder? In some cases, people may self-medicate their depression or anxiety with alcohol use. In others, excessive alcohol use may lead a person to make maladaptive choices (e.g., driving while drunk, missing work or school), the negative effects of which foster the development of depression or anxiety.

Substance-Use Disorder

Substance-use disorder (what many people might think of as drug abuse and addiction) has a cluster of cognitive, behavioral, and physiological symptoms that develop from a person’s excessive use of a substance despite its creating significant problems in their life (American Psychiatric Association, 2013). Diagnostic criteria also include the failure to fulfill major role obligations at work, school, and home; the desire and perhaps failed efforts at stopping or cutting back on use; cravings or preoccupation with obtaining the substance; and using increasingly larger amounts of the substance over time to achieve the desired effect. These are, essentially, the same diagnostic criteria as for alcohol-use disorder. Excessive use of the substance (whether it be heroin, cocaine, methamphetamine, etc.) activates the brain’s reward system, making the user feel an intense sensation of being rewarded for their behavior.

Substance-use disorder: A psychological disorder characterized by excessive use of a substance (e.g., heroin), an associated failure to fulfill major role obligations (e.g., work, school, home), failure to cut back on use, cravings, and using increasingly greater amounts of the substance over time.

Although drug addiction is stereotyped as masculine, plenty of women suffer from addictions, and the pattern is not at all new. During the 19th century, the majority of morphine and opium addicts were women (Kandall, 1996). In 1894 Dr. Joseph Pierce proclaimed, “We have an army of women in America dying from the opium habit—larger than our standing army. The profession [medicine] is wholly responsible for the loose and indiscriminate use of the drug” (Kandall, 1996, p. 631). Addiction to prescription painkillers remains a public health problem in the 21st century.

Today, as Table 15.1 shows, substantial proportions of women continue to use illicit drugs such as cocaine, and many use the licit drugs of alcohol and nicotine (tobacco). Several historical shifts have also occurred in recent decades. For example, the decriminalization of marijuana has made its use less stigmatized and more socially acceptable.

Another historical shift is evident in the use of the illicit drug heroin and the attention it receives. In particular, the use of heroin, an opioid, has attracted considerable media attention in recent years as we’ve witnessed demographic shifts in the population of users. When heroin was disproportionately used by men of color in lower income communities, there was little media attention or public health funding regarding heroin addiction and treatment. Today, 90% of those who began using heroin in the last decade are White, and about half are women (Cicero et al., 2014). Most users live in rural and suburban communities and began using heroin when their use of prescription opioids such as OxyContin became too expensive (Cicero et al., 2014). While it is difficult to prove that media and public health attention for heroin use is dependent on the race, class, and gender of users, the pattern is disturbing. Moreover, an intersectional perspective would note that low-income men of color, and their well-being, have historically been marginalized.

Gender dynamics are also important in women’s substance-use disorder. Men often are the gatekeepers who get women involved in illicit drug use and addiction (Collins, 2002). Straight women are more likely to have used heroin at the urging of a male sex partner, and men are more likely to have tried it due to pressure from other men. The economics of addiction also mean that many women who become addicted to illicit drugs may be drawn into prostitution to pay for their drugs (Collins, 2002).

As to the factors that increase a woman’s risk of developing substance-use disorder, the list looks much like the one predicting alcohol-use disorder. It includes genetic factors, childhood sexual abuse, inadequate parenting, drug use by peers, and adult victimization by intimate partner violence (Goldberg, 1995; Hicks et al., 2007; Kilbey & Burgermeister, 2001). In one large, well-sampled study, 6.6% of women who had a history of child sexual abuse met criteria for substance-use disorder, compared with 1.4% of women with no history of abuse (MacMillan et al., 2001).

In sum, while women may not abuse alcohol and other drugs to the same extent that men do, substance-use disorder is an important issue for women. Not only do they themselves suffer enormously from dependence on drugs, but also, increasingly, women are being legally charged for damage to a fetus exposed to harmful drugs during a pregnancy (Martin, 2015).

Eating Disorders

Disordered eating behaviors are common among adolescent girls and adult women. Among college women, 26% engage in dietary restraint, 21% to 32% binge eat, 9% self-induce vomiting, 6% to 9% misuse laxatives, and 7% misuse diuretics (Celio et al., 2006; Luce et al., 2008). By age 20, approximately 5% of women in the United States have developed an eating disorder (Stice et al., 2013). These disorders are noteworthy in part because they are chronic and have high relapse rates; they are also deadly. In the DSM-5, diagnostic categories for eating disorders include anorexia nervosa and bulimia, as well as binge-eating disorder and others. Here we focus on anorexia and bulimia, which are well researched and overwhelmingly more common among women, with gender ratios of 10:1 (American Psychiatric Association, 2013).

Anorexia Nervosa

When asked if she had a personal motto, the supermodel Kate Moss famously replied, “Nothing tastes as good as skinny feels” (quoted in Selby, 2014). This quote has been embraced by those with a singular focus on thinness, including pro-anorexia websites and individuals with anorexia nervosa.

Anorexia nervosa is a disorder in which one essentially starves oneself. Anorexia disproportionately affects girls and women: More than 90% of people with anorexia are female. In addition, the great majority of people with anorexia are adolescents, with the usual age of onset being between 13 and 25. Anorexia is estimated to afflict 0.8% to 2.8% of young women (Stice et al., 2013).

Anorexia nervosa: An eating disorder characterized by over-control of eating for purposes of weight reduction, sometimes to the point of starvation.

According to the DSM-5, the following are the official criteria for a diagnosis of anorexia nervosa: (a) restriction of energy intake, leading to a body weight that is at or below the minimum normal weight for that person’s age and height; (b) an intense fear of gaining weight or becoming fat, even though the person is underweight; and (c) disturbance in the experience of one’s body weight or shape, an undue influence of body weight or shape on self-evaluation, or persistent denial of the seriousness of the current low body weight. Anorexia may also include recurrent episodes of binge-eating and purging, such as self-induced vomiting.

The extreme weight loss characteristic of anorexia results from the individual’s compulsive dieting. Although they may begin with “normal” dieting, it soon gets out of control. They might limit their food intake to perhaps 600 to 800 calories per day or restrict their diet to only a few low-calorie foods, perhaps existing solely on cottage cheese and apples. Their thoughts become excessively focused on food and eating, and rituals develop around eating. They eat in private and generally become so preoccupied with their diet that social activities and relationships become irrelevant.

The compulsive dieting is a result of an intense fear of gaining any weight and a corresponding drive toward thinness. But their body image is severely distorted, so that they believe they are fat even though they are emaciated, perhaps 20% or more under normal body weight. Despite the low intake of calories, the individual with anorexia often undertakes overly strenuous exercise to try to burn off more calories. Only making matters worse, a person with anorexia usually engages in denial: They firmly maintain that they have no problem and that they are not underweight. They also tend to resist any treatment or psychotherapy, convinced that such efforts will only make them fat.

Bulimia Nervosa

Bulimia nervosa is an eating disorder characterized by episodes of binge-eating large amounts of food while feeling a lack of control over eating, followed by purging behaviors, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessively exercising. Like anorexia, bulimia also includes an undue influence of body weight or shape on self-evaluation. An individual with bulimia may consume 4,000 to 5,000 calories per day yet continue to lose weight because they purge the food.

Bulimia nervosa: An eating disorder in which the person binges on food and then purges the body of the calories by vomiting, using laxatives or diuretics, fasting, or excessively exercising.

Prevalence estimates are that 2.6% of young women are bulimic and that 4.4% engage in bulimic behaviors but are below the threshold for diagnosis (Stice et al., 2013). The prevalence of bulimia is alarming, especially because the health consequences of it are so serious. Some of these are the result of starvation. An individual with bulimia may suffer serious damage to their teeth and esophagus, due to the acidity associated with vomiting. They may also develop problems with their stomach, heart, and bones, and may even die from complications of the disorder.

Causes of Eating Disorders

Many factors have been proposed as causes of or risk factors for eating disorders, including biological factors, personal traits such as perfectionism and low self-esteem, traumatic life events, and a culture that is obsessed with thinness (Jacobi et al., 2004; Striegel-Moore & Bulik, 2007; Tylka & Hill, 2004).

For example, it has been proposed that anorexia is a result of biological causes. People with anorexia do have some abnormalities in their biological functioning, but it’s not clear whether the physiological problems are the cause of the anorexia or the result of starvation (Piran, 2001). The problem is that physicians may not identify these physiological problems until the patient is already anorexic. Many of the problematic conditions seem to be the result of starvation; that is, most of the conditions reverse and return to normal as the person gains weight. For example, electrolytes are important for the proper functioning of the nervous system, and electrolyte levels (e.g., potassium) are disturbed in people with anorexia. In people with bulimia, low potassium levels may result from vomiting and use of laxatives and diuretics. Convulsions, low blood pressure, low heart rates, and irregular heartbeats are other results of the starvation. It seems, though, that each of these physiological problems is a result, rather than a cause, of eating disorders.

Nonetheless, other biological characteristics that are not problems or abnormalities might indirectly be associated with eating disorders. For example, a large longitudinal study of young women with body dissatisfaction found that adolescent girls with a lower body mass index (BMI) had a greater risk for later developing anorexia (Stice et al., 2017). Researchers are not sure why being thin makes a woman more likely to develop anorexia.

There is also emerging evidence that eating disorders such as bulimia involve brain mechanisms like those seen in substance addiction. Research points to the possibility of dysfunction in the brain’s reward system that leads individuals to engage in binge-eating (Schulte et al., 2016).

Another possible biological factor for eating disorders is genetics. Both twin studies and adoption studies show that there are significant genetic effects on eating disorders (Baker et al., 2009; Klump et al., 2009).

Personal characteristics or traits may also increase risk. For example, global self-esteem has been negatively associated with disordered eating behaviors (Zeigler-Hill & Noser, 2015). In addition, perfectionism has been identified as a risk factor for both anorexia and bulimia (Fairburn et al., 1999). Of course, not all perfectionists develop eating disorders. Perfectionism is a vulnerability that, combined with a particular stressor—like the belief that one is overweight or a comment from a gymnastics coach that one is getting too heavy to be successful in the sport—leads to the development of an eating disorder (Joiner et al., 1997).

Like many mental health issues, traumatic life events increase risk for eating disorders. Traumatic events may predispose a person to developing an eating disorder or may precipitate an eating disorder in someone who is already vulnerable. For example, compared with healthy controls, patients with eating disorders are much more likely to have a history of child sexual abuse (11% vs. 35%; Fairburn et al., 1997). Those with eating disorders are also considerably more likely (50%) to have been teased repeatedly about their weight or appearance compared with healthy controls (28%).

Finally, research indicates that a major factor in the development of eating disorders is the internalization of the thin ideal and the pressure to be thin (Stice et al., 2017). Many feminists have linked this thin-ideal internalization to objectified body consciousness and our culture’s obsession with thinness.

Feminist Perspective

The feminist perspective emphasizes the socialization practices and media messages of our society over the pathology of the individual (e.g., Gilbert et al., 2005). The person with anorexia shows an extreme reaction to the socialization and thin-ideal messages that all women in American society hear while growing up. High-fashion models, Playboy centerfolds, and Miss America contestants present images of slimness that are difficult to live up to. Just as wealthy Chinese for centuries bound the feet of their daughters to achieve a culturally defined standard of beauty, so a particular standard of appearance of thinness is enforced in American society, not through physical methods but rather by socialization.

Here are some of the data on historical shifts of the past 75 years: In the 1950s, the average BMI of Miss America winners was 19.4; by the late 1980s it had declined to 18.0 (Spitzer et al., 1999). The average model, dancer, or actress today weighs less and looks thinner than 95% of the female population in the United States (Wolf, 1991). The World Health Organization’s cutoff for anorexia is a BMI less than 17.5. Meanwhile, the average actual BMI of American women age 18 to 24 went from a little over 22 in 1970 to a bit over 24 in 1990 (Spitzer et al., 1999). In other words, despite decades of emphasis by the women’s movement on these issues, the gap between ideal and actual women’s bodies has only increased.

Photo 15.1 “Nothing tastes as good as skinny feels,” according to fashion model Kate Moss (pictured here). The media feature models who are unrealistically thin, which contributes to a culture that fosters eating disorders in women.


David M. Bennett/Getty Images Entertainment/Getty Images.

College women rate their ideal figure as considerably thinner than their actual figure (Lamb et al., 1993). In fact, dissatisfaction with weight is so common among adolescent girls and women that it has been termed a normative discontent (Rodin et al., 1985). In one study of sixth-, seventh-, and eighth-grade girls, 72% dieted (Levine et al., 1994). And in another study among fourth graders (10-year-olds), 51% of White girls and 46% of Black girls selected an ideal body size, from an array of drawings, that was thinner than their current size (Thompson et al., 1997).

Research indicates that being exposed to thin-ideal models in the media leads girls and women to feel dissatisfied with their own bodies (Grabe et al., 2008). These findings hold true in both correlational and experimental studies. That is, women who watch more thin-ideal media experience more body dissatisfaction, and women experimentally exposed to media experience more body dissatisfaction compared with women in the control group.

These standards of beauty are attached to White culture. For example, Black women tend to hold a larger body as the standard and feel more positively about their bodies, relative to White women (Grabe & Hyde, 2006). Similarly, Latinx beauty standards tend to value curves over thinness (Perez et al., 2016). Yet these ethnic differences are not as large as they once were, and women of color are often held to White standards of beauty. Immigration and acculturation may also lead to shifts in which beauty standard women of color internalize. One study with female international students from Asian nations studying in the United States found that eating disorder symptoms were correlated with the internalization of Western appearance norms (Stark-Wrobleski et al., 2005).

Psychologist Eric Stice (2001) put many of these factors into a model of the development of bulimic symptoms (see Figure 15.2) and tested the model with a sample of girls initially assessed when they were in ninth or tenth grade and then followed up 10 months and 20 months later. According to the model, the initial force is cultural pressure to be thin. This cultural pressure is internalized, leading the girl to become dissatisfied with her body. This dissatisfaction in turn leads to two outcomes: She engages in dieting, and she experiences increased negative affect (moodiness and feelings of depression). Dieting further contributes to the negative affect. The dieting and negative affect in turn lead to actual bulimic symptoms. Stice’s results with the high school sample indicated significant support for every link in the model, and other studies have shown similar findings (e.g., Tylka & Hill, 2004).

Treatments for Eating Disorders

For people with eating disorders, three treatments have been used: cognitive-behavioral therapy, family-based therapy, and antidepressants (Wilson et al., 2007).

Cognitive-behavioral therapy (CBT) is a frequently used therapy for people with eating disorders such as anorexia and bulimia. Cognitive-behavioral therapy helps people change not only their behaviors but also the way they think about themselves and the world around them. People with anorexia or bulimia often have distorted perceptions of their own bodies, believing themselves to be fat when they are thin. They may believe that weight gain is a sign of indulgence or lack of control and that thinness would solve all other problems. They base their own feelings of self-worth on how well they are controlling their eating and their weight, feeling worthless or inadequate. They are preoccupied with weight control such that it distracts them from other matters. CBT targets all of these problematic thought patterns. People with eating disorders are often extremely rigid in holding onto these ideas, making any form of therapy difficult. CBT therefore also targets a patient’s motivation to change.

Cognitive-behavioral therapy: A system of psychotherapy that combines behavior therapy and restructuring of dysfunctional thought patterns.

Figure 15.2 A model of the factors that contribute to the development of bulimia.


Source: Stice (2001). Copyright © 2001 by the American Psychological Association.

Research evidence suggests that CBT is effective in treating anorexia, despite methodological flaws (Wilson et al., 2007). A review of studies comparing CBT to other treatments found that CBT led to improvements in important outcomes like BMI, eating disorder symptoms, and related psychopathology such as depression (Galsworthy-Francis & Allan, 2014). Still, the review concluded that CBT doesn’t appear to be any more effective than other current forms of treatment, such as family therapy, in treating anorexia.

Family-based therapy (FBT) is based in family systems theory, which regards the person with anorexia not as an isolated, disturbed individual, but rather as a person embedded in a complex system that includes their family and society at large (Minuchin et al., 1978). Family events during the person’s childhood may predispose the individual to anorexia. Family interaction and communication patterns trigger and then perpetuate the problem in adolescence.

The predominantly upper-middle-class families of anorexic girls tend to emphasize beauty (and therefore thinness) and tangible signs of success, such as good grades. Dieting produces external, tangible signs of “success” and simultaneously allows the girl to gain a sense of control. But the girl’s problem behavior also has devastating effects on the functioning of the family. Parents feel scared and powerless about their daughter’s eating disorder, which then becomes the focus of the family.

Following from family systems theory, FBT is necessary. Therapy for the girl alone is believed to be inadequate because she remains embedded in the family that maintains her illness. Thus, both the person with bulimia or anorexia and her family must participate.

Research evaluating the effectiveness of FBT on eating disorders has focused mainly on a specific form called the Maudsley model (Lock & le Grange, 2005; Schmidt et al., 2015). Data indicate that the Maudsley model of family therapy is effective for many adolescents with anorexia (Blessitt et al., 2015).

How effective is FBT with bulimia? One study randomly assigned adolescents (mostly girls) with bulimia to receive either CBT or FBT for 6 months (Le Grange et al., 2015). Researchers evaluated the patients at the end of the treatment, and then again at 6 and 12 months posttreatment. The results are shown in Figure 15.3. While both forms of therapy improved outcomes for many of the individuals with bulimia, FBT demonstrated quicker effects. The researchers also found that FBT was especially effective in families where there wasn’t a high amount of family conflict.

Antidepressants—especially fluoxetine, an SSRI—have also been used in the treatment of anorexia, but there is little evidence that they are effective (Chavez & Insel, 2007; Wilson et al., 2007). Some people with anorexia also have depression, and antidepressants may be helpful with that aspect. Antidepressants are also sometimes used successfully with people with bulimia (Chavez & Insel, 2007).

Despite encouraging findings with CBT and FBT, the sad truth is that outcomes for people with anorexia and bulimia are not good enough. Successful treatment of anorexia and bulimia often takes many years, and some people never recover. For example, one review found that only about 50% of people with anorexia ever fully recover from their disorder, while 20% to 30% continue to experience some symptoms, 10% to 20% remain ill, and 5% to 10% die from complications of the disorder (Steinhausen, 2002). Data on outcomes of people with bulimia are only slightly better (Steinhausen & Weber, 2009).

Figure 15.3 Percentage of adolescent patients who abstained from binge eating and purging at the end of 6 months of treatment with randomly assigned cognitive-behavioral therapy or family-based therapy, and at 6 and 12 months posttreatment.


Source: Data from Le Grange et al. (2015).

Prevention of Eating Disorders

Of course, it would be far better to prevent eating disorders rather than to treat them after they have developed. A number of prevention programs have been created, and some show evidence that they are effective (Stice & Shaw, 2004; Stice et al., 2009). Programs that just provide education are not effective, nor are single-session workshops. Multiple sessions that actively involve participants are needed. Effective programs tend to have any or all of the following emphases: promoting self-esteem, stress management skills, healthy weight-control behaviors, and critical analysis of the thin ideal in our culture. Prevention programs are also most successful if they are targeted at high-risk girls rather than general samples of girls. Peer-led interventions for college women in sororities have also been effective (Becker et al., 2008).

Sexism and Psychotherapy

As the second wave of feminism emerged in the late 1960s, psychotherapists and the institution of psychotherapy became the object of sharp attacks for sexism (e.g., Chesler, 1972). A widely cited experiment used as evidence in support of these attacks was done by the psychologist Inge Broverman and her colleagues (1970). They examined the judgments of clinicians (psychiatrists, clinical psychologists, and social workers) on the criteria of mental health for men and women. Broverman and her colleagues gave the clinicians in their sample a questionnaire with a list of rating scales of gender-stereotyped personality characteristics, such as aggressive, affectionate, and tactful.

Focus 15.2 The Politics of Psychiatric Diagnosis: Gender Dysphoria

When the American Psychiatric Association published the DSM-5 in 2013, a new diagnosis was available: gender dysphoria. The symptoms of this disorder in adolescents and adults include at least two of the following for 6 months or more:

1. A clear incongruence between one’s natal gender and one’s gender identity

2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because they are incongruent with one’s gender identity

3. A strong desire to have the primary and/or secondary sex characteristics of another gender

4. A strong desire to be treated as another gender

5. A strong conviction that one has the typical feelings and reactions of another gender

On their own, these symptoms do not indicate gender dysphoria. Instead, they must be accompanied by considerable distress or impairment in social, occupational, or other areas of functioning (American Psychiatric Association, 2013).

As you can see, this diagnosis is intended to apply to individuals who are transgender and are distressed by the experience of having a natal gender and gender identity that do not match. There are several important and complex controversies over the American Psychiatric Association’s inclusion of gender dysphoria in the DSM-5.

This diagnosis reflects an important shift from the DSM-IV to the DSM-5. In the DSM-IV, the diagnosis given to most transgender people was gender identity disorder (GID). Note that gender dysphoria is not labeled a disorder, unlike GID. The GID diagnosis centered on the mismatch between natal gender and gender identity, which was framed as “cross-gender identification.” Thus, the GID diagnosis rested on several problematic assumptions. First, it assumed that gender is a biological fact, not a social construction. Second, it assumed that one’s natal gender was one’s correct gender. Third, it assumed that one’s gender identity was the “problem” to be treated. It was classic cisgenderism: To be cisgender was to be normal, but to be transgender was to be mentally ill or deviant. Trans activists pointed out that this diagnosis pathologized gender nonconformity and stigmatized an already vulnerable group of people (Davy, 2015; Lev, 2013). Was this diagnosis really necessary? Whom did it help?

It turns out that there were also some advantages to having these diagnoses. The diagnosis of GID (and, today, gender dysphoria) legitimized and elevated transgender people’s experiences, which helped to promote the development of effective treatments, including surgical and medical therapies for transition (see Chapter 11; Lev, 2013). And for many transgender people, a direct benefit of these diagnoses is that receiving one from a psychiatrist provides access to therapy. That is, access to medical and surgical therapies for transition typically requires that a patient be diagnosed with gender dysphoria. Equally important, insurance companies in North America won’t reimburse or cover these expensive treatments or even psychotherapy if a patient does not have a psychiatrist’s diagnosis of gender dysphoria. In short, many transgender people are desperate for the diagnosis because it provides access to the important therapies and care that will help them live healthier lives (Davy, 2015). This puts psychiatry squarely in the role of the gatekeeper to care for a marginalized group of people. Yet many insurance policies do not cover care for transgender individuals.

The shift from GID to gender dysphoria is remarkable because of the shift from pathologizing gender nonconformity to emphasizing psychological distress. Still, concerns remain that psychiatry could do more to help transgender people by removing this diagnosis altogether, thereby embracing gender diversity as part of the range of human experience. Concerns about access to therapy and medical care are important. How can that access be ensured without stigmatizing transgender people as mentally ill? Some trans advocates have suggested that medical and surgical therapies for transition, as part of gender affirming care, are part of a civil and human right to personal agency and to have one’s body match one’s gender identity. They note that some professional organizations around the world disagree with the American Psychiatric Association’s position (Lev, 2013). Moreover, they contend that the psychological distress experienced by some transgender people stems primarily from societal intolerance of gender diversity rather than a psychopathology within transgender people.

The sample of clinicians was split into three groups. One group was instructed to use the list of rating scales to describe a mature, healthy, socially competent man. Another group was instructed to do this for a woman, and the remaining group was told to do so for an adult (with no gender specified). Three interesting results emerged. First, although clinicians rated mature, healthy, socially competent men and adults as having similar personality characteristics, they rated mature, healthy, socially competent women differently. In other words, the man was indistinguishable from the adult, but the woman was a deviation from that norm. There was a double standard for mental health. As one feminist put it, the Broverman results show that “a normal, average, healthy woman is a crazy human being.”

A second interesting result was that socially desirable personality characteristics tended to be used to describe men, whereas undesirable ones were used to describe women. For example, a mature, healthy, socially competent woman was supposed to be more submissive, be more excitable in minor crises, have her feelings more easily hurt, and be more conceited about her appearance than a mature, healthy, socially competent man.

A third result was that the clinician’s gender was unrelated to their ratings. That is, female clinicians were just as sexist as male clinicians in their standards of mental health. Based on these findings, many concluded that psychotherapy had fundamental problems with sexism.

Yet, like any study, the Broverman study is flawed. The basic problem is that it does not provide a direct measure of the problem we are concerned with: whether therapists, in their treatment of clients, behave in a sexist manner. This study does not measure what therapists actually do in therapy, but rather what their attitudes are, based on their responses to a paper-and-pencil questionnaire. What we need are data on therapists’ actual treatment of clients, but such information is in short supply.

Despite these and other flaws with the experiment, psychotherapy and training for psychotherapists have changed in response to such criticism. And later attempts to replicate the study have generally found less evidence of sexism (Widiger & Settle, 1987). The Broverman study is now more than 45 years old. Does sexism remain a problem in psychotherapy today? To answer that question, let’s examine the research on gender bias in diagnosis and gender bias in treatment.

Gender Bias in Diagnosis

Clinicians’ diagnoses of women seeking therapy may be influenced by gender stereotypes (Ali et al., 2010; Hartung & Widiger, 1998). For example, in one study a stereotyped description of a single, middle-class White woman was labeled by clinicians as a hysterical personality (Landrine, 1987). By contrast, clinicians who were given the same description for a married, middle-class woman labeled her depressed. As another example, a female client might be labeled as having a histrionic personality disorder, but a male client with the same characteristics might be labeled as antisocial (Ford & Widiger, 1989).

Focus 15.1 and 15.2 provide two illustrations of the ways in which the very diagnostic labels that are available in the DSM may be influenced by gender politics and stereotypes.

In short, the diagnosis of a mental disorder is not an objective, value-free process. Clinicians have stereotypes and values just like everyone else. If they are not mindful of these stereotypes and values, however, clinicians may make inaccurate diagnoses or provide therapy that is inappropriate and unhelpful. And on an institutional level, we must be vigilant about the ways that gender stereotypes and values can affect the very diagnostic categories that are officially available.

Gender Bias in Treatment

Gender bias in psychotherapy may occur in a number of forms, some of them blatant and some of them quite subtle (American Psychological Association, 2007a; Gilbert & Rader, 2001):

1. A client’s concerns are conceptualized stereotypically. For example, the therapist may assume that a woman’s problems will be solved by getting married to a man or becoming a better wife. Or the therapist may expect lesbian and gay relationships to mimic heterosexual relationships with regard to masculine and feminine roles.

2. The therapist uses essentialist, gender-difference beliefs in working with clients. For example, in viewing women as especially competent at relationships and less competent in the world of work, the therapist may fail to help the client construct a vision of herself that transcends traditional gender roles.

3. The therapist misuses the power of the therapist role. This may include using diagnosis as a means of categorizing and controlling a client and viewing a client who disagrees with the therapist’s interpretations as being “difficult.” Seduction of a female client is one of the worst abuses of a therapist’s power (see Focus 15.3).

Gender bias in treatment may also stem from the theoretical orientation of the therapist or the system of therapy that a therapist uses. As an example, let’s consider psychoanalysis. Psychoanalysis is a system of therapy based on Freud’s theory. As discussed in Chapter 2, feminists have long sharply criticized Freudian theory as sexist. Similarly, psychoanalysis has also been criticized on similar grounds, as some of its central concepts are fundamentally sexist (e.g., American Psychological Association, 1975). For example, women’s achievement strivings may be interpreted as penis envy. Women who enjoy orgasm from masturbation may be regarded as immature and thus be urged to strive for the more mature “vaginal orgasm” from penile-vaginal intercourse (see Chapter 12). The evidence indicates that women in psychoanalysis have sometimes been convinced that they are inferior, masochistic, and so on (American Psychological Association, 1975).

Psychoanalysis: A system of therapy based on Freud’s psychoanalytic theory in which the analyst attempts to bring repressed, unconscious material into consciousness.

Can a system of therapy such as psychoanalysis be applied in an unbiased way? Some have proposed this and have even proposed feminist psychoanalysis (e.g., Eichenbaum & Orbach, 1983; Shainess, 1977). Recall from Chapter 2 that some psychoanalytic theorists, such as Nancy Chodorow, are explicitly feminist. Reflecting on how psychoanalysis has evolved in response to feminist critique, Chodorow stated, “I’ve learned that from my feminist medical-psychiatric colleagues, that being aware of one’s body and bodily sexuality does not mean that anatomy is destiny, as Freud put it” (quoted in Chiang, 2017, p. 14).

Focus 15.3 Sexual Misconduct by Therapists

One of the most serious problems for women in therapy is the possibility of a male therapist initiating sex with a female client (American Psychological Association, 2007a; Pope, 2001).

The 1978 revision of the American Psychological Association’s ethical code states: “Sexual intimacies between therapist and client are unethical.” This means that under no circumstances is a therapist to have a sexual relationship with a client. Although there have been vigorous efforts to educate therapists about these ethical problems, the evidence indicates that inappropriate sexual activity still occurs (American Psychological Association, 2007a).

How common is sexual misconduct by therapists? Studies from North America, Great Britain, and Australia indicate that around 4% to 9% of therapists admit to having a sexual relationship with a client (Garrett & Davis, 1998; Grenyer & Lewis, 2012; Lamb et al., 2003; Pope, 2001). A survey study with therapists found that 95% of men and 76% of women reported feeling sexually attracted to their clients at some point (Pope, 2001). Of course, feeling sexually attracted to someone and acting on that attraction are two different things. Professional training of psychotherapists is essential, and it should include guidance for therapists about how to ethically manage sexual attraction toward a client.

Experts regard this situation as having the potential for serious emotional damage to the client (Pope, 2001). Like other cases of sexual coercion, it is a situation of unequal power, in which the more powerful person, the therapist, imposes sexual activity on the less powerful person, the client. The situation is regarded as particularly serious, because people in psychotherapy have opened themselves up emotionally to the therapist and therefore are extremely vulnerable emotionally. Results from a national survey indicate that about 90% of clients who have sex with their therapist are harmed by it (Pope, 2001).

Psychotherapeutic Approaches

One of the most important factors influencing a woman’s experience in therapy is the theoretical orientation of the therapist and the corresponding type of therapy they use. Below we will consider two kinds of therapy to see how they relate to women and whether they are likely to be biased.

Cognitive-Behavioral Therapy

In cognitive-behavioral therapy (discussed earlier with regard to eating disorders), the therapist and client identify not only dysfunctional behaviors, but also dysfunctional thought patterns. As an example of a problem behavior, a woman might have become so concerned that her hips are fatter than those of the models she sees on TV and in magazines that she refuses to go to the swimming pool because she will have to be seen in a swimsuit, despite the fact that she loves to swim and it’s a hot summer. The therapist can help the woman confront such avoidant behaviors and substitute adaptive behaviors. In the cognitive realm, the therapist can help the client discover negative beliefs (my hips are fat and therefore no one can love me). The client can then discover how irrational those beliefs are and engage in cognitive restructuring, in which she substitutes positive beliefs (my hips are just fine, they’re just fatter than those of skinny models, and I have lots of valuable qualities that people will notice, rather than staring at my hips).

While there is nothing inherently gender-biased about CBT, an individual therapist certainly could use it in a biased manner. Some feminist therapists have developed feminist cognitive-behavioral therapies (e.g., Srebnik & Saltzberg, 1994).

Feminist Therapy

In response to the critiques of traditional therapies, particularly psychoanalysis, feminist psychologists developed feminist counseling and psychotherapy. The basic assumptions and principles of feminist therapy are as follows (Enns, 2004; Worell & Johnson, 2001; Worell & Remer, 1992; Wyche & Rice, 1997):

Feminist therapy: A system of therapy informed by feminist theory.

1. Gender is a salient variable in the process and outcomes of therapy, but it can be understood only in the context of many other factors in a woman’s life. Women have multiple identities defined by gender, race/ethnicity, social class, sexual orientation, and disability.

2. The personal is political: A person’s experiences must be understood from a sociocultural perspective that includes an analysis of power relationships as well as intrapsychic or individual perspectives. A person’s experiences of sexism and discrimination must also be addressed. “Symptoms” can be seen as a person’s best attempts to cope with a restrictive and oppressive environment. Social activism can help a person gain a sense of personal strength and control over their life.

3. A major goal of feminist therapy is personal empowerment and helping people expand their alternatives and choices.

4. The therapeutic relationship is mutual and egalitarian.

5. Therapy focuses on a person’s strengths rather than only on their deficits.

6. The qualities of caring and nurturing are valued and honored. Clients are encouraged to nurture themselves and to bond with others in a community of support.

Empowerment is a key feature of feminist therapy (American Psychological Association, 2007a; Enns, 2004; Worell & Remer, 2002). This process begins with the declaration that the therapist and client are equal—that is, they both are persons of equal worth—in the therapy process. Therapy cannot empower a woman or a person from a marginalized group if it begins by making them less powerful or valuable than the therapist. The client is then encouraged to develop two sets of skills, one dealing with the internal and the other with the external. They are empowered in dealing with their personal situation by developing flexibility in problem solving and by developing a wide range of interpersonal and life skills. In addition, focusing on external issues, the person is empowered by the therapist’s encouragement to identify and challenge external conditions in their life that devalue them as a woman or a person of a marginalized group. Rather than “fixing” the client’s problems, the feminist therapist encourages the client to discover their strengths and develop new strengths that empower them to deal with situations that have previously caused their distress.

Addressing the Mental Health Needs of People of Color

Access to mental health services has long been a privilege of middle- and upper-middle-class White people, and the services have been designed to meet their needs. Women of color and poor women have had less access to these services. Psychotherapy not only is financially inaccessible to many of these women, but also has not been sensitive to their needs (American Psychological Association, 2007; Comas-Diaz & Greene, 1994). Feminisms of color, discussed in Chapter 4, can provide some guiding principles (Enns, 2004).

An intersectional approach that is attentive to the multiple disadvantages of women of color is also helpful. In therapy with women of color, therapists must assess women’s experiences as individuals of multiply marginalized groups. Women of color are likely to experience not only sexist discrimination, but also racist discrimination (American Psychological Association, 2007). Gendered racism, or other forms of intersectional disadvantage, should also be considered in the therapy setting. For example, gendered racial microaggressions (Lewis & Neville, 2015; discussed in Chapter 4) are likely to be a source of chronic stress. Each of these experiences can have a profound negative effect on psychological well-being.

For many women of color, ethnic and racial identity are important to their sense of self. Thus, in therapy with women of color, therapists need to consider the woman’s degree of identification with her ethnic group. In some cases, immigrant status and degree of acculturation may also be relevant. For example, one first-generation Mexican American woman might speak Spanish almost exclusively and live in a Mexican American community in California, whereas another Mexican American woman’s family might have lived in a suburb of Milwaukee for four generations, and she might speak very little Spanish. Such factors affect the cultural values the woman brings to therapy and therefore affect the goals that she and the therapist set for her. In general, therapists need to familiarize themselves with the cultures from which their clients come.

For immigrant women, challenges in maintaining relationships with family in their home country can be a unique source of stress. While they may feel lonely and miss their loved ones, returning to their home country to visit can be complicated. One study of immigrants from Latin American countries and migrants from Puerto Rico found that, for Latinas, returning to their home country was linked to later depressive episodes (Alcántara et al., 2015). By contrast, sending money home to family was linked to better mental health. Researchers believed that the trips home exacerbated Latinas’ family conflicts and feelings of stress about caregiving demands, but that the financial remittances helped them feel effective in helping and caring for their families. Given the large number of immigrants living in the United States and Canada, it is important for therapists to assess these unique types of stressors that immigrant women may experience.

In addition, therapists need to be culturally competent in diagnosis. That is, mental health symptoms may vary across different ethnic and cultural groups based on cultural display rules (Brown et al., 2003). For example, hwa-byung is a disorder commonly found among Korean American women and involves constricted sensations in the chest, palpitations, heat sensations, a flushed face, headache, negative mood, anxiety, irritability, and difficulty concentrating (Brown et al., 2003). About half of the Korean Americans who experience hwa-byung meet the diagnostic criteria for major depression. A therapist working with Korean American women should be familiar with hwa-byung.

Most psychotherapists are White. Yet clients who are women of color may prefer to have a therapist from their own ethnic group, with whom they will feel comfortable and who will understand their cultural background better. It is critical that the field of psychology support more women of color in becoming psychotherapists. In the meantime, as White women therapists work with clients who are women of color, they will need to make extra efforts to provide culturally competent therapy.

The American Psychological Association (2003) issued guidelines for multicultural issues in therapy that are consistent with the principles of multicultural feminist therapy (Enns & Byars-Winston, 2010). Here are three key points:

1. Psychologists are encouraged to recognize that, as cultural beings, they may hold attitudes and beliefs that can have a negative influence on their perceptions of and interactions with people who are of a different ethnicity than their own. Just as in Chapter 1 we saw that there is no such thing as an unbiased researcher, so, too, there are no unbiased therapists. A first step is for them to recognize the cultural embeddedness of their beliefs and perceptions.

2. Psychologists are encouraged to recognize the importance of multicultural sensitivity and responsiveness to individuals who are of a different ethnicity. The commitment to sensitivity and responsiveness involves a commitment to acquiring knowledge about ethnicity issues; one cannot be sensitive without that knowledge.

3. Psychologists are encouraged to apply culturally appropriate skills in clinical practice. This guideline also requires that the therapist acquire the necessary knowledge and then be ready to adapt treatment methods as needed for the particular individual and their cultural context. Testing and diagnosis may require adaptation as well.

As an example, let’s consider the particular needs of Asian American women (Bradshaw, 1994; Chin et al., 1993; Kawahara & Espin, 2007). A number of potential sources of stress exist in their lives. Some stresses arise from traditional Asian cultures, which are generally patriarchal and expect women to be passive and obedient. Younger, more educated Asian American women may embrace modern egalitarian values in the United States and thus may come into conflict with older family members, who hold more traditional values. Interracial dating and marriage is another potential source of stress. Although such relationships are common statistically for Asian American women, they are strongly discouraged by Asian families (True, 1990), again producing conflict and stress. On top of these stressors, there are, of course, stresses such as work—family conflicts that are commonly experienced by other women as well.

Culturally sensitive or culturally adapted therapy for Asian American women involves several features (True, 1990):

1. Use of bilingual therapists for non-English-speaking clients

2. Use of family-focused rather than individual-focused approaches, with respect for the women’s family ties

3. Respect for Asian American women who are not verbally or emotionally expressive

4. Attention to the women’s physical (somatic) complaints as possible reflections of psychological distress, knowing that in Asian culture it is more acceptable to have physical health problems than it is to have mental health problems

5. Recognition that there may be strong sentiment against feminism within the Asian American community

Just as we have discussed the importance of valuing women’s experiences and perspectives in a feminist approach to therapy, so an ethnic validity model has been proposed in working with people of color (Chin et al., 1993; Enns & Byars-Winston, 2010). According to this model, the values and lifestyles of people of color must be valued. In addition, the deficit hypothesis, which views ethnic cultures other than European American culture to be deficient, must be abandoned and replaced by a difference hypothesis, which acknowledges differences among cultures while at the same time valuing them equally. These are important new directions for feminist therapy in the next decade.

Psychological Practice With Trans People

In Chapter 7, we introduced the topic of trans-affirmative practice, which is care that is respectful, aware, and supportive of the identities and life experiences of transgender and gender nonconforming people (American Psychological Association, 2015). The American Psychological Association (2015) has provided 16 guidelines for psychological practice with transgender and gender nonconforming people. We include some of those guidelines here. With regard to foundational knowledge and awareness:

1. Psychologists understand that gender is a nonbinary construct that allows for a range of gender identities and that a person’s gender identity may not align with sex assigned at birth. Across cultures and history, there exists ample evidence of gender diversity (e.g., Nanda, 2014). Rejecting the gender binary and acknowledging gender diversity are essential to providing respectful and supportive care to trans people.

2. Psychologists understand that gender identity and sexual orientation are distinct but interrelated constructs. Gender identity and sexual orientation are often conflated, but they are separate aspects of an individual. Gender identity typically develops earlier in the lifespan than sexual orientation (Adelson & American Academy of Child and Adolescent Psychiatry Committee on Quality Issues, 2012). And while they are often experienced in related ways, it’s important not to make assumptions about sexual orientation based on a person’s gender identity, and vice versa.

3. Psychologists seek to understand how gender identity intersects with the other cultural identities of transgender and gender nonconforming people. Trans women of color are multiply marginalized, experiencing disproportionate discrimination and violence as trans people, as women, and as people of color. Understanding the intersectionality of social categories and identities is important in assessing the full and complex experiences of trans people (Chang & Singh, 2016).

4. Psychologists are aware of how their attitudes about and knowledge of gender identity and gender expression may affect the quality of care they provide to transgender and gender nonconforming people and their families. Psychotherapists, like all people, have their own biases and values that will shape their understanding and behavior toward others. Therefore, they must continually examine and reflect on these biases and values in order to provide supportive care.

And regarding stigma, discrimination, and barriers to care:

5. Psychologists recognize how stigma, prejudice, discrimination, and violence affect the health and well-being of transgender and gender nonconforming people. Trans people face a disproportionate amount of marginalization and victimization that can contribute to their mental health (see Chapter 7). Discrimination related to housing, health care, employment, education, public assistance, and other social services is common.

6. Psychologists strive to recognize the influence of institutional barriers on the lives of transgender and gender nonconforming people and to assist in developing transgender and gender nonconforming—affirmative environments. Cisgenderism is often enacted at an institutional level. For example, transgender people have been prohibited from openly serving in the military (White House, 2017; U.S. Department of Defense, 2011), and some U.S. state laws prohibit them from using restrooms that correspond to their gender identity. These and other institutional barriers—including access to health care (see Chapter 11)—can profoundly shape trans people’s daily lives.

7. Psychologists understand the need to promote social change that reduces the negative effects of stigma on the health and well-being of transgender and gender nonconforming people. The profession of psychology exists to improve people’s psychological well-being. Advocating for trans-affirmative public policy, including legal protections for trans people, is one way that psychologists can work toward that goal.

With regard to assessment, therapy, and intervention:

8. Psychologists strive to understand how mental health concerns may or may not be related to a transgender or gender nonconforming person’s gender identity and the psychological effects of minority stress. Given trans people’s increased risk for stress and related mental health issues, careful assessment and diagnosis are essential. Still, it is important to recognize the full range of mental health among trans people and that not all mental health issues will be related to trans identity.

9. Psychologists recognize that transgender and gender nonconforming people are more likely to experience positive life outcomes when they receive social support or trans-affirmative care. Evidence is clear that, when trans youth and adults receive trans-affirmative care and adequate social support, they show positive mental health outcomes (e.g., Bockting et al., 2013; Olson et al., 2016).

10. Psychologists strive to understand the effects that changes in gender identity and gender expression have on the romantic and sexual relationships of transgender and gender nonconforming people. Much like romantic and sexual relationships between cisgender partners, such relationships with trans partners are complex and vary in quality. Respect, honesty, trust, love, understanding, and open communication are critical to the quality of romantic and sexual relationships (Kins et al., 2008). Bodily changes related to surgical or medical transition contribute to new possibilities in trans people’s sexual relationships.

11. Psychologists seek to understand how parenting and family formation among transgender and gender nonconforming people take a variety of forms. Many trans people have and want children (Wierckz et al., 2012), and evidence suggests that children of trans parents fare as well as children of cisgender parents (White & Ettner, 2004). Trans people may encounter difficulties with legal adoption and infertility.

12. Psychologists recognize the potential benefits of an interdisciplinary approach when providing care to transgender and gender nonconforming people and strive to work collaboratively with other providers. Collaboration with health care providers, psychologists, psychiatrists, social workers, speech therapists, and other providers contributes to more informed and holistic care for trans people.

These guidelines are designed to help psychologists and other psychotherapists provide sensitive and effective care to trans people. The guidelines are particularly valuable because the majority of psychologists report that they feel unfamiliar with trans issues and lack training in trans-affirmative practice (American Psychological Association, 2015). Moreover, trans people have reported problematic psychotherapy experiences related to psychotherapists’ lack of awareness and education about trans issues (Mizock & Lundquist, 2016). As trans people face considerable stress related to discrimination, stigma, harassment, and violence, psychologists can contribute at the institutional or structural level by cultivating a more welcoming society and advocating for trans-affirmative public policy. They can also contribute at the individual level by promoting resilience and psychological well-being among trans people. As psychologists, our goal is to promote psychological well-being among all people, and therefore it is part of our ethical responsibility to provide trans-affirmative care (Singh & dickey, 2016).

Experience the Research: Gender Stereotypes and Psychotropic Drugs

In your school’s library, locate the medical journals, particularly those in the area of family medicine and psychiatry (e.g., Archives of General Psychiatry, American Journal of Psychiatry). If your school’s library does not carry these specialty journals, it probably will at least carry the New England Journal of Medicine and Journal of the American Medical Association, and you can use those for this exercise, too. Inspect three issues. Locate all the ads for drugs for treating psychological disorders. These ads will mostly be for anti-anxiety drugs and antidepressants. For each ad, record the following: the gender of the physician in the ad, the gender of the patient, and the emotion expressed by the patient’s facial expression. How does the ad signal which person is the physician and which is the patient? Also analyze the text of the ad. Does it carry a message about the expected gender of patients receiving this drug? How does it describe these patients and their problem?

Are the ads gender stereotyped? That is, do they portray physicians as men and people suffering from depression or anxiety as women? Or do the ads try to break down stereotypes, for example, by showing a woman physician? Are women of color shown in the ads? In what roles? What kinds of effects do you think these ads might have?

Chapter Summary

Major mental health issues show lopsided gender ratios in prevalence, including depression, alcohol- and substance-use disorders, and the eating disorders of anorexia and bulimia. While women experience a disproportionate share of depression, anorexia, and bulimia, men are more likely to experience alcohol- and substance-use disorders.

Major theoretical perspectives take multiple aspects of gender into account when explaining the development of these disorders. Such theories include biological and genetic factors, cognitive factors, and sociocultural factors and take a decidedly interactionist approach.

Researchers have examined gender bias in psychotherapy, beginning with the landmark Broverman study. Today, sexism in diagnosis and treatment is more subtle. Psychotherapeutic approaches, including cognitive-behavioral therapy, family-based therapy, and feminist therapy were introduced and evaluated with regard to their equitable treatment of women.

Evidence is clear that discrimination—such as that based on gender and race or ethnicity—is destructive to mental health. The American Psychological Association guidelines for psychological practice with two marginalized groups, trans people and women of color, were introduced. The role of psychology in promoting the psychological well-being of all people is especially important in providing care to members of marginalized groups. Psychological practice extends to both institutional and individual levels, and psychologists have an ethical responsibility to advocate for groups who have historically faced discrimination and marginalization, including women, people of color, and trans people.

Suggestions for Further Reading

American Psychological Association. (2007). Guidelines for psychological practice with girls and women. American Psychologist, 62, 949—979. These guidelines, too extensive to include here, are a must-read for anyone considering therapy and for anyone training to be a therapist.

Enns, Carolyn Z., Rice, Joy K., & Nutt, Roberta L. (2015). Psychological practice with women: Guidelines, diversity, empowerment. Washington, DC: American Psychological Association. This book builds on the previous article and incorporates a more intersectional approach to providing therapy to women from diverse groups.

Singh, Anneliese A., & dickey, lore m. (2017). Affirmative counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC: American Psychological Association. The full list of guidelines for providing psychotherapy to trans clients. Essential reading for therapists.