gender and psychopathy

Behavioral Sciences and the Law

Behav. Sci. Law 23: 729–741 (2005)

Published online inWiley InterScience (www.interscience.wiley.com). DOI: 10.1002/bsl.677

Gender and Psychopathy: AnOverview of Important Issuesand Introduction to the SpecialIssue

Tonia L. Nicholls, Ph.D.*and John Petrila, J.D., LL.M.

One of the most important concepts to ever emerge in

forensic psychology and law is psychopathy. It would be

difficult to exaggerate the profound effect the construct has

had on research and practice in correctional psychology,

psychiatry, and criminology. Much less pronounced has

been an interest in understanding the potential relevance

and practical implications that this personality disorder

might have for providing insights into antisocial beha-

viors and crimes committed by girls and women. In this

paper we provide an overview of some of the pressing

issues confronting clinicians and researchers and provide

an introduction to this special issue dedicated to gender

and psychopathy. Copyright # 2005 John Wiley & Sons,

Ltd.

INTRODUCTION

There is little question that the creation of the construct of psychopathy is one of the

most important developments in psychology and law. While few question the

validity of the construct, there are important theoretical and practical questions

regarding its extension to discrete populations that until recently were at the margins

of much psychopathy research. For example, there are important concerns over

extending the construct of psychopathy downward to youths (Edens, Skeem,

Cruise, & Cauffman, 2001; Hart, Watt, & Vincent, 2002; Seagrave & Grisso,

2002; see the special issues in this journal, Petrila & Skeem, 2003; Skeem & Petrila,

2004). Commentators have raised similar issues regarding the appropriateness of

applying the construct, as currently defined and measured, to diverse ethnic and

cultural groups (e.g. Cooke & Michie, 1999; Cooke, Kosson, & Michie, 2001;

Skeem, Edens, & Sanford, 2003; Skeem, Edens, Camp, & Colwell, 2004).

Copyright # 2005 John Wiley & Sons, Ltd.

*Correspondence to: Tonia L. Nicholls, Ph.D, Senior Research Fellow, British Columbia ForensicPsychiatric Services Commission, Forensic Psychiatric Hospital, 70 Colony Farm Road, Port Coquitlam,British Columbia, Canada, V3C 5X9. E-mail: [email protected]

This two-volume special issue of BSL examines emerging issues in the applica-

tion of psychopathy to females. There has been discussion elsewhere of the degree to

which psychopathic features, measured by the ‘‘gold standard’’ (Fulero, 1995)

PCL-R (Hare, 1991, 2003), are likely to evidence similar correlates and, in

particular, yield a comparable predictive relationship with antisocial behavior

among girls and women. Prominent scholars have suggested that there is little

reason to expect that psychopathy would not be relevant to females (Hare, 1991,

2003; Webster, 1999). Hart (1998) asserted ‘‘Psychopathy must be considered a

central part of any comprehensive assessment of risk for violence . . . Indeed,

psychopathy is such a robust and important risk factor for violence that failure to

consider it may constitute professional negligence’’ (p. 133). Similarly, in their

discussion of psychopathy and the international predictive validity of the PCL-R,

Hare, Clark, Grann, and Thornton (2000) observed that while the PCL-R was

initially developed from data derived from men, research has shown higher rates of

recidivism and institutional infractions among women with psychopathic traits than

among women without these characteristics. Despite this apparent consensus of

opinion, to date, the application of psychopathy to females has garnered little

research attention. In addition, some have cautioned against the uncritical accep-

tance of the construct for females (Rogers, 2000). For example, its potential clinical

value has been questioned (Laishes, 2002) because of some sex differences in the

correlates (e.g. anxiety, intelligence; Vitale, Smith, Brinkley, & Newman, 2002) and

early research indicating differential factor structure (Salekin, Rogers, & Sewell,

1997).

The Importance of Studying Psychopathy in Females:

The Prevalence and Impact of Female

Aggression and Crime is Not Insignificant

There are a number of reasons why further research into the applicability of

psychopathy to females is particularly timely. One of the most important is that

the number of adolescent girls (see Odgers et al., this issue) and adult women

(Weizmann-Henelius, Viemero, & Eronen, 2004) coming into contact with the

criminal justice system is steadily rising. Further, in other institutional settings

where personality disorder evaluations and violence risk assessments are common,

women represent approximately 40% (civil hospitals) and 10% (forensic psychiatric

hospitals) of the population. A growing literature suggests that female aggression

among people with serious mental disorders (Hodgins, Mednick, Brennan,

Schulsinger, & Engberg, 1996; Nicholls, Brink, Webster, & Martin, manuscript

under review; Nicholls, Ogloff, &Douglas, 2004; Skeem et al., 2005; Stueve & Link,

1998; Swanson, Holzer, Ganju, & Jono, 1990) and intellectually impaired indivi-

duals (Crocker et al., in press; Hodgins, 1992) rivals, and sometimes surpasses, the

prevalence rates and severity of aggression among their male counterparts. In the

family violence field, removal of the ‘‘cloak of secrecy’’ (Steinmetz & Lucca, 1988,

p. 233) reveals that men’s and women’s rates of perpetrating intimate partner abuse

are roughly equal (Archer, 2000; Dutton & Nicholls, 2005; Nicholls & Dutton,

730 T. L. Nicholls and J. Petrila

Copyright # 2005 John Wiley & Sons, Ltd. Behav. Sci. Law 23: 729–741 (2005)

2001; Straus, 1999), despite contrary evidence derived from criminal databases and

victim surveys. Women are also the most frequent perpetrators of child abuse,

making gender-biased custody assessments particularly problematic (Dutton, in

press). In each of these forensic settings/populations psychopathy might play an

important role in informing assessment of the risk of harm to others presented by

female clients.

Psychopathy is a Theoretically Relevant

Explanation for Female Aggression and Crime

There is little evidence to suggest that personality disorders, and psychopathic traits

specifically, are any less relevant to female offending than they are to male offending.

Both Cleckley (1941/1976) and Hare (1993) provided examples of female psycho-

paths in their early descriptions of psychopathic individuals. Given that there is little

reason to doubt the general applicability of the construct to women, further research

to determine whether the construct should be refined or its measurement modified

(e.g., deletion/addition of items, revised item descriptions) as applied to women is

essential.

Psychopathy is a Central Issue in Violence Risk Assessments

and Risk Management Decisions

Psychopathy also should be a focus of further empirical investigation into the

accuracy of violence risk assessments with girls and women. First, unstructured

violence risk assessments with females are vulnerable to the same and perhaps

greater limitations as reduce the accuracy of such assessments with men (Skeem

et al., 2005). Risk assessments with women with serious mental illnesses tend

not to exceed chance accuracy (Lidz, Mulvey, & Gardner, 1993; McNiel &

Binder, 1995; Nicholls, Ogloff, & Ledwidge, 2003; Rabinowitz & Garelik-Wyler,

1999), and some studies suggest that female gender can impact on the assessment

process itself (e.g. the likelihood a client is asked about violence risk at all) (Coontz,

Lidz, & Mulvey, 1994; also see Elbogen, Williams, Kim, Tomkins, & Scalora,

2001).

At the same time, women’s violence and men’s violence share many similar

correlates (Giordano, Millhollin, Cernkovich, Pugh, & Rudolph, 1999; Loucks &

Zamble, 2000; Magdol, Moffitt, Caspi, & Silva, 1998; Richards, Casey, & Lucente,

2003; Vitale et al., 2002). For instance, Weizmann-Henelius, Viemero, and Eronen

(2004) reported that psychopathy and several other variables commonly associated

with violence risk in men were good predictors of recidivism in women. As such, it

would be disingenuous to overlook the importance of this construct to female

offending. It is also worth considering that the PCL instruments figure prominently

in several high profile risk assessment instruments (e.g. HCR-20, Webster, Douglas,

Eaves, & Hart, 1997; Violence Risk Appraisal Guide, Quinsey, Harris, Rice, &

Introduction 731


Cormier, 1998); to the extent the field fails to demonstrate the generalizability (or

lack thereof) of psychopathy to women we further limit our ability to apply these

other well conceived instruments to female populations.

Preliminary investigations into psychopathy as a predictor of risk for future

violence among women are promising. It appears to be a reliable and viable

construct in women (Vitale et al., 2002) and has a moderate association with

women’s antisocial behavior (Salekin et al., 1997). The vast majority of the research

with women indicates that psychopathy assessments with females serve to confirm

their low risk and are associated with a continuum of antisocial behavior that

generally parallels that seen with males (see Jackson, Rogers, Neumann, & Lambert,

2002; Nicholls Ogloff, Brink, & Spidel, this issue; Vitale & Newman, 2001). Gender

differences in the observed prevalence of psychopathy are well established (Salekin,

Rogers, Ustad, & Sewell, 1998). According to the review by Vitale et al. (2002)

of psychopathy in women, the base rate ranges from 9 to 23% in women and

15 to 30% for men. Similarly, in the second edition of the PCL-R Hare (2003)

reported that approximately 7.5% of female offenders and 15% of male offenders

meet the diagnostic cut-off on the PCL-R. (i.e. scores� 30). Assessments affecting

the civil liberties of women and the safety of the public are not uncommon and

risk assessments ‘‘cut both ways’’ (Bonta, 2002). To the extent that tools such

as the PCL instruments can serve to identify high and low risk females, mental

health professionals will be serving the best interests of the community and the

client.

Psychopathy is Relevant to Treatment

Personality disorders also offer important information with regard to prognosis and

treatment responsiveness. Most have assumed that the prognosis for psychopathic

individuals is extremely poor. Their affective and interpersonal characteristics and

the prevalence of criminogenic risk factors may make them poor candidates for

treatment. Early investigations indicated that treatment that reduced recidivism

rates in other offenders likely would have little therapeutic value with psychopathic

offenders, and in fact might inadvertently result in worse outcomes (Hare,

2003; Ogloff, Wong, & Greenwood, 1990; Rice, Harris, & Cormier, 1992; cf.,

D’Silva, Duggan, & McCarthy, 2004). In the first investigation of treatment of

women with psychopathic traits, Richards, Casey, and Lucente (2003) studied

the treatment response of 404 incarcerated women and found that scores on the

PCL:SV/PCL-R were associated with poor treatment outcome as measured by

program retention, removal for serious noncompliance, violent and disruptive

rule violations, avoidance of urinalysis testing, treatment module attendance,

and therapist ratings. Their findings have substantial implications for demonstrat-

ing the construct validity of the PCL measures with women and also offer some

of our first insights into the prominent role that a more thorough understanding

of psychopathy might play in informing treatment development for female

offenders.

Recent research revisiting the ‘‘nothing works’’ and ‘‘treatment makes psycho-

paths worse’’ perspectives (e.g. D’Silva et al., 2004; Salekin, 2002; Skeem,



Monahan, & Mulvey, 2002) is guardedly optimistic. Although the prevailing

perspective remains skeptical when it comes to traditional interventions (Hare,

2003), emerging advances (Wong & Hare, in press, cited by Hare, 2003) may

reduce some of the stigma associated with the psychopath label and the reluctance of

some professionals and policy makers (e.g. Correctional Service of Canada, see

Laishes, 2002) to explore the relevance of the construct in females (see Warren &

South, this issue, volume 2). A particularly exciting development with regard to

treating women at high risk for violence, that is likely to capture the international

attention of scholars and mental health professionals alike, is the Dangerous and

Severe Personality Disorder Programme’s Primrose Project in England (DSPD,

2005; Logan, 2004).

Psychopathy Might be Expressed Differently

in Females than in Males

It is generally agreed that the PCL-R (Hare, 1991, 2003) and PCL:SV (Hart, Cox,

& Hare, 1995) provide clinicians and researchers with valid and reliable means of

assessing psychopathic personality disorder in adult, Caucasian, North American

males. Hare (1991) proposed, however, that psychopathy might be ‘‘expressed’’

differently in males and females and, therefore, some items on the PCL-R might

require modification (p. 64). Just as developmental differences in cognitive and

emotional development secondary to age are likely to be reflected in the differential

manifestation of psychopathic-like traits in children, gender-role socialization and

biological sex differences might result in psychopathic traits being expressed

differently in males and females (Cale & Lilienfeld, 2002; Hamburger, Lilienfeld,

& Hogben, 1996; Logan, 2004).

Females with psychopathic traits might rely on different tactics than males to

achieve the same goals. Women tend to have less upper body strength than men and

so brute force in general is less likely to achieve the same results for women as for

men. As a result, women might resort to manipulation, flirtation, or coercion (or the

use of weapons) to achieve the same goals. Experts also postulate that males and

females show different developmental pathways to antisocial behavior (Eme &

Kavanaugh, 1995; Loeber & Loeber-Stouthamer, 1998; Silverthorn & Frick,

1999), though this claim has been challenged by empirical data (Moretti, Lessard,

Wiebe, & Rybee, 2001, cited by Moretti & Odgers, 2002). A brief consideration of

gender differences in charges and convictions also suggests some clear gender

differences in criminal offending (e.g. women tend to commit few sexual offences

and more arson) (see Strand & Belfrage, this issue). Female antisocial behavior is

also more likely to involve relational aggression (see, e.g. Crick, 1995), to occur in

the home, and to target family, friends, or acquaintances rather than strangers

(Robbins, Monahan, & Silver, 2003). As such, female antisocial behavior might be

less likely than male antisocial behavior to be recorded on official records and/or the

item descriptions on existing instruments might be poor descriptions of the type of

aggression typically demonstrated by females. Our knowledge of aggression and

violence in girls and women suggests that items such as ‘‘Adolescent Antisocial

Introduction 733


Behavior’’ and ‘‘Adult Antisocial Behavior’’ might be less discriminating

for diagnosing psychopathy in females than in males.

Generalizability Must Be Demonstrated

Some studies have reported that the internal consistency of the PCL-R items is

lower in samples of females than in samples of males (Neary, unpublished doctoral

dissertation; Strachan, Williamson, & Hare, unpublished manuscript). Investigations

of the generalizability of the PCL-R across diverse populations, thus far, have focused

predominantly on structural equivalence (Bolt, Hare, & Vitale, 2004). The factor

structure of the PCL-R has been demonstrated to be relatively consistent across

genders (Hare, 2003; Warren et al., 2003). ‘‘Scalar equivalence is said to hold when

test scores represent the same levels of the construct across diverse populations’’ (Bolt

et al., 2004, p. 155). Social or cultural influences are likely to reduce scalar equivalence

of the PCL-R (Bolt et al., 2004; Hare, 1998); thus, it is important to demonstrate this

in females.

Studies of cross-gender differences in the assessment of psychopathy can learn

from pioneering work in the cross-cultural study of the generalizability of psycho-

pathy. Cooke, Michie, Hart, and Clark (2005) concluded that PCL-R scores are not

equivalent across cultures. Using IRT analyses they found that lower scores in the

UK are equivalent in the degree of psychopathy to higher scores in North American

samples. Similar concerns about the generalizability of the PCL-R to women can be

found in the literature (Vitale et al., 2002). In the same way that cross-cultural

differences might result in the same level of psychopathy being expressed at lower

levels, gender differences in socialization might reflect sex differences in equivalent

levels of the disorder.

CONTRIBUTIONS MADE BY THE

ARTICLES IN THIS ISSUE

As the above discussion suggests, there are many compelling reasons for a closer

examination of the application of psychopathy to girls and women. This two-volume

special issue provides a platform for exploring what we know about psychopathy in

females and for suggesting areas for further, systematic investigation. The articles

presented here bring considerable breadth and depth, as well as new knowledge,

to this important topic. The contributions to this special issue address a number

of questions, including the following.

Are There Gender-Specific Manifestations

of the Same Construct?

One of the controversies surrounding the application of the construct of

psychopathy to women is the assertion by some commentators that



psychopathy may be expressed differently in females than it is in males. Elham

Forouzan and David Cooke provide a thorough and insightful glimpse into

the paucity of knowledge about psychopathy and gender. They persuasively argue

that despite a rapidly expanding research base the core features of the disorder

among females, and the possibility that gender moderates the expression

of psychopathy, require much more study. They suggest a number of issues ripe

for further investigation; they also assert that the PCL-R has resulted in ‘‘construct

drift’’, something bound to be controversial. Importantly, they propose that a failure

to consider gender differences in psychopathy assessments may give rise to human

rights issues.

Is Psychopathy a Viable Construct in Females?

Schrum and Salekin (this issue, volume 2) used item response theory (IRT) to

analyze test and item functioning of the PCL:YV. Consistent with previous

research with adult and adolescent males, from their study of 123 detained

adolescent girls they conclude the PCL:YV F1 was more discriminating of the

underlying construct of psychopathy than F2. They assert that psychopathy may

be applicable to adolescent females, pointing to three principal findings as

evidence: (1) the base rate of psychopathy does not appear to be inflated in their

sample of female youths, (2) a relatively high degree of homogeneity for the four

facets of psychopathy, and (3) IRT analysis revealed the hallmark symptoms of

psychopathy were evidenced at high levels of the construct.

Similarly, Kimonis and colleagues (volume 2) report that girls did not differ

from boys in the association between aggression, psychopathic traits, and respon-

siveness to distressing stimuli. The authors propose that cross-gender investiga-

tions of the processing of negative emotional stimuli, psychopathy, and aggression

have important theoretical and practical implications. Their findings suggest that

psychopathic characteristics are useful in distinguishing between subgroups of

aggressive and/or antisocial children and could provide insight into the diverse

pathways to offending and violence. Unusual emotional responses to distressing

stimuli are a characteristic feature of psychopathy in males; these results suggest

that it may also be key to understanding the development of psychopathy

in females.

What is the Relationship Between Psychopathy,

Antisocial Behavior, and Prior Victimization?

Theoretically, personality disorders increase the risk for violence. As such,

if psychopathy exists in females it would be expected to be associated with female

offending because psychopaths lack the interpersonal, affective, and emotional

characteristics that would normally inhibit crime and violence. Psychopathy, while

it is just one risk factor for violence (Hart, 1998), has been found to be one of

the ‘‘preeminent’’ variables in analyses of female recidivism (Loucks & Zamble,

2000).

Introduction 735


Berardino and colleagues (this volume) examine the performance of the Psycho-

pathic Personality Inventory (PPI, Lilienfeld & Andrews, 1996), a relatively new

self-report measure of psychopathy, in a sample of 105 women incarcerated in a

maximum security jail. They studied the reliability and convergent and discriminant

validity of the PPI and concluded that the psychometric properties of measures

of psychopathy may not replicate those obtained with men. Their results also

suggest that the PPI correlates moderately with the PCL-R’s Factor 1, and is

therefore tapping into more of the same aspects of the construct than any other

available measure (e.g. MMPI-2 Pd scale).

Strand and Belfrage (this volume) present findings from a sample of adult

Swedish female and male offenders. The authors compared female and male

offenders on several domains: the prevalence of psychopathy, item scores, differ-

ences in the psychopathic profiles of men and women, factor structure of the

PCL:SV and differential item functioning. They conclude that the three factor

model (Cooke & Michie, 2001) fits best for women and that gender specific

assessment approaches may be required.

Marsee and colleagues (this volume) studied the degree to which psychopathic

traits, measured by teachers and self-report ratings, were associated with self-

reported aggression and delinquency in a non-referred sample of boys and girls.

Contrary to the proposition that psychopathic traits are less predictive of antisocial

behavior in females, they report that psychopathic traits predicted aggression and

delinquent behaviors in both boys and girls. Of note, girls who scored high

on psychopathic features were particularly likely to engage in relational aggression

and boys with psychopathic features were particularly likely to engage in

overt aggression. The authors suggest that overt aggression in boys and relational

aggression in girls might be ‘‘gender-specific manifestations of the same construct’’

and that future studies should endeavor to measure these and other forms of

aggression that might be expressed uniquely in females.

Odgers and colleagues (this volume) discuss the role that psychopathic traits

might play in assessing violence risk in adolescent girls. Treating psychopathy and

victimization as competing risk domains, their study of 125 incarcerated adolescent

females suggests that negative life events such as victimization at the hands of

trusted adults in the position of care-givers, specifically mothers, might contribute

substantially to our ability to identify girls at risk for aggression and violence. In fact,

their results showed that victimization experiences that reportedly predicted short-

term recidivism and psychopathy scores on the PCL:YV (Forth, Kosson, & Hare,

2003) were unrelated to aggression once maternal victimization experiences were

accounted for statistically. They propose that the exceptional trauma experienced

across the lifespan of some girl offenders might be reflected in an interpersonal style

that resembles psychopathic characteristics. The article closes with brief reflections

on the potential treatment implications of victimization being at the root of adoles-

cent female offending and the malleability of ‘‘psychopathic’’ traits in juveniles.

Warren and South (this issue, volume 2) also report the victimization experiences

of females scoring in the psychopathic range on the PCL-R (Hare, 1991). Their

study explores the differential relationship of psychopathy and Antisocial Person-

ality Disorder (APD) to patterns of criminal behavior, psychological adjustment,

co-morbidity with other personality disorders, victimization, and institutional

adjustment and other forms of maladaptive functioning in a sample of 137 female



maximum security inmates. They classify the women in their sample into four

groups: those meeting the diagnostic criteria for APD only (17%), those meeting

a PCL-R score of 25 or higher (15%), those receiving an APD diagnosis and a PCL-

R score of 25 or higher (32%), and those women who were not diagnosed for either

disorder (36%). The authors conclude that it is possible to meet criteria for one

disorder and not the other, and that when this occurs the probability is almost equal

that one of the two disorders will occur without the other, but that in this sample

of high-risk women the two disorders were most likely to occur in the same

individual. The women diagnosed with psychopathy had consistent patterns of

prior offending, incarceration, and instrumental aggression, and were often lacking

remorse.

Nicholls and colleagues (this volume) present an overview of existing research

examining the prevalence of psychopathy among women in diverse correctional,

psychiatric, and community populations. They report the degree to which psycho-

pathy, measured primarily by the PCL instruments, relates to crime, aggression, and

violence in women. The review concludes that there is considerable evidence to

suggest that psychopathy is likely to be an important risk marker for aggression and

antisocial behaviour among women.

Are Psychopathy, Gender, and Stigma Related?

Finally, Guy and Edens (volume 2) note that in comparison to the considerable

research conducted on the validity of the psychopathy construct comparatively little

is known about the implications of psychopathy for decision-making. They exam-

ined the impact of the gender of mock jurors on recommendations for civil

commitment under sexually violent predator laws. Their study was an attempt to

replicate the findings in a previous publication in Behavioral Sciences and the Law

(Guy & Edens, 2003) suggesting that there are gender differences in the impact of

expert testimony regarding psychopathy. The nature of the testimony (psychopathy,

actuarial, or clinical) presented in sexually violent predator case scenarios to

undergraduate students had little impact when the victim described was a child

because recommendations for civil commitment were almost unanimous. However,

despite high rates of support for commitment overall, gender comparisons in the

psychopathy condition indicated that the same basic effect noted in the earlier study

was replicated here, with significantly more women than men supporting commit-

ment. This is one of few publications in the literature investigating the stigma

associated with expert testimony on psychopathy in jury trials.

Conclusion

These papers provide insight into the state of the field and highlight future

challenges facing researchers, policy-makers, and clinicians. As such, these volumes

complement and extend the discussion of the application of psychopathy to

adolescents in two earlier issues of BSL (Petrila & Skeem, 2003; Skeem & Petrila,

2004). Perhaps what this issue demonstrates most clearly is the need for further

Introduction 737


investigation into psychopathy and gender. Further research is necessary to deter-

mine whether the findings in several of the studies presented here can be replicated

in other (perhaps larger) samples of females, but in several cases novel findings will

need to be explored in samples of males as well (e.g. Odgers et al., this issue; Warren

& South, this issue). There are also several topics not covered in this volume that are

essential to expand our knowledge of psychopathy and gender. These include

research investigating psychophysiological measurement issues, gender differences

in the assessment of psychopathy (e.g. diagnostic biases, gender of the assessor and

gender of the client), and what the source of so-called ‘‘gender’’ differences might

be. It simply is not yet clear whether the cause of some of the differences between

males and females reflects gender (i.e. a socio-cultural construction) or sex (i.e.

biological and genetic components) differences (see, e.g. Hamburger, Lilienfeld, &

Hogben, 1996), or some combination of the two. Finally, research into the

implications of psychopathy for treatment in females is urgent. Given the small

(but rapidly growing) number of women offenders and forensic psychiatric patients,

conduct of further research into both assessment and treatment will require close

collaboration between researchers and those providing care, in order to gain access

to the substantial number of research subjects required to further our under-

standing.

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gender and psychopathy

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