A woman's view of DSM-III.

Women's treatment rates for mental illness are higher than men's. This article argues that one explanation for this sex difference is that masculine-biased assumptions about what behaviors are healthy and what behaviors are crazy are codified in diagnostic criteria and thus influence diagnosis and treatment patterns. Several theories accounting for women's higher treatment rates are reviewed. Chester's theory of women's overconforming and underconforming to sex role stereotypes is evaluated in the light of Broverman et al. 's findings. The implications of DSM-IH's definition of mental disorder, the diagnoses of Histrionic Personality Disorder and Dependent Personality Disorder, and two fictitious diagnostic categories are discussed to illustrate assumptions implicit in DSM-III diagnoses. A past diagnosis regarding women's sexuality is reviewed to specifically illustrate past assumptions resulting in the labeling of healthy women as sick. More adult women than adult men are treated for mental illness (e.g., Gove & Tudor, 1973; Rohrbaugh, 1979). There are a variety of theories, most of which concern sex roles, that account for this sex difference. There is good reason for the sex role related explanation. According to Bern (1974) and Berzins, Welling, and Wetter (1978), most females are feminine typed and most males are masculine typed. Kelly (1983) concludes that sex differences in behavioral disorders may be associated not with sex but with sex role typing. In this article I will review several of the popular sex role related theories on sex differences in mental illness treatment rates and then posit an additional one: A contributor to the sex differences in treatment rates is clinicians' diagnostic criteria—that is, in DSM-II (American Psychiatric Association, 1968) and now DSM-III (American Psychiatric Association, 1980). In other words, masculine-biased assumptions about what behaviors are healthy and what behaviors are crazy are codified in diagnostic criteria; these criteria then influence diagnosis and treatment rates and patterns. In my discussion of the influence of diagnostic criteria on sex differences in treatment patterns, I will look at some criteria for specific diagnoses. Theories About Sex Differences in Treatment Rates One theory (which has not adequately been supported by data) that accounts for the sex difference in treatment rates is that women are not sicker, they are just more willing to express symptomatology (Phillips & Segal, 1969). Another (more data-supported) theory is that women actually are sicker; their disadvantaged status in society makes them more at risk for mental illness. For instance, the Subpanel on the Mental Health of Women of the President's Commission on Mental Health (1978) documented ways in which inequality creates dilemmas for women in certain contexts (e.g., marriage, child rearing, aging, work). Carmen, Russo, and Miller (1981) add that this same inequality facilitates the occurrence of events (e.g., incest, rape, and marital violence) that heighten women's vulnerability to mental illness. They also point out the link between alienation, powerlessness, and poverty— many women's lot—and impaired mental health. The theories that women are more willing to express symptomatology and that women's disadvantaged status makes them more vulnerable to mental illness are broad ones. Gove (1979) and Gove and Tudor (1973) formulated several more specific sex role related explanations for gender differences in disordered behavior. First they refined the finding that adult women have higher rates of mental illness and reported that women's higher rate is primarily due to the higher rate of mental illness among married women than among married men. (Widowered, divorced, and never-married men have higher rates of mental illness, respectively, than widowed, divorced, and never-married women [Gove, 1972].) Gove and Tudor offer several sex role related explanations for married women's greater vulnerability to mental illness. These are: (a) Whereas men have two sources of gratification (family and work), traditional married women have only one source of gratification (family); (b) even when a married woman works, she is discriminated against in the workplace and expected to work and be a homemaker, whereas the man is only expected to work; (c) homemaking is a frustrating, low-prestige job, unconsonant with the education and intellectual 786 July 1983 • American Psychologist Copyright 1983 by the American Psychological Association, Inc. attainment of a large number of women; (d) the role of housewife is unstructured and invisible, allowing the individual time to brood alone; (e) expectations confronting women are unclear; for instance, women are supposed to adjust to and prepare for contingencies (Gove, 1979). (Data supporting these explanations are not supplied.) Another sex role related theory accounting specifically for married women's higher treatment rates is based on Gilligan's (1979) work. Gilligan claims that whereas for men identity precedes intimacy (Erikson, 1950), sex roles dictate that for women identity and intimacy tasks are simultaneous. In other words, women claim an identity through intimate relationships. Bernard (1975) and Mischel (1966) suggest that women are thus more dependent on others than are men. Nadelson and Notman (1981) mention some resulting difficulties for women (and for men who marry early). For instance, those who marry before establishing identities may find their marital choices inappropriate later, and those who are "burdened by excessive dependency needs, unrealistic expectations of their partners, or unresolved psychological issues" (p. 1355) may find their intimate relationships difficult and stressful and their mental health at risk. Sex Ratios of Specific Disorders I turn now from the subject of women's higher treatment rates for disordered behavior in general to the subject of specific behavioral disorders. Table 1 divides those adult disorders for which (according to DSM-III) there are data on sex ratio into two categories: those more commonly diagnosed in adult women and those more commonly diagnosed in adult men. (Disorders whose onset is in adolescence are not included in the table; thus, Anorexia and Bulimia, primarily diagnosed in females, are not listed.) Inspecting Table 1 might lead one to the conclusion that women internalize conflict and that men act it out or, to use Allport's (1958) terms, that women are intropunitive and men, extropunitive. What are some of the more specific sex role related explanations for so-called female disorders? There are two popular sex role related theories that account for depression (Weissman, 1980). One is the social status hypothesis: Sex discrimination results in "legal and economic helplessness, dependency on others, chronically low self-esteem, low aspirations, and, ultimately, clinical depression" (Weissman & Klerman, 1977, p. 106). The second sex role related popular theory that accounts for depression is the Requests for reprints should be sent to Marcie Kaplan, Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers—The State University, P.O. Box 819, Piscataway, New Jersey 08854. learned helplessness hypothesis (Seligman, 1973, 1975). Another theory less frequently cited than the above two is drawn from Lewinsohn (1974): Women have sex role related deficits in their capacity to obtain reinforcement from the environment. Thus, according to Kelly (1983), feminine-typed responses such as kindness, emotionality, self-subordination, and gentleness may not obtain reinforcement as effectively as masculine-typed responses such as assertiveness and forcefulness. Thus, those limited to feminine-typed responses might reach fewer goals than others might reach and thus would be more vulnerable to depression.