figuring out la femme fatale

Behavioral Sciences and the Law

Behav. Sci. Law 23: 765778 (2005)

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/bsl.669

Figuring Out la femme fatale:Conceptual and AssessmentIssues Concerning Psychopathyin Females

Elham Forouzan, Ph.D.*,yand David J. Cooke, Ph.D.z,

Despite the growing number of studies on psychopathy in

females, the core characteristics of this personality dis-

order among females remain uninvestigated. Most studies

on psychopathy in females have attempted to understand

the disorder by applying male criteria to adult females:

they have ignored putative gender differences in the con-

stitution and expression of this disorder. Several issues

require resolution: first, whether practitioners apply the

same criteria to diagnose psychopathy in women, second,

whether the instruments used to assess psychopathy are

tapping the same construct across gender, third, whether

the same types of behavioral expression of key traits are

similar across genders, and fourth, whether the diagnosis

possesses the same forensic utility across genders. The

relevant literature is reviewed and issues of design and

analysis are considered. Copyright # 2005 John Wiley &Sons, Ltd.

GENDER DIFFERENCES AND BIASES

IN THE SYMPTOMATOLOGY AND THE

ASSESSMENT OF PSYCHOPATHY

Despite early depictions of psychopathy in females in both legend and mythology

(e.g. Aphrodite, Medea, Hera), as well as disparate clinical references to female

cases of psychopathy (e.g. Cleckley, 1941; Pinel, 1801; Schneider, 1923), this

phenomenon has received comparatively little systematic investigation. Empirical

research on psychopathy in females has increased during the past ten years, mainly

in order to investigate the role of the disorder in females violence and criminality,

but the corpus of studies is tiny compared with that referring to psychopathy in

Copyright # 2005 John Wiley & Sons, Ltd.

*Correspondence to: Elham Forouzan, Institut Philippe Pinel de Montreal, Canada.E-mail: [email protected] Philippe Pinel de Montreal, Canada.zGlasgow Caledonian University, U.K.Douglas Inch Centre, Glasgow, U.K.

males. Most studies are based on the implicit assumption that the male template of

the disorder can be superimposed upon females: studies have evaluated the core

traits and the behavioral expression of psychopathy as recognized in men in an

attempt to understand the disorder in adult females (e.g. Cale & Lilienfeld, 2002;

Forth, Brown, Hart, & Hare, 1996; Loucks & Zamble, 2000; Louth, Hare, &

Linden; 1998; Neary, unpublished doctoral dissertation; Richards, Casey, &

Lucente, 2003; Spencer, Presse, & Brown, 2001; Strachan, 1995; Warren et al.,

2003). Potential gender differences in traits and expression of the disorder have

been ignored.

The evaluation of gender equivalence in psychopathy is important for both

practical and theoretical reasons. Much of the drive behind psychopathy research

with males has been based on the apparent utility of the construct for predicting

future offending (see, e.g., Hare, 2002; Hemphill, Hare, & Wong, 1998; Langstrom

& Grann, 2002; Nicholls, Ogloff, & Douglas, 2004; Salekin, Rogers, & Sewell,

1996; Walters, 2003), poor institutional adjustment (see, e.g., Hobson, Shine, &

Roberts, 2000; Walters, 2003), and poor treatment responsivity (see, e.g., Reid &

Gacono, 2000; Salekin, 2002; Seto & Barbaree, 1999; Sherman, 2000; Spain,

Douglas, Poythress, & Epstein, 2004; Young, Justice, Erdberg, & Gacono, 2000).

However, the utility of the construct in relation to females remains to be clarified

(Webster, 1999). Failure to take gender into account, that is, assuming that the

predictive utility of psychopathy applies to females, may have human rights

implications given that a diagnosis of psychopathy is often used to justify the

lengthening of incarceration, the exclusion from treatment, or other constraints

on liberty.

In this paper we first consider why psychopathy may vary by gender. Second, we

consider the evidence for differences in the core traits and characteristic expression

of the disorder across gender. Third, we address gender biases in the current

assessment procedures for psychopathy and how these may affect our current

knowledge of this disorder in females. Finally, we will present some strategies

directed towards achieving a greater understanding of gender bias in psychopathy.

WHY MIGHT PSYCHOPATHIC PERSONALITY

DISORDER VARY ACROSS GENDER?

Gender differences are reported in many of the behavioral and personality disorders

that bear similarities toor encompass elements ofpsychopathy (i.e. antisocial,

histrionic, narcissistic, and borderline personality disorders) (Goldstein, Powers,

McCusker, & Mundt, 1996; Hartung & Widiger, 1998; Verona & Carbonnel,

2000). Psychopathy is considered by some commentators to be a form of profound

personality disorder (PD) in which many of the diagnostic features of antisocial,

narcissistic, histrionic, paranoid, and schizotypal PDs coalesce (see, e.g., Blackburn

& Coid, 1998; Nedopil, Hollweg, Hartmann, & Jaser, 1998; Widiger & Lynam,

1998). Thus, to the extent that gender bias is reported in related personality

disorders, it may be expected in psychopathic PD as well. It is noteworthy that

certain DSM criteriaspecifically those for ASPDhave been criticized as being

gender biased. It has been argued that they encompass an over-representation of

766 E. Forouzan and D. J. Cooke

Copyright # 2005 John Wiley & Sons, Ltd. Behav. Sci. Law 23: 765778 (2005)

male symptoms (see, e.g., Gerstley, Alterman, McLellan, & Woody, 1990;

Sutker, Fowles, Sutker, & Goodman, 1994). When specific features of psychopathy

are considered, for example grandiosity and affective deficits, these have also been

viewed as being subject to gender bias (Brebner, 2003; Burton, Cullen, Evans,

Alarid, & Dunaway, 1998; Fujita, Diener, & Sandvik, 1991; Kelly & Hutson-

Comeaux, 1999; Rutherford, Cacciola, Alterman, & McKay, 1996; Zagon &

Jackson, 1994). Generally speaking, commentators suggest that females are viewed

as less superior and less arrogant in their interpersonal style, and less self-absorbed

and self-admiring than males (Rutherford et al., 1996; Zagon & Jackson, 1994).

Emotionally, females are reported to experience negative affects (anger, fear, guilt,

sadness) more frequently and intensely, whereas men are reported to show more

anger whatever the context, and score higher in intensity of Pride (Brebner, 2003;

Fujita et al., 1991; Kelly & Hutson-Comeaux, 1999).

Second, Widiger, and Lynam (1998) have theorized that psychopathy should be

regarded as a virulent combination of certain facets underpinning the five-factor

model (FFM) of personality (Costa & McCrae, 1992). To the extent that these

fundamental traits are linked to personality disorders (PDs), and they are linked to

gender, then psychopathy might be expected to be gender linked. It is noteworthy

that many tests of both personality and personality pathology (e.g. MCMI, MMPI,

NEO) take gender into account when they are scored; it is thus likely that

pathology of personality will be gender linked. This is because a persons gender

influences their responses to test items. Some authors (Choca, Shanley, & van

Denburg, 1992; Hathaway & McKinley, 1943; Millon, 1987) have judged it

necessary to use different tables for the conversion of raw scores to standardized

scores for men and women; for example, in relation to the MCMI, it has been

argued The use of different conversion tables equalizes the test results if one is

going to offer the same interpretation to the similar elevations regardless of the

persons gender (Choca et al., 1992, p. 58). Particularly for female populations,

the gender differences reported on these tests suggest that such tests may

pathologize some stereotypically feminine traits (Cantrell & Dana, 1987; Choca

et al., 1992). As a result, some authors recommend that elevations of such scales

should be interpreted with caution in the case of women, making sure that the

patient clearly meets other diagnostic criteria (e.g. DSM-III-R) before a diagnosis

is given (Choca et al., 1992).

Third, Wood and Eagly (2003) recently proposed a comprehensive biosocial

model to explain gender based psychological differences linked to evolved

characteristics, developmental experiences, and activities within society. For

example, there is evidence that the psychological attributes and characteristic

adaptations of women have become closer to those of men over the last 70 years;

this is attributed to women taking on roles formerly associated with men. These

include attributes and behaviors relevant to the construct of psychopathy,

for example increases in assertiveness and dominance (Twenge, 2003), and

increases in the amount of risky behavior undertaken (Byrnes, Miller, & Schafer,

1999).

Thus, we would argue that there are several good reasons, a priori, to expect

gender differences in psychopathy, and the presumption that diagnostic criteria

and measures developed for men can be applied unchanged to women appears

questionable.

Psychopathy in women 767

Copyright# 2005 John Wiley & Sons, Ltd. Behav. Sci. Law 23: 765778 (2005)

EVIDENCE FOR GENDER DIFFERENCES IN THE

CORE TRAITS ANDCHARACTERISTIC EXPRESSION

OF PSYCHOPATHIC TRAITS

From the clinical point of view, female cases have been rarely reported by pioneers in

the study of psychopathy (Cleckley, 1941; Pinel, 1801; Schneider, 1923). As a

consequence, adequate clinical descriptions of the core traits and characteristic

expression of the disorder in females do not exist. Clinical and qualitative studies are

a fundamental step required to ensure that there is sufficient coverage of the

construct of concern; to ensure that the construct does not suffer from under-

representation (Shadish, Cook, & Campbell, 1999; Smith, Fischer, & Fister, 2003).

Results of a preliminary qualitative study on the affective, interpersonal and

behavioral characteristics of psychopathy in females, based on 25 clinicians evalua-

tions and observations of psychopathic traits and behaviors in females detainees in a

provincial correctional service of Canada, suggest that, although most features

reported in male psychopathy could be identified in psychopathy in females, three

key differences can be discerned (Forouzan, 2003). These are differences in how the

traits are expressed through different behaviors, differences in degree of the disorder

that must be present before certain symptoms become apparent, and finally differ-

ences in the psychological significance or meaning of certain behaviors across gender.

First, with regard to behavioral expression, manipulative women were reported to

be more likely to be flirtatious, whereas men were more likely to engage in conning

behavior. Also, in females, impulsivity and conduct disorder were characterized by

running away, self-harming behavior, manipulation, and complicity in committing

crimes (essentially theft and fraud), whereas in males it was more likely to

characterized by violent behaviors. This is consistent with the empirical literature

(Lanctot & Leblanc, 2002; Lipman, Bennett, Racine, Mazumdar, & Offord, 1998;

Salekin, Rogers, & Machin, 2001).

Second, clinicians reported that in females the interpersonal symptoms of glib-

ness, superficial charm, and grandiose sense of self-worth were more muted and only

became apparent in extreme cases of the disorder; culture has been demonstrated to

have a similar effect on the expression of these symptoms, suggesting that certain

symptoms are pathoplastic in response to culture, gender, and perhaps age (Cooke,

Michie, Hart, & Hare, 1999; Cooke, Michie, Hart, & Clark, 2005; Vincent, in press).

Third, clinicians reported that some indicators of psychopathy have different

psychological meaning in females and males. For example, in female psychopathy,

promiscuous sexual behavior may be underpinned by a desire to exploit. Such

behavior may reflect the impersonal lifestyle but also may be related to a parasitic

lifestyle, with sexuality being used as a strategy for manipulating and obtaining

financial, social, or narcissistic gain. By way of contrast, in male psychopathy such

behavior may be underpinned by sensation seeking or mating effort (Quinsey, 2002).

Fourth, societal norms may affect the assessment of some psychopathic traits

among females and males. For example, some degree of material dependency may be

socially and culturally acceptable for women, whereas similar behaviors are perceived

as parasitic for men. A woman who reports relying on her family (husband/partner

or her parents) may not be considered as parasitic, whereas a man reporting that he

relies on his family is more likely to be perceived as parasitic (Forouzan, 2003). Such

gender linked variations will adversely affect gender equivalence.



Thus, it would appear that there are theoretical and empirical reasons why there may

be gender differences in the expression of the psychopathic personality disorder.

GENDER BIASES IN THE PSYCHOMETRIC

ASSESSMENT OF PSYCHOPATHY

In general, diagnostic procedures for the assessment of psychopathy in females are

based on the tools elaborated to assess male psychopathy. Such tools include expert

ratings based on semi-structured interviews and file review (e.g. PCL-R, Hare, 1991;

PCL-R:SV, Hart, Cox, & Hare, 1995) and self-report multiscale inventories (Table 1).

The limitations of these tools have not been examined systematically (see Vitale &

Newman, 2001). For example, even though the PCL-R/PCL:SV have been devel-

oped and validated primarily among correctional male populations, it is claimed that

The PCL-R functioned much the same in one group as in another, with only small

differences at the lower and upper levels of the psychopathy trait. This suggests that

in midrange a given PCL-R score may represent much the same level of psychopathy

in male offenders, male forensic psychiatric patients, female offenders, and male

offenders assessed from file reviews (Hare, 2003, p. 74). This statement assumes

that the symptoms and characteristic adaptations of the disorder are the same across

gender. As argued above, this may not be a valid assumption. Also, differences at the

upper levels of measurement, small or otherwise, are critical both from the point of

view of the individual and the point of view of services. From the perspective of the

individual a small difference can make the difference between detention and non-

detention; from the point of view of a system, a small difference in the cut-off score

can make a large difference in the estimated prevalence of a disorder. Cooke and

Michie (2001a) applied IRT methods to provide an explicit link between scores

across gender using data from the PCL:SV standardization sample. On average

women scored 1.8 points less (out of a total score of 24) than men for the same level

of psychopathy. Such a difference may appear small, but because of the effect of

shifting the tail of the distribution of total scores the effect on prevalence can be

substantial: in this case doubling the prevalence of women diagnosed as psychopathic.

One important characteristic of a psychometric test is its factor structure; the

factor structure indicates which items cluster together and can be distinguished from

other distinct clusters of items. A core requirement of gender equivalence is that the

factor structures should be equivalent. Most studies on factor structure of the PCL-

R/PCL:SV suggest that some symptoms of psychopathy may not coalesce to form

equivalent syndromes in males and females (Cooke & Michie, 2001a; Grann, 2000;

Jackson, Rogers, Neumann, & Lambert, 2002; Salekin et al., 1997). Some items do

not load on the traditional two factors1 in the same way as they do in male samples

1The two-factor model defines psychopathy as consisting of two distinct, but related factors, with F1reflecting the core personality traits of psychopathy and F2 reflecting a deviant lifestyle (Hare, 1991). Thismodel has been demonstrated to be statistically inadequate (Cooke & Michie, 2001a) but it is consideredhere because previous studies used this model. More recently, studies using more sophisticated statisticaltechniques (confirmatory factor analysis (CFA) and item response theory (IRT)) indicated that psychopathyis best characterized by three factors, and the two-factor model does not provide an adequate description ofpsychopathy in either men or women. Results of such a procedure indicate that psychopathic traits constitutea hierarchical three-factor structure, named Arrogant and Deceitful Interpersonal Style, Affective Experi-ence, and Impulsive and Irresponsible Behavioral Style, corresponding to the three domains described inthe traditional clinical description of psychopathy (Cooke & Michie, 2001a).



(i.e. poor behavioral controls, impulsivity, and lack of realistic long-term goals), and

other items (failure to accept responsibility, many short-term marital relationships,

and revocation of conditional release) do not load on any factor (Salekin et al.,

1997). Such differences could be explained in part by the fact that the instrument

developed in a specific sample (e.g. incarcerated male offenders) may not tap a

similar construct in other types of sample. Therefore, refinement of the factor

structure of psychopathy for female populations may be necessary (Cooke & Michie,

Table 1. Results of self-report measures of psychopathy among women

Self-report measure Study Female Resultssamples

SRP-II (Hare, Zagon and Jackson (1994) Students Construct validityunpublished test) Some bias: detect larger proportion

of males than femalesRutherford et al. (1996) Substance Weak correlation (0.3) with PCL-R

abusers total & factor scores

SRPS (Levenson, Lynam, Whiteside, Students Reliability and validityKiehl, & Fitzpatrick, and Jones (1999) Association with BFI1995) Antisocial scale (BFI, John, 1995)

The two factors represent distinctconstellations of personality traits

Levenson et al. (1995) Inmates Significant differences in the meanscores of psychopaths andnon-psychopaths

PPI (Lilienfeld & Cale and Lilienfeld (2002) Actors Males score higher than femalesAndrews, 1996)

Hamburger, Lilienfeld, Students Males score higher than femalesand Hogben (1996)Salekin et al. (2001) Students Males score higher than females

MMPI-II Pd & Spencer et al. (2001) Inmates Positive association for PCL-R &ASP scales (Hathaway Psychopathic Deviate (Pd) scores& McKinley, 1943)MCMI-II Antisocial Rutherford et al. (1996) Substance Modest correlation with the PCL-Rscale (Millon, 1987) abusers F1, but larger correlation with F2CPI So scale Strachan (unpublished Inmates Significant negative association with(Gough, 1969) doctoral dissertation) PCL-R scores

Rutherford et al. (1996) Substance Negative but not significant associationabusers with PCL-R scores

Vitale, Smith, Brinkley, Offenders Negative but not significant associationand Newman (2002) with PCL-R scores

PAI-ANT scale Salekin et al. (1997) Inmates Yielded a larger proportion of female(Morey, 1991) inmates with psychopathic traits than

did the PCL-RModest correlations with thecorrectional officers ratings

Salekin et al. (1998) Inmates Validity (PCL-R, PAI-ANT scale &antisocial scale of the PDE measurea similar construct)

EPQ-R (Eysenck & Rutherford et al. (1996) Substance Correlations between the PCL-R andEysenck, 1991) abusers such personality inventories subscalesIRI (Davis, Hull, Rutherford et al. (1996) Substance are generally weak or negative,Young, & Warren, abustance providing some evidence for the1987) validity of the PCL-RMPQ (Tellegen, 1982) Vitale et al. (2002) InmatesMach-IV Rutherford et al. (1996) Substance(Christie & Geis, abusers1970)



2001b; Forth et al., 1996; Grann, 2000; Jackson et al., 2002; Rutherford et al.,

1996; Salekin et al., 1997; Spencer et al., 2001; Strachan, 1995; Strachan,

Williamson, & Hare, unpublished study).

In part as a consequence of uncertainties about the equivalence of factor

structures and the equivalence of individual symptoms, there is still no consensus

on whether raw PCL-R/PCL:SV total scores represent the same level of psycho-

pathy across gender. Thus the issue of the equivalence of diagnostic cut-offs remains

contentious. Using the traditional cut-off score of the PCL-R to diagnose psycho-

pathy in males (30 and more), some authors have raised questions about the need to

lower cut-off scores when using the PCL-R with females. As a result, while some

studies used a traditional PCL-R cut-off score of 30 (Loucks, unpublished doctoral

dissertation; Neary, unpublished doctoral dissertation; Salekin et al., 1997; Salekin,

Rogers, Ustad, & Sewell, 1998; Strachan, unpublished doctoral dissertation;

Spencer et al., 2001; Tien, Lamb, Bond, Gillstrom, & Paris, 1993; Vitale et al.,

2002), others established a cut-off score based on the results obtained in their

sample (e.g. a total score of 20 or more) (Grann, 2000; Jackson et al., 2002; Logan,

personal communication; Rutherford, Alterman, Cacciola, & McKay, 1998;

Rutherford, Cacciola, & Alterman, 1999; Rutherford et al., 1996; Warren et al.,

2003) because none, or very few, of the women in these studies scored at the

traditional cut-off score level. These adjustments have yielded higher prevalence

rates of psychopathy in some female populations (Jackson et al., 2002; Rutherford

et al., 1996, 1999; Warren et al., 2003). For example, the base rate of psychopathy

in females in the same sample increased from 17.4 to 46.4% (Warren et al., 2003) or

from 6 to 21.9% (Jackson et al., 2002), depending on the PCL-R cut-off score

utilized (Table 2). Unfortunately, such adjustments are essentially ad hoc and are not

tied to an explicit linking between the scores in men and scores in women (see

below).

Due to the limits and contradictory results of studies on PCL-R/PCL:SV in

females (e.g. base rates and factor model), one could consider that there has been a

misinterpretation of the underlying dimensions and the nature of psychopathy in

women, and that the information reported in the literature to date should be

interpreted with a great deal of caution. There is growing evidence that the PCL-

R in its current form includes items that limit its utility in female samples (Hare,

1991; Salekin et al., 1997; Strachan et al., unpublished study). One authority had

already suggested that there may be sex differences in the behavioral manifesta-

tions of psychopathy, that psychopathy may be expressed differently in men and

women, and that some items of the PCL-R may require modification when used

with women (Hare, 1991, p. 64).

THE CONSTRUCT VALIDITY OF SYMPTOMS OF

PSYCHOPATHY ACROSS GENDER

Further empirical evidence on gender differences in the pattern of symptoms and

presentation of psychopathy is provided by consideration of the reported comor-

bidity between psychopathy and other PDs (e.g. antisocial, histrionic, narcissistic,

borderline, paranoid, passiveaggressive, and obsessivecompulsive personality



disorders). For instance, it is reported that the PCL-R Total, prior F1, and prior F2

scores are significantly correlated with antisocial personality disorder in both males

and females (Hare, 2003). However, a more detailed analysis suggests that child

antisocial personality criteria are significantly related to PCL-R old F1 scores for

men, but not for women, whereas adult antisocial personality criteria have a stronger

relationship to the PCL-R Total and prior F1 scores in women than in men

(Rutherford et al., 1998). Similarly, histrionic personality disorder is correlated

with PCL-R Total and personality (F1) scores in males (Blackburn & Coid, 1998;

Hart & Hare, 1989; Kosson, Nichols, & Newman, unpublished manuscript;

Rutherford, Alterman, Cacciola, & McKay, 1997; Shine & Hobson, 1997), whereas

it is correlated with PCL-R Total and behavioral (prior F2) scores in females (Cale

& Lilienfeld, 2002; Rutherford et al., 1996; Shine & Hobson, 1997; Warren et al.,

2003). Similar gender differences in the pattern of correlations are reported for other

personality disorders, such as narcissistic, paranoid, or obsessivecompulsive per-

sonality disorders. Moreover, comorbidity between psychopathy and some person-

ality disorders is reported only for males and not for females or vice versa. For

instance, comorbidity between psychopathy and sadistic personality disorder is

reported in males (Rutherford et al., 1997; Shine & Hobson, 1997; Stone, 1998),

but not in females.

Based on the aforementioned gender differences in the symptomatology and

expression of psychopathy across gender, it seems that if our understanding of

psychopathy in females is to be enhanced it is necessary to consider empirically that

the constellation of features that defines psychopathy in males differs from that

defining psychopathy in females.

Table 2. PCL-R means and prevalences reported in women

Author(s) N Nature of sample Mean Prevalence PrevalencePCL-R (PCL-R total (PCL-R totalscores scores>29) scores>24)

Neary (1990) 120 Inmates 21.10 11% Tien et al. (1993) 74 Inmates 23% Strachan (1993) 75 Inmates 31% Loucks (unpublished Inmates 11% doctoral dissertation)Rutherford et al. (1996) 58 Methadone patients 13.8 0% Weiler and Widom (1996) 320 Community (abused/neglected) 7.0 Weiler and Widom (1996) 212 Community 4.6 Salekin et al. (1997) Forensic patients 15.5% Salekin et al. (1998) 78 Inmates 12.9% Rutherford et al. (1998) 121 Patients for substance 14.8 2.5%

abuse treatmentRutherford et al. (1999) 137 Patients for substance 14.2 1.5% 3.6%

abuse treatmentGrann (2000) 36 Inmates 17.7 11%Spencer et al. (2001) 61 Inmates 10.7 Logan (2002) 47 Inmates 19.3 11%Logan (2002) 48 Forensic patients 18.0 19%Jackson et al. (2002) 119 Inmates 18.1 6% 21.9%Vitale et al. (2002) 528 Inmates 18.7 9% de Vogel, de Ruiter, and 42 Forensic 16.5 10%Oosterhof (in press) patientsWarren et al. (2003) 138 Inmates 22.5 17.4% 46.4%



TOWARDS GREATER UNDERSTANDING OF

GENDER BIAS IN PSYCHOPATHY

If psychopathy is manifested differently across gender, then the symptoms con-

sidered as the best indicators of psychopathy in men may not be appropriateor

sensitive enoughfor identifying psychopathy in women. If this is the case, then the

diagnostic criteria and, as a consequence, the process of assessment of psychopathy

in females should be based on other characteristics than those established for

psychopathy in males.

Developing a viable construct of psychopathy in women requires the aggregation

of evidence of both reliable and valid measurement of the construct. The first base is

establishing the existence of a coherent syndrome (i.e. a pattern of symptoms that

cluster together and that can be distinguished from other cluster of symptoms; see,

e.g., Blashfield & Draguns, 1976; Eysenck, 1970; Kendell, 1989). Regrettably,

gender research on psychopathy remains at first base.

To progress, three measurement issues need to be considered. (1) Do the same

features (e.g. thoughts, feelings, and behaviors) specify the symptoms across gender?

(2) Is there configural invariance across gender (i.e., do the same symptoms cluster

together to create equivalent composites across gender)? (3) Do the symptoms

specify the construct in the same way across gender? We will consider how each of

these questions might be addressed through future research.

(1) Do the same symptoms capture the disorder or do different symptoms have relevance?

In our opinion, we argue that a better understanding of the nature and

manifestation of this disorder among females requires us to go back to basics,

through clinical and qualitative studies. An essential task is to map the domain

of symptoms of the disorder and their expression in females (Shadish et al.,

1999; Smith et al., 2003). Reliance on instruments such as the PCL-R/PCL:SV

may lead to difficulties because it does not map the domain of potential

symptoms adequately (see, e.g., Cooke, Hart, & Michie, submitted). While it

is widely reported that the items of the PCL-R are derived directly from

Cleckleys conceptualization of the disorder it should be noted that it excludes

5 of the 13 (38%) key traits of Cleckleys conceptualization (i.e. absence of

nervousness, absence of psychoneurotic manifestations, poor judgment

and failure to learn by experience, pathological egocentricity and incapacity

for love, specific loss of insight, and unresponsiveness in general inter-

personal relations). Also, and at variance with Cleckleys view, the PCL-R is

oversaturated with variables linked to criminality. Therefore, the PCL-R in its

current form may miss some important characteristics of Cleckleys conceptua-

lization of psychopathy, and has been the cause of construct drift.

(2) Do the same symptoms cluster together to create equivalent composites across gender?

We assess an individuals level on a latent construct (e.g. intelligence, depres-

sion, or psychopathy) by inference from manifest variables, including their

behavior or response to test items (Borsboom, Mellenbergh, & van Heerden,

2003; Meredith & Millsap, 1992; Waller, Thompson, & Wenk, 2000). Manifest

variables should be good exemplars of the latent trait being measured; the first

step for assessing the latent trait in females is to demonstrate that the key

features of the disorder covary in a systematic way. The extent to which this is



similar to or different from that found in males can be assessed using multi-

group confirmatory factor analysis. The covariation between the manifest

variables and latent traits can be modeled to allow the identification of

gender-based variations across the patterns of symptoms that define the latent

trait and the structure of the disorder.

(3) Do the same symptoms specify the construct in the same way across gender? To answer

this question it is necessary to go beyond CFA approaches and use other strong

psychometric modeling techniques. Item response theory (IRT) provides

powerful methods for modeling the performance of items and tests (Embretson,

1996; Embretson & Reise, 2000). A full account of these methods is beyond the

scope of this brief paper (see Cooke, Kosson, & Michie, 2001; Cooke & Michie,

1997; Cooke, Michie, Hart, & Clark, 2004, for detailed accounts). These

methods allow symptoms to be compared in terms of their levels of discrimina-

tion. For instance, does impulsivity define the latent trait as precisely in females

as it does in males, and in terms of their difficulty or extremity (e.g., does

grandiosity become apparent at the same level of the latent trait in men and

women or not)?

One major advantage of IRT approaches is that they provide a strong psycho-

metric model that allows different groups (e.g. men versus women) to be matched

on the underlying latent trait. By focusing on latent variables rather than manifest

variables it is possible to distinguish between measurement bias and true group

differences. It is thus possible to establish whether a value on the latent trait in males

is equivalent to a value of the latent trait in females or is different. If cross gender

equivalence of the underlying metric is not achieved it is meaningless, for example,

to assume that numerically equivalent values of total scores represent the same level

of the latent traits across gender. It therefore follows that cut-offs and prevalence

estimates will also lack equivalence across genders.

We would argue therefore that clinical studies are necessary to map out the range

of potential symptoms and that psychometric studies are necessary to model the

inter-relationships amongst symptoms and their diagnostic significance. Only

through an iterative process such as this can a clear appreciation of gender

differences be achieved (Smith et al., 2003).

CONCLUSION

Although female cases of psychopathy have been reported for as long as male

psychopathy, the core characteristics of this personality disorder among females

have been subject to little systematic investigation, as yet. Despite the growing

number of studies on psychopathy in females, little research has been carried out on

the etiological, affective, interpersonal, and behavioral characteristics of psycho-

pathy in women. In addition, studies of the base rate and symptomatology have

failed to provide clear and consistent results. The continued application of the male

template is likely to be misleading. This is not merely a problem for research but it is

also a problem for ethical practice.

This lack of consistent information on the specific nature and expression of

psychopathy in females has crucial ethical implications for forensic and correctional



practice (court evaluations and forensic testimony; Webster, 1999). Indeed, the

inchoate diagnostic criteria of psychopathy in females make it difficult for practi-

tioners to distinguish psychopathy from other personality disorders sharing similar

underlying traits (Antisocial PD (ASPD), Histrionic PD (HPD), Borderline per-

sonality disorder). Also, it may limit mental health professionals abilities to offer

adequate intervention with violent/criminal females presenting with psychopathic

characteristics. Moreover, because of the pejorative nature of the diagnosis of

psychopathy it may have severe consequences for females so identified, or inappro-

priately so identified (e.g. inappropriate treatment, denial of access to treatment,

longer sentences, denial of parole). In other words, the generalization of the

diagnostic criteria and assessment tools (e.g. PCL-R) developed primarily for

male cases enhances prejudices among forensic and correctional professionals

with regard to females presenting with psychopathic characteristics.

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